Effect of Binasal Occlusion in Children with Concomitant Esotropia

Objective: To investigate the effect of binasal occlusion in the treatment of children with concomitant esotropia. Methods: In this propective clinical study, 21 children aged 3 to 10 years with nonaccommodative esotropia or partly accommodative esotropia who had more than +20△ esotropia after full refraction correction for 6 to 9 months at Xiamen Children's Hospital from January 2019 to July 2019 were examined. All the children were given binasal occlusion. Vision function and strabismic degree were re-examined every month. Data were analyzed by single factor analysis of variance. Results: The average strabismus was +33△±13△ before binasal occlusion. After binasal occlusion for 3 months, average strabismus was +21△±15△. Three cases were markedly corrected, 11 cases were effectively corrected, 7 cases were invalid. After binasal occlusion for 6 months, average strabismus was +18△±12△. Five cases were markedly corrected, 13 cases were effectively corrected, 3 cases were invalid. The difference was statistically significant (F=8.316, P=0.001). Conclusions: Binasal occlusion can effectively assist the treatment of concomitant esotropia in children.     

双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果

目的：观察双鼻侧遮盖法辅助治疗儿童共同性内斜视的效果。方法：前瞻性临床研究。纳入2019年 1─7月期间在厦门市儿童医院经阿托品眼膏散瞳验光连续配戴远视全矫眼镜6～9个月后仍有+20△ 以上内斜视的3～10岁非调节性内斜视或部分调节性内斜视患儿21例。给予双鼻侧遮盖辅助治疗。 每个月定期复查观察患儿视力及斜视度的矫正情况。数据采用重复测量方差分析进行分析。结果： 遮盖前斜视度为（+33±13）△;遮盖3个月后斜视度为（+21±15）△,其中矫正显效3例,有效11例, 无效7例;遮盖6个月后斜视度为（+18±12）△,其中矫正显效5例,有效13例,无效3例。3个时间点 斜视度比较,总体差异有统计学意义（F=8.316,P=0.001）。结论：双鼻侧遮盖法可以有效地辅助治 疗儿童共同性内斜视。     

直肌后徙可调缝线术在儿童共同性斜视中的应用

目的：观察直肌后徙可调整缝线术治疗儿童共同性斜视的临床效果。方法对34例儿童共同性斜视在全麻下采用直肌后徙调整缝线术治疗,术后1～2 d内进行缝线调整,随访6～24个月,观察手术效果。结果34例儿童共同性斜视患者中,11例达正常眼位,23例因欠矫或过矫需要调整,其中过矫9例及欠矫11例均调至正位,有3例欠矫者经集合训练后得到改善。在6～24个月随访中,未调整的患者中欠矫1例,经过调整的患者中欠矫2例,术后视功能较术前有明显的改善。结论采用可调整缝线治疗儿童共同性斜视是简便而有效的手术方式,可以减少再次手术风险,使儿童全麻斜视矫正手术的成功率获得较大的提高。     

眼外肌注射肉毒毒素及布比卡因治疗斜视

斜视的眼外肌药物注射疗法相比于斜视矫正手术具有更加安全、微创、麻醉时间短、术后疼痛轻、患者易于接受等优点。目前应用最广泛的减弱眼外肌力量的药物为肉毒毒素，其对小角度斜视、鼻内窥镜术后斜视、斜视矫正手术的辅助治疗等有重要作用；有效地增强肌肉力量的药物为布比卡因，其对小角度的共同性斜视、非陈旧性麻痹性斜视早期有治疗作用；肉毒素及布比卡因联合注射可对中等角度的水平共同性斜视、非陈旧性麻痹性斜视早期有较好治疗效果。（国际眼科纵览， 2018,  42:   169-174）     

Use of botulinum toxin in ophthalmology

Botulin toxin A was introduced as a treatment in ophthalmology by Dr. Scott of San Francisco. One important application is in cases of blepharospasm, where the toxin is injected into the lateral parts of the lower and upper lid and, if necessary, over the eyebrows in a single dose of 1-2 nanograms, preferably using a needle under electromyographic control. The effect on the blepharospasm is visible after a few days and lasts for several months. The procedure can be repeated several times. The second application is in cases of strabismus. In paralytic strabismus, contracture of the antagonist of the paralyzed muscle can be weakened by local injection of botulin toxin with a coaxial electrode under electromyographic control. Good results were observed in cases of eye muscle disorders in endocrine ophthalmopathy. In concomitant strabismus (exotropia or esotropia) administration of botulin toxin is also possible although a certain paresis of the injected muscle has to be taken into account. The doses for strabismus vary between 1/2 and 2 nanograms of the toxin. The administration of botulin toxin either in blepharospasm or strabismus has no systemic side effects and is a safe procedure if performed under careful electromyographic control. First personal experiences in the treatment both of blepharospasmus as well paralytic strabismus and concomitant strabismus are reported.     

Concomitant strabismus: of strabismus in strabismus syndromes]

PURPOSE: To show how to progress from the deviation of the visual axis (provided the diagnosis of concomitant strabismus is certain) to the classification of the squint in one out of the different squint syndromes and consequently to adopt the appropriate therapeutic strategy. METHOD: Every sign correlated with the deviation contributes to progress step by step to the diagnosis of a given squint syndrome. The age on onset of strabismus, either convergent or divergent, and its characteristic, intermittent or constant, allow in a first step to evaluate the potential binocularity, as well in early as late (acquired) strabismus. The first group of early strabismus includes manifest infantile strabismus and microstrabismus. Both have abnormal binocularity. The possibility of functional amblyopia, angle variability and additional incomitances have to be investigated. Early intermittent strabismus keeping a potential normal binocularity are seldom. In the second group of late onset strabismus, retinal correspondence has to be investigated by correspondence tests and prism or bifocus compensation to distinguish between the two possible types (including the accommodative forms of strabismus), i.e. decompensated microstrabismus with abnormal binocularity or normosensorial strabismus with potential normal binocularity. In some cases potential binocularity may be initially uncertain and/or remain later on subnormal. RESULTS: As the result of this systematic approach, every cases of squint can be classified in one out of the different squint syndromes. Based on the precise diagnosis, the appropriate treatment can be carried out. The goals of treatment which can be reached in every syndrome are indicated. DISCUSSION: For an overall view of the squint syndromes a classification with two entrances are necessary, on the one hand early or late onset, on the other hand normal or abnormal binocular conditions. CONCLUSION: This approach of concomitant strabismus should serve as guide lines for clinical practice.     

Horizontal rectus muscle anatomy in naturally and artificially strabismic monkeys

PURPOSE: Structural abnormalities of extraocular muscles (EOMs) or their pulleys are associated with some forms of human strabismus. This experiment was conducted to investigate whether such abnormalities are associated with artificial or naturally occurring strabismus in monkeys. METHODS: Binocular alignment and grating visual acuities were determined in 10 monkeys representing various species using search coil recording and direct observations. Four animals were orthotropic, two had naturally occurring "A"-pattern esotropia, two had concomitant and one had "V"-pattern esotropia artificially induced by alternating or unilateral occlusion in infancy, and one had "A"-pattern exotropia artificially induced by prism wear. After euthanasia, 16 orbits were examined by high-resolution magnetic resonance imaging (MRI) in the quasi-coronal plane. Paths and sizes of horizontal rectus EOMs were analyzed quantitatively in a standardized coordinate system. Whole orbits were then serially sectioned en bloc in the quasi-coronal plane, stained for connective tissue, and compared with MRI. Nerve and EOM features were analyzed quantitatively. RESULTS: Quantitative analysis of MRI revealed no significant differences in horizontal rectus EOM sizes or paths among orthotropic or naturally or artificially strabismic monkeys. Histologic examination demonstrated no differences in EOM size, structure, or innervation among the three groups, and no differences in connective tissues in the pulley system. The accessory lateral rectus (ALR) EOM was present in all specimens, but was small, inconsistently located, and sparsely innervated. Characteristics of the ALR did not correlate with strabismus. CONCLUSIONS: Major structural abnormalities of horizontal rectus EOMs and associated pulleys are unrelated to natural or artificial horizontal strabismus in the monkeys studied. The ALR is unlikely to contribute to horizontal strabismus in primates. However, these findings do not exclude a possible role of pulley abnormalities in disorders such as cyclovertical strabismus.     

甘露醇静脉滴注引起过敏性休克1例

患者，女，５２岁，工人。因右眼阵发性胀痛伴视力障碍５天，于１９９７年９月２８日来我院就诊。全身检查无特殊。眼部检查，视力：右眼０．０１，结膜混合性充血（），角膜呈雾状混浊水肿，前房浅，瞳孔直径６ｍｍ，对光反应消失，晶体呈灰白色混浊，眼底窥不清。眼压...     

急性共同性内斜视的临床特征分析和手术 治疗体会

目的：分析101例急性共同性内斜视患者的临床特征、手术方式及治疗效果。方法：回顾性系列病例 研究。连续纳入2018年11月至2020年11月于武汉爱尔眼科医院就诊的急性共同性内斜视患者101例, 其中男71例,女30例,年龄5~76（20.7±11.3）岁。收集患者的临床资料包括患者基本资料、眼部情 况以及头颅影像学检查等。采用配对t检验对看近和看远斜视度及手术前后斜视度进行比较。采用 χ2检验分析不同年龄段、不同性别的患者屈光状态的差异。结果：101例患者中近视81例,远视19例, <12岁组以远视为主,12~30岁组以中高度近视为主,>30岁组以低中度近视为主。发病年龄12~30 岁有71例,占比70.3%（71/101）。其中学生有63例,近距离用眼时长大于8 h的占比46.5%（47/101）。 裸眼看近斜视度（+42.0±18.3） △,裸眼看远斜视度（+43.7±17.2） △,裸眼看远斜视度大于看近斜视 度（t=2.82, P=0.011）;戴镜看近斜视度（+41.6±18.6） △,戴镜看远斜视度（+43.2±17.7） △,戴镜看远 斜视度大于看近斜视度（t=2.61, P=0.007）。裸眼与戴镜看远斜视度数大于看近斜视度数患者占总人 数24.8%,裸眼与戴镜看近斜视度数大于看远斜视度数患者占总人数7.9%。83例内直肌止端距角膜 缘的距离平均为4.74 mm,小于正常值的5.50 mm。最常用的手术方式为内直肌后徙联合外直肌缩 短术,所有患者手术均一次成功,术后患者看近看远的斜视度的均数为0 △。结论：急性共同性内斜 视患者多为青少年和20多岁的年轻人,可能与近距离用眼时长过长有关。不同屈光状态患者均有出 现急性共同性内斜视的可能。内直肌止端前移解剖异常。急性共同性内斜视患者中裸眼和戴镜看远 斜视度数大于看近斜视度数占比高于看近斜视度数大于看远斜视度数。采用内直肌后徙联合外直肌 缩短术治疗的患者术后均有良好的手术效果。     

Clinical presentation, diagnosis and treatment of strabismus combined with ptosis

On the basis of examination of 172 patients with strabismus concomitant with ptosis, different clinical forms of the former were defined and their clinical variations were classified. Symptomatology was described for each form. An independent type of false positive ptosis was pointed out. The notion of "positive and negative fixation tests" was introduced. A proper interpretation of the origin of true and false ptosis was presented. Finally, a sequence and tactics of surgical and functional treatment of different clinical presentations of squint concomitant with ptosis are lain down.     

共同性斜视眼外肌病理改变的研究

目的:通过对共同性斜视患者眼外肌的病理学研究,了解其发病机制及手术时机。方法:用光学显微镜和电子显微镜对56例共同性斜视的眼外肌进行观察。结果:斜视患者弱侧眼肌不同程度萎缩变性,肌原纤维稀疏,H带不清,肌原纤维排列方向紊乱,线粒体多,嵴密,肌质网扩张,有些有髓神经髓鞘层次不清,轴突水肿,随病程延长,肌纤维病变加剧。结论:共同性斜视患者斜视弱侧眼肌在结构上有明显的病理性改变,萎缩变性是产生共同性斜视的重要原因。斜视患者应尽早行手术治疗。     

A型肉毒毒素注射与手术治疗儿童共同性斜视的临床比较

目的比较A型肉毒毒素(BTA)注射与手术治疗儿童共同性斜视的疗效。 方法纳入2018年4月至2019年8月就诊于北京同仁医院眼科中心的共同性斜视患儿142例作为研究对象。其中,男性74例,女性68例;年龄3~15岁,平均年龄(7.2±2.6)岁。按照家属的选择意愿分为注射组和手术组。注射组患儿采用BTA眼外肌注射治疗,手术组患儿采用斜视矫正术治疗。检查并记录治疗前与治疗后6个月患儿的斜视度、双眼视觉功能以及并发症情况,治疗后6个月患儿的眼位正位率等指标。注射组和手术组患儿斜视度与双眼视觉功能的定量数据,用均数±标准差描述,采用独立样本t检验进行组间比较,采用配对样本t检验进行组内比较。患儿双眼视觉功能的定性数据,眼位正位率与并发症等指标的描述采用频数和百分率表示,采用卡方检验进行组间比较。 结果治疗后6个月,注射组患儿的眼位正位率为58.2%,手术组患儿的眼位正位率为69.3%。两组患儿眼位正位率的比较,差异无统计学意义(χ²＝1.90,P>0.05)。注射组患儿斜视度绝对值在注射前和注射后6个月分别为(35.23±6.69)△和(12.35±10.16)△;手术组患儿斜视度绝对值在手术前和手术后6个月分别为(35.40±8.74)△和(9.16±9.43)△。治疗前与治疗后6个月,两组患儿斜视度绝对值的比较,差异无统计学意义(t＝-0.13,1.92;P>0.05)。注射组和手术组患儿在治疗后6个月随访时,具有正常同视机Ⅰ级功能(同时视)的分别有25例(占39.1%)和38例(占50.7%);具有正常同视机Ⅱ级功能(融合视)的分别有43例(占67.2%)和70例(占93.3%);具有正常同视机Ⅲ级功能(立体视)的分别有26例(占40.6%)和37例(占49.3%);具有正常近立体视功能的分别有27例(占42.2%)和38例(占50.7%),与治疗前相比均有所增加。治疗后6个月,手术组具有同视机Ⅱ级功能(融合视)患儿的比例高于注射组,差异有统计学意义(χ²＝15.52,P<0.05),其余差异均无统计学意义(χ²＝1.88,1.06,0.99;P>0.05)。注射组所有患儿主诉出现复视,16例患儿表现出轻度上睑下垂和结膜下出血,均于随访1~3个月时消失。 结论对于斜视度为中低度数(15△~50△)的患儿,BTA注射与手术治疗儿童共同性斜视在治疗后6个月临床疗效相近,是一种安全有效的治疗方法。     

Hemifield Slide Phenomenon as a Result of Heteronymous Hemianopia

Heteronymous hemianopic defects may lead to the hemifield slide phenomenon. We report one case of binasal and two of bitemporal visual field defects causing hemifield slide. Both patients with bitemporal visual field defects underwent strabismus surgery. One with adjustable sutures reported omission or duplication of a central strip of vision dependent on alignment during adjustment, but did not have long-term improvement of hemifield slide in two patients. Visual field improvement resolved hemifield in two patients, one of whom had strabismus surgery. Strabismus surgery to restore binocular visual function can be performed in hemifield slide patients. Patients with improving visual fields may have a better sensory prognosis.     

共同性水平斜视的再次手术

目的 探讨共同性水平斜视手术后施行再次斜视手术的临床特点及手术处理的特殊性.方法 共同性水平斜视手术后施行再次斜视手术的55例患者进行了回顾性临床分析,手术前后进行眼位检查、眼球运动,Titmus立体视检查双眼视觉功能.手术方法:手术前做全麻下或局麻下行牵拉试验.手术方式选择原则:依据视近和视远斜视角的不同,眼球运动受限制的受累肌肉和牵拉试验结果选择术式.术后追踪观察1～8年,平均2年.结果 (1)内斜视术后继发外斜视13例中,除即刻过矫3例在手术后48h内施行内直肌探查术外,其余施行原后徙内直肌完全复位或部分复位术,联合外直肌截除.治愈率76.9%.外斜视术后继发内斜视11例,施行原后徙外直肌完全复位或部分复位术,联合内直肌截除.治愈率81.8%.伴有V型斜视和垂直性斜视者联合水平直肌移位或斜肌减弱术.(2)内斜视欠矫15例中,8例施行内直肌边缘切开联合外直肌截除术;选择单纯在同一眼上外直肌截除术2例;伴有斜肌异常患者,则选择对侧眼内直肌后徙联合外直肌截除并下斜肌后徙5例.术后正位率86.7%.外斜视欠矫16例中:6例施行原外直肌后徙眼边缘切开联合内直肌截除术;2例Ⅴ型外斜视联合双下斜肌后徙,4例外直肌周围瘢痕松解术,4例联合调整缝线.术后正位率87.5%.结论 (1)水平斜视过矫伴有受累肌运动障碍,结合看近与看远斜视角的差别,选择内直肌或外直肌复位术.(2)调整术后缝线可将再次斜视手术的非预期结果降低到最小程度.     

先天性和共同性斜视眼外肌病理变化的比较

目的观察先天性斜视、共同性斜视眼外肌的病理变化,探讨共同性斜视、先天性斜视等肌源性病变特点。方法对50例先天性斜视及共同性斜视患者行斜视矫正术,将截除的眼外肌标本及选取的2例正常眼外肌标本制作石蜡切片,行HE染色并置于光镜下观察眼外肌的病理特点。结果正常眼外肌标本未见纤维组织增生;先天性内、外斜视眼外肌标本显示出不同程度的眼外肌纤维化、玻璃样变及肌纤维变性、结构消失等改变,以先天性内斜视改变较为显著。共同性内、外斜视可见肌纤维体积减小、数量减少,排列紊乱,发病较早、手术年龄大的共同性斜视患者多可见肌肉部分萎缩、肌纤维间隙增宽,胶原含量增多等改变。结论先天性斜视会引起眼外肌纤维化等的改变,而共同性斜视也会出现轻度眼外肌病理性改变。     

Types of occlusion in the treatment of convergent strabismus]

The different kinds of penalizations which are used in strabismus therapy--occlusion, atropine penalization, optic penalization, filters, partial occlusion of the glasses (sectors)--are being discussed with their advantages and disadvantages. Their indications and their results are reported according to the age of the child and the degree of the amblyopia.     

Strabismus and eye muscle function

Studies of external eye muscle morphology and physiology are reviewed, with respect to both motor and sensory functions in concomitant strabismus. The eye muscles have a more complex fibre composition than other striated muscle, and they are among the fastest and most fatigue-resistant muscles in the body. However, it is not generally believed that concomitant strabismus is due to a primary abnormality of the eye muscles or the ocular motor system. The gross anatomy of eye muscles, including the shape and position of the eye muscle pulleys, was not changed in strabismus. The histology of the eye muscle fibres was also basically the same, but changes have been observed in the cellular and biochemical machinery of the fibres, most notably in the singly innervated orbital fibres. Functionally, this was seen as slower contractions and reduced fatigue resistance of eye muscles in animals with strabismus and defects of binocular vision. Most likely the changes represented an adaptation to modified visual demands on the ocular motor control, because of the defects of binocular vision in strabismus from an early age. Adaptation of eye muscle function to visual demands could be seen also in the adult human ocular motor system, but here the effects could be reversed with treatment in some conditions. External eye muscles in the human have sensory organs, muscle spindles and tendon organs, responding to changes in muscle force and length. It is not known how these proprioceptors are used more specifically in ocular motor control, and there is no stretch reflex in the external eye muscles. However, a clear influence on space localization and eye position can be demonstrated with vibratory stimulation of the eye muscles, presumably activating muscle spindles. Different effects were observed in normal subjects and in adult patients with strabismus, which would indicate that the proprioceptive input from one eye of strabismic patients could be suppressed by the other eye, similar to visual suppression in concomitant strabismus. Such an interaction would most likely occur in the visual cortex, and not in the ocular motor system. Further studies of proprioceptive mechanisms, during the postnatal developmental stage and in adult concomitant strabismus may shed light on the mechanisms of childhood strabismus and may, in this respect, be a more fruitful avenue for further research than eye motor studies.     

共同性斜视患者眼外肌本体感受器组织形态及超微结构研究

目的：研究共同性斜视患者眼外肌本体感受器（extraocular muscle proprioceptor,EMP)的形态学改变,为探讨斜视的发病机制提供依据。方法：取28例共同性斜视患者和11例眼球摘除者的眼外肌,采用Holmes‘法染色后在光镜及透射电镜观察,并计算相同放大倍数下每例标本面积4000mm^2的轴突中线粒体个数。结果：光镜下可见位于眼外肌肌－腿连接处的EMP神经纤维终止于邻近单个梭外肌纤维的起始处或两侧;电镜下斜视患者EMP与对照组比较,结构紊乱,神经成分消失;每例标本面积4000m^2轴突中线粒体个数实验组明显少于对照组（P＜0．05）。结斜视患者EMP结构的紊乱,导致EMP接收传递信息功能异常,从形态学角度证实了EMP紊乱在共同性斜视发病机制中具有重要作用。     

共同性斜视眼外肌的病理变化及肝细胞生长因子表达研究

目的研究共同性斜视弱侧眼外肌的病理变化及肝细胞生长因子（HGF）的表达。方法实验研究。收集在武汉大学人民医院眼科行共同性斜视手术的58例患者手术中切下的眼外肌作为斜视组,将其分成共同性外斜视（32例）和共同性内斜视（26例）2组,同期10例角膜移植供体眼眼外肌作为对照组（供体均无斜视）。观察眼外肌的组织结构变化,用免疫组织化学法检测眼外肌中HGF的表达,并测定其平均光密度值。比较斜视组与对照组眼外肌HGF的表达差异,并分析其与斜视度、患者年龄之间相关性。所得数据采用t检验及直线相关分析进行统计学处理。结果①共同性外斜视组内直肌肌纤维横截面积（308.9±68.4）µm2,显著低于对照组内直肌[（738.4±56.3）µm2]（t=16.74,P<0．05）,共同性内斜视组外直肌肌纤维横截面积（217.9±34.7）µm2,显著低于对照组外直肌[（620.9±46.5）µm2]（t=28.34,P<0．05）,差异有统计学意义。②Masson染色显示共同性斜视弱侧眼外肌肌纤维数量减少,排列紊乱,胶原纤维含量增多,纤维组织、脂肪组织和肌纤维间隙增宽。③免疫组化检测HGF在对照眼眼外肌及斜视眼弱侧眼外肌中均有阳性表达,主要表达于胞浆,细胞外基质中有少量的表达。其中共同性外斜视组内直肌（t=6.33,P<0．05）、共同性内斜视组外直肌（t=4.75,P<0．05）HGF的表达均低于对照组。④HGF的表达与患者病程（r=-0.856,P＜0．05）以及斜视度（r=-0.525,P＜0．05）呈负相关。结论共同性斜视弱侧眼外肌出现胶原纤维增生,肌纤维横截面积减小等萎缩性病理改变;HGF的低表达可能是共同性斜视发生的危险因素。     

Impact of a surgical treatment stage on the accommodability and binocular functions in patients with concomitant strabismus

The surgical stage of treatment for concomitant strabismus was studied for its impact on accommodability and inocular functions. Thirty-four patients were examined. The author used the laser stroboscopic technique, estimated the accommodation convergence/accommodation (AC/A) ratio, and evaluated binocular functions at different working distances (in the color, polaroid, and scanning separation of the fields of vision) and on a synoptophore. Surgical treatment was shown to reduce the AC/A ratio, to normalize accommodation tone, and to improve or to restore binocular functions, which suggest their close relationship.