本文關(guān)鍵詞： 先天性眼球震顫 改良Kestenbaum術(shù) 視頻眼動圖 眼外肌 超微結(jié)構(gòu)　出處：《天津醫(yī)科大學》2010年博士論文　論文類型：學位論文

【摘要】：目的 本課題旨在分析先天性眼球震顫(congenital nystagmus, CN)患者眼震中間帶移位術(shù)(改良Kestenbaum術(shù))治療前后的臨床指標和視頻眼動參數(shù),為評價此種術(shù)式的療效提供客觀依據(jù)；通過CN患者眼外肌(EOMs)超微結(jié)構(gòu)的觀察,從形態(tài)學角度分析EOMs結(jié)構(gòu)對CN的影響,以探討CN的發(fā)病機制。 方法 1.選取伴有明顯代償頭位但不伴有斜視的CN患者16例進行改良Kestenbaum術(shù)。對于頭位扭轉(zhuǎn)角度為25°-30°的患者,采用Parks5-6-7-8手術(shù)設(shè)計量,300以上的患者調(diào)整擴大手術(shù)量；對于雙中間帶者將眼震一組慢相側(cè)的直肌減弱；對水平眼震面轉(zhuǎn)并伴有垂直頭位者同時行水平和垂直肌減弱術(shù)。 2.對CN患者進行詳細的臨床檢查,包括視力、屈光、眼前段、眼底、眼位、眼球運動、頭位扭轉(zhuǎn)角度,做三棱鏡耐受試驗。 3.對上述16例CN患者進行手術(shù)前后的視頻眼動儀檢測,對所記錄的眼動參數(shù)加以分析。眼動參數(shù)包括眼震振幅、頻率、黃斑中心凹注視時間、NAFX值(眼震視力函數(shù)值)和眼震中間帶范圍。手術(shù)前后眼動參數(shù)比較采用配對t檢驗,眼震振幅、眼震頻率、黃斑中心凹注視時間與NAFX值的相關(guān)分析采用Pearson相關(guān)性分析,P0.05為差異有統(tǒng)計學意義。 4.對CN患者術(shù)中截除的眼震快相側(cè)的眼外肌末梢進行光鏡和透射電鏡觀察,正常對照來自因眼外傷需行眼球摘除且無眼球運動障礙患者的健康眼外肌和正常尸檢標本,共同性斜視組來自本院行斜視矯正術(shù)患者術(shù)中截除的水平直肌。 結(jié)果 1.CN患者手術(shù)治療前后的臨床指標：患者術(shù)前均有明確的中間帶和代償頭位,術(shù)后所有患者代償頭位均有顯著改善,術(shù)后殘余水平代償頭位扭轉(zhuǎn)角平均4.8°。1例水平雙中間帶30°者,手術(shù)只做一組眼震慢相側(cè)直肌減弱術(shù),術(shù)后頭位基本消失,未出現(xiàn)相反方向的代償頭位。1例因垂直代償頭位明顯,故在行中間帶方向兩條水平直肌減弱的同時行垂直直肌和斜肌的減弱術(shù),術(shù)后垂直頭位消失,水平殘留5°代償頭位,手術(shù)前后均未發(fā)現(xiàn)斜視。術(shù)后雙眼最好視力提高者8例(占50%),其中提高3行者：1例,提高2行者：1例,提高1行者：6例；下降1行者：2例；視力無變化者：6例。手術(shù)前后視力(換算為對數(shù)視力)比較,經(jīng)統(tǒng)計學分析,t=-2.373,p=0.031,差異具有統(tǒng)計學意義。術(shù)后Titmus提高者11例,占61%,但手術(shù)前后立體視比較經(jīng)統(tǒng)計學分析,t=1.147,p=0.270,差異無統(tǒng)計學意義。術(shù)前伴有搖頭或點頭者3例(占18%),術(shù)后其中2例搖頭改善。術(shù)后主觀感覺視物清晰度增加者12例(占71%),自覺視物清晰范圍擴大者6例(占35%),術(shù)后無變化6例(占35%)。 2.CN患者視頻眼動圖分析：16例患者眼動記錄均為速度遞增型眼震,以水平眼震為主,其中11例伴有不同程度的垂直眼震(占65%),13例有集合抑制存在(占76%),9例伴有隱性眼震(占53%)。手術(shù)前后眼震振幅、NAFX值和中間帶范圍的比較,經(jīng)統(tǒng)計學分析,差異均有顯著性(P0.05),術(shù)后眼震振幅下降,NAFX值增加,眼震中間帶擴大,眼震振幅與NAFX值具有相關(guān)性(r=-0.528,p=0.002),眼震頻率與NAFX值呈一定線性趨勢,但無相關(guān)性(r=-0.263,p=0.145夕,每秒黃斑中心凹注視時間與NAFX值之間為非線性關(guān)系。 3.CN患者眼外肌超微結(jié)構(gòu)觀察：光鏡下CN患者眼外肌肌纖維變細,排列不規(guī)則,細胞核細長。透射電鏡下眼外肌肌漿網(wǎng)呈明顯空泡樣變,柵欄樣終末的層狀結(jié)構(gòu)不同程度的溶解甚至消失,呈無結(jié)構(gòu)的嗜鋨酸樣黑色變化,而正常和共同性斜視對照組卻無此改變。無論是正常和共同性斜視對照組還是CN組,直肌止點附近柵欄樣神經(jīng)終末結(jié)構(gòu)數(shù)量少,肌肉肌腱連接區(qū)此結(jié)構(gòu)數(shù)量最多。 結(jié)論 1.改良Kestenbaum術(shù)不僅改善代償頭位,而且近期能夠減輕眼震和擴大眼震中間帶范圍。 2.NAFX值可以作為CN患者中間帶移位手術(shù)療效判別較為準確、客觀的眼動參數(shù)指標,視頻眼動儀檢測有助于眼震的診斷和治療。 3.CN患者水平直肌末梢顯示特有的超微結(jié)構(gòu)改變,即肌漿網(wǎng)擴張呈空泡狀,柵欄樣終末呈無結(jié)構(gòu)的嗜鋨酸樣黑色變化,這些改變可能與CN的病因或發(fā)病機制有關(guān)。
[Abstract]:Purpose The purpose of this study was to analyze the clinical indexes and video eye movement parameters before and after the treatment of congenital eyeball tremor ( CN ) in patients with congenital eye tremor ( CN ) . To provide an objective basis for evaluating the curative effect of this procedure , the effect of EOMs structure on CN was analyzed from the morphological angle by observing the ultrastructure of extraocular muscles ( EOMs ) of CN patients , so as to explore the pathogenesis of CN . method 1 . The modified Kestenbaum technique was performed in 16 patients with CN patients with obvious compensatory head position but not accompanied with oblique view . For patients with head torsion angle of 25 擄 - 30 擄 , the operation volume was adjusted by using Parks5 - 6 - 7 - 8 operation design . 2 . A detailed clinical examination of CN patients , including visual acuity , refractive index , anterior segment , eyeground , eye position , eye movement , head torsion angle , and triprism tolerance test were performed . 3 . The eye movement parameters of 16 CN patients before and after operation were analyzed . The eye movement parameters include the amplitude of the eye , the frequency of the center of the macula , the time of the concave fixation of the center of the macula , the value ( the value of the visual function of the eye shake ) and the range of the median zone of the eye . 4 . Observation of the extraocular muscle tip and transmission electron microscopic observation of the quick - phase side of the extraocular muscles during the operation of CN patients were observed . The normal controls were derived from the healthy extraocular muscles and normal autopsy specimens from patients with ocular trauma . Results 1 . There was a significant improvement in postoperative visual acuity ( 50 % ) . 2 . Analysis of video eye movement in patients with CN : The eye movement recorded in 16 cases was speed - increasing type eye shock . Among them , 11 cases were accompanied with different degrees of vertical eye shock ( 65 % ) , 13 cases had significant difference ( P < 0.05 ) , 9 cases had significant difference ( P = 0.002 ) , and the amplitude of the eye shock was correlated with the value of the middle band ( r = - 0.528 , p = 0.002 ) . 3 . The ultrastructural observation of extraocular muscles of CN patients showed that the muscle fibers of extraocular muscles of CN patients were thinner , irregular in arrangement and elongated in nucleus . Conclusion 1 . The modified Kestenbaum technique not only improves the compensatory head position , but also can reduce the eyestrain and enlarge the mid - band range of the eyestrain in the near term . 2 . It can be used as an accurate and objective index of eye movement parameters for the diagnosis and treatment of eye shock in patients with CN . 3 . At the end of the horizontal rectus muscle of the CN patients , the specific ultrastructural changes , that is , the dilatation of the sarcoplasmic reticulum , appear to be empty , and the end of the palisade sample presents a non - structural osmiophilic black change which may be related to the etiology or pathogenesis of the CN .

【學位授予單位】：天津醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2010
【分類號】：R777.46

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