不同术式治疗垂直分离性斜视的临床疗效分析

目的探讨治疗垂直分离性斜视（DVD）的最佳手术方式。方法对43例（72眼）DVD根据不同的术前检查结果选择不同的术式。有下斜肌亢进者首选下斜肌切断加转位,根据亢进程度不同决定下斜肌在转位之前的截除量。无下斜肌亢进者首选上直肌后退术。双眼DVD不伴有下斜肌功能亢进者,且上斜程度相等者行双跟上直肌等量后徙术;双眼上斜程度不等者行双眼上直肌不等量后徙,或先行上斜明显眼手术,改期行另眼手术;合并水平斜视者尽可能同时完成,否则先矫正水平斜视,半年后矫正DVD。结果52眼疗效良好（72．22％）,16眼好转（22．22％）,4眼（5．56％）无效,1眼（1．38％）退上直肌和双眼外直肌后出现继发内斜视和对侧眼下斜肌亢进。结论对不同类型的DVD采用不同的术式可获得良好的疗效。     

三种下斜肌转位术治疗分离性垂直斜视疗效观察

目的观察三种下斜肌转位术治疗分离性垂直斜视的手术疗效,探讨治疗DVD的最佳手术方法。方法伴有下斜肌功能亢进的DVD患者75例,根据手术方式分为3组:单纯下斜肌转位术组、下斜肌截除联合转位术组、下斜肌截除联合前徙并转位术组。观察3组术后1个月、3个月及6个月的眼位、下斜肌运动、代偿头位及并发症情况。结果 3组患者术后下斜肌亢进均消失;代偿头位均不同程度改善;单纯下斜肌转位术组和下斜肌截除联合转位术组术后效果良好者23例(92%)、下斜肌截除联合前徙并转位术组术后效果良好者24例(96%),3组间疗效无明显差异,P<0.05。单纯下斜肌转位术无明显的睑裂变化及上转受限,而联合截除术式有少部分患者出现睑裂变小和眼球上转受限。结论单纯下斜肌转位术可矫正15△~25△的垂直斜视,且术后眼球上转受限和睑裂变化也不明显,是伴有下斜肌功能亢进DVD的首选方法。     

不同术式治疗上睑下垂疗效分析

上睑下垂是一种严重影响美容与功能的眼科常见病，需采用手术矫正。自1996年，我们对28例上睑下垂患者分为AB两组，分别进行利用提上睑肌和额肌的手术，现将两种手术的方式特点、治疗效果及并发症进行对比分析，报告如下。     

改良的下斜肌前转位术治疗伴有下斜肌功能亢进的垂直分离性斜视

目的:探讨伴有下斜肌功能亢进的分离性垂直斜视(disso-ciated vertical deviation,DVD)的临床特征,分析改良的下斜肌前转位术治疗伴有下斜肌功能亢进的DVD的疗效。方法:手术治疗伴有下斜肌功能亢进的DVD48例。将下斜肌离断,然后转位固定于下直肌止端颞侧1mm后1mm处。术后随访2wk～12mo。结果:下斜肌转位术对小度数DVD组和中等度数DVD组的原在位垂直斜度的矫正效果无显著性差异,小度数DVD组和中等度数DVD组与大度数DVD组在原在位垂直斜度的矫正效果有显著性差异。结论:改良的下斜肌前转位术治疗伴有下斜肌功能亢进的垂直分离性斜视安全有效。     

不同量下斜肌转位术治疗双眼不对称DVD

目的:通过不同量的下斜肌转位术对双眼不对称的分离性垂直斜视(DVD)的治疗,观察眼位矫正效果和并发症情况。方法:选择双眼垂直斜度不相等的DVD患者15例,均伴有下斜肌功能亢进+～+++,上斜度为15△～20△眼采取下斜肌部分转位术,上斜度>20△眼采取下斜肌全部转位术。术后观察眼位矫正情况及睑裂变化、眼球运动情况。结果:术后双眼第一眼位上斜明显改善,下斜肌功能亢进均消失,双眼睑裂大小基本对称,向上注视时上转程度相等。结论:DVD患者双眼上斜程度往往不对称,可根据第一眼位垂直斜度大小分别采取下斜肌全部转位和部分转位,以减少术后双眼睑裂不等大或上转程度不相等的并发症。     

水平斜视矫正后DVD消失四例

分离性垂直偏斜(dissouated vertical deviation.DVD)是一种原因不明的与一般眼球运动支配法则相矛盾的异常眼球运动.常合并有水平斜视与隐性眼球震颤。患者在疲劳或遮盖一只眼打破融合时眼球上转、同时伴轻度外转、外旋。手术为其唯一有效的治疗方法。但只能改善外观,不能根治.且手术效果不肯定。因其可随年龄增长而改善.有些学者不主张积极手术.我科自l985年以来陆续发现4侧水平斜视矫正后DVD消失病例。现报告如下。     

间歇性外斜视手术远期疗效分析

目的 探讨影响间歇性外斜视远期疗效的因素。方法 对107例手术治疗的间歇性外斜视,按年龄、术式、斜视类型、融合功能、非自主性辐辏功能强弱分组观察其疗效。随访2～10年,平均2.8年。结果 107例眼位:正位85例(79.44%),外斜14例(13.88%),内斜8例(7.48％);眼位正位率与年龄、术式、斜视类型均无相关性(P>0.05),而与术前有无融合功能有关,井与非自主性辐辏的强弱有关(P<0.01);非自主性辐辏功能较差或术前无融合功能者眼位回退率较高(P<0.05);眼位过矫率与上述诸因素无关。双眼视功能:年龄越小,立体视功能恢复率越高(P<0.01)。A-V征全部消失。结论术前融合功能和辐辏功能对术后眼位有较大影响,早期手术有利于双眼视功能的恢复。     

水平肌手术对DVD的影响(附5例报告)

5例水平斜视患者眼位检查过程中发现合并分离性垂直偏斜(DVD)。经单纯水平斜视矫正手术后,水平斜视矫正效果满意,其中两例术后DVD 完全消失,一例DVD 度数明显减轻,1例转为交替性上隐斜,1例DVD 无明显变化。我们认为在水平斜视检查中应注意有无DVD 存在,水平斜视合并DVD 患者应先矫正水平斜视。     

超常量后徙并直肌移位术在治疗重度外斜视合并 DVD 中的体会

目的：探讨外直肌超常量后徙和上直肌后徙并移位治疗重度外斜视合并垂直分离性斜视（ DVD）的效果。方法回顾近3年来对18例（36只眼）大于25°的外斜视合并DVD的患者施行双外直肌超常量后徙9～12 mm,上直肌后退6～10 mm并鼻侧移位半个或一个肌腹的手术,随访6个月至2年。结果术后眼位：15例正位,2例外斜视欠矫,1例外斜视过矫,DVD治疗效果基本满意。有4只眼外转不足1～2 mm,其余眼球运动协调。结论外直肌超常量后徙和上直肌后徙并移位治疗重度外斜视合并DVD操作简便快捷,损伤小,一次手术成功率高,效果满意,值得推广。     

不同术式在V征治疗中的观察

目的 观察下斜肌切断或部分切除术和水平直肌垂直移位术在V征治疗中的疗效.方法 44例V征患者中,其中内斜V征13例,外斜V征31例.有下斜肌亢进患者34例,无下斜肌亢进患者10例.在34例下斜肌亢进患者中,30例亢进程度(++～+++),4例亢进程度(+).30例亢进程度(++～+++)患者中,28例行下斜肌切断或部分切除术,2例行下斜肌部分切除加水平直肌移位术,4例亢进程度(+)和10例无下斜肌亢进患者行水平直肌垂直移位术.所有患者常规矫正相应的水平斜视度.观察手术前、后斜视度数,上、下注视25°时斜视度数的差值,代偿头位的变化.平均随访时间4.2周.结果 28例行下斜肌切断或部分切除术患者,术后V征消失率82.14%,缓解率10.71%,存在率7.15%.2例行下斜肌切断加部分切除同时行水平直肌垂直移位术.术后V征全部消失.对4例下斜肌亢进程度(+)和10例无下斜肌亢进患者行水平直肌垂直移位术.术后V征消失率78.57%,缓解率14.28%,存在率8.25%.有代偿头位患者8例,6例术后头位消失,2例头位缓解.结论 根据V征的不同术前检查及V征的大小不同,采取不同的手术方式,可以取得满意的效果.

Abstract：

Objective To investigate the inferior obliquus weakening procedure or horizontal rectus vertical transposition used in V-pattems. Methods There were 13 cases of V-esotropia and 31 cases of V-exotropia. There were 34 cases of inferior obliquus overaction and 10 cases without that. The inferior obliquus weakening procedure used for overaction of inferior obliquus ++～+++ in 28 cases and the other 2 cases for inferior obliquus weakening procedure combined with horizontal rectus vertical transposition. And the horizontal rectus vertical transposition for overaction of inferior obliquus + were in 4 cases and 10 cases without that.Then we analyzed the strabismus degree and head position of compensation before and after surgery. Results The rate of disappearance for V-patterns was 82.14% in 28 cases and the remission rate was 10.71%, the existence rate was 7.15%. After operation the V-patterns disappeared completely for 2 cases with combined surgery. For other 4 cases and 10 cases the rate of disappearance was 78.57%, the remission rate was 14.28% and the existence rate was 8.25%. For 8 cases with head position of compensation, there were 6 cases disappearance and 2 cases remission. Conclusions The V-patterns can be correct by surgery according to the V-patterns features.     

不同术式在V征治疗中的观察

Objective To investigate the inferior obliquus weakening procedure or horizontal rectus vertical transposition used in V-pattems. Methods There were 13 cases of V-esotropia and 31 cases of V-exotropia. There were 34 cases of inferior obliquus overaction and 10 cases without that. The inferior obliquus weakening procedure used for overaction of inferior obliquus ++～+++ in 28 cases and the other 2 cases for inferior obliquus weakening procedure combined with horizontal rectus vertical transposition. And the horizontal rectus vertical transposition for overaction of inferior obliquus + were in 4 cases and 10 cases without that.Then we analyzed the strabismus degree and head position of compensation before and after surgery. Results The rate of disappearance for V-patterns was 82.14% in 28 cases and the remission rate was 10.71%, the existence rate was 7.15%. After operation the V-patterns disappeared completely for 2 cases with combined surgery. For other 4 cases and 10 cases the rate of disappearance was 78.57%, the remission rate was 14.28% and the existence rate was 8.25%. For 8 cases with head position of compensation, there were 6 cases disappearance and 2 cases remission. Conclusions The V-patterns can be correct by surgery according to the V-patterns features.     

先天性眼外肌纤维化综合征的手术治疗

目的 探讨治疗先天性眼外肌纤维化综合征的手术方法和疗效.方法 术前行被动牵拉试验,垂直斜视眼均行垂直直肌悬吊和(或)断腱术,伴水平斜视眼同时行水平直肌悬吊和(或)断腱术,退后缝合球结膜;二期行上脸下垂矫正术.结果 共23例病人,22例术后眼位和头位均有改善,1例术后斜视无变化;其中8例二期行上睑下垂矫正术,术后头位和外观明显改善.结论 先天性眼外肌纤维化综合征手术治疗是有效的.由于患者临床表现各不相同,对每个患者应进行个性化治疗.     

显微镜下斜视矫正术对斜视患者视觉恢复及并发症的影响

目的探讨微镜下斜视矫正术对斜视患者视觉恢复及并发症的影响。方法选取2017年3月-2018年7月在我院进行治疗的斜视患者78例,参照随机数字表法的分组方式,分为传统组和显微组,每组各39例。传统组患者采用传统手术治疗,显微组患者采用显微镜下斜视矫正术进行治疗,观察分析两组患者临床指标、视觉恢复状况及不良反应现象。结果显微组患者手术时间及术中出血量显著低于传统组患者,差异有统计学意义(P<0.05);显微组患者视觉恢复状况显著高于传统组患者,差异有统计学意义(P<0.05);显微组患者不良反应发生率显著低于传统组患者,差异有统计学意义(P<0.05)。结论采用显微镜下斜视矫正术治疗可改善斜视患者临床症状,促进视觉恢复,且产生的不良反应较少,安全性较高。     

The Association between Level of Control and Exodeviation after the Monocular Occlusion Test in Pediatric Patients with Intermittent Exotropia

PurposeWe investigated the association between the level of control and exodeviation after the monocular occlusion test (MO) in pediatric patients with intermittent exotropia.MethodsWe retrospectively reviewed the records of pediatric patients with intermittent exotropia who visited Yeungnam University Hospital between September 2015 and December 2020. The largest exodeviation obtained before and after 1 hour of MO were compared. The LACTOSE (Look And Cover, then Ten seconds of Observation Scale for Exotropia) control scoring system was used to measure the level of control. Controllability was defined when the patient had the subjective awareness of exotropia and the instinctive ability to correct ocular deviation.ResultsFive hundred and three consecutive patients (260 male and 243 female patients; mean age, 7.8 years) were included. In all control scores, exodeviation significantly increased after the MO (p < 0.001). However, the patients with an increase in exodeviation ≥5 prism diopters (PD) after the test did not show any significant association with the control scores. The presence of controllability was significantly associated with an increase of ≥5 PD at near (p = 0.034).ConclusionsExodeviation showed significant increase after the MO, regardless of the level of control, in pediatric patients with intermittent exotropia. There was no significant association between the control scores and an increase of ≥5 PD after the MO. Patients with controllability were more likely to show increase in exodeviation after the MO.     

先天性上斜肌不全麻痹手术前后Bielschowsky歪头试验的变化

目的 探讨先天性上斜肌不全麻痹手术前、后Bielschowsky歪头试验的变化。方法 根据患眼原在位的垂直斜视度数,按照麻痹性斜视的手术原则,采用常规手术方式,减弱麻痹肌的直接拮抗肌和配偶肌,即减弱患眼的下斜肌和对侧眼的下直肌,治疗38例单眼先天性上斜肌不全麻痹患者。手术前、后采用三棱镜遮盖法定量进行Bielschowsky歪头试验,检查患者原在位和头部向双侧倾斜时患眼的垂直斜视度数。以头部向患眼侧倾斜时患眼的垂直斜视度数高于头部向健眼侧倾斜时患眼的垂直斜视度数的数值≥5．0^△为Bielschowsky歪头试验阳性。结果 术前全部患眼的垂直斜视度数原在位为3．0^△～25．0^△,平均为11．0^△;头部向患眼侧倾斜时为15．0^△～40．0^△,平均为23．0^△;头部向健眼侧倾斜时为0．0^△～10．0^△,平均为2．5^△,Bielschowsky歪头试验均为阳性。术后全部患眼原在位的垂直斜视度数为0．0^△～5．0^△,平均为2．0^△;4例患者Bielschowsky歪头试验转为阴性,34例仍为阳性(89．5％)。结论 采用减弱患眼下斜肌和对侧眼下直肌方法治疗先天性上斜肌不全麻痹,术后患者Bielschowsky歪头试验的转阴率较低。以其作为手术疗效的评价标准值得探讨。     

斜视性弱视皮层损害的功能性磁共振成像研究

目的 利用血氧水平依赖的功能性磁共振成像(BOLD—fMRI)技术，探讨斜视性弱视的可能机制。 方法 以1.5T磁共振成像系统采集11例斜视性弱视、8例正常人枕叶视皮层BOLD-fMRI数据，比较斜视性弱视组与正常组皮层双眼像素指数以及斜视性弱视组两眼皮层神经元的平均活动水平。结果 正常组双眼像素指数：47．82％±5．34％，斜视性弱视组：14．13％±4．55％，两组差异有显著性的意义(P<0．05)。选用高空问频率(1、2 cycle／degree)刺激时，弱视眼驱使皮层神经元平均活动水平较对侧眼降低(PO．05)。 结论 斜视性弱视可能与皮层双眼细胞减少以及弱视眼对高空间频率视信息存在采样、编码的异常有关。BOLD-fMRI为深入探讨弱视的神经病理机制提供了新的途径。 （中华眼底病杂志，2004，20：19-22）     

甲状腺相关眼病患者斜视手术量效关系分析

目的探讨甲状腺相关眼病（TAO）患者斜视手术量与矫正效果的关系。方法回顾分析作者在中山大学中山眼科中心自1999年1月至2006年3月期间诊治的甲状腺相关眼病患者行斜视矫正手术的全部病例。结果TAO患者因斜视需要手术矫正者共30例（32只眼）,其中男性19例,女性11例;平均年龄49．4岁;左眼21只,右眼11只。32只患眼中,10只眼行下直肌后徙术,10只眼行上直肌后徙术,6只眼行内直肌后徙术,3只眼行上直肌断腱术,2只眼行下直肌后徙联合内直肌后徙术,1只眼行上直肌后徙联合内直肌后徙术。32只眼中眼位完全矫正30只眼,术后正位率为93．75％。以29只眼行直肌后徙术后正位的28只眼计算每毫米矫正量,平均为（3．93±1．67）°／mm。上直肌矫正量最小为（2．63±0．83）°／mm,内直肌矫正量最大为（5．33±1．46）°／mm,下直肌矫正量为（4．11±1．55）°／mm;斜视度数≤15°者,矫正量为（2．30±1．09）°／mm;斜视度数16°-30°者,矫正量为（3．56±0．79）°／mm;斜视度数〉30°者,矫正量为（6．02±1．01）°／mm。结论TAO斜视患者单位手术矫正量均大于其他类型斜视的单位手术矫正量;随着斜视度数的增加,每毫米矫正量增大。但其手术定量性仍较差,手术效果预测较为困难。（中华眼科杂志,2007,43：982-986）     

Analysis of the effects of medial rectus muscle resection for recurrent exotropia

Purpose

The purpose of this paper is to investigate how much correction is obtained per millimeter of medial rectus (MR) resection for recurrent exotropia after bilateral lateral rectus (BLR) recession, and to determine the difference in the effects between unilateral and bilateral resection, and the influence of previous lateral rectus (LR) recession on the effects of MR resection.

Methods

A total of 59 patients who had undergone MR resection after BLR recession were included in this study. The unilateral group consisted of 38 patients and bilateral group, 21 patients. Thirty patients in the unilateral group were divided into two groups: patients who had undergone previous LR recession of 7 mm or greater (21 patients) and less than 7 mm (9 patients). Main outcome measures were average deviation corrected per millimeter of MR resection at 1 month postoperative.

Results

The average effect of MR resection was 4.2 prism diopters (PD, 2.0 to 6.7 PD)/mm. The average effect in the unilateral group was 4.2 PD/mm and 4.1 PD/mm in the bilateral group. There was no significant difference between groups (P = 0.60). The average effect in the recession 7 mm or greater group was 4.0 PD/mm, and the average effect in the recession less than 7 mm group was 4.2 PD/mm (P = 0.698).

Conclusions

The effect of MR resection per millimeter was variable. The laterality and previous amount of LR recession did not influence the effect of MR resection. These variable outcomes dictate that caution be exercised when MR resection is performed for recurrent exotropia.     

Changes in Exodeviation after the Monocular Occlusion Test in Adult Patients with Intermittent Exotropia and Its Association with the Level of Control

PurposeWe investigated the changes in ocular deviation after the monocular occlusion test in adults with intermittent exotropia and evaluated its association with the level of control.MethodsWe retrospectively enrolled adults (aged ≥18 years) with intermittent exotropia who visited our clinic between September 2015 and May 2019. Patients with basic intermittent exotropia with a distant deviation within 10 prism diopters (PD) of the near deviation were included. The largest ocular deviations obtained before and after 1 hour of monocular occlusion were compared. The level of control was measured using the LACTOSE (Look and Cover, then Ten seconds of Observation Scale for Exotropia) control scoring system.ResultsForty-six consecutive adult patients (28 males, 18 females; mean age, 34.3 years) were enrolled. The mean ocular deviation was 36.3 PD (range, 18 to 5 PD) at distant fixation and 38.5 PD (range, 18 to 80 PD) at near fixation, which increased significantly to 38.5 PD (p = 0.043) and 41.1 PD (p = 0.011), respectively, after monocular occlusion. The mean ocular deviation increased ≥5 PD in 14 (30.4%) and 15 (32.6%) patients at distant and near fixation, respectively. The level of control was measured in 30 patients. A higher degree of near control was significantly associated with an increase of ≥5 PD in near fixation after the test (p = 0.009 for a near control score ≤2).ConclusionsThe monocular occlusion test may help to determine the largest ocular deviation in adults with intermittent exotropia. Approximately one-third of patients exhibited an increase in ocular deviation ≥5 PD. Patients exhibiting good control were more likely to manifest an increase in the ocular deviation.