垂直斜视的手术治疗

目的垂直斜视手术治疗的临床观察方法垂直斜视病例43例,其中麻痹性斜视33例,垂直性分离性偏斜(DVD)8例,甲状腺相关性眼病2例。检查双眼和单眼运动、角膜映光法、三棱镜遮盖试验及同视机检查垂直和水平斜视角,垂直斜视角3△～60△,水平斜视角10△～70△,作牵拉试验和Bielschowsky头位倾斜试验。手术一期完成31例,二期手术12例。手术选择在高位眼,麻痹眼及非注视眼。上斜肌麻痹26例行单侧或双侧下斜肌减弱术,5例行下斜肌和垂直直肌手术。1例上直肌麻痹行对侧眼下斜肌后退术,另1例行同侧眼下直肌后退术。8例DVD均采用一眼或双眼上直肌等量或不等量后退,后退量为6～9mm,合并下斜肌亢进的同时作下斜肌减弱术,其中1例行下斜肌转位术。2例甲状腺相关性眼病,行下直肌后退术。结果40例病人第一眼位正位,复视消失。2例DVD患者术后明显改善,1例甲状腺相关性眼病患者术后垂直斜视8△。结论垂直斜视的手术起点是垂直斜度大于10△,在斜度最大视野内起作用的肌肉上手术,垂直斜视矫正应保证正前方及前下方注视野,手术宜选择在高位眼,麻痹眼及非注视眼上进行。     

上斜肌麻痹患者斜视矫正术后眼球旋转状态的改变

目的 以眼底照相为客观定量检查方法,探讨单眼上斜肌麻痹患者斜视矫正术后眼球客观旋转状态的改变情况。方法 住院手术的40例（50只眼）单眼上斜肌麻痹的患者分别行患眼下斜肌切断术（15例15只眼）、患眼下斜肌部分切除术（15例15只眼）、患眼下斜肌切断+对侧眼下直肌后退术（10例20只眼）。于手术前和术后1、7、30、90 d行双眼眼底照相检查,使用绘图软件测量黄斑-视乳头夹角,定量记录客观旋转角度。并观察记录垂直斜视角度和眼球运动情况。同时对30例（60只眼）正常人行双眼眼底照相检查,记录眼球客观旋转角度。手术前后比较采用ANOVA即单因素重复测量资料方差分析方法,术后1、7、30、90d分别与术前比较采用平均值之间的多重比较q检验（SNK法）方法,不同术式间比较采用配对t检验方法。结果 30例正常人双眼眼底黄斑-视乳头夹角为右眼6.7°±2.5°,左眼5.9°±2.3°,双眼总和12.6°±4.3°,双眼间差异无统计学意义(t=1.29,P=0.20)。40例单眼上斜肌麻痹患者,术前双眼眼底黄斑-视乳头夹角为患眼14.3°±6.6°,对侧眼12.2°±4.8°,双眼总和26.5°±10.3°-双眼间差异无统计学意义(t=1.64,P=0.11)。上斜肌麻痹患者术前双眼总黄斑-视乳头夹角与正常人比较,差异有统计学意义。手术前后比较,双眼总黄斑-视乳头夹角术前为26.5°±10.3°-术后1、7、30及90d分别为11.7°±4.3°、11.9°±4.9°、13.5°±5.2°、15.9°±3.6°,组间比较差异有统计学意义(F =40.13-P＜0.01)。随术后时间延长眼球客观旋转角度又有逐渐增加的趋势,术后90d与术后1、7d对比差异有统计学意义。下斜肌切断手术组与下斜肌部分切除手术组相比,术眼手术前后黄斑-视乳头夹角改变量的差异无统计学意义(t =0.57,P=0.57)。患眼下斜肌切断+对侧眼下直肌减弱手术组,双眼间对比,手术前后黄斑-视乳头夹角改变量的差异无统计学意义(t=1.78,P=0.09)。结论 单眼上斜肌麻痹患者的眼底为外旋转位,并同时影响麻痹眼和非麻痹眼;减弱下斜肌或下直肌功能均可矫正眼球的外旋转状态,随时间延长,眼球的客观旋转角度有回退的趋势;下斜肌切断和下斜肌部分切除术矫正垂直旋转斜视的效果基本相同。     

上斜肌手术方式的探讨

目的 探讨上斜肌折叠或肌腱切断手术的特殊性，掌握其手术适应证。方法 对18例先天性上斜肌麻痹施行上斜肌折叠术；对7例外斜视A征和7例动眼神经麻痹施行上斜肌肌腱切断术。观察手术中上斜肌解剖的特点及手术前后眼位、斜视角和临床特征的改变。结果 先天性上斜肌麻痹单侧12例、双侧6例行上斜肌折叠手术，均联合下斜肌减弱术。术中见上斜肌异常者9／18（50．00％），表现为肌腱松弛、肌止端附着点位于上直肌的鼻侧止端。手术矫正了原在位上斜视15^△～25^△，矫正鼻侧方向最大上斜视15^△～40^△。术后眼位恢复正位15眼，欠矫3眼，无过矫。外斜视A征伴双上斜肌亢进7例行双眼上斜肌肌腱切断术联合水平直肌手术，矫正了上下外斜角之差别20^△～30^△，消除了A征，未发现过矫，术后4例恢复双眼视觉。单侧动眼神经麻痹7例行上斜肌肌腱切断术矫正了原在位下斜视平均15^△，术后垂直斜视矫正6例，欠矫1例。结论 上斜肌肌止端解剖异常是先天性上斜肌麻痹发病原因之一；上斜肌折叠或肌腱切断术主要改善旋转功能和矫正鼻下方垂直斜角，宜联合下斜肌或水平直肌手术。     

改良上斜肌矢状移位术治疗外旋转斜视

目的 探讨改良上斜肌移位术治疗后天性获得性上斜肌麻痹所致外旋转斜视的疗效.方法 对21例上斜肌麻痹致外旋转斜视的患者行改良法上斜肌矢状移位术,对手术前后患者的自觉症状、眼球运动、眼位、旋转斜视度数及双眼立体视觉变化进行分析.结果 术后患者主观症状得到较大程度的改善,旋转复视症状消失,立体视觉得到改善.结论 改良法上斜肌矢状移位术可改善上斜肌麻痹引起的外旋转斜,消除患者的旋转复视症状,改善患者的立体视觉,提高患者生活质量.     

Harada—Ito手术治疗上斜肌麻痹的疗效观察

目的观察Harada—Ito手术治疗上斜肌麻痹的效果。方法对10例(先天性9例,外伤性1例)头位倾斜严重(向麻痹眼对侧肩倾斜≥20°)的上斜肌麻痹患者施行Harada—Ito手术。双马氏杆检查原在位≥10°外旋斜视5例;不能很好配合主观检查,用三棱镜中和垂直斜视后代偿头位无明显改善者5例,术中以移位后的前部上斜肌纤维有一定张力为准。结果代偿头位消失6例,改善4例,外伤性1例视物倾斜及复视消失。结论Hara-da—Ito手术治疗先天性上斜肌麻痹表现的外旋斜视和严重代偿头位效果确切良好,不能配合主观旋转斜视检查、三棱镜中和垂直斜视后代偿头位无改善者可以手术。     

先天性上斜肌麻痹其下斜肌病变程度的观察

目的:测量先天性上斜肌麻痹患者其下斜肌异常的程度。方法:采用临床横断面研究,自身配对对照设计。选取30例合并单眼上斜肌麻痹的外斜视(间歇性外斜视、恒定性外斜视)患者做双眼外直肌后退和下斜肌减弱等相应的垂直肌手术时,观察患者麻痹眼和非麻痹眼的下斜肌,测量下斜肌的紧张度。下斜肌的紧张度是以斜视钩垂直于巩膜勾出下斜肌,肌肉离开巩膜的最大距离表示。结果:麻痹眼的下斜肌粗细不等,但都比健眼下斜肌坚韧、紧绷。麻痹眼的下斜肌平均紧张度为6.33±1.35mm,非麻痹眼的下斜肌平均紧张度为7.76±0.81mm,两者的差异具有统计学意义(P<0.01)。结论:上斜肌麻痹时患眼的下斜肌紧张度较高、弹性较差。     

后天性双眼上斜肌麻痹外旋转斜视的临床处理

目的 探讨不同术式对双眼上斜肌麻痹病人的矫正效果.方法 5例双上斜肌麻痹致外旋转斜视患者,根据不同检查结果两例行双眼上斜肌加强,两例行高位眼上斜肌加强合并另眼的上斜肌前部前徙,一例行双眼上斜肌前部前徙.结果 所有患者主诉症状消肖失,随访中未出现复视及视物倾斜症状.结论 不同术式治疗双眼上斜肌麻痹,在解决旋转性斜视的同时可兼顾到垂直斜视和水平斜视的矫正.     

水平直肌移位术在斜视治疗中作用

目的 探讨斜视手术中施行水平直肌垂直移位术和转位术的作用.方法 手术前后采用三棱镜遮盖法测定62例斜视患者各诊断眼位的斜视角及眼球运动等,并通过同视机检查和眼底照相评估主客观旋转斜视.手术年龄5～33岁,平均14岁.术后随访1～34个月,平均6个月.结果 (1)不伴有斜肌功能异常V型斜视26例,施行双侧水平直肌同方向垂直移位术或施行单眼水平直肌反方向垂直移位术,分别矫正垂直非共同性10～30△和8-25△,并未发现旋转斜视. (2)伴有斜肌功能异常A型斜视25例,单纯施行水平直肌垂直移位术,可矫正垂直非共同性8～30△,原在位与向下注视之间残留斜视角5～25△,而联合双侧上斜肌减弱术组,残留斜视角2～8△. (3)治疗共同性水平斜视伴有小角度垂直斜视8例,双侧水平直肌的向下或向上移位术矫正上斜视2～8△,残余上斜视2～5△. (4)治疗单眼先天性双上转肌麻痹3例,施行水平直肌垂直转位至上直肌肌止端两侧,矫正垂直斜视角25～30△,残余垂直斜视角5△,眼球双上转运动均明显改善.结论 水平直肌垂直移位术能有效地矫正下斜肌功能无异常V型斜视垂直非共同性,联合双侧上斜肌减弱术能更有效解决A型斜视向下注视的斜视角,而治疗共同性垂直斜视的作用则有一定的局限性;转位术治疗单眼先天性双上转肌麻痹疗效较好.     

隐匿性双眼上斜肌麻痹性斜视的临床特征和手术治疗

目的探讨双侧隐匿性双眼上斜肌麻痹性斜视的临床特点和诊疗方法。方法对1999年1月至2003年12月住院行手术治疗的7例双侧隐匿性双眼上斜肌麻痹性斜视患者的临床资料进行回顾性分析,观察患者手术前、后的代偿头位、原在位垂直偏斜度数、上斜肌和下斜肌功能状况的变化情况。结果全部患者首次就诊时头均向健侧肩倾斜,均诊断为单侧上斜肌麻痹性斜视,原在位平均上斜视度数为19．7^△（6^△-30^△）,麻痹眼下斜肌功能亢进程度为＋2～＋4,上斜肌功能不足程度为-1或-2,对侧眼上、下斜肌功能未见明显异常。第1次手术2例患者选择单纯下斜肌减弱术,5例患者选择下斜肌前转位联合同侧上直肌后退术,术后原在位平均上斜视度数为12．0^△（0^△～20^△）。术后1周至4年内全部患者对侧眼均出现不同程度的上斜肌麻痹表现,下斜肌功能亢进程度为＋2或＋3,上斜肌功能不足程度为0或-1。全部患者均在第1次手术后4个月至4年内接受第2次手术,术后原在位平均上斜视度数为2．3^△（0^△-7^△）,眼位矫正效果较为满意。结论双侧隐匿性双眼上斜肌麻痹性斜视难以在第1次手术前确诊,对于单侧上斜肌麻痹性斜视患者术前应考虑到对侧眼存在上斜肌麻痹的可能。下斜肌减弱手术与垂直肌后退术宜分期进行。第1次手术后当对侧眼隐匿的麻痹症状明显表现时,应考虑行第2次矫正手术。     

双上和双下转肌麻痹的临床特点及手术治疗

目的探讨双上转肌麻痹和双下转肌麻痹的临床特征和手术方式及疗效。方法根据患者不同情况进行个化手术治疗,并观察手术前后视力、眼位、眼外肌功能及代偿头位变化。结果23例双上转肌麻痹和双下转肌麻痹患者均有明显地垂直运动障碍并部分伴低位眼上睑下垂及代偿头位,术前垂直斜度平均为38.3△±16.7△,经手术治疗后患者垂直斜视度平均为9.2△±9.2△,较术前改善29.1△±15.0△;其中17例(73.9%)患者垂直斜度<10△。治愈12例占52.2%;好转10例占47.5%;仅1例双下转肌麻痹患者经两次手术后上斜矫正40△但仍残留40△垂直斜度。结论双上转肌麻痹和双下转肌麻痹是临床上少见的两种眼垂直运动障碍性疾病,他们的诊断和治疗较为复杂,但通过仔细的眼外肌功能检查和个体化的手术治疗可获得良好的疗效,不但眼位偏斜明显矫正,假性上睑下垂和代偿头位获得明显改善,也为提高斜视性弱视眼视力和双眼立体视觉提供了有利基础。     

Treatment of a complication after surgical removal of an aneurysmal cyst of the ethmoid

INTRODUCTION: An aneurysmal cyst (AC) is a rare benign bony tumor with a possible aggressive extension. We present a complication following the surgical ablation of an ethmoidal AC. CLINICAL HISTORY AND FINDINGS: A 40-year-old man with a left ethmoidal AC extending to the orbital roof underwent 2 surgeries. After the second one involving a neuro-surgical approach, a bilateral palsy of the superior oblique muscles (SO) appeared. The diplopia did not improve following a bilateral asymmetrical recession of the inferior recti muscles done elsewhere. There was an excyclotorsion up to 20 degrees in down gaze and a vertical deviation of 10 degrees in primary position. THERAPY AND OUTCOME: We performed a bilateral tucking of the anterior SO fibres with, on the left, an advancement of the inferior rectus and a resection of the medial rectus muscles. Two weeks after surgery the absence of cyclotorsional deviation allowed a binocular vision. CONCLUSION: The double vision due to the excyclotorsion, which was the main complaint, could be alleviated by an anterior strengthening of the SO. A precise measurement of the cyclotorsion is required for the surgical procedure.     

Surgical outcome in monocular elevation deficit: a retrospective interventional study

Background and Aim: Monocular elevation deficiency (MED) is characterized by a unilateral defect in elevation, caused by paretic, restrictive or combined etiology. Treatment of this multifactorial entity is therefore varied. In this study, we performed different surgical procedures in patients of MED and evaluated their outcome, based on ocular alignment, improvement in elevation and binocular functions. Study Design: Retrospective interventional study. Materials and Methods: Twenty-eight patients were included in this study, from June 2003 to August 2006. Five patients underwent Knapp procedure, with or without horizontal squint surgery, 17 patients had inferior rectus recession, with or without horizontal squint surgery, three patients had combined inferior rectus recession and Knapp procedure and three patients had inferior rectus recession combined with contralateral superior rectus or inferior oblique surgery. The choice of procedure was based on the results of forced duction test (FDT). Results: Forced duction test was positive in 23 cases (82%). Twenty-four of 28 patients (86%) were aligned to within 10 prism diopters. Elevation improved in 10 patients (36%) from no elevation above primary position (-4) to only slight limitation of elevation (-1). Five patients had preoperative binocular vision and none gained it postoperatively. No significant postoperative complications or duction abnormalities were observed during the follow-up period. Conclusion: Management of MED depends upon selection of the correct surgical technique based on employing the results of FDT, for a satisfactory outcome.     

眶下壁骨折后下直肌麻痹的手术治疗

目的 探讨眶壁骨折后,或眶壁骨折修复手术后发生单独的下直肌麻痹斜视患者的诊断和最佳手术治疗方案.方法 回颐分析诊治的8例下直肌麻痹斜视患者,均有眶壁骨折或眶壁骨折修复手术病史,6例患者正前方垂直斜度小于20△,下方斜度显著,行下直肌缩短加强手术,缩短量从3.5mm到6mm;2例患者正前方垂直斜度大于20△,上转、外转、下转时垂直斜度均较显著,行下直肌缩短联合同侧上直肌后徙手术.手术采用术中调整缝线的方法.结果 5例患者术后正前方正位,复视和代偿头位消失,远期随访眼位维持稳定,2例患者正前方过矫2△,远期随访正前方正位,复视和代偿头位消失.1例患者正前方欠矫4△,复视消失,头位改善.所有8例患者正前方和下方阅读距离视野复视消失.结论 下直肌缩短加强手术对于眶壁骨折后下直肌麻痹斜视患者消除复视,代偿头位是有效的,如果正前方斜度大,并且斜视累及上方视野,可行下直肌缩短联合同侧上直肌后徙手术,可有效增大双眼单视野.

Abstract：

Objective To study the diagnosis and surgical management of isolated inferior rectus paralysis following orbital trauma or caused by contusion at the time of surgical repair of a blow out orbital fracture.Methods In 8 patients with isolated inferior rectus paralysis,all of which had orbital fracture and 7 of them had history of surgical repair for orbital fracture,3.5mm～6mm resection of the paralyzed inferior rectus was done in 6 patients whose vertical deviation was less than 20△ in primary position;resection of inferior rectus combined with ipsilateral recession of superior rectus was done in other 2 patients whose vertical deviation was over 20△.Adjustable suture technique was used during surgery.The patients were followed up for more than 6 months.Results Postoperatively,5 patients were orthophoria without diplopia or abnormal head position,2 patients were 2△ over correction in primary position which became orthophoria during follow up,I patient was 4△ less correction with no diplopia and improved head position.Diplopia in primary and downward gaze position was disappeared in all the patients.Conclusions Resection of paralyzed inferior rectus is effective to correct vertical deviation both in primary and in downward gaze position for isolated inferior rectus paralysis.When the deviation is most pronounced in both downward and upward gaze position and the deviation in primary position is over 20△ resection and recession is effective to increase single binocular vision.     

下直肌后退术治疗甲状腺相关眼病性眼外肌病变

目的 探讨下直肌后退术治疗甲状腺相关眼病性眼外肌病变的适应证、手术特点和效果等.方法 回顾分析诊治的39例甲状腺相关眼病性眼外肌病变需作下直肌后退术的患者.其中男24例:女15例:年龄28.0～66.0岁(平均49.9岁).手术方式包括下直肌后退术31例;下直肌断腱术1例:下直肌后退+上白:肌缩短3例;下直肌后退+内直肌后退2例:右眼下直肌后退+左眼内直肌后退外直肌缩短1例;左眼下直肌后退+右眼上直肌后退下直肌缩短1例.术后平均随访1.4年.结果 术后25例正位,复视消失;欠矫5～15°10例,复视明显改善:过矫4例.20°以内的下斜视行下直肌后退术每1mm后退平均可矫止2.5°.大度数垂直斜(20°～＞45.),78.9%(15/19)行患眼下直肌后退术可矫正;21.0%(4/19)需行下直肌断腱术或加患眼上直肌缩短术.所有大度数垂直斜均需作眼球缝线固定术.结论 下直肌后退术治疗甲状腺相关眼病性眼外肌病变的限制性下斜视效果满意,文中对手术时机、手术特点、手术方式与手术注意点进行了详细的讨论.     

Helveston综合征手术治疗的临床分析

目的：探讨Helveston综合征的一次性手术治疗方法。

方法：回顾分析我院眼科收治的7例14 眼Helveston 综合征患者,根据患者上斜肌亢进的程度和斜视程度,实施一次性手术治疗Helveston综合征。

结果：患者7例14眼均行双眼上斜肌鞘内断腱术。其中3例6眼联合双眼外直肌后徙并一眼内直肌缩短术; 4例4眼联合单眼外直肌后徙并内直肌缩短术。术后随访观察6mo,7例14眼术后眼位均正位,外斜A征消失,分离性垂直偏斜消失。儿童患者3例恢复双眼视功能和立体视觉。

结论：Helveston综合征可以实施一次性手术治疗,且尽早手术治疗可帮助双眼视功能的恢复。     

先天性单眼上斜肌麻痹不同手术方式疗效观察

目的:探讨不同手术方式治疗先天性单眼上斜肌麻痹的疗效以及术后双眼视觉功能的恢复重建情况。方法:回顾性病例研究。选择2016-05/2019-05郑州市第二人民医院斜视与小儿眼科收治的82例先天性上斜肌麻痹患儿作为研究对象,根据患者第一眼位垂直斜视度、患眼下斜肌功能亢进程度、单眼及双眼运动情况等术前检查结果,设计相应的手术方式。包括下斜肌断腱术(3例)、下斜肌部分切除术(63例)、下斜肌徙后术(6例)、健眼下直肌徒后术(4例)、下斜肌减弱+对侧/同侧直肌术(5例)、上斜肌折叠术(1例)。结果:和手术前比较,手术后同时知觉、融合功能、远立体视、近立体视、矫正视力、代偿头位均得到明显改善(P<0.05);有无代偿头位患儿手术后立体视无差异(P>0.05)。结论:根据先天性单眼上斜肌麻痹病情严重程度选择不同的手术方式,在改善患儿视力、代偿头位方面具有积极意义,有助于重建双眼视觉功能。     

Strabismus surgery in Grave's disease--dose-effect relationships and functional results

BACKGROUND: Strabismus in thyroid ophthalmopathy is based on a loss of the contractility and distensibility of the external ocular muscles. Different therapeutic approaches are available, such as recession after pre-. or intraoperative measurement, adjustable sutures, antagonist resection, or contralateral synergist faden-operation. PATIENTS AND METHODS: 26 patients with strabismus in thyroid ophthalmopathy were operated between 2000 and 2003. All patients were examined preoperatively, then 1 day and 3 - 6 months (maximum 36 months) postoperatively. Before proceeding with surgery, we waited at least 6 months after stabilization of ocular alignment and normalization of thyroid chemistry. RESULTS: Preoperative vertical deviation was 10-44 PD (mean 22), 3 months postoperatively it was 2-10 PD (mean 1.5). Recession of the fibrotic muscle leads to reproducible results: 3.98 +/- 0.52 PD vertical deviation/mm for the inferior rectus. In the case of a large preoperative deviation a correction should be expected, which might not be sufficient in the first few days or weeks; a second operation should not be carried out before 3 months. 7 patients were operated twice, 1 patient need three operations. 4 patients (preop. 0) achieved no double vision at all; 15 patients (preop. 1) had no double vision in the primary and reading positions; 3 patients (preop. 0) had no double vision with a maximum of 5 PD; 1 patient (preop. 7) had double vision in the primary or reading position even with prisms; and 2 patients (preop. 17) had double vision in every position. CONCLUSIONS: We advocate that recession of the restricted inferior or internal rectus muscle is precise, safe and effective in patients with thyroid ophthalmopathy. The recessed muscle should be fixed directly at the sclera to avoid late over-correction through a slipped muscle. The success rate in terms of binocular single vision was 76 % and 88 % with prisms added.     

内直肌缩短治疗共同性外斜视手术的效果分析

目的:探讨双眼或单眼内直肌缩短术或联合外直肌后退术治疗集合不足型共同性外斜视的疗效。方法:收集行双眼或单眼内直肌缩短术或联合外直肌后退术的集合不足型共同性外斜视患者181例,术前及术后1wk;2,6mo均行常规的眼科检查、斜视角测量、眼球运动及同视机检查,分别对眼位、视功能等结果进行统计学分析。结果:术后1wk;2,6mo,患者正位率分别为80.1%,83.7%和81.3%,眼位同术前相比有明显改善(P<0.01),术后双眼视功能同术前相比无明显恢复(P>0.05)。结论:对于集合不足型共同性外斜视,行双眼或单眼内直肌缩短术可获得较满意的效果。     

67例V型斜视的手术探讨

目的 探讨V型斜视的临床特征及不同手术方法及效果.方法 回顾性分析了67例V型斜视的手术治疗.其中外斜V征46例,内斜V征21例,依据是否伴有下斜肌功能亢进及亢进程度,行下斜肌减弱术或水平直肌垂直移位术,所有患者按原在位水平偏斜度常规矫正水平斜视.观察手术前后的眼位、斜肌功能和双眼视觉.结果 67例手术中,49例行下斜肌后徙术或后徙转位术,术后43例上、中、下均正位,V征消失;术前无下斜肌功能亢进或下斜肌功能亢进"+"者13例,行水平直肌垂直移位术后11例正位,V征消失.67例患者术后19例恢复双眼视.结论 下斜肌后徙,后徙转位术适用于下斜肌功能亢进(++)-(+++)的V征,水平直肌垂直移位术适用于无下斜肌功能亢进或下斜肌功能亢进+的V征,应根据下斜肌功能亢进程度选择手术方式.