共同性水平斜视患者水平直肌中睫状前血管的形态学观察

Morphological observation on the anterior ciliary vessels in the horizontal rectus muscles of patients with concomitant horizontal strabismus

目的观察共同性水平斜视患者水平直肌中睫状前血管(ACV)的数量及解剖特点。方法横断面研究。征集2016年7月至2019年9月于厦门大学附属厦门眼科中心拟行斜视矫正手术的共同性水平斜视患者,排除既往有眼部手术史者。截取斜视矫正手术视频中水平直肌中ACV图像,观察ACV的形态特点,比较内、外直肌中ACV数量以及形态上分布的差异。在不保留ACV的肌肉截除手术后,选择长度约4 mm、带有完整肌鞘的手术截除内直肌或外直肌组织,HE染色后观察ACV的动静脉属性以及其在肌肉和筋膜组织中的分布情况。采用χ2检验进行统计学分析。结果共纳入387例共同性水平斜视患者(内斜视176例、外斜视211例),其中男性198例,女性189例;年龄1~68岁(中位数为13岁)。383例患者的742条水平直肌的ACV图像显示,351条内直肌中分别有24条(6.8%)、163条(46.4%)、164条(46.7%)内直肌含有1、2、≥3根(或束)ACV;391条外直肌中分别有161条(41.2%)、156条(39.9%)、74条(18.9%)外直肌含有1、2、≥3根(或束)ACV,ACV在内、外直肌中数量分布差异有统计学意义(χ2=133.87,P<0.01)。根据ACV的数量及形态学特点,内、外直肌中ACV可分别分为4类3型3亚型及3类3型2亚型;31.6%(25/79)的患者双眼内直肌中ACV属于同一类型,26.1%(29/111)的患者双眼外直肌中ACV属于同一类型,内、外直肌间差异无统计学意义(χ2=0.69,P=0.41),但同一患者左、右眼中同一类型的ACV,其具体形态也不完全相同。内、外直肌中存在交通支的ACV比例分别为3.7%(13/351)和24.3%(95/391),差异有统计学意义(χ2=63.07,P<0.01)。4例患者的内直肌或外直肌组织HE染色显示,ACV中包含了动脉和静脉,内直肌中ACV分布于肌肉组织和筋膜组织,外直肌中ACV仅分布于筋膜组织。结论与外直肌不同,共同性水平斜视患者中近50%的内直肌包含3根(或束)以上的ACV。内、外直肌中ACV形态具有多样性,外直肌中ACV交通支比例更高。ACV中动、静脉共存,内直肌中ACV分布于肌肉和筋膜组织,外直肌中ACV仅分布于肌肉表面的筋膜组织。

Objective To observe the number of blood vessels and the anatomical characteristics of the anterior ciliary vessels(ACVs)in the horizontal rectus muscles of patients with concomitant horizontal strabismus.Methods Cross-sectional study.From July 2016 to September 2019 patients with concomitant horizontal strabismus treated by realignment surgeries in Xiamen Eye Center of Xiamen University were included.Patients who had previous operations on eyes were excluded.The high resolution surgical imaging of ACVs in the horizontal rectus muscles was performed during operation.The photos of ACVs in muscles were tagged and observed to compare the distribution of the various numbers of blood vessels and morphological characteristics of the ACVs in the medial and lateral rectus muscles.In addition,muscle tissues about 4 mm with an intact sheath were gained from patients undergoing the muscle resection.The muscle sections were stained with hematoxylin-eosin staining,and the arteriovenous properties and their distribution in muscles and fascia tissues were observed.The chi-square test was used for statistical analysis.Results A total of 387 patients with concomitant horizontal strabismus(176 with esotropia,211 with exotropia)were enrolled in this study,among whom 198 were male and 189 were female.The age ranged from 1 to 68 years(median,13 years).Photos of ACVs in 742 horizontal rectus muscles from 383 patients were observed.Of the 351 medial rectus muscles,24(6.8%)contained 1 major(or bundle of)ACV,163(46.4%)contained 2 major(or bundles of)ACVs,and 164(46.7%)contained 3 or more major(or bundles of)ACVs.Of the 391 lateral rectus muscles,161(41.2%)contained 1 major(or bundle of)ACV,156(39.9%)contained 2 major(or bundles of)ACVs,and 74(18.9%)contained 3 or more major(or bundles of)ACVs.The distribution of ACVs in the medial and lateral rectus muscles was statistically different(χ2=133.87,P<0.01).According to the number and morphological characteristics of vessels,the ACVs in the medial and lateral rectus muscles were divided into 4 and 3 categories,respectively,as well as various types and subtypes.The rate of patients whose both eyes had the same type of ACVs in the medial or lateral rectus muscles was 31.6%(25/79)and 26.1%(29/111),respectively,and there was no significant difference(χ2=0.69,P=0.41).However,the ACVs of the same type from both eyes of the same patient were not identical in morphology.The ACVs in the medial and lateral rectus muscles with collateral circulation accounted for 3.7%(13/351)and 24.3%(95/391),respectively,and the difference was statistically significant(χ2=63.07,P<0.01).The hematoxylin-eosin staining of the medial lateral rectus tissues from 4 patients showed that the ACVs contained arteries and veins.The vessels in the medial rectus muscles were distributed in muscle tissue and fascia tissue,while the vessels in the lateral rectus muscles were only distributed in fascia tissue.Conclusions Compared with the lateral rectus muscles,there are about 50%medial rectus muscles contain more than 3 major(or bundles of)vessels in patients with concomitant horizontal strabismus.The accompanying patterns of arteries and veins of ACVs are varied.ACVs are distributed in muscle tissue of the medial rectus muscles and in fascia tissue of the medial and lateral rectus muscles.(Chin J Ophthalmol,2020,56:197-204)