Sadiq Saghir Ahmed, Dharmasena Aruna
Manchester Royal Eye Hospital, Oculoplastics, Orbital and Lacrimal Surgery.
Strabismus. 2014 Sep;22(3):111-4. doi: 10.3109/09273972.2014.932394. Epub 2014 Jul 9.
Botulinum toxin A (BTXA) injection to the levator palpebrae superioris muscle to induce a protective ptosis can adversely cause reduced upgaze due to diffusion of BTXA to the superior rectus muscle.
To compare the incidence of reduced upgaze in trascutaneous versus transconjunctival administration of BTXA to induce protective ptosis in patients with exposure keratopathy due to facial nerve palsy.
All patients included in this study suffered from acute exposure keratopathy and they all required chemodenervation of the levator muscle to induce a protective ptosis. Patients in group A received BTXA (Dysport) transcutaneously though the upper eyelid skin crease. Patients in group B received BTXA (Dysport) into the subconjunctival space at the superior border of the tarsal plate of the upper eyelid transconjunctivally. All subjects were closely monitored after BTXA injection and during each follow-up assessment the upper eyelid was lifted in order to uncover the effects on ocular motility. All patients had a follow-up of at least 1 year following injection of BTXA for their facial nerve palsy and its complications.
In group A, 20 patients were included. Reduced upgaze occurred in 9 patients (45%). Five required treatment with a Fresnel prism or ocular occlusion to avoid intractable diplopia. There were 15 patients in Group B, and only 2 of them developed post-treatment superior rectus underaction. One of these patients resolved spontaneously and the other patient required treatment with a spectacle-mounted Fresnel prism for diplopia. The difference in incidence of reduced upgaze between the 2 techniques was statistically significant (Fisher's exact test, P=0.0493).
Injecting BTXA to induce protective ptosis via a transconjunctival supratarsal route was significantly less likely to induce superior rectus underaction than when given via the transcutaneous route.
向上睑提肌注射A型肉毒杆菌毒素（BTXA）以诱导保护性上睑下垂可能会因BTXA扩散至眼直肌而对向上注视产生不利影响。
比较经皮与经结膜注射BTXA以诱导因面神经麻痹导致暴露性角膜病变患者产生保护性上睑下垂时向上注视减弱的发生率。
本研究纳入的所有患者均患有急性暴露性角膜病变，且均需要对提上睑肌进行化学去神经支配以诱导保护性上睑下垂。A组患者经上睑皮肤皱襞经皮注射BTXA（丽舒妥）。B组患者经结膜在上睑睑板上缘的结膜下间隙注射BTXA（丽舒妥）。BTXA注射后对所有受试者进行密切监测，在每次随访评估时提起上睑以发现对眼球运动的影响。所有患者在注射BTXA治疗面神经麻痹及其并发症后至少随访1年。
A组纳入20例患者。9例（45%）出现向上注视减弱。5例需要使用菲涅尔棱镜或眼罩治疗以避免难治性复视。B组有15例患者，其中仅2例在治疗后出现上直肌功能减退。其中1例患者自行缓解，另1例患者需要使用佩戴在眼镜上的菲涅尔棱镜治疗复视。两种技术在向上注视减弱发生率方面的差异具有统计学意义（Fisher精确检验，P = 0.0493）。
经结膜睑板上缘途径注射BTXA诱导保护性上睑下垂时，引起上直肌功能减退的可能性明显低于经皮途径。
