【摘要】：第一部分： 三種術(shù)式治療兒童集合不足型間歇性外斜視的療效比較 研究目的：比較單側(cè)內(nèi)直肌截除術(shù)、雙側(cè)內(nèi)直肌截除術(shù)、改良的單側(cè)外直肌后徙聯(lián)合內(nèi)直肌截除術(shù)(一退一截術(shù))三種術(shù)式治療兒童集合不足型間歇性外斜視的療效。研究方法：前瞻性隨機(jī)對照研究。本研究納入45例集合不足型間歇性外斜視患兒,根據(jù)手術(shù)方式的不同,所有患兒被分為3組：單側(cè)內(nèi)直肌截除術(shù)組15例,雙側(cè)內(nèi)直肌截除術(shù)組14例,改良的一退一截術(shù)組16例。采用三棱鏡加交替遮蓋試驗進(jìn)行斜視度測量,根據(jù)1小時診斷性遮蓋后測量的最大斜視度手術(shù)。單側(cè)內(nèi)直肌截除術(shù)組和雙側(cè)內(nèi)直肌截除術(shù)組均按照看遠(yuǎn)斜視度設(shè)計手術(shù)；改良的一退一截術(shù)組按照看遠(yuǎn)斜視度行外直肌后徙、按照看近斜視度行內(nèi)直肌截除術(shù)。單側(cè)內(nèi)直肌截除術(shù)組和改良的一退一截術(shù)組均選擇在患兒非注視眼上手術(shù)。術(shù)后隨訪時間為6個月。療效成功的評價標(biāo)準(zhǔn)：第一眼位看遠(yuǎn)斜視度為+5～-10PD。 結(jié)果：最后隨訪時,改良的一退一截術(shù)組的手術(shù)成功率(87.5%)明顯高于單側(cè)內(nèi)直肌截除術(shù)組(13.3%)和雙側(cè)內(nèi)直肌截除術(shù)組(42.9%)(P=0.000,P=0.008)；三組術(shù)后平均看遠(yuǎn)和看近斜視度均較術(shù)前明顯減少(單側(cè)內(nèi)直肌截除術(shù)組：P=0.004、P=0.000；雙側(cè)內(nèi)直肌截除術(shù)組：P=0.003、P=0.000；改良的一退一截術(shù)組：P=0.000、P=0.000)；改良的一退一截術(shù)組術(shù)后看遠(yuǎn)和看近斜視度較術(shù)前減少的度數(shù)優(yōu)于單側(cè)內(nèi)直肌截除術(shù)組(P=0.000)和雙側(cè)內(nèi)直肌截除術(shù)組(P=0.001)。而單側(cè)內(nèi)直肌截除術(shù)組與雙側(cè)內(nèi)直肌截除術(shù)組兩組之間看遠(yuǎn)和看近斜視度減少的程度差異無統(tǒng)計學(xué)意義(P=0.080、P=0.989)。三組術(shù)后看遠(yuǎn)與看近斜視度的差值均較術(shù)前明顯減小(P=0.000)：單側(cè)內(nèi)直肌截除術(shù)組由術(shù)前11.3±2.1PD減少到術(shù)后1.5±7.6PD；雙側(cè)內(nèi)直肌截除術(shù)組由術(shù)前12.3±2.5PD減少到術(shù)后5.0±5.2PD；改良的一退一截術(shù)組由術(shù)前11.9±2.8PD減少到術(shù)后1.9±2.7PD。改良的一退一截術(shù)組與單側(cè)內(nèi)直肌截除術(shù)組和雙側(cè)內(nèi)直肌截除術(shù)組術(shù)后看遠(yuǎn)與看近斜視度差值的比較差異均無統(tǒng)計學(xué)意義(P0.05)。 結(jié)論：根據(jù)看遠(yuǎn)斜視度定量行外直肌后徙、根據(jù)看近斜視度定量行內(nèi)直肌截除的改良的單側(cè)一退一截術(shù)治療兒童集合不足型間歇性外斜視的療效優(yōu)于根據(jù)看遠(yuǎn)斜視度定量行單側(cè)內(nèi)直肌截除術(shù)和雙側(cè)內(nèi)直肌截除術(shù)。三種術(shù)式均可減小集合不足型間歇性外斜視患兒看遠(yuǎn)與看近斜視度的差值。 第二部分： 改良的單側(cè)一退一截手術(shù)治療兒童中小度數(shù)集合不足型間歇性外斜視的療效觀察 研究目的：評價按照看遠(yuǎn)斜視度行外直肌后徙、按照看近斜視度行內(nèi)直肌截除(改良的一退一截術(shù))治療中小度數(shù)兒童集合不足型間歇性外斜視的療效。 研究方法：對50例在山東大學(xué)附屬山東省立醫(yī)院眼科中心就診的集合不足型間歇性外斜視兒童的連續(xù)性病例進(jìn)行前瞻性為期1年的術(shù)后隨訪研究。所有患兒根據(jù)術(shù)前看遠(yuǎn)斜視度隨機(jī)分成兩組：A組19例,看遠(yuǎn)斜視度為15PD～25PD；B組31例,看遠(yuǎn)斜視度為30PD-40PD。療效評價標(biāo)準(zhǔn)：看遠(yuǎn)斜視度在+5～-1OPD范圍內(nèi)為眼位正位。對A、B兩組的手術(shù)成功率、看遠(yuǎn)和看近斜視度、看遠(yuǎn)與看近斜視度的差值進(jìn)行比較。采用方差分析對兩組術(shù)后看遠(yuǎn)、看近斜視度以及看遠(yuǎn)與看近斜視度的差值進(jìn)行比較；采用卡方檢驗對兩組手術(shù)正位率進(jìn)行比較。以P值0.05為有統(tǒng)計學(xué)意義。 結(jié)果：術(shù)后12個月隨訪時,50例集合不足型間歇性外斜視兒童的手術(shù)成功率為74%；A組和B組的手術(shù)成功率分別為78.9%和71.0%。從術(shù)后早期到最后隨訪的各個時間點,A組與B組的手術(shù)成功率的差異均無統(tǒng)計學(xué)意義(P=0.537)。在術(shù)后12個月隨訪時,A組(17例)和B組(28例)的平均看遠(yuǎn)斜視度分別為-3.18±5.15PD和-5.96±6.43PD,平均看近斜視度分別為-6.76±8.86PD和-7.18±7.78PD；平均看遠(yuǎn)與看近斜視度的差值分別為3.82±5.1OPD和1.21±4.36PD。兩組之間看遠(yuǎn)和看近斜視度及看遠(yuǎn)與看近斜視度差值的差異均無統(tǒng)計學(xué)意義(P=0.137,P=0.870,P=0.07)。結(jié)論：改良的單側(cè)一退一截術(shù)對兒童中小度數(shù)集合不足型間歇性外斜視具有較好的療效,并可減小看遠(yuǎn)與看近斜視度的差值。
[Abstract]:Part one:
Comparison of three surgical treatments for children with concomitant intermittent exotropia
Objective: To compare the efficacy of unilateral medial rectus myotomy, bilateral medial rectus myotomy, modified unilateral lateral lateral rectus recession combined with medial rectus myotomy (one retraction and one amputation) in the treatment of children with intermittent exotropia with insufficient collection. Strabismus children were divided into three groups according to different surgical methods: unilateral medial rectus myotomy group (15 cases), bilateral medial rectus myotomy group (14 cases) and modified one-step myotomy group (16 cases). Both the rectus myotomy group and the bilateral medial rectus myotomy group were designed according to the degree of hyperopia and strabismus; the modified one-step retraction group was performed according to the degree of hyperopia and strabismus, and the medial rectus myotomy was performed according to the degree of myopia. The follow-up period was 6 months. The criterion of success was +5-10 PD in the first eye.
Results: At the end of the follow-up, the success rate of the modified one-step myotomy group (87.5%) was significantly higher than that of the unilateral medial rectus myotomy group (13.3%) and the bilateral medial rectus myotomy group (42.9%) (P = 0.000, P = 0.008); the average postoperative distant and near strabismus of the three groups were significantly lower than those of the preoperative group (P = 0.004, P = 0.000). Lateral medial rectus myotomy group: P = 0.003, P = 0.000; modified one-step retraction and one-step myotomy group: P = 0.000, P = 0.000; modified one-step retraction and one-step myotomy group: postoperative distant and myopic strabismus were less than preoperative strabismus than unilateral medial rectus myotomy group (P = 0.000) and bilateral medial rectus myotomy group (P = 0.001). There was no significant difference between the two groups in the degree of reduction of distant and myopic strabismus (P = 0.080, P = 0.989). The difference of distant and myopic strabismus was significantly reduced in the three groups (P = 0.000). The unilateral medial rectus myotomy group was reduced from 11.3 [2.1PD] preoperatively to 1.5 [7.6PD] postoperatively, and the bilateral medial rectus myotomy group from 11.3 [2.1PD] preoperatively to 1.5 [7.6PD There was no significant difference in the difference of visual acuity and nearsightedness between the two groups (P 0.05).
CONCLUSION: The modified unilateral retraction and amputation of medial rectus according to the degree of hypertropia is superior to unilateral and bilateral myotomy of medial rectus according to the degree of hypertropia. The difference between the distant and near strabismus in children with concomitant intermittent exotropia.
The second part:
Observation on the effect of modified unilateral one-step retraction and one-step resection in the treatment of children with intermittent exotropia of mild and moderate aggregation insufficiency
Objective: To evaluate the effect of external rectus recession according to the degree of hypertropia and medial rectus amputation (modified one step retraction and one amputation) according to the degree of myopia on children with intermittent exotropia of small and medium degree of convergence.
Methods: A prospective 1-year follow-up study was conducted in 50 consecutive children with aggregated insufficient intermittent exotropia who were admitted to the Ophthalmological Center of Shandong Provincial Hospital Affiliated to Shandong University. The degree of hyperopia and strabismus was 30PD-40PD.The evaluation criteria of the curative effect were: the degree of hyperopia and strabismus was positioned in the range of +5-1 OPD. Chi-square test was used to compare the positioning rate of the two groups.
Results: At 12 months follow-up, the success rate of operation was 74% in 50 children with intermittent exotropia with insufficient collection, 78.9% in group A and 71.0% in group B. There was no significant difference in the success rate between group A and group B at all time points from early postoperative to final follow-up (P = 0.537). In group A (17 cases) and group B (28 cases), the average hyperopia and myopia were - 3.18 [5.15PD] and - 5.96 [6.43PD] respectively, and the average myopia was - 6.76 [8.86PD] and - 7.18 [7.78PD] respectively. The difference between the two groups was 3.82 [5.1OPD] and 1.21 [4.36PD] respectively. There was no significant difference between the two groups (P = 0.137, P = 0.870, P = 0.07). Conclusion: Modified unilateral retraction and one amputation is effective in treating children with intermittent exotropia of small and moderate aggregation insufficiency, and can reduce the difference between distant and nearsighted strabismus.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R779.6

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