上斜肌加强术与下斜肌减弱术矫正先天性单眼上斜肌麻痹的疗效分析

发布时间：2018-04-21 10:47

本文选题：上斜肌折叠术 + 下斜肌切断术　；参考：《天津医科大学》2016年硕士论文

【摘要】：目的:探讨上斜肌折叠术与下斜肌切断术对单侧先天性上斜肌麻痹的手术效果。主要从原在位垂直斜度的矫正,眼底客观旋转度数的改变,代偿头位的改善、双眼视觉以及Bielschowsky歪头试验的影响等方面,对两种术式疗效分析对比,为临床治疗提供参考。方法:回顾分析2014年2月到2015年10月因“单侧先天性上斜肌麻痹”于天津市眼科医院住院治疗,并行单眼上斜肌折叠术或者下斜肌切断术,所有手术均由同一术者完成。上斜肌折叠组22例(单眼22例)及下斜肌切断组25例(单眼25例)纳入本研究。观察记录手术前后原在位垂直斜度的改变、眼底客观旋转斜度的变化、Bielschowsky歪头试验的变化、头位的变化、以及双眼视的变化。手术前后根据眼底照片记录眼底客观旋转度数,使用Coredraw软件测量黄斑-视盘夹角(fovea disc angle,FDA);测量头部向健眼和患眼两侧倾斜时,患眼垂直斜视度数的差值,大于5.0PD为Bielschowsky歪头试验阳性;骨科测量进行代偿头位的度数测量,一侧平行于脸部矢状轴,另一侧垂直于地面;同视机、Titmus立体视评估双眼视功能。所有数据资料的统计学分析均在SPSS l7.0软件上进行。结果:1、单眼下斜肌切断术组,术前原在位垂直数斜视度为(12.22±3.79)PD,术后减少至(3.52±2.17)PD,平均矫正量为(8.52+2.67)PD。22例行单眼上斜肌折叠的手术患者,术前原在位垂直斜视度为(4.24±1.72)PD,平均矫正量为(2.23±1.91)PD。两种术式矫正原在位垂直斜视的差值有统计学意义(F=11.38,P(27)0.05),上斜肌折叠手术中,原在位斜视度数的矫正量与上斜肌折叠的手术量无相关性(Spearman相关系数=0.235,P(29)0.05)。2、下斜肌切断组中,患者术前头部向患眼侧与健眼侧两侧倾斜时,患眼的斜视度数的差值为10.00PD~28.00PD;术后末次复诊,差值为2.00PD~12.00PD。术前组与术后末次复查组差值差异具有统计学意义(P0.05(8)。术前25例患者Bielschowsky歪头试验均为阳性,术后转阴率24%(6/25),其余76%(19/25)患者仍为阳性。22例上斜肌折叠组,术前头部向两侧倾斜时,患眼的斜视度数的差值为5.00PD~17.00PD;术后末次复诊,差值为0.00PD~14.00PD。术前组与术后末次复查组差异有统计学意义(P0.05/3(8)。术前患者Bielschowsky歪头试验均为阳性,末次复诊77.27%(17/25)的患者Bielschowsky歪头试验转阴,22.73%(5/22)的患者仍为阳性。6例患者术后转为阴性。两组采用Fisher确切检验,差异有统计学意义(P0.05(8),两种术式对 Bielschowsky歪头试验的转阴率有明显差别。3、25例单眼下斜肌切断患者,术前总FDA为(22.67士7.77)°,末次复查总FDA分别为(15.94士7.81)°,FDA各组间差异有统计学意义(F=12.99,P0.05)。22例单眼上斜肌折叠患者,术前总FDA为(17.76士6.23)°,末次复查总FDA为(9.60士6.26)°,FDA各组间差异有统计学意义(F=23.634,P0.05),术后1天组与末次复查组组间对比的差异无统计学意义(P(29)0.05)。4、下斜肌切断和上斜肌折叠两种术式,均可提高双眼视功能。下斜肌切断手术和上斜肌折叠手术术后代偿头位均可得到改善。上斜肌折叠手术的患者,术后短期出现轻度的内上转受限,远期仅1例患者出现内转眼极度内上转时出现复视。而下斜肌切断组并未出现任何的并发症。结论:1、上斜肌折叠术通过加强松弛的上斜肌肌腱,解决上斜肌功能落后。下斜肌切断术可有效的缓解因先天性单侧上斜肌麻痹引起的继发性下斜肌功能亢进。根据Knapp分型,选择合适的术式,两种手术方式在矫正原在位垂直斜度上有明显差异。上斜肌折叠手术适用于:上斜肌肌腱松弛,符合Knapp II型;原在位垂直斜度较小;已行下斜肌减弱术,仍有残留头位;存在明显客观或者主观旋转。下斜肌切断手术适用于:下斜肌亢进为主,符合Knapp I型;垂直斜度15PD;代偿头位明显;存在客观旋转。2、对于因先天性上斜肌麻痹引起的外旋转偏斜,上斜肌折叠术与下斜肌切断术均能明显矫正。两种手术方式在旋转偏斜量的矫正上,下斜肌切断手术稍多于上斜肌折叠手术,但差异无统计学意义,术后短期效果稳定,远期效果尚需进一步观察。3、上斜肌折叠手术与下斜肌切断手术这两种术式对Bielschowsky歪头试验的转阴率有明显差别,上斜肌折叠手术对Bielschowsky歪头试验的转阴率(77.27%)明显高于下斜肌切断术(24%)4、两种术式均能有效改善代偿头位。5、本研究中,本研究随访时间较短,平均3个月,对于手术效果是否随着时间延长而呈现回退趋势,远期效果有待进一步探讨。
[Abstract]:Objective: To investigate the effect of superior oblique muscle folding and inferior oblique muscle transection on unilateral congenital superior oblique paralysis, mainly from the correction of the primary vertical slope, the change of the objective rotation degree of the fundus, the improvement of the compensatory head position, the binocular vision and the effect of the Bielschowsky skew test. Bed treatment provided reference. Methods: retrospective analysis was carried out from February 2014 to October 2015 in Tianjin Ophthalmological Hospital for "unilateral congenital superior oblique paralysis" in Tianjin Ophthalmological Hospital, parallel monocular superior oblique muscle folding or inferior oblique muscle resection. All the operations were performed by the same operator. 22 cases (22 cases of monocular and inferior oblique) and 25 cases of inferior oblique muscle resection group (22 cases of single eye) and inferior oblique muscle group (25 cases). 25 cases of monocular were included in this study. The changes of primary vertical slope before and after surgery, changes in objective rotation slope of the fundus, changes in Bielschowsky head test, changes in head position, and changes in binocular vision were recorded. The objective rotation degree of the fundus was recorded before and after the operation, and the angle of the macula optic disc was measured by Coredraw software. Fovea disc angle, FDA); the difference in the degree of vertical strabismus of the eyes when the head was tilted on both sides of the eye and the affected eyes was greater than that of 5.0PD as a Bielschowsky skew test; the measurement of the compensatory head in the Department of orthopedics was parallel to the sagittal axis of the face, and the other side was perpendicular to the ground; and the Titmus stereopsis evaluated binocular vision with the visual machine. Statistical analysis with data was carried out on SPSS l7.0 software. Results: 1, the preoperatively orthodontic strabismus was (12.22 + 3.79) PD before operation, and decreased to (3.52 + 2.17) PD after operation, and the average correction was (8.52+2.67) PD.22 routine upper oblique muscle folds, and the preoperatively vertical strabismus was (4.24). 1.72) PD, the average correction was (2.23 + 1.91) PD., and the difference between two orthodontic orthoptic orthopotropia was statistically significant (F=11.38, P (27) 0.05). There was no correlation between the correction of primary strabismus degree and the amount of upper oblique muscle folding (Spearman correlation coefficient =0.235, P (29) 0.05).2, and the lower oblique muscle cutting group. The difference between the strabismus degree of the affected eyes was 10.00PD~28.00PD when the head of the head was tilted to the side of the eye and the side of the healthy eye before operation. The difference was statistically significant (P0.05 (8)). The difference value between the pre operation group and the final reexamination group was (P0.05). The 25 cases before the operation were all positive for the Bielschowsky skew test and 24% (6/25) after the operation. The other 76% (19/25) patients were still positive.22 cases of superior oblique muscle folding group. The difference between the strabismus degree of the affected eyes was 5.00PD~17.00PD when the head was tilted on both sides of the head before operation, and the difference was statistically significant (P0.05/3 (8)). The difference was statistically significant (P0.05/3 (8)). 77.27% (17/25) patients at the last visit (17/25) were turned into negative Bielschowsky test, and 22.73% (5/22) patients were still positive for positive.6 patients after operation. The two groups were confirmed by Fisher, the difference was statistically significant (P0.05 (8), and the two kinds of surgical methods had significant difference in the negative rate of Bielschowsky in.3,25 case of single eye oblique muscle resection. The total FDA was (22.67 se 7.77), and the final review total FDA was (15.94. 7.81) degrees respectively. There were statistical significance (F=12.99, P0.05).22 cases with unilateral upper oblique muscle fold. The total FDA before operation was (17.76, 6.23) degrees, and the final review total FDA was (9.60. 6.26) degrees. The difference between the FDA groups was statistically significant (F=23.634, P0.05), and the group 1 days after the operation and the end of the operation. There was no significant difference in the contrast between the two groups (P (29) 0.05).4, the lower oblique muscle and the upper oblique muscle folded two kinds, which could improve the binocular function. The compensatory head of the inferior oblique and upper oblique muscle foldable surgery could be improved. Only 1 patients appeared diplopia in the case of extreme internal rotation. The lower oblique muscle group did not have any complications. Conclusion: 1, the upper oblique muscle folding can solve the inferior oblique muscle function backwardness by strengthening the relaxed superior oblique muscle tendon. The inferior oblique muscle transection can effectively relieve the secondary slant caused by the first unilateral unilateral superior oblique palsy. Hyperfunction of the muscle. According to the Knapp classification, the appropriate surgical procedure was selected. The two surgical methods were significantly different in the orthodontic vertical slope. The upper oblique muscle folding operation was suitable for the relaxation of the superior oblique muscle, which was in line with the Knapp II type; the original ortho vertical slope was smaller; the lower oblique muscle weakened and still had the residual head position; there was obvious objective or subjective rotation. The operation of inferior oblique muscle resection is suitable for the hyperactivity of the inferior oblique muscle, conforming to the Knapp I type, the vertical gradient 15PD, the compensatory head obvious, the existence of the objective rotation.2, the external rotation deviation caused by the congenital superior oblique paralysis, the superior oblique muscle folding and the inferior oblique muscle transection, and the two surgical methods in the correction of the rotation deviation. A little more than the upper oblique muscle folding operation, the difference was not statistically significant, and the short-term effect was stable after operation. The long-term effect still needed to be further observed by.3. There was a significant difference between the two types of superior oblique muscle folding surgery and the inferior oblique muscle cutting operation on the negative rate of the Bielschowsky head test, and the upper oblique muscle folding operation on the Bielschowsky head test. The negative rate (77.27%) was significantly higher than that of the inferior oblique muscle (24%) 4, and the two kinds of surgical methods could effectively improve the compensatory head.5. In this study, the follow-up time was shorter and the average of 3 months was 3 months.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R779.6

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