Repka M X, Lam G C, Morrison N A
Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, Md. 21287-9009.
J Pediatr Ophthalmol Strabismus. 1994 Mar-Apr;31(2):79-83; discussion 84. doi: 10.3928/0191-3913-19940301-04.
Esotropia from chronic sixth nerve palsy or paresis usually requires surgery. Chemodenervation of the antagonist medial rectus muscle, while popular for the treatment of acute sixth nerve palsies and pareses, has not been used extensively for chronic cases. In this study, 22 patients with sixth nerve palsies or partially recovered palsies of greater than 5 months duration were treated with chemodenervation. The etiologies of the sixth nerve palsies were trauma (n = 7), tumor (n = 4), infection/inflammation (n = 3), nerve compression from aneurysm or increased intracranial pressure (n = 4), congenital (n = 1), ischemia (n = 2), and idiopathic (n = 1). The mean preinjection deviation was 41 prism diopters. A total of 38 injections were administered (mean, 1.7 per patient). Each patient received an injection of 2.5 to 7.5 units (mean, 4.1) of botulinum neurotoxin A to the ipsilateral medial rectus muscle. Treatment success was assessed 6 months after the last injection. A course of chemodenervation significantly improved the alignment of 9 of the 22 patients (41%). The mean postinjection deviation was 8 delta. Seven patients (32%) had single binocular vision in primary position restored. These patients had a mean horizontal binocular field of 70 degrees (range, 40 degrees to 100 degrees). Thirteen patients (59%) had only modest improvement and required surgery. The data suggest that injection of botulinum neurotoxin A is a useful treatment for some patients with chronic sixth nerve weakness. A course of chemodenervation therapy compares less favorably with transposition surgery with concomitant neurotoxin injection for the treatment of these difficult problems.
慢性第六脑神经麻痹或不全麻痹所致的内斜视通常需要手术治疗。尽管拮抗肌内直肌化学去神经支配术在急性第六脑神经麻痹和不全麻痹的治疗中很常用，但在慢性病例中尚未得到广泛应用。在本研究中，22例病程超过5个月的第六脑神经麻痹或部分恢复的麻痹患者接受了化学去神经支配治疗。第六脑神经麻痹的病因包括创伤（n = 7）、肿瘤（n = 4）、感染/炎症（n = 3）、动脉瘤或颅内压升高导致的神经受压（n = 4）、先天性（n = 1）、缺血（n = 2）和特发性（n = 1）。注射前平均斜视度为41棱镜度。共进行了38次注射（平均每位患者1.7次）。每位患者向同侧内直肌注射2.5至7.5单位（平均4.1单位）的A型肉毒杆菌神经毒素。在最后一次注射后6个月评估治疗效果。一个疗程的化学去神经支配治疗使22例患者中的9例（41%）的眼位明显改善。注射后平均斜视度为8△。7例患者（32%）在第一眼位恢复了单眼双眼视觉。这些患者的平均水平双眼视野为70度（范围为40度至100度）。13例患者（59%）仅略有改善，需要手术治疗。数据表明，注射A型肉毒杆菌神经毒素对一些慢性第六脑神经麻痹患者是一种有效的治疗方法。对于这些难题的治疗，一个疗程的化学去神经支配疗法与转位手术联合神经毒素注射相比效果欠佳。
