本文選題：上斜肌折疊術(shù) + 下斜肌切斷術(shù)　； 參考：《天津醫(yī)科大學》2016年碩士論文

【摘要】：目的:探討上斜肌折疊術(shù)與下斜肌切斷術(shù)對單側(cè)先天性上斜肌麻痹的手術(shù)效果。主要從原在位垂直斜度的矯正,眼底客觀旋轉(zhuǎn)度數(shù)的改變,代償頭位的改善、雙眼視覺以及Bielschowsky歪頭試驗的影響等方面,對兩種術(shù)式療效分析對比,為臨床治療提供參考。方法:回顧分析2014年2月到2015年10月因“單側(cè)先天性上斜肌麻痹”于天津市眼科醫(yī)院住院治療,并行單眼上斜肌折疊術(shù)或者下斜肌切斷術(shù),所有手術(shù)均由同一術(shù)者完成。上斜肌折疊組22例(單眼22例)及下斜肌切斷組25例(單眼25例)納入本研究。觀察記錄手術(shù)前后原在位垂直斜度的改變、眼底客觀旋轉(zhuǎn)斜度的變化、Bielschowsky歪頭試驗的變化、頭位的變化、以及雙眼視的變化。手術(shù)前后根據(jù)眼底照片記錄眼底客觀旋轉(zhuǎn)度數(shù),使用Coredraw軟件測量黃斑-視盤夾角(fovea disc angle,FDA);測量頭部向健眼和患眼兩側(cè)傾斜時,患眼垂直斜視度數(shù)的差值,大于5.0PD為Bielschowsky歪頭試驗陽性;骨科測量進行代償頭位的度數(shù)測量,一側(cè)平行于臉部矢狀軸,另一側(cè)垂直于地面;同視機、Titmus立體視評估雙眼視功能。所有數(shù)據(jù)資料的統(tǒng)計學分析均在SPSS l7.0軟件上進行。結(jié)果:1、單眼下斜肌切斷術(shù)組,術(shù)前原在位垂直數(shù)斜視度為(12.22±3.79)PD,術(shù)后減少至(3.52±2.17)PD,平均矯正量為(8.52+2.67)PD。22例行單眼上斜肌折疊的手術(shù)患者,術(shù)前原在位垂直斜視度為(4.24±1.72)PD,平均矯正量為(2.23±1.91)PD。兩種術(shù)式矯正原在位垂直斜視的差值有統(tǒng)計學意義(F=11.38,P(27)0.05),上斜肌折疊手術(shù)中,原在位斜視度數(shù)的矯正量與上斜肌折疊的手術(shù)量無相關(guān)性(Spearman相關(guān)系數(shù)=0.235,P(29)0.05)。2、下斜肌切斷組中,患者術(shù)前頭部向患眼側(cè)與健眼側(cè)兩側(cè)傾斜時,患眼的斜視度數(shù)的差值為10.00PD~28.00PD;術(shù)后末次復診,差值為2.00PD~12.00PD。術(shù)前組與術(shù)后末次復查組差值差異具有統(tǒng)計學意義(P0.05(8)。術(shù)前25例患者Bielschowsky歪頭試驗均為陽性,術(shù)后轉(zhuǎn)陰率24%(6/25),其余76%(19/25)患者仍為陽性。22例上斜肌折疊組,術(shù)前頭部向兩側(cè)傾斜時,患眼的斜視度數(shù)的差值為5.00PD~17.00PD;術(shù)后末次復診,差值為0.00PD~14.00PD。術(shù)前組與術(shù)后末次復查組差異有統(tǒng)計學意義(P0.05/3(8)。術(shù)前患者Bielschowsky歪頭試驗均為陽性,末次復診77.27%(17/25)的患者Bielschowsky歪頭試驗轉(zhuǎn)陰,22.73%(5/22)的患者仍為陽性。6例患者術(shù)后轉(zhuǎn)為陰性。兩組采用Fisher確切檢驗,差異有統(tǒng)計學意義(P0.05(8),兩種術(shù)式對 Bielschowsky歪頭試驗的轉(zhuǎn)陰率有明顯差別。3、25例單眼下斜肌切斷患者,術(shù)前總FDA為(22.67士7.77)°,末次復查總FDA分別為(15.94士7.81)°,FDA各組間差異有統(tǒng)計學意義(F=12.99,P0.05)。22例單眼上斜肌折疊患者,術(shù)前總FDA為(17.76士6.23)°,末次復查總FDA為(9.60士6.26)°,FDA各組間差異有統(tǒng)計學意義(F=23.634,P0.05),術(shù)后1天組與末次復查組組間對比的差異無統(tǒng)計學意義(P(29)0.05)。4、下斜肌切斷和上斜肌折疊兩種術(shù)式,均可提高雙眼視功能。下斜肌切斷手術(shù)和上斜肌折疊手術(shù)術(shù)后代償頭位均可得到改善。上斜肌折疊手術(shù)的患者,術(shù)后短期出現(xiàn)輕度的內(nèi)上轉(zhuǎn)受限,遠期僅1例患者出現(xiàn)內(nèi)轉(zhuǎn)眼極度內(nèi)上轉(zhuǎn)時出現(xiàn)復視。而下斜肌切斷組并未出現(xiàn)任何的并發(fā)癥。結(jié)論:1、上斜肌折疊術(shù)通過加強松弛的上斜肌肌腱,解決上斜肌功能落后。下斜肌切斷術(shù)可有效的緩解因先天性單側(cè)上斜肌麻痹引起的繼發(fā)性下斜肌功能亢進。根據(jù)Knapp分型,選擇合適的術(shù)式,兩種手術(shù)方式在矯正原在位垂直斜度上有明顯差異。上斜肌折疊手術(shù)適用于:上斜肌肌腱松弛,符合Knapp II型;原在位垂直斜度較小;已行下斜肌減弱術(shù),仍有殘留頭位;存在明顯客觀或者主觀旋轉(zhuǎn)。下斜肌切斷手術(shù)適用于:下斜肌亢進為主,符合Knapp I型;垂直斜度15PD;代償頭位明顯;存在客觀旋轉(zhuǎn)。2、對于因先天性上斜肌麻痹引起的外旋轉(zhuǎn)偏斜,上斜肌折疊術(shù)與下斜肌切斷術(shù)均能明顯矯正。兩種手術(shù)方式在旋轉(zhuǎn)偏斜量的矯正上,下斜肌切斷手術(shù)稍多于上斜肌折疊手術(shù),但差異無統(tǒng)計學意義,術(shù)后短期效果穩(wěn)定,遠期效果尚需進一步觀察。3、上斜肌折疊手術(shù)與下斜肌切斷手術(shù)這兩種術(shù)式對Bielschowsky歪頭試驗的轉(zhuǎn)陰率有明顯差別,上斜肌折疊手術(shù)對Bielschowsky歪頭試驗的轉(zhuǎn)陰率(77.27%)明顯高于下斜肌切斷術(shù)(24%)4、兩種術(shù)式均能有效改善代償頭位。5、本研究中,本研究隨訪時間較短,平均3個月,對于手術(shù)效果是否隨著時間延長而呈現(xiàn)回退趨勢,遠期效果有待進一步探討。
[Abstract]:Objective: To investigate the effect of superior oblique muscle folding and inferior oblique muscle transection on unilateral congenital superior oblique paralysis, mainly from the correction of the primary vertical slope, the change of the objective rotation degree of the fundus, the improvement of the compensatory head position, the binocular vision and the effect of the Bielschowsky skew test. Bed treatment provided reference. Methods: retrospective analysis was carried out from February 2014 to October 2015 in Tianjin Ophthalmological Hospital for "unilateral congenital superior oblique paralysis" in Tianjin Ophthalmological Hospital, parallel monocular superior oblique muscle folding or inferior oblique muscle resection. All the operations were performed by the same operator. 22 cases (22 cases of monocular and inferior oblique) and 25 cases of inferior oblique muscle resection group (22 cases of single eye) and inferior oblique muscle group (25 cases). 25 cases of monocular were included in this study. The changes of primary vertical slope before and after surgery, changes in objective rotation slope of the fundus, changes in Bielschowsky head test, changes in head position, and changes in binocular vision were recorded. The objective rotation degree of the fundus was recorded before and after the operation, and the angle of the macula optic disc was measured by Coredraw software. Fovea disc angle, FDA); the difference in the degree of vertical strabismus of the eyes when the head was tilted on both sides of the eye and the affected eyes was greater than that of 5.0PD as a Bielschowsky skew test; the measurement of the compensatory head in the Department of orthopedics was parallel to the sagittal axis of the face, and the other side was perpendicular to the ground; and the Titmus stereopsis evaluated binocular vision with the visual machine. Statistical analysis with data was carried out on SPSS l7.0 software. Results: 1, the preoperatively orthodontic strabismus was (12.22 + 3.79) PD before operation, and decreased to (3.52 + 2.17) PD after operation, and the average correction was (8.52+2.67) PD.22 routine upper oblique muscle folds, and the preoperatively vertical strabismus was (4.24). 1.72) PD, the average correction was (2.23 + 1.91) PD., and the difference between two orthodontic orthoptic orthopotropia was statistically significant (F=11.38, P (27) 0.05). There was no correlation between the correction of primary strabismus degree and the amount of upper oblique muscle folding (Spearman correlation coefficient =0.235, P (29) 0.05).2, and the lower oblique muscle cutting group. The difference between the strabismus degree of the affected eyes was 10.00PD~28.00PD when the head of the head was tilted to the side of the eye and the side of the healthy eye before operation. The difference was statistically significant (P0.05 (8)). The difference value between the pre operation group and the final reexamination group was (P0.05). The 25 cases before the operation were all positive for the Bielschowsky skew test and 24% (6/25) after the operation. The other 76% (19/25) patients were still positive.22 cases of superior oblique muscle folding group. The difference between the strabismus degree of the affected eyes was 5.00PD~17.00PD when the head was tilted on both sides of the head before operation, and the difference was statistically significant (P0.05/3 (8)). The difference was statistically significant (P0.05/3 (8)). 77.27% (17/25) patients at the last visit (17/25) were turned into negative Bielschowsky test, and 22.73% (5/22) patients were still positive for positive.6 patients after operation. The two groups were confirmed by Fisher, the difference was statistically significant (P0.05 (8), and the two kinds of surgical methods had significant difference in the negative rate of Bielschowsky in.3,25 case of single eye oblique muscle resection. The total FDA was (22.67 se 7.77), and the final review total FDA was (15.94. 7.81) degrees respectively. There were statistical significance (F=12.99, P0.05).22 cases with unilateral upper oblique muscle fold. The total FDA before operation was (17.76, 6.23) degrees, and the final review total FDA was (9.60. 6.26) degrees. The difference between the FDA groups was statistically significant (F=23.634, P0.05), and the group 1 days after the operation and the end of the operation. There was no significant difference in the contrast between the two groups (P (29) 0.05).4, the lower oblique muscle and the upper oblique muscle folded two kinds, which could improve the binocular function. The compensatory head of the inferior oblique and upper oblique muscle foldable surgery could be improved. Only 1 patients appeared diplopia in the case of extreme internal rotation. The lower oblique muscle group did not have any complications. Conclusion: 1, the upper oblique muscle folding can solve the inferior oblique muscle function backwardness by strengthening the relaxed superior oblique muscle tendon. The inferior oblique muscle transection can effectively relieve the secondary slant caused by the first unilateral unilateral superior oblique palsy. Hyperfunction of the muscle. According to the Knapp classification, the appropriate surgical procedure was selected. The two surgical methods were significantly different in the orthodontic vertical slope. The upper oblique muscle folding operation was suitable for the relaxation of the superior oblique muscle, which was in line with the Knapp II type; the original ortho vertical slope was smaller; the lower oblique muscle weakened and still had the residual head position; there was obvious objective or subjective rotation. The operation of inferior oblique muscle resection is suitable for the hyperactivity of the inferior oblique muscle, conforming to the Knapp I type, the vertical gradient 15PD, the compensatory head obvious, the existence of the objective rotation.2, the external rotation deviation caused by the congenital superior oblique paralysis, the superior oblique muscle folding and the inferior oblique muscle transection, and the two surgical methods in the correction of the rotation deviation. A little more than the upper oblique muscle folding operation, the difference was not statistically significant, and the short-term effect was stable after operation. The long-term effect still needed to be further observed by.3. There was a significant difference between the two types of superior oblique muscle folding surgery and the inferior oblique muscle cutting operation on the negative rate of the Bielschowsky head test, and the upper oblique muscle folding operation on the Bielschowsky head test. The negative rate (77.27%) was significantly higher than that of the inferior oblique muscle (24%) 4, and the two kinds of surgical methods could effectively improve the compensatory head.5. In this study, the follow-up time was shorter and the average of 3 months was 3 months.

【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R779.6

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