RU2336060C1 - Method of surgical treatment of incomitant strabismus of any oculomotor muscles - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: two muscle bundles are formed of healthy rectus muscles laying in plane perpendicular to paretic muscle. Muscular bunches are cut off in sclera fix point and then brought and fixed to sclera under paretic muscle string. Paretic muscle is spliced to two flaps of length within 7 to 12 mm. Flaps are cut off from sclera. Proximal end of unspliced paretic muscle belly is brought to cut off point and fixed. Formed flaps of paretic muscle are shifted and fixed to sclera in fix point of pre-spliced healthy rectus muscles.

EFFECT: method provides possibility of one-stage strabismus correction of wide angle of deviation associated with muscle paresis.

2 cl, 3 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for the surgical treatment of paralytic strabismus.

Paralytic strabismus is characterized by a restriction of eye movements in the direction of action of the paralyzed muscle.

There are methods of surgical treatment for paresis of the abducent nerve, manifested by a monolateral convergent deviation of the affected eye. The task of surgical treatment in such cases is not only to bring the paralyzed eye to a normal position, but also to achieve at least a slight mobility.

The closest analogue to the prototype of the proposed method is the operation Gummerlsheim, consisting in the formation of tendon-muscle flaps from the upper and lower rectus muscles and suturing these flaps to the sclera at the site of attachment of the external rectus muscle ("Guide to eye surgery" edited by ML Krasnov , V. S. Belyaev, Moscow, “Medicine”, 1988).

The prototype has several disadvantages:

- correct only horizontal deviation;

- the appearance of vertical deviation is possible, because the formation of muscle flaps on healthy vertical rectus muscles with horizontal paralytic strabismus can cause a violation of their function;

- restoration of mobility of the eyes outside and correction of not more than 5-7 degrees of the angle of squint;

- at strabismus angles of more than 20 degrees, this method requires several additional stages of surgical treatment on intact or previously operated muscles;

- the difficulty of predicting the result of each subsequent stage of surgical treatment, because each subsequent operation on previously operated muscles is traumatic, leading to cosmetic eyeball defects due to gross postoperative scarring of muscles and conjunctiva, trophic disturbance and corneal opacities.

The objective of the invention is to propose a method for the simultaneous correction of strabismus with paresis of any muscles.

The technical result is the ability to simultaneously correct strabismus at a large angle of deviation of the eye with paresis of muscles of both horizontal and vertical action.

The technical result is achieved as follows: from the healthy direct oculomotor muscles lying in the plane perpendicular to the paretic muscle, two muscle bundles are formed, after being cut off from the sclera in the place of their fixation, they are brought down and fixed to the sclera under the tendon of the paretic muscle. Then, the paretic muscle is split into two flaps from 7 mm to 12 mm long, after flashing and cutting off the flaps from the sclera, the proximal end of the unsplit abdominal paretic muscle is pulled to this place and fixed. The formed muscle flaps are not resected, but to replenish muscle mass, they are moved and fixed to the sclera in the plane of attachment of healthy rectus muscles, the bundles of which were used to reinnerve the paretic muscle.

Depending on the predominant limitation of the mobility of the eye in one direction or another, the width of the moved flaps of the split paretic muscle varies from 1/4 to 3/4 of its plane.

The proposed method for the surgical treatment of paralytic strabismus has several advantages over the prototype:

- can correct both horizontal and vertical deviations at the same time, because the undigested abdomen of the paretic muscle fixed to the sclera plays the role of a resection, which reduces the strabismus angle in the plane of action of this muscle, and the flaps of the paretic muscle moved to the attachment point of previously split healthy muscles eliminate the deficit of their action in the perpendicular plane arising from the previous splitting of these healthy muscles ;

- avoids the appearance of postoperative vertical deviation, because displaced flaps of the paretic muscle make up for the deficit of muscle mass of previously split healthy muscles in a perpendicular plane;

- allows you to achieve one step correct strabismus and improve mobility, sufficient to overcome double vision with various options for paralytic strabismus;

- forecasting of the expected result is possible;

- this method is universal and can be used for paresis of any muscles with various types of strabismus:

- paralytic vertical-horizontal strabismus;

- friendly strabismus with a paretic component;

- friendly strabismus with a vertical component;

- the method corrects large deviation angles, obviously requiring a 2-3-stage surgical treatment of the prototype;

- the possibility of application in cases where all other known options for surgical treatment of paralytic strabismus are exhausted;

- it can be used if it is impossible, for various reasons, to plan several stages of surgical treatment (somatic state, social factors - the impossibility of a return visit, etc.);

- the operation is technically available and can be used in any ophthalmic surgery department.

Example No. 1

Patient B., 6 years old. DS: paralytic convergent strabismus of the right eye with hypotropy. Weak hypermetropia in both eyes. Weak dysbinocular amblyopia of the right eye.

Visual acuity with correction: right eye 0.7 n / a, left eye 1.0. The squint angle of the right eye: +15 degrees to the nose, 5-7 degrees down. (according to Hirschberg). In the lead-reduction, the vertical deviation does not increase. The nature of vision is simultaneous. Outward mobility of the eye is significantly limited. Forced position of the head up and with a turn to the right. Previously, several times unsuccessfully operated.

The operation was performed on the right eye according to the proposed method: after splitting in half healthy upper and lower rectus muscles, their external halves are sutured under the external rectus muscle, then the external rectus muscle is split posteriorly from the attachment by 10 mm (the value calculated according to the Avetisov-Makhkamov resection scheme) 2 flaps, while the width of the upper flap was 2/3, and the bottom - 1/3 of the plane of the external rectus muscle. The flaps are stitched, cut off from the sclera. The proximal end of the undigested abdomen of the paretic external rectus muscle is fixed to the sclera to the initial attachment point of the external rectus muscle 6-7 mm from the limbus, and the split flaps of the paretic muscle are moved and sutured to the sclera at the attachment point of the healthy upper and lower rectus muscles.

At discharge: orthotropy, mobility outward within 30-40 degrees, upward - in full.

Example No. 2

Patient M., 53 years old. DS: A paralytic acquired divergent alternating strabismus with a vertical component. Mild myopia in both eyes. Hypertensive retinal angiosclerosis in both eyes. HIBS.

2 years ago after a hypertensive crisis a divergent strabismus appeared, limiting the mobility of both eyes to the nose, severe diplopia. She regularly received conservative treatment from a neurologist and therapist without a sufficient effect.

Visual acuity of both eyes without correction of 0.1, with correction - 2.5 D 1.0.

Strabismus angle: alternating divergence up to - 17-20 degrees. according to Hirschberg, upward 10-12 degrees., X-syndrome. No convergence. Periodically diplopia near. Inner mobility is maintained within 15-20 degrees, slightly limited downward. The palpebral fissure of both eyes is widened by 1.5-2.0 mm.

An operation was performed on both eyes: bundles were taken from the upper and lower healthy rectus muscles and fixed at the site of attachment of the paretic internal rectus muscle; then the paretic internal rectus muscle is divided into 2 flaps, while the lower flap was 3/4, and the upper one 1/4 of the muscle plane. The length of the lobules was 9-10 mm. The unsplit abdomen of the paretic internal rectus muscle is fixed with sutures to the sclera to the previous muscle attachment site 6 mm from the limbus, and the paretic muscle flaps are hemmed with tension at the attachment points of the upper and lower healthy rectus muscles, respectively.

At discharge and after 1 year - orthotropy, full mobility of the eyes, good convergence. There is no diplopia.

Example No. 3

Patient S., 6 years old. DS: Congenital paralytic vertical squint of the left eye. Dysbinocular amblyopia of the middle degree of the left eye.

Visual acuity: right eye 1.0, left eye 0.3 n / a. Emmetropia of both eyes. The nature of the vision is monocular right-sided. Strabismus angle: the left eye is deflected upward by 10 degrees. The mobility of the left eye is significantly limited downward, in the lead the left eye deviates upward to 15 degrees.

An operation was performed on the left eye: previously, after splitting, the lower halves of the healthy internal and external rectus muscles were sutured under the paretic lower rectus muscle, then the paretic lower rectus muscle was split in half posteriorly from the attachment by 7 mm (the value of the calculated resection) into 2 flaps, the flaps were stitched, cut off from the sclera. The proximal end of the unsplit abdomen of the paretic lower rectus muscle is fixed to the sclera to the initial attachment point of the lower rectus muscle 6 mm from the limbus, and the split flaps of the paretic lower rectus muscle are moved and sutured to the sclera at the attachment point of healthy internal and external rectus muscles.

At discharge and after 6 months - orthotropy, eye mobility without features. The nature of vision after 6 months is simultaneous.

Claims (2)

1. A method for the surgical treatment of paralytic strabismus of any oculomotor muscles, which consists in the formation of tendon-muscle flaps from the rectus muscles and suturing of these flaps to the sclera, characterized in that two muscle bundles are formed from straight healthy muscles lying in a plane perpendicular to the paretic muscle, which, after being cut off at the place of their fixation from the sclera, are brought and fixed to the sclera under the tendon of the paretic muscle, then the paretic muscle is split into two flaps from 7 to 12 mm long, obtained the flaps are cut off from the sclera, then the proximal end of the unsplit abdomen of the paretic muscle is pulled up and fixed to the cut-off point, while the formed muscle flaps of the paretic muscle are moved and fixed to the sclera at the attachment point of previously split healthy rectus muscles. 2. The method according to claim 1, characterized in that the width of the movable flaps of the split paretic muscle varies from 1/4 to 3/4 of its plane.