Newman Steven A
University of Virginia Health System, Charlottesville, North Carolina, USA.
Trans Am Ophthalmol Soc. 2009 Dec;107:72-90.
Thyroid orbitopathy is the most common cause of restrictive strabismus. Patients often present with vertical or horizontal double vision, or both, due to restriction involving most commonly the inferior and medial rectus muscles. Traditional muscle surgery involves release of the tight muscles. Previous literature has described a frequent need for secondary operations and an overcorrection incidence of up to 50%. Recognizing that the tight muscles are also limited in their excursion, it was proposed that operating on the better-moving eye, particularly the inferior oblique, might produce an improvement in binocularity and decrease the incidence of overcorrection.
A total of 37 patients with restrictive strabismus due to thyroid orbitopathy treated at the University of Virginia over 12 years with inferior oblique surgery were retrospectively reviewed.
Eight patients were treated with a combination of inferior oblique surgery and horizontal muscle surgery at the same time. One patient was treated with simultaneous inferior oblique and superior rectus surgery. Seven patients had vertical correction with inferior oblique surgery alone. Twenty-three patients required secondary procedures. Eight patients were overcorrected but only one following primary surgery. At the time of last follow-up, ranging from 6 months to 8 years, 33 patients had no diplopia, 2 had minimal diplopia, and 2 had persistent diplopia. All but two were completely functional.
Inferior oblique surgery by balancing the overall excursion of extraocular muscles in thyroid patients may produce binocularity in primary position and down reading gaze. The amount of vertical correction from inferior oblique surgery alone is limited, often requiring ipsilateral superior or contralateral inferior rectus surgery. Inferior oblique surgery likely increases the area of binocular single vision and decreases the incidence of overcorrection. The use of Hess screen and binocular single vision fields is helpful in assessment and planning of surgery in these patients.
甲状腺相关性眼病是限制性斜视最常见的病因。由于下直肌和内直肌最常受累，患者常出现垂直或水平复视，或两者皆有。传统的肌肉手术包括松解紧张的肌肉。既往文献报道二次手术的需求频繁，过度矫正发生率高达50%。认识到紧张的肌肉活动范围也受限，有人提出对活动较好的眼，特别是下斜肌进行手术，可能会改善双眼视功能并降低过度矫正的发生率。
回顾性分析弗吉尼亚大学12年间接受下斜肌手术治疗的37例甲状腺相关性眼病所致限制性斜视患者。
8例患者同时接受了下斜肌手术和水平肌手术。1例患者同时接受了下斜肌和上直肌手术。7例患者仅通过下斜肌手术进行垂直矫正。23例患者需要二次手术。8例患者发生过度矫正，但仅1例发生在初次手术后。在最后一次随访时，随访时间为6个月至8年，33例患者无复视，2例有轻微复视，2例有持续性复视。除2例患者外，其余患者功能均完全恢复。
通过平衡甲状腺相关性眼病患者眼外肌的整体活动范围，下斜肌手术可能会在第一眼位和向下阅读注视时产生双眼视。仅下斜肌手术的垂直矫正量有限，通常需要同侧上直肌或对侧下直肌手术。下斜肌手术可能会增加双眼单视面积并降低过度矫正的发生率。使用Hess屏和双眼单视视野有助于评估和规划这些患者的手术。
