RU2531458C1 - Method of treating hyperactive inferior oblique muscle of eye - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmic surgery, and can be applicable for treating hyperactive inferior oblique muscle of the eye. That is ensured by separating the inferior oblique muscle. It is stretched between two muscle hooks. That is followed by vascular electric coagulation along the planned incision lines. Edge Z- or W-incisions are performed by 1/2-1/3 width of the separated muscle. The width and number of the incisions depends on the adducted eye hypertropia. The incisions are perpendicular to its axis; the incision distance makes 2-5 mm. It is the lateral incision that is performed first from a distal end of the muscle. The following incision is performed in a more medial perpendicular direction from the previous incision.

EFFECT: method provides higher effectiveness with reducing its injuries and the absence of postoperative complications.

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Description

The invention relates to medicine, namely to ophthalmic surgery, and can be used in the surgical treatment of hyperfunction of the lower oblique muscle of the eye.

The most common cause of vertical eye deviation is paresis or paralysis of the superior oblique muscle, which is accompanied by a manifestation of the relative hyperfunction of the inferior oblique muscle, as well as V-syndrome. To eliminate vertical strabismus, the main and reasonable surgical method is a recession of the lower oblique muscle.

A known method of eliminating hyperfunction of the inferior oblique muscle by recession of the latter, which consists in the following: retreating 6-8 mm from the limb, perform an oblique incision of the conjunctiva in the lower outer quadrant 8-10 mm long, then the lower rectus muscle is hooked, the lower oblique muscle is captured J-hook at the lateral edge of the lower rectus muscle, where it is close enough and goes in the form of a cord 5-6 mm thick. The external rectus muscle and lower oblique muscle are pushed back with a spatula, and they are cut off from the sclera under the control of vision without preliminary flashing. In this case, the lower oblique muscle contracts anteriorly, remaining in its muscle plane, as it goes into the surgical wound, and here its canopy is sutured and fixed in the right place at the lateral edge of the lower rectus muscle with two interrupted sutures (Patent RU 2188610 C1, 09/10/2002).

A known method of dosed anterior transposition of the inferior oblique muscle, which consists in the following: through a small incision of the conjunctiva in the outer half of the lower conjunctival arch take the external rectus muscle for ligature. The ends of the ligature are fixed to the operating napkin in the projection of the opposite eyebrow so that the operated eye moves inwards and upwards. The conjunctival wound in the lower arch is opened in the form of a triangle, pulling the conjunctiva one retractor outward, the other down. Thus, the lower oblique muscle can be seen in the lower-outer part of the wound between the retractors. The lower oblique muscle is taken on a hook, released from surrounding tissues, stitched at the site of natural attachment with two interrupted sutures and cut off from the sclera. The ligature is removed from the external rectus muscle. The lower rectus muscle is hooked, which helps to visualize the lower-outer quadrant of the sclera and facilitates further manipulations. The stitched lateral part of the inferior oblique muscle is moved to the anterior segment of the eye and fixed with interrupted sutures to the sclera at a certain point, corresponding to the degree of hyperfunction of the inferior oblique muscle, being oriented and counting from the outer edge of the attachment point of the inferior rectus muscle. A suture is placed on the conjunctiva (Popova N.A. A new operation for strabismus - anterior transposition of the lower oblique muscle. Fedorov readings. - 2002. - M., 2002, p. 286-290).

The disadvantages of the described methods are:

- the possibility of incomplete capture of the lower oblique muscle due to its anatomical features (wide fan-shaped attachment to the sclera), which subsequently leads to a hypoeffect;

- the possibility of perforation of the sclera when crossing at the site of attachment of the lower oblique muscle;

- Dosing of the stitching and fixing stage at the lateral edge of the lower oblique muscle;

- high risk of injury to the optic nerve and macular region, due to manipulation of the needle in the inaccessible posterior region of the eyeball;

- the duration of the surgery.

The closest to the claimed method - the prototype - is a method of treating hyperfunction of the inferior oblique muscle, which consists in the following: a conjunctiva is cut in a length of 12-14 mm in the lower-outer section 7-9 mm from the limbus, the lower oblique muscle is isolated, then it is pulled with two hooks conjunctiva outwards and downwards, and the third oblique muscle is taken with the third hook. After the muscle is released from the capsule, it is stretched on two hooks, delaminated and a part of the lower oblique muscle is secreted from the attachment point to the lateral part of the lower rectus muscle. In this case, the width of the secreted part of the muscle is selected depending on the angle of deviation to obtain the planned dosage of the effect of the operation. The selected part of the muscle is stitched at the attachment site and cut off. Move the selected part of the muscle to the place of attachment of the lower rectus muscle and sew. A continuous suture is placed on the conjunctiva (Patent RU 2288680 C2, 12/10/2006).

The disadvantages of the prototype are:

- the movement of only part of the selected (stratified) muscle to the site of attachment of the inferior rectus muscle while maintaining the remaining part of the inferior oblique muscle at the site of physiological attachment, which leads to overcorrection of the planned result of the operation, which is subsequently accompanied by an additional stage of the operation;

- trauma to the lower oblique muscle with the risk of muscle bleeding and, subsequently, severe chemosis and subcutaneous hematoma of the lower eyelid;

- the impossibility of dosing the expected result for various types and degrees of manifestation of hyperfunction of the lower oblique muscle;

- limitation of eye mobility when looking up and narrowing of the palpebral fissure.

The objective of the invention is to increase the effectiveness of treatment and reduce the morbidity of the operation and side complications.

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

After appropriate preparation of the surgical field and performing intravenous multicomponent balanced or retrobulbar anesthesia, access to the lower oblique muscle and to the retro-equatorial space is released. The muscle is secreted, stretched on two muscle hooks with a limiter and a muscle clamp is applied. Make edge cuts of the muscle, perpendicular to its axis, using scissors, having previously performed electrocoagulation or using an electrocoagulator. In this case, the lateral incision is made first from the distal edge of the muscle (closer to the external rectus muscle), the subsequent incisions (one or two) are performed more medially (closer to the lower rectus muscle) in the perpendicular direction with respect to the previous incision (Figs. 1, 2).

The distance between the cuts is 2-5 mm. The number of edge incisions and their size depend on the degree of hyperfunction of the inferior oblique muscle, which is expressed in the magnitude of the eye hypertropy (upward deviation) when brought down (horizontal movement to the nose). In the particular case, with a magnitude of hypertropy up to 7 °, a Z-shaped marginal myotomy of the lower oblique muscle is performed at 1/2 the width of the muscle; when the magnitude of hypertropy is 8-12 °, a Z-shaped marginal myotomy of the lower oblique muscle is performed at 2/3 of the muscle width; with a magnitude of hypertropy of 13-15 °, a W-shaped marginal myotomy of the lower oblique muscle is performed at 1/2 the width of the muscle; with a magnitude of hypertropy of 16-20 °, a W-shaped marginal myotomy of the lower oblique muscle is performed at 2/3 of the muscle width.

A significant difference of the proposed method from the prototype is that on the lower oblique muscle perform edge Z- or W-shaped incisions perpendicular to its axis, 1 / 2-2 / 3 of the width of the muscle, using an electrocoagulator or using scissors, after preliminary electrocoagulation of blood vessels along the lines of the planned incisions, the width of which depends on the magnitude of the eye hypertropy when it is brought in, with a distance between the incisions of 2-5 mm, while the first is a lateral incision from the distal edge of the muscle, the subsequent incision is made more medially in the perpendicular direction with respect to the previous incision, which allows to increase the stability of the manipulation, reduce its invasiveness and reduce side complications.

The positive effect of the operation is achieved due to the following induced biomechanical changes created when incomplete marginal myotomy of the lower oblique muscle is performed:

- the distal portion of the inferior oblique muscle responsible for its uplifting function is primary and maximally weakened;

- during the operation, the intersection of neuromuscular synapses is performed, which leads to a decrease in the quantitative afferent innervation;

- the stretched (weakened) lower oblique muscle remains anatomically in the plane of its functional action.

The combination of the above mechanisms causes a decrease in dynamometric and dynamostatic indicators of the lower oblique muscle, which induces its reduced tone. This, in turn, causes a reduction in hypertropy in the cast. As a result, more favorable conditions are created for binocular vision and an increase in the quality of life.

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

Example 1

Patient K., 23 years old. Diagnosis: Acquired paresis of n.trochlearis of the right eye.

On examination (11 months after occurrence):

Strabismus angle:

Gaze Right eye Left eye Seen to the right 0 ° 0 ° When looking directly ↓ 7 ° ↑ 5 ° When looking to the left ↓ 17 ° ↑ 12 ° Looking up 0 ° -5 ° When looking down + 7 ° + 15 °

The dynamics are weakly positive. The patient is disturbed by vertical double vision, which occurs in the direct position of the gaze and increases with the translation of the gaze to the left. Therefore, the patient avoids this direction of gaze and compensatory turns his head to the left (17 °).

The patient underwent surgery by the claimed method. After a multicomponent balanced anesthesia and treatment of the surgical field, an eyelid was introduced, exposing the eyeball as much as possible. Further, to provide access to the lower oblique muscle of the right eye, the conjunctiva was taken with tweezers at 6 o’clock, lowered and brought the eyeball. Conjunctival spring scissors performed radial sections of the conjunctiva and tenon capsule 10 mm long along the meridians of 6 and 8 hours and paralymbally, connecting the proximal borders of the radial sections. The tenon capsule from the episclera was separated with scissors in the lower-outer quadrant. The separated tenon capsule was taken with tweezers, raised above the sclera and pulled to the limbus to visualize the lower oblique muscle. A muscle hook with a limiter was placed into the formed lower-outer space to a depth sufficient to capture the muscle, while the tip of the hook was directed to the medial side. Rotating the handle of the hook 90 ° clockwise, they captured the muscle in its middle third. A second muscle hook with a limiter was inserted behind the muscle. The muscle was stretched and raised above the sclera, a muscle clamp was applied to the muscle perpendicular to the axial line of the muscle. Using an electrocoagulator, coagulation of blood vessels was carried out along the lines of the planned incisions. Scissors made an incision from the distal edge of the muscle to 2/3 of its width from the lateral side of the clamp. The second incision 2/3 of the width of the muscle was performed from the proximal edge with the medial side of the clamp 5 mm from the first. Thus formed two edge incisions in the perpendicular direction (Z-shaped). The clamp was removed from the muscle, the muscle hooks were pulled out. The wound was sutured with a non-absorbable thread 7-0. Under the conjunctiva, 0.3 ml of a 1% dexazone solution was administered. The eyelid was removed and a sterile dressing was applied.

During the follow-up examination after 1 month, the patient noted the absence of vertical double vision in the upright position of the head and horizontal double vision when moving the gaze up and down, the minimum vertical double when moving the gaze to the extreme left. An objective examination revealed:

The amount of deviation:

Gaze Right eye Left eye Seen to the right 0 ° 0 ° When looking directly 0 ° 0 ° When looking to the left ↓ 3 ° ↑ 2 ° Looking up 0 ° 0 ° When looking down + 2 ° + 3 °

Example 2

Patient S., 4 years old. Diagnosis: Congenital paresis of n.trochlearis in both eyes. On examination:

Strabismus angle:

Gaze Right eye Left eye Seen to the right ↓ 10 ° ↑ 17 ° When looking directly ↑ 3 ° ↑ 5 ° When looking to the left ↑ 17 ° ↓ 12 ° Looking up 0 ° -5 ° When looking down + 15 ° + 12 °

According to the mother, strabismus became clearly noticeable from 5 months. The child performs alternate occlusion. The magnitude of strabismus without dynamics. Orthoptic treatment due to strabismus is not possible.

The patient underwent an operation by the claimed method analogously to example 1, except that the incisions were made using an electrocoagulator, the third incision was made from the distal edge of the muscle, medial to the second proximal incision (W-shaped), the distance between the incisions was 2 mm, the operation was performed on both eyes.

During the follow-up examination after 3 months, the mother did not notice a cosmetically visible strabismus, the occlusion was canceled, the child receives orthoptic treatment. An objective examination revealed:

The amount of deviation:

Gaze Right eye Left eye Seen to the right 0 ° ↑ 2 ° When looking directly 0 ° 0 ° When looking to the left ↑ 3 ° 0 ° Looking up -1 ° 0 ° When looking down + 3 ° + 4 °

The proposed method will improve the efficiency of the operation, reduce its invasiveness and side complications. In addition, the use of the proposed method will eliminate double vision by correcting vertical strabismus and V-syndrome, eliminate the forced position of the head in which double vision is compensated, maintain binocular work in the maximum possible field of vision, create conditions for orthoptic treatment, eliminate physical discomfort and asthenopic complaints patients.

Claims (5)

1. A method of treating hyperfunction of the lower oblique muscle of the eye, including the allocation of the lower oblique muscle and stretching the latter on two muscle hooks, characterized in that the edge Z- or W-shaped incisions are made per 1/2 to 2/3 of the width of the selected muscle, perpendicular to it axis, using an electrocoagulator or using scissors after preliminary electrocoagulation of vessels along the lines of the planned incisions, the width and number of which depends on the magnitude of the eye hypertropy in the cast, with a distance between the incisions of 2-5 mm, with the first A lateral incision is made from the distal edge of the muscle, the subsequent incision is performed medially in the perpendicular direction with respect to the previous incision. 2. The method according to claim 1, characterized in that with a magnitude of hypertropy of up to 7 °, a Z-shaped marginal myotomy of the lower oblique muscle is performed at 1/2 the width of the muscle. 3. The method according to claim 1, characterized in that when the magnitude of the hypertropy is 8-12 °, a Z-shaped marginal myotomy of the lower oblique muscle is performed on 2/3 of the muscle width. 4. The method according to claim 1, characterized in that with a magnitude of hypertropy of 13-15 °, a W-shaped marginal myotomy of the lower oblique muscle is performed at 1/2 the width of the muscle. 5. The method according to claim 1, characterized in that when the magnitude of the hypertropia is 16-20 °, a W-shaped marginal myotomy of the lower oblique muscle is performed on 2/3 of the muscle width.

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