眼表微创法注射A型肉毒毒素治疗斜视

Minimally invasive injection of botulinum toxin type A from ocular surface for strabismus

目的探讨手术显微镜下微创法经球结膜行眼外肌A型肉毒毒素(botulinum toxinA,BTXA)注射,治疗不同种类斜视的可行性和安全性。方法选取2010年5月至2011年4月来我院接受BTXA治疗的18例(18眼)斜视患者,在手术显微镜下于所需注射眼外肌附着处旁切开结膜约2mm,分离并清晰暴露巩膜和肌肉止端,用斜视钩将眼外肌肉轻轻提起,注射针头走向与肌肉呈15°夹角,在显微镜直视下将BTXA注入肌肉或肌鞘内。治疗后1周和6周时随访,观察眼位、眼球运动、代偿头位、复视症状改善程度以及并发症等。结果治疗前、治疗后1周及6周时的平均斜视度数分别为22.9△、6.9△、7.7△;随访中仅1例较治疗前无改善;治疗前分别与治疗后1周及6周的斜视度数进行比较,差异均有统计学意义(均为P<0.05);治疗后1周及6周间差异无统计学意义(P>0.05)。两次复诊的斜视度数以及正位率之间差异无统计学意义(均为P>0.05)。治疗前有明显眼球运动障碍者12例经BTXA注射后均得到改善;伴复视者12例中11例经治疗正前方及前下方复视消失,1例有所改善;伴代偿头位者3例,均得到改善。2例出现上睑下垂,2例出现垂直斜视。结论手术显微镜下经球结膜微小切口对眼外肌进行BTXA注射治疗斜视,近期效果理想,安全性高,且并发症少。

Objective To study the feasibility and security of the bulbar conjunctiva injection of botulinum toxin A（BTXA） operated under a microscope by minimally invasive surgery for different kinds of strabismus.Methods Eighteen patients（18 eyes） were diagnosed as strabismus and received the injection of BTXA from May 2010 to April 2011 in our hospital.After a minimal conjunctival incision（2 mm） was made under a microscope,the extraocular muscles were pulled up with a strabismus hook to ensure the safe distance between the extraocular muscles and eyeball.Thus the target muscles under the conjunctiva exposed completely and the operator injected the varying doses of BTXA at 15° according to the patients’ conditions.All patients were followed up for 1 week and 6 weeks after the operation,the deviation angles,eye movement,compensated head position,diplopia and complications were observed.Results The mean preoperative and postoperative 1 week and 6 weeks deviation angle were 22.9△,6.9△ and 7.7△,respectively,and only one patient had no obvious improvement,there were statistical differences between preoperative and postoperative 1 week,6 weeks（both P0.05）,but no statistical difference in deviation angle and normotopic rate between postoperative 1 week and 6 weeks（both P0.05）.Twelve patients with preoperative eye movement disorders all improved after BTXA injection.Among the 12 subjects with diplopia,11 cases recovered in straight-ahead gaze and anteroinferior gaze,and 1 case improved.Three patients with preoperative compensated head position all improved.Ptosis occurred in 2 cases and vertical strabismus in another 2 cases.Conclusion The injection of BTXA into extraocular muscles by minimally invasive surgery under the microscope for strabismus is safe and effective with little complications.