RU2789745C1 - Method for the treatment of horizontal jerky nystagmus associated with exotropia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. Horizontal jerky nystagmus associated with exotropia is treated. An access to the external and internal rectus muscles of the eye is formed, followed by a weakening of the action of the muscles of the horizontal action of both eyes of the patient on the side of the slow phase of nystagmus. At the same time, in order to weaken the external rectus muscle of the eye, assigned to the zone of relative rest, the muscle is sutured at the base, cut off from the sclera, displaced posteriorly by 8-9 mm from the anatomical site of attachment and sutured to the sclera. To strengthen the internal rectus muscle of the averted eye, the selected middle third of the muscle is stitched 8-9 mm from its anatomical site of attachment, the same needle is injected into the sclera directly in front of the muscle. The sutured muscle bundle is pulled up, forming a median duplication, and fixed with an interrupted suture to the sclera. And to weaken the internal rectus muscle of the eye, which is brought in the zone of relative rest, the muscle is sutured at the base, cut off from the sclera, displaced 4-5 mm posteriorly from the anatomical site of its attachment and sutured to the sclera.

EFFECT: method allows to reduce trauma and reduce the duration of surgical treatment.

1 cl, 2 ex, 4 tbl

Description

The invention relates to medicine, namely to ophthalmology, and can be used to treat horizontal jerky nystagmus associated with exotropia.

One of the complex disorders of the oculomotor system, leading to a pronounced decrease in the quality of vision and social adaptation of patients, is nystagmus. The frequency of this pathology, according to numerous studies, ranges from 0.24 to 1.8%.

The main types of nystagmus are pendular and jerky.

With jerky nystagmus, a zone of relative rest is formed in patients, which is located on the side of the slow phase. To move the gaze to the zone of relative rest, the patient makes a forced turn of the head in the direction of the fast phase of nystagmus, while the following development of secondary changes is possible in the oculomotor system: the volume of induction decreases towards the fast component of nystagmus, resulting in a weakening of convergence, secondary exotropia occurs.

Thus, the patient has two types of disorders of the oculomotor system: nystagmus and exotropia, for the treatment of each there is a separate surgical protocol.

The main goal of surgical treatment of nystagmus is to transfer the zone of relative rest to the first position of gaze, as a result, the frequency and amplitude of nystagmus decrease, and visual acuity increases. The goal of surgical treatment of exotropia is to achieve orthophoria in a straight line of sight and compensate for asthenopic complaints.

Some authors recommend monolateral surgery in case of combination of nystagmus and strabismus, which is illogical from the point of view of the etiopathogenetic mechanism.

Known methods for the treatment of horizontal nystagmus, which consists in moving the zone of relative rest in the primary position of the gaze.

For example, a method for the treatment of nystagmus is known, according to which a recession of the rectus muscles is performed by 5 mm on the side of the slow phase and resection of their ipsilateral antagonists by 5 mm (Kestenbaum A. A nystagmus operation. Acta XVII Concilium Ophthalmologicum // Int. J. Ophthalmol. 1954; 2:1071-1075). In addition, a method of treating Anderson's nystagmus is known (Anderson J. Causes and treatment of congenital eccentric nystagmus // Br. J. Ophthalmol, 1953; 37(5):267-281). Subsequently, the technique was combined into a method of surgical treatment of Kestenbaum-Anderson nystagmus (Sternberg-Raab A. Anderson-Kestenbaum operation for asymmetrical gaze nystagmus // British Journal of Ophthalmology. 1963; 47(6): 339-345. doi: 10.1136/bjo. 47.6.339) and consisted of a simultaneous recession of the rectus muscles, more than 5 mm on the side of the slow phase and resection of the rectus muscles on the side of the fast phase.

A known method of surgical treatment of nystagmus in combination with exotropia, which consists in bilateral recession of the external rectus muscles and bilateral tenotomy of the internal rectus muscles, followed by suturing to the original anatomical site of attachment. This method of treatment is based on a decrease in the activity of proprioreceptors present in the tendon portion of the extraocular muscles (Wang Z.L, et. al. Combining recessions (nystagmus and strabismus) with tenotomy improved visual function and decreased oscillopsia and diplopia in acquired downbeat nystagmus and in horizontal infantile nystagmus syndrome // J. AAPOS 2007; 11(2): 135-141 doi: 10.1016/j.jaapos.2006.10.012).

The above methods have a number of significant drawbacks, the main of which is high trauma, since surgical treatment is carried out on four oculomotor muscles, without taking into account the degree of head rotation and concomitant deviation of the eyeballs.

Closest to the claimed method - the prototype is a method of surgical treatment of nystagmus, including recession of the external rectus muscle and resection of the internal rectus muscle of the retracted eye, as well as recession of the internal rectus muscle and resection of the external rectus muscle of the adducted eye, consisting in the following. In the case of a forced turn of the head by 15-24° with right-sided nystagmus with a zone of relative rest to the left in the left eye, an incision is made in the conjunctiva and Tenon's capsule and access to the external rectus muscle is formed. The muscle is isolated, cleaned of associated tissues and sutured. The stitched muscle is cut off from the sclera. A new attachment site is determined 7 mm distal to the root, after which the muscle is sutured to the sclera with interrupted sutures in the new planned fixation site. The conjunctival flap is spread and sutured with 8-0 silk suture. Next, access to the internal rectus muscle of the left eye is formed. To do this, incisions are made in the conjunctiva and Tenon's membrane, the muscle is isolated and cleaned of associated tissues. After isolation, the muscle is sutured 6 mm from the root. The muscle is taken on a straight clamp and cut off from the sclera at the base. The sutured muscle is sutured to its original attachment site. The resected part of the muscle is cut off. The conjunctival access is sutured with 8-0 silk thread. In a similar way, recession of the internal rectus muscle of the right eye by 5 mm and resection of the external rectus muscle by 8 mm of the eye are performed (Parks M.M. Congenital Nystagmus Surgery // American Orthoptic Journal. 1973; 23(1): 35-39. doi: 10.1080 /0065955X.1973.11982319).

The known method leads to a weakening of the muscles of horizontal action on the side of the slow phase and strengthening of the muscles on the side of the fast phase of nystagmus, while the zone of relative rest moves to the direct position of the gaze and conditions are created to compensate for the forced turn of the head and to increase visual acuity.

However, the known method does not allow to take into account the accompanying deviation of any direction. In addition, the intersection of the ciliary arteries of all four muscles of the horizontal action can lead not only to ischemia of the anterior segment of the eye, but also to intraoperative bleeding, which will lead to manifestations of a more pronounced adhesive process and, as a result, a decrease in the effectiveness of surgical treatment. The risk of perforation of the sclera during muscle suturing cannot be excluded.

The objective of the invention is to eliminate the forced turn of the head by moving the zone of relative rest of nystagmus to the direct position of gaze and to reduce exotropia with a decrease in trauma with a decrease in the duration of surgical treatment.

EFFECT: reduced trauma and reduced duration of surgical treatment.

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

After anesthesia and preparation of the surgical field, an eyelid retractor is applied to the eye, which is retracted in the zone of relative rest.

To provide access to the external rectus muscle, radial incisions of the conjunctiva and Tenon's membrane 9-10 mm long are performed, followed by a paralimbal incision between them. The muscle is then hooked and isolated. At the base, the muscle is stitched with Vicryl 6:0 and cut off from the sclera. Next, the muscle is displaced posteriorly by 8-9 mm from the anatomical site of attachment and sutured to the sclera. The surgical wound is sutured with 8-0 Virginia silk.

In the projection of the internal rectus muscle of the eye, which is retracted in the zone of relative rest, to provide access to the internal rectus muscle, radial incisions of the conjunctiva and Tenon's membrane 7-10 mm long are performed, followed by a limbal incision between them. The muscle is then hooked and isolated. The middle third of the muscle is grasped with tweezers 8-9 mm from its attachment site and stitched with Vicryl 6-0. With the same needle, an injection is made into the sclera directly in front of the muscle, the stitched muscle bundle is pulled up, forming a fold (median duplication), and fixed with an interrupted suture. The surgical wound is sutured with 8-0 Virginia silk.

An eyelid retractor is applied to the eye, which is brought into the zone of relative rest. To provide access to the internal rectus muscle, radial incisions of the conjunctiva and Tenon's membrane 7-9 mm long are performed, followed by a paralimbal incision between them. The muscle is then hooked and isolated. At the base, the muscle is stitched with Vicryl 6-0 and cut off from the sclera. Next, the muscle is displaced posteriorly by 4-5 mm from the anatomical site of attachment and sutured to the sclera. The surgical wound is sutured with 8-0 Virginia silk.

The indication for the application of the proposed method of treatment is the forced position of the head with horizontal jerky nystagmus in combination with exotropia. The method makes it possible to reduce the amplitude and frequency of horizontal jerky nystagmus in the direct position of gaze under orthophoric/orthotropic conditions.

The defining differences of the proposed method, compared with the prototype, are:

- one augmentation operation is performed on the internal rectus muscle of the averted eye, without concomitant strengthening of the external rectus muscle of the adducted eye, which allows compensating for divergent strabismus, providing orthophoria and maintaining convergence in the conditions of existing exotropia;

- weaken the internal rectus muscle on the eye, which is adducted in the zone of relative rest, by no more than 5 mm, which avoids the pronounced manifestation of anisoconvergence and anisoaccommodation;

- they form a median duplication (instead of resection) on the internal rectus muscle of the averted eye, which reduces the risk of scleral perforation, ischemia of the anterior segment of the eyeball, reduces the risk of intraoperative bleeding, the degree of adhesions, and reduces the duration of surgical treatment.

The positive effect of the operation is achieved due to induced biomechanical changes that are created by weakening the action of chronically contracted muscles on the side of the slow phase and strengthening the action of the weak medial rectus muscle of the averted eye:

- weakening of the direct contralateral synergists on the side of the slow phase allows you to move the zone of relative rest from the lateral direction to the primary gaze position;

- strengthening the action of the direct medial muscle of the averted eye allows to improve the ductus of the eyeball, thereby compensating for exotropia.

A search through sources of scientific, technical and patent information did not reveal a method identical to the claimed one, and therefore, 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 execution of the method.

Example 1

Patient A., aged 15, was admitted to the clinic with a diagnosis of horizontal medium-sweeping jerky right-sided nystagmus in both eyes. Exotropia. Moderate amblyopia in both eyes.

On examination: visual acuity in the direct position of the gaze - the right eye 0.2, the left eye - 0.25. Visual acuity in the zone of relative rest to the left - right eye 0.35, left - 0.35. The zone of relative rest to the left is 10°.

The refraction of both eyes is emmetropic.

The amplitude of nystagmus in the direct position of the gaze is 10-12 °, when the gaze is shifted to the right - 15 °, to the left - inconstantly up to 2-5 °. There is a pronounced forced position of the head to the right. The anterior segment of the eyes, optical media and fundus without pathological features.

The magnitude of the angle of strabismus:

The patient complained of a decrease in visual acuity when looking straight, when looking to the right, visual acuity decreases more pronounced. To improve visual acuity, the patient turns her head to the right and directs her gaze to the left. When you try to fix your gaze on an object, there is a deviation of the left eye to the temple.

The patient was operated on both eyes by the claimed method.

After anesthesia and preparation of the surgical field, an eyelid retractor was placed on the left eye.

Left eye. Access was made to the external rectus muscle of the left eye, for which radial incisions were made in the conjunctiva and Tenon's membrane 9 mm long, followed by a paralimbal incision between them. The muscle was hooked and isolated. At the base, the muscle was stitched with Vicryl 6-0, cut off from the sclera and displaced posteriorly by 8 mm from the anatomical site of attachment, and sutured to the sclera. The surgical wound was closed with 8-0 Virginia silk. In the projection of the internal rectus muscle of the left eye, radial incisions of the conjunctiva and Tenon's membrane 9 mm long were performed, followed by a limbal incision between them. The muscle was hooked and isolated. The middle third of the muscle was captured with tweezers 8 mm from its anatomical site of attachment and sutured with 6-0 Vicryl. The same needle was injected into the sclera directly in front of the muscle, the stitched muscle bundle was pulled up, forming a fold, and the latter was fixed with an interrupted suture. The surgical wound was closed with 8-0 Virginia silk. 0.3 ml of 1% dexamethasone solution and 0.2 ml of gentamicin were injected under the conjunctiva. The speculum was removed.

Right eye. Next, an eyelid dilator was applied to the right eye, access to the internal rectus muscle was formed, for which radial incisions of the conjunctiva and Tenon's membrane 7 mm long were performed, followed by a paralimbal incision between them. The muscle was then hooked and isolated. At the base, the muscle was stitched with Vicryl 6-0 and cut off from the sclera. Next, the muscle was displaced posteriorly by 4 mm from the anatomical site of attachment and sutured to the sclera. The surgical wound was closed with 8-0 Virginia silk. 0.2 ml of 1% dexamethasone solution and 0.2 ml of gentamicin were injected under the conjunctiva. The speculum was removed.

At the control examination after 1 month, an objective examination revealed: visual acuity in the direct position of the gaze - the right eye 0.3, the left eye - 0.35. Visual acuity in the zone of relative rest to the left - the right eye - 0.35, the left - 0.4. Zone of relative rest to the left up to 3°.

The amplitude of nystagmus in the direct position of the gaze is up to 3-5 °, when the gaze is shifted to the right - 10-15 °, to the left - is absent. There is a delicate forced position of the head to the right.

Deviation value:

The patient noted an increase in visual acuity in the primary gaze position in the straight position of the head and the absence of deviation of the left eyeball to the temple.

Example 2

Patient I., 46 years old, was admitted to the clinic with a diagnosis of horizontal large-scale jerky left-sided nystagmus in both eyes. Exotropia. Moderate amblyopia in both eyes. Mild hypermetropia in both eyes.

During the examination: visual acuity in the direct position of the gaze - the right eye - 0.1, the left - 0.15. Visual acuity in the zone of relative rest to the right - the right eye - 0.25, the left - 0.3. The zone of relative rest to the right is 15°.

The amplitude of nystagmus in the straight position of the gaze is 10-12°, when the gaze is shifted to the right - 5-7°, to the left - up to 20°. There is a pronounced forced position of the head to the left. The anterior segment of the eyes, optical media and fundus without pathological features.

The magnitude of the angle of strabismus:

The patient complained of a decrease in visual acuity when looking straight, when looking to the left, visual acuity decreases more pronounced. To improve visual acuity, the patient is forced to turn his head to the left to exercise right-sided gaze. When trying to examine the object, the right eye deviates to the temple.

The patient underwent surgery on both eyes by the claimed method.

Right eye. After anesthesia and preparation of the surgical field, an eyelid retractor was placed on the right eye.

Access was made to the external rectus muscle of the right eye: radial incisions of the conjunctiva and Tenon's membrane 10 mm long were made, followed by a paralimbal incision between them. The muscle was then hooked and isolated. At the base, the muscle was stitched with Vicryl 6-0, cut off from the sclera and displaced posteriorly by 9 mm from the anatomical site of attachment, and sutured to the sclera. The surgical wound was closed with 8-0 Virginia silk.

In the projection of the internal rectus muscle of the right eye, radial incisions of the conjunctiva and Tenon's membrane 10 mm long were performed, followed by a limbal incision between them. The muscle was then hooked and isolated. Next, the middle third of the muscle was captured with 9 mm forceps. from her attachment point and flashed with Vicryl 6-0. The same needle was injected into the sclera directly in front of the muscle, the stitched muscle bundle was pulled up, forming a fold, and fixed with an interrupted suture. The surgical wound was closed with 8-0 Virginia silk. 0.3 ml of 1% dexamethasone solution and 0.2 ml of gentamicin were injected under the conjunctiva. The speculum was removed.

An eyelid speculum was applied to the left eye. An access to the internal rectus muscle of the left eye was formed: radial incisions of the conjunctiva and Tenon's membrane 9 mm long were made, followed by a paralimbal incision between them. The muscle was hooked and isolated. At the base, the muscle was stitched with Vicryl 6-0 and cut off from the sclera. The muscle was displaced posteriorly by 5 mm from the anatomic site of attachment and sutured to the sclera. The surgical wound was closed with 8-0 Virginia silk. 0.2 ml of 1% dexamethasone solution and 0.2 ml of gentamicin were injected under the conjunctiva. The speculum was removed.

At the control examination after 1 month. An objective examination revealed:

Visual acuity in the direct position of the gaze - the right eye 0.2, the left eye - 0.25. Visual acuity in the zone of relative rest to the right - right eye 0.25, left eye - 0.3. Zone of relative rest to the right up to 3°.

The amplitude of nystagmus in the direct position of the gaze is up to 3-5 °, when the gaze is shifted to the right - absent, to the left - 10-15 °. There is a delicate forced position of the head to the left.

Deviation value:

The patient noted an increase in visual acuity in the primary gaze position in the straight position of the head and the absence of deviation of the left eyeball to the temple.

The proposed method allows to reduce the invasiveness and duration of the operation, while ensuring a decrease in the amplitude and frequency of nystagmus in the direct position of the gaze, which eliminates the need for compensatory head rotation to improve visual acuity. As a result, more favorable conditions are created for the formation or restoration of binocular vision and improving the quality of life.

Claims (1)

A method for the treatment of horizontal jerky nystagmus associated with exotropia, including the formation of access to the external and internal rectus muscles of the eye, followed by weakening the action of the muscles of the horizontal action of both eyes of the patient on the side of the slow phase of nystagmus, characterized in that to weaken the external rectus muscle of the eye assigned to the zone relative rest, the muscle is sutured at the base, cut off from the sclera, displaced posteriorly by 8-9 mm from the anatomical site of attachment and sutured to the sclera, to strengthen the internal rectus muscle of the averted eye, the selected middle third of the muscle is sutured 8-9 mm from its anatomical site of attachment , the same needle is injected into the sclera directly in front of the muscle, the stitched muscle bundle is pulled up, forming a median duplication, and fixed with an interrupted suture to the sclera, and to weaken the internal rectus muscle of the eye, which is brought into the zone of relative rest, the muscle is stitched at the base, cut off from the sclera, displace t posteriorly 4-5 mm from the anatomical site of its attachment and sutured to the sclera.