动眼神经麻痹性斜视的手术方式探讨

目的 探讨动眼神经麻痹性斜视的手术方式.设计回顾性病例系列.研究对象单侧动眼神经麻痹性斜视患者13例.方法 动眼神经不完全麻痹者8例,行外直肌的超常量后退,同侧内直肌折叠,对侧外直肌后退术.动眼神经完全麻痹、上斜肌健康者3例,行外直肌的超常量后退,同侧内直肌折叠,上斜肌转位术,即将上斜肌移位至内直肌上方;动眼神经完全麻痹且伴上斜肌麻痹者2例,行外直肌的超常量后退,内直肌鼻侧眶缘固定术.主要指标手术前后的水平、垂直斜视度.结果 术前外斜视在80^△～120^△以上,5例伴有下斜视15^△～35^△,2例伴有上斜视15^△～20^△;术后随访6～27个月,残余外斜6^△～20^△,残余下斜视4^△～10^△.结论 根据动眼神经麻痹造成的眼外肌麻痹程度的不同,采取不同的手术方式,可获得眼位的美容正位.     

上斜肌转位治疗动眼神经麻痹

目的探讨上斜肌转位手术治疗动眼神经麻痹的临床效果。方法回顾我院1999年1月～2007年9月采用上斜肌转位术矫正动眼神经麻痹所致重度外斜视病例,并观察分析。结果20眼动眼神经麻痹行外直肌后退,内直肌折叠,上斜肌转位术。下斜视者3眼加下直肌后退术,上斜视6眼二次手术行上直肌超常量后退及下直肌超常量缩短术。患者外观取得满意效果,随访6月～3年眼位无明显改变。结论上斜肌转位术矫正动眼神经麻痹性斜视是可行的。     

单眼动眼神经麻痹性斜视手术治疗病例报告

动眼神经麻痹导致的外斜视是眼科难治性斜视之一，手术治疗的目的为使眼球在第一眼位时处于正位。作者成功的对一例先天性左动眼神经麻痹行手术治疗，术后眼位达到基本正位，取得了良好的疗效。     

改良带蒂眶骨膜锚定术治疗固定性内下斜视

目的探讨改良带蒂眶骨膜锚定术治疗固定性内下斜视的方法。方法12例固定性内下斜视均采取内直肌大量后徙,下直肌后徙,联合带蒂眶骨膜外直肌附着点锚定手术矫正。结果术后8例眼位原在位正位,2例残余内斜视,2例残余下斜视。结论此改良术式远期效果稳定;且不行外直肌缩短术,为同期手术解决内下斜视创造条件,并大大降低发生眼前段缺血的危险性。     

上斜肌转位术

动眼神经麻痹在眼运动神经麻痹中约占1/3,仅次于外展神经麻痹而居第二位。但动眼神经完全麻痹所引起的外斜视和上睑下垂却给患者带来严重的视功能障碍和外貌上的缺陷。手术矫正也很困难。在查清病因、又经过半年—1年药物及物理等治疗无效、病情稳定的前提下,为使患者在第一眼位获得正位和一定量的内转能力,可以施行上斜肌转位术。国外已有Jackson Peter Metz Scott、丸尾等报告。目前国内尚无报导。我们用上斜肌转位术治疗9例动眼神经完全麻痹引起的外斜视,效果比较满意,特报告如下。     

部分直肌转位治疗单条直肌完全麻痹斜视的疗效分析

目的：分析部分直肌转位术治疗单条直肌完全麻痹性斜视的临床疗效。方法：回顾性分析22例25眼单条直肌完全麻痹性斜视患者行部分直肌转位术,手术前后眼位、复视、代偿头位及眼球运动情况。随访6 mo。结果：根据22例25眼患者的术前、术中检查结果,采用不同的术式组合：单纯部分直肌转位术2眼,麻痹肌的拮抗肌后退及部分直肌转位术20眼,麻痹肌的拮抗肌后退、部分直肌转位并对侧眼配偶肌后退术3眼。术后20例第一眼位完全正位,代偿头位及复视均消除,2例双眼外直肌麻痹患者轻度欠矫,分别配戴8△、10△三棱镜后复视及代偿头位均消失。斜视度术前100．23△±42．61△,术后0.82△±2．67△（ t＝10．797,P＜0．001）。眼球运动评分术前－4．52±0．51分,术后－2．68±0．63分（t＝－19．468,P＜0.001）。结论：部分直肌转位术治疗单条直肌完全麻痹性斜视能有效矫正第一眼位的斜视、复视,消除代偿头位,改善眼球运动,获得满意的临床效果。     

内直肌超常量后徙和继发性外斜视的关系

目的 研究内直肌超常量后徙与继发性外斜视的关系.方法 对2003～2009年住院的43例内斜术后继发外斜的病人进行回顾性分析,分别观察常规量内直肌后徙(内直肌附着点距角膜缘的距离≤11.5mm)和超常量内直肌后徙(内直肌附着点距角膜缘的距离＞11.5mm)与眼球运动和继发性外斜视的关系.结果 13例眼球内转受限,其中发现内直肌常规量后徙33例中只有3例眼球内转受限,超常量内直肌后徙的10例患者均有眼球运动受限,经x2检验,P＜0.05;对10例内直肌超常量后徙的患者6例行内直肌前徙,术后眼球运动无受限,眼位正位;而经同等手术量内直肌缩短的4例患者中只有1例术后眼球内转轻度受限,但术后眼位正位.另外3例患者术后眼球运动仍明显受限,残留外斜视.39例术中内直肌附着点距角膜缘的距离≤11.5mm,35例(89.7%)术后正位,4例内直肌附着点距角膜缘的距离＞11.5mm,术后只有1例(25%)正位.结论 (1)内直肌超常量后徙可造成术后眼球运动受限,从而导致继发性外斜视.(2)单纯内直肌缩短术后斜视度不稳定,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.     

直肌联扎术在麻痹性斜视手术中的临床应用

目的对直肌联扎术在麻痹性斜视手术中的应用进行回顾评价。方法对14例(14只眼)应用直肌联扎术的麻痹性斜视病例的矫正结果进行临床分析。结果 14例麻痹性斜视患者术后12例正位,2例欠矫;麻痹水平直肌术后运动恢复平均10,°麻痹垂直肌术后运动平均恢复5;°9例后天性麻痹性斜视患者术前有复视者术后正前方及正下方有限视野范围内复视消除,5例先天性麻痹性斜视者手术前后均无复视。结论直肌联扎术应用于麻痹性斜视除可获得满意眼位外,还可获得部分运动功能。     

A型肉毒毒素在麻痹性内斜视治疗中的应用

目的　探讨A型肉毒毒素 (botulinumtoxinA ,BTXA)治疗外展神经麻痹致麻痹性内斜视(paralyticesotropia ,PE)的方法和效果。方法　将 89例PE患者分为两组 ,注射组 6 2例PE患者行BTXA眼外肌注射治疗 ,其中 16例患者在BTXA眼外肌注射治疗后 3～ 2 8个月因眼位欠矫行二期手术治疗 ;手术组 2 7例PE患者行BTXA眼外肌注射联合手术治疗。手术方法包括内直肌后退及外直肌截除术、眼外肌边缘切开及截除术、Jenson术和上下直肌转位术等。术后随访时间 3～ 33个月 ,平均 7 5个月。结果　注射组中 ,35例患者经 1～ 4次BTXA眼外肌注射治疗后眼位恢复至正位并获得双眼单视功能 ;11例患者术后眼位恢复至正位 ,矫正的平均斜视度数 (△)为 4 2 7△ ± 32 2 △ 。手术组中 ,术后14例患者眼位恢复至正位 ,矫正的平均斜视度数为 90 0 △ ± 4 0 1△ 。 14例术后患者恢复融合功能 ,双眼注视野范围为 2 0°～ 70°。结论　BTXA眼外肌注射方法可有效防止内直肌挛缩并促进外直肌肌力恢复 ,使部分患者眼位恢复至正位 ,是治疗PE的有效方法之一。同时其作为手术治疗PE的辅助措施 ,可为手术治疗奠定良好的基础     

外直肌和上直肌部分联结术治疗常规手术无效的高度近视眼限制性内下斜视

目的探讨应用外直肌和上直肌部分联结术治疗常规手术无效的高度近视眼限制性内下斜视的效果。 方法收集2012年9月至2017年12月因常规退缩手术治疗无效到厦门大学附属厦门眼科中心再次行斜视矫正手术的高度近视眼限制性内下斜视患者5例(8只眼),男性2例(4只眼),女性3例(4只眼);年龄52.0～73.0岁,平均(61.2±2.4)岁。手术前后,全部患者均进行视力、验光、裂隙灯显微镜、眼底、眼球运动、斜视角、眼轴长度及眼眶冠状位和水平位计算机X射线断层扫描(CT)检查。采用外直肌和上直肌部分联结术进行治疗。 结果全部患者5例(8只眼)患眼处于内下斜位,外转和上转功能受限;CT显示所有患眼存在上直肌向鼻侧移位、外直肌向下方移位、眼球后部向颞上方疝出肌圆锥。2例双眼(4只眼)行外直肌和上直肌部分联结术,1例双眼(2只眼)行外直肌和上直肌部分联结术联合内直肌后徙悬吊术,2例单眼(2只眼)行外直肌和上直肌部分联结术。患者随访超过6个月时,4例(6只眼)患者术后第一眼位正位,1例(2只眼)患者术后远期第一眼位为－15°,CT显示脱位的眼球被还纳回肌圆锥内,眼球的外转和上转功能逐渐恢复。所有患者未出现复视。无并发症发生。 结论外直肌和上直肌部分联结术可有效矫正经常规退缩手术治疗无效的高度近视眼限制性内下斜视,还纳脱出的眼球至肌圆锥内,并改善眼球运动功能。     

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall

BACKGROUND/AIMS: Surgical correction of ocular alignment in patients with third cranial nerve paralysis is challenging, as the unopposed lateral rectus muscle often pulls the eye back to exotropia following surgery. The authors present a simple surgical approach to overcome this difficulty. This approach is also applicable to removal of unwanted overactivity of the lateral rectus in Duane syndrome. METHODS: A review was made of the records of four patients with third cranial nerve paralysis and one with Duane syndrome with exotropia in which the lateral rectus muscle was removed from its scleral insertion and reattached to the orbital wall. Additional surgery to bring the eye to the midline included medial rectus resection, medial transposition of the vertical recti, and passive suturing of the eye to the medial orbit wall. RESULTS: All patients achieved satisfactory ocular alignment following surgery. Ocular ductions were limited. These results were stable for 1.5-4 years of follow up. No major complications occurred. CONCLUSION: Lateral rectus muscle disinsertion and reattachment to the orbital wall to absorb its force and thus remove abduction torque was a simple and safe surgical procedure for restoring ocular alignment in four patients with third cranial nerve paralysis and in one patient with Duane syndrome with severe exotropia.     

Myectomy of lateral rectus muscle for third nerve palsy

PURPOSE: To introduce myectomy of the lateral rectus muscle for correcting exotropia in patients with third nerve palsy. METHODS: The lateral rectus muscle of the paretic eye was myectomized without suturing it to the globe. This was combined with a medial rectus muscle resection and a contralateral lateral rectus muscle recession. Magnetic resonance imaging was performed to observe the re-attachment of the lateral rectus muscle to the globe. RESULTS: The patient was able to fuse in the primary position without any noticeable limitation in abduction. Magnetic resonance imaging showed that the lateral rectus muscle was attached to the globe through fibrous tissue. CONCLUSION: Myectomy of the lateral rectus muscle is an effective and simple procedure to accomplish a super-maximal weakening effect of abduction in patients with complete third nerve palsy.     

Surgery for strabismus secondary to ethmoid sinus surgery

PURPOSE: To review the outcome of surgery for strabismus due to ethmoid sinus surgery. CASES AND METHODS: The series comprised 13 cases, 1 of inferior rectus paresis, 1 of superior oblique paresis, 6 of medial rectus paresis, and 5 of medial rectus muscle palsy due to third nerve palsy. In the cases of paresis of the rectus muscle, resection of the rectus muscles was mainly performed. In the cases of palsy of the rectus muscle, transposition of the extraocular muscle with simultaneous recession of the lateral rectus muscle was performed. The major aim of surgery was to bring both eyes into alignment and to eliminate diplopia in the primary position. RESULTS: The mean preoperative horizontal deviation of 18.1 degrees of exotropia in the paresis cases was reduced to 1.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 3.8 degrees of hypertropia was reduced to 1.4 degrees of hypertropia postoperatively. The mean preoperative horizontal deviation of 35.6 degrees of exotropia in the palsy cases was reduced to 9.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 2.0 degrees of hypertropia was increased to 2.6 degrees of hypertropia postoperatively. Postoperatively, diplopia was absent in 11 cases with a slightly compensatory head posture. CONCLUSION: Surgery for strabismus due to sinus surgery induces improvements in eye position and diplopia.     

Unaugmented vertical muscle transposition surgery for chronic sixth nerve paralysis

INTRODUCTION: Chronic sixth nerve palsy can cause incapacitating diplopia requiring vertical muscle transposition surgery. Augmentation of surgery, with lateral fixation sutures, medial rectus recession or botulinum toxin injection, is associated with an increased risk of complications. PURPOSE: Our aim was to evaluate the efficacy and safety of unaugmented full-tendon vertical rectus transposition in chronic sixth nerve paralysis. METHODS: Longitudinal study of 21 patients with chronic sixth nerve paralysis of longer than 6 months duration, who underwent superior and inferior recti transposition surgery without medial rectus recession or botulinum toxin injection. Details of surgery, preoperative and postoperative examinations including full orthoptic examination were obtained from an electronic database. Outcomes included the change in angle of deviation, the requirement for further surgery to the medial rectus and postoperative improvement in diplopia. SPSS software (Version 12.0.1, SPSS Inc. Chicago, IL) was used to summarize baseline characteristics and outcomes and to compare preoperative and postoperative deviation (paired t-test). RESULTS: Twenty-one patients (10 (47.6%) men and 11 (52.4%) women) with a mean age of 41 years (range 4 to 74 years) were operated in the period between April 1998 and November 2000. Eighteen patients had unilateral and three had bilateral acquired sixth nerve palsy. Nineteen patients required unilateral surgery and two had bilateral transposition procedures. In patients with unilateral sixth nerve palsy, mean esotropia in primary position before surgery was 46.7 prism-diopters (PD) (95% CI 35.9-57.4 PD) and improved to 14.6 PD after surgery (95% CI 6.4-22.7 PD). The angle of deviation was significantly reduced by an average of 32.1 PD (p < 0.001, paired t-test; 95% CI 22.6-41.6 PD). Over all, 10 patients (55.6%) had a well-controlled esophoria with a postoperative alignment of within 10 PD of orthophoria without diplopia in the primary position, for distance and near. A further six patients (28.6%) required additional medial rectus recessions to achieve success. The only complication observed was slippage of the inferior rectus in one patient (4.2%), who consequently required further surgery. CONCLUSION: Botulinum toxin infiltration of the medial rectus in vertical rectus transposition surgery may be unnecessary, incurring cost, additional attendances and interventions for patients. Less than a third of all patients in our series required additional medial rectus recession later.     

A new surgical technique for ocular fixation in congenital third nerve palsy.

PURPOSE: To present a new technique of ocular fixation to restore and maintain the ocular alignment in primary position for patients with total third nerve paralysis. METHOD: We fixated the globe (medial rectus muscle insertion) to the medial palpebral ligament insertion at the anterior lacrimal crest by using nonabsorbable 5-0 polyester sutures in a prospective study of 5 patients (5 eyes) with congenital total third nerve paralysis. A large recession of the lateral rectus muscle (12 to 16 mm) was also performed in four patients. RESULTS: Four patients achieved satisfactory ocular alignment and one patient had residual exotropia. After an initial exotropic shift, no significant change in ocular alignment was observed during the follow-up period of 6 to 9 months. Mild fullness and congestion over the medial rectus muscle area was observed in the immediate postoperative period in all the patients, which resolved in about two months time. CONCLUSION: This technique of ocular fixation is easy, safe, and effective for the management of exotropia secondary to total third nerve paralysis.     

Unaugmented Vertical Muscle Transposition Surgery for Chronic Sixth Nerve Paralysis

Introduction: Chronic sixth nerve palsy can cause incapacitating diplopia requiring vertical muscle transposition surgery. Augmentation of surgery, with lateral fixation sutures, medial rectus recession or botulinum toxin injection, is associated with an increased risk of complications. Purpose: Our aim was to evaluate the efficacy and safety of unaugmented full-tendon vertical rectus transposition in chronic sixth nerve paralysis. Methods:Longitudinal study of 21 patients with chronic sixth nerve paralysis of longer than 6 months duration, who underwent superior and inferior recti transposition surgery without medial rectus recession or botulinum toxin injection. Details of surgery, preoperative and postoperative examinations including full orthoptic examination were obtained from an electronic database. Outcomes included the change in angle of deviation, the requirement for further surgery to the medial rectus and postoperative improvement in diplopia. SPSS software (Version 12.0.1, SPSS Inc. Chicago, IL) was used to summarize baseline characteristics and outcomes and to compare preoperative and postoperative deviation (paired t-test). Results: Twenty-one patients (10 (47.6%) men and 11 (52.4%) women) with a mean age of 41 years (range 4 to 74 years) were operated in the period between April 1998 and November 2000. Eighteen patients had unilateral and three had bilateral acquired sixth nerve palsy. Nineteen patients required unilateral surgery and two had bilateral transposition procedures. In patients with unilateral sixth nerve palsy, mean esotropia in primary position before surgery was 46.7 prism-diopters (PD) (95% CI 35.9–57.4 PD) and improved to 14.6 PD after surgery (95% CI 6.4–22.7 PD). The angle of deviation was significantly reduced by an average of 32.1 PD (p < 0.001, paired t-test; 95 % CI 22.6–41.6 PD). Over all, 10 patients (55.6%) had a well-controlled esophoria with a postoperative alignment of within 10 PD of orthophoria without diplopia in the primary position, for distance and near. A further six patients (28.6%) required additional medial rectus recessions to achieve success. The only complication observed was slippage of the inferior rectus in one patient (4.2%), who consequently required further surgery. Conclusion: Botulinum toxin infiltration of the medial rectus in vertical rectus transposition surgery may be unnecessary, incurring cost, additional attendances and interventions for patients. Less than a third of all patients in our series required additional medial rectus recession later.     

A Comparison of Visual Field and Optic Disc Appearance Depending on the Peak Intraocular Pressure in Patients with Normal-tension Glaucoma

Purpose To review the outcome of surgery for strabismus due to ethmoid sinus surgery.Cases and Methods The series comprised 13 cases, 1 of inferior rectus paresis, 1 of superior oblique paresis, 6 of medial rectus paresis, and 5 of medial rectus muscle palsy due to third nerve palsy. In the cases of paresis of the rectus muscle, resection of the rectus muscles was mainly performed. In the cases of palsy of the rectus muscle, transposition of the extraocular muscle with simultaneous recession of the lateral rectus muscle was performed. The major aim of surgery was to bring both eyes into alignment and to eliminate diplopia in the primary position.Results The mean preoperative horizontal deviation of 18.1 degrees of exotropia in the paresis cases was reduced to 1.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 3.8 degrees of hypertropia was reduced to 1.4 degrees of hypertropia postoperatively. The mean preoperative horizontal deviation of 35.6 degrees of exotropia in the palsy cases was reduced to 9.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 2.0 degrees of hypertropia was increased to 2.6 degrees of hypertropia postoperatively. Postoperatively, diplopia was absent in 11 cases with a slightly compensatory head posture.Conclusions Surgery for strabismus due to sinus surgery induces improvements in eye position and diplopia. Nippon Ganka Gakkai Zasshi (J Jpn Ophthalmol Soc 107:425–432, 2003)     

Botulinum toxin treatment of acute sixth and third nerve palsy

Thirty-four patients with acute sixth nerve palsy and nine patients with acute third nerve palsy were treated with botulinum toxin injection to the antagonist, nonparalytic horizontal rectus muscle. In a control group of 52 patients with acute sixth nerve palsy not treated with botulinum in the acute stage, only 16 (31 %) recovered spontaneously and did not require surgery. Twenty-two of the 31 surviving patients who could be followed with acute sixth nerve palsy had lateral rectus recovery and surgery was avoided. Four required prisms in their glasses to obtain fusion. Nine patients developed chronic sixth nerve palsy and required surgery. In this group of acute sixth nerve palsy patients, eleven were bilateral. Seven of these eleven developed chronic sixth nerve paralysis, and required strabismus surgery. This suggests the prognosis for recovery following botulinum treatment in cases of acute bilateral sixth nerve palsy is not as good as in the unilateral cases. Botulinum toxin treatment does not appear to be effective in chronic sixth nerve palsy, as judged by results of treatment in one patient known to have a chronic palsy. Nine of nine patients with acute third nerve palsy had medial rectus recovery with fusion horizontally in primary gaze. None have required surgery. Only four of nine showed improvement in vertical rotations. The remaining five patients avoid vertical diplopia by a compensatory chin position. Botulinum toxin treatment of patients with acute sixth and third nerve palsy appears beneficial. However, since some in this group of patients may recover spontaneously, a randomized, double-blind study may be necessary to more definitively determine the effectiveness of this therapy.Dedicated to Dr. G.K. von Noorden on the occasion of his 60th birthday     

Surgical management of oculomotor nerve palsy with lateral rectus transplantation to the medial side of globe

An operation for complete third nerve paralysis involving lateral rectus muscle transplantation to the medial side of the globe as a basic procedure is described. An inferior rectus muscle recession plus resection of an apparent completely paralysed medial rectus was subsequently performed at a second stage operation. The results appeared to be an improvement on previous surgery, particularly in terms of ocular motility, with almost full adduction of the operated eye being achieved. This adduction movement occurred as part of a normal conjugate movement of the two eyes, and the question arises as to the responsible muscles, with some evidence to suggest that relearned action of the transplanted lateral rectus muscle may be implicated. Finally, a Fasanella-Servat procedure as a third stage operation appeared to be adequate to correct the ptosis.     

Surgical management of oculomotor nerve palsy with lateral rectus transplantation to the medial side of globe.

An operation for complete third nerve paralysis involving lateral rectus muscle transplantation to the medial side of the globe as a basic procedure is described. An inferior rectus muscle recession plus resection of an apparent completely paralysed medial rectus was subsequently performed at a second stage operation. The results appeared to be an improvement on previous surgery, particularly in terms of ocular motility, with almost full adduction of the operated eye being achieved. This adduction movement occurred as part of a normal conjugate movement of the two eyes, and the question arises as to the responsible muscles, with some evidence to suggest that relearned action of the transplanted lateral rectus muscle may be implicated. Finally, a Fasanella-Servat procedure as a third stage operation appeared to be adequate to correct the ptosis.