上斜肌手术方式的探讨

The surgery of superior oblique muscle

目的 探讨上斜肌折叠或肌腱切断手术的特殊性，掌握其手术适应证。方法 对18例先天性上斜肌麻痹施行上斜肌折叠术；对7例外斜视A征和7例动眼神经麻痹施行上斜肌肌腱切断术。观察手术中上斜肌解剖的特点及手术前后眼位、斜视角和临床特征的改变。结果 先天性上斜肌麻痹单侧12例、双侧6例行上斜肌折叠手术，均联合下斜肌减弱术。术中见上斜肌异常者9／18（50．00％），表现为肌腱松弛、肌止端附着点位于上直肌的鼻侧止端。手术矫正了原在位上斜视15^△～25^△，矫正鼻侧方向最大上斜视15^△～40^△。术后眼位恢复正位15眼，欠矫3眼，无过矫。外斜视A征伴双上斜肌亢进7例行双眼上斜肌肌腱切断术联合水平直肌手术，矫正了上下外斜角之差别20^△～30^△，消除了A征，未发现过矫，术后4例恢复双眼视觉。单侧动眼神经麻痹7例行上斜肌肌腱切断术矫正了原在位下斜视平均15^△，术后垂直斜视矫正6例，欠矫1例。结论 上斜肌肌止端解剖异常是先天性上斜肌麻痹发病原因之一；上斜肌折叠或肌腱切断术主要改善旋转功能和矫正鼻下方垂直斜角，宜联合下斜肌或水平直肌手术。

Objective To study the characteristics of tucking and tenectomy of superior oblique muscle （SOM） for sake of operating with optimal indications.Methods The tucking of SOM were taken on 18 patients with congenital superior oblique paralysis, and the tenectomy of SOM were operated on 7 patients with A exotropia while another 7 with Ⅲ nerve paralysis respectively. The gross anatomy characteristics of SOM during the surgery were concerned. Before and after the treatment, the ocular alignment, angle of deviation and the clinical manifestation were also recorded. Results 1. Tucking group ： the all 18 patients with congenital superior oblique paralysis （12 unilateral ＆ 6 bilateral） combined with recession of inferior oblique muscle. There were 9 in 18 eyes （50%） showing anomalies. They appeared to be loose tendon or the insertion locating at the nasal side of superior rectus insertion. Hypertropia of 15- 25 prism diopters（△） in primary position and maximal hypertropia of 15 - 40^△ in adduct position were all corrected. Despite of 3 cases that were undercorrected, 15 cases recovered with normal ocular alignment and no overcorrection. 2. Tenectomy group： 7 patients of A exotropia with bilateral excessive superior oblique. After the bilateral tenectomy of SOM, the A exotropia patterns were corrected between 20 - 30^△ , and no overcorrection was found. 4 patients obtained stereopsis. The other 7 patients suffered from unilateral Ⅲ nerve paralysis with hypotropia on average 15^△ in primary position were corrected. The vertical deviation was optimal corrected in 6 cases though 1 case was undercorrected. Conclusions The abnormalities of superior oblique insertion appear to be one of the causes of congenital superior oblique paralysis. The tucking and tenectomy of superior oblique muscle are capable to optimally correct the cyclo-function and vertical deviation in downward gaze.