RU2272601C2 - Surgical method for treating patients for horizontal jerky nystagmus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves reducing horizontal action muscle activity of both patient eyes on the slow nystagmus phase side. Sutures are placed on internal direct muscle of the eye on which the muscle potentiates slow nystagmus phase and on external direct muscle of the other eye, for fixing to sclera in zone located on the other side of eyeball equator. The sutures are placed on 1/3 of muscle width taking 1/3 of sclera thickness. The sutures are placed on the external direct muscle 5-7 mm distal when compared to the internal direct muscle case.

EFFECT: enhanced effectiveness in achieving artificial paresis of horizontal muscles; reduced nystagmus amplitude.

3 cl, 2 dwg, 2 tbl

Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of horizontal jerky nystagmus.

Horizontal jerky nystagmus is an imbalance of extraocular muscles in which the eyes are in a state of horizontal jerky movements. In this case, slow eye movements in one direction alternate with their fast movement in the opposite direction. The mechanism of this pathology is the unequal tone of the pairs of oculomotor muscles that move the eyes respectively to the right and left sides. A stronger pair of muscles is involved in the formation of a slow phase, a weak pair - fast. When the eyes are turned towards the slow phase, the dynamometric indicators of the muscle pairs are balanced, the intensity of the nystagmus decreases, and the visual functions increase. This zone is called the "zone of relative peace." In order for this zone to move to the first position of the gaze (directly in front of itself), the patient compensatoryly turns his head in the opposite direction (towards the fast phase of nystagmus). Such a turn of the head is called "forced."

There are various methods of surgical treatment of horizontal jerky nystagmus, the essence of most of which is to weaken the stronger horizontal muscles on the side of the slow phase and (or) to strengthen the weak muscles on the side of the fast. As a result, muscle tone is approximately balanced. The zone of relative rest of the eyes moves to the middle position. Horizontal muscles include two internal rectus muscles and two external rectus muscles.

There is, for example, a method for surgical treatment of horizontal jerky nystagmus, which consists in the fact that to move the "resting zone" of the nystagmus to the primary position, the same resection is performed not of the tendon, but of the anterior segment of the abdomen of the muscles of both eyes on the side of the fast phase of nystagmus. Muscle abdomens contain muscle spindles that serve as gauges of muscle length that control the frequency of a pulsed discharge, which leads to an increased amplitude of nystagmus (Manual on eye surgery edited by M.L. Krasnov, B.C. Belyaeva, Moscow: 1988, p. 460-461).

The method of surgical treatment of horizontal pendulum-like nystagmus described above has several disadvantages.

1. The technical complexity of this method leads to the duration of surgery.

2. The same resection of the anterior abdominal segment of the muscles of both eyes on the side of the fast phase of the nystagmus creates the risk of underdosed surgical procedures, since the biometric and biomechanical differences between the internal and external direct oculomotor muscles are not taken into account.

3. In places of stitching the edges of the abdomen of the muscles, after performing their resections, the inevitable formation of duplicates leads to the danger of mechanical irritation of the surrounding tissues and the deterioration of the cosmetic result.

4. Due to the intersection of the anterior ciliary arteries during the operation, there is a risk of ischemia of the anterior segment of the eye.

Closest to the claimed method, the prototype is a method of surgical treatment of horizontal jerky nystagmus (Anderson J.R. Br.J. Ophthalmol., 1953, 37 (5): 267-281), which consists in the following.

In both eyes, recessions of horizontal oculomotor muscles located on the side of the slow phase of the jerky nystagmus are performed according to the following procedure.

For example, with right-sided nystagmus on the right eye, after installing the eyelid, the eyes are deployed temporarily using fixative sutures that are placed on the conjunctiva and episclera at 6 and 12 hours. A conjunctiva and tenon capsule incision 7-8 mm long is performed parallel to the limbus. In the middle of the section, the tenon shell is captured and lifted and it is separated from the sclera with scissors in the direction of the muscle attachment site. A muscle hook is brought into the lower nasal sector, and the end of the hook is directed away from the muscle. Then, rotating the hook 180 ° clockwise and sliding the tip of the muscle hook across the sclera, they grab the muscle at the point of attachment. Scissors cross the lower and upper muscle fascial ligaments. Using a 6-0 thread, two double sutures are placed on the muscle at its attachment point to the sclera on the upper and lower third of the width of the muscle. The muscle is cut off with scissors from the sclera and hemmed in 2-6 millimeters distal to the physiological site of attachment. Separated conjunctival and tenon membranes are straightened, the wound is sutured with two interrupted sutures 7-0, then they proceed to surgery on the second eye. By a similar technique, a recession of the external rectus muscle is performed, with the only difference being that the muscle is trimmed after clipping, departing 5-9 mm from the physiological attachment site.

The proposed method leads to a weakening of the action of horizontal muscles on the side of the slow phase of nystagmus. This pair of muscles is balanced with the muscles on the side of the fast phase. The relative rest zone moves to a direct gaze position. Conditions are created to increase visual acuity.

However, the proposed method for the treatment of horizontal jerky nystagmus by performing muscle recession on the side of the slow phase of the nystagmus has a number of significant drawbacks.

Firstly, due to the plastically adaptive reaction of the oculomotor system to paresis of the extraocular muscles, the effect of the operation is unstable.

Secondly, after performing this operation, patients often developed secondary strabismus.

Thirdly, the intervention on the horizontal oculomotor muscles, accompanied by the intersection of the anterior ciliary arteries, can lead to ischemia of the anterior segment of the eye.

An object of the invention is to increase the stability of the result of treatment and reduce side complications.

The technical task is achieved by the proposed method, which consists in the following.

After preparation of the surgical field and retrobulbar or intravenous multicomponent balanced anesthesia, access to the internal rectus muscle (that eye, on which the internal rectus muscle potentiates the slow phase of nystagmus) and to the retro-equatorial space is released. The muscle is fixed to the sclera with two double entwined interrupted sutures in the area lying behind the equator of the eyeball. The surgical wound is sutured. In a similar way, surgical procedures are performed on the external rectus muscle of the other eye.

The location of the fixation sutures should be different for the inner and outer rectus oculomotor muscles. At the same time, the external muscles are sutured 5-7 mm further than the internal ones. The minimum effect is achieved when suturing the internal rectus muscles 11 mm from their physiological attachment site, on the external muscles - 17 mm. To achieve the maximum effect, sutures are applied to the internal rectus muscles of 18 mm, and to the external - 23 mm. Dosing of the volume of operation depends on the characteristics of nystagmus, the size of the relative dormancy zone of nystagmus and the size of the patient’s eyeball.

A significant difference between the proposed method and the prototype is that one internal rectus muscle of horizontal action of one patient’s eye and one external rectus of the other eye on the side of the slow phase of nystagmus are fixed to the sclera with two double entwined interrupted sutures in the area behind the eyeball equator (Fig. 1), which allows to increase the stability of the operation, reduce its invasiveness and reduce side complications. At the same time, sutures are applied on 1/3 of the muscle width with capture of 1/3 of the sclera thickness.

The positive effect of the operation is achieved due to the following biomechanical action of the fixing sutures placed on the muscles:

- muscle shoulder decreases;

- the contractile part of the muscle is shortened;

- the elasticity of the part of the muscle located behind the seam increases (compared with the preoperative elasticity of the entire muscle);

- the part of the muscle that lies behind the seam relaxes, while the front part remains unchanged;

- the muscle is not in a straight line with respect to the point in contact with the eyeball, but bypasses it (figure 2).

The combination of these mechanisms causes artificial paresis of the horizontal muscles, inducing a slow phase of nystagmus, eliminates their imbalance with the muscles of the fast phase in the forward direction of the gaze. As a result, there is a decrease in the amplitude of nystagmus in the first position of the gaze and more favorable conditions are created for increasing visual acuity.

A search by sources of scientific, technical and patent information did not reveal a method identical to the claimed one, in connection with which we can conclude that the claimed technical solution meets the criteria of "novelty" and "inventive step".

The proposed method operated on 7 patients aged 7 to 18 years. Duration of observation from 9 months to 4 years.

The results of changes in visual acuity are shown in table 1.

Changes in the relative dormancy zone of nystagmus are presented in table 2.

The invention is illustrated by the following example of a specific implementation of the method.

Example.

Patient D., 19 years old, was admitted to the hospital with a diagnosis of Horizontal coarse push-right right-sided nystagmus of both eyes with a zone of relative rest to the left of 10 °. Severe amblyopia in both eyes.

During the examination: visual acuity in the first position - the right eye is 0.1, the left is 0.15. Visual acuity in the zone of relative peace to the left - the right eye is 0.25, the left is 0.3. Zone of relative rest to the left 10 °.

The refraction of both eyes is emmetropic.

The amplitude of the nystagmus in the forward gaze position is 10-12 °, with the translation of the gaze to the right - 15-20 °, to the left - inconstantly up to 2-5 °. The forced position of the head to the right is noted. The anterior segment of the eyes, the optical media and the fundus without pathological features.

The patient underwent surgery by the claimed method. After intravenous multicomponent balanced anesthesia and treatment of the surgical field, an eyelid was introduced, exposing the right eyeball as much as possible. Further, to provide access to the internal rectus muscle, the conjunctiva was taken with tweezers for 3 hours and the eyeball was taken away. Conjunctival spring scissors performed two radial incisions of the conjunctiva and tenon capsule 7-8 mm long along the meridians of 2 hours and 4 hours. The tenon capsule was separated from the episclera, forming a tunnel. A conjunctiva and tenon capsule incision was performed congruently to the limb, connecting the proximal borders of the radial sections. The formed U-shaped flap was thrown back. The tenon shell from the episclera was separated with scissors in the upper medial and lower medial directions. In the formed nasal nasal space, a muscle hook without a limiter was placed parallel to the sclera, while the tip of the hook is directed away from the intended place of muscle attachment. Rotating the handle of the hook clockwise 180 ° (while the tip of the hook slides freely on the sclera), we fixed the muscle at the place of its attachment. Two frenum sutures were placed on the muscle directly at the place of its attachment to the sclera with silk threads. The muscle hook was removed. The sutures were captured with clamps, the eyeball was taken 40-50 °, after which the clamps were fixed on an operating napkin. Next, the conjunctiva and tenon capsule were raised with tweezers, exposing the muscle and pulling its fascial ligaments with the tenon capsule. Ligaments and intermuscular septa were crossed with scissors, sliding along the muscle in the distal direction to a depth of about 20-25 mm. The tenon capsule and conjunctiva were displaced with the help of a spatula towards the orbit, freeing access to the retro-equatorial space. We measured the place of the proposed application of the fixing suture on the sclera along the lower and upper edge of the muscle using a ruler - 13 mm from the physiological site of attachment and marked. Then the muscle was displaced with the help of a muscle hook to the edge opposite from the place of suturing. The sclera was stitched in a marked place with the help of 5-0 Mercilin with a needle, the length of which is 3/8 of a circle. The puncture depth is 1/3 of the sclera thickness from its surface, its length is 3 mm, its direction is perpendicular to the axial projection of the muscle onto the sclera from its edge to the middle. The muscle was stitched to 1/3 of its width, after which a second puncture was performed through the sclera and the muscle was 2 mm proximal to the first. The seam threads were tightened with a triple knot and cut off. In a similar way, they sutured from the opposite edge of the muscle. A muscle hook was brought under a muscle distal to the formed new place of muscle attachment to the sclera and, using a traction test, the quality of suturing was checked. The spatula was removed from the surgical field, the frenum sutures were removed from the muscle and the U-shaped flap of the conjunctival and tenon membranes was straightened. The wound was sutured with absorbable suture 7-0. At the same time, nodal seams were laid at the corners of the U-shaped flap and in the middle of its radial edges. Under the conjunctiva, 0.3 ml of a 1% Dexazone solution was injected and dry Albucid was poured. The eyelid was removed and a sterile dressing was applied.

After that, they went on to perform an operation on the external rectus muscle on the left eye according to the technology described above, with the only difference being that the distance of the fixation sutures was 20 mm.

In the postoperative period, a 0.25% solution of Levomycetin was installed in the conjunctival cavities 4 times a day for 10 days.

14 days after the operation, a control examination was performed.

Visual acuity in the first position - the right eye of 0.2, the left - 0.25. Visual acuity in the zone of relative peace to the left - the right eye is 0.25, the left is 0.3. Zone of relative rest to the left up to 3 °.

The amplitude of nystagmus in the direct position of the gaze is up to 3-5 °, when you look to the right - 10-15 °, to the left - is absent. A delicate forced position of the head to the right is noted, as the patient notes, out of habit.

When viewed after 1 year: the nature and amplitude of nystagmus remained unchanged. Visual acuity in the first position - the right eye of 0.7, the left - 0.8. Visual acuity in the zone of relative peace to the left - the right eye is 0.7, the left is 0.8, but subjectively, vision in this position is slightly more comfortable. The zone of relative rest to the left is unstable up to 3-5 °.

The amplitude of nystagmus in the direct position of the gaze is up to 3 °, when the gaze is moved to the right - up to 10 °, to the left - unstable up to 2-3 °. According to the patient and with an objective study of the compensatory position of the head there.

The proposed method has several advantages when compared with known methods.

1. Biomechanical changes in the functioning of the oculomotor muscles on the side of the slow phase of the nystagmus are created without violating their anatomical integrity and without changing their physiological attachment location, therefore, the amplitude of eye mobility in response to pathological impulse decreases without changing their position in orbits. Thus, the imposition of rear fixing sutures on two muscles of horizontal action minimizes the risk of secondary strabismus in the postoperative period.

2. The postoperative period proceeds more calmly, because there is no gross violation of the anatomical integrity of the muscular system, healing begins earlier.

3. The safety of the posterior ciliary vessels during surgery does not cause ischemia of the anterior segment of the eyes.

4. The absence of the occurrence of retraction mechanisms when working on the muscles does not lead to a change in the position of the eyeballs in the orbit, the width of the eye slits does not change, which eliminates the occurrence of cosmetic defects.

Thus, the method allows you to change the biomechanics of the oculomotor muscles of horizontal action without gross violation of their anatomical structure and the initial place of attachment and dosed to reduce the rotational effect of muscle contractions, which reduces the amplitude of nystagmus in the first position of the gaze and creates conditions for increasing visual functions.

Table 1. No. Vis before surgery Vis after surgery Vis Increase (%) without correction with correction without correction with correction without correction with correction OD OS OD OS OD OS OD OS OD OS OD OS one 0.1 0.09 0.15 0.2 0.2 0.3 0.4 0.5 one hundred 233 167 150 2 0.1 0.1 0.15 0.15 0.3 0.2 0.5 0.4 200 one hundred 233 167 3 0.1 0.05 0.15 0.1 0.3 0.2 0.3 0.25 200 300 one hundred 150 four 0.4 0.5 0.6 0.6 0.6 0.7 0.8 0.9 fifty 40 33 fifty 5 0.2 0.2 0.3 0.2 0.3 0.3 0.5 0.6 fifty fifty 67 200 6 0.15 0.3 0.3 0.3 0.4 0.6 0.7 0.8 167 one hundred 133 167 7 0.1 0.15 0.2 0.3 0.2 0.3 0.4 0.7 one hundred one hundred one hundred 133 wed 0.15 0.19 0.24 0.24 0.30 0.33 0.46 0.52 109.52 98.57 95.24 123.81 table 2 Relative rest zone less than 5 ° 5 to 10 ° 10 to 15 ° more than 15 ° Before surgery 0 one 2 four After operation four 2 one 0

Claims (3)

1. A method of surgical treatment of horizontal jerky nystagmus by weakening the action of the muscles of the horizontal action of both eyes of the patient on the side of the slow phase of nystagmus, characterized in that on the internal rectus muscle of that eye, on which this muscle potentiates the slow phase of nystagmus, and the external rectus muscle of the other eye is superimposed fixing sutures to the sclera in the area lying behind the equator of the eyeball, while the sutures are applied to 1/3 of the width of the muscle with capture 1/3 of the thickness of the sclera, while the sutures are applied to the external muscle and 5-7 mm distal than on the inner arm. 2. The method according to claim 1, characterized in that the muscles are fixed to the sclera with two double entwined nodal sutures 5-5 Mercilin. 3. The method according to claim 1, characterized in that the sutures are laid on the inner rectus muscle 11–18 mm apart and 17-23 mm on the outer muscle from the place of their physiological attachment.

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