【作者】 王涛；

【导师】 王利华；

【作者基本信息】 山东大学 ， 眼科学（专业学位）， 2014， 博士

【摘要】 残余性和复发性斜视是共同性斜视手术后普遍存在的问题,常常困扰着手术者。目前临床上解决的方法主要有三棱镜矫正,缩瞳剂,肉毒素注射以及再次手术的矫正等。对于中小度数的残余性和复发性斜视,再次手术的矫正由于能获得良好的术后效果,而被众多手术者作为一种首选的方式。残余性和复发性斜视传统的手术方法为：既往曾行双侧肌肉后徙术的患者,双侧外或内直肌截除作为再次手术方式；既往曾行一侧眼的肌肉截除联合肌肉后徙术的患者,对侧眼的肌肉截除联合肌肉后徙术作为再次手术方式。所谓残余是指斜视矫正术后欠矫,残留斜视度≥5°-10。；复发是指内斜视或外斜视矫正术后患者可以控制正位,随访3个月以上再次出现内斜视或外斜视,斜视度大于15个棱镜度。据报道,内斜视术后出现欠矫的比率为20%-40%,而外斜视术后出现欠矫的比率为22%-59%,发生欠矫的主要原因为：术前斜视度测量不准确；手术设计不合理；术中操作不规范；术者经验不足等因素有关。斜视术后复发的因素为：患者双眼单视功能缺陷；术后产生的非共同性；术后未进行屈光矫正(是内斜视复发的主要原因)。由于斜视手术治疗不仅仅是矫正患者的眼位偏斜而是复杂的神经感觉系统,大部分斜视手术者面对这种术后常见问题,往往利用自己的手术经验进行治疗。单侧直肌截除术目前被用于临床作为矫正儿童残余性和复发性斜视的一种手术方式,它具有手术及麻醉时间短,创伤小,保留了另一条完整的肌肉进行再次手术,可以按照标准的手术量手术进而获得可以预测的手术效果。本研究选择了年龄小于15岁；没有弱视；没有其他眼部疾病；排除DVD及斜肌功能异常；垂直斜视度小于等于5PD；眼球运动正常；随访时间大于等于6个月的患者,评价单侧直肌截除术治疗残余性和复发性斜视的有效性及安全性,探讨单侧直肌截除术在不同斜视类型及不同初次手术方式应用的差异性。第一部分单侧内直肌截除术治疗儿童残余性和复发性外斜视的疗效观察[目的]探讨单侧内直肌截除术治疗儿童残余性和复发性外斜视的有效性及安全性,评价其在不同外斜视类型及不同初次手术方式应用的差异性。[方法]回顾性病例系列研究。收集2009年1月至2013年2月在山东大学附属山东省立医院眼科中心住院行单侧内直肌截除术治疗的残余性和复发性外斜视连续性病例48例,其中第一次手术曾行双侧外直肌后徙术22例、单侧外直肌后徙术16例、一侧眼外直肌后徙联合内直肌截除术10例；既往诊断为间歇性外斜视32例,恒定性外斜视16例。所有患儿均无弱视、不伴有斜肌功能异常、看远斜视度≥12PD、看近斜视度≥看远斜视度、垂直斜视度-≤5PD、随访时间均≥6个月。手术眼的选择：曾行双侧外直肌后徙术,选择非注视眼为手术眼；曾行单侧外直肌后徙术,选择术眼为手术眼；曾行一侧眼外直肌后徙术联合内直肌截除术,选择对侧眼为手术眼。手术前后均采用三棱镜加交替遮盖法进行看远(6m)及看近(33cm)的斜视度检查,采用手电筒Worth四点灯和Titmus立体视图行双眼视功能检查。本组48例中,男27例,女21例；年龄3-13岁,平均年龄7.69±2.53岁；术前看远斜视角为18.57±3.96(范围12～30PD),看近斜视角为23.49±5.21(范围15-35PD)；平均随访时间11.99±7.06月。手术角按单侧内直肌截除：4-4.5mm、5mm、5.5mm、6mm、6.5mm、7mm-7.5mm,矫正的棱镜度为：12-14PD、15PD、18PD、20PD、22PD、25-30PD计算。疗效评价以眼位+5PD～-10PD为手术成功的标准。[结果]术后第1天手术正位率为83.3%(40/48),欠矫率为4.2%(2/48),过矫率为12.5%(6/48)；术后6周手术正位率为81.25%(39/48),欠矫率为12.5%(6/48),过矫率为6.25%(3/48)；最终随访发现患儿的正位率为75%(36/48),欠矫率为25%(12/48),无1例过矫。既往曾行不同手术方式和不同外斜视类型患儿最终随访时手术正位率的差异均无统计学意义(P=.122；P=.50)。术后最终随访单侧内直肌截除平均矫正的斜视度为2.09±1.12PD/mm。术后所有病例均未出现眼球运动非共同性和眼球外转受限。[结论]单侧内直肌截除术是治疗儿童中小度数残余性和复发性外斜视的安全有效术式,其在不同外斜视类型及不同初次手术方式应用的差异无统计学意义。第二部分单侧外直肌截除术治疗儿童残余性和复发性内斜视的疗效观察[目的]探讨单侧外直肌截除术治疗儿童残余性和复发性内斜视的有效性及安全性。[方法]回顾性病例系列研究。收集自2010年12月至2013年5月期间因残余性或复发性内斜视在山东大学附属山东省立医院眼科中心住院行单侧外直肌截除术患儿24例,其中曾行双侧内直肌后徙术22例,单侧内直肌后徙术2例,既往诊断为非调节性内斜视10例,部分调节性内斜视5例,先天性内斜视4例,高AC/A性内斜视5例。所有患儿均无弱视、不伴有斜肌功能异常、眼球运动正常、既往行内直肌最大量后徙(≤7mm)并且不存在内转受限、垂直斜视度≤5PD、随访时间均≥6个月。手术眼的选择：均选择非注视眼作为手术眼。手术前后均采用三棱镜加交替遮盖法进行看远(6m)及看近(33cm)的斜视度检查,采用手电筒Worth四点灯和Titmus立体视图行双眼视功能检查。本组24例中,男14例,女10例；年龄3-9岁,平均年龄5.46±1.73岁；术前看远斜视角为21.25±6.62(范围10～30PD),看近斜视角为23.04±6.58(范围14-35PD)；平均随访时间12.15±6.07月。手术角按单侧外直肌截除：6mm、7mm、8mm、9mm、10mm,矫正的棱镜度为：15PD、18PD、20PD、25PD、30PD计算。疗效评价以眼位≤±10PD为手术成功的标准。[结果]术后6周手术正位率为87.5%(21/24),术后欠矫率为12.5%(3/24)；最终随访发现患儿的手术正位率为67%(16/47),欠矫率为33%(8/24)；无1例过矫。术后6周单侧外直肌截除平均矫正的斜视度为1.91±0.51PD/mm,术后最终随访单侧外直肌截除平均矫正的斜视度为1.71±0.72PD/mm。术后所有病例均未出现眼球运动非共同性和眼球内转受限。[结论]单侧外直肌截除术是治疗儿童中小度数残余性和复发性内斜视的安全有效术式。更多还原

【Abstract】 Residual and recurrent strabismus is common problem found after the strabismus operations that frustrates surgeons, orthoptists, and patients. Recently,the clinical methods have been used to correct residual or recurrent strabismus, including prismatic correction, miotics, botulinum toxin, reoperation and so on. Because reoperation could obtain good postoperative effect, it should be chosen to treat small-to moderate-angle residual or recurrent strabismus by many pediatric ophthalmologists. The surgical management of residual or recurrent strabismus depends on the primary surgery. Bilateral medial or lateral rectus resection is routinely performed on patients having previously undergone bilateral LR recession for intermittent exotropia. Contralateral RR can be used for a patient previously have undergone an RR procedure.The so-called residual refers to undercorrection after strabismus surgery (any deviation≥5°-10°). Patients who undergone the surgical treatment of exotropia or esotropia achieving satisfactory outcome can be defined as surgery recurrence that were found secondary esotropia and exotropia (deviation^15PD) at the follow-up (time≥3months). According to previous reports, the incidence of undercorrection and recurrence after the correction of esotropia varied from20%to40%and the incidence of undercorrection and recurrence after the correction of exotropia varied from22%to59%. The main reasons underlying postoperative undercorrection include inadequate measurement of the preoperative angle of strabismus, inaccurate dosing of surgery, inaccurate intraoperative measurement, inadequate experience of the surgeon, and postoperative recurrence include the deficiency of binocular vision, postoperative uncorrected refractive error, lateral rectus incomitance or underaction and so on. Because strabismus surgery affects not only simple ocular deviations but also complex neuromuscular and sensory systems, many pediatric ophthalmologists have to confront the frustrating postoperative problems and treat them with empirical surgical procedures.Unilateral rectus resection is a safe and effective surgical procedure for treating small-to-moderate angle residual or recurrent exotropia. In particular, this procedure involves short surgical and anesthetic durations and a relatively low incidence of scleral perforation and retinal detachment; more importantly, surgeons may accurately predict the effect of the surgery on residual or recurrent strabismus and remain an intact muscle to provide a possibility for further surgery treatment. In our study, we performed a retrospective study to evaluate the efficacy and safety of unilateral rectus resection in patients. In addition, we analyzed the influence of difference types of strabismus and methods of primary surgery on the surgical outcome. These patients met the following inclusion criteria:1) an age of less than15years;2) the absence of amblyopia;3) the absence of ocular diseases other than exotropia;4) the absence of dissociated vertical deviation (DVD) or oblique muscle dysfunction;5) vertical deviation of5prism diopters (PD) or less;6) the presence of normal eye movement; and7) a follow-up period of longer than6months.Part I The efficacy of unilateral medial rectus resection in children with residual and recurrent exotropiaObjective:To investigate the efficacy of unilateral medial rectus resection in children with residual and recurrent exotropia and analyze the influence of difference types of strabismus and methods of primary surgery on the surgical outcome.Methods:This investigation was a retrospective case series study that examined data from48pediatric patients who underwent unilateral medial rectus resection between January2009and February2013for residual and recurrent exotropia. In total,22of these patients had first undergone bilateral lateral rectus recession,16of these patients had first undergone unilateral lateral rectus recession, and10of these patients had first undergone unilateral lateral rectus recession combined with medial rectus resection. Among the examined individuals,32patients were diagnosed with intermittent exotropia,16patients were diagnosed with constant exotropia. For the patient who undergone bilateral LR recession as a primary surgery, the non-fixation eye acted as operation eye. For the patient who undergone unilateral LR recession as a primary surgery, first eye surgery acted as operation eye. For the patient who undergone R&R as a primary surgery, the contralateral eye acted as operation eye. No patients presented with amblyopia or exhibited associated oblique muscle dysfunction. The patients demonstrated no more than5prism diopters (PD) of vertical deviation. The follow-up period was at least6months. Before and after surgery, deviation was measured by the alternate prism cover test at far (6m) and near (33cm) fixations; in addition, the Worth4-Dot flashlight test and the Titmus stereo test were performed to assess binocular vision. The48patients examined in the study included27males and21females. The mean age of these patients was7.69±2.53years. The patients’ mean deviations before the surgery were18.57±3.96PD (range12-30PD) at far fixation and23.49±5.21PD (range15-35PD) at near fixation. The mean follow-up time was11.99±7.06months. The operative angles for unilateral medial rectus resection were4-4.5mm、5mm、5.5mm、6mm、6.5mm、7mm-7.5mm. The calculated prism corrections were12-14PD、15PD、18PD、20PD、22PD、25-30PD. The standard for successful surgery was defined as a deviation that was+5PD～-10PD.Results:At1day after the surgery, the rate of surgical success was83.3%(40/48), and the rate of undercorrection and overcorrection was4.2%(2/48) and12.5%(6/48), respectively. At6weeks after the surgery, the rate of surgical success was81.25%(39/48), and the rate of undercorrection and overcorrection was12.5%(6/48) and6.25%(3/48), respectively. At the final follow up, the surgical success rate was75%(36/48), and the rate of undercorrection was25%(12/48). No patients were overcorrected. There were no significant differences in the surgical success rate either among pediatric patients who had previously undergone different types of surgery or among patients who had been diagnosed with different types of exotropia (P=.122and P=.50, respectively). The mean correction of deviation at the last follow-up after unilateral medial rectus resection was2.09±1.12PD/mm. No patients presented with lateral incomitance or limited ocular motility. Conclusion:Unilateral medial rectus resection is a safe and effective surgical approach for treating in children with residual and recurrent exotropia. In addition, it may achieve the same surgical effectiveness regardless of the patients’previous surgical procedures or types of exotropia.Part II The efficacy of unilateral lateral rectus resection in children with residual and recurrent esotropiaObjective:To investigate the effect and safe of unilateral lateral rectus resection for treating in children with residual and recurrent esotropia.Methods:In a retrospective, consecutive and interventional case series,24pediatric patients who underwent unilateral lateral rectus resection between December2010and May2013for residual or recurrent esotropia. In total,22of these patients had first undergone bilateral medial rectus recession,2of these patients had undergone unilateral medial rectus recession. Among the examined individuals,10patients were diagnosed with non-accommodative esotropia,5patients were diagnosed with partially accommodative esotropia,4patients were diagnosed with congenital esotropia, and5patients were diagnosed with high AC/A ratio esotropia. No patients presented with amblyopia or exhibited associated oblique muscle dysfunction. The patients demonstrated no more than5prism diopters (PD) of vertical deviation and had the normal eye movement. The follow-up period was at least6months. In preoperative and postoperative, deviation was measured by the alternate prism cover test at far (6m) and near (33cm) fixations; The worth four dot test and Titmus test were performed to evaluate binocularity function examination. The preoperative data of24patients were as follows:The ratio of man and female was14:10; the average age was5.46±1.73year; the mean of distance esodeviation measured was21.25± 6.62PD (range,10to30PD), whereas near esodeviation was23.04+6.58PD (range,14to35PD); the mean follow-up time was12.15±6.07months. The surgical landmarks were defined that ULR resection of6,7,8,9,10mm was performed15,18,20,25,30PD of esotropia. Successful surgical alignment was defined as±10PD of orthophoric in primary and lateral gaze while viewing distance accommodative targets.Results:At the follow-up of6weeks, the rate of surgical success was87.5%(21/24), and the rate of undercorrection was12.5%(3/24). At the final follow up, the surgical success rate was67%(16/24), and the rate of undercorrection was33%(8/24).No patients were overcorrected. The mean correction of deviation at6weeks after unilateral lateral rectus resection was1.91±0.51PD/mm. The mean correction of deviation at the last follow-up after unilateral lateral rectus resection was1.71±0.72PD/mm. No patients presented with lateral incomitance or limited ocular motility.Conclusion:The ULR resection is safe and effective surgical approach for treating in children with residual and recurrent esotropia.更多还原