RU2749407C1 - Method for myoplasty of rigid extraocular muscle - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to ophthalmic surgery. For myoplasty of the extraocular muscle, the extraocular muscle is isolated, longitudinally divided into three parts, two parts are cut from the sclera, the third part is intersected and the parts are sutured edge-to-edge. After the extraocular muscle is isolated, two blanket sutures are applied thereto from the lateral sides, two lateral ¼ parts of the muscle are cut at 4 to 10 mm from the attachment point. A stump of the middle part of the muscle of 4 to 10 mm in size is formed. The cut lateral parts are sutured with the distal edge of the stump with an edge-to-edge blanket suture. Two twisted sutures are applied at the point of attachment of the muscle. The tendon is cut from the attachment point and sutured to the sclera at 4 to 7 mm more distal.EFFECT: method increases efficiency of reducing the angle of strabismus with muscle rigidity by additionally weakening the extraocular muscle.1 cl, 3 ex

Description

The proposed invention relates to the field of medicine, namely to ophthalmic surgery, and can be used for the surgical treatment of restrictive strabismus associated with endocrine ophthalmopathy.

Muscle rigidity is a steady increase in muscle tone, uniform muscle resistance in all phases of passive movement, lack of response to stimuli or resistance to them, for example, due to a sharp increase in the tone of anatomical structures.

Extraocular muscle stiffness manifests as restrictive strabismus.

Restrictive strabismus is a condition of the oculomotor system in which one or several extraocular muscles irreversibly completely or partially lost their function due to their hypertrophy and (or) partial degeneration of muscle tissue into connective tissue. Symptoms of restrictive strabismus are: the absence of some voluntary movements of the affected eye towards the counter-action of the affected muscle, asymmetric position of the eyes, double vision, which occurs or increases when looking towards the counter-action of the affected muscle and when trying to fix the object binocularly. In the vast majority of cases, the lower rectus muscle is involved in the pathological process, the lesion is unilateral or asymmetric (Sharma P., Reinecke R.D. Single-stage adjustable strabismus surgery for restrictive strabismus. J AAPOS, 2003, 7 (5): 358-62).

Muscle stiffness can occur, in particular, against the background of endocrine ophthalmopathy in patients with dysfunction of the thyroid gland, such cases of strabismus are one of the most severe types, both in terms of symptoms and the complexity of surgical correction.

Treatment of atypical forms of strabismus (which includes, in particular, strabismus that has arisen against the background of endocrine ophthalmopathy) is carried out by a surgical method. By changing muscle balance, i.e. relative force of tension of the eye muscles, it is possible to achieve a symmetrical or close to it position of the eyes, improve their mobility, eliminate diplopia, restore binocular vision.

With muscle rigidity, operations are performed aimed at weakening it: tenotomy, recession, prolongation, fadeno operation. In cases where the weakening is not enough, the second stage is an operation aimed at strengthening the counter-acting muscle.

There is a known method of plastic extraocular muscle, including lengthening the rigid lower rectus muscle by cutting the sclera with a width equal to the width of the tendon part of the muscle, parallel and proximal to the line of its attachment to the sclera, stratification of the sclera in the distal direction, cutting out a trapezoidal scleral flap 2-8 mm long, which becomes continuation of the tendon part of the muscle.

At the second stage, which is carried out if the patient is not satisfied with the achievement of the orthoposition of the eyes in the straight gaze position and when double vision occurs when looking upward, the superior rectus muscle, which is a contralateral antagonist in the healthy eye, is fixed to the sclera with two overhead sutures, retreating 12 -16 mm from the physiological place of its attachment in the zone lying behind the equator of the eyeball. (Plisov I.L. Method for the treatment of restrictive strabismus associated with endocrine ophthalmopathy. RF Patent 2313319, 2007, bull. No. 36)

The method described above for the surgical treatment of strabismus with muscle rigidity has a number of disadvantages:

1. The method involves thinning of the sclera, which means the risk of staphyloma, sclera, as well as its ruptures;

2. The muscle fiber does not lengthen, the rigidity remains.

Closest to the claimed, is the method of median myoplasty of the extraocular muscle. (Patent 2508082. 2014. Bul. No. 6), including the allocation of extraocular muscle, longitudinal division of the muscle into 3 parts, cutting off two parts from the sclera, crossing the third part, stitching edge-to-edge parts

This method is as follows.

The extraocular muscle is isolated. Divide it longitudinally into three equal parts. The lower 1/3 is excised by 5-6 mm, the upper 1/3 is cut off from the sclera, the middle 1/3 is cut. Sew the upper and middle parts of the muscle edge-to-edge with one thread with one needle by applying one continuous "X" -shaped suture and tying one submerged knot.

The disadvantages of this method are:

1. Poor surgical efficiency as an independent operation;

2. Uneven thinning of the muscle and, as a consequence, the displacement of the vector of the direction of the muscle downward, displacement of the plane of the muscle and a change in the movement of the eye along the vertical.

The objective of the proposed method of myoplasty of the extraocular muscle is to increase the efficiency of reducing the angle of strabismus with muscle rigidity.

The problem is solved by the fact that in the known method of the median myoplasty of the extraocular muscle, including the isolation of the extraocular muscle, longitudinal division of the muscle into 3 parts, cutting off two parts from the sclera, crossing the third part, stitching the edge-to-edge parts,

части мышцы на 4-10 мм от места прикрепления, сшивают эти части обвивным швом край-в-край с дистальным краем третьей части, накладывают два обвивных шва у места прикрепления мышцы, отсекают сухожилие от места прикрепления и подшивают его к склере дистальнее на 4-7 мм.after the extraction of the extraocular muscle, two twisted sutures are placed on it from the lateral sides, two lateral

parts of the muscle 4-10 mm from the attachment point, these parts are sewn with an edge-to-edge winding suture with the distal edge of the third part, two winding sutures are applied at the muscle attachment point, the tendon is cut off from the attachment point and sutured to the sclera 4- 7 mm.

The technical result of the invention is to increase the effectiveness of reducing the angle of strabismus with muscle rigidity.

The technical result is achieved due to additional weakening of the extraocular muscle.

The scientific and technical level of the invention is due to new scientific information obtained as a result of studies carried out related to the study of the mechanisms of strabismus development as a result of increased rigidity of the extraocular muscle.

The novelty of the method is due to the fact that, according to the available scientific and practical information, the proposed technical solution was not used in ophthalmic surgery to solve the problem.

The efficiency of the proposed method is confirmed by clinical trials carried out on the basis of the Federal State Autonomous Institution "NMITs" MNTK "Eye Microsurgery" them. acad. S.N. Fedorov ”of the Ministry of Health of Russia with good short-term and long-term results.

The method is carried out as follows

часть волокон с латеральных сторон и отсекают латеральные

части мышцы от места прикрепления на 4-10 мм в зависимости от анатомических особенностей (в частности, степени ригидности мышцы). Проводят гемостаз. Формируют культю средней части мышцы по необходимым размерам (4-10 мм), с дистальной частью культи сшивают отсеченные латеральные части мышцы. У места прикрепления на сухожилие мышцы накладывают 2 обвивных шва 7-00 викрил, сухожилие отсекают от места прикрепления и подшивают к склере дистальнее места прикрепления на 4-7 мм в зависимости от анатомических особенностей (переднезаднего размера глаза). На конъюнктиву накладывают узловые швы 8-00 викрил. Под конъюнктиву вводят раствор Дексона и Гентамицина 0,3.After treatment of the operating field with Betadine solution, local infiltration anesthesia is performed with articaine 4.0 solution. An incision of the conjunctiva is made in the projection of the extraocular muscle, the muscle is isolated. Apply 2 twisted seams 7-00 vicryl on

part of the fibers from the lateral sides and cut off the lateral

parts of the muscle from the site of attachment by 4-10 mm, depending on the anatomical features (in particular, the degree of muscle rigidity). Hemostasis is performed. A stump of the middle part of the muscle is formed according to the required dimensions (4-10 mm), the cut off lateral parts of the muscle are sutured to the distal part of the stump. At the site of attachment, 2 twisting sutures 7-00 vicryl are applied to the muscle tendon, the tendon is cut off from the attachment site and sutured to the sclera distal to the attachment site by 4-7 mm, depending on anatomical features (anteroposterior eye size). Interrupted sutures are applied to the conjunctiva at 8-00 vicryl. A solution of Dexon and Gentamicin 0.3 is injected under the conjunctiva.

The advantage of this method is additional weakening of the rigid extraocular muscle, which increases the efficiency of eliminating the angle of restrictive strabismus.

If necessary, the second stage is the strengthening of the external muscle with the transposition of the vertical muscles to it.

The proposed method is illustrated by examples:

Example # 1

Patient L., 37 years old, was admitted to the Orenburg branch of the FSAU NMITs IRTC "Eye Microsurgery" named after acad. S.N. Fedorov with a diagnosis of convergent paralytic strabismus, ophthalmoplegia, restrictive monolateral entropy of the right eye. Corneal dystrophy. Lower eyelid volvulus. Paralytic lagophthalmos. Partial atrophy of the optic nerve of the right eye.

From the anamnesis 5 years ago, after the removal of a benign neoplasm of the auditory nerve on the right, there was a limitation of the mobility of the right eye outward, which was accompanied by the appearance of double vision of objects horizontally and vertically when looking at them in front of you.

An objective examination of the oculomotor system revealed the following:

Vis OD = 0.02 n.k. Deviation angle +60, with full ophthalmoplegia.

часть волокон с латеральных сторон и отсекли латеральные

части мышцы от места прикрепления на 4 мм. Провели гемостаз. Сформировали культю средней части мышцы по необходимым размерам (4 мм), с дистальной частью культи сшили отсеченные латеральные части мышцы. У места прикрепления на сухожилие мышцы наложили 2 обвивных шва 7-00 викрил, сухожилие отсекли от места прикрепления и подшили к склере дистальнее места прикрепления на 4 мм. На конъюнктиву наложили узловые швы 8-00 викрил. Под конъюнктиву ввели раствор Дексона и Гентамицина 0,3.The patient underwent the operation according to the claimed method: after treatment of the operating field with Betadine solution, local infiltration anesthesia was performed with a solution of articaine 4.0. An incision was made in the conjunctiva in the projection of the extraocular muscle, and the muscle was isolated. We applied 2 twisting stitches 7-00 vicryl on

part of the fibers from the lateral sides and cut off the lateral

parts of the muscle from the attachment site by 4 mm. Hemostasis was performed. A stump of the middle part of the muscle was formed according to the required dimensions (4 mm), the cut off lateral parts of the muscle were sutured to the distal part of the stump. At the place of attachment, 2 twisting sutures 7-00 vicryl were placed on the muscle tendon, the tendon was cut off from the place of attachment and sutured to the sclera distal to the place of attachment by 4 mm. Interrupted sutures were placed on the conjunctiva at 8-00 vicryl. A solution of Dexon and Gentamicin 0.3 was introduced under the conjunctiva.

At the follow-up examination 10 days later, the patient noted the absence of double vision in the straight position of the head and the expansion of the monovision zone. An objective examination revealed:

The angle of DEVIATION +40, the movement of the eyeball to the outside began to be determined.

The patient underwent the II stage of the operation on transposition to the external rectus muscle, after which orthophoria was reached, with movement to the outside up to -10. Vis OD = 0.5 n.s.

Protocol of the II stage of the operation (strengthening of the external muscle with transposition of vertical muscles on it):

часть волокон с латеральных сторон на верхней и нижней прямых мышцах и отсекли от места прикрепления. Провели гемостаз. Отступя 8 мм от места прикрепления наружной прямой мышцы наложили 2 обвивных шва 7-00 викрил, которые подшили к склере в месте прикрепления мышцы. Латеральные пучки верхней и нижней прямых мышц подшили к месту прикрепления сухожилия наружной прямой мышцы. На конъюнктиву наложили узловые швы 8-00 викрил. Под конъюнктиву ввели раствор Дексона и Гентамицина 0,3.After treatment of the operating field with Betadine solution, local infiltration anesthesia was performed with articaine 4.0 solution. An incision of the conjunctiva was performed in the projection of the superior, external and inferior rectus extraocular muscles, which were isolated. We applied 2 twisting stitches 6-00 vicryl on

part of the fibers from the lateral sides on the upper and lower rectus muscles and cut off from the attachment site. Hemostasis was performed. At a distance of 8 mm from the site of attachment of the external rectus muscle, 2 twisting sutures 7-00 vicryl were applied, which were sutured to the sclera at the site of muscle attachment. The lateral bundles of the superior and inferior rectus muscles were sutured to the insertion site of the tendon of the external rectus muscle. Interrupted sutures were placed on the conjunctiva at 8-00 vicryl. A solution of Dexon and Gentamicin 0.3 was introduced under the conjunctiva.

At the follow-up examination after 3 months, the patient noted the absence of double vision in the upright position of the head and the expansion of the monovision zone when looking upward. An objective examination revealed the following: Orthophoria persisted, movement to the outside -10. Vis OD = 0.5 n.s.

Example No. 2

Patient M., 49 years old, was admitted in 2018 to the PF FSAU NMITs IRTC "Eye Microsurgery" named after V.I. acad. S.N. Fedorov with a diagnosis of secondary vertical restrictive strabismus of the left eye. Partial ophthalmoplegia. From the anamnesis - the main disease is endocrine ophthalmopathy for 4 years, periodically takes pulse therapy (metipred), according to MRI - thickening of the lower and lateral muscles 2 times compared with the norm (up to 9 mm). Vis OS = 0.2 with correction 0.3-0.4., Angle of deviation - hypotropia 25 degrees, upward movement is sharply limited. Movements up to 15 degrees.

часть волокон с латеральных сторон и отсекли латеральные

части мышцы от места прикрепления на 7 мм. Провели гемостаз. Сформировали культю средней части мышцы по необходимым размерам (7 мм), с дистальной частью культи сшили отсеченные латеральные части мышцы. У места прикрепления на сухожилие мышцы наложили 2 обвивных шва 7-00 викрил, сухожилие отсекли от места прикрепления и подшили к склере дистальнее места прикрепления на 5 мм. На конъюнктиву наложили узловые швы 8-00 викрил. Под конъюнктиву ввели раствор Дексона и Гентамицина 0,3. После операции - ортофория. VisOS=0.6-0,7 н.к. Двоение отсутствовало.The patient underwent the operation according to the claimed method: after treatment of the operating field with Betadine solution, local infiltration anesthesia was performed with a solution of articaine 4.0. An incision was made in the conjunctiva in the projection of the extraocular muscle, and the muscle was isolated. We applied 2 twisting stitches 7-00 vicryl on

part of the fibers from the lateral sides and cut off the lateral

parts of the muscle from the attachment point by 7 mm. Hemostasis was performed. A stump of the middle part of the muscle was formed according to the required dimensions (7 mm), the cut off lateral parts of the muscle were sutured to the distal part of the stump. At the place of attachment, 2 twisting sutures 7-00 vicryl were placed on the muscle tendon, the tendon was cut off from the place of attachment and sutured to the sclera distal to the place of attachment by 5 mm. Interrupted sutures were placed on the conjunctiva at 8-00 vicryl. A solution of Dexon and Gentamicin 0.3 was introduced under the conjunctiva. After surgery - orthophoria. VisOS = 0.6-0.7 n.s. There was no doubling.

During control examinations within 12 months. orthophoria persisted. VisOS = 0.6-0.7 n.s. The patient noted the absence of double vision in the straight position of the head. However, vertical double vision occurred when looking up.

After 1 year, an upward retraction of the right eye appeared. On MRI, the superior rectus muscle was also thickened and rigid. The operation was performed using the claimed method on the superior rectus muscle of the right eye. In the postoperative period, double vision did not bother, the position of the eye was orthophoric.

At follow-up examination after 1 month, the patient noted the absence of double vision in the straight position of the head. The orthophoric position was maintained in both eyes.

Example No. 3

The patient is 68 years old. entered the PF FSAU NMITs MNTK "Eye Microsurgery" them. acad. S.N. Fedorov with a diagnosis of secondary convergent strabismus, partial ophthalmoplegia of the left eye. From the anamnesis - operated convergent strabismus in his youth.

During examination, the deviation angle is +30 degrees, movements to the outside are preserved, but not in full. Diplopia when looking straight ahead. VIS OS - 0.6.

часть волокон с латеральных сторон и отсекли латеральные

части мышцы от места прикрепления на 10 мм. Провели гемостаз. Сформировали культю средней части мышцы по необходимым размерам (10 мм), с дистальной частью культи сшили отсеченные латеральные части мышцы. У места прикрепления на сухожилие мышцы наложили 2 обвивных шва 7-00 викрил, сухожилие отсекли от места прикрепления и подшили к склере дистальнее места прикрепления на 7 мм. На конъюнктиву наложили узловые швы 8-00 викрил. Под конъюнктиву ввели раствор Дексона и Гентамицина 0,3. В после операционном периоде ортофория, явления диплопии купировались, острота зрения не изменилась.The operation was performed according to the claimed method: after treatment of the operating field with Betadine solution, local infiltration anesthesia was performed with a solution of articaine 4.0. An incision was made in the conjunctiva in the projection of the extraocular muscle, and the muscle was isolated. We applied 2 twisting stitches 7-00 vicryl on

part of the fibers from the lateral sides and cut off the lateral

parts of the muscle from the attachment point by 10 mm. Hemostasis was performed. A stump of the middle part of the muscle was formed according to the required dimensions (10 mm), the cut off lateral parts of the muscle were sutured to the distal part of the stump. At the place of attachment, 2 twisting sutures 7-00 vicryl were placed on the muscle tendon, the tendon was cut off from the place of attachment and sutured to the sclera distal to the place of attachment by 7 mm. Interrupted sutures were placed on the conjunctiva at 8-00 vicryl. A solution of Dexon and Gentamicin 0.3 was introduced under the conjunctiva. In the postoperative period, orthophoria, diplopia phenomena were stopped, visual acuity did not change.

On repeated examination after 3 months, orthophoria was preserved, movements were in full volume, visual acuity did not change.

Thus, the results of the practical application of the proposed method indicate the achievement of the effect of orthophoria in most cases, and an effective decrease in the angle of strabismus in all cases after surgical treatment of strabismus with muscle rigidity.

Claims (1)

The method of myoplasty of the extraocular muscle, including the isolation of the extraocular muscle, the longitudinal division of the muscle into three parts, the cutting of two parts from the sclera, the intersection of the third part, the stitching of the edge-to-edge parts, characterized in that after the extraocular muscle is isolated, two twisted sutures are applied to it with lateral sides, cut off two lateral ¼ parts of the muscle 4-10 mm from the attachment point, form a stump of the middle part of the muscle 4-10 mm in size, sew the cut off lateral parts with an edge-to-edge twisting suture with the distal edge of the stump, impose two twisting sutures at muscle attachment site, cut off the tendon from the attachment site and suture it to the sclera 4-7 mm distal.