RU2407492C1 - Method of treating secondary strabismus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and is intended for treatment of secondary strabismus. Limbal cut of conjunctiva is carried out in lower-lateral quadrant and inferior rectus muscle is isolated. Middle longitudinal part of inferior rectus muscle, which constitutes 1/3 of its width, is released from anterior ciliary arteries and from fascia, then is caught with pincers, forming middle muscle bundle. After that indenting 6-8 mm from place of its physiological attachment, double interrupted suture is applied on formed bundle and then by the same needle performed is shot in sclera 9-11 mm from limb between inferior rectus and lateral rectus muscles, inferior rectus muscle is pulled by suture to shot and fixed to sclera by interrupted sutures. Analogical actions are carried out with superior rectus muscle, sewing it to sclera between superior rectus and lateral rectus muscles.

EFFECT: method makes it possible to simplify operation, to reduce its trauma and improve cosmetic effect.

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Description

The invention relates to medicine, namely to ophthalmology, and is intended to eliminate secondary strabismus due to paralysis or paresis of the muscle and pseudoparalytic strabismus due to post-traumatic, postoperative muscle loss or aplasia.

As with paralytic strabismus, and with pseudoparalytic strabismus, one or more extraocular muscles irreversibly completely or partially lose their function. Symptoms 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 moved 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 switching off the affected or healthy eye from visual work.

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

1) Operation O. Connor, which consists in isolating 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 Jensen, 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 preliminarily 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 Pacijic 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. Use of the operation of E.S. Avetisov for paralysis of the external rectus muscle. Ophthalm. Journal. 1985, N 2, p. 77-80).

The disadvantage of the described methods is the high morbidity, since it is necessary to operate on three, 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.

The closest to the claimed method of the prototype is a method of treating 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 using traction sutures placed through the episcler 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, it 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 intervention 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 method is illustrated in figure 1-2

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

After anesthesia and preparation of the surgical field, a limbal incision of the conjunctiva is made in the lower lateral quadrant and the lower rectus muscle is isolated. The middle longitudinal part of the lower rectus muscle, which is 1/3 of its width, is freed from the anterior ciliary arteries and fascia, then it is captured with forceps, forming the median muscle bundle. Then, having retreated 6-8 mm from the place of physiological attachment of the muscle, a double nodal suture is applied to the formed muscle bundle and then an injection into the sclera is made with the same needle 9-11 mm from the limb between the lower rectus and lateral rectus muscles, the lower rectus muscle is pulled for the thread to inject and fix to the sclera with interrupted sutures (Fig. 1).

Similar actions are performed with the superior rectus muscle, hemming it to the sclera between the superior rectus and lateral rectus muscles. At the end of the conjunctiva impose nodal sutures (figure 2).

The proposed method can be used for damage to the external rectus muscle. Using the proposed method will simplify the operation, reduce its invasiveness and improve the cosmetic effect.

In the presence of secondary divergent types of strabismus with detachment elements, the proposed method, by weakening the reduction of the rectus muscles of the vertical action, allows to obtain not only a persistent cosmetic effect, but also restore mobility.

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

Example 1

Patient M., 3.6 years old, was admitted to the Novosibirsk branch (NF) of the Federal State Institution IRTC “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 position of the head 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.

Hirschberg strabismus angle with a carpet test (+) 17 degrees. Constantly mows, to the nose, the left eye. Optical media are clean. The fundus is unchanged.

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 median transposition was performed according to the following procedure: the lower rectus muscle was taken onto the muscle hook, the middle longitudinal 1/3 of the muscle was freed from the anterior ciliary arteries and fascia, then it was captured with forceps, forming the median muscle bundle, retreating 6 mm from the place of its physiological attachment, to the formed muscle bundle was superimposed with a double nodal suture and then injected with the same needle into the sclera 9 mm from the limb between the lower rectus and lateral rectus muscles, pulled the lower rectus muscle by the thread to the injection and fix Rowan scleral interrupted sutures.

Similar actions were performed with the superior rectus muscle, suturing it to the sclera 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., 46 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of Secondary divergent strabismus of the left eye (post-traumatic genesis - complete separation of the medial rectus muscle). Weak hypermetropia in both eyes.

Visual acuity:

OD 0.9;

OS 0.7.

Biometry OD 23.12;

OS 23.27.

The nature of the view is right-handed.

Severe limitation of the mobility of the left eye to the nose.

The strabismus angle according to Hirschberg with a carpet test (-) of 35-40 degrees. Limit the mobility of the left eye to the nose. Optical media are clean. The fundus is unchanged. Separation of the medial rectus muscle was confirmed by examination by the Spiral CT scan technique.

After the preparation of the surgical field, the external rectus muscle was recessed according to the standard technique.

Then a limbal section of the conjunctiva was performed in the lower lateral quadrant. The median transposition was carried out according to the following procedure: the lower rectus muscle was taken onto the muscle hook, the middle longitudinal 1/3 of the muscle was freed from the anterior ciliary arteries and fascia, then it was captured with forceps, forming the median muscle bundle, retreating 8 mm from its physiological attachment, on the formed bundle was superimposed with a double nodal suture and then injected with the same needle into the sclera 11 mm from the limb between the lower straight and lateral rectus muscles, pulled the lower rectus muscle by the thread to the injection and fixed to sclera with interrupted sutures.

Similar actions were performed with the superior rectus muscle, suturing it to the sclera 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. The presence of mobility of the left eye in the cast.

Example 3

Patient K., 6 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of secondary divergent strabismus of the right eye (operated intropy - separation of the medial rectus muscle). Hypermetropia of an average degree of both eyes. Amblyopia of an average degree of the right eye, of mixed genesis.

Visual acuity:

OD 0.3;

OS 0.8

Biometry OD 22.12;

OS 22.67.

The nature of the vision is left-sided.

Severe restriction of mobility of the right eye to the nose.

Hirschberg squint angle with carpet test (-) 20 degrees. Limit the mobility of the right eye in the cast. Optical media are clean. The fundus is unchanged. Separation of the medial rectus muscle was confirmed by examination by the Spiral CT scan technique.

After the preparation of the surgical field, the external rectus muscle was recessed according to the standard technique.

Then a limbal section of the conjunctiva was performed in the lower lateral quadrant. The median transposition was carried out according to the following procedure: the lower rectus muscle was taken onto the muscle hook, the middle longitudinal 1/3 of the muscle was freed from the anterior ciliary arteries and fascia, then it was captured with forceps, forming the median muscle bundle, retreating 7 mm from the place of its physiological attachment, to the formed bundle was superimposed with a double nodal suture and then injected with the same needle into the sclera 10 mm from the limb between the lower straight and lateral rectus muscles, pulled the lower rectus muscle by the thread to the injection and fixed to sclera with interrupted sutures.

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

In total, the claimed method operated on 16 patients with good cosmetic and functional results. Using the proposed method will allow, in comparison with the prototype, to simplify the operation, reduce its invasiveness, eliminate postoperative complications and improve the cosmetic effect of the operation.

Claims (1)

A method of treating secondary strabismus, including conducting a conjunctival incision and isolating the lower and upper rectus muscles, characterized in that first the middle longitudinal part of the lower rectus muscle, which is 1/3 of its width, is freed from the anterior ciliary arteries and captured by forceps from the fascia, forming the median muscle the beam, departing 6-8 mm from the place of its physiological attachment, a double nodal suture is applied to the formed beam and then an injection into the sclera is made with the same needle 9-11 mm from the limb between the lower line and lateral rectus muscle, pull the lower rectus muscle by the thread to the injection and fix it to the sclera with interrupted sutures, and then similar actions are performed with the upper rectus muscle, hemming it to the sclera between the superior rectus and lateral rectus muscles.

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