RU2702601C1 - Method of treating primary hyperfunction of lower oblique muscle - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology, and can be used for treating primary hyperfunction of lower oblique muscle. Tenon's capsule is incised. Incision is expanded towards the inferior and external rectus muscles so that the total length of the incision does not exceed  cm. Tenon's membrane is removed, which is brought upwards and outside into a projection of the incision, and the exposed oblique muscle is injected with a preparation of Botox in amount of 3–5 units to depth of 1.5–3 mm with subsequent superposition of interrupted sutures on conjunctive.

EFFECT: method enables avoiding separation of the lower oblique muscle, scleral perforation, and reducing the intervention time.

1 cl, 3 dwg, 5 tbl

Description

The invention relates to medicine, namely to ophthalmology and can be used to treat strabismus associated with primary hyperfunction of the lower oblique muscle of the eye.

Hyperfunction of the inferior oblique muscle according to the CEMAS classification is defined as hyperelevation in adduction. Primary hyperfunction (PG) occurs in patients with infant esotropia under the age of three years in 72% of cases. In cases of acquired esotropia, this probability decreases to 30%. PG occurs in 17% of cases among all hypertropias. First of all, the occurrence of hyperfunction is promoted by constant occlusion. Secondly, horizontal dystopia is possible, in particular hypotopia of the external rectus muscles. In addition, the loss of binocular vision is perceived by the central nervous system as a further step, requiring an increase in tone to extraocular muscles and manifested in the form of PG (Brodsky M.S., Donahue SP Primary oblique muscle overreaction // Arch Ophthalmol. 2001; 119: 1307-1314 ) Clinically, the hyperfunction of the inferior oblique muscle can be divided into 4 degrees depending on the magnitude of the lifting of the eyeball in the cast.

A known method of treating primary hyperfunction of the inferior oblique muscle, which consists in isolating the inferior oblique muscle, suturing and cutting it off from the attachment site, moving the muscle to the attachment site of the inferior rectus muscle and sewing it on, suture and cut off part of the inferior oblique muscle, for which the muscle is stratified and isolated its part, depending on the angle of deviation, which is moved to the sewing site. Conjunctival access is sutured with a continuous suture (patent RU 2288680 C1, op. 10.12.2006).

Another known method of treating vertical strabismus caused by hyperfunction of the lower oblique muscle is the method that the lower oblique muscle is displaced anteriorly and fixed at the site of attachment of the lower rectus muscle, thereby changing the plane of action and changing the function of the muscle, which after suturing in the projection of the Lockwood ligament, it acquires a J-shaped contour and becomes an eyeball lowering device (patent RU 2161466 C1, op. 10.01.2001).

There is a method of surgical treatment of hyperfunction of the inferior oblique muscle, which consists in its intersection with subsequent fixation in a new place, ensuring the absence of hypertonicity: retreating 10-12 mm from the outer edge of the limb, make a vertical incision of the conjunctiva 12-15 mm long, highlight the outer straight muscle, push it up and hook grab the lower oblique muscle at a distance of 2-3 mm from the point of attachment to the sclera. 2 stitches are placed on the muscle above and below, capturing 1/3 of the width of the muscle. The lower oblique muscle is crossed at the site of its attachment to the sclera and fixed at the required distance with two previously applied sutures to the sclera at a new place down and anteriorly along the muscle plane (Avetisov ES, Squintered strabismus. - M .: Medicine, 1977. - 312 from.).

The disadvantages of the above known methods are:

- morbidity (large conjunctival wound, injuries of the Lockwood ligament, the threat of perforation of the sclera in the immediate vicinity of the macula during muscle flashing);

- the risk of developing serious intra- and postoperative complications (scarring, gross violation of the anatomical relationships of tissues, limiting the possibility of repeated surgical interventions).

Closest to the claimed method, the prototype, is a method of treating hyperfunction of the lower oblique muscle, which consists in the fact that temporally from the lower internal angle of the orbit at the attachment point of the lower oblique muscle, transcutaneous injections of the botulinum toxin A preparation are performed in a volume of 20 PIECES, while the preparation is preliminarily restore in 1.5 ml of physiological solution of sodium chloride, and then carry out conservative rehabilitation treatment to restore oculomotor function. The method allows to eliminate vertical deviation in case of refusal of surgical intervention, which allows the use of conventional treatment to restore binocular vision (patent RU 2436550 C1, op. 20.12.2011).

The disadvantages of the prototype are the lack of visual control of the targeted muscle, a high risk of side complications (scleral perforation, possible diffusion of the drug into the lower rectus muscle), a poorly predicted result of the operation due to the possible loss of botulinum toxin A to the lower oblique muscle. In addition, the complexity of parabulbar injections in children, due to their cautious attitude to injections, namely, possible excessive mobility can lead to undesirable effects of the injection, such as perforation of the sclera, further refusal of any type of treatment, fear of a doctor, etc.

The objective of the invention is to reduce the risk of side complications and providing visual control of the targeted muscle.

Effect: reduce the risk of side complications and increase the effectiveness of the operation.

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

After processing the surgical field, local anesthesia and installing an eyelid extender, access to the lower oblique muscle is performed. To do this, in the lower outer quadrant at 7-8 hours, 11-15 mm from the limbus, the conjunctiva is taken with tweezers and slightly lifted above the sclera (Fig. 1).

The formed fold is incised with conjunctival scissors, after which the tenon capsule is incised, the incision is expanded towards the lower and external rectus muscles so that the total incision length does not exceed 1 cm (Fig. 2).

Next, muscle scissors are introduced into the incision and the access is enlarged in a blunt manner. After forming the access, using a micro-forceps, a tenon shell is isolated, which is brought up and out into the projection of the section. At the same time, the lower oblique muscle is visualized in the surgical field. Under conditions of elevated and retracted tenon sheath, 3-5 units of botulinum toxin A are injected into the lower oblique muscle to a depth of 1.5-3 mm (Fig. 3). In a preferred embodiment, Botox is used. The conjunctiva is sutured with interrupted sutures.

Indications for the application of the proposed method for the treatment of primary hyperfunction are: hyperfunction of 2 degrees or more (more than 7 °); asymmetric degree of hyperelevation, even if on one of the eyes it is less than 7 °; the presence of V-syndrome of more than 15 prism diopters.

The positive effect of the proposed method is achieved by introducing botulinum toxin A directly into the lower oblique muscle, which leads to a decrease in its functions, and therefore to a decrease in hyperelevation in the cast. Thus, the prospects for the formation of binocular and stereoscopic vision increase, as well as the possibility of using orthoptic treatment.

The invention is illustrated by the following figures:

FIG. 1 - conjunctival access performed;

FIG. 2 - access to the lower oblique muscle;

FIG. 3 - Botox is injected into the lower oblique muscle.

A search by 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 performance of the method.

Example 1

Patient Sh., 4 years old. According to the parents, the strabismus in the child became noticeable from 6-7 months, after which point correction of ametropia and occlusion in the 1/1 mode were constantly recommended. By 1 year and 6 months without sticking, when looking to the side, parents began to note the deviation of the eyeballs up. The amount of deviation is presented in table 1.

In the period from 1 year 6 months to the time of treatment, the angle of deviation without significant dynamics. Due to hyperelevation in adduction, orthoptic treatment does not seem appropriate.

The patient was treated with the claimed method.

Botulinum toxin A (Botox preparation) was preliminarily prepared in a dilution of 100 PIECES per 1 ml of physiological saline. In the insulin syringe, 3 units of Botox were taken in a volume of 0.03 ml.

After multicomponent balanced anesthesia, treatment of the surgical field and installation of an eyelid expander, access to the lower oblique muscle is performed. To do this, in the lower outer quadrant at 7-8 hours, 11 mm from the limbus, the conjunctiva is taken with tweezers and slightly raised above the sclera. The formed fold is incised by conjunctival spring scissors, after which the tenon capsule is incised, the incision is extended. Then, muscle scissors were introduced into the incision and the access was expanded, the tenon capsule was separated in a blunt way. After forming the access, the tenon capsule is taken by the inner sheet using micro-tweezers, pulled up and out into the projection of the incision. At the same time, the lower oblique muscle is visualized in the surgical field. In conditions of elevated and retracted tenon sheath, 3 Botox units (0.03 ml) were introduced into the lower oblique muscle to a depth of 1.5 mm. The conjunctiva is sutured with interrupted sutures using a non-absorbable thread 7-0. Under the conjunctiva, 0.3 ml of a 1% dexazone solution was administered. The eyelid expander is removed, a sterile aseptic dressing.

A similar manipulation was performed on the left eye with the introduction of 3 units of Botox. After standard antibacterial and anti-inflammatory therapy in the postoperative period, maximum point correction of ametropia is recommended.

During the follow-up examination after 1 month, the patient's parents noted a moderate decrease in esodiation and the absence of vertical strabismus. The amount of deviation is presented in table 2.

Further, the patient is recommended orthoptic treatment, observation in dynamics.

Example 2

Patient K., 8 years old. The patient's mother complained of deviation of the eyes upward when looking to the side. According to the mother, the vertical strabismus in a child is noted throughout life. The child makes complaints of an asthenopic nature, including complaints of periodic doubling at school. Earlier, spectacle correction, occlusion, and other types of treatment were not used. The value of deviation is presented in table 3.

After a diagnostic examination revealed moderate hyperopia.

The treatment by the proposed method for both eyes was carried out analogously to example 1, except that 5 Botox units were introduced in a volume of 0.05 ml into each lower oblique muscle to a depth of 3 mm. The use of glasses correction is recommended constantly.

After 1 month, there are no asthenopic complaints and complaints about diplopia, my mother notes a pronounced positive trend. The value of deviation is presented in table 4.

After 4 months.

There are no complaints, the child uses glasses regularly, which helps prevent the recurrence of ezodeviation, avoids occlusion and loss of binocular vision, which reduces the risk of recurrence of primary hyperfunction of the lower oblique muscle.

Using the proposed method will allow:

- reduce the side effects of surgery (exclude the possibility of separation of the lower oblique muscle, the risk of perforation of the sclera);

- reduce the time of intervention and the duration of the anesthetic benefit;

- reduce the cost of the procedure;

- provide the possibility of the sole execution of the procedure without the assistance of an assistant;

- exclude surgery on the lower oblique muscle using surgical instruments and exclude the risk of fatty hypertrophy of the muscle or the occurrence of adhesions on it.

Claims (2)

1. A method of treating primary hyperfunction of the lower oblique muscle, comprising administering a drug based on botulinum toxin type A at the first stage into the lower oblique muscle, and then conservative treatment until the oculomotor function of the muscle is restored, characterized in that the conjunctival cavity is opened and the lower oblique is excreted muscles, for which a tenon capsule is incised through conjunctival access, the incision is expanded towards the lower and external rectus muscles so that the total length of the incision does not exceed 1 cm, a tenon sheath is secreted, which is brought up and out into the projection of the incision, and Botox is injected into the exposed oblique muscle in the amount of 3-5 units to a depth of 1.5-3 mm, followed by nodal joints on the conjunctiva. 2. The method according to p. 1, characterized in that the opening of the conjunctival cavity is carried out in the lower outer quadrant for 7-8 hours, 11-15 mm from the limbus, while the conjunctiva is taken with tweezers, raised above the sclera, and the formed fold is incised with the conjunctival scissors.

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