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Title: [Diagnosis and treatment of strabismus caused by nasal endoscopic surgery].
Author: Ai LK, Wu X, Wang JN, Li J, Wu Y, Zhou J, Song WX, Guo RL.
Journal: Zhonghua Yan Ke Za Zhi; 2017 Dec 11; 53(12):917-923. PubMed ID: 29325384.
Abstract:
Objective: Strabismus with diplopia is the main orbital complication of functional endoscopic sinus surgery (FESS). This study was to analyze clinical findings, treatment and outcomes of such cases. Methods: Retrospective case series. Twenty-three cases were divided into 3 groups based on the disease severity: group A, partial transection of the medial rectus muscle, group B, complete transection of the medical rectus, group C, transection of the medial rectus combined with the other orbital injuries. Complete ophthalmology examinations, including eye alignment, eye motility, force duction test, force generation test, general eye exam, and medical imaging (orbital CT or MRI), were performed for each case. The treatment included botulinum toxin (Botox) injection to the lateral rectus muscle, transposition of the vertical rectus muscle, and orbital surgery if needed. Results: In group A with Botox injection, all the cases achieved single vision in primary position, but still remained some adduction weakness. In group B treated by vertical transposition surgery combined with Botox, 22% of the cases got single vision in primary gaze. In group C, even with more efforts of treatment, the cases with orbital injury can only get cosmetic improvement, and diplopia and adduction dysfunction were found in most cases. Conclusions: Due to the variety of the complications of FESS, force duction test is a crucial exam to detect the direction and severity of synechia in the orbit, which will give solid information to surgery approach as well as prognosis. Botox injection at early stage will minimize the contraction of antagonist lateral rectus, helping to postpone the transposition surgery which may cause anterior segment ischemia when performed right after the medial rectus transection injury. Botox may even reduce the synechia by minimizing the scarring process. Partial vertical rectus transposition combined with muscle resection may effectively correct the eye misalignment in primary gaze and improve eye motility. The prognosis of FESS induced orbital complications is quite related with the severity of the injury. Botox combined with surgery may help medial rectus transection cases to achieve single vision in primary gaze, but when there is any other orbital injury, treatment may only improve cosmetic appearance. (Chin J Ophthalmol, 2017, 53: 917-923). 目的： 探讨鼻内窥镜手术误入眶内引起斜视等并发症的临床特点及治疗方法与预后的关系，探寻最佳治疗方案。 方法： 回顾性病例系列研究。收集2006至2016年在首都医科大学北京同仁眼科中心就诊的因鼻内窥镜手术误入眶内引起眼部并发症患者23例，其中男性17例，女性6例，平均年龄（41.8±12.8）岁。经过眼位、眼球运动、牵拉试验等临床检查及影像学检查明确诊断，按病情轻重分为3个组，A组部分内直肌离断（3例），B组单纯完全内直肌离断，C组内直肌离断合并其他眶内损伤（12例）。适时对上述3个组实施肉毒毒素外直肌注射治疗，垂直肌转位等斜视手术等治疗。对治疗前后斜视度数及运动功能改善等数据进行秩和检验。 结果： A组仅需肉毒毒素注射即可达到原在位无复视，仅存轻度的内转不足，但治疗前后差异无统计学意义（P>0.05）；B组经过肉毒毒素合并手术预后较好，2例患者原在位无复视，仅企图内转时出现复视。A组治疗前后斜视度数分别为（-23.33±5.77）和（0.00±0.00）PD（Z=-1.63，P>0.05），B组分别为（-81.25±6.41）和（-2.63±3.50）PD（Z=-2.53，P<0.05）；C组分别为（-77.92±18.76）和（-14.58±10.32）PD（Z=-3.06，P<0.05）。A组治疗前后内转功能受损程度分别为-1.67±1.16和-1.00±0.00（Z=-1.63，P>0.05），B组分别为-4.00±0.00和-2.13±0.84（Z=-1.00，P>0.05），C组分别为-3.75±0.62和-2.58±0.79（Z=-2.74，P<0.05）。C组往往仅能部分改善外观，复视仍较明显，且眼球运动多无明显改善。 结论： 鼻内窥镜术引起眶内损伤中复视和眼球运动受损是主要的临床表现。早期进行外直肌肉毒毒素注射可缓解外直肌的张力性收缩，注射前后适时的进行上、下直肌转位术不失为治疗此类斜视的最佳选择，治疗预后与伤情的轻重直接相关，部分内直肌离断及单纯内直肌离断多数病例可以达到原在位无复视或轻度复视，内直肌离断合并粘连者多数仅能改善外观。（中华眼科杂志，2017，53：917-923）.

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