蝴蝶结调整缝线术应用于间歇性外斜视术后过矫的临床观察

Clinical observation of bow-tie adjustable suture technique for overcorrection in intermittent exotropia

目的探讨蝴蝶结调整缝线术应对间歇性外斜视患者术后过矫的临床效果。方法回顾性病例系列研究。收集2020年1月至2021年9月于山西省眼科医院斜视与小儿眼科行斜视矫正手术的间歇性外斜视患儿的临床资料,手术方式包括含蝴蝶结调整缝线术和常规术式。术后第6天内斜视度数≥15 三棱镜度(PD)的患儿根据术式和自身情况给予不同处理方法,包括调整缝线和保守治疗。观察不同术式患儿术后过矫率及变化,术后第6天过矫患儿经不同方法处理后眼位及双眼视功能的恢复情况,以及不同术式患儿术后并发症。采用独立样本t检验、Wilcoxon秩和检验、重复测量方差分析、Bonferroni检验、χ2检验或Fisher精确概率检验进行统计学分析。结果共纳入行间歇性外斜视矫正手术患儿643例。其中325例行蝴蝶结调整缝线术,男性185例,女性140例;年龄(9.50±2.69)岁。其余318例行常规术式,男176例,女142例;年龄(9.90±2.67)岁。两种术式患儿的年龄和性别分布差异均无统计学意义(均P>0.05)。术后第1天,行蝴蝶结调整缝线术患儿内斜视度数≥10 PD者40例,过矫率12.3%(40/325),行常规术式患儿内斜视度数≥10 PD者32例,过矫率10.1%(32/318);术后第6天分别降至5.5%(18/325)和3.1%(10/318)。术后第1、6、12个月,行蝴蝶结调整缝线术患儿过矫率均为0,而行常规术式患儿过矫率较之前无明显下降,两种术式相比差异均有统计学意义(均P<0.05)。术后第6天,内斜视度数≥15 PD患儿中行缝线调整者13例,保守治疗者7例。重复测量方差分析结果显示,接受不同处理方法患儿视近、视远斜视度数差异有统计学意义(F=145.20、106.87,均P<0.001),患儿不同时间点视近、视远斜视度数差异有统计学意义(F=81.67、35.09,均P<0.001),接受不同处理方法的患儿在不同时间点视近、视远斜视度数变化趋势间存在差异(F=79.90、36.73,均P<0.001)。进一步两两比较结果显示,术后第6天与术后第1、6、12个月视近、视远斜视度数比较,调整缝线患儿差异有统计学意义(均P<0.05),保守治疗患儿差异无统计学意义(均P>0.05)。术后第12个月,13例调整缝线患儿中12例有近立体视觉;7例保守治疗患儿在去除配戴的三棱镜后均为近立体视盲。所有患儿术后均未发生严重并发症。结论间歇性外斜视矫正手术后第6天过矫度数≥15 PD的患儿术后1年眼位恢复正位的比例较低;蝴蝶结调整缝线术应对间歇性外斜视患者术后过矫操作简单,术后第6天调整,可降低术后过矫率,较为安全有效。

Objective To investigate the clinical effects of the bow-tie adjustable suture technique in managing overcorrection in patients with intermittent exotropia after surgery.Methods This was a retrospective case series study.Clinical data were collected from children with intermittent exotropia who underwent strabismus correction surgery,including the bow-tie adjustable suture technique and conventional techniques,at the Department of Strabismus and Pediatric Ophthalmology,Shanxi Eye Hospital,from January 2020 to September 2021.Children with postoperative esodeviation≥15 prism diopters(PD)within the first 6 days were treated differently based on the surgical technique and their individual conditions,including suture adjustment and conservative treatment.The overcorrection rate and its changes among different surgical groups,the recovery of ocular alignment and binocular visual function after different treatment methods in children with overcorrection on the sixth postoperative day,and the postoperative complications in different surgical groups were observed.Statistical analysis was performed using independent samples t-test,Wilcoxon rank-sum test,repeated-measures analysis of variance,Bonferroni test,chi-square test,or Fisher′s exact probability test,as appropriate.Results A total of 643 children who underwent intermittent exotropia correction surgery were included in the study.Among them,325 children underwent the bow-tie adjustable suture technique,with 185 males and 140 females,and the mean age was(9.50±2.69)years.The remaining 318 children underwent conventional techniques,with 176 males and 142 females,and the mean age was(9.90±2.67)years.There were no statistically significant differences in age and gender distribution between the two surgical groups(all P>0.05).On the first postoperative day,among children who underwent the bow-tie adjustable suture technique,40 had an esodeviation of≥10 PD,resulting in an overcorrection rate of 12.3%(40/325),while among children who underwent conventional techniques,32 had an esodeviation of≥10 PD,resulting in an overcorrection rate of 10.1%(32/318).On the sixth postoperative day,these rates decreased to 5.5%(18/325)and 3.1%(10/318)in the two groups,respectively.At 1,6,and 12 months postoperatively,the overcorrection rate in children who underwent the bow-tie adjustable suture technique was 0,while in children who underwent conventional techniques,the overcorrection rate did not show a significant decrease compared to before surgery.The differences between the two surgical groups were statistically significant(all P<0.05).On the sixth postoperative day,among children with an esodeviation of≥15 PD,13 underwent suture adjustment and 7 received conservative treatment.The results of repeated-measures analysis of variance showed statistically significant differences in near and distance esodeviation angles among children who received different treatment methods(F=145.20,106.87,both P<0.001),as well as statistically significant differences in near and distance esodeviation angles at different time points within each group of children(F=81.67,35.09,both P<0.001).There were also significant differences in the trends of change in near and distance esodeviation angles at different time points among children who received different treatment methods(F=79.90,36.73,both P<0.001).Further pairwise comparisons showed significant differences in near and distance esodeviation angles between the sixth postoperative day and 1,6,and 12 months postoperatively in children who underwent suture adjustment(all P<0.05),while no statistically significant differences were observed in children who received conservative treatment(all P>0.05).At 12 months postoperatively,among the 13 children who underwent suture adjustment,12 achieved stereopsis,while among the 7 children who received conservative treatment,all became stereo-blind after removing the prismatic correction.No serious complications occurred in any of the children postoperatively.Conclusion The proportion of children with intermittent exotropia who achieved orthotropic alignment one year after surgery was relatively low among those who had an overcorrection of≥15 PD on the sixth postoperative day.The bow-tie adjustable suture technique is a simple and effective approach for managing overcorrection in patients with intermittent exotropia.Adjusting the sutures on the sixth postoperative day can reduce the overcorrection rate and is considered a safe and effective method.