RU2698440C1 - Method for surgical management of repeatedly operated strabismus with hyperactive effect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. For surgical treatment of repeatedly operated strabismus with hypereffect during operation, a recessive muscle is extracted, sutured with a needle thread so that each needle is sutured transversely to a half of the muscle at its attachment point, at distance of 1–2 mm from it, thorough hemostasis is carried out, then the stitched muscle is cut off from the attachment point and its reduction is performed by fixing the two-sutured muscle to the sclera in the projection of the anatomical attachment point, wherein the same needles are made in the scleral thickness parallel to each other, after the needle sticking, a single knot is first knotted, and then the knot joint, on the second opposite muscle, 2–4 mm recession is made, the conjunctiva are sutured in the projection of both muscles so that knot-knot on each muscle is exposed. On the next postoperative day, if the eye is in the correct position, the knotted knot is transformed into a single knot, a double knot is added and sutures are applied on the conjunctiva. In the case of hypereffect, the knotted rib on the repositioned muscle is dissolved, and the single knot is moved to a length depending on the postoperative squint angle, the knotted knot is tied, the patient is asked to look towards the repositioned muscle, wherein the single unit moves to the sclera to the required length, then one additional and one double nodes are additionally applied. In case of insufficient effect after this manipulation, knot-rib is untied on recessed muscle, muscle is moved by two ends of thread closer to place of its initial attachment by length, depending on angle of residual strabismus, single unit is moved to sclera and knot is added, said actions are repeated until achieving the required result, wherein the knot-rib is transformed into a single knot, on which a double knot and seams are applied on the conjunctiva. In case of hypoeffect, knot-bow is unfolded, single unit is moved 2 mm above sclera, knot-knot is again fastened, patient is asked to look towards recessive muscle, wherein the unit moves to the sclera at the required length, the above actions are repeated until achieving the required result, wherein the knot-rib is transformed into a single knot, on which a double knot and seams are applied on the conjunctiva.

EFFECT: method improves accuracy of correction of repeatedly operated squint by means of action, including, and on opposite from the operated muscle for balance achievement, and also improves cosmetic effect due to elimination of effect of "pulling" of an eyeball into an orbit.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used to treat repeatedly operated strabismus with a hyper-effect using the method of adjustable sutures.

As you know, the main principle of the method of adjustable sutures is to ensure the safety of extraocular muscles using a temporary or sliding node. After the patient has recovered from anesthesia, the alignment of the eyes is checked and the length of the suture between the attachment point and the muscle is shortened or lengthened to fine tune the alignment. The advantage of this technique is to reduce the need for reoperation by clarifying alignment in the early postoperative period before the muscle is firmly attached to the sclera.

Historically, the first description of controlled strabismus suture surgery was presented by Bielschowsky in 1907 German scientific literature (Bielschowsky A. Die neueren Anschauun genuber Wesen und Behandlung des Schielens // Med Klin. - 1907, pp. 335-336). The first modern article on the Jampolsky method of adjustable sutures was published in 1975 (Jampolsky A. Am J Ophthalmol. Current techniques of adjustable strabismus surgery // Am J Ophthalmol. - 1979. - No. 88. - pp. 406-418). The author described a two-step approach, with a muscle attached to the eye using a butterfly node, and then after 4-24 hours with the adjustment of the sutures under local anesthesia and the transformation of the butterfly node into a permanent node (Jampolsky A. J AAPOS. - The Philip Knapp Lectureship [commentary] // J AAPOS. - 1998. - No. 2. - p. 131-132).

According to several authors, indications for strabismus surgery using adjustable sutures may include restrictive strabismus (Graves' disease, scleral filling or anesthetic myotoxicity), previous trauma or surgery, gliding, loss or impairment of muscle attachment, unfriendly deviation (Duen syndrome, Moebius syndrome , myasthenia gravis or paralytic strabismus), combined horizontal, vertical and torsion deviations, any long-term complication strabismus.

The closest analogue is the method of surgical treatment of repeatedly operated strabismus with a hyper-effect, which consists in the fact that after standard treatment of the surgical field, the conjunctiva is cut 1-5 mm from the limbus, opposite the muscle whose resection must be performed, then this muscle is extracted in a “blunt” way . On the sclera, in the place of future muscle attachment, at two points located 3-4 mm from each other, the thread with the needle 6-0 is sutured closer to the limb relative to the existing muscle attachment site, while the thread is carried out under the muscle without flashing it. Pull the thread, creating a duplicate of the muscle, after tensioning the muscle and creating a duplicate of the thread, tie the bow. After reposition, the muscles are sutured to the conjunctiva, at the end of the operation, subconjunctival

glucocorticoid preparation and antibiotic solution are administered, the day after surgery under local topical anesthesia the conjunctiva sutures are removed, the conjunctival surgical wound is opened and the suture is adjusted until the residual strabismus angle is completely eliminated, then the conjunctiva is re-sutured and the glucocorticoid drug is administered subconjunctively antibiotic. (RF patent for the invention No. 2598801).

The disadvantage of the closest analogue is that it is less physiological, due to folding the muscle in half, i.e. creating a duplicate of it, is also less dosed, since when creating a duplicate muscle in the postoperative period, an active inflammatory reaction and extensive formation of scar tissue are observed, which can significantly affect the length of the operated muscle and, as a result, in the late postoperative period, the result will be less stable. Another disadvantage of the closest analogue is that adjusting the duplicate of the oculomotor muscle the day after surgery is a very difficult manipulation, these actions with the correction of the effect on the day after surgery are not described.

The objective of the claimed invention is to develop a method of surgical treatment of repeatedly operated strabismus with a hyper-effect.

The technical result of the proposed method is to increase the accuracy of correction of repeatedly operated strabismus, including exposure to the opposite from the operated muscle to achieve balance, as well as improving the cosmetic effect due to the elimination of the effect of “pulling” the eyeball into orbit.

Between the totality of essential features and the achieved technical result, there is a causal relationship.

As you know, in an eye with previously operated strabismus, the anatomical balance of the muscles and their qualitative characteristics are violated, therefore, exposure to only one muscle can cause the eyeball to “drag” into orbit and entail asymmetry of the eye slits, which, in turn, will significantly reduce cosmetic and functional result from the operation. Isolation, including of the opposite intact muscle, helps to establish the desired balance between two opposite muscles.

The method is illustrated by the figure, which depicts the stitching stage. Position 1 denotes a muscle, 2 - the place of attachment of the muscle to the sclera, 3 - the first needle of the thread, 4 - the second needle of the thread, 5 - thread, 6 - conditional line dividing the muscle in half, which is a guide for the surgeon in determining the injection site of each of needle thread.

The method is as follows

The conjunctiva is cut 2 mm from the limbus, the tenon membrane and the conjunctiva are separated, the previously recessed muscle is isolated, taken on hooks, flashed with two needles 6-0 vikril so that each of the needles is sutured transversely half the portion of the muscle at its place

attachment, at a distance of 1-2 mm from it. A thorough hemostasis is performed. Next, the stitched muscle is cut off from the attachment site, and its reposition is performed by fixing the muscle stitched with two sutures to the sclera in the projection of the place of its anatomical attachment (that is, the place where the muscle was originally attached). In this case, the needles are carried out in the thickness of the sclera parallel to each other, after the needles are punctured, a single knot is knotted and then a bow knot to correct the position of the eyes the next day. On the second, opposite muscle, a recession of 2-4 mm is performed depending on the initial corrected strabismus angle using the bow-knot. A muscle is secreted, taken on hooks, stitched with a thread with two needles of 6-0 vikril y so that each of the needles is stitched longitudinally half the portion of the muscle at the point of attachment, at a distance of 1-2 mm from it. A thorough hemostasis is performed. Next, the stitched muscle is cut off from the attachment site, and its recession is performed by fixing the muscle stitched with two sutures to the sclera by 2-4 mm, depending on the initial corrected strabismus angle. In this case, the needles are carried out in the thickness of the sclera parallel to each other, after the needles are punctured, a single knot is knotted and then a bow knot to correct the position of the eyes the next day. Stitches are placed on the conjunctiva in the projection of both muscles, so that the bow-knot on each muscle is exposed.

The day after the operation, the strabismus angle is checked according to Hirschberg and the surgeon, based on the result, is guided by one of the following strategies:

In the case of the correct position of the eye, the nodes on both muscles are tied as follows: the bow-knot is transformed into a single knot and a double knot is added (three knots in total - two single and one double) and suture the conjunctiva.

In the case of a hyper-effect, the bow-knot on the reposed muscle is dissolved, and the single knot is moved to a length (about 2 mm), which depends on the angle of postoperative strabismus, the bow-knot is tied, the eye is fixed with tweezers. The patient is asked to look in the direction of the reposed muscle, as a result of which the muscle is tightened and shortened, while the single node moves to the sclera to the required length, thus, the weakened muscle is weakened. Next, they put one single and one double knot (only two single and one double knot) and suture the conjunctiva. In case of insufficient effect after this manipulation, it is possible to strengthen the opposite, recessed muscle. To do this, untie the bow-knot on the recessed muscle, for the two ends of the thread, by tension, move the muscle closer to the place of its initial attachment to a length depending on the angle of residual strabismus. The single node is moved to the sclera, the assistant intercepts the given node with tweezers, the surgeon adds a bow-knot, thus strengthening the recessed muscle. The above steps are repeated until the desired result is achieved.

With the correct position of the eye, the bow-knot is transformed into a single, on which an additional double knot is placed (three nodes in total - two single and one double) and sutures on the conjunctiva.

In the case of a hypoeffect, they act on a previously recessed muscle as follows. The bow-knot is dissolved, the single knot is moved 2 mm above the sclera, the bow-knot is again tied up for the possibility of subsequent additional adjustment of the eye position. The patient is asked to look towards the recessed muscle (the muscle that was affected), as a result of which the muscle is tightened and shortened, while the node moves to the sclera to the required length, thus strengthening the recessed muscle. The above steps are repeated until the desired result is achieved.

With the correct position of the eye, the bow-knot is transformed into a single, on which an additional double knot is placed (three nodes in total - two single and one double) and sutures on the conjunctiva. After tying all the catch, the needles are cut off.

According to the proposed method, OOO “Ophthalmological Center Konovalova" was performed 108 operations (108 eyes). In all cases, after treatment, strabismus was cured with the maximum cosmetic effect.

The invention is confirmed by the following examples.

Example 1. Patient P., 20 years old.

Diagnosis: convergent friendly alternating strabismus, mild hyperopia of the right eye. Objectively: eye movement in full, optical media are transparent, the fundus without foci of pathology. The objective angle of converging squint at the synoptophor is 20 degrees. Visual acuity of the right eye = 0.2 sphere + 2.0 = 0.4 does not correct (n / a). Visual acuity of the left eye = 0.8 n / a. The nature of vision is monocular, the leading eye is left. Fusion reserves are absent.

An operation was performed on the motor muscles of the eye (recession of the internal rectus muscle 4 mm and resection of the external rectus muscle 6 mm) according to the claimed method.

Visual acuity after surgery:

Right eye = 0.2 sphere + 2.0 n / a and left eye = 0.8 n / a.

Doubling is absent. The deviation angle is 0.

The day after the operation, in connection with the achievement of the desired cosmetic result, the bow-knot in the operating room is transformed into a single knot, then a double knot and stitches are placed on the conjunctiva.

After 1 month, a deviation angle of 0 degrees

Example 2

Patient K., 17 years old.

On admission: Complaints of divergent strabismus. 11 years ago she was operated on for a convergent strabismus in her left eye.

On examination:

Visual acuity of the left eye is 0.8 n / a.

Fields of view are the norm.

Intraocular pressure 15 mmHg

Examination revealed a divergent strabismus of 15 degrees in the study on synoptophore. The cornea is transparent. The fundus without pathology. The operation was performed on the left eye in accordance with the claimed method. The day after the operation, the presence of a hypereffect was revealed, for the correction of which weakened the reposed muscle and strengthen the recessed muscle in accordance with the claimed method. The desired cosmetic result is achieved. Visual acuity of the left eye of 0.8, n / a. When viewed, the optical media are transparent. The anterior chamber of the eye is of medium depth. The fundus without pathology. The deviation angle is 0 degrees.

After 1 month, a deviation angle of 0 degrees

Example 3

Patient M., 21 years old.

On admission: Complaints of divergent strabismus. 9 years ago she was operated on for a convergent squint in her right eye.

On examination:

Visual acuity of the right eye - 0.9 n / a

Intraocular pressure 18 mmHg

Examination revealed a divergent strabismus of 20 degrees in the study on synoptophore. The cornea is transparent. The fundus without pathology. An operation was performed on the right eye in accordance with the claimed method. The next day after the operation, the presence of a hypoeffect was revealed, for the correction of which reinforcement of the previously recessed muscle was performed. A cosmetic result is being achieved.

Visual acuity of the left eye of 0.9 n / a. When viewed, the optical media are transparent. The anterior chamber of the eye is of medium depth. The fundus without pathology. The deviation angle is 0 degrees.

After 1 month, the deviation angle is 0 degrees.

Claims (5)

A method of surgical treatment of repeatedly operated strabismus with a hyper-effect, including a conjunctiva incision 2-3 mm from the limbus in the projection of the operated oculomotor muscle, the application of a knot in the form of a bow to loosen or tighten the muscle, characterized in that the previously recessed muscle is isolated during the operation and stitched with a thread with two needles so that each of the needles is sutured transversely half the muscle at the site of its attachment, at a distance of 1-2 mm from it, thorough hemostasis is performed, then the stitched muscle is cut off from replication and perform its reposition by fixing the muscle stitched with two sutures to the sclera in the projection of the place of its anatomical attachment, while these same needles are carried out in the thickness of the sclera parallel to each other, after the needles are punctured, a single knot is tied and then a bow knot, on the other , muscle, perform a recession of 2-4 mm, suture the conjunctiva in the projection of both muscles so that the bow-knot on each muscle is exposed; the day after the operation, in the case of the correct position of the eye, the knot-bow is transformed into a single knot, a double knot is added and stitches are placed on the conjunctiva; in the case of a hyper-effect, the knot-bow on the reposed muscle is dissolved, and the single knot is moved to a length depending on the angle of postoperative strabismus, the knot-bow is tied, the patient is asked to look towards the reposed muscle, while the single knot moves to the sclera to the required length, then impose additionally one single and one double node, in case of insufficient effect after this manipulation, untie the bow-knot on the recessed muscle, move the muscle for two ends of the thread closer to the place of its initial attachment to a length depending on the angle of residual strabismus, move the single knot to the sclera and add the bow-knot, repeat the above steps until the desired result is achieved, the bow-knot is transformed into a single knot, on which a double knot and stitches are placed on the conjunctiva; in case of a hypoeffect, the bow knot is dissolved, the single knot is moved 2 mm above the sclera, the bow knot is again tied, the patient is asked to look towards the recessed muscle, while the knot moves to the sclera to the required length, the above steps are repeated until the desired result is achieved, when In this case, the bow-knot is transformed into a single knot, on which a double knot and seams are placed on the conjunctiva.

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