切换至 "中华医学电子期刊资源库"
高级检索
中华眼科医学杂志(电子版)

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
全文 ( ) 下载PDF ( ) 导出引用
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]. 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]. 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
[1]
Mohney BG, Huffaker RK. Common forms of childhood exotropia[J]. Ophthalmology, 2003, 110(11): 2093-2096.
[2]
Chia A, Dirani M, Chan YH, et al. Prevalence of amblyopia and strabismus in young singaporean Chinese children[J]. Invest Ophth Vis Sci, 2010, 51(7): 3411-3417.
[3]
Zhuang W, Fang S, Fan H, et al. Anatomical study of the extraocular check ligament system[J]. J Plast Reconstr Aes, 2019, 72(12): 2017-2026.
[4]
Choi J, Chang JW, Kim SJ, et al. The long-term survival analysis of bilateral lateral rectus recession versus unilateral recession-resection for intermittent exotropia[J]. Am J Ophthalmol, 2012, 153(2): 343-351.
[5]
Xie F, Zhao K, Zhang W. Comparison of surgical outcomes between bilateral recession and unilateral recession-resection in moderate-angle intermittent exotropia[J]. J AAPOS, 2019, 23(2): e71-e77.
[6]
Chougule P, Kekunnaya R. Surgical management of intermittent exotropia: do we have an answer for all？[J]. BMJ Open Ophthalmol, 2019, 4(1): 1-9.
[7]
Nusz KJ, Mohney BG, Diehl NN. The course of intermittent exotropia in a population-based cohort[J]. Ophthalmology, 2006, 113(7): 1154-1158.
[8]
王利华，赵堪兴. 间歇性外斜视治疗中的热点问题[J]. 中华眼科杂志，2015，51(6)：465-469.
[9]
Uretmen O, Egrilmez S, Kose S, et al. Negative social bias against children with strabismus[J]. Acta Ophthalmol Scan, 2003, 81(2): 138-142.
[10]
Hatt SR, Leske DA, Adams WE, et al. Quality of life in intermittent exotropia child and parent concerns[J]. Arch Ophthalmol-Chic, 2008, 126(11): 1525-1529.
[11]
Hatt SR, Leske DA, Yamada T, et al. Development and initial validation of quality-of-life questionnaires for intermittent exotropia[J]. Ophthalmology, 2010, 117(1): 163-201.
[12]
Sloper J. Clinical strabismus management: principles and surgical techniques[J]. Br J Ophthalmol, 2000, 84(11): 1333-1335.
[13]
Chiu AK, Din N, Ali N. Standardising reported outcomes of surgery for intermittent exotropia-a systematic literature review[J]. Strabismus, 2014, 22(1): 32-36.
[14]
Clarke MP. Intermittent exotropia[J]. J Pediat Ophth Strab, 2007, 44(3): 153-157.
[15]
Lim SH, Hwang BS, Kim MM. Prognostic factors for recurrence after bilateral rectus recession procedure in patients with intermittent exotropia[J]. Eye (Lond), 2012, 26(6): 846-852.
[16]
Kim SH, Cho YA, Park CH, et al. The ultrastructural changes of tendon axonal profiles of medial rectus muscles according to duration in patients with intermittent exotropia[J]. Eye (Lond), 2008, 22(8): 1076-1081.
[17]
Tan N, Jolly RK, Jain S. Fornix-based incision for strabismus surgery: the parks technique revisited[J]. J Pediat Ophth Strab, 2011, 48(5): E55-E57.
[18]
Parks MM. Fornix incision for horizontal rectus muscle surgery[J]. Am J Ophthalmol, 1968, 65(6): 907-909.
[19]
Zheng SF, Wang JM. Observation on the curative effects of different surgical methods for small strabismus degree of basic intermittent exotropia[J]. Int Eye Sci, 2013, 13(12): 2407-2410.
[20]
Burian HM, Spivey BE. The surgical management of exodeviations[J]. Am J Ophthalmol, 1965, 59(6): 603-620.
[21]
Kushner BJ. Selective surgery for intermittent exotropia based on distance near differences[J]. Arch Ophthalmology-Chic, 1998, 116(3): 324-328.
[22]
Fiorelli VM, Goldchmit M, Uesugui CF, et al. Intermittent exotropia: comparative surgical results of lateral recti-recession and monocular recess-resect[J]. Arq Bras Oftalmol, 2007, 70(3): 429-432.
[23]
Pediatric Eye Disease Investigator Group, Writing C, Donahue SP, et al. A randomized trial comparing bilateral lateral rectus recession versus unilateral recess and resect for basic-type intermittent exotropia[J]. Ophthalmology, 2019, 126(2): 305-317.
[24]
Kim H, Yang HK, Hwang JM. Comparison of long-term surgical outcomes between unilateral recession and unilateral recession-resection in small-angle exotropia[J]. Am J Ophthalmol, 2016, 166(4): 141-148.
[25]
Yang X, Man TT, Tian QX, et al. Long-term postoperative outcomes of bilateral lateral rectus recession vs unilateral recession-resection for intermittent exotropia[J]. Int J Ophthalmol, 2014, 7(6): 1043-1047.
[26]
Jin KW, Choi DG. Outcome of two-muscle surgery for large-angle intermittent exotropia in children[J]. Br J Ophthalmol, 2017, 101(4): 462-466.
[27]
Cho SY, Lee SY, Jung JH. Comparison of surgical outcomes with unilateral recession and resection according to angle of deviation in basic intermittent exotropia[J]. Korean J Ophthalmol, 2015, 29(6): 411-417.
[28]
Wright KW. Coloratlas of strabismus surgery[M]. St. Petersburg: Wright Publishing, 2000: 249-250.
[29]
米静. 儿童间歇性外斜视手术年龄及术后视功能的临床观察[D]. 乌鲁木齐：新疆医科大学，2014.
[30]
Bandyopadhyay R, Shetty S, Vijayalakshmi P. Surgical outcome in monocular elevation deficit: A retrospective interventional study[J]. Indian J Ophthalmol, 2008, 56(2): 127-133.
[31]
Prattjohnson JA, Barlow JM, Tillson G. Early surgery in intermittent exotropia[J]. Am J Ophthalmol, 1977, 84(5): 689-694.
[32]
Govindan M, Mohney BG, Diehl NN, et al. Incidence and types of childhood exotropia: a population-based study[J]. Ophthalmology, 2005, 112(1): 104-108.
[33]
Kordic H, Sturm V, Landau K. Long-term follow-up after surgery for exodeviation[J]. Klinische Monatsblatter fur Augenheikunde, 2009, 226(4): 315-320.
[34]
Struck MC, Hariharan L, Kushner BJ, et al. Surgical manage-ment of clinically significant hypertropia associated with exotropia[J]. J AAPOS, 2010, 14(3): 216-220.
[35]
Min FCL, Gesite-de-Leon BU, Quah BL. Postoperative strabis-mus control and motor alignment for basic intermittent exotropia[J]. Int J Ophthalmol-Chi, 2016, 9(7): 1011-1015.
[36]
Wu H, Sun J, Xia X, et al. Binocular status after surgery for constant and intermittent exotropia[J]. Am J Ophthalmol, 2007, 143(1): 201-201.
[37]
赵淑静，王利华. 间歇性外斜视手术矫正前后融合和立体视功能对照研究[J]. 中国实用眼科杂志，2013，31(9): 1119-1122.
[38]
Abroms AD, Mohney BG, Rush DP, et al. Timely surgery in intermittent and constant exotropia for superior sensory outcome[J]. Am J Ophthalmol, 2001, 131(1): 111-116.
[1] 刘嘉嘉, 王承华, 陈绪娇, 刘瑗玲, 王善钰, 屈海花, 张莉. 经阴道子宫-输卵管实时三维超声造影中患者疼痛发生情况及其影响因素分析[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 959-965.
[2] 高玲, 于哲, 范然, 臧银善. 外周血细胞计数比值评估类风湿关节炎疗效的价值[J]. 中华关节外科杂志(电子版), 2023, 17(05): 642-647.
[3] 王蓓蓓, 董启秀, 郗红燕, 于庆云, 张丽君, 式光. 早孕期孕妇药物流产失败的影响因素分析与构建相关预测模型及其对药物流产成功的预测价值[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(05): 588-594.
[4] 陈絮, 詹玉茹, 王纯华. 孕妇ABO血型联合甲状腺功能检测对预测妊娠期糖尿病的临床价值[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(05): 604-610.
[5] 王鹏, 肖厚安, 贾赤宇. 不同因素调控巨噬细胞极化在慢性难愈性创面中的研究进展[J]. 中华损伤与修复杂志(电子版), 2023, 18(05): 454-459.
[6] 古丽米拉·亚森江, 阿依努尔·艾尔肯, 李佳隆, 郭强, 蒋铁民, 吐尔干艾力·阿吉. 胆囊切除术后胆管损伤不同治疗方式的疗效分析[J]. 中华普通外科学文献(电子版), 2023, 17(04): 262-266.
[7] 甄子铂, 刘金虎. 基于列线图模型探究静脉全身麻醉腹腔镜胆囊切除术患者术后肠道功能紊乱的影响因素[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 61-65.
[8] 杨倩, 李翠芳, 张婉秋. 原发性肝癌自发性破裂出血急诊TACE术后的近远期预后及影响因素分析[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 33-36.
[9] 黄汇, 朱信强. 131I治疗45岁以下分化型甲状腺癌的疗效及影响因素[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 627-630.
[10] 王帆, 马秋月, 刘小莉. 基于分位数回归模型的切口疝手术患者住院费用影响因素分析[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(05): 522-529.
[11] 顾娇娇, 邹燕, 陈奕辰, 黄师菊, 张慧玲, 林楠. 基于简易营养评价精法评估肝癌患者出院后营养状况及其影响因素[J]. 中华肝脏外科手术学电子杂志, 2023, 12(05): 534-539.
[12] 杨静, 顾红叶, 赵莹莹, 孙梦霞, 查园园, 王琪. 老年血液透析患者短期死亡的影响因素及列线图预测模型的预测作用[J]. 中华肾病研究电子杂志, 2023, 12(05): 254-259.
[13] 程莉, 章晓良. 血尿酸和胱抑素C与糖尿病视网膜病变患者合并糖尿病肾病的关系及影响因素[J]. 中华肾病研究电子杂志, 2023, 12(04): 194-199.
[14] 刘代江, 蒋俊艳, 万晓强, 马莎英. 结直肠癌肝转移患者生存状况及预后影响因素分析[J]. 中华消化病与影像杂志(电子版), 2023, 13(05): 284-288.
[15] 杜振双, 胡清福, 林颖艺, 张月霞, 陈美丽, 李祎祺, 王振华. 社区全科医师激励机制的影响因素分析[J]. 中华临床医师杂志(电子版), 2023, 17(08): 876-883.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号