先天性眼球震颤患者视频眼动图的分析和眼外肌超微结构的观察

发布时间：2018-02-24 13:53

本文关键词： 先天性眼球震颤改良Kestenbaum术视频眼动图眼外肌超微结构　出处：《天津医科大学》2010年博士论文　论文类型：学位论文

【摘要】：目的本课题旨在分析先天性眼球震颤(congenital nystagmus, CN)患者眼震中间带移位术(改良Kestenbaum术)治疗前后的临床指标和视频眼动参数,为评价此种术式的疗效提供客观依据；通过CN患者眼外肌(EOMs)超微结构的观察,从形态学角度分析EOMs结构对CN的影响,以探讨CN的发病机制。方法 1.选取伴有明显代偿头位但不伴有斜视的CN患者16例进行改良Kestenbaum术。对于头位扭转角度为25°-30°的患者,采用Parks5-6-7-8手术设计量,300以上的患者调整扩大手术量；对于双中间带者将眼震一组慢相侧的直肌减弱；对水平眼震面转并伴有垂直头位者同时行水平和垂直肌减弱术。 2.对CN患者进行详细的临床检查,包括视力、屈光、眼前段、眼底、眼位、眼球运动、头位扭转角度,做三棱镜耐受试验。 3.对上述16例CN患者进行手术前后的视频眼动仪检测,对所记录的眼动参数加以分析。眼动参数包括眼震振幅、频率、黄斑中心凹注视时间、NAFX值(眼震视力函数值)和眼震中间带范围。手术前后眼动参数比较采用配对t检验,眼震振幅、眼震频率、黄斑中心凹注视时间与NAFX值的相关分析采用Pearson相关性分析,P0.05为差异有统计学意义。 4.对CN患者术中截除的眼震快相侧的眼外肌末梢进行光镜和透射电镜观察,正常对照来自因眼外伤需行眼球摘除且无眼球运动障碍患者的健康眼外肌和正常尸检标本,共同性斜视组来自本院行斜视矫正术患者术中截除的水平直肌。结果 1.CN患者手术治疗前后的临床指标：患者术前均有明确的中间带和代偿头位,术后所有患者代偿头位均有显著改善,术后残余水平代偿头位扭转角平均4.8°。1例水平双中间带30°者,手术只做一组眼震慢相侧直肌减弱术,术后头位基本消失,未出现相反方向的代偿头位。1例因垂直代偿头位明显,故在行中间带方向两条水平直肌减弱的同时行垂直直肌和斜肌的减弱术,术后垂直头位消失,水平残留5°代偿头位,手术前后均未发现斜视。术后双眼最好视力提高者8例(占50%),其中提高3行者：1例,提高2行者：1例,提高1行者：6例；下降1行者：2例；视力无变化者：6例。手术前后视力(换算为对数视力)比较,经统计学分析,t=-2.373,p=0.031,差异具有统计学意义。术后Titmus提高者11例,占61%,但手术前后立体视比较经统计学分析,t=1.147,p=0.270,差异无统计学意义。术前伴有摇头或点头者3例(占18%),术后其中2例摇头改善。术后主观感觉视物清晰度增加者12例(占71%),自觉视物清晰范围扩大者6例(占35%),术后无变化6例(占35%)。 2.CN患者视频眼动图分析：16例患者眼动记录均为速度递增型眼震,以水平眼震为主,其中11例伴有不同程度的垂直眼震(占65%),13例有集合抑制存在(占76%),9例伴有隐性眼震(占53%)。手术前后眼震振幅、NAFX值和中间带范围的比较,经统计学分析,差异均有显著性(P0.05),术后眼震振幅下降,NAFX值增加,眼震中间带扩大,眼震振幅与NAFX值具有相关性(r=-0.528,p=0.002),眼震频率与NAFX值呈一定线性趋势,但无相关性(r=-0.263,p=0.145夕,每秒黄斑中心凹注视时间与NAFX值之间为非线性关系。 3.CN患者眼外肌超微结构观察：光镜下CN患者眼外肌肌纤维变细,排列不规则,细胞核细长。透射电镜下眼外肌肌浆网呈明显空泡样变,栅栏样终末的层状结构不同程度的溶解甚至消失,呈无结构的嗜锇酸样黑色变化,而正常和共同性斜视对照组却无此改变。无论是正常和共同性斜视对照组还是CN组,直肌止点附近栅栏样神经终末结构数量少,肌肉肌腱连接区此结构数量最多。结论 1.改良Kestenbaum术不仅改善代偿头位,而且近期能够减轻眼震和扩大眼震中间带范围。 2.NAFX值可以作为CN患者中间带移位手术疗效判别较为准确、客观的眼动参数指标,视频眼动仪检测有助于眼震的诊断和治疗。 3.CN患者水平直肌末梢显示特有的超微结构改变,即肌浆网扩张呈空泡状,栅栏样终末呈无结构的嗜锇酸样黑色变化,这些改变可能与CN的病因或发病机制有关。
[Abstract]:Purpose The purpose of this study was to analyze the clinical indexes and video eye movement parameters before and after the treatment of congenital eyeball tremor ( CN ) in patients with congenital eye tremor ( CN ) . To provide an objective basis for evaluating the curative effect of this procedure , the effect of EOMs structure on CN was analyzed from the morphological angle by observing the ultrastructure of extraocular muscles ( EOMs ) of CN patients , so as to explore the pathogenesis of CN . method 1 . The modified Kestenbaum technique was performed in 16 patients with CN patients with obvious compensatory head position but not accompanied with oblique view . For patients with head torsion angle of 25 掳 - 30 掳 , the operation volume was adjusted by using Parks5 - 6 - 7 - 8 operation design . 2 . A detailed clinical examination of CN patients , including visual acuity , refractive index , anterior segment , eyeground , eye position , eye movement , head torsion angle , and triprism tolerance test were performed . 3 . The eye movement parameters of 16 CN patients before and after operation were analyzed . The eye movement parameters include the amplitude of the eye , the frequency of the center of the macula , the time of the concave fixation of the center of the macula , the value ( the value of the visual function of the eye shake ) and the range of the median zone of the eye . 4 . Observation of the extraocular muscle tip and transmission electron microscopic observation of the quick - phase side of the extraocular muscles during the operation of CN patients were observed . The normal controls were derived from the healthy extraocular muscles and normal autopsy specimens from patients with ocular trauma . Results 1 . There was a significant improvement in postoperative visual acuity ( 50 % ) . 2 . Analysis of video eye movement in patients with CN : The eye movement recorded in 16 cases was speed - increasing type eye shock . Among them , 11 cases were accompanied with different degrees of vertical eye shock ( 65 % ) , 13 cases had significant difference ( P < 0.05 ) , 9 cases had significant difference ( P = 0.002 ) , and the amplitude of the eye shock was correlated with the value of the middle band ( r = - 0.528 , p = 0.002 ) . 3 . The ultrastructural observation of extraocular muscles of CN patients showed that the muscle fibers of extraocular muscles of CN patients were thinner , irregular in arrangement and elongated in nucleus . Conclusion 1 . The modified Kestenbaum technique not only improves the compensatory head position , but also can reduce the eyestrain and enlarge the mid - band range of the eyestrain in the near term . 2 . It can be used as an accurate and objective index of eye movement parameters for the diagnosis and treatment of eye shock in patients with CN . 3 . At the end of the horizontal rectus muscle of the CN patients , the specific ultrastructural changes , that is , the dilatation of the sarcoplasmic reticulum , appear to be empty , and the end of the palisade sample presents a non - structural osmiophilic black change which may be related to the etiology or pathogenesis of the CN .

【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2010
【分类号】：R777.46

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