作者：陶利娟,王 平,王曦琅,杨慧玲,郭 燕,肖志刚
作者单位：中国湖南省长沙市,湖南省儿童医院眼科 湖南省儿童眼视光弱视斜视防治中心
【摘要】 目的：探讨V型外斜视的临床特点和手术方法及疗效方法：分析2003 01/2007 07在我院行手术治疗的93例V型外斜视患者，其中男51例,女42例，年龄4～27（平均13.2)岁，术后随访时间为6mo～4a，V征向上向下注视的斜视度之差最小为15△，最大相差100△，其中15～50△者85例，＞50△者8例，第一眼位斜视角在20～110△，术前行同视机检查有双眼单视功能者18例。手术根据有无斜肌异常和V征的程度,在水平斜视矫正的同时，选择下斜肌切断或部分切除，直肌附着点垂直移位、及下斜肌部分切除并水平直肌垂直移位三种术式。 结果：采用下斜肌断腱或部分切除术和水平直肌附着点移位均取得满意效果，下斜肌断腱或部分切除术适应于下斜肌亢进的外斜V型，垂直肌移位术适应因无下斜肌亢进的外斜V征，术后第一眼位正位者84例，V征消失者87例，双眼视功能恢复者达49例。结论：V型外斜视是一种常见的斜视类型，常合并水平斜视，发病原因以斜肌功能异常为主，可根据病因选择不同手术方式，手术不仅可以矫正眼位，而且有利用双眼单视功能的建立。
【关键词】 V征外斜视;临床特点;手术
Clinic characteristics and surgical management in Vpattern deviation
LiJuan Tao, Ping Wang, XiLang Wang, HuiLing Yang, Yan Guo, ZhiGang Xiao
Department of Ophthalmology, the Hunan Childrens Hospital, The Center for Children Optometry Ambliopia and Strabismus of Hunan Province, Changsha 410007, Hunan Province, China
AbstractAIM: To study the clinic characteristics, surgical treatment and postoperative effect of V pattern deviation.
METHODS: The surgical effects of 93 patients with vpattern deviation (male 51, female 42), treated in our hospital during January 2003 to July 2007, with ages ranging from 4 to 27 years ( meaning 13.2 years) were analyzed. Followup time after surgery was 6 48 months. Viewing the differences between superior strabismus angles and inferior strabismus angles, 85 cases of askant difference were 15△50△, and 8 cases of askant difference were more than 50△. The smallest askant difference was 15△, the greatest was 100△. The cases of askant were between 20△～100△ at primary position of eye. Eighteen cases had binocular function by synoptophore test. According to dysfunction of oblique muscle and level of vpattern, patients were treated with horizontal rectus vertical transporting, completely or partly inferior oblique reduction or horizontal rectus vertical transporting combined with inferior oblique reduction.
RESULTS: Patients treated with horizontal rectus vertical transporting, partly inferior oblique reduction had satisfied results. The cases, with vexotropia complicating overaction degrees of inferior oblique muscle, should be treated with partly inferior oblique reduction. If not complicating dysfunction of oblique muscles, case were treated with horizontal rectus vertical transporting. Eightyfour cases return normal at primary position of eye, 87 cases got vsign correction and 49 case got binocular vision.
CONCLUSION: V pattern deviation is a common type in strabismus. Its etiology is a mainly oblique muscle dysfunction. Different surgical procedures should be selected according to different etiological factors. Such surgical procedures should not only align the eye and also promote the binocular function.
KEYWORDS: V pattern deviation; clinic characteristics; surgical treatment
Tao LJ, Wang P, Wang XL, et al. Clinic characteristics and surgical management in Vpattern deviation. Int J Ophthalmol(GuojiYanke Zazhi)2008;8(11):22862287
0引言
AV综合征是共同性外斜视的一种亚型，属特殊类型的水平斜视，患者在向上下方25°注视时水平斜视角的大小发生改变，V型斜视是指眼向下方注视时集合加大，眼位的变化呈“V”字型，外斜视向上看时外斜视度比向下看时加大相差15△者称V型外斜视，此类型斜视在临床上常见， 它是一种同时伴有垂直非共同性的亚型水平性斜视，外斜V是AV综合征中最为常见的一种类型，其病因复杂，手术方法多样，正确的诊断和术式选择对眼位的矫正和双眼视功能的建立非常重要，现将2003 01/2007 07近4a来我院手术治疗的93例V型外斜视患者报告如下。
1对象和方法
1.1对象 本组V型外斜视患者93例，男51例，女42例，年龄4～27（平均15）岁，随访时间6mo～4a，按中华医学会眼科学分会全国儿童弱视斜视学组规定：以向上注视时的斜视度和向下注视是的斜视度之差≥15△为V型外斜视的诊断标准。
1.2方法 所有患者常规行视力、眼前节、屈光眼底检查，有屈光不正者配戴合适的矫正眼镜，详查眼肌情况，包括眼位、眼外肌功能、眼外肌运动断判是否伴有下斜肌亢进及其程度，同视机查三级功能，三棱镜+交替遮盖检查远近斜视角，以上转和下转25°注视5m距离三棱镜水平度数的差值作为V型外斜的诊断依据，。本组向上向下注视时的水平斜视度之差为15～100△，其中15～40△者有62例，40～50△ 者23例，＞50△者 8例，最大相差105△，第一眼位斜视角在20～110△，术前有同视机检查有双眼单视功能者18例。眼运动检查：通过六方位眼球运动检查或同视机九方位斜度判断6条眼外肌功能状态，结合Bielschowsky征鉴别上斜肌或上直肌不全麻痹。69例伴有垂直肌肉功能异常，原发性下斜肌亢进44例，先天性上斜肌麻痹29例，上直肌不全麻痹2例，伴水平肌异常18例。据有无下斜肌功能亢进程度，向上注视时与向下注视斜视度差值大小和33cm、5m的水平外斜视度数来设计手术。手术方法包括：(1)无斜肌功能亢进者，在水平斜视矫正同时行外直肌退后并上移1/2或2/3肌腱或单眼外直肌退后并上移+内直肌缩短并下移，共18例；（2）伴下斜肌亢进者行水平肌肉退后+缩短术+下斜肌断腱或部分切除术,共67例；（3）上下斜度＞50△且伴下斜肌亢进者,在行下斜肌减弱术的同时作水平直肌垂直移位术,共8例；（4）水平斜视的矫正：基本型或外展过强型外斜，选择双外直肌退后 ,集合过强型外斜视选择单眼外直肌退后+内直肌缩短,水平外斜视度＞70△者在双外直肌退后，外加非主导眼的内直肌缩短，合并有上直肌功能不足，先行上直肌缩短手术，隔6wk后再行水平斜视矫正术。
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