【作者】 张莹；

【导师】 齐首楠；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2023， 硕士

【摘要】 目的：探讨下斜肌后固定术(Inferior oblque belly transpositon,IOBT)在伴有轻中度下斜肌亢进(inferior oblique muscle overaction,IOOA)的垂直斜视中的治疗效果。方法:回顾性病例研究。收集2020年4月至2022年8月于吉林大学第二医院斜视与小儿眼病科行IOBT患者的临床资料,所有患者术前均明确诊断为伴有不同程度IOOA的斜视,术前及术后随访病例资料完整。术前常规行眼科一般检查及斜视专科检查,手术按照统一标准操作。收集患者的基本信息、术前及术后原在位视远(5m)、视近(33cm)的垂直及水平斜视度、IOOA等级、黄斑中心凹-视盘中心夹角(fovea disc angle,FDA)、近立体视、代偿头位,以及合并V型斜视患者视远(5m)上、下转25°水平斜视度的差值(V值)。根据IOOA等级分为IOOA1+组、IOOA2+组,根据是否伴有V型斜视分为V型斜视组、非V型斜视组,评估手术效果。治愈标准:眼球运动无IOOA,原在位视远垂直斜视度为0,V型斜视患者V值<10PD。对水平斜视、近立体视、代偿头位改善效果评价标准:水平斜视术后<±10PD为水平斜视治愈;术前无近立体视,术后近立体视≤800",即为近立体视恢复;术前有面转、头倾、下颌上抬或内收,术后消失或减轻即为代偿头位改善。结果:1、纳入患者共40例(45眼),男性14例,女性26例,年龄3~24岁,平均9.72±5.24岁。术后随访1~27个月,平均6个月。IOOA1+患者22例,IOOA2+患者18例。内斜视患者6例,外斜视患者34例。伴有V型斜视患者19例。2、(1)术前IOOA等级对VD产生显著的正向影响关系。视远与视近原在位VD与IOOA呈正相关,相关系数为:视远r=0.439,视近r=0.431,P<0.01。(2)40例患者术后原在位视远VD改善4.37±2.99PD,视近4.35±2.38PD,VD矫正成功率85%。IOBT对各组患者VD改善情况:IOOA1+组3.45±2.84PD、IOOA2+组5.50±2.85PD,VD矫正成功率分别为86.36%、83.30%,两组间比较差异无统计学意义(P>0.05);V型斜视组4.00±3.32PD、非V型斜视组4.71±2.70PD,VD矫正成功率分别为90.48%、78.95%,两组间比较差异无统计学意义(P>0.05)。(3)40例患者IOOA术前1.0(1.0,2.0),术后0.0(0.0,0.0),矫正成功率82.5%。IOOA1+组及IOOA2+组矫正成功率分别为95.45%和66.66%,两组间比较差异有统计学意义(P<0.05),IOBT对IOOA1+的患者下斜肌亢进改善效果更好。V型斜视和非V型斜视患者IOOA矫正成功率分别为84.21%和80.95%,两组间比较差异无统计学意义(P>0.05)。(4)19例伴V型斜视患者术前V值为20(17,26)PD,术后为4(2,6)PD,差异有统计学意义(P<0.05),V征矫正成功率89.47%,仍有2例患者术后存在V征,但V值较术前降低。(5)整体FDA较术前改变4.68±5.05°,97.5%的患者眼底客观外旋状态改善,1例患者术后出现眼底客观内旋改变。V型斜视组FDA改变5.10±5.37°,非V型斜视组4.62±4.79°,虽然IOBT对于非V型斜视的FDA改变量较V型斜视大,但两组间比较差异无统计学意义(P>0.05)。IOOA1+组FDA改变4.06±4.44°,IOOA2+组5.81±5.62°,两组间比较差异无统计学意义(P>0.05)。(6)10(41.6%)例患者恢复近立体视。11(84.61%)例患者术后代偿头位消失或改善。(7)内斜视视远改善42.5±17.17PD,视近改善50.33±18.51PD,内斜视治愈率83.3%;外斜视视远改善38.23±19.28PD,视近改善43.11±21.85PD,外斜视矫正成功率91.17%。以上各项观察指标术前术后结果组间比较差异均有统计学意义(P<0.05)。术后未出现抗上转综合征、V征过矫为A征等并发症。结论:1、IOBT是轻中度IOOA源性的10PD以下垂直斜视患者的一种有效的手术治疗方法,未出现医源性Brown综合征及抗上转综合征等并发症。2、IOBT对IOOA1+患者的肌肉功能亢进的改善更有效。3、单侧行IOBT在伴有轻度IOOA的V型斜视患者中取得了令人满意的结果,矫正V征的同时避免了过矫为A征的风险。更多还原

【Abstract】 Purpose:To evaluate the efficacy of IOBT treating vertical deviation with mild to moderate IOOA.Methods:The medical records of patients,who underwent IOBT for VD and coexisting IOOA at the Second Hospital of Jilin University between april 2020 and august 2022,were retrospectively reviewed.All patients underwent general ophthalmological examination and strabismus specialist examination.Data were collected: age,gender,diagnosis,angle of deviation at distance and near(in the primary),ocular motility,FDA,V pattern,near stereopsis,compensatory head position.Criteria for successful surgery: 0 PD of primary position VD,without residual IOOA,10 PD or less of V pattern.Secondary outcome measures : motor success was defined as alignment within 10 PD at distance,stereoacuity 800" postoperatively and lack of stereopsis preoperatively were used to determine stereoscopic recovery,improvement or resolution of compensatory head position.Results:1.A total of 40 patients(45 eyes)were included in this study,14 males and 26 females with a mean age of 9.72±5.24 years(range,3–24 years).The follow-up period ranged from 1 to 27 months(mean,6months).Diagnoses were: IOOA coexist with exotropia(34 case),IOOA coexist with esotropia(6 cases),IOOA1+(22 case),IOOA2+(18 case),IOOA coexist with V pattern(19 case).2.(1)Correlation analysis of preoperative IOOA and VD: the preoperative IOOA was positively correlated with VD(distance and near),and the correlation coefficients were r = 0.439,0.431(P < 0.01).(2)The primary position VD at distance decreased to 4.37±2.99 PD,at near decreased to 4.35±2.38 PD,with an 85% success rate.The correction VD angle of IOOA1+ group was 3.45±2.84 PD,while IOOA2+ group was 5.50±2.85 PD,with86.36%、83.30% success rate.There was no statistical significance(P>0.05).The correction VD angle of V pattern group was 4.00 ± 3.32 PD,while non-V pattern group was 4.71 ± 2.70 PD,with 90.48% 、 78.95% success rate.There was no statistical significance(P>0.05).(3)The IOOA was 1.0(1.0,2.0)preoperatively and 0.0(0.0,0.0)postoperatively,the success rate of IOOA correction was 82.5%.IOOA1 + group and IOOA2 + group corrective success rates were 95.45% and 66.66% respectively.The difference was statistically significant(P<0.05).IOBT achieved better postoperative effect in individuals with 1+IOOA than 2+IOOA.V pattern group and non-V pattern group corrective success rates were 84.21% and 80.95%.There was no statistical significance(P>0.05).(4)The amount of V pattern was 20(17,26)PD preoperatively and 4(2,6)PD postoperatively,the success rate of V pattern correction was 89.47%.(5)The FDA showed a change of 4.68±5.05°.Patients had extorsion before surgery,which was modified to be almost normal after surgery,1 patients showed incyclotropia after surgery.The FDA change was 5.10 ±5.37 ° in the V pattern group and 4.62 ±4.79 ° in the non-V pattern group.The difference was not statistically significant(P>0.05).The FDA change was 4.06±4.44° in the IOOA1+ group and5.81±5.62° in the IOOA2+ group.The difference was not statistically significant(P>0.05).(6)Near stereopsis was restored in 10(41.6%)patients.Postoperative compensatory head position disappeared or improved in 11(84.61%)patients.(7)The primary position HD at distance of esotropia showed a diminution of42.5±17.17 PD,while the HD at near of exotropia was 50.33±18.51 PD,with an 83.3%success rate.The success rate was 91.17% for the HD at distance of exotropia correction,which showed a diminution of 38.23±19.28 PD,while the HD at near of exotropia was 43.11±21.85 PD.Conclusions1.IOBT might be a useful surgical treatment for patients with primary position hypertropia of less than 10 PD that was associated with mild to moderate IOOA,without any risk of Brown’s syndrome and anti-elevation syndrome.2.IOBT achieved better postoperative effect in individuals with 1+IOOA than2+IOOA.3.Unilateral IOBT achieved satisfactory outcomes in patients with V pattern that is associated with mild IOOA,without the risk of continuous A pattern.更多还原