眼科学：07 眼肌

1、Strabismus & Amblyopia,case,5y, Female ，right eye strabismus afer 1 y general eye examination (-) , VA(distance)： OD: 4.3(0.2) OS: 4.9(0.8) corneal light reflection（near and distance）： 50eso，the angle of deviation is the same in all directions of gaze，usually left eye fixation ,right eye deviation f

2、ull cycloplegic refaction OD: +2.50DS+0.50X090-4.4 OS: +1.50DS+0.25X090-5.0,extraocular muscles function,medial rectus 内直肌: adduction 内转 Lateral rectus 外直肌: abduction 外转 Superior rectus 上直肌: elevation上转 adduction,intorsion内转内旋 Inferior rectus下直肌: depression 下转 adduction ,extorsion内转外旋 Superior obliq

3、ue 上斜肌: intorsion内旋 depression,abduction下转外转 Inferior oblique下斜肌: extorsion外旋 elevation,abduction上转 外转,Binocular Vision 双眼单视分级,Simultaneous perception Sensory fusion Stereopsis,Sensory changes in strbismus斜视的双眼视觉改变,Diplopia 复视 Suppression 抑制 Anomalous retinal correspondence异常视网膜对应 Eccentric fixation

4、 偏心注视 Amblyopia 弱视,Strabismus 斜视,Deviation from perfect ocualr alignment 斜视指的是两眼向前注视时，两只眼位不平行，有一只眼向内斜（内斜视）或向外斜（外斜视）,或向上(上斜)。,Examination,History General eye examination Visual acuity Determination of refractive error Determination of angle of strbismus,Determination of angle of strbismus斜视的定性和定量检查,C

5、over test 遮盖试验 uncover test alternate cover test prism and cover test Corneal reflection 角膜映光法 Prism 三棱镜法 Synoptophore 同视机检查法,Determination of angle of strabismus 1.Corneal light reflection 2.Prism plus corneal light reflection (Krimsky test),150 300 450,phoria隐斜视,A deviation present only afer binoc

6、ular vision has been interrupted 隐斜视是指二眼在分离情况下（如遮一眼），融合功能被打断而出现偏斜，除去遮盖，融合功能恢复，则眼球又成正位 Duke-Elder统计在人群中正位眼仅占10左右，而90的人都有一定程度的隐斜。,phoria,Mechanism 病因 : 1.muscular imbalance 眼外肌肌力强弱、附着点异常以及节制韧带肌间膜有异常。 2Refractive error, accommodation /convergence imbalance屈光不正的因素，调节与集合的不协调所致。 3Abnormal nervel innervati

7、on眼外肌的神经支配异常所致。 4 Abnormal central nervel innervation 中枢性集合兴奋强弱异常。,Esophoria 内隐斜,Tendency for one eye to turn inward眼位有内斜倾向 Symptoms Willing to lookup病人喜欢向上看以减轻症状，因向上眼位可略分开而克服部分内隐斜,Esophoria,Correction of refractive error Train surgery,Exophoria 外隐斜,Tendency for one eye to turn outward指眼位有外斜倾向，平时受融合

8、反射控制不出现偏斜，能保持双眼单视 Mosty due to the problem of convergence。 Easy to tire,Exophoria外隐斜,Correction of refractive error Train surgery,hyperphoria上隐斜,Tendency for one eye to deviate upward Easy to tire,hyperphoria上隐斜,prism Surgery 10,Nonparalytic ,comitant esotropia共同性内斜,Infantile esopropia 先天性内斜,Occur b

9、efore six month of age Alternation of fixation ,vision equal Deviation is often large 25 Low to moderate hyperopia Vertical deviation may be observed ,overaction of the inferior oblique muscle Cross fixation Abduction may be limited 约50斜眼外展受限 Genetically determined basis,Accommodative esotropia 调节性内

10、斜,Due to accommodation with an associated overactive convergence 2025 among esotropia (1) Sufficiently high hyperopia,requiring so much accommodation (therefore convergence) (2) high AC/A,Accommodative esotropia(due to hyperopia ),Begins at age 23,but may occur earlier or later hyperopia +2+6D，avera

11、ge 4.0D Norman AC/A Deviation 2030 Glasses with full cycloplegic refaction allow the eyes to become aligned,Accommodative esotropia(due to high AC/A ),Begins at age 14 ,may occur later Low to moderate hyperopia ,about +2.0D High AC/A ratio Normal AC/A ratio 35/D，for this case 7/D Deviation is greate

12、r at near than at distance Glasses with full cycloplegic refraction plus bifocal or miotics to relieve excess deviation at near,Partially accommodation esotropia部分调节性内斜,Mixed mechanism-part muscular imbalance and part accommodative/convergence imbalance Begins at age 6m15y Antiaccommodative therpy d

13、ecreases the angle of deviation,but not eliminated Preliminary no surgical treatment (correction of refractive error,treat amblyopia) Surgery is performed for nonaccommodative component,Nonaccommodative esotropia非调节性内斜,Develops in childhood,usually after the age of 2 Refractive error is not the caus

14、e The angle of strabismus is often but increase with time Treatment is surgical and follows the guidelines,Secondary esotropia继发性内斜,Due to the paretic extraocualr muscles 继发于各种麻痹性斜视的内斜 Due to the surgery of strabismus 继发于术后的内斜，内斜欠矫、外斜过矫。 Due to sensory (vision) abnormality 知觉性内斜。,Intermittent exotro

15、pia间隙性外斜,Between exphoria to extropia Manifest deviation of eyes manifest in the absence of binocualr vision (cover test ),Intermittent exotropiaclinical findings,Moderate to high exphoria Closing one eye in bright light Usually a manifest exotropia for distance The condition can become progressivel

16、y worse Fuses at least part of time,no gross sensory abnormality,Mechanism,muscular imbalance accommodative/convergence imbalance,Mechanism,Convergence is excellent during childhood,extropia is not manifest at that time Dut to the extent of abnormality of muscular imbalance ,accommodative/convergenc

17、e imbalance The condition can become progressively worse with age,treatment,Nonsurgical treatment for small angle deviationyoungnormal retinal correspondence, fuses most of tiem Refractive correction Amblyopia therapy,antisuppression Convergence exercises,Surgical treatment,In large angles(30) With

18、evidence of porgression Poor convergence or lateral incomitance Fusion is badly damaged,Constant exotropia恒定性外斜,Less common than intermittent exotropia May be prsent at birth or occur when intermittent exotropia progresses to constant exotropia Some has relationship with myopia,Constant exotropia,Su

19、rgery is nearly always indicated The choice and amount are as described for intermittent exotropia The difference angle of deviation (near and at distance)-the way of surgery,Paretic (incomitant) strabismus麻痹性斜视,always one or more paretic extraocular muscles, As a result of palsy of the nervemuscle,

20、problem of nucleus Congenital paretic strbismus： Begins before 1y,result from birth injuries affecting the musclenerve,or from congenital anomaly Adult paretic strbismus:trauma,central nervous system,systemic diseases,Paretic (incomitant) strabismus麻痹性斜视,Limitation of eye movemnt ,devitation Diplopi

21、a is almost prsent if strbismus develops past age 6-8,sensory adaptation occurs if the onset is before this age Head tilt,turn,or abnormal posture of the head,Paretic (incomitant) strabismus麻痹性斜视,Paretic vertical muscl-superior oblique上斜肌麻痹,Special forms of strabismus,分离性垂直偏斜（dissociated vertical de

22、viation, DVD） each eye drifts upward under cover,Special forms of strabismus,Duanes retraction syndrome Duane眼球后退综合征： is typically characterized by marked limitation of abduction ,retraction of the globe and narrowing of the palpebral fissure on attemp adduction ,upshoot and downshoot,Special forms

23、of strabismus,A-V patterns A-V综合征 the deviation is different in upgaze and downgaze (A or V pattern),固定型斜视,Amblyopia弱视,Defined as a condition in which reduced visual acuity is not corrected by refractive means, no obvious structural or pathoolgic anomalies Onset during vision development,Amblyopia t

24、ype,Strabismic amblyopia 斜视性弱视 Refractive amblyopia 屈光性弱视 Ametropia amblyopia 屈光不正性弱视 anisometropic amblyopia屈光参差性弱视 Form deprivation amblyopia 形觉剥夺性弱视 Congenital amblyopia 先天性弱视,Amblyopia type,Strabismic amblyopia斜视性弱视,Amblyopia type,anisometropic amblyopia 屈光参差性,Examination,History General eye exa

25、mination Visual acuity Determination of refractive error Determination of angle of strbismus,Management of amblyopia,Etiology treatment Optimal refracton and lenses Occlusion Vision therapy,实例1,患儿，女性，5岁，曾有左眼先天性上睑下垂病史，半年前行矫正术。现父母带患儿行眼部检查。检查结果如下： 裸眼视力(远用)： OD: 4.9(0.8) OS: 4.2(0.15) 遮盖试验（远距）： 正位视 遮盖试验（近 距）： 5内隐斜 睫状肌麻痹扩瞳验光： OD: +1.50DS-0.50X010-5.0 OS: +1.25DS-0.25X180-4.4,实例2,