A型肉毒毒素注射治疗外伤性完全性展神经麻痹性斜视的临床观察

Clinical observation on the efficacy of botulinum toxin type A injection for the treatment of traumatic strabismus caused by complete abducens nerve palsy

目的观察A型肉毒毒素注射治疗外伤性完全性展神经麻痹性斜视的效果。方法回顾性队列研究。纳入2018年1月至2022年10月就诊于空军军医大学第一附属医院外伤性完全性展神经麻痹性斜视患者29例(33眼)。根据病程分为两组:病程6个月内为注射组,14例(18眼),行A型肉毒毒素注射治疗,注射后3个月残余斜视度数≥15^(△)者予以重复注射或眼外肌手术;病程6个月以上为对照组,15例(15眼),行眼外肌手术。比较两组患者治疗前后斜视度数、患眼外直肌功能、立体视等。结果注射组治疗前、A型肉毒毒素治疗后1个月、3个月视近斜视度数分别为55.00(40.00,91.25)^(△)、11.00(6.25,18.75)^(△)、20.00(8.25,53.75)^(△);视远斜视度数分别为92.50(75.00,105.00)^(△)、20.00(11.00,30.50)^(△)、27.50(16.25,76.25)^(△);患眼外直肌功能分别为-5.00(-5.00,-4.75)级、-3.00(-4.00,-1.75)级、-3.00(-4.00,-1.00)级,治疗后各时间点与治疗前比较差异有统计学意义(Waldχ^(2)=109.16、125.18、54.01,均P<0.001)。注射后3例治愈,9例好转及2例无效者行眼外肌手术。治疗后6个月,13例正位、1例欠矫,8例恢复三级视功能、6例恢复近立体视;视近斜视度数2.00(0,2.00)^(△)、视远斜视度数3.00(1.75,5.00)^(△),患眼外直肌功能-1.00(-2.00,0)级与治疗前比较差异均有统计学意义(Waldχ^(2)=114.51、280.42、366.46,均P<0.001)。对照组患者治疗后6个月视近斜视度数2.00(1.00,3.00)^(△)、视远斜视度斜视度数3.00(2.00,5.00)^(△),患眼外直肌功能-2.00(-2.00,-1.00)级与治疗前视近斜视度数80.00(60.00,90.00)^(△)、视远斜视度数100.00(90.00,120.00)^(△),患眼外直肌功能-5.00(-5.00,-5.00)级比较差异有统计学意义(Z=3.41、3.41、3.49,P=0.001、P=0.001、P<0.001)。14例正位、1例欠矫,2例恢复三级视功能、1例恢复近立体视。两组患者治疗前视近、视远斜视度数及外直肌功能比较差异无统计学意义(U=61.50、84.00、147.00,均P>0.05)。治疗后6个月注射组视近视远斜视度数较对照组差异均无统计学意义(U=84.00、89.00,均P>0.05),患眼外直肌功能比较差异存在统计学意义(U=180.00,P<0.05)。结论A型肉毒毒素注射治疗外伤性完全性展神经麻痹性斜视可矫正眼位、改善外直肌功能,恢复视功能。部分残余斜视度患者需联合眼外肌手术矫正眼位。

ObjectiveTo observe the efficacy of botulinum toxin type A injection for the treatment of traumatic strabismus caused by complete abducens nerve palsy.MethodsThis was a retrospective case-control study.A total of 33 eyes of 29 patients who were diagnosed as traumatic strabismus caused by complete abducens nerve palsy in the First Affiliated Hospital of Air Force Military Medical University from Jan.2018 to Oct.2022 were included.The patients were divided into two groups based on disease duration.Fourteen patients(18 eyes)with a disease course of<6 months who were treated with botulinum toxin type A were included in the injection group,in which the patients with residual strabismus≥15^(△)after 3 months of injection were subjected to extraocular muscle surgery or repeated injections.Fifteen patients(15 eyes)with a disease course of≥6 months underwent extraocular muscle surgery were included in the control group.The deviation,rectus muscle function and stereopsis of the affected eye before and after treatment were compared between the two groups.ResultsIn the injection group,the deviation of near-vision before and after botulinum toxin type A treatment(1 month,3 months)were 55.00(40.00,91.25)^(△),11.00(6.25,18.75)^(△),and 20.00(8.25,53.75)^(△),respectively.The deviation of far-vision were 92.50(75.00,105.00)^(△),20.00(11.00,30.50)^(△),and 27.50(16.25,76.25)^(△),respectively.The function of the lateral rectus muscle were-5.00(-5.00,-4.75),-3.00(-4.00,-1.75),and-3.00(-4.00,-1.00),respectively.The deviation at each follow-up time point after treatment reduced compared with those before treatment(Waldχ^(2)=109.16,125.18,54.01;all P<0.001).Three cases were cured,9 cases improved and 2 invalid cases underwent extraocular muscle surgery.At 6 months after treatment,13 cases were in the primary position,1 case was under-corrected,three-dimensional visual function was recovered in 8 cases,and near stereopsis was recovered in 6 cases.The deviation of near 2.00(0,2.00)^(△),the deviation of far 3.00(1.75,5.00)^(△),and the function of the lateral rectus muscle-1.00(-2.00,0)significantly improved with comparison of those before treatment(Waldχ^(2)=114.51,280.42,366.46;all P<0.001).At 6 months after treatment,the deviation of near 2.00(1.00,3.00)^(△),the deviation of far 3.00(2.00,5.00)^(△),and the function of the lateral rectus muscle-2.00(-2.00,-1.00)in the control group were compared with near 80(60,90)^(△),far 100(90,120)^(△),and the function of the lateral rectus muscle-5(-5,-5)level before treatment.The difference was statistically significant in comparison(Z=3.41,3.41,3.49;P=0.001,P=0.001,P<0.001).Fourteen cases were in the primary position,1 case was under-corrected,three-dimensional visual function was recovered in 2 cases,and near stereopsis was recovered in 1 case.There was no statistically significant difference in the deviation and the function of the lateral rectus muscle between the two groups before treatment(U=61.50,84.00,147.00;all P>0.05).At 6 months after treatment,there was no statistically significant difference in the deviation between the two groups(U=84.00,89.00;all P>0.05),but there was statistically significant difference in the function of the lateral rectus muscle(U=180.00,P<0.05).ConclusionBotulinum toxin type A injection can correct deviation,improve the function of the lateral rectus muscle and restore visual function,but a few patients with residual strabismus still require combined extraocular muscle surgery.