RU2446779C1 - Method of treating non-concomitant strabismus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and is intended for elimination of non-concomitant strabismus, complicated by expressed V- or A-syndromes. Carried out are: conjunctival cut, isolation and weakening of rectus oculomotor muscles by recession with further application of sutures. At the first stage performed is recession of rectus medial muscle on 4-5 mm with transposition on 3-5 mm in case of entropia or recession of rectus lateral muscle on 7-9 mm with transposition on 7-9 mm in case of exotropia. In case of A-syndrome transposition of rectus medial muscle is performed with upward displacement, and transposition of rectus lateral muscle - with downward displacement. In case of V-syndrome transposition of rectus medial muscle is performed with downward displacement, and transposition of rectus lateral muscle - with upward displacement. At the second stage carried out is strengthening operation by formation of muscle fold on rectus lateral muscle on 7-9 mm with its further transposition 7-9 mm upwards in case of entropia or by formation of muscle fold on rectus medial muscle on 6-8 mm with its further 5-6 mm transposition in case of exotropia.

EFFECT: method makes it possible to eliminate side effects and increase cosmetic result of operation.

5 dwg, 4 ex

Description

The invention relates to medicine, namely to ophthalmology, and is intended to eliminate unfriendly strabismus, complicated by severe V or A syndromes without the participation of vertical motors.

In the surgical practice of cosologists, there are often clinical cases of mixed types of strabismus - horizontal and vertical. Vertical strabismus is most often accompanied by the presence of V- or A-syndromes. The presence of V-or A-syndrome can be said with a difference in the strabismus angle in the gaze positions with the head up and down. With V-syndrome, the change in the angle of strabismus when moving the gaze from bottom to top, with A-syndrome, from top to bottom. Most often, the manifestations of V- or A-syndromes are associated with hyper (or hypo) function of extraocular muscles (EOM) of vertical action (upper oblique muscle, lower oblique muscle). The tactics of a surgical approach to these types of strabismus are traditional.

In the presence of pronounced V- or A-syndromes without vertical motor dysfunction, one of the surgical methods of choice is the vertical transposition of horizontal muscles. The principle of the vertical transposition method was first described by Knapp P (Knapp P: Vertically incomitant horizontal strabismus: The so-called A and V syndrome Trans Am Ophthalmol Soc57: 666, 1959. Knapp P: A and V patterns. In Symposium on Strabismus. Transactions of the New Orleans Academy of Ophthalmology St Louis, Mosby-Year Book, 1971, p. 242.). It is based on a change in the position of the muscle plane of the EOM of horizontal action relative to the center of rotation of the eye.

The disadvantage of this method is the low efficiency of one weakening type of operations-recessions for the complete elimination of syndromes V or A.

In EOM - m.r.medialis et m.r. lateralis muscle planes coincide with the horizontal plane (X axis). The axis of rotation coincides with the Z axis - the muscles rotate the eye only horizontally. Horizontal muscles help in raising the eyeball when looking up and in lowering when looking down, and their main physiological effect, the horizontal movement in these leads is reduced. By moving EOM of horizontal action vertically (raising or lowering) this physiological action can be enhanced.

When m.r.medialis moves down, its horizontal action decreases when looking down and it acts as a lowering device. When moving m.r. lateralis up its horizontal action will be reduced by increasing the lifting function. Thus, transposition of EOM of horizontal action can affect the magnitude of V- or A-syndromes. The transposition of horizontal muscles is performed both on one eye and on both eyes, mainly when conducting only a weakening recession operation.

A known method of eliminating unfriendly strabismus, which consists in resection and recession of the direct oculomotor muscles of vertical action. To perform a recession, the rectus muscle is secreted and, after preliminary suturing on both it and the sclera, is cut off. During resection, the rectus muscle is secreted, a ligature suture is applied to it, the supposed resection site is measured, the muscle is sutured with two threads at this point, the muscle tendon is crossed, the sutures are inserted through the tendon strip and episclera, the muscle is pulled by the ligature, the suture is tied, and the remaining stump muscles are cut off (Avetisov E.S. Conjugate strabismus. - M.: Medicine, 1977, p. 280-286).

The main disadvantage of this method is its complexity due to the need to lay two nodal sutures at each stage of the operation, high invasiveness and low efficiency in eliminating V- or A-syndromes.

There is a method of eliminating strabismus on previously operated muscles, including a conjunctival incision, isolation of the rectus muscle, its separation. Next, the middle longitudinal part of the previously operated separated straight or oblique muscle, which is 1/3 of the muscle width, is sutured 4-8 mm from the point of attachment and a scleral suture of 2-8 mm in front of the muscle is applied with the same needle and thread. The stitched area of the muscle is pulled anteriorly by the thread, forming the median muscle fold (median duplication). The method provides restoration of the anatomical place of attachment of previously recessed muscles and their strengthening, reducing postoperative complications (patent RU 2363428 C2, 08/10/2009).

The closest to the claimed method, the prototype is a method of treating unfriendly strabismus by the method of vertical transposition of extraocular muscles (EOM) horizontal action according to the scheme proposed by Noorden GK von Noorden GK von Atlas of Strabismus, ed 4. St Louis, Mosby-Year Book, 1983). Figure 1 presents a diagram of the transposition of EOM horizontal action in V-syndrome (A) and A-syndrome (B).

Transposition with V-syndrome is as follows:

- m.r.medialis is shifted towards the top of the syndrome - down;

- m.r. lateralis is displaced from the top of the syndrome - up.

Transposition with A-syndrome is as follows:

- m.r.medialis is shifted towards the top of the syndrome - up;

- m.r. lateralis is displaced from the top of the syndrome - down.

Depending on the type of horizontal strabismus, the weakening operation on the EOM is performed in the form of a recession according to the standard method, and the amplifying operation is performed as a resection according to the standard method.

The disadvantage of the described method is the high invasiveness, which sometimes leads to trophic changes in the anterior segment of the eye and the inflammatory reaction of the iris and ciliary body.

An object of the invention is to simplify the method, eliminate side effects and increase the cosmetic result of the operation.

The technical task is achieved by the proposed method, which consists in the following. The invention is illustrated figure 2-5.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 2 and 4 hours with the release of the rectus medial muscle during intropy, or at 6-8 hours with the release of the rectus lateralis muscle during exotropy. To eliminate unfriendly strabismus with V-syndrome during intropy, the first stage, depending on the severity of the syndrome, performs a recession of the rectus medial muscle 4-5 mm with a transposition down 3-5 mm or a recession of the rectus lateral muscle 7-9 mm with a transposition up to 7-9 mm with exotropia. The second step is to perform an intensifying operation - the median duplicate, by forming a muscle fold on the rectus lateralis muscle by 7-9 mm, followed by its transposition upward by 7-9 mm (with intropy) or by forming a muscle fold on the rectal medial muscle by 6-8 mm followed by a transposition of it down by 5-6 mm with exotropia.

Elimination of non-friendly strabismus with A-syndrome is carried out in a similar way, except that the transposition of the rectus medial muscle is carried out with an upward shift, and the transposition of the rectus lateral muscle is carried out with a downward shift.

The middle duplicate is carried out in a known manner (patent RU 2363428 C2, 08/10/2009) as follows:

Take lateral (with intropy) rectus muscle on muscle hooks. They capture 1/3 of the width of the muscle, stitch it 7-9 mm from the place of muscle attachment, depending on the required volume of reinforcement, and apply the scleral suture with the same needle and thread, pulling it up and down (syndrome V) or down (syndrome A) stitched a muscle section with the formation of a muscle fold, parallel to the limb, 7-9 mm from the upper edge of the root of the lateral rectus muscle (Figs. 2, 5).

With exotropia, 1/3 of the width of the medial muscle is captured, stitched 6-8 mm from the place of muscle attachment, depending on the required volume of reinforcement, and the scleral suture is applied with the same needle and thread, pulling and moving down (syndrome V) or up (syndrome A) the stitched portion of the muscle with the formation of the muscle fold, parallel to the limb 5-6 mm from the lower edge of the root of the rectus medial muscle (Figs. 3, 4).

The use of median duplicate as an enhancing type of surgery for EOM in combination with vertical transposition of EOM of horizontal action allows eliminating V- and A-syndromes with unfriendly strabismus, as well as obtaining a persistent cosmetic effect.

The invention is illustrated by clinical examples.

Example 1

Patient M., 7 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of Non-accommodation, alternating, congenital intropy, complicated by severe V-syndrome. Hypermetropia of a weak degree of the left eye. Complex hyperopic astigmatism of the left eye.

Visual acuity:

OD 1.0;

OS 1.0

Biometry OD 23.12; OS 22.27.

Nature of vision simultaneous

Hirschberg strabismus angle with carpet test:

To the left + 17 ° + 15 ° Look up +15 +15 Straight + 15 ° + 15 ° To the right + 17 ° + 17 ° Look down +25 +25

The expressed V-syndrome without vertical motor dysfunction is determined.

Optical media are clean.

The fundus is unchanged.

To eliminate strabismus, a recession of the rectus medial muscle was performed by 5 mm with a transposition of 5 mm downward and a median duplicate of the rectus lateralis muscle by 8 mm with a transposition of 7 mm upward. The operation was carried out as follows in the right eye.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 2 and 4 hours with the release of the rectus medial muscle. A rectal medial muscle recession is performed 5 mm from the physiological attachment site according to the standard method with a parallel offset to the limb, 5 mm wide tendon width - down the equator, towards the lower rectus muscle. Then perform median duplication on the rectus lateralis muscle. To do this, take on the muscle hooks the lateral rectus muscle. They capture 1/3 of the muscle width, stitch it 8 mm from the muscle attachment point and apply the scleral suture with the same needle and thread, pulling and stitching up the stitched muscle section with the formation of a muscle fold, parallel to the limb 7 mm from the upper edge of the root of the lateral muscle ( figure 2). At the end of the operation, nodal sutures are placed on the conjunctiva.

The postoperative period was uneventful. After the operation, the strabismus angle according to Hirschberg with the carpet test:

To the left 0 0 Look up +5 +5 Straight +2 +2 To the right 0 0 Look down 0 0

Example 2

Patient A., 17 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of Non-accommodation, alternating, congenital exotropia, complicated by severe V-syndrome. Acquired myopia of an average degree of the right eye, a weak degree of the left eye. Visual acuity:

OD 0.08 cc sph-3.0 = 1.0;

OS 0.07 ck sph-2.0 = 1.0;

Biometry OD 24.17; OS 23.96.

Nature of vision simultaneous

Hirschberg strabismus angle with carpet test:

The expressed V-syndrome without vertical motor dysfunction is determined.

Optical media are clean. The fundus is unchanged.

To eliminate strabismus, a 9 mm straight lateral muscle recession with a transposition of 7 mm upward and a median duplicate of the rectus medial muscle 8 mm with a transposition of 6 mm downward in the right eye were performed. The operation was carried out as follows in the right eye.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 7 and 9 hours with the release of the rectus lateralis muscle. Recession of the rectus lateralis muscle is performed at 9 mm from the physiological attachment site according to the standard method with displacement parallel to the limb, along the width of its tendon by 7 mm, upward, along the equator, towards the superior rectus muscle. Then perform median duplication of the rectus medial muscle by 8 mm. To do this, take the latter on muscle hooks, grab the middle 1/3 of the muscle width, stitch 8 mm from the muscle attachment point and apply the scleral suture with the same needle and thread, pulling and moving the muscle fold down 6 mm with a reference to the lower edge of the root of the straight medial muscle parallel to the limb (figure 3). At the end of the operation, nodal sutures are placed on the conjunctiva.

The postoperative period was uneventful. After the operation, the strabismus angle according to Hirschberg with the carpet test:

Patient K., 26 years old, was admitted to the NF FSI MNTK “Eye Microsurgery” with a diagnosis of Non-accommodative, alternating, congenital exotropia, complicated by severe A-syndrome. Myopia acquired, axial, stable, weak degree of both eyes.

Visual acuity:

OD 0.08 cc sph-2.0 = 1.0;

OS 0.07 ck sph-2.5 = 1.0;

Biometry OD 24.12; OS 24.27.

Nature of vision simultaneous

Hirschberg strabismus angle with carpet test:

The expressed A-syndrome without vertical motor dysfunction is determined.

Optical media are clean. The fundus is unchanged.

To eliminate strabismus, an operation was performed on the right eye: a recession of the rectus lateral muscle by 7 mm with a transposition of 8 mm downward and a median duplicate of the rectus medialis muscle by 6 mm with a transposition of 5 mm upward. The operation was carried out on the right eye as follows.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 7–9 hours with the release of the rectus lateralis muscle. Recession of the rectus lateralis muscle is performed 7 mm from the physiological attachment site according to the standard method with displacement parallel to the limb, by the width of its tendon, by 8 mm downward, along the equator, towards the lower rectus muscle. Then perform median duplication of the rectus medial muscle by 6 mm. To do this, take the latter on muscle hooks, capture the average 1/3 of the muscle width, stitch 6 mm from the muscle attachment point and apply the scleral suture with the same needle and thread, pulling and moving the muscle fold upward by 5 mm with a reference to the upper edge of the root of the straight medial muscle parallel to the limb (figure 4) At the end of the operation on the conjunctiva impose nodal sutures.

The postoperative period was uneventful. After the operation, the strabismus angle according to Hirschberg with the carpet test:

To the left 0 0 Look up -2 -2 Straight 0 0 To the right 0 0 Look down 0 0

Example 4

Patient P., 13 years old, was admitted to the NF FSI MNTK "Eye Microsurgery" with a diagnosis of Non-accommodation, alternating, congenital intropy, complicated by severe A-syndrome. Hypermetropia of a weak degree of the left eye. Complex hyperopic astigmatism of the left eye.

Visual acuity:

OD 0.9;

OS 1.0

Biometry OD 23.54; OS 23.29.

Nature of vision simultaneous

Hirschberg strabismus angle with carpet test:

To the left + 17 ° + 15 ° Look up +25 +25 Straight + 15 ° + 15 ° To the right + 17 ° + 17 ° Look down +18 +18

The expressed A-syndrome without vertical motor dysfunction is determined.

Optical media are clean. The fundus is unchanged.

To eliminate strabismus, a recession of the rectus medial muscle was performed by 5 mm with a transposition of 4 mm upwards and a median duplicate of the rectus lateralis muscle by 7 mm with a transposition of 9 mm downward. The operation was performed on the left eye as follows.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 7 and 9 hours with the release of the rectus medial muscle. A rectal medial muscle recession is performed 5 mm from the physiological attachment site according to the standard method with a parallel displacement to the limb, 4 mm wide tendon width - upward, along the equator, towards the superior rectus muscle. Then perform median duplication on the rectus lateralis muscle. To do this, take the latter on muscle hooks, capture the average 1/3 of the muscle width, stitch it 7 mm from the muscle attachment point and apply the scleral suture with the same needle and thread, pulling and moving the muscle fold down by 9 mm with a reference to the outer edge of the lower root rectus muscle, parallel to the limb (figure 5). At the end of the operation, nodal sutures are placed on the conjunctiva.

The postoperative period was uneventful. After the operation, the strabismus angle according to Hirschberg with the carpet test:

To the left 0 0 Look up 0 0 Straight +2 +2 To the right 0 0 Look down 0 0

In total, 76 patients with a good cosmetic and functional result were operated on by the claimed method. The method is simple to implement and allows to achieve good results with less invasiveness of the intervention.

Using the proposed method will allow, in comparison with the prototype, to simplify, reduce the morbidity and improve the cosmetic effect of the operation.

Claims (1)

A method for the treatment of unfriendly strabismus complicated by V- or A-syndrome, including conjunctival incision, isolation and weakening of the direct oculomotor muscles by recession, followed by suturing, characterized in that the first stage performs a recession of the rectus medial muscle by 4-5 mm with a transposition of 3-5 mm for intropy or recession of the rectus lateralis muscle by 7-9 mm with transposition of 7-9 mm for exotropia, while with the A-syndrome the transposition of the rectus medial muscle is carried out with an upward shift, and the transposition прямой of the rectus lateral muscle with a shift downward, and in the case of V syndrome, the transposition of the rectus medial muscle is carried out with a shift downward, and the transposition of the rectus lateral muscle is carried out with a shift upward, and the second step is to perform an amplifying operation by forming a muscle fold on the rectus lateralis muscle 7- 9 mm followed by a transposition of it upward by 7–9 mm during intropy or by formation of a muscle fold on the rectus medial muscle by 6–8 mm with subsequent transposition of it downward by 5–6 mm during exotropy.

Images