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中华眼科医学杂志(电子版) ›› 2020, Vol. 10 ›› Issue (02) : 76 -82. doi: 10.3877/cma.j.issn.2095-2007.2020.02.003

论著

微创小切口单眼外直肌后徙联合内直肌缩短术治疗基本型间歇性外斜视的疗效观察
张晶议1, 苗泽群2, 许欣3, 欧阳倩如3, 付皓丽4, 郭丽莉5, 王乐今5,†()   
  1. 1. 100044　北京大学人民医院2017级硕士研究生
    2. 100044　北京大学人民医院2017级博士研究生
    3. 100044　北京大学人民医院2018级硕士研究生
    4. 100044　北京大学人民医院2019级硕士研究生
    5. 100044　北京大学人民医院眼视光中心、眼科　视网膜脉络膜疾病诊治研究北京市重点实验室
  • 收稿日期:2020-02-10 出版日期:2020-04-28
  • 通信作者: 王乐今
  • 基金资助:
    国家自然科学基金项目(31427801)

Surgical outcomes of the minimally invasive small incision unilateral recession-resection for intermittent exotropia

Jingyi Zhang1, Zequn Miao2, Xin Xu3, Qianru Ouyang3, Haoli Fu4, Lili Guo5, Lejin Wang5,†()   

  1. 1. Master′s degree 2017, Peking University People′s Hospital, Beijing 100044, China
    2. Doctor′s degree 2017, Peking University People′s Hospital, Beijing 100044, China
    3. Master′s degree 2018, Peking University People′s Hospital, Beijing 100044, China
    4. Master′s degree 2019, Peking University People′s Hospital, Beijing 100044, China
    5. Center of Optometry, Department of Ophthalmology, Peking University People′s Hospital; Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing 100044, China
  • Received:2020-02-10 Published:2020-04-28
  • Corresponding author: Lejin Wang
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引用本文：

张晶议, 苗泽群, 许欣, 欧阳倩如, 付皓丽, 郭丽莉, 王乐今. 微创小切口单眼外直肌后徙联合内直肌缩短术治疗基本型间歇性外斜视的疗效观察[J/OL]. 中华眼科医学杂志(电子版), 2020, 10(02): 76-82.

Jingyi Zhang, Zequn Miao, Xin Xu, Qianru Ouyang, Haoli Fu, Lili Guo, Lejin Wang. Surgical outcomes of the minimally invasive small incision unilateral recession-resection for intermittent exotropia[J/OL]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2020, 10(02): 76-82.

目的

评价微创小切口单眼外直肌后徙联合内直肌缩短术(R&R)治疗基本型间歇性外斜视(IXT)的疗效。

方法

收集2018年3月至2019年4月于北京大学人民医院眼视光中心的患者52例(52只眼)进行回顾性研究。其中，男性24例(24只眼)，女性28例(28只眼)；年龄3~16岁，平均年龄(7.3±3.1)岁。按照斜视度的不同，将患者分为小角度斜视组和大角度斜视组。检查并记录全部患者术前与术后6个月的远视力、屈光度、同视机融合功能及近立体视功能等指标；检查并记录全部患者术前、术后1周、术后1个月、术后3个月及术后6个月的远近斜视度。患者的发病年龄、病程、术龄、屈光度及斜视度以均数±标准差表示，采用t检验进行组间比较；两组的眼位正位率和近立体视提高率以百分率表示，采用卡方检验进行比较；术前与术后同视机融合功能的比较，采用配对t检验。

结果

本研究纳入的52例(52只眼)基本型IXT患者，平均发病年龄为(4.7±3.2)岁，术前平均斜视度为(-38.56±14.96)个三棱镜度(PD)。两组患者性别比的比较，差异无统计学意义(χ2＝1.15，P>0.05)；两组患者发病年龄、病程、平均年龄、术眼及非术眼屈光度的比较，差异无统计学意义(t＝0.07，0.02，0.08，0.27，0.28；P>0.05)。两组术前平均斜视度的比较，差异有统计学意义(t＝6.49，P<0.05)。行R&R术的患者中采用"退5缩4"、"退6缩3"、"退6缩4"、"退7缩4"及"退7缩5"术式者分别有24例(24只眼)、8例(8只眼)、8例(8只眼)、12例(12只眼)、2例(2只眼)及6例(6只眼)。术后6个月时，小角度斜视组和大角度斜视组患者眼位正位率分别为82.1%和79.2%。经卡方检验，两组差异无统计学意义(χ2＝0.07，P>0.05)。两组患者术后从第1周开始逐渐发生外斜漂移，并且术后1个月之前外斜漂移发展较快，之后眼位趋于稳定。患者术前与术后6个月融合范围的绝对值分别为(14.56±9.53)°和(21.79±6.93)°。经t检验，两者的差异有统计学意义(t＝4.02，P<0.05)。小角度斜视组和大角度斜视组患者近立体视功能的提高率分别为53.6%和75.0%。经卡方检验，两组的比较差异无统计学意义(χ2＝2.56，P>0.05)。

结论

对斜视度为-20 PD~-85 PD的基本型IXT患者行微创小切口单眼R&R术，术后6个月患者的眼位正位率较高，融合功能及近立体视功能均得到明显改善。该术式对于小角度和大角度斜视患者均具有较好疗效。因此，该术式可作为治疗基本型IXT的手术选择。

关键词: 间歇性外斜视, 手术治疗, 正位率, 影响因素
Objective

The aim of this study was to investigate the surgical outcomes of the minimally invasive small incision unilateral recession-resection (R&R) for basic-type intermittent exotropia (IXT).

Methods

52 patients (52 eyes) with basic-type IXT (-20 PD~-85 PD) who underwent the minimally invasive small incision R&R from March 2018 to April 2019 in Center of Optometry, Peking University People′s Hospital were analyzed retrospectively. Among of them, there were 24 male patients (24 eyes) and 28 female patients (28 eyes), aged 3 to 16 years-old with the average age of (7.3±3.1) years-old. According to the severity of exotropia, patients were divided into small angle group ( A group) and large angle group ( B group). Ophthalmologic and orthoptic examination were carried out, including visual acuity, cycloplegic refraction, motility evaluation, near stereoacuity and fusion function, anterior segment and fundus examination before and after operation for 1 week, 1 month, 3 months and 6 months. The age of onset, course of disease, operation age, diopter and strabismus angle were represent by means±standard deviation and t-test was used to compare; the orthotopic rate and increased rate of near stereoacuity were represented by percentage and chi-square test was used for comparison. The preoperative and postoperative fusion range was used to compare by t-test.

Results

Among of 52 cases (52 eyes) with basic-type IXT, the mean age of patients was (4.7±3.2) years-old, and preoperative exotropia angle was (-38.56±14.96) prism diopter (PD). There was no significant difference in sex ratio(χ2=1.15, P>0.05) and the mean age of patients, course of disease, the average age and cycloplegic refraction between them (t=0.07, 0.02, 0.08, 0.27, 0.28; P>0.05). The preoperative average strabismus of 2 groups were significant difference (t=6.49, P<0.05). Among of patients with R&R, there were 24 cases (24 eyes), 8 cases (8 eyes), 8 cases (8 eyes), 12 cases (12 eyes), 2 cases (2 eyes), and 6 cases (6 eyes) by the lateral rectus 5 mm-medial rectus 4 mm (LR5-MR4), LR6-MR3, LR6-MR4, LR7-MR4 and LR7-MR5, respectively. After opeartion for 6 months, the successful rate of postoperative ocular alignment in A and B group was respectively 82.1% and 79.2% with non-significant difference between them (χ2=0.07, P>0.05). Patients gradually developed exotropia drift from the first week after operation. And the speed of exotropia drift was faster before postoperative 1 month, and then slow down. The preoperative and postoperative fusion range was respectively (14.56±9.53)°and (21.79±6.93)° with significant difference between them (t=4.02, P<0.05). The increased rate of near stereoacuity in A and B group was respectively 53.6% and 75.0% with non-significant difference between them (χ2=2.56, P>0.05).

Conclusions

For basic-type IXT patients with exotropia angle from -20 PD to -85 PD, application of the minimally invasive small incision R&R could achieve a high orthotopic rate, and the fusion function and near stereoacuity were significantly improved after operation. Thus, this surgery could be used as a new choice for basic-type IXT patients.

Key words: Intermittent exotropia, Surgical treatment, Orthotopic rate, Factors
图2 手术显微镜下术中充分剪开节制韧带的彩色照相　图2A示剪断外直肌表面节制韧带(箭头处)；图2B示剪断外直肌下缘节制韧带；图2C示剪断外直肌上缘节制韧带；图2D示彻底暴露外直肌(箭头处)
表1 两组患者术后6个月眼位矫正效果的比较[例数(%)]
组别 例数 正位 欠矫 过矫
小角度斜视组 28 23(82.1) 3(10.7) 2(7.1)
大角度斜视组 24 19(79.2) 4(16.7) 1(4.2)
χ2值   0.07 0.39 0.21
P值   >0.05 >0.05 >0.05
图4 患者术后6个月近立体视Titmus锐度值的分布图
表2 两组患者术后6个月同视机融合功能的比较(°)
时间 例数 融合范围 集合性融合 离散性融合
术前 43 14.56±9.53 10.14±7.24 4.00±3.35
术后 43 21.79±6.93 16.14±6.05 5.63±2.02
t值   4.02 4.00 2.66
P值   <0.05 <0.05 <0.05
表3 两组患者术后6个月近立体视功能的比较[例数(%)]
组别 例数 提高 不变 降低
小角度斜视组 28 15(53.6) 9(32.1) 4(14.3)
大角度斜视组 24 18(75.0) 5(20.8) 1(4.2)
χ2值   2.56 0.84 1.52
P值   >0.05 >0.05 >0.05
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