悬吊缝线后退术矫正内斜视的临床效果

目的 探讨悬吊缝线后退术矫正内斜视的疗效.方法 对内斜视39例(共同性内斜视37例、外伤后周定性内斜视2例)实施内直肌悬吊缝线后退术加外直肌缩短术.结果 术后远期正位35例.正位率89.74%;好转2例.总有效率94.87%.欠矫1例,欠矫率2.56%;过矫1例,过矫率2.56%.无并发症.结论 该术式是一种简便易行、安全有效的方法.     

新鲜羊膜在儿童共同性斜视缝线调整显微手术中的应用

目的：探讨新鲜羊膜在儿童共同性斜视缝线调整显微手术中的应用疗效,为临床治疗提供指导。
　　方法：应用临床随机对照研究方法,依据眼科门诊就诊号将2010-01/2015-10在我科住院并行显微斜视矫正术的60例112眼儿童共同性斜视患者平均分为两组,A组30例58眼行直肌后徙缝线调整联合羊膜移植术, B组30例54眼行单纯直肌后徙缝线调整术,斜视矫正术后随访均≥6 mo。
　　结果：斜视患者27例48眼术后眼位需调整,眼位需调整率为42.9%。术后1mo,眼位可调整18例29眼,其中A组16例26眼,眼位可调整率为44.8%,眼位可调整量平均为2.56±0.64 mm;B 组2例3眼,眼位可调整率为5.6%,眼位可调整量平均为0.52±0.28mm,两组比较眼位可调整率及可调整量差异均有统计学意义(χ2=22.477,P<0.01;t=16.502,P<0.01)。除3例患儿术后不配合眼位调整外,其余均在术后1 mo内行不同程度的眼位调整,眼位调整后, A组27例53眼眼位正位,正位率为91.4%, B 组16例28眼眼位正位,正位率为51.9%,两组比较斜视术后正位率差异有统计学意义(χ2=21.827,P<0.01)。
　　结论：在儿童共同性斜视缝线调整显微手术过程中应用新鲜羊膜效果确切,可明显延长眼位调整时间及增加眼位调整量,提高了儿童斜视手术的可控性和成功率。     

Clifford Terry滑结联合可调节缝合在斜视手术中的应用

目的：探讨Clifford Terry滑结联合可调节缝合在斜视手术中的临床应用。

方法：采取回顾性研究方法,选取我院2012-05/2015-05收治的行常规斜视矫正术的45例71眼患者(对照组)与应用Clifford Terry滑结斜视矫正术45例70眼患者(研究组)为研究对象,对其术后随访1d～12mo。观察术后眼位、有无调整眼位及是否有二次手术,对术后眼位与术前眼位矫正变化情况比较分析。

结果：术后第1d Clifford Terry滑结联合可调节缝合达正位42例 67眼,1例1眼过矫,2例2眼欠矫,正位率为96%。经过Clifford Terry滑结调整松紧,正位率达到100%,研究组1、3、6、12mo术后眼位情况与对照组矫正正位效果比较未见明显差异。两组均未出现结膜裂开、肌肉滑脱、感染等术后并发症。采用Clifford Terry滑结联合可调节缝合在术中及术后早期对眼位进行微调,可即刻达到目标眼位。

结论：Clifford Terry滑结术中操作简单、术后调整缝线松紧容易操作,联合可调节缝合在斜视手术的术中及术后早期表面麻醉下即可达到目标眼位,减低术后早期二次手术的风险,优于单纯可调节缝合法。     

Effectivity of intraoperative adjustable suture technique in horizontal strabismus

AIM:To compare the long-term effectivity of intraoperative adjustable suture technique with traditional non-adjustable strabismus surgery.METHODS:Two hundred and thirty-three patients, who underwent strabismus surgery either with traditional procedures or one-stage intraoperative adjustable suture technique, were included in our long-term follow-up study. One hundred and eighteen patients were evaluated in traditional surgery group (TSG) and 115 who underwent adjustable suture were in the one-stage intraoperative adjustable surgery group (ASG). In this group 9 patients had paralytic strabismus and 16 had reoperations, 2 patients had restrictive strabismus related to thyroid eye disease. The mean follow up in the TSG was 26.2 months and it was 24.8 months in the ASG group.RESULTS:In patients with exotropia (XT) the mean correction of deviation for near fixation in ASG (32.4±13.2PD) and in TSG (26.4±8.2PD) were similar (P=0.112). The correction for distant fixation in ASG (33.2±11.4PD) and TSG (30.9±7.2PD) were not significantly different (P=0.321). In patients with esotropia (ET) even the mean correction of deviation for both near (31±12PD) and distant (30.6±12.8PD) fixations were higher in ASG than in TSG, for both near (28.27±14.2PD) and distant (28.9±12.9PD) fixations, the differences were not significant (P=0.346, 0.824 respectively). The overall success rate of XT patient was 78.9% in TSG and 78.78% in ASG, the difference was not significant (P=0.629). The success rates were 78.75% in TSG and 75.51% in ASG in ET patient, which was also not significantly different (P=0.821).CONCLUSION:Although patients in ASG had more complex deviation such as paralysis, reoperations and restrictive strabismus, success rates of this tecnique was as high as TSG which did not contain complicated deviation. One-stage intraoperative adjustable suture technique is a safe and effective method for cooperative patient who has complex deviation.     

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.     

Adjustable suture strabismus surgery.

The adjustable muscle recession procedure is described. The criteria for patient selection are reviewed as well as the surgical results during the past 5 years when the technique has been in active use. The philosophy behind the adjustable suture technique is the following: a procedure which would allow the surgeon to bring ocular alignment to a favorable position at the time of the first postoperative dressing change would be of significant value. Adjustable suture surgery is just such a technique. It does not insure a successful result. The ophthalmologist must still decide upon the preferred eye position. The surgeon is merely allowed to come closer to his desired immediate postoperative alignment by the ability to adjust muscle position after surgery.     

Ocular muscle surgery in thyroid eye disease

This paper is about the results of muscle surgery to correct double vision and any associated compensatory head posture in 58 patients with thyroid eye disease. A strict definition of success whereby the patient has binocular single vision in the straight ahead and reading areas restored by a single operation on the muscles without the subsequent use of prisms is used. The pre-operative states which may influence the outcome of surgery are examined and it is concluded that the preferred starting point for ocular muscle surgery is that the patient is euthyroid, with proptosis less than 26 mm and that binocular single vision has thus far been maintained by the use of prisms and/or a compensatory head posture. Records of the ocular movements must have been stable for at least six months. The techniques of surgical correction are described including the use of adjustable sutures.     

Adjustable suture use in strabismus surgery

PURPOSE OF REVIEW: This review includes updated information regarding adjustable suture strabismus surgery for children and adults. RECENT FINDINGS: Main themes in the literature reviewed in this article include the appropriate timing for the adjustment technique, appropriate anesthesia, recent modifications in adjustable strabismus surgery techniques, and future developments. SUMMARY: Improved timing of adjustment, improved anesthesia, and newer surgical techniques allow strabismus surgeons to offer treatment options better suited to the needs of each strabismus patient.     

Economizing strabismus surgery: Using half the double-armed suture for horizontal muscles

In a developing country like India, both availability and affordability of medical care are obstacles, leading to delay in seeking timely treatment. To reduce the cost incurred to the patients for strabismus surgery, we used half of a 6-0 polyglactin suture for performing common muscle weakening and strengthening procedures: a fixed and hang back recessions with plication and resection. We cut the 45-cm-long double-armed 6-0 polyglactin sutures in two halves, and with a modified approach, used one-half in each of two patients planned for monocular two horizontal muscles surgeries: fixed recession-plication and hang back recession-resection. By devising an intuitive manner of threading a single armed 22.5 cm suture we successfully carried out horizontal extraocular muscle surgeries on each of two patients of exotropia. We believe in the long run, this will reduce the cost to individual patients and sponsoring groups, and suggest that strabismus surgeons consider adopting this option.     

Delayed Conjunctival Closure in Adjustable Strabismus Surgery

Adjustable suture strabismus surgery has proved to be a significant aid in handling difficult strabismus cases, and various methods of conjunctival closure have been discussed. A new method of conjunctival closure, enabling direct visualization and manipulation of the muscle with minimal tissue drag during adjustment, is described. The conjunctiva can be fully closed over the knot after adjustment, providing increased patient comfort and a better cosmetic result.     

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。     

Adjustable Strabismus Surgery under Topical Anesthesia: Alignment in Supine vs Seated Position

Purpose: To compare ocular deviation in the operating room depending on whether the patient is in supine decubitus or seated after single-stage adjustable strabismus surgery under topical anesthesia.

Material and method: We performed a prospective observational study of 30 patients with horizontal and/or vertical strabismus who underwent single stage adjustable strabismus surgery under topical anesthesia. Both distance and near deviation were evaluated before surgery, during surgery in both positions (seated and supine), and at 1 day, 1 month, and 3 months after surgery. A final horizontal deviation <10 pd and a vertical deviation <5 pd without diplopia was considered to be a good outcome (3 months after surgery).

Results: The mean age of the sample was 55 years and 76.7% were women. Most had esotropia (70%). The most frequently used surgical combination was the medial rectus and lateral rectus (36.7%). Surgical adjustment was necessary in 40% of cases. Mean preoperative deviation was 21.9 ± 12.63 pd (distance) and 20.66 ± 4.76 (near). Deviation with the patient supine was 8 ± 8.25 pd (distance) and 7.26 ± 5.81 (near). Deviation with the patient seated was 8.13 pd±8.38 (distance) and 8.5 ± 7.41 (near). There was no significant difference between the positions. Outcome was favorable in 70% of patients; this percentage increased to 83.33% at 1 day, 1 month, and 3 months after surgery.

Conclusions: No statistically significant differences were found between ocular deviations in the seated or supine position in the operating room. Outcome was favorable in most cases 3 months after surgery. Intraoperative ocular deviation was not a predictor of outcome.     

急性共同性内斜视矫正手术中可调节缝线的效果观察

目的观察术中置可调节缝线矫正急性共同性内斜视的效果。方法12例急性共同性内斜视进行手术治疗,术中置可调节缝线,术后同视机训练15d。结果术后复视情况：11例看远看近复视消失,均恢复双眼单视;1例欠矫8^△,1m以内复视消失,1m以外复视较前明显减轻。结论急性共同性内斜视全矫手术置可调节缝线效果良好。     

不同时间给予昂丹司琼预防小儿斜视术后恶心呕吐的临床观察

目的：不同时间静脉注射昂丹司琼在小儿斜视术后恶心呕吐（postoperative nausea and vomiting,PONV）中的效果观察。方法：随机选择2013-06/08在我院拟行斜视手术的患儿90例,ASAⅠ～Ⅱ级,年龄3～11岁。随机分为3组,每组30例。A组在手术开始前静脉注射昂丹司琼0.1mg/kg; B组在手术结束后静脉注射昂丹司琼0.1mg/kg; C组为对照组,不用昂丹司琼。在术后24h内观察患者恶心、呕吐的发生例数及严重程度。结果：三组患者的性别、体重、年龄、麻醉时间、氯胺酮用量各组间比较无统计学意义（P〉0.05）。A,B组的PONV发生率明显低于C组（P〈0.05）,A组和B组的PONV发生率比较无统计学意义（P〉0.05）。结论：在手术前或手术结束时应用昂丹司琼可有效、安全地预防小儿斜视手术后的PONV,提高眼科手术安全性,且费用低,是一种值得推广应用的止吐方法。     

The efficacy of intravenous ketorolac for pain relief in single-stage adjustable strabismus surgery: a prospective, randomized, placebo-controlled trial

Purpose

To determine the efficacy of preoperative intravenous ketorolac in reducing intraoperative and postoperative pain and improving patient satisfaction in patients undergoing single-stage adjustable strabismus surgery.

Methods

A prospective, randomized, placebo-controlled clinical trial was performed with 67 patients who underwent horizontal recti muscle surgery with adjustable sutures. The test group received intravenous ketorolac (60 mg) before surgery, and the control group received intravenous normal saline. Topical 0.5% proparacaine was administered to both groups during surgery. Vital signs including heart rate and blood pressure were recorded every 10 min throughout the surgery. The patients were asked to rate their maximum intraoperative and postoperative pain scores using a numerical pain rating scale. Patient satisfaction was also assessed using a five-point analogue scale.

Results

The ketorolac-premedicated patients had less pain both during and after surgery (P=0.033 and P=0.024, respectively). There were no differences in vital signs during surgery and patient satisfaction between the two groups.

Conclusions

Intravenous ketorolac, when administered preoperatively for single-stage adjustable strabismus surgery under topical anaesthesia, was effective in reducing pain during and after surgery.     

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。     

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)