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要約 目的:正面視で複視や眼位異常を伴わない斜視の症例は,通常,手術適応とならない。今回,正面視で正位,下方視のみ8プリズム(以下,PD)左眼上斜視を生じる甲状腺眼症に対してmini-tenotomyを施行したので,報告する。
症例:41歳,男性。既往歴にバセドウ病があった。左眼下転障害による下方視での複視を主訴に三豊総合病院眼科を受診した。MRIで両眼上直筋,下直筋に腫大と炎症所見があり,甲状腺眼症と診断された。近見26PD左上斜視があった。ステロイドテノン囊下注射を右2回,左3回施行した。2年後,MRIの炎症所見は改善し,眼位は近見下方視8PD左上斜視で安定していたが,下方視のみ複視と頸部痛を自覚した。下方視での膜プリズム眼鏡を使用開始したが,眼痛,頸部痛,気分不良の訴えがあり,使用を中止した。手術目的にて香川県済生会病院眼科を紹介受診した。局所麻酔下で左眼上直筋mini-tenotomyを施行した。上直筋の中央1/2筋腹を切開した。近見下方視の眼位は術後11日目では8PD左上斜視で改善がなかったが,術後1年目には2PDまで改善し,下方視での複視や頸部痛の改善がみられた。また,膜プリズムの試用でさらに自覚症状の改善を認めた。
結論:下方視のみ複視のある甲状腺眼症の微小斜視の症例で,mini-tenotomyによって症状が軽減する可能性が示唆された。
Abstract Purpose:Strabismus in primary position without diplopia is usually not indicated for surgery. Here we report a case of mini-tenotomy for thyroid ophthalmopathy with a left hypertropia of 8 prism diopters(PD)at near and downgaze without ocular deviation in the primary position.
Case:A 41-year-old man had a medical history of Graves'disease. Magnetic resonance imaging(MRI)revealed swelling and inflammation in the superior and inferior rectus muscles of the bilateral eyes, and he was diagnosed with thyroid ophthalmopathy. He had a left hypertropia of 26 PD at near and downgaze. A steroid sub-Tenon subcapsular injection was performed twice on the right and three times on the left. Postoperative MRI showed improved inflammatory findings. He had a left hypertropia of 8 PD at near and downgaze, so he suffered from diplopia and neck pain only at downgaze. He started using membrane prism glasses at downgaze, but discontinued them due to ocular and neck pain, and nausea. He was referred to Kagawa Saiseikai Hospital for surgery. A mini-tenotomy of the left superior rectus muscle was performed under local anesthesia. An incision was made in the center of the insertion of the superior rectus muscle. At 1 year postoperative, the reduction in strabismus angle was achieved, with a left hypertropia of 2 PD at near and downgaze. His neck pain disappeared at downgaze. His ocular position remained orthophoria in primary position at both near and far.
Conclusion:These findings suggest that mini-tenotomy may alleviate symptoms in patients with microtropia and thyroid ophthalmopathy who have diplopia only at downgaze.
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