RU2793259C1 - Method for surgical treatment of paralytic strabismus associated with abducens nerve paresis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. The access to the medial and lateral rectus muscles is formed, the medial rectus muscle is recessed, the lateral rectus muscle is isolated and stratified into 2 longitudinal bundles, while the upper bundle is 2/3 of the muscle width, and the lower one is 1/3 of the muscle width. Next, the upper bundle of the lateral rectus muscle is captured at 7-10 mm from its anatomical site of attachment, displaced towards its anatomical site of attachment, a muscle fold is formed and sewn to the sclera in front of the muscle root. Then the lower bundle of the lateral rectus muscle is captured at 6-8 mm from its anatomical site of attachment, displaced towards its anatomical site of attachment, a muscle fold is formed and sewn to the sclera behind the muscle root.

EFFECT: method allows to increase the efficiency of the surgery, reduce the risk of complications.

1 cl, 1 dwg, 8 tbl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of paretic strabismus.

Compartmental (separate) innervation and selective function have long been known in skeletal muscles. But only recently has this concept been applied to extraocular muscles. It is assumed that individual extraocular muscles (EOM) can perform many functions using specialized groups of nerve fibers. A necessary condition for such functional diversity is the anatomical feature of innervation. Thus, individual regions of the EOM can be differently innervated to exhibit independent oculo-rotational actions, expanding the oculomotor range and potentially explaining the diverse pathophysiology of strabismus. In this case, the lateral rectus muscle is no exception. Partial abducens nerve palsy usually involves the superior lateral rectus muscle more than the inferior, causing vertical strabismus, which may be misdiagnosed as cyclovertical pathology of the extraocular muscles. It is the understanding of the functional anatomy of the EOM that is necessary in the diagnosis and treatment of paralytic strabismus. Therefore, compartmentalization of the extraocular muscles is a new innovative idea that may open new surgical possibilities in the treatment of paralytic strabismus.

Various methods of surgical treatment of paralytic strabismus are known, the essence of most of which is to perform resection of the paralyzed muscle, recession of its ipsilateral antagonist and (or) transposition of intact vertical muscles (or parts thereof) to the anatomical site of attachment of the paralyzed extraocular muscle.

For example, there is a known method for the treatment of paralytic strabismus by ultrasound therapy followed by electrical stimulation of the affected oculomotor muscles (SU1738277, publ. 06/07/1992).

The disadvantages of the known method are its low efficiency and the need to use complex expensive equipment.

A known method for the treatment of paralytic strabismus, including the introduction of the drug Dysport at a dose of 10-20 Units into the extraocular ipsilateral muscle-antagonist of the paralyzed extraocular muscle, while additionally, depending on the type of paralysis, the drug is injected into one or more muscles that are contralateral synergists of the paralyzed muscles (patent RU 2257914 C1, published on August 10, 2005).

The disadvantages of the known method are: the technical complexity of the injection in case of contracture of the target muscle, as a result, the risk of needle perforation of the sclera increases.

A known method for the treatment of paralytic strabismus, which consists in the following: determine the magnitude of the deviation of the visual axis of the eye according to Hirshberg using prisms and synoptophore, measure the anterior-posterior axis of the eye. Clinical assessment of the strength of the muscles, assessment of the degree of hypo- and hyperfunction is carried out on the basis of a study of the amplitude of the mobility of the eyeball. The assessment of the degree of functional activity of hyperfunctional muscles is carried out using a superposition electromagnetic scanner - "SPEMS-2 Obninsk". After determining the angle of deviation, the size of the eyeball and the strength of the action of hyper- or hypofunction of the oculomotor muscles, taking into account these factors, recession of the internal rectus muscle of the eye is performed, displacing and sewing from the place of attachment posterior to the limbus by 3-7 mm, and when performing resection the external rectus muscle of the eyeball is cut off and shortened to a distance of 4-6 mm and sewn to its primary site of attachment (patent RU 2491902 C2, publ. 12/17/2010). The disadvantages of the known method are:

- insufficient accuracy in determining the angle of strabismus on the synoptophore, since paralytic strabismus is unfriendly and its characteristics change with different directions of gaze;

- use of complex expensive equipment.

The closest to the claimed method - the prototype is

a method for the treatment of paralytic strabismus, which consists in the following. In right-sided abducens nerve palsy, the right eye is rotated medially with traction sutures placed through the episclera near the limbus at 1 and 5 o'clock. Perform a partial peritomy. Separate the superior, lateral and inferior rectus muscles. They are split with a muscular hook along the middle longitudinal line from the tendon part in the peripheral direction. The temporal half of the superior rectus muscle and the upper half of the lateral rectus muscle are tied with a non-absorbable suture in the equatorial region of the eye. Similarly, the temporal part of the lower rectus muscle and the lower half of the lateral rectus muscle are combined. The conjunctiva is sutured with two limbal sutures (Jensen C.D.F. Rectus muscle union. A new operation for paralysis of the rectus muscles // Transactions of the Pacific Coast Oto-Ophthalmological Society annual meeting. - 1964; - Vol. 45; - P. 359-387) .

The known method allows you to restore some degree of eye mobility in the direction of the action of the paralyzed muscle, however, it has a number of significant drawbacks:

- insufficient efficiency due to the lack of dosage of surgical interventions, not eliminating the vertical component of strabismus;

- high labor intensity of the operation, due to surgical manipulations on four oculomotor muscles;

- postoperative complications in the form of conjunctival edema and ischemia of the anterior segment of the eye;

- the risk of enophthalmos, narrowing of the palpebral fissure, the appearance or intensification of vertical strabismus due to intervention on the vertical rectus muscles.

The objective of the invention is to increase the efficiency of the operation by metering the external rectus muscle, increasing the amplitude of rotation of the visual axis of the eyeball in the affected eye, as well as simplifying the method.

The technical result of the proposed solution is to increase the efficiency of the operation, simplify the method, reduce side effects.

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

After preparation of the surgical field and retrobulbar or intravenous multicomponent balanced anesthesia, access is made through the U-shaped limbal incision of the conjunctiva to the medial and lateral rectus muscles of the eye. Next, the recession of the medial rectus muscle is performed by 5 mm from the anatomical site of attachment according to the standard method. Then the lateral rectus muscle is taken on a muscle hook, released from the fascia, stratified into 2 longitudinal bundles, while the upper bundle is 2/3 of the muscle width, and the lower bundle is 1/3 of the muscle width. Next, the upper bundle of muscle is taken on a hook, stepping back 7-10 mm distally from the place of its attachment, and an interrupted suture is applied. Then, without cutting the threads, the upper bundle is displaced by 7-10 mm towards the anatomical place of its attachment, the same needle is injected into the sclera in front of the muscle root, the upper muscle bundle is pulled by the thread to the injection, forming a muscle fold and sewn to the sclera.

Similar actions are performed with the lower bundle of the lateral rectus muscle, with the only difference being that an interrupted suture is applied 6-8 mm from the attachment site and the lower bundle is displaced to the anatomical attachment site and sutured to the sclera behind the muscle root. At the end of the operation, interrupted sutures are applied to the conjunctiva.

Dosing of the volume of the operation depends on the characteristics of paralytic strabismus, the mobility of the eye in the direction of the action of the affected muscle and the magnitude of the secondary deviation.

The figure 1 schematically shows the topography of the imposition of interrupted sutures on the lateral rectus muscle and the magnitude of the displacement of the fold, where

- верхний пучок мышцы;

- upper bundle of muscle;

- нижний пучок мышцы.

- the lower bundle of muscle.

Significant differences between the proposed method and the prototype are:

- the lateral rectus muscle is stratified into 2 longitudinal bundles, while the upper bundle is 2/3 of the width of the muscle, the lower one is 1/3, which makes it possible to increase the efficiency of the operation due to the dosed strengthening of the lateral rectus muscle;

- the upper bundle of the lateral rectus muscle is captured 7-10 mm from its anatomical site of attachment, and the lower bundle of the lateral rectus muscle is captured 6-8 mm from its anatomical site of attachment, displaced towards the anatomical site of their attachment, a muscle fold is formed and sutured to the sclera, while the muscle fold formed from the lower muscle bundle is sutured to the sclera behind the root of the lateral rectus muscle, which makes it possible to eliminate the vertical component of strabismus without intervention on the muscles of the vertical action, thereby facilitating the implementation of surgical intervention and reducing the likelihood of complications.

The positive effect of the operation is achieved due to the following:

- dosed strengthening of the upper and lower parts of the muscle;

- no need for surgical intervention on the muscles of vertical action.

The combination of these mechanisms makes it possible to activate different EOM zones separately, potentially mediating the previously underestimated, but significant torsion and vertical oculorotatory actions of the lateral rectus muscle. As a result, there is a decrease in vertical deviation, a decrease in the mismatch between the direction of the visual axes of the affected and healthy eyes.

A search through the sources of scientific, technical and patent information did not reveal a method identical to the claimed one, and therefore it can be concluded that the claimed technical solution meets the criteria of "novelty" and "inventive step".

The invention is illustrated by the following specific examples.

Example 1

Patient K., aged 56, was admitted with a diagnosis of Paresis n. abducens of the right eye (ischemic genesis). Mild hypermetropia in both eyes.

The patient complained of constant double vision diagonally when looking straight, when trying to look to the right, double vision increases. I noticed the appearance of doubling 6 months ago, after suffering an ischemic stroke. The patient underwent a course of etiopathogenetic treatment by a neurologist.

At the first stage, the patient underwent a complete ophthalmological and strabismus examination. Refraction was evaluated using an autorefractometer under physiological conditions:

OD sph + 1.5 D cyl + 0.50 D ax 130°

OS sph + 1.0 D cyl + 0.50 D ax 90°

Visual acuity was determined according to the Golovin-Sivtsev table:

OD 1.0

OS 1.0

Optical biometrics using IOL Master Carl Zeiss:

OD 23.12mm

OS 23.27mm

An objective examination of the oculomotor system revealed the following:

The patient was operated by the claimed method.

After retrobulbar anesthesia and processing of the surgical field, an eyelid expander was introduced, exposing the eyeball as much as possible. Further, to provide access to the medial rectus muscle of the right eye, the conjunctiva was captured with tweezers at 9 o'clock and the eyeball was retracted. Conjunctival spring scissors made a U-shaped limbal incision of the conjunctiva and Tenon's capsule. The tenon capsule was separated with scissors from the episclera in the upper and lower temporal quadrants. Next, the recession of the medial rectus muscle was performed by 5 mm from the anatomical site of attachment according to the standard method. Then, using the obtained U-shaped access, the lateral rectus muscle was isolated. The lateral rectus muscle was taken on a muscle hook, freed from the fascia, stratified into 2 longitudinal bundles: the upper one was 2/3 of the muscle width, the lower one - 1/3. Next, the upper muscle bundle was taken on a hook, receded by 7 mm from the place of its attachment, and an interrupted suture was placed. Then, without cutting the thread, the upper bundle was displaced by 7 mm towards the anatomical site of its attachment, the same needle was injected into the sclera in front of the muscle root, the upper muscle bundle was pulled by the thread to the injection, forming a muscle fold and sewn to the sclera.

Similar actions were performed with the lower bundle of the lateral rectus muscle, with the only difference being that an interrupted suture was placed 6 mm from the attachment site and the lower bundle was displaced to the anatomical attachment site and sutured to the sclera behind the muscle root. At the end of the operation, interrupted sutures were applied to the conjunctiva.

At the control examination after 1 month, the patient did not notice torsion doubling and strabismus in the direct position of the gaze and when looking to the right, noted an improvement in the mobility of the right eye. An objective examination revealed:

No side effects were observed.

Example 2

Patient U., aged 50, was admitted with a diagnosis of paresis n. abducens of the left eye. Acquired axial myopia, moderate degree, stabilized. Presbyopia in both eyes.

The patient complained of constant diagonal double vision when looking straight ahead and when trying to look to the left. I noticed the appearance of doubling 9 months ago. Seen by a neurologist.

At the first stage, the patient underwent a complete ophthalmological and strabismus examination. Refraction was evaluated using an autorefractometer under physiological conditions:

OD sph - 3.0 D cyl - 0.75 D ax 30°

OS sph - 3.5 D cyl - 0.50 D ax 120°

Visual acuity was determined according to the Golovin-Sivtsev table:

OD 0.1 corrected sph - 3.5 D=1.0 OS 0.1 sph-3.5D=1.0

Optical biometrics using IOL Master Carl Zeiss:

OD 24.50 mm

OS 25.27mm

An objective examination of the oculomotor system revealed the following:

After preparing the surgical field, the medial rectus muscle of the left eye was recessed according to the standard method, similar to example 1.

Then the lateral rectus muscle was taken on a muscle hook, freed from the fascia, stratified into 2 longitudinal bundles: the upper one was 2/3 of the muscle width, the lower one - 1/3. Next, the upper muscle bundle was taken on a hook, retreated 10 mm from the place of its attachment, and an interrupted suture was placed. Then, without cutting the thread, the upper bundle was displaced by 10 mm towards the anatomical site of its attachment, the same needle was injected into the sclera in front of the muscle root, the upper muscle bundle was pulled by the thread to the injection, forming a muscle fold, and sutured to the sclera.

Similar actions were performed with the lower bundle of the lateral rectus muscle, with the only difference being that an interrupted suture was placed 8 mm from the attachment site and the lower bundle was displaced to the anatomical attachment site and sutured to the sclera behind the muscle root. At the end of the operation, interrupted sutures were applied to the conjunctiva.

At the control examination after 3 months, the patient does not notice torsion doubling and strabismus in the direct position of gaze and when looking to the right, when looking to the left in the extreme abduction notes horizontal doubling. This does not bother the patient. An objective examination revealed:

No side effects were observed.

The proposed method allows to increase the efficiency of the operation, reduce its trauma and the incidence of complications. In addition, the use of the proposed method will eliminate the vertical deviation and compensate for torsion doubling, which will eliminate physical discomfort and the main complaint of patients.

Claims (1)

A method of surgical treatment of paralytic strabismus associated with abducens nerve paresis, including the formation of access to the medial and lateral rectus muscles of the eye, the recession of the medial rectus muscle, the isolation and stratification of the lateral rectus muscle, characterized in that the lateral rectus muscle is stratified into 2 longitudinal bundles, with In this case, the upper bundle is 2/3 of the muscle width, and the lower one is 1/3 of the muscle width, then the upper bundle of the lateral rectus muscle is captured 7–10 mm from its anatomical site of attachment, and the lower bundle of the lateral rectus muscle is captured 6–8 mm from its anatomical site of attachment is displaced towards the anatomical site of their attachment, a muscle fold is formed and sutured to the sclera, while the muscle fold formed from the upper muscle bundle is sutured to the sclera in front of the muscle root, and the muscle fold formed from the lower muscle bundle, sewn to the sclera behind the muscle root.

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