상사시를 동반한 간헐 외사시에서 상사시 교정에 대한 임상적 고찰
Correction of Hypertropia Coexisting with Intermittent Exotropia
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목적: 상사시를 동반한 간헐 외사시에서 동반된 수직사시의 임상적 형태와 함께 사근과 수직근의 동시수술 또는 수평근 수술만 시행후의 상사시 교정효과를 알아보고자 한다. 대상과 방법: 간헐 외사시로 수술 받은 환자 중 ≥4 prism diopter (PD)의 상사시가 있었던 148명의 의무기록조사를 통한 후향적 연구로, 마비사시는 대상에서 제외하였다. 동반된 상사시에 대해 임상적 진단을 내릴 수 있었던 I군과 단순 상사시를 동반한 II군으로 나누어, 동반된 상사시의 임상적 형태와 수술결과를 분석하였다. 결과: I군은 38명, II군은 110명이었고, 술전 평균 상사시각은 각각 9.58 ± 3.89 PD, 6.62 ± 2.69 PD이었다. I군은 해리수직편위12명, 단안 하사근 기능항진 10명, 비대칭 양안 하사근 기능항진 13명, 비대칭 양안 상사근 기능항진 3명이었다. II군에서 일치 상사시는 19명이었고, 고개 기울임 검사 양성인 유사 상사근마비 형태가 84명으로 가장 많았으며 기타 다양한 불일치성을 보였다. I군의29명이 외사시 수술과 동시에 상사시 수술을 받았고 4예에서 >1 PD의 과교정 혹은 >4 PD의 부족교정을 보였다. I군의 술 후 상사시각은 1.41 ± 2.93 PD, II군은 외사시 수술만 시행한 후 상사시각 0.45 ± 1.60 PD로 교정되었다. 결론: 상사시를 동반한 간헐 외사시에서 사근기능이상 혹은 해리수직편위를 술 전에 진단하여 사근이나 수직근 수술을 동시 시행함으로써 좋은 결과를 얻었다. 비특이 상사시에서는 외사시 수술만으로 상사시가 교정되었으나, 다양한 불일치 사시를 보이므로 감별진단에 유의해야 할 것으로 생각한다.
Abstract
Purpose: To investigate the clinical features associated with hypertropia and report the surgical outcomes of hypertropia coexistingwith exotropia. Methods: We reviewed the medical records of 148 patients with intermittent exotropia coexisting with hypertropia over 4 PD whoreceived exotropia surgery. The cases accompanied by apparent paralytic strabismus such as superior oblique palsy wereexcluded. Patients were divided into groupⅠ(clinically diagnosed hypertropia) and group Ⅱ (non-specific hypertropia) and theclinical features of coexisting hypertropia and surgical outcomes were analyzed. Results: Among the 148 patients, groupⅠconsisted of 38 patients (26%) and group Ⅱ of 110 patients (74%). The averageamount of preoperative hypertropia angle in primary gaze was 9.58 ± 3.89 PD and 6.62 ± 2.69 PD in group Ⅰ and Ⅱ, respectively. Group Ⅰ included 12 patients with dissociated vertical deviation (DVD), 10 patients with unilateral inferior oblique overaction, 13patients with asymmetric bilateral inferior oblique overaction and 3 patients with superior oblique overaction. Group Ⅱ included19 patients with comitant hypertropia (17%), head tilt positive pattern (simulated superior oblique palsy) was found in 84 patients(76.3%) and variable incomitance was observed. In groupⅠ, 29 patients received simultaneous horizontal muscle with hypertropiasurgery. Postoperative hypertropia angle in groupⅠ was 1.41 ± 2.93 PD and 4 cases were considered surgical failure. IngroupⅡ, hypertropia was resolved with horizontal muscle surgery only and the amount of postoperative hypertropia was 0.45 ±1.60 PD. Conclusions: In this study, vertical deviations in intermittent exotropia with concomitant hypertropia related to obvious obliquemuscle dysfunction or DVD were corrected effectively by oblique or vertical rectus muscle surgery. Nonspecific hypertropia canbe resolved after horizontal muscle surgery alone, however, for precise differential diagnosis, careful examination for variableclinical features is necessary before determining surgery.
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