继发性外斜视手术方式及术后眼位变化

目的研究内斜视术后继发外斜视的手术方式及术后眼位的变化。方法手术治疗43例内斜视术后继发外斜视的病人,探讨其手术方式并观察术后1周、6周、6个月和1年的眼位变化情况。结果单眼内直肌前徙7例,单眼内直肌缩短4例,单眼内直肌前徙＋单眼外直肌后徙20例,双眼外直肌后徙5例,单眼外直肌后徙3例;4例外斜视度数≥50△行3条肌肉的手术。术后1年35例眼位正位（81.3%）,其中单眼内直肌前徙或缩短11例术后8例（72.7%）正位,外直肌后徙8例（5例为双眼,3例为单眼）术后6例（75%）正位,单眼内直肌前徙＋单眼外直肌后徙20例术后18例（90%）正位;1周～6周斜视度数变化-5.2△±0.4△,6周～6个月变化-1.2△±0.4△,1周～1年变化-6.4△±2.1△。1周～6周有25例患者（58.1%）有外斜视漂移,变化-8.0△±1.4△,其中术中过矫组的10例继发外斜视患者,术后6周内均出现了外斜视漂移,平均为-8.3±2.0△。结论外直肌后徙联合后徙的内直肌前徙是治疗继发性外斜视的有效方式。术中5△～10△小度数过矫可提高远期的术后正位率。     

急性共同性内斜视的手术治疗

目的探讨急性共同性内斜视的手术治疗效果.方法采用单眼内直肌后徙加外直肌截除,或双眼内直肌后徙加单眼或双眼外直肌截除,手术量比普通内斜视略加大的手术方法治疗急性共同性内斜视.结果13例术后眼位得到满意矫正,并且消除了复视,改善了双眼单视功能.结论对于复视干扰明显,斜视度大的急性共同性内斜病例,在发病6个月后尽快施行手术治疗,能有效矫正眼位,消除复视,保全或改善双眼单视功能.     

高AC/A调节性内斜视治疗效果分析

目的探讨双内直肌后徙术治疗共同性内斜视的适用范围及手术量.方法对28例共同性内斜视患者行双内直肌后徙术,7例行双内直肌后徙后继发外斜视行再矫正术,并行回顾性分析.结果对于高AC/A,非屈光性调节性内斜视,看近大于看远15△以上的中等斜度患者适合行双内直肌后徙术,且手术量应保守些.结论常规量的双内直肌后徙术对中等斜视度,高AC/A内斜视患者矫正效果满意,超常量双内直肌后徙术易致术后过矫.     

间歇性外斜视手术效果分析

目的 探讨间歇性外斜视手术的疗效、方法手术量按外直肌后徙1mm，矫正2^Δ～3^Δ及内直肌截除1mm，矫正4^Δ～5^Δ计算，3例行单眼外直肌后徙，1例行内直肌缩短，42例行单眼外直肌后徙加内直肌缩短或双眼外直肌后徙术，10例行双眼外直肌后徙加内直肌缩短术。45例局麻下手术，11例全麻下手术。结果56例中完全功能治愈23例，临床治愈25例，总治愈者48例，占85．7％。结论间歇性外斜视应止确选择手术时机，有利于双眼单视功能的建立。     

眼眶减压术后与未行眼眶减压术TAO患者的斜视矫正手术比较研究

目的 比较眼眶减压术后与未行眼眶减压术TAO患者的斜视矫正手术效果。方法 回顾55例TAO斜视患者的临床资料,根据患者是否行眼眶减压手术分为减压组（DG）和非减压组（NDG）,分别比较两组患者斜视特征和手术治疗效果。结果 减压组37例,非减压组18例。减压组平均年龄（38.97±9.56岁）小于非减压组（45.61±9.29岁）,且女性多于男性。减压组术前水平斜视度和垂直斜视度均小于非减压组（P=0.036,0.002）,减压组手术肌肉条数略多于非减压组（P=0.56）。减压组与非减压组合并外旋斜视人数和随访时间均无明显差异。减压组垂直肌后徙效应量（3.17±2.59PD/mm）低于非减压组（4.93±1.45PD/mm）（P=0.015）。减压组与非减压组完全治愈率分别为75.68%和72.22%（P=0.783）,减压组二次手术患者多于非减压组（P=0.262）。结论 眼眶减压术后TAO斜视的复杂性增加,通过调整缝线下斜视矫正术可以获得与常规TAO斜视相当的治疗效果。手术以解除限制因素为主,对于大角度或限制因素严重的内斜视,内直肌后徙联合限制较重眼外直肌缩短术可取得良好效果。     

急性共同性内斜视的手术治疗

目的 探讨急性共同性内斜视的手术治疗及效果.方法 对29例急性共同性内斜视患者进行回顾性研究,手术采用单眼或双眼内直肌后徙、单眼内直肌后徙加外直肌截除、双眼内直肌后徙加单眼或双眼外直肌截除,手术量较普通内斜视略大.同视机及颜氏立体图检查术前及术后双眼视觉和立体视.结果 29例患者术后眼位矫正满意,患者复视消失.双眼单视功能改善,术后1个月融合范围平均20.57°± 3.93°,与术前比较差异有显著统计学意义(t=3.396,P<0.01);术后1 a融合范围平均26.91°±4.09°,与术后1个月比较差异有统计学意义(t=1.971,P<0.05).结论 急性共同性内斜视在保守治疗3～6个月后尽早实行手术治疗,达到斜视和复视消失及功能治愈目的 .[眼科新进展2009;29(6).466-167]     

眶壁骨折修复术后斜视和复视手术处理

目的观察眶壁修复术后斜视和复视眼外肌手术矫正效果。方法对14例眼眶爆裂性骨折修复手术6月后仍有斜视和复视的患者，采取二期眼外肌手术治疗。结果4例为限制性斜视，二期手术后徙受累肌或／和缩短拮抗肌后，功能视野内复视消除；10例为非限制性眼肌功能不足所致斜视，二期手术缩短受累肌或／和后徙拮抗肌后，     

单眼超常规量直肌手术矫正共同性内斜视

目的观察单眼水平直肌超常量手术矫正共同性内斜视的术后眼位成功率和眼球运动情况。方法回顾性无对照病例方法。对2009年1月至2014年7月在广西医科大学第一附属医院眼科行单眼超常量眼肌手术的30例资料齐全的不同偏斜度共同性内斜视患者入选。排除非共同性内斜视及既往有眼肌手术病史的患者。共同性内斜视患者30例,含知觉性内斜22例,行主斜眼内直肌后徙6～7mm,或伴有同眼外直肌截短6-9mm。随访时间：1．5～60个月。观察指标：术后不同时期的眼位和眼球运动。末次随访的眼位偏斜度〈10PD视为正位,眼球内转或外转不足-1--14均视为运动异常。结果30例共同性内斜视患者末次随访时双眼正位24例,正位率为80％。30例共同性内斜视患者术前8例存在外转不足（-1--2）,大部分存在内转不同程度亢进,术后6周以上随访,29例患者眼球内外转均到位,1例术前外转-2,术后改善为外转-1。结论单眼直肌超常量手术可有效地矫正共同性内斜视;内直肌后徙6～7mm或联合外直肌截短术未导致眼球运动障碍,术前外转不足的患者术后得到改善。     

上直肌转位联合内直肌后徙术在治疗外展神经全麻痹中的应用

目的探讨上直肌颞侧转位联合内直肌后徙术治疗外展神经全麻痹内斜视的疗效。方法回顾性病例研究。分析11例就诊于天津市眼科医院或徐州市第一人民医院眼科的外展神经全麻痹患者术前、术后末次随访时的斜视度、代偿头位角度、受累眼外转和内转受限的程度。11例患者均行上直肌颞侧转位手术,其中8例同期联合内直肌后徙术。内直肌后徙手术采用术中调整缝线方法,根据术中眼位,确定内直肌后徙的位置。平均随访6个月以上。采用配对t检验比较术前、术后第一眼位内斜度、代偿头位角度、外转及内转受限的程度。结果10例患者一次手术矫正至正位,患者代偿头位和复视消失,患者均对手术结果满意。1例患者上直肌全肌腹转位联合内直肌后徙术后欠矫,残余代偿头位及复视,3个月后行下直肌颞侧转位术,头位及复视消除。11例患者内斜视从术前31.2°±13.7°矫正至术后3.4°±1.7°（t=7.28,P<0.01）;代偿头位从术前26.1°±7.7°矫正至术后0.9°±3.0°（t=10.75,P<0.01）;外转受限从术前-4.8±0.9矫正至术后-2.0±0.9（t=8.84,P<0.01）;内转受限从术前-0.2±0.4矫正至术后-1.0±0.4（t=4.62,P<0.05）。本组患者术后均未出现垂直或旋转复视。结论上直肌转位联合内直肌后徙术,可以同期进行。单独上直肌转位不会带来新的垂直斜视和旋转斜视。上直肌转位术联合调整缝线下的内直肌后徙术是治疗外展神经全麻痹的有效方法之一。     

间歇性外斜视手术治疗疗效分析

目的探讨间歇性外斜视最佳手术时期,术后眼位对患者术后复视及舒适度的影响。方法对546例患者随机行单眼外直肌后徙术,双眼外直肌等量后徙术、单眼内直肌缩短外直肌后徙术,双眼外直肌等量后徙术 内直肌缩短术,并对术后眼位及融合功能进行观察。结果546例患者,术后正位(交替遮盖0°～15△之间)493例,感觉舒适,术后残留外斜(交替遮盖≥-15△)45例,感觉尚可,术后微内斜交替遮盖( 2△～10△之间)8例患者感觉复视。     

甲状腺相关眼病复视的手术治疗

目的 探讨手术治疗甲状腺相关眼病导致限制性斜视的特点与疗效。方法 对14例（16条眼肌）甲状腺相关眼病致限制性斜视行眼外肌后徙术或断键术，其中下直肌后退术7条；内直肌后退术3条；上直肌后退术3条，断腱术1条；外直肌后退术2条。结果 术后随访时间3～9月（平均5．6月），所有患者术后水平及向下注视时复视症状消失，眼位基本正常。结论 手术是治疗甲状腺相关眼病所致限制性斜视的有效方法。     

松眼综合征研究进展

眼眶结缔组织在眼球运动中发挥重要作用,其随年龄增长发生退行性改变,这种变化能够引起眼球控制眼外直肌运动的Pulley结构的位置发生改变,从而引起某些特殊类型的斜视发生,即“松眼综合征”,包括分开功能不足性内斜视及小度数的垂直斜视.眼眶磁共振检查发现其产生与眼外直肌Pulley位置的退行性改变有关.对于松眼综合征产生的不同类型的斜视,其治疗方法及手术方式不同,对于分开功能不足性内斜视,临床上既有内直肌后退手术,也可采用外直肌缩短手术,而对于小度数的垂直斜视,则可采用不同程度的垂直肌部分切除术.     

共同性斜视再次手术的术式和手术矫正量

目的：分析共同性斜视过矫或欠矫后,再次手术的术式和手术矫正量。
　　方法：共同性斜视术后过矫或欠矫计96例,男41例,女55例;平均年龄21.90依14.70岁。术前行斜视常规检查,共同性内斜视过矫者23例,欠矫者15例;共同性外斜视过矫者28例,欠矫者30例。术式选择主要依据斜视角的大小、远近斜视角的不同、原来的术式及双眼视力等情况而定。
　　结果：共同性内斜视过矫者：后徙的内直肌行前徙9例,矫正量(5.51依2.63)?/ mm;内直肌前徙+外直肌后徙9例,矫正量(6.25依1.59)?/ mm;内直肌截除+外直肌后徙3例,矫正量(4.26依1.04)?/ mm;仅行外直肌后徙2例,矫正量(4.21依1.91)?/ mm。共同性内斜视欠矫者：行外直肌截除6例,矫正量(4.03依0.98)?/ mm;外直肌截除+内直肌后徙6例,矫正量(6.86依1.32)?/ mm;内直肌后徙3例,矫正量(4.33依0.29)?/ mm。共同性外斜视过矫者,行外直肌前徙16例,矫正量(5.37依1.56)?/ mm;内直肌后徙6例,矫正量(6.29依3.68)?/ mm;外直肌前徙+内直肌后徙5例,矫正量(5.46依1.78)?/ mm;外直肌截除1例,矫正量5.00?/ mm。共同性外斜视欠矫者,行内直肌截除12例,矫正量(4.47依0.54)?/ mm;行外直肌后徙+内直肌截除16例,矫正量(5.11依0.75)?/ mm;外直肌后徙2例,矫正量(2.65依0.42)?/ mm。
　　结论：共同性内外斜视过矫者,通常对做过手术的水平肌行加强或/和减弱术,其手术矫正量偏大、且不甚稳定。欠矫者,通常对未行手术的水平肌行加强或/和减弱术,其手术矫正量同常规量。     

继发性内斜视的手术治疗

目的 探讨手术治疗继发性内斜的效果.方法 回顾分析近3年诊治的13例继发性内斜患者,均有外斜手术矫正病史,术后继发内斜持续均大于6个月.3例患者正前方内斜小于等于+20PD,外转不受限,行内直肌后徙手术;5例患者正前方小于等于+35PD,外转不同程度受限,行外转受限眼的外直肌复位手术;5例患者正前方内斜大于等于+50PD,外转不同程度受限,行外直肌复位联合内直肌后徙手术.术后随访超过6个月.结果 13例患者术后无复视及代偿头位,平均眼位为(-2.0±6.0)PD,术后远期(大于6个月)随访眼位平均为(-2.8±4.4)PD,远期随访眼位的变化为(-0.8±4.2)PD.内斜矫正手术后手术成功率为84.62%(11/13),远期随访眼位矫正成功率为84.62%(11/13).所有患者均对术后眼位满意,未行再次手术.结论 继发性内斜的手术治疗有效,对于大角度的继发内斜视,外直肌复位联合内直肌后徙手术可取得较好的疗效,并且远期随访患者满意度较高.

Abstract：

Objective To evaluate the surgical management of consecutive esotropia.Methods In 13 patients with consecutive esotropia which persisted over 6 months after exotropia surgery were observed.Three patients less than +20PD in primary position without limited abduction were treated with recession of medial rectus; 5 patients less than +35PD in primary position with abduction impairment were treated with advancement at insertion of lateral rectus muscle; 5 patients with large angle esotropia in primary position were treated with advancement of lateral rectus combined with recession of medial rectus.The patients were followed up for more than 6 months.Results Postoperatively, 13 patients were orthophoria without diplopia or abnormal head position, mean deviation was -2.0± 6.0PD, -2.8± 4.4PD as long term follow up.The success rate was 84.62% (11/13) both immediately after surgery and for long term follow up.All patients were satisfied with the surgical correction and no one needed more surgery.Conclusions Surgical management is effective for consecutive esotropia.For large angle consecutive esotropia, advancement of lateral rectus muscle combined with recession of medial rectus is an effective choice with high level satisfactory from follow up.     

One-muscle surgery in small-angle residual esotropia.

PURPOSE: To report the outcome of unilateral lateral rectus resection for treatment of small-angle residual esotropia following bilateral medial rectus muscle recession. METHODS: A retrospective medical record review was performed for all patients who had undergone bilateral medial rectus muscle recession for congenital esotropia prior to 6 years of age that required further surgical treatment of residual esotropia. We compared two different dosing strategies for resection of a single lateral rectus muscle in the nondominant eye. In group 1, the amount of resection was calculated by doubling the angle of strabismus and applying the recommended surgical dosage to one lateral rectus muscle. In group 2, the amount of unilateral resection was the same as the bilateral dosage for the measured angle, but augmented by 1.5 mm. Postoperative evaluation was performed 1 and 6 months after surgery. RESULTS: Data from 35 patients were analyzed, 17 in group 1 and 18 in group 2. No significant intergroup difference was noted in terms of age at first surgery (p = 0.266), initial surgical dosage (p = 0.693), residual angle of esotropia (p = 0.881), or age at reoperation (p = 0.679). Postoperative alignment was better in group 1 patients at 6 months than at 1 month (residual deviation 3.5(Delta) versus 6.7(Delta), p = 0.022). CONCLUSIONS: Resection of a single lateral rectus muscle with the surgical dosage calculated by doubling the angle of strabismus and applying the recommended surgical dosage to one lateral rectus muscle is a treatment option for patients with small-angle residual esotropia following bilateral medial rectus muscle recession.     

Surgical management of severe cocontraction, globe retraction, and pseudo-ptosis in Duane syndrome.

BACKGROUND: Correction of severe cocontraction and pseudo-ptosis present unique surgical challenges in patients with Duane syndrome. METHODS: We report four Duane syndrome patients with esotropia in primary position, poor abduction, and severe cocontraction causing limitation to adduction, globe retraction, and pseudo-ptosis. All were treated with partial tendon transposition of the vertical rectus muscles augmented with Foster fixation sutures and surgical weakening of the ipsilateral lateral rectus muscle. One patient had a large recession of the lateral rectus muscle, and in three patients, the lateral rectus muscle was inactivated by removing from the globe and attaching its insertion to the lateral orbital wall. RESULTS: Postoperatively, all patients were aligned within eight prisms diopters of orthotropia, had no face turn, and improved adduction and abduction. The two patients who had restriction to abduction on intraoperative forced ductions also had residual esotropia in primary position and underwent recession of the ipsilateral medial rectus muscle as a second procedure. Postoperative binocular single visual field was enlarged by 56 to 500% in the three patients who were tested preoperatively and postoperatively. Globe retraction and cocontraction were markedly relieved. Palpebral fissure widened 1.0 and 6.0 mm in two patients who had preoperative and postoperative measurements. CONCLUSION: In Duane syndrome patients, severe cocontraction, globe retraction, and limitation to adduction may improve if the lateral rectus muscle is maximally recessed or its insertion is inactivated from the globe. Partial transposition of the vertical rectus muscles augmented with Foster sutures improved the angle of esotropia in primary position and abduction. Medial rectus muscle recession is indicated when the passive forced duction test reveals moderate-to-severe restriction to abduction.     

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.     

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）     

Rectus muscle recession and resection without scleral sutures.

PURPOSE: To eliminate the risk of scleral perforation during strabismus surgery in susceptible patients, we introduce a technique to allow predictable rectus muscle recession and resection without the placement of scleral sutures. METHODS: Three patients with thin sclera underwent rectus muscle surgery by use of a double-arm suture technique that avoids placement of sutures directly into the sclera. Two of the patients had esotropia and underwent bilateral lateral rectus muscle resections and a unilateral recess/resect operation, respectively. One of the patients had exotropia and underwent bilateral lateral rectus muscle recessions. RESULTS: All three patients achieved postoperative alignment to within 15 PD of orthotropia and had no evidence of slipped or lost muscle when examined 2 months postoperatively. The appearance of the ocular surface was excellent in all three cases. CONCLUSIONS: Predictable and secure rectus muscle recession and resection can be performed without the placement of scleral sutures in patients in whom scleral suturing may be hazardous.     

Bilateral medial rectus muscle recession and lateral rectus muscle resection in the treatment of congenital esotropia

In a retrospective study of 36 patients with congenital esotropia treated surgically by bilateral medial rectus muscle recession and lateral rectus muscle resection, we found that 22 patients (61%) had not required further surgery and that 14 patients (39%) had required further corrective surgery. Seven of these 14 patients had overcorrections and seven had undercorrections. Patients who required a second operation were significantly younger (mean age, 12 months) than those who did not (mean age, 23 months). The most common second surgical procedure was bilateral tenotomy or disinsertion of the inferior oblique muscle. Bilateral medial rectus muscle recession and lateral rectus muscle resection is useful in severe (50 prism diopters or more) congenital esotropia. The surgical success rate may be improved with bilateral inferior oblique muscle disinsertions or tenotomies in patients with inferior oblique muscle overaction. Accurate preoperative examinations in patients old enough to cooperate may help avoid overcorrection and undercorrection.