上斜肌再折叠术矫正复发或残留代偿头位的疗效观察  

Clinical effect of superior oblique re-tucking for recurrent or residual compensatory head position

作　　者：冉敏 薛彩虹 陈丽萍 郭雅图 张伟[1] Ran Min;Xue Caihong;Chen Liping;Guo Yatu;Zhang Wei(Clinical College of Ophthalmology of Tianjin Medical University,Tianjin Eye Hospital,Tianjin Eye Institute,Tianjin Key Laboratory of Ophthalmology and Visual Science,Tianjin 300020,China;Centural Hospital of Enshi Tujia and Miao Autonomous Prefecture,Enshi 445000,China)

机构地区：[1]天津医科大学眼科临床学院、天津市眼科医院、天津市眼科研究所、天津市眼科学与视觉科学重点实验室,天津300020 [2]恩施土家族苗族自治州中心医院眼科,恩施445000

出　　处：《中华眼科杂志》2024年第3期265-271,共7页Chinese Journal of Ophthalmology

基　　金：天津市卫生健康科技项目(TJWJ2022XK037)。

摘　　要：目的观察上斜肌再折叠术矫正先天性上斜肌麻痹患者首次手术后复发或残留代偿头位的临床疗效。方法回顾性系列病例研究。收集2015年3月至2021年7月行上斜肌再折叠术治疗复发或残留代偿头位的12例(12只眼)先天性上斜肌麻痹患者的临床资料,患者均有上斜肌折叠术史,术后残留或复发代偿头位,第一眼位垂直斜视度数较小,眼球运动检查见受累眼上斜肌运动落后,不伴同侧下斜肌亢进。术中全身麻醉下行Guyton被动牵拉试验评估上斜肌肌腱松弛程度,根据上斜肌肌腱松弛程度来决定上斜肌再折叠长度。随访并观察患者手术前后代偿头位、第一眼位垂直斜视度数、眼球运动、彩色眼底相、Bielschowsky征的变化。采用t检验和配对样本秩和检验进行统计学分析。结果12例患者中,男性8例,女性4例;年龄范围为2~9岁,首次手术年龄为6(5,7)岁,首次上斜肌折叠术的上斜肌折叠长度为(7.17±1.03)mm,11例患者术后(3.82±0.98)个月出现复发歪头,1例患者为术后残留歪头,复发或残留头位随访半年及以上。所有患者眼球运动检查提示上斜肌落后,Bielschowsky征阳性,术中Guyton被动牵拉试验提示麻痹眼上斜肌肌腱松弛,探查上斜肌后松解上斜肌止端周围瘢痕,根据牵拉试验的上斜肌肌腱松弛程度行上斜肌再折叠术,再次折叠上斜肌的长度为(7.83±1.59)mm。术后随访12~18个月,患者术后代偿头位均消失,上斜肌落后明显改善,眼球运动正常,无Brown综合征发生。9例患者Bielschowsky征转为阴性,3例患者仍为阳性。术前第一眼位斜视度数为2.5(2.0,5.3)三棱镜度,术后为1(0,1)三棱镜度,两者差异有统计学意义(U=6.00,P<0.001)。黄斑中心凹-视盘中心夹角度数(FDA)术前为(-22.04±5.47)°,术后为(-15.27±6.08)°,差异有统计学意义(t=2.87,P=0.009)。所有患者歪头症状均得到满意改善,随访效果稳定,未发生回退。结论上斜肌再折叠术Objective To evaluate the effects of re-tucking the superior oblique muscle on recurrent or residual compensatory head position.Methods A retrospective case series study was conducted.12 recurrent or residual compensatory head position patients(12 eyes)with congenital superior oblique palsy who underwent superior oblique re-tucking in Tianjin Eye Hospital from March 2015 to February 2021 were included.All patients had a history of superior oblique tucking procedure and showed signs of superior oblique muscle palsy without inferior oblique muscle overaction.During surgery,the Guyton forced duction test is used to evaluate the relaxation of the superior oblique muscle tendon,which affects the re-tucking length of the muscle.Their head position,vertical deviation,eye movement,fovea-disa angle,and Bielschowsky head tilt test were assessed pre-and post-surgery.Statistical analysis was performed using ttest and paired samples Wilcoxon signed rank test.Results Out of the 12 patients,8 were male and 4 were female,aged between 2 and 9 years.The initial surgery was done at age 6,with a superior oblique recession length of(7.17±1.03)mm.Recurrent head tilt occurred in 11 patients after(3.82±0.98)months postoperatively,and 1 patient had residual head tilt,with a followup period of six months or more.Ocular motility examination revealed underaction of the superior oblique muscle,positive Bielschowsky′s head tilt test,and Guyton forced duction tese indicating relaxation of the paralyzed superior oblique muscle tendon.Scar adhesion was observed at the stop of the superior oblique muscle,as well as the previous sutures.The scar and the sutures around the stop of the superior oblique muscle were released,the mean re-tucking amount was(7.83±1.59)mm.Follow-up at 12 to 18 months postoperatively showed disappearance of compensatory head position,significant improvement in superior oblique muscle lag,normal ocular motility,and no occurrence of Brown syndrome.The results of Bielschowsky head tilt were negative in 9 cases and still

关 键 词：斜视 动眼肌 眼外科手术 复发 

分 类 号：R779.6[医药卫生—眼科]