不同临床特点的分离性垂直偏斜手术疗效

探讨不同临床特点的分离性垂直偏斜（DVD）的手术方式及其疗效以期提高治疗效果。方法：回顾性系列病例研究。收集青岛眼科医院2013年1月到2016年12月期间诊断为DVD上斜明显并行上直肌手术的患者共49例。根据双眼上斜程度不等对患者进行分组，设计手术量，并对手术疗效进行分析。A组：双眼上斜≥20△，上斜程度差别<5△，共18例；B组：双眼上斜≥20△，双眼上斜程度差别≥5△，共14例；C组：一眼上斜≥20△，另一眼上斜<5△，共17例。C组的上斜<5△是指仅有微小上转动度或未引出上斜。C组根据手术方式不同分为C1组（双眼手术）和C2组（单眼手术）。手术指征： A组：上斜程度明显影响外观，双眼上斜程度基本相等，上斜度数≥20△者，行双眼上直肌等量的大量后徙7～10 mm；B组：双眼上斜程度不等，上斜度数较大眼，行大量上直肌后徙7～10 mm，另一眼上直肌后徙为5～6 mm；C1组：一眼明显上斜者行其后徙7～10 mm，另一眼则后徙4 mm（10例）， C2组：只一眼行矫正手术（7例）。2组独立样本比较采用Wilcoxon秩和检验。结果：所有患者术后均未出现睑裂明显不等的变化。A组患者手术满意度为94%。B组患者手术满意度为93%。C1组行双眼手术者，手术满意度为100%。C2组行单眼手术者，手术满意度仅为29%。对C1和C2组进行比较，满意度差异有统计学意义（Z=-3.656，P<0.001）。结论：DVD是双眼性疾病，根据分离以及上斜程度是否相同，可行双眼上直肌等量及不等量的后徙。即便一眼无明显上斜，仍须按不等量手术设计给予最小量的上直肌后徙，若仅行明显上斜眼手术则易引起对侧眼术后上斜视和反转性的代偿头位。

Effectiveness of Surgical Treatment for Dissociated Vertical Deviation with Different Clinical Characteristics

To investigate the effectiveness of surgery for dissociated vertical deviation (DVD) with different clinical characteristics. Methods: A retrospective study was conducted on 49 patients who underwent surgical correction for DVD at Qingdao Eye Hospital of Shandong Eye Institute from January 2013 to December 2016. Patients were divided into four groups according to their angle of vertical deviation. Different surgical designs were used, and surgical efficacy was analyzed. In group A, the deviation angle was ≥20△ in both eyes of 18 patients with a difference of <5△. In group B, the deviation angle was ≥20△ in both eyes of 14 patients with a difference of ≥5△. In group C, 17 patients had a large deviation angle ≥20△ in one eye and a small deviation angle <5△ in the other eye. Small vertical strabismus (<5△) meant a slight rotation or no vertical strabismus. Group C was divided into group C1 and group C2 based on different surgical methods used. A 7-to-10 mm recession of the superior rectus muscle was reserved for patients in group A. A 7-to-10 mm recession of the superior rectus muscle was reserved for eyes with a large vertical angle and a 5-to-6 mm recession of the superior rectus muscle was reserved for the other eyes in group B. A 7-to-10 mm recession of the superior rectus muscle was reserved for eyes with a large vertical angle, and a 4 mm recession (10 patients) was reserved in group C1, or no surgery (7 patients) was performed on eyes with a small deviation angle in group C2. Results: No eyelid retraction was observed after large recessions of the superior recuts muscle. The rate of surgical satisfaction was 94% in group A and was 93% in group B. Among the patients with bilateral surgeries in group C1, the rate of surgical satisfaction was 100%. Among the patients with unilateral surgical treatment in group C2, the rate of surgical satisfaction was 29%. There was a statistically significant difference between group C1 and group C2 (Z=-3.656, P<0.001). Conclusions: For DVD, usually a binocular disease, bilaterally equal or unequal recession of the superior rectus muscle could be reserved according to the symmetry or asymmetry degree of vertical strabismus. A 4 mm recession of the superior rectus muscle may be reserved in the preferred eye of patients with a small vertical angle or no vertical strabismus. If the non-preferred eye with a large vertical angle is operated on, the preferred eye with a small vertical angle may show obvious vertical strabismus or a new compensatory head position.