上直肌移位及其联合加强缝线术与垂直肌移位术治疗完全性展神经麻痹性斜视的临床效果观察

Clinical observation of superior rectus transposition with/without augmented suture and vertical rectus transposition for the treatment of strabismus caused by complete abducens nerve palsy

目的比较上直肌移位术(SRT)、上直肌移位术联合加强缝线术(SRTA)与垂直肌移位术(VRT)治疗完全性展神经麻痹性斜视的疗效和安全性。方法回顾性队列研究。收集2015年1月至2020年11月在天津市眼科医院行斜视矫正手术的完全性展神经麻痹性斜视42例(42只眼)患者资料。根据术式分为:SRT组(16例),即SRT联合内直肌后徙术(MRc);SRTA组(13例),即SRT联合Buckley缝线和MRc;VRT组(13例)。分析比较3个组术前及术后1、6、12个月的斜视度数、眼球运动、双眼视功能及术后并发症等情况。计数资料组间比较采用χ^(2)检验;计量资料采用重复测量方差分析,组间及组内两两比较采用LSD-t检验。结果3个组间性别分布、年龄及病程差异均无统计学意义(均P>0.05)。3个组术后1、6、12个月的斜视度数均低于术前,差异均有统计学意义(均P<0.001),其中SRT组、SRTA组、VRT组术后12个月斜视度数分别为(+0.8±5.8)、(+0.8±4.5)、(+1.2±2.5)三棱镜度(PD),均低于术前的(+82.8±17.2)、(+77.7±26.1)、(+71.5±18.6)PD;但术后各时间点间差异均无统计学意义(均P>0.05)。术前及术后3个组之间斜视度数差异无统计学意义(P>0.05)。3个组术后1、6、12个月的麻痹眼外转功能分级与术前比较差异均有统计学意义(均P<0.001),如SRT组、SRTA组、VRT组术前外转功能分级分别为(-4.4±0.5)、(-4.4±0.5)、(-4.5±0.5)级,术后12个月分别为(-2.3±0.7)、(-2.2±0.5)、(-2.1±0.6)级;但术后各时间点间差异均无统计学意义(均P>0.05)。术前及术后3个组之间麻痹眼外转功能差异无统计学意义(P>0.05)。3个组术后1、6、12个月麻痹眼内转功能分级与术前比较差异均有统计学意义(均P<0.05),术后各时间点之间差异均无统计学意义(均P>0.05)。术后6、12个月麻痹眼内转功能分级,SRT组[(-0.9±0.6)、(-0.8±0.6)级]与SRTA组[(-1.5±0.5)、(-1.4±0.5)级](t=-2.62、-2.52)、SRTA组与VRT组[(-0.8±0.8)、(-0.6±0.7)级](t=2.62、3.01)比较,差异均有统计学意义(均P<0.05)。术后12个月第一眼位获得立体视患者的比例3个组之间差异无统计学意义(P>0.05)。所有患者术后均无旋转复视、眼前节缺血并发症。SRTA组中2例术后术眼下斜视4~5 PD伴上转轻度落后。结论SRT、SRTA和VRT均能有效治疗完全性展神经麻痹性斜视且疗效相当,矫正眼位并能改善患者外展功能,恢复双眼视功能,疗效稳定,术后较少出现垂直及旋转斜视。

Objective To evaluate the efficacy and safety of superior rectus transposition(SRT)with/without augmented suture and vertical rectus transposition(VRT)for the treatment of strabismus caused by complete abducens nerve palsy.Methods This was a retrospective cohort study.Forty-two patients(42 eyes)with complete abducens nerve palsy underwent strabismic surgeries from January 2015 to November 2020 in Tianjin Eye Hospital.According to the different procedures,the patients were divided into three groups:SRT group(16 cases,SRT with medial rectus recession),superior rectus transposition with augmented suture(SRTA)group(13 cases,SRT with Buckley suture and medial rectus recession)and VRT group(13 cases).The preoperative and postoperative(1,6 and 12 months)data including deviations,ocular motility,binocular vision and surgical complications among three groups were analyzed and compared.χ^(2) test was used for comparison of count data among three groups.The measurement data were compared among three groups by the repeated measures ANOVA.LSD-t test was used for within-group comparison and between-group comparison.Results There was no difference in sex ratio,age and course of disease among the groups(all P>0.05).The horizontal deviations of the three groups at 1,6 and 12 months after surgeries was lower than that before surgeries,and the difference was statistically significant(all P<0.001).The horizontal deviations of the SRT group,SRTA group and VRT group at 12 months after surgeries were(+0.8±5.8),(+0.8±4.5),(+1.2±2.5)prism diopters(PD),respectively,lower than that of the preoperative(+82.8±17.2),(+77.7±26.1),(+71.5±18.6)PD.However,there was no significant difference among different postoperative follow-up timepoints(all P>0.05).There was no difference in horizontal deviations before surgeries and at 1,6 and 12 months after surgeries among three groups(P>0.05).There were significant differences in the scales of abduction motility among preoperative,postoperative 1,6 and 12 months measurements for three group(all P<0.001).The scales of abduction before surgeries in the SRT group,SRTA group,and VRT group were(-4.4±0.5),(-4.4±0.5),(-4.5±0.5)scale and at 12 months after surgeries were(-2.3±0.7),(-2.2±0.5),(-2.1±0.6)scale respectively.But there was no change among different postoperative follow-up timepoints(all P>0.05).Preoperative and postoperative 1-,6-and 12-month abduction motility was similar among three groups(P>0.05).There were significant differences in the scales of adduction limitation among preoperative,postoperative 1-,6-and 12-months measurements for three group(all P<0.05).But there was no change among different postoperative follow-up timepoints(all P>0.05).There were significant differences between the SRT group[(-0.9±0.6),(-0.8±0.6)scale]and the SRTA groups[(-1.5±0.5),(-1.4±0.5)scale](t=-2.62,-2.52)and between the SRTA group and the VRT group[(-0.8±0.8),(-0.6±0.7)scale](t=2.62,3.01)at 6 and 12 months after surgeries(all P<0.05).The outcomes of binocular vision at postoperative 12 months were similar among three groups(P>0.05).No patient had torsional diplopia and anterior segment ischemia.Only 2 patients from the SRTA group had hypotropia of 4 to 5 PD in the primary position associated with supraduction limitation.Conclusions SRT with/without augmented suture and VRT are effective and safe procedures for the treatment of strabismus caused by complete abducens nerve palsy.They could correct deviations,improve abduction motility and restore binocular vision,with stable outcomes and a small risk of vertical and torsional diplopia.