RU2363427C1 - Method of treating incomitant strabismus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology and can be used in surgical treatment of incomitant strabismus. A conjunctival incision is made. Lower and upper straight muscles are selected and split into two longitudinal fascicles - lateral, which makes up 1/3 of the width of the muscle, and a medial - which makes up 2/3 of the width of the muscle. The lower muscle is split first. The lateral fascicle is taken on a lifter and, moving 10-12 mm from the point of its attachment to the sclera, interrupted stitches are made. Without cutting the thread, the lateral fascicle is shifted to the paralysed muscle towards the equator of the eye at a distance, corresponding to the angle of deviation and piercing is done in the sclera using the same needle, between the lower straight and lateral straight muscles. The lateral fascicle is pulled behind the thread to the point of piercing and is stitched to the sclera. The upper straight muscle is manipulated the same way.

EFFECT: design of a less traumatic method, which reduces the probability of postoperative chemosis, ischemia of the anterior segment of the eye, occurrence of cosmetic defects (enophthalmia, constriction of palpebral aperture).

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Description

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

Paralytic strabismus is a condition of the oculomotor system in which one or more extraocular muscles irreversibly completely or partially lose their function. Symptoms of paralytic strabismus are: the absence of some arbitrary movements of the affected eye, the asymmetrical position of the eyes, double vision that occurs or increases when the gaze is turned to the side of the affected muscle and when trying to fix the object with the affected eye or binocularly. In both cases, the amplification of double vision is compensated by the patient either by means of a certain, compensating double vision, rotation of the head, or by turning off the affected or healthy eye from the visual work.

Known methods for the treatment of paralytic convergent strabismus, based on the use of vertical muscles:

1. Operation O. Connor, which consists in the selection of the outer third of the upper and lower rectus muscles and suturing the distal ends of their tendons to the tendon of the external rectus muscle (Transposition of ocular muscles. American J.Ophtalm. 1921, v.4, p.838-842 );

2. Operation Yensen, which consists in splitting the paralyzed muscle into two halves - the upper and lower and stitching the upper half of the muscle with the outer third of the abdomen of the upper straight, and the lower half - with the outer third of the abdomen of the lower straight. Both vertical muscles are previously freed from the fascia and stratified to a depth of 10-15 mm (Jensen CDF Rektus muscle uniov: a new operation for paralisis of the rectus muscle. Trans. Of Pacific Coast Ophthalm. Society. 1964, v. 45, p. 359 );

3. The operation of E. S. Avetisov, consisting in resection of the external rectus muscle and suturing to the sclera behind the site of its attachment of flaps of the upper and lower rectus muscles containing one third of their body. Usually this operation is combined with a recession of the internal rectus muscle (Yu.Z. Rosenblum. Application of the operation of E.S. Avetisov for paralysis of the external rectus muscle. Ophthalm. Journal. 1985, No. 2, p. 77-80).

The disadvantage of the described methods is the high morbidity, since it is necessary to operate on four muscles at once, which sometimes leads to trophic changes in the anterior segment of the eye and the inflammatory reaction of the iris and ciliary body.

A known method of treating paralytic strabismus, which consists in the following. Through a vertical incision of the conjunctiva produce a typical recession of the internal rectus muscle. Conjunctival incisions are made over the attachment points of the upper, lower and external rectus muscles. The latter is freed from fascia and taken on the ligature. The outer halves of both vertical muscles are isolated, the ligature is fixed, cut off from the sclera and separated from the remaining muscle to a depth of 10-12 mm. The ends of the ligatures are carried out under conjunctival flaps. The distal ends of both flaps with ligatures are brought under the tendon of the external rectus muscle, directly at its attachment to the sclera, and the ligatures are connected, then ligatures are passed through the muscle tendon to its outer surface, where they are tied. Sutures are continuously applied to the conjunctiva (RF Patent No. 2112479, class A61F 9/007, publ. 06/10/98).

The disadvantages of this method are the high morbidity and the possibility of postoperative complications.

A known method of treating paralytic strabismus, including the allocation and splitting into two halves of the upper and lower rectus muscles, and the length of the splitting is performed at least 20 mm The free ends of the upper and lower cut flaps spend criss-cross above and under the paralyzed external muscle, placing it between the upper and lower flaps. Placing the paralyzed external muscle between the flaps of the upper and lower muscles, giving direct contact with the latter on both sides, enhances the transmission of excitation to the paralyzed muscle, causing it to contract (RF Patent No. 2077293, class A61F 9/007, publ. 04/20/97) .

The disadvantage of this method is the high complexity of the operation and increased trauma in relation to the upper oblique muscle.

The closest to the claimed method, the prototype is a method for the treatment of paralytic strabismus (Jensen C. D. F. Trans. Pacific Coast Ophthalmol. Soc. 1964, 45: 359), which is as follows.

In case of right-sided paralysis of the abducent nerve, the right eye is rotated medially with the help of traction sutures applied through the episclera near the limbus at 1 and 5 hours. Partial peritomy is performed. The upper, lateral and lower rectus muscles are distinguished. They are cleaved with a muscle hook in the mid-longitudinal line from the tendon in the peripheral direction. The temporal half of the upper rectus muscle and the upper half of the lateral rectus muscle are connected using a non-absorbable filament in the equatorial region of the eye. Similarly, combine the temporal part of the lower rectus muscle and the lower half of the lateral rectus muscle. The conjunctiva is sutured with two limbal sutures.

The known method allows you to restore some degree of mobility of the eye in the direction of action of the paralyzed muscle, however, has a number of significant disadvantages:

1. Postoperative complications in the form of conjunctival edema and ischemia of the anterior segment of the eye.

2. The risk of enophthalmos, narrowing of the palpebral fissure and the appearance of vertical strabismus due to interference on the vertical rectus muscles.

3. The secondary strabismus angle, which will invariably occur in the healthy eye when the patient tries to fix the object with the affected eye or binocularly, or when turning his gaze towards the affected muscle, is not taken into account.

An object of the invention is to simplify the method and reduce its morbidity.

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

The method is illustrated in figures 1-3.

After anesthesia and preparation of the surgical field, a limbal incision of the conjunctiva is made in the lower lateral quadrant. The lower rectus muscle is taken on a muscle hook, freed from the fascia and maximally stratified into 2 longitudinal muscle bundles. The lateral bundle is 1/3, and the medial is 2/3 of the muscle width. The lateral muscle bundle is taken on a hook and retreating 10-12 mm from the place of its physiological attachment impose a nodal suture. Further, without cutting the threads, the lateral beam is displaced in the direction along the equator of the eye to the paralyzed muscle by a distance corresponding to the angle of squint, injected with the same needle into the sclera, pulled by the thread to the injection, positioning it between the lower straight and lateral rectus muscles, and fixed to the sclera with interrupted sutures (Fig. 1).

Similar actions are performed with the superior rectus muscle, suturing the lateral longitudinal bundle to the sclera in the direction along the equator to the paralyzed muscle at a distance corresponding to the strabismus angle between the superior rectus and lateral rectus muscles (Fig. 2). At the end of the operation on the conjunctiva impose nodal sutures (figure 3).

The invention is illustrated by the following examples of specific performance.

Example 1

Patient M., 3 years old, was admitted to the NF FSI MNTK "Eye Microsurgery" with a diagnosis of Duane's syndrome of the left eye. Hypermetropia of a weak degree of the left eye. Complex hyperopic astigmatism of the left eye. Amblyopia of a weak degree of the left eye.

Visual acuity:

OD 0.6;

OS 0.4 is not corrected.

Biometry OD 23.12;

OS 22.27.

The nature of the view is right-handed.

Forced head position to the left (look to the right). Limit the mobility of the left eye to the temple. Narrowing of the palpebral fissure upon adduction. Diplopia in 1 and 3 positions of the head.

The strabismus angle according to Hirschberg with a carpet test (+) 12-15 degrees. Constantly mowing (to the nose) the left eye. Optical media are clean. The fundus is unchanged.

The patient underwent surgery by the claimed method. After anesthesia and preparation of the surgical field, a limbal incision of the conjunctiva was made in the lower lateral quadrant. The lower rectus muscle was taken on a muscle hook, freed from the fascia, and stratified into 2 longitudinal bundles: lateral was 1/3 of the muscle width, medial was 2/3. Then the lateral bundle was taken on a hook, retreated 10 mm from the place of its attachment, and a nodal suture was applied. Then, without cutting the filaments, the lateral bundle was displaced by 6 mm in the direction along the equator to the paralyzed muscle, the same sclera was injected with the same needle between the lower straight and lateral rectus muscles, the lateral longitudinal bundle was pulled by the filament to the injection and sewn to the sclera.

Similar actions were performed with the superior rectus muscle by suturing the lateral longitudinal bundle in the direction of the equator to the sclera, only between the superior rectus and lateral rectus muscles. At the end of the operation, nodal sutures were placed on the conjunctiva.

The postoperative period was uneventful. After the operation, the strabismus angle is 0 degrees. The absence of a forced head position.

Example 2

Patient K., 56 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of Paralysis of n.abducens of the right eye (post-traumatic origin). Weak hypermetropia in both eyes. Severe amblyopia of the right eye, dysbinocular.

Visual acuity:

OD 0.2;

OS 1.0

Biometry OD 23.12;

OS 23.27.

The nature of the vision is left-sided.

Pronounced restriction of the mobility of the right eye to the temple.

Hirschberg strabismus angle with a carpet test (+) 30 degrees. Constantly mowing (to the nose) the right eye. Optical media are clean. The fundus is unchanged.

The patient underwent surgery by the claimed method. After the preparation of the surgical field, the internal rectus muscle was recessed according to the standard technique. Then a limbal section of the conjunctiva was performed in the lower lateral quadrant. The lower rectus muscle was taken on a muscle hook, freed from the fascia, and stratified into 2 longitudinal bundles: lateral was 1/3 of the muscle width, medial was 2/3. Then the lateral muscle bundle was taken on a hook, retreated 12 mm from the place of its attachment and a nodal suture was applied. Then, without cutting the filaments, the lateral bundle was displaced by 7 mm in the direction along the equator to the paralyzed muscle, the same sclera was injected with the same needle between the lower straight and lateral rectus muscles, the lateral muscle bundle was pulled by the filament to the injection and sewn to the sclera.

Similar actions were performed with the superior rectus muscle, suturing the lateral longitudinal bundle of muscle to the sclera, only between the superior rectus and lateral rectus muscles. At the end of the operation, nodal sutures were placed on the conjunctiva.

The postoperative period was uneventful. After the operation, the strabismus angle is 0 degrees.

In total, by the claimed method, 8 patients with a good cosmetic and functional result were operated on. Using the proposed method will allow, in comparison with the prototype, to simplify the operation, reduce its invasiveness and improve the cosmetic effect.

Claims (1)

A method of treating paralytic strabismus, including a conjunctival incision, isolation of the upper and lower rectus muscles, stratification of the latter into 2 longitudinal bundles, characterized in that the lower rectus muscle is first stratified into a lateral bundle of 1/3 of the muscle width and a medial bundle of 2 / 3 the width of the muscle, then take the lateral bundle on a hook, departing 10-12 mm from its attachment place a nodal suture without cutting the threads, move the lateral bundle to the paralyzed muscle towards the equator of the eye for a distance corresponding to the angle of strabismus, they inject with the same needle into the sclera between the lower straight and lateral rectus muscles, pull the thread to the injection and sew to the sclera, and then similarly sew to the sclera between the upper rectum and lateral rectus muscles the lateral bundle of the upper straight the muscles.

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