共同性斜视矫正术后双眼总和图形视觉诱发电位的对比分析

目的：通过分析共同性斜视矫正手术前后双眼总和图形视觉诱发电位的变化,探讨共同性斜视手术时机及其在斜视性弱视治疗中的作用。 方法：回顾性分析18岁以内在院接受共同性斜视矫正术治疗,且术后斜视矫正正位（斜视度≤±10△）的病历资料67例。按手术前斜视类型、接受手术时年龄、弱视程度分组,对各组术前、术后1,3 mo分别进行双眼总和P-VEP检测。结果以双眼反应/单眼反应（ B/M）比值作为评价指标。 结果：所有病例术后1 mo B/M值均升高,差异有显著统计学意义（P〈0.01）。其中（1）内斜视组术后3mo的B/M值升高较外斜视组明显（P〈0.05）;（2）≤6岁组,术后3mo B/M值升高较〉12岁组明显（P〈0.05）。（3）重度弱视组术后1mo的B/M值升高较轻度弱视组明显（P〈0.05）;术后3mo,重度弱视组B/M值升高较轻度、中度弱视组明显（P〈0.01）。 结论：经过弱视治疗后视力仍难以提高的共同性斜视患者建议6岁前行斜视矫正手术,特别是重度弱视及内斜视患儿（调节性内斜视除外）。早期手术有利于弱视的进一步治疗及双眼视功能的恢复。     

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。     

Resolution in partially accomodative esotropia during occlusion treatment for amblyopia

PURPOSE: To evaluate alignment changes in partially accommodative esotropia during occlusion treatment for amblyopia. METHOD: Changes at the deviation angles of 63 partially accommodative esotropia patients, who had occlusion treatment for amblyopia, were evaluated retrospectively. RESULTS: Mean deviation angle at the start of therapy without glasses was 45 PD (10-90 PD) and became 27 PD (5-70 PD) after at least 2 months with glasses. During 12 (2-36) months of occlusion period, mean manifest deviation angle with glasses decreased to 11 PD (0-50) (P < 0.001) and amblyopia resolved in 71.5% of the cases. After termination of amblyopia treatment 24 (38%) cases had surgery for the residual deviation but if we had planned surgery before amblyopia treatment, 81% of the patients would have had surgery. DISCUSSION: Should amblyopia be treated initially or should we operate first in patients with strabismus and amblyopia together? Our research suggests that we should not hurry to operate in high hypermetropic partially accommodative cases, which have amblyopia and a long-term history of strabismus. Initial amblyopia treatment in these cases allows time for resolution of the nonaccomodative component in strabismus and can significantly decrease the necessity for surgery.     

儿童部分调节性内斜视的治疗及调整缝线在手术中的应用

目的 探讨儿童部分调节性内斜视的术前治疗、手术时机与手术量以及调整缝线在治疗中的应用。设计 回顾性病例系列。研究对象 北京儿童医院眼科接受手术治疗的部分调节性内斜视患者30例。方法 对手术治疗的部分调节性内斜视患者的临床资料进行回顾性分析。患儿术前矫正屈光异常,观察斜视度稳定,并予适当弱视治疗,在双眼视力相当的情况下进行手术,按照裸眼和戴镜斜视度的平均值设计手术量。术中常规使用调整缝线技术,术后早期依据眼位情况决定是否需要调整。术后随访6~15个月。观察眼位及双眼视功能。主要指标 术后眼位、双眼视功能、眼位调整情况。结果 有3例患儿进行了眼位调整,均为过矫,避免了二次手术。末次随访时30例患者中26例（87%）眼位在正位~+8△之间,4例（13%）眼位+10△~+15△。术前能合作行双眼视功能检查者19例,有双眼视功能者2例（11%）。末次随访时能合作双眼视功能检查者21例,有双眼视功能者15例（71%）。结论  内斜视伴有调节因素时应及时全矫配镜,在残余斜视度稳定、双眼矫正视力基本相当后应尽早手术。手术设计根据戴镜与裸眼视近的平均斜视度,调整缝线有助于保证术后早期的眼位满意,降低了二次手术的风险。（眼科, 2013,22: 121-123）     

斜视性弱视手术后视功能恢复情况的短期疗效研究

目的:了解斜视手术后3mo内对斜视性弱视眼的视功能恢复情况的研究。方法:对2006-06/2008-03在我院行斜视手术的合并有弱视的98例患儿,年龄3.5～15(平均7)岁,其中共同性外斜76例,共同性内斜22例,手术前后用国际标准视力表进行视力的检测、同视机进行双眼视功能检查以及睫状肌麻痹下屈光状态的检查,采用自身对照的方法,将术后1wk;1,3mo的弱视眼视力、双眼视功能以及屈光状态与术前对比,统计学采用两因素方差分析(two-way ANOVA)。结果:术后1wk弱视眼视力较术前提高有显著性差异(P<0.05),双眼融合范围较术前提高有显著性差异。立体视觉的产生在术后1mo较术前有显著性差异。术后1mo的屈光状态与术前相比无统计学差异。结论:斜视性弱视经过斜视手术后可以迅速改善斜视性弱视眼的注视性质,使弱视眼视力和双眼视功能在术后1wk即可得到有效的提高,屈光状态无明显改变,眼位的正常是恢复视功能的关键。     

Congenital esotropia

Congenital esotropia represents the most common type of strabismus. Its pathogenesis, however, remains uncertain. It is typically characterized as a large angle, constant esotropia with onset during the first six months of life. Associated clinical findings include normal refractive errors for age, amblyopia, dissociated vertical deviation, inferior oblique muscle overaction and nystagmus. It must be distinguished from Duane's retraction syndrome, Moebius syndrome, nystagmus blockage syndrome, and early onset accommodative esotropia, as well as other causes of esotropia in infancy. The surgical management may involve recession of both medial recti muscles, unilateral recession of a medial rectus muscle and a resection of a lateral rectus muscle or three or four muscle surgery.     

Comitant strabismus

This article briefly overviews the recent literature regarding comitant strabismus. The evaluation and management of esodeviations and exodeviations, which are still topical questions today, are discussed. Several relevant basic studies focus on the prevalence and the role of sensory mechanisms in the clinical findings of essential infantile esotropia. Data reported on by the authors reinforce the validity of early surgery in congenital strabismus. Other articles deal with the accommodative esotropia. The beneficial effect of adequate corrective eyeglasses in accommodative esotropia is emphasized, in both children and adult patients. A major informative review of intermittent exotropia and a worldwide survey of current management of intermittent exotropia are also presented.     

Surgical success rates in infantile esotropia

An extensive literature search covering the last 35 years was undertaken to retrieve all English language articles reporting results of surgical management of infantile esotropia. Only 27 of the 48 studies retrieved met the minimum criteria which we established for inclusion in our analysis. The success rate for achieving some level of binocular vision was 22% in 1286 patients, while the overall cosmetic success rate was 63% in 2113 patients. Newer surgical procedures appear to be more effective in achieving cosmetic success. Although controversy still exists about the optimal time for surgery, the most reasonable approach appears to be the concept of performing surgery as soon as an accurate determination can be made of the deviation and associated characteristics, and only after attention has been directed to any accommodative component and treatment of amblyopia. Although approximately 60% of patients referred for surgery can be expected to achieve cosmetic improvement after the first operation, the need for multiple surgery is common. There is a trend toward recurrence of the strabismus, and the need for short interval, long-term optometric follow-up is essential.     

Diagnosis and management of accommodative esotropia

Background: Accommodative esotropia is the most common form of childhood strabismus presenting to optometric practice. Functional and cosmetic outcomes are often excellent but depend on accurate diagnosis, urgent and correct initial management and careful follow‐up. Case reports: We present several cases that highlight important aspects of the clinical care of accommodative esotropia. The first patient was mismanaged by undercorrection of hypermetropia, but was later accurately diagnosed to have accommodative esotropia and was subsequently managed successfully with full hypermetropic correction alone. The second patient had an accommodative esotropia with amblyopia. The third patient used a near addition to correct a residual near esotropia. Conclusions: The published evidence and these cases make several points regarding assessment, diagnosis and management of esotropia. Assessment must aim to reach a diagnosis based on aetiology, as the aetiology of esotropia has a significant impact on management decisions and prognosis.     

Strabismus surgery for elimination of bifocals in accommodative esotropia

PURPOSE: This study reports the outcomes of strabismus surgery to eliminate bifocals in patients with accommodative esotropia with a high accommodative convergence to accommodation (AC:A) ratio. DESIGN: Retrospective interventional case series. METHODS: Sixteen patients who wore bifocals for treatment of accommodative esotropia with a high AC:A ratio underwent strabismus surgery following prism adaptation testing (PAT) for the near angle of esotropia without bifocals. Outcomes were considered successful if patients had microtropias and maintained fusion without bifocals. RESULTS: All patients had successful outcomes after one or two surgeries. Three of 13 (23%) patients with positive PATs required two surgeries. Two of three (67%) patients with negative PATs required two surgeries. Binocularity remained the same in 13 patients and improved in three patients. Glasses were eliminated entirely in eight of 16 (50%) patients. CONCLUSIONS: Strabismus surgery may eliminate the need for bifocal glasses in patients with accommodative esotropia with a high AC:A ratio, with many patients able to discontinue glasses entirely. Preoperative PAT may help predict the risk of requiring more than one surgery.     

Accommodative esotropia following surgical treatment of infantile esotropia: frequency and risk factors

Purpose: We aimed to examine the frequency of and risk factors for the development of accommodative esotropia following surgical treatment for infantile esotropia. Methods: A total of 29 children were recruited. Potential risk factors for the development of accommodative esotropia included: sex; angle of deviation at initial and final visits; cycloplegic refractive error at initial and final visits; increase in hyperopia; amblyopia; amblyopia treatment; age at surgical treatment; pre‐ and postoperative latent nystagmus; dissociated vertical deviation or inferior oblique muscle overaction; additional surgical procedures; unstable alignment, and binocular sensory status. Results: Overall, 14 (48.2%) of 29 children developed accommodative esotropia during the 36‐ to 132‐month postoperative follow‐up period. Twelve (85.7%) of the 14 patients developed refractive accommodative esotropia and two developed non‐refractive accommodative esotropia. The onset of accommodative esotropia occurred at a mean of 8.8 months (range 6–24 months) after the initial surgical alignment. This corresponded to a mean age of onset for accommodative esotropia of 43.2 months. We determined that, among children with infantile esotropia, those who had hyperopia of ≥ 3.0 D and increasing hyperopia after surgery and those who did not develop dissociated vertical deviation during the follow‐up period were more likely to develop accommodative esotropia. Conclusions: Children who have the established risk factors should be followed closely for the development of accommodative esotropia. The treatment of these children with appropriate glasses may prevent the development of adverse effects of accommodative esotropia on sensory and motor functions.     

四川省乐山市夹江县第一小学小儿斜弱视流行病学调查分析

目的：了解小学生斜弱视的流行病学及相关因素,为制定防治策略提供指导。
　　方法：对四川省乐山市夹江县第一小学600例学生进行视力、屈光及眼位等进行筛查,比较不同性别、年龄阶段的斜视患病率、弱视患病率,并统计不同弱视或斜视种类患儿的弱视程度及有无立体视。
　　结果：弱视患病率与斜视患病率分别为4.0%,2.5%;各年龄段、不同性别的学生斜视患病率、弱视患病率对比差异无统计学意义(P>0.05);屈光不正性是主要的弱视类型,占55.6%,且主要的弱视程度为轻、中度;屈光不正性弱视、屈光不正性弱视及外斜视大多数有立体视,而大部分的斜视性弱视及全部的内斜视均无立体视。
　　结论：屈光不正性弱视是小学生主要的弱视类型,其斜弱视的患病率与性别的关系不明显,但斜弱视的治疗效果、立体视的建立等与年龄、眼位存在密切的关系,应早发现、早治疗。     

斜视弱视治疗中应注意的几个问题

近年来国内斜视、弱视的诊断与治疗水平不断提高。但在斜视、弱视治疗中尚存在一些需要进一步澄清和强调的问题,如斜视手术的目的是什么、斜视手术时机如何选择、如何规范弱视的诊断与治疗等。有些问题在一些眼科医师中还存在着比较模糊的认识。本文就相关问题进行阐述,并藉此与眼科同道探讨。     

Effect of Binasal Occlusion in Children with Concomitant Esotropia

Objective: To investigate the effect of binasal occlusion in the treatment of children with concomitant esotropia. Methods: In this propective clinical study, 21 children aged 3 to 10 years with nonaccommodative esotropia or partly accommodative esotropia who had more than +20△ esotropia after full refraction correction for 6 to 9 months at Xiamen Children's Hospital from January 2019 to July 2019 were examined. All the children were given binasal occlusion. Vision function and strabismic degree were re-examined every month. Data were analyzed by single factor analysis of variance. Results: The average strabismus was +33△±13△ before binasal occlusion. After binasal occlusion for 3 months, average strabismus was +21△±15△. Three cases were markedly corrected, 11 cases were effectively corrected, 7 cases were invalid. After binasal occlusion for 6 months, average strabismus was +18△±12△. Five cases were markedly corrected, 13 cases were effectively corrected, 3 cases were invalid. The difference was statistically significant (F=8.316, P=0.001). Conclusions: Binasal occlusion can effectively assist the treatment of concomitant esotropia in children.     

双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果

目的：观察双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果。方法：前瞻性临床研究。纳入2019年 1─7月期间在厦门市儿童医院经阿托品眼膏散瞳验光连续配戴远视全矫眼镜6～9个月后仍有+20△ 以上内斜视的3～10岁非调节性内斜视或部分调节性内斜视患儿21例。给予双鼻侧遮盖辅助治疗。 每个月定期复查观察患儿视力及斜视度的矫正情况。数据采用重复测量方差分析进行分析。结果： 遮盖前斜视度为（+33±13）△;遮盖3个月后斜视度为（+21±15）△,其中矫正显效3例,有效11例, 无效7例;遮盖6个月后斜视度为（+18±12）△,其中矫正显效5例,有效13例,无效3例。3个时间点 斜视度比较,总体差异有统计学意义（F=8.316,P=0.001）。结论：双鼻侧遮盖法可以有效地辅助治 疗儿童共同性内斜视。     

Decreased Binocular Summation in Strabismic Amblyopes and Effect of Strabismus Surgery

Purpose: Binocular summation (BiS) occurs when binocular visual function surpasses that of the better eye alone. We sought to evaluate whether strabismic amblyopia reduces BiS more than strabismus alone, and determine whether BiS improves in strabismic amblyopes after strabismus surgery. Methods: We prospectively recruited 15 patients with strabismic amblyopia who then underwent strabismus surgery. Thirty age-matched normal subjects and 30 non-amblyopic strabismic patients served as controls. Subjects underwent binocular and monocular visual acuity testing on high-contrast Early Treatment Diabetic Retinopathy Study (ETDRS) as well as 2.5% and 1.25% Sloan low contrast acuity (LCA) charts. BiS was calculated as the difference between better eye and binocular scores. Results: Strabismic amblyopes and strabismic controls did not significantly differ in preoperative BiS, but both had subnormal BiS preoperatively on LCA charts. Among 11 strabismic amblyopes with preoperative and postoperative BiS measurements, average postoperative BiS was not significantly different from preoperative. Improved LCA BiS postoperatively occurred in some patients and was associated with measurable preoperative stereoacuity (P=0.02), older age at strabismus onset (P=0.02), and larger preoperative angle of strabismus (P=0.0043).Conclusions: In this preliminary study, strabismic amblyopes experienced subnormal BiS, but amblyopia generally did not further impair BiS beyond that due to strabismus alone. Some strabismic amblyopes experienced improved low-contrast BiS after strabismus surgery. This suggests that further investigation in larger groups of patients should be undertaken to analyze a previously unrecognized functional benefit of strabismus surgery in strabismic amblyopes.     

Bilateral phakic hypermetropic epikeratoplasty for accommodative esotropia

Optical correction of high hypermetropia with glasses is the primary treatment for accommodative esotropia. These glasses are often poorly accepted by adolescents and young adults for they are cosmetically undesirable, heavy, and esotropia occurs with their removal. We report an 11 1/2-year-old, physically mature female with high hypermetropia and accommodative esotropia corrected to orthophoria with glasses who was unable to be weaned from her glasses. She became intolerant to glasses wear, refused contact lenses, and was treated successfully with bilateral phakic hypermetropic epikeratoplasty. Two years postepikeratoplasty her visual acuity is 20/40 and 20/20 uncorrected and the vision in the amblyopic right eye has remained at its maximum preoperative level. She is orthophoric at distance and has a 2 prism diopter monofixational esophoria at near without glasses. Epikeratoplasty is an option in the treatment of accommodative esotropia for patients who are past the amblyopia forming age, have a stable angle of strabismus, and who require their full hypermetropic optical correction to maintain orthophoria.     

Hyperacuity deficits in anisometropic and strabismic amblyopes with known ages of onset

In order to evaluate the influence of etiology of amblyopia and of age at onset of amblyopia on the resulting constellation of spatial vision deficits, resolution/vernier and recognition/resolution acuity ratios were measured in groups of children with either strabismic amblyopia or anisometropic amblyopia with known ages of onset. Strabismic amblyopia with infantile onset (<9 months) and strabismic amblyopia with late onset (18-30 months) were both associated with abnormally low resolution/vernier and abnormally high recognition/resolution acuity ratios. Among amblyopes with infantile onset (<9 months), moderate amblyopia was associated with different resolution/vernier and recognition/resolution acuity ratios in anisometropic and strabismic groups. Infantile amblyopes with poor acuity outcomes included children who initially presented with anisometropia but later developed strabismus and children who initially presented with esotropia but later developed anisometropia; both subgroups with mixed amblyopia had poor resolution/vernier acuity ratios. Data from moderate amblyopes support the hypothesis that anisometropia and strabismus disrupt visual maturation in fundamentally different ways rather than simply at different stages in visual development.     

Form vision deprivation amblyopia: Further observations

Nine cases of esotropia occurring in deprivation amblyopia, where exotropia rather than esotropia is usually found, showed a refractive error of hypermetropia. This fact suggested that an accommodative factor is largely responsible for the development of esotropia. A- or V-pattern strabismus was encountered in a higher incidence in deprivation amblyopia than in ordinary strabismus. Pattern-reversal VEP showed more prominent abnormality than flash VEP did. Studies of the sensitive period of the visual system revealed that the sensitivity is likely to be low for a month or two after birth and increases with a peak around the 18th month of age, decreasing thereafter with a waning slope to the end of the 8th year of life.Dedicated to Dr. G.K. von Noorden on the occasion of his 60th birthday     

Acute comitant esotropia after cataract surgery

A 52-year-old woman developed comitant esotropia after cataract surgery. The ocular history was significant for accommodative esotropia; preoperatively, she manifested peripheral fusion with central suppression. Immediately postoperatively, the patient was diplopic with comitant esotropia and was treated with extraocular muscle surgery. The appearance of horizontal strabismus after cataract surgery in patients with a history of accommodative esotropia, especially those with subnormal binocularity, is a possible complication that should be discussed with the patient.