先天性上睑下垂与弱视成因的再探讨

随机抽取我院５２例７５只眼先天性上睑下垂病历，其中屈光不正６７只眼，散光６１只眼。散光（≥１．５０Ｄ）者３２只眼，在上睑下垂占４４％，其弱视患病率为３４．６％在统计学有显著性意义。结果表明，先天性上睑下垂是形成散光性屈江不正的主要因素，也是形成弱视的间接因素。     

斜视矫正手术前后眼屈光状态变化的短期临床观察

目的：临床观察涉及不同眼外肌数的斜视矫正术前后术眼屈光状态的短期变化。

方法：选取接受斜视矫正术的患者41例64眼,按手术涉及的眼外肌数目分三组：单纯一条水平直肌后徙组(Ⅰ组,25眼),一条水平直肌后徙联合其拮抗肌缩短组(Ⅱ组,32眼),一条水平直肌后徙联合其拮抗肌缩短组及斜肌切断组(Ⅲ组,7眼)。观察斜视患者术前1d,术后1wk,1mo各项屈光状态参数,并进行统计学分析。

结果：斜视矫正术后1wk患者的等效球镜屈光度及散光值较术前有所增高(P=0.011、0.013),球镜屈光度、柱镜屈光度、水平与垂直子午线角膜曲率,散光轴位及角膜中央3mm半径光学区内曲率较术前均无显著差异(P>0.05)。而在术后1mo,所有观测值均较术前无统计学差异。比较斜视矫正术所涉不同眼外肌数目对术眼屈光参数的影响,术后1wk,Ⅰ组患者各项屈光参数值均无统计学差异,Ⅱ组患者散光值变化有统计学差异(P=0.035),Ⅲ组患者柱镜屈光度、等效球镜屈光度及散光值较术前均具有统计学差异(P=0.022、0.048、0.014)。而术后1mo,三组患者各项屈光参数较术前均无统计学差异。

结论：斜视矫正术后1wk可引起术眼屈光状态变化,术后1mo恢复至术前屈光状态; 实施斜视矫正术的眼外肌数目不同,对屈光状态的影响亦不同。     

4125例哈萨克族儿童斜视及弱视调查

本文对本地区五个县九所哈萨克族小学学生共计4125人进行了斜视、弱视的调查。调查对象全部为4—14岁哈萨克儿童。在受检儿童中发现斜视者48例,患病率为1.1％。外斜视32例占66.67％,内斜视16例占33.33％,斜视并有弱视者15例占31.25％。斜视而视力正常者33例占68.75％。在4125例受检儿童中发现弱视139例(209只眼),其患病率为3.37％,双眼弱视70例,单眼弱视69例,二者无显著差异。139例弱视中男性患者73例,女性患者66例,二者亦无差异。209例只弱视眼中轻度弱视84只眼占40.19％,中度弱视104只眼占49.76％,重度弱视21只眼共占10.05％。调查中笔者发现哈萨克族儿童弱视眼尤以屈光不正为多,209例眼中有106只为单纯性远视眼,因此笔者提出如何早期发现屈光不正并予以纠正将有可能防止许多弱视的发生。     

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）     

垂直斜视术后屈光状态的动态分析

目的了解斜视术后眼球屈光状态的动态变化及不同术式对屈光状态的影响,并对其发生机理进行初步探讨。方法用散瞳验光和角膜地形图检查,对35例垂直斜视进行手术前后屈光状态的动态分析。结果斜肌手术对眼球屈光状态无影响,上直肌后徙术可使上方角膜变陡峭,但对鼻、下、颞侧角膜及散光度无影响。上直肌后徙术及下直肌截除术对上、下侧角膜及散光度的影响有显著性差异(P<0．01)。结论斜视手术对眼球屈光状态的影响是可恢复的,不同术式所需恢复的时间不同。     

分离性垂直斜视手术探讨

目的探讨分离性垂直斜视(Dissociated vertical deviation,DVD)的有效手术方法。方法对40例58眼DVD根据双眼视力状况,双眼上斜程度及合并其他类型斜视进行综合分析,设计手术。双眼DVD不伴有下斜肌功能亢进者,若双眼视力良好,且上斜程度相等者做双眼上直肌等量后徙术;双眼上斜程度不等者做双眼上直肌不等量后徙或先做上斜明显眼手术。若单眼弱视明显先做弱视眼手术。单眼DVD,仅做单眼手术。伴有下斜肌功能亢进者做下斜肌缩短4-5mm后徙转位术。DVD合并水平斜视者,尽可能一期完成。否则,先矫正水平斜视,6个月后行DVD矫正术。上直肌后徙按1mm矫正3Δ计算,最大后徙量为8mm。结果40例58眼DVD,50眼满意(85．21％), 8眼好转(13．79％)。结论对不伴有下斜肌功能亢进的DVD行上直肌超常量后徙术疗效满意;伴有下斜肌功能亢进的DVD行下斜肌缩短4-5mm后徙转位术疗效满意。     

儿童弱视的类型与屈光状态分析

目的探讨儿童弱视的类型与屈光状态的关系。方法对1018例2．5～14岁弱视儿童按年龄、类型及屈光状态进行分类统计。结果学龄前与学龄期弱视患儿之比为1∶1．1；斜视性弱视占65．5％，屈光不正性弱视占22．5％，屈光参差性弱视占12．0％；内、外斜视性弱视之比为2．3∶1，屈光不正性与屈光参差性弱视之比为1．9∶1；各类弱视的屈光状态为，远视及远视散光占79．1％．近视及近视散光占16．1％，混合性散光占4．1％，正视眼占0．69％。结论儿童弱视的类型、年龄分布及屈光状态之间的关系有显著意义。     

下斜肌减弱术在先天性麻痹性垂直斜视治疗中的应用

目的探讨下斜肌减弱术在不同类型先天性麻痹性垂直斜视治疗中的效果及手术选择的基本原则。方法分析近2年行手术治疗的先天性麻痹性垂直斜视患者65例(82眼),根据垂直斜视的度数分别行下斜肌截腱术,下斜肌后徙转位前徙术和下斜肌后徙转位前徙联合上下直肌徙后术。结果垂直斜视的治愈好转率达89.1%,行断腱术者60眼,平均矫正8.33±4.25°;转位术18眼平均矫正13.45±5.91°;联合术4眼,平均矫正22.00±9.79°。术后46例代偿头位改善或消失,66眼下斜肌功能亢进改善或消失;术后出现同时视者22例,建立融合功能者5例,获得立体视觉者3例。结论下斜肌减弱术是治疗先天性麻痹性垂直斜视的首选术式,该术式简单易行,疗效可靠,术后早期疗效明显,有一定促进双眼单视恢复的功能。     

分离性垂直斜视手术

目的 探讨分离性垂直斜视(DVD)的最有效的手术方法.方法 对36例(56眼)DVD根据不同情况设计手术.双眼DVD不伴有下斜肌功能亢进者,且上斜程度相等者行双眼上直肌等量后徙术;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;伴有下斜肌功能亢进者行下斜肌断腱并转位术合并上直肌后徙术;单眼DVD仅行单眼手术;单眼弱视明显先行弱视眼手术.合并水平斜视者尽可能同时完成,否则先矫正水平斜视,6个月后矫正DVD.结果 47眼疗效良好(83.92%),8眼好转(14.28%),1眼无效(1.78%).结论 对不同类型的DVD采用不同的手术方法均收到比较好的疗效.     

上下直肌止端部分移位术治疗外伤性外展神经麻痹性斜视

目的 探讨外伤性外展神经麻痹性斜视的手术效果及术后并发症.方法 对11例外伤性外展神经麻痹患者.应用上下直肌止端部分移位术配合对抗肌后徙术进行矫治和观察.结果 术后2例眼位为正位,眼球外转有改善者9例.10只眼有不同程度的眼球后退占87%;7例术后仍有复视占64%.结论 上下直肌止端部分移位术配合对抗肌后徙是外伤性外展神经麻痹性斜视的一种部分有效的治疗方法.     

Classification and surgical management of patients with familial and sporadic forms of congenital fibrosis of the extraocular muscles

PURPOSE: To outline the clinical features and surgical treatment of patients with familial and sporadic (simplex) forms of congenital fibrosis of extraocular muscles (CFEOM) from 2 countries, and to classify them according to phenotype and mode of inheritance. DESIGN: Observational and experimental study. METHODS: Twenty-eight affected individuals from 20 families with familial or sporadic CFEOM underwent assessment of ocular motility, visual acuity, slit-lamp biomicroscopy, tonometry, and ophthalmoscopy. Seventeen patients had a variety of eye muscle procedures and ptosis repair. RESULTS: There were 1 Iranian family with autosomal dominant CFEOM, 4 Iranian families with autosomal recessive disease, and 15 simplex cases with various CFEOM phenotypes. Two simplex patients had unilateral disease. All other cases were bilateral. Inferior rectus recession improved hypotropia and Bell's phenomenon in the patients with infraducted eyes and chin elevation. Horizontal muscle recession, sometimes combined with opposite muscle resection, corrected horizontal strabismus satisfactorily in most cases. Ptosis was repaired by frontalis sling and/or levator resection. CONCLUSION: Definite recessive CFEOM was present only in Iranian patients. American patients had the classic phenotype of dominant CFEOM, which was also observed in some of the Iranian patients. The surgical management of patients with CFEOM is challenging. Correction of vertical and horizontal strabismus was addressed using large muscle recessions. Ptosis repair should aim at placing the lid level 1 to 2 mm above the pupil in the primary position to avoid exposure keratopathy.     

Outcome of lamellar keratoplasty for limbal dermoids in children.

PURPOSE: We report on the surgical management, complications, postoperative visual acuity, and astigmatism of limbal dermoids in children. METHODS: This was a retrospective study of 49 children (51 eyes) treated between 1990 and 2000. Demographic data, age at surgery, details of the surgical procedure, the preoperative and postoperative visual acuity and astigmatism, the complications of surgery, and the ocular and systemic associations were recorded. Age at surgery was regressed against the size of the corneal graft, the visual outcome, and astigmatism. The size of the corneal graft was regressed against the visual outcome and astigmatism. A test for a difference in proportions of the preoperative and postoperative astigmatism was conducted. Postoperatively children were followed up until suture removal if necessary at 4 weeks. Children living locally continued follow-up at The Hospital for Sick Children, Toronto, Ontario, Canada; the rest were referred to their referring ophthalmologist. RESULTS: The mean age of the patients at surgery was 4.4 +/- 3.8 years (range, 1 month to 15 years). Excision of the dermoid and lamellar keratoplasty was performed in 48 eyes, simple excision was performed in 2 eyes, and a penetrating graft was performed in 1 eye. The mean graft size (6.6 +/- 1.2 mm; range, 3.5-10 mm) was inversely related to the age of the patient (P =.04). Three eyes had microperforations during excision of the dermoid. Opacification of part of the graft was seen in 10.2% of eyes (5/49) with a mild haze in 3 eyes. Postoperatively 96.7% of eyes (29/30) had a visual acuity greater than or equal to 6/24, with 86.7% (26/30) greater than or equal to 6/12; one eye had a visual acuity of 6/120. The size of the graft correlated inversely with the visual acuity (P =.03). Preoperative and postoperative refraction was recorded in 23 patients. Astigmatism greater than 1 D was present in 43.4% preoperatively and in 60% postoperatively (P =.6). There was no association between age at surgery (P =.6) and the size of the graft (P =.2) and the presence of postoperative astigmatism. CONCLUSION: Excellent visual results were achieved in the majority of patients. Younger children were operated on for visual reasons with larger grafts and a tendency for a lower visual acuity. Although astigmatism was noted to decrease in a few children after excision, a significant number had an increase in astigmatism postoperatively, which warrants a close follow-up in children operated during the amblyogenic age.     

AcrySof Toric人工晶状体矫正白内障患者术后残留散光的研究

目的 研究AcrySof Toric人工晶状体（IOL）矫正白内障患者术后残留散光的有效性、安全性和稳定性.方法 前瞻性病例对照研究.2008年5月至2009年4月期间在南通大学附属医院眼科住院的白内障患者59例（69眼）,术前角膜散光≥0.75 D,根据患者意愿分为实验组33例（37眼）和对照组26例（32眼）.两组患者行超声乳化白内障吸除术后,实验组植入AcrySof Toric IOL,对照组植入AcrySof SN60AT IOL.术后1d、1周、1个月、3个月检查记录两组患者的裸眼视力（UCVA）、最佳矫正视力（BCVA）、屈光状态、角膜曲率、AcrySof Toric IOL的轴位.采用Fisher精确概率法、独立样本t检验对数据进行分析.结果 术后3个月,实验组和对照组中UCVA为0.1～0.3的分别有1眼（3％）和10眼（31％）；0.4～0.6分别有22眼（60％）和15眼（47％）；0.7～0.9分别有5眼（14％）和6眼（19％）；≥1.0分别有9眼（24％）和1眼（3％）,两组比较差异有统计学意义（ Fisher＇s exact=0.000,P＜0.05）.实验组和对照组中残留散光为0～0.75 D的分别有25眼（68％）和4眼（12％）;1～1.75 D的分别有12眼（32％）和19眼（59％）；≥2 D的分别有0眼（0％）和9眼（28％）,两组差异有统计学意义（ Fisher＇s exact =0.000,P＜0.05）.术后3个月,实验组37眼中有32眼发生旋转,IOL旋转均＜20°,其中≤5°有16眼（57％）,6°～10°有7眼（19％）,11°～15°有9眼（24％）,平均值为5.8°±5.0°（0°～15°）.术后3个月,实验组和对照组术源性散光分别为（0.66±0.17）D和（0.62±0.24）D,两组差异无统计学意义.结论 白内障手术中植入AcrySof Toric IOL在短期内可安全有效地矫正白内障患者部分术后散光,提高患者术后的裸眼视力.     

先天性眼外肌纤维化伴少年白发一家系

目的探讨先天性眼外肌纤维化家系临床表现,诊断和治疗方法。方法回顾性总结和分析了先天性眼外肌纤维化（CFEOM）家系患者的临床特征,包括遗传学特征、性别、年龄、临床表现及手术情况。结果该先天性眼外肌纤维化家系具有常染色体显性遗传特征,为CFEOM1型,14例患者临床表现的共同特征为双眼位于下斜位,上转不到中线,双眼上睑下垂。不同之处为垂直眼位、水平眼位及眼球运动限制各异,部分患者伴有瞳孔异常,异常神经支配和少年白发。根据眼睑和眼位情况可行额肌悬吊术,提上睑肌缩短术,直肌后徙或直肌悬吊术矫正。结论先天性眼外肌纤维化患者临床少见,该先天性眼外肌纤维化家系具有表现型异质性,并伴有瞳孔异常,异常神经支配和毛发异常,以往文献未曾报道。充分掌握临床特征并结合遗传基因分析是做出正确诊断的基础,亦为深入研究该病发病机制提供依据。     

脑瘫患儿伴发视觉障碍的临床研究

目的：了解脑瘫患儿常见的视觉障碍情况,为临床早期行眼部筛查、诊断及治疗提供依据,促进脑瘫患儿的视觉康复。

方法：对223例确诊为脑瘫的患儿行眼部常规检查,包括眼位及眼球运动检查,间接检眼镜或Retcam Ⅱ检查眼底,散瞳验光检查了解屈光状态,闪光视觉诱发电位(F-VEP)检查了解视觉通路传导,记录并分析常见的视觉障碍。

结果：脑瘫患儿223例中,主要的视觉障碍表现为斜视、屈光不正及闪光视觉诱发电位的改变,部分患儿还同时伴有不同类型的眼底病变。其中有174例伴有不同类型的斜视,内斜最常见为121例,外斜次之为36例,垂直性斜视者15例,眼球震颤者2例。129例247眼存在屈光不正,复性远视散光118眼,单纯远视51眼,混合散光33眼,复性近视散光19眼,单纯远视散光21眼,单纯近视散光4眼,单纯近视1眼。194例381眼存在闪光视觉诱发电位的异常,主要表现为P2波的潜伏期延长,振幅降低。51例伴有不同类型的眼底改变,视神经萎缩及眼底出血最为常见。

结论：脑瘫患儿常常伴发不同类型的视觉功能障碍,严重影响了患儿的视觉质量及全身康复,重视眼部常规检查及视觉训练,对患儿视觉系统的正常发育及脑瘫的全面康复具有重要的意义。     

Combined Special Capsular Tension Ring and Toric IOL Implantation for Management of Astigmatism and High Axial Myopia with Cataracts

Aim: This study aimed to compare the effects of toric intraocular lens (IOL) implantation with a capsular tension ring and toric IOL implantation only in patients with axial myopic astigmatism who had undergone cataract surgery. Methods: Of 34 patients with axial myopia, 16 patients who had received IOL and capsular tension ring (CTR) implantation were included in the combined group and 18 patients who received toric IOL implantation only were included in the simple group. Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) were evaluated by measuring subjective refraction, residual astigmatism, and the toric IOL axis six months post-surgery. Results: At six months postoperatively, the UCVA for the combined and simple groups was 4.6 ± 0.1 and 4.5 ± 0.2, respectively, a statistically significant difference (t = 3.531, P<0.05). The toric IOL in all of the cases was located in the capsular sac, but there were more cases with IOL rotation (12 eyes) in the simple group than in the combined group (4 eyes). The rotation angles were 20°~30° (one eye), 10°~20° (four eyes), and <10° (seven eyes) compared with 2°~5° (four eyes). The residual astigmatism was –0.50 ± 0.25 D in the combined group, not a significant difference from the predicted residual astigmatism (–0.35 ± 0.13 D). There was a significant difference in the simple group (–1.25 ± 0.33 D) when the predicted residual astigmatism was compared (–0.37 ± 0.11 D) (t = –9.511, P < 0.01). Conclusions: In patients with axial myopic astigmatism, CTR can effectively increase the rotational stability of a toric IOL, achieving improvement in corneal astigmatism and visual acuity.     

Experimental modification of the corneal curvature by means of scleral surgery

Most surgical procedures for correcting astigmatism are done on the cornea. The present article shows the modification of the corneal curvature by scleral surgery. The experiments were conducted on rabbit eyes. The most spherical eyes were chosen according to the keratometric measurements. A geometrical analysis of the astigmatism shows that beginning with an ellipse (image of an astigmatic eye in the corneascope), by modifying the main radii of the ellipse, while the perimeter is maintained constant a perfect circle is thus obtained. This analysis enables us to calculate the amount of sclera surgery required to obtain a given correction for a given degree of astigmatism. Four scleral procedures were investigated: folds, resections, imbrications, and sclerotomies; the results show that the first three procedures steepen the meridian where the surgery is performed while flattening simultaneously the ortogonal meridian. The main advantages of scleral surgery vs corneal surgery for correction of astigmatism are: (a) the cornea remains untouched, (b) the surgical area will be protected by the conjunctiva, (c) the stitches are left permanently, and (d) larger astigmatic errors can so be corrected.     

表面麻醉下手法劈核小切口白内障囊外摘除术在防盲治盲中的应用

目的：观察表面麻醉下手法劈核小切口白内障囊外摘除术在防盲治盲中的疗效及安全性。方法对80例（80只眼）白内障防盲患者在表面麻醉下行手法劈核小切口白内障囊外摘除联合人工晶状体植入术治疗,观察手术前后视力、散光值及术中术后并发症情况。结果术后1 d,视力≥0．3者63只眼（78．8％）,≥0．5者26只眼（32．5％）。术后3个月视力≥0．3者69只眼（86．3％）,≥0．5者43只眼（53．8％）。术后3个月,平均角膜散光值（1．10±0．31）D与术前平均角膜散光值（1．08±0．52）D比较无统计学差异（ P ＞0．05）。术中后囊膜破裂3只眼（3．6％）,角膜后弹力层脱离1只眼（1．3％）。术后角膜水肿5只眼（6．3％）,反应性葡萄膜炎1只眼（1.3％）,继发性高眼压2只眼（2．5％）,未出现角膜内皮失代偿、感染性眼内炎及视网膜脱离等严重并发症。结论表面麻醉下手法劈核小切口白内障囊外摘除术术后恢复快,并发症少,安全有效,简单易行。     

成人屈光不正性弱视屈光手术的效果分析

目的:观察成人屈光不正性弱视患者的准分子激光原位角膜磨镶术的治疗效果。方法:弱视患者141例(188眼),包括单纯中低度近视21例(24眼)、单纯高度近视36例(44眼)、复合近视散光84例(120眼),回顾性观察这些患者的LASIK手术治疗效果。结果:单纯中低度近视、单纯高度近视、复合近视散光患者术后视力高于术前最佳矫正视力的眼数分别为10眼,27眼,77眼;超常率分别为41.7%,61.4%和64.2%。部分患者LASIK术后视力高于术前最佳矫正视力,其中对单纯高度近视和复合近视散光类患者效果最佳。结论:LASIK手术能有效的治疗弱视患者的屈光不正。