RU2436550C1 - Method of treating vertical squint with hyperfunction of inferior oblique eye muscle - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to ophthalmology, and can be applied in treatment of vertical squint with hyperfunction of inferior oblique eye muscle. For this purpose temporally in area of lower-internal angle of orbit near the place of inferior oblique eye muscle attachment transcutaneous injections of medication of botulinic toxin A in dose 20 UN are made. Preliminarily medication is diluted in 1.5 ml of physiological solution of sodium chloride. Then, immediately after this introduction rehabilitative conservative treatment is performed until eye-moving function is restored.

EFFECT: in case of refusal from surgery method creates conditions of maximal patient's plasticity to perception of typical conservative treatment of said type of squint, which leads to restoration of sight in shorter terms, prevention of disease recurrence.

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Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the treatment of vertical strabismus with hyperfunction of the lower oblique muscle of the eye (NKM).

Vertical strabismus occurs in 30-72% of children with strabismus in children and is often combined with horizontal. The leading place in the pathogenesis of vertical strabismus is paresis (paralysis) of the superior oblique muscle. The mechanical imbalance caused by the loss of function of the superior oblique muscle leads to the hyperfunction of its antagonist, the inferior oblique muscle. In this case, a position of the eyes is created in which the visual axes do not converge on the subject in question, the eye deviates to the side, the perception and conduction of visual information throughout the visual system is disturbed, the connections between the right and left eyes are disrupted, and the correct balance between the oculomotor muscles is disturbed ability for volumetric visual perception.

The main treatment for vertical strabismus is to weaken the lower oblique muscle surgically.

There are many ways to weaken the action of the lower oblique muscle. Complete myotomy of the inferior oblique muscle according to Landoit B. (1885), complete myotomy of the inferior oblique muscle at the site of scleral attachment according to Duington L.H. (1923), myoectomy of the middle third according to McNeer K.W., Scott A.V. and Yampolsky A. (1965) are currently of only historical interest, as they are characterized by low efficiency in correcting vertical deviation and a noticeable violation of eye mobility.

The method for weakening the action of the inferior oblique muscle, proposed by E.S. Avetisov (Avetisov E.S., Strabismus. - M .: Medicine, 1977. - 312 p.), Consisting in its intersection with subsequent fixation in a new place, was adopted as an analogue. ensuring the absence of her hypertonicity: retreating 10-12 mm from the outer edge of the limb, make a vertical incision of the conjunctiva 12-15 mm long, isolate the external rectus muscle, move it up and hook the lower oblique muscle at a distance of 2-3 mm from the attachment point to the sclera. 2 stitches are placed on the muscle above and below, capturing 1/3 of the width of the muscle. The lower oblique muscle is crossed at the site of its attachment to the sclera and fixed at the required distance with two previously applied sutures to the sclera in a new place down and anteriorly along the muscle plane.

The disadvantages of the analogue are:

1) performing surgery under general anesthesia;

2) trauma (large conjunctival wound, injuries of the Lokwood ligament, the threat of perforation of the sclera in the immediate vicinity of the macula during muscle flashing);

3) the risk of developing serious intra- and postoperative complications: scarring, gross violation of the anatomical relationships of tissues, limiting the possibility of repeated surgical interventions.

For the closest analogue, the method of treatment for paralytic strabismus proposed by I. Plisov was adopted. (Plisov I.L. A method for the treatment of paralytic strabismus. Patent of the Russian Federation for the invention. RU 2257914 C1, priority dated 03/31/2004). The method consists in the fact that the injection of the drug Dysport containing Botulinum toxin-A is performed intraoperatively in extraocular muscles, which are ipsilateral antagonists and contralateral synergists of paralyzed muscles. After preparation of the surgical field and retrobulbar (or intravenous balanced multicomponent) anesthesia, access to the direct extraocular muscle, which is an antagonist of the muscle involved in paralysis, is released. A muscle is secreted without violating the integrity of the muscular bag. Further, departing at least 5 mm from the place of attachment of the muscle bag to the sclera, in its middle part, the drug Dysport is administered in a dose of 10-20 units. The surgical wound is sutured. In a similar way, surgical procedures are performed on the extraocular muscle, which is the contralateral synergist of the paralyzed muscle. If two or more extraocular muscles are involved in paralysis, then the drug is injected into the corresponding extraocular muscles - contralateral synergists.

Disadvantages: for the introduction of botulinum toxin-A, it is necessary to perform surgery, which also entails the risk of the same complications as in the analogue.

Objectives of the invention:

1. Reducing the morbidity of treatment due to the refusal to perform surgery and anesthesia.

2. Reducing the duration of manipulation.

3. The reversibility of the process in relation to the function of the oculomotor muscle.

The essence of the invention lies in the fact that the treatment of vertical strabismus with hyperfunction of the lower oblique muscle, including its lengthening, is carried out in two stages: at the first stage, a drug based on botulinum toxin type A is injected into the lower oblique muscle of the eye once, then, on the second stage, carry out rehabilitation conservative treatment according to the standard scheme (orthoptic treatment, prismatic correction) until the oculomotor function is restored.

The drug (Dysport®) is administered at the rate of 20 PIECES. The method is carried out without opening the conjunctival cavity and the allocation of the lower oblique muscle, which does not require anesthesia, is short-term (3-4 months), safe, makes it possible to repeat the procedure several times during rehabilitation measures.

The method is as follows. After treating the skin of the lower eyelid with 70% alcohol at 5 mm, a transcutaneous injection of 20 units of botulinum toxin type A (Dysport®) reconstituted in 1.5 ml of a 0.9% sodium chloride solution is made temporarily from the lower internal angle of the orbit at the site of attachment of the lower oblique muscle. (see drawing, where a is the injection site).

The technical result of the method is:

1. The reversibility of the process: temporary paralysis of the lower oblique muscle develops on the 7th day, lasts no more than 4 months. During this period of time, ongoing rehabilitation measures (orthoptic treatment, prismatic correction) can eliminate the imbalance of the oculomotor apparatus and cure the patient of this pathology without changing the anatomical relationship of the oculomotor system.

2. Refusal of surgical intervention having the above disadvantages.

3. Refusal from general anesthesia, which itself can cause a number of complications, especially in pediatric practice.

4. The technique does not require ultra-precise administration of the drug (the spread at the injection point is ± 10 mm). The diffusion zone of botulinum toxin injection is 20 mm; in this anatomical zone there are no other points of application for exposure to botulinum toxin. Therefore, the side effect of botulinum toxin injection is excluded.

5. Economic effect by eliminating the cost of surgical intervention.

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 treated 14 patients - in all cases a positive result was obtained, there were no complications.

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

Example

Patient M., 5 years old. Diagnosis: friendly convergent strabismus, alternating with the vertical component, mild hyperopia of both eyes. The initial strabismus angle is + 15º and 12º upward in the cast on both sides. A transcutaneous injection of 20 IU of botulinum toxin type A (Dysport®) was injected into the lower oblique muscle of the eye on both sides (see the appendix, where a is the point of introduction of botulinum toxin into the lower oblique muscle). After 3 weeks, the vertical component of strabismus was leveled. There were no side effects. For 3 months, the child underwent rehabilitation conservative measures (orthoptic treatment on synoptophore, prismatic correction of the horizontal component of the squint, electrical stimulation of the external rectus muscles of both eyes), which were previously prevented by vertical squint. Binocular vision has been developed. No surgical treatment was needed.

Claims (1)

A method of treating vertical strabismus with hyperfunction of the lower oblique muscle of the eye, including the use of botulinum toxin A, characterized in that transcutaneous injections of the botulinum toxin A preparation are performed temporarily from the lower internal angle of the orbit at the site of attachment of the lower oblique muscle, in a volume of 20 PIECES, while the drug is previously restored to 1.5 ml of physiological solution of sodium chloride, and then carry out rehabilitation conservative treatment until the oculomotor function is restored.

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