先天性上斜肌麻痹患者二次手术的临床研究

Clinical study of reoperation on inferior oblique in patients with congenital superior oblique palsy

目的探讨先天性上斜肌麻痹患者二次手术的原因及治疗效果。方法对12例首次行下斜肌减弱术,术后出现欠矫的先天性上斜肌麻痹患者行下斜肌探查术和下斜肌二次减弱术。根据术中探查结果对二次手术的原因进行分析,并对手术前后的眼位、眼球运动、代偿头位、Bielschowsky征等评价指标进行比较分析。结果 12眼探查术中:发现4眼下斜肌断端与Tenon囊等组织包裹在一起,形成了连接;3眼下斜肌断端附着于眼球颞下方巩膜上;3眼有残留下斜肌肌束;2眼下斜肌后徙位置较常规后徙位置偏颞下方。术后随访1a,1例患者33cm垂直斜视度2△,其余11例患者33cm正位,所有患者6m正位,患眼下斜肌无亢进,Bielschowsky征为(-),无异常头位,与术前相比差异均有统计学意义,治愈率100%。3例下斜肌肌束残留患者首次行下斜肌减弱术后出现欠矫时间(平均18d)与其余9例患者(平均1.06a)相比缩短,差异有统计学意义(Z=2.593,P=0.009)。结论先天性上斜肌麻痹患者首次行下斜肌减弱术后出现的欠矫可表现为类似上斜肌麻痹的症状,通过下斜肌探查术可以明确病因,针对病因采取恰当的下斜肌二次减弱术可以获得较好的手术效果。

Objective To investigate the reason for and therapeutical effect of reoperation on inferior oblique （IO） in patients with congenital superior oblique palsy （CSOP）. Methods IO exploratory surgery and a second IO weakening were performed on 12 patients （ 12 eyes） with CSOP who showed undercorrection after the flrst IO weakening. The reason for reoperation was analyzed according to the result of IO exploratory surgery. Then factors before and after operation including Position of eye, eye movement, compensatory head posture （CHP） and Bielschowsky symptom were comparatively analyzed. Results IO exploratory surgery showed that broken ends of IO entwined with TENON capsule in 4 eyes;Broken ends of IO adhered to infratemporal sclera in 3 eyes;Residual IO muscle bundles existed in 3 eyes;anterior transpositions of IO were further infratemporal than normal in 2 eyes. After 1 year follow-up, strabismus degree（33 cm） of 1 eye was with 2a vertical deviation,strabismus degrees（33 cm） of the rest eyes were normal,strabismus degrees（6 m） of all eyes were normal. No hyperfunction, abnormal CHP or Bielschowsky symptom was found after operation, compared with those before operation （ all P 〈 0.05 ）. The cure rate was 100%. Undercorrection time after the first IO weakening of the 3 eyes with residual IO muscle bundles was significantly shorter than that of the rest eyes （ Z = 2. 593, P = 0. 009 ）. Conclusion Symptom of undercorrection in eye with CSOP after the first IO weakening is similar to CSOP. Good therapeutical effect of nichetargeting reoperation may be achieved after determining specific pathogenesis by IO exploratory surgery.