Evaluation of single-stage adjustable strabismus surgery under conscious sedation

Purpose

To evaluate the feasibility and stability of ocular alignment after single-stage adjustable strabismus surgery (SSASS) performed under topical anesthesia.

Materials and Methods

Forty-five patients of concomitant exodeviations were randomized into three groups of 15 cases each and were operated with three different techniques: Group I - conventional surgery, Group II - two-stage adjustable suture technique with suture adjustment performed 6h postoperatively and Group III- SSASS under topical anesthesia and intravenous conscious sedation with midazolam and fentanyl. Intraoperative suture adjustment was done by giving a cross target to the patient on the ceiling at the end of the procedure. Surgical results were compared among the three groups at three months follow-up. Intraoperative hemodynamic parameters and patients'' experience of the surgery (by questionnaire) were also compared.

Results

Mean preoperative deviation for distance in Groups I, II, III was −41.67 prism diopter (pd) ±9.0, −38.93 pd ±11.05 and −41.87 pd ±8.91 (P=0.6) respectively. At three months, mean correction achieved for distance was +31.87 pd ±11.71, +35.47 pd ±10.86 and +42.80 pd ±10.71 respectively which was significantly different between Group III and Group I (P =0.03). Intraoperatively all hemodynamic parameters remained stable and comparable (P=0.5) in all groups. Intraoperative pain (P<0.001) and time taken for surgery (P<0.001) was more in the SSASS group. Amount of exodrift was 10-12 pd, comparable in all three groups (P = 0.5).

Conclusions

SSASS, performed under topical anesthesia, is safe and has better outcomes than conventional recession-resection surgery for concomitant exodeviation. An overcorrection of about 10-12 pd is recommended to check the exodrift and achieve stable alignment.     

伊朗亚兹德省斜视手术的效果和并发症(英文)

目的:斜视是一种注视方向不重合而双眼指向不同方向的视觉缺陷。其患病率为2%~5%。依斜视的不同表现,其治疗方法有:手术、眼镜、滴眼液、训练、注射液。斜视手术有不同的并发症。本研究旨在评估亚兹德省斜视手术的并发症和效果。方法:本研究对连续10a来的200例斜视手术的并发症和效果进行了回顾性分析。随访时间为6mo。数据被收集并进行了相应的统计分析。结果:本组病例中女98例,男102例,平均年龄15.31±11.7岁。外斜视和内斜视分别占43.5%和47%。斜视手术的效果和手术方式显著相关,但与斜视的发病年龄及病因无关。结论:斜视手术的效果是有效而持久的。随访可观察到长期效果和晚期并发症。基于本研究的结果和我们的个人经验,基于过矫和欠矫的Rosenbaum Santiago表格需要被修订。     

Consecutive exotropia after surgical treatment of childhood esotropia: a 40‐year follow‐up study

Purpose: To determine the incidence of consecutive exotropia (XT) following successful surgical correction of childhood esotropia (ET) and identify factors associated with its development. Material and Methods: This is a retrospective study of 85 patients with ET, aged 2–24 , who underwent strabismus surgery by a single surgeon between 1958 and 1969 in Sweden, until they were successfully aligned to ET within 10 prism dioptre, after primary or reoperation(s). The charts of these patients were reviewed, and data regarding age at onset of strabismus, surgery performed and outcome were recorded. The patients were recalled for a complete orthoptic examination in 2001–2003. Results: The incidence of consecutive XT in this cohort was 21% (18/85). Patients who had undergone multiple surgeries had a higher risk of developing consecutive XT compared to those successfully aligned with one surgery (p = 0.00036). Restriction of adduction and convergence postoperatively was associated with a high risk of consecutive XT (p = 0.0437). The incidence of consecutive XT did not vary with the level of visual acuity in the operated eye (p = 0.6428). Age of onset, age at surgery and amount of surgery did not appear to influence the risk for developing consecutive XT (p > 0.05). Conclusion: This 40‐year postoperative follow‐up of patients with childhood ET who underwent strabismus surgery by a single surgeon in Sweden showed that multiple surgeries and presence of postoperative adduction deficit were the most important factors influencing the incidence of consecutive XT after surgery. Presence of uncorrected amblyopia did not alter the prognosis for long‐term development of consecutive XT.     

斜视矫正术对共同性斜视患者双眼视觉功能的影响

目的 探讨共同性斜视患者接受斜视矫正手术前后双眼视觉功能的改变及其影响因素。设计 回顾性病例系列。研究对象 北京同仁医院2013年12月至2014年8月进行斜视矫正术的共同性斜视患者191例。方法 将患者按斜视类型分为共同性内斜视组、恒定性外斜视组和间歇性外斜视组;按手术时年龄分为≤9岁组和＞9岁组。观察术前、术后1、3个月双眼视觉功能。主要指标 同视机双眼视觉三级功能及近立体视功能。结果 191例患者中,术前分别有26.7%、19.4%、11.0%及41.9%的患者具备同视机Ⅰ、Ⅱ、Ⅲ级及近立体视功能,术后1个月分别提高至90.1%、64.4%、33.0%及57.1%,术后3个月分别提高至94.8%、79.1%、37.7%及63.9%,与术前相比均有统计学差异（P均＜0.001）。术前,间歇性外斜视组38.1%、29.5%及72.4%的患者具备同视机Ⅰ、Ⅱ级及近立体视功能,高于另两组（P＜0.01）。术后3个月,间歇性外斜视组93.3%、48.6%及87.6%的患者具备同视机Ⅱ、Ⅲ级及近立体视功能,高于另两组（P均＜0.05）;恒定性外斜视组55.8%的患者具备近立体视功能,共同性内斜视组为14.0%（P＜0.001）。＞9岁组,术前28.1%、21.9%、14.6%及31.3%的患者具备同视机Ⅰ、Ⅱ、Ⅲ级及近立体视功能,术后3个月分别提高至93.8%、75.0%、37.5%及58.3%,与术前相比均有统计学差异（P＜0.01）。结论 斜视矫正术有助于共同性斜视患者双眼视觉功能的改善;间歇性外斜视患者术前术后双眼视觉功能优于其他类型斜视;大龄斜视患者术后也可能获得双眼视觉功能的改善。     

斜视矫正术中并发症的处理

目的探讨斜视矫正术中并发症的处理方法及效果。方法回顾研究了2003年8月至2006年5月完成的348例斜视手术,对术中出现的并发症、处理及效果进行观察。结果348例斜视手术中,术中巩膜穿孔3例,一例在行肌肉退后时发生,两例发生于肌肉缩短时,发生穿孔后即行巩膜外冷冻,术后随访未发现有进一步损害发生;术中缝线被剪断7例,牵引肌肉断端,重新安置套环缝线后继续完成手术;全麻术中发生严重眼心反射1例,患者出现频发室性早博,不得不终止手术,二次手术时加用阿托品及球后利多卡因浸润麻醉,平稳完成手术;术中严重出血1例,考虑为肌鞘缝合不完整所致;肌肉滑脱1例,为行内直肌缩短时发生,经仔细寻找得断端,完成手术。结论斜视矫正术中操作须认真细致,一旦发生并发症,冷静应对通常仍可取得较好手术效果。     

共同性水平斜视的再次手术

目的 探讨共同性水平斜视手术后施行再次斜视手术的临床特点及手术处理的特殊性.方法 共同性水平斜视手术后施行再次斜视手术的55例患者进行了回顾性临床分析,手术前后进行眼位检查、眼球运动,Titmus立体视检查双眼视觉功能.手术方法:手术前做全麻下或局麻下行牵拉试验.手术方式选择原则:依据视近和视远斜视角的不同,眼球运动受限制的受累肌肉和牵拉试验结果选择术式.术后追踪观察1～8年,平均2年.结果 (1)内斜视术后继发外斜视13例中,除即刻过矫3例在手术后48h内施行内直肌探查术外,其余施行原后徙内直肌完全复位或部分复位术,联合外直肌截除.治愈率76.9%.外斜视术后继发内斜视11例,施行原后徙外直肌完全复位或部分复位术,联合内直肌截除.治愈率81.8%.伴有V型斜视和垂直性斜视者联合水平直肌移位或斜肌减弱术.(2)内斜视欠矫15例中,8例施行内直肌边缘切开联合外直肌截除术;选择单纯在同一眼上外直肌截除术2例;伴有斜肌异常患者,则选择对侧眼内直肌后徙联合外直肌截除并下斜肌后徙5例.术后正位率86.7%.外斜视欠矫16例中:6例施行原外直肌后徙眼边缘切开联合内直肌截除术;2例Ⅴ型外斜视联合双下斜肌后徙,4例外直肌周围瘢痕松解术,4例联合调整缝线.术后正位率87.5%.结论 (1)水平斜视过矫伴有受累肌运动障碍,结合看近与看远斜视角的差别,选择内直肌或外直肌复位术.(2)调整术后缝线可将再次斜视手术的非预期结果降低到最小程度.     

斜视手术中遇到的困难及处理对策

斜视手术中有时会遇到一些意想不到的困难,如手术中观察仍矫正不足或过度矫正,钩不到下斜肌或上斜肌,手术眼睑裂变大或变小等。手术者必须镇定思考,冷静分析,才能找出可行的解决方法。本文分析其可能的原因,提出几种可选择的解决方法。(眼科,2007,16:291-293)     

屈光手术在成人斜视弱视领域中的应用

屈光手术包括角膜屈光手术和眼内屈光手术,不仅仅用来矫正单纯的屈光不正,其在治疗斜弱视领域也担任着重要角色。本文系统介绍了屈光手术在治疗儿童以及成人屈光参差性弱视以及调节性内斜视方面的一些研究进展,尤其是在治疗成人屈光参差性弱视和调节性内斜视方面,显示出独特的疗效,本文对此进行综述。     

Long-term outcomes of strabismus surgery in Mobius sequence

ABSTRACT

Purpose: Mobius sequence is a rare disorder that results from underdevelopment of the sixth and seventh cranial nerves, with subsequent facial weakness and impairment of ocular abduction. Approximately half of the affected patients have esotropia with limitation of extraocular movements. This study retrospectively reviews the long-term outcome of strabismus surgery for such patients.

Methods: The long-term follow-up results in five children with Mobius sequence, who were observed after strabismus surgery for congenital esotropia, were analyzed.

Results: All patients had a limitation of abduction in both eyes. Preoperative esotropia ranged from 20 to 30 prism diopters (PD) (mean 27 PD). Patient age at surgery ranged from 4.5 to 14 months. Bilateral medial rectus muscle recession was performed in all cases, ranging from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of V-pattern, and two patients also had surgery for vertical strabismus. Follow-up ranged from 4 to 19.5 years (mean 11.7 years). The final horizontal alignment was <8 PD in all patients, and all demonstrated some binocularity.

Conclusion: Bilateral medial rectus muscle recession is an effective treatment for esotropia associated with Mobius sequence, with good long-term stability.     

球后麻醉在斜视手术中的应用

目的探讨在斜视手术中应用球后麻醉的可行性及其临床意义。方法将84例斜视随机分为传统麻醉组及传统麻醉联合球后麻醉组,记录钩取眼外肌前后心率变化,比较两组眼心反射发生的阳性率并对其术后正位率进行统计学分析。结果联合球后麻醉组眼心反射发生的阳性率明显低于传统麻醉组,两组术后正位率在统计上无差异。结论在传统麻醉的基础上联合球后麻醉可以减少眼心反射的发生,在提高斜视手术安全性的同时并不影响手术效果。     

共同性斜视手术后AC/A比率的变化

目的分析共同性斜视术后AC/A比率的变化特点及其相关的主要因素。方法AC/A比率测量同术前一样采用同视机法。随访术后≥6周病例,内斜视19例:外斜视32例。将各类型的斜视均值同其术前相应的AC/A比率均值及正常人的均值对比,并行不同术式AC/A比率均值分析。结果术后ACJA比率均值:内斜视3.16±1.15;外斜视2.32±1.03。内斜视主要类型的AC/A比率较术前下降(P<0.01),同正常人比无统计学意义(P>0.05)。外斜视分开过强型较术前下降(P<0.01),集合不足型较术前上升(P=0.012),其它类型无统计学意义(P>0.05)。外斜视仅基本型低于正常人(P<0.05)。共同性斜视的异常值均较术前显著减少(P<0.05或0.01)。各术式对内斜视AC/A比率的影响无明显差异(P>0.05),对外斜视的影响部分有差异(P<0.05或0.01)。结论手术可使共同性斜视异常的AC/A比率趋于正常。其影响与斜视的种类及类型有关,内斜视所受影响与术式无关,外斜视尚不能肯定其与术式的关系。     

盐酸奥布卡因表面麻醉剂在斜视矫正术中的应用

目的:探讨盐酸奥布卡因滴眼液表面麻醉下行斜视矫正术的临床麻醉效果。方法:对118例斜视患者术前滴盐酸奥布卡因滴眼液5次,常规行斜视矫正术。结果:Ⅰ级麻醉效果83例(70.3%),Ⅱ级麻醉效果34例(28.8%),因眼胃反射终止手术1例。结论:盐酸奥布卡因表面麻醉下行斜视矫正术安全、有效、并发症少,简单易行。     

Learning curves for strabismus surgery in two ophthalmologists

Purpose:

To identify the average turning point by comparing the learning curves of two surgeons learning to perform strabismus surgery.

Materials and Methods:

Patients who underwent procedures to correct exotropia between January 2010 and December 2014 followed for at least 3 months were retrospectively assessed. The first 70 patients on whom each of two ophthalmologists (A and B) performed surgery to treat strabismus were divided into 7 cohorts comprising 10 patients each based on the chronological order of the surgery. Factors, including patient age, preoperative angle of deviation, operative time, and success or failure of the operation, were compared between the two surgeons. Learning curves were calculated based on changes in operative time and operation success rate. Operation success was determined by measuring the angle of deviation at a distance of 5 m 3 months after the operation.

Results:

A turning point was observed after 40 cases for Surgeon A and 50 cases for Surgeon B based on the operative time learning curve. No turning point was observed in the operation success rate learning curve based on the absence of a specific trend. Success rate by cohort was not significantly different between the two surgeons (P > 0.05). Surgeon B had a significantly longer mean operative time than Surgeon A (P = 0.045).

Conclusions:

Approximately 50 cases are required for an ophthalmologist to reach a turning point in strabismus surgery. This outcome can be used as a guideline when training surgeons to perform strabismus surgery.     

水平直肌斜视矫正术对散光的影响

目的:探讨水平直肌斜视矫正术对患者散光的影响。方法:选取30名水平斜视患者进行前瞻性研究,对所有患者术前和术后第1d均进行三棱镜交替遮盖试验、视力和屈光检查,根据三棱镜度进行不同的手术矫正。将术前和术后测定的散光值转变为Cartesian坐标系下的数值,然后再对术前和术后第1d的散光变化进行统计学分析。结果:共有30名患者50眼参与本次研究,所有接受水平直肌斜视矫正术的患者术后第1d较术前散光无显著性变化。结论:水平直肌斜视矫正术对患者散光无显著影响,长期效果需进一步观察。     

水平斜视矫正术后睑裂变化观察

目的 探讨水平斜视矫正术后睑裂高度变化.方法 将29例水平斜视患者,行一眼的一退一缩手术,检测术前术后睑裂高度,并对两组资料行配对t检验.结果 睑裂高度无变化的10只眼,占34.5％,睑裂高度增加11只眼,占37.9％,睑裂变小8只眼,占27.6％.两组资料配对t检验无统计学意义(P＞0.05).结论 水平斜视患者行单眼一退一缩手术,对睑裂大小无明显改变.     

斜视术后立体视锐度的测定

目的：探讨斜视矫正术后立体视恢复情况。方法：采用颜氏《立体视觉检查图》和《随机点同视机立体图》,进行远、近立体视锐度测定。结果：远、近立体视锐度无明显差异。立体视的恢复随发病年龄增长和视力的增加而上升,外斜视高于其他类型斜视。结论：斜视矫正术后,立体视锐度的恢复与斜视类型、发病年龄和视力有密切关系。发病早、视力低则立体视恢复差。     

局部麻醉或辅助地西泮在斜视矫正术中的作用

目的　应用面部表情分级评分（ｆａｃｅｒａｔｉｎｇｓｃａｌｅ,ＦＲＳ）、焦虑评分（ｓｅｌｆ-ｒａｔｉｎｇａｎｘｉ-ｅｔｙｓｃａｌｅ,ＳＡＳ）,观察共同性斜视矫正术患者应用局部麻醉及麻醉前应用地西泮注射液的效果,比较手术前、后的疼痛情况、焦虑、术中牵拉不适及术后随访情况。方法　对２０１２年８月至２０１４年８月在我院住院的眼科共同性斜视患者８８例（１０８眼）,年龄１１～４０岁,进行显微镜下斜视矫正术,采用随机、对照、双盲的研究方法,随机分为两组:对照组４４例５４眼（局部注射盐酸罗哌卡因注射液）,用药组４４例５４眼术前辅助肌肉注射地西泮注射液０．２ｍＬ·ｍｇ－１。记录术中、术后１ｈ的ＦＲＳ、ＳＡＳ,同时记录术中患者手术时间、牵拉反射及随访情况。结果　用药组与对照组患者术中、术后ＦＲＳ差异均有统计学意义（均为Ｐ＜０．０５）。用药组与对照组患者ＳＡＳ评分术中、术后差异均有统计学意义（均为Ｐ＜０．０５）。用药组手术时间较对照组缩短（均为Ｐ＜０．０５）;用药组患者牵拉反射不适减轻,与对照组差异有统计学意义（Ｐ＜０．０５）,同时用药组患者手术中生命体征平稳,更好配合医师手术。结论　局部麻醉手术辅助术前应用抗焦虑、镇静药物行斜视矫正术具有较好的镇痛效果;明显缓解因术中精神紧张、疼痛及恶心等所致眼位异常,提高手术舒适度、减轻术后不适感,术中医师操作顺利、术后眼位复位较好。     

A retrospective pilot study to assess the impact of strabismus surgery on the corneal endothelium in children

PURPOSE: To investigate if strabismus surgery has an impact on the corneal endothelium in children. METHODS: Fourteen children who had undergone uncomplicated strabismus surgery an average of 41 months previously (range 24-73 months) were compared with a group of age-matched (range 5-12 years) and refractive error (RE)-matched (range -4.74 to +4.25 D) children. Following noncontact specular microscopy, areas of at least 100 cells were measured, the number of sides for each cell recorded, and endothelial cell density (ECD) calculated from the area measures. Corneal diameter was measured with a clinical rule, corneal curvature with a manual keratometer, central corneal thickness (CCT) by ultrasound pachometry, and IOP by non-contact tonometry. RESULTS: The average ECD (+/-S.D.) in the post-surgery group was 4467+/-627 cells mm(-2), which was significantly higher (p < 0.02) than in the control group (3781+/-452 cells mm(-2)). This was because the average endothelial cell area in the surgery group was significantly smaller than in the control group (p < 0.005; 252+/-25 microm2 vs 296+/-29 microm2). Differences in cell areas were slightly greater for smaller cells (-15.7% for five-sided cells, -15.6% for six-sided cells, -14.3% for seven-sided cells and -13.8% for eight-sided cells). The cell differences appear to be related to both a slightly smaller corneal diameter (11.00+/-0.52 mm vs. 11.21+/-0.58 mm) and a slightly higher CCT (0.528+/-0.033 mm vs. 0.515+/-0.032 mm) in the post-operative group. CONCLUSION: The endothelial mosaic in children after strabismus surgery can show a higher than expected ECD value and slight cell pleomorphism. These signs indicate that there might be differences in eye growth and endothelial inflammatory stress associated with uneventful strabismus surgery.     

Gain beyond cosmesis: Demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20

Background:

Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively.

Aim:

The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment.

Settings and Design:

We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery.

Materials and Methods:

Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia.

Statistical Analysis:

We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05.

Results:

At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS.

Conclusions:

Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.     

共同性斜视的矫正手术量

分析446例共同性斜视水平直肌后退、缩短的手术矫正量.结果:在双内直肌后退术中,学龄前儿童每后退lmm,内直肌(MR)平均矫正2.15°,学龄期儿童为2.06°”/mm,中青年为1.94”/mm.在MR后退或外直肌(LR)缩短术中,学龄前儿童为1.80°/mm,学龄期儿童为2.07°/mm,中青年为1.93°/mm.3组平均MR后退2.05°/mm,LR后退1.35°/mm,并作直线回归方程.MR后退7mm治疗大角度内斜是有效和安全的,并详细讨论了手术矫正量和技巧.