RU2705041C1 - Method for surgical treatment of concomitant, nonconcomitant and restrictive strabismus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmosurgery. At the first stage, after extraction, stitching of muscle with suturing material and its cutting off attachment point, assumed new place of localization is measured on sclera, towards equator. Stitched muscle is then displaced to the specified distance towards the equator and fixed on the sclera with the help of suspending sutures. Muscle is tightened by a thread localizing the muscle at the corresponding distance equal to 4–5 mm from the attachment point of the muscle accompanying esotropia for the medial rectus muscle or equal to 7–9 mm in exotropia for a lateral rectus muscle. At the second stage, a middle duplication is performed by forming a muscular fold on the lateral rectus muscle in esotropia in amount of 7–9 mm, or by forming a muscular fold on a medial rectus muscle with exotropia of 6–8 mm.

EFFECT: invention provides higher functional and cosmetic stability of operation, reduced risk of complications during surgery.

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Description

The invention relates to ophthalmic surgery and can be used in the treatment of friendly, unfriendly and restrictive strabismus.

The tactics of choosing weakening (recession, myotomy, myoplasty, tenoscleroplasty, adjustable sutures) and reinforcing techniques (resection, median duplication, prorafia, adjustable sutures) of surgical treatment of friendly and paralytic (non-friendly) strabismus depends on many factors (Barbel I.E. ocular muscles / I.E.Barbel // The multivolume guide to eye diseases. - M., 1962. - T. 4,1. - S. 313-356). It takes into account the type of strabismus (friendly, unfriendly, restrictive), the direction of deviation of the eyeball (to the nose - convergent strabismus (esotropy), to the temple - divergent strabismus (exotropy)), the magnitude of the strabismus angle, operations on extraocular muscles (EOM) in history and anatomical the integrity of their attachment site, the features of innervation (paresis, atypical), restrictive components of strabismus (post-traumatic, post-circulation, post-inflammatory). In strabismus surgery, it is important to minimize operational injuries, maintain anatomical and physiological relationships, and avoid the occurrence of postoperative complications.

There is a method of weakening the action of muscles (recession), which consists in isolating the rectus muscle, suturing it, moving the muscle, crossed at the attachment point, to the posterior pole of the eyeball with fixation to the sclera (Avetisov E.S. , "Medicine", 1977. - 286 s).

The disadvantages of the recession are the difficulty of fixing the EOM to the thinned sclera with the risk of its perforation, especially in scleromalization sites after removing the circulatory tape, the difficulty in choosing the dosage on previously operated EOM, weakening of convergence (when performed on the internal rectus muscles) and the danger of developing a hyper-effect.

A known method of attenuating the action of EOM, which consists in the isolation and recession of a hyperfunctioning muscle, fixes the muscle being weakened using a graft of silicone tape cut along the width of the muscle and the length of the proposed recession. One end of the graft is fixed to the muscle, and the other to the sclera, at the site of the initial attachment of the operated muscle (patent RU 2353337 C1, publ. 04/27/2009).

The disadvantages of the method are the risk of a hyper-effect due to the difficulty of dosing muscle weakening, as well as a high risk of separation from the transplant of the operated oculomotor muscle, which is a serious complication in the postoperative period.

A known method of recession of horizontal action muscles with friendly strabismus is that the operated muscle is flashed and cut off from the attachment point, the muscle is hemmed to the episclera in the region of the eye equator on the loop, which is lowered behind the eye equator. The length of the loop is calculated by the formula: DP = (UK-1.2 × E): 1.5, where DP is the length of the loop; UK - strabismus angle; E - the distance from the place of initial attachment of the muscle to the equator of the eye, determined on the operating table; 1.2 - correction factor for the angle of deviation per 1 mm of muscle recession to the equator of the eye; 1.5 - correction factor for the deviation angle per 1 mm loop behind the equator (patent RU 2289367 C1, publ. 12/20/2006).

The disadvantages of the method are the difficulty of dosing the amount of attenuation on the rigid muscle and the characteristics of the characteristics (stretching) of suture material for calculating the length of the loop, as well as the limited use of the method only for the treatment of friendly strabismus.

Closest to the claimed method - the prototype, is a method of surgical treatment of strabismus, which consists in the following. On the first day, a conjunctiva is cut 2-3 mm from the limbus and parallel to it, as well as in the projection of each operated oculomotor muscle. The muscle is isolated, stitched and cut off from the attachment point, the thread is drawn in the sclera parallel to each other and a first simple knot and a second knot are tied in the form of a bow to loosen or tighten, recession or resection of the muscle. On the second day, after determining the position of the operated eye, the muscle tension is adjusted by changing the tension of the threads (the knot tied with a bow is dissolved) until the eye is in the straight position (Dev = 0 °). Knots turn into bow knots into ordinary knots, and the third and fourth simple knots make the seam completely reliable. The remaining threads are cut off, and 2-3 nodal sutures are placed on the conjunctiva, combining the edges of the surgical wound (patent RU 2271183 C1, publ. 10.03.2006).

The disadvantages of the method are the lack of effectiveness in eliminating the strabismus angle, associated with the difficulty of dosing weakening and enhancing types of operations, a pronounced pain effect during additional weakening or pulling of the oculomotor muscles by the applied thread, in the early delayed (next day) postoperative period, surgical treatment strabismus for 2 days, which complicates the application of the method in pediatric patients.

The objective of the invention is to increase the efficiency of the method, increase the stability of the functional and cosmetic result of the operation, eliminate side complications, expand the indications for the use of suspension sutures in strabismological surgical practice.

Effect: increasing the efficiency of the method due to a significant decrease in the strabismus angle, eliminating side complications and increasing the stability of the result of the operation.

The problem is achieved by the proposed method, which consists in the fact that in order to eliminate friendly, unfriendly or restrictive strabismus, at the first stage, depending on the magnitude of the strabismus angle, a weakening operation is performed using suspensory sutures on the rectus medialis muscle during esotropia or on the rectus lateralis muscle exotropy, and at the second stage, an intensifying operation is performed.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva is performed at 7 and 9 hours with the release of the rectus lateralis muscle during exotropy, or at 2 and 4 hours with the release of the rectus medialis muscle during esotropia. Then the muscle is hooked, it is freed from the anterior ciliary arteries, fascia, with restrictive strabismus components from adhesions with retrobulbar structures, the muscle is sutured with Vikril 6-0 suture material. (Fig. 1) and cut off the muscle (Fig. 2) from the place of attachment (from the root of the muscle). The planned new site of localization is measured on the sclera for the rectus medial muscle with esotropia (4-5 mm), or for the rectus lateral muscle with exotropy (7-9 mm) from the anatomical muscle attachment site (Fig. 3). The stitched muscle is displaced by a predetermined distance towards the equator and fixed on the sclera with the help of hanging seams. To do this: with the same needle and thread, the first injection is made through the sclera to the upper part of the anatomical place of attachment of the cut muscle (upper part of the muscle root) towards the limbus (Fig. 4), then a second injection is made through the sclera to the lower part of the anatomical place of attachment of the cut off muscles (in the lower part of the muscle root) towards the limb (Fig. 5). Tighten the muscle by the thread, localizing at the corresponding weakening distance: with esotropia by 4-5 mm for the rectus medial muscle, with exotropy by 7-9 mm for the rectus lateral muscle. Then tie the ends of the thread with triple multidirectional nodes (Fig. 6). After making sure the seam is reliable, the threads are cut off.

The second step is to perform an enhancement operation - the mid-duplicate, by forming a muscle fold on the rectus lateralis muscle with an esotropia in the volume of 7 to 9 mm or by forming a muscle fold on the rectus medial muscle with exotropy in the volume of 6 to 8 mm. At the end of the operation, nodal sutures are placed on the conjunctiva (Virginia silk 8-0).

According to the invention, in a particular case, with restrictive strabismus, at the end of episcleral filling (circulating) during retinal detachment, the attenuation volumes are increased by 1 mm: with esotropy, the stitched (Fig. 7) and cut straight medial muscle are lowered onto the threads for a 5-piece circular tape -6 mm from the attachment point of the muscle, towards the equator, with exotropia, the stitched (lateral Fig. 7) stitched straight lateral muscle is lowered onto the threads behind the circulating tape by 8-10 mm, towards the equator. Moreover, the hanging threads of the stitched rectus medial muscle or rectus lateralis muscle are placed on the front surface of the circulating tape, which maintains the necessary tight contact of the tape with the sclera (Fig. 8).

The defining differences of the proposed method from the prototype are:

1) at the first stage, depending on the magnitude of the strabismus angle, a weakening operation is performed using suspensory sutures on the rectus medialis muscle during esotropia or on the rectus lateralis muscle during exotropia, which allows to increase the efficiency of the proposed method and expand its functionality by providing it use with a pronounced restrictive component of strabismus, in areas with a thinned sclera as a result of removing the circulating tape or with deep integrity damage Claire during previous operations at the EOM and EOM with severe rigidity, impedes traditional mitigation techniques on previously operated muscles;

2) at the second stage, an amplifying operation is performed - median duplication, by forming a muscle fold on the rectus lateralis muscle during esotropia or on the rectus medialis muscle during exotropia, which allows to achieve the most persistent effect of reducing the squint angle.

The claimed method allows to increase the effectiveness of the operation by significantly reducing the deviation of friendly, unfriendly and restrictive strabismus, both primary and reoperated oculomotor muscles, especially with a pronounced restrictive component, provides long-term stability of the result of the operation, and also reduces the risk of complications during surgery .

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 figures:

FIG. 1 - stitching muscle suture material Vikril 6-0;

FIG. 2 - cutting off the muscle from the place of attachment (from the root of the muscle);

FIG. 3 - displacement and localization of the muscle to a new place of attachment;

FIG. 4 - the first injection into the upper part of the sclera in the area of the anatomical site of attachment of the cut muscle in the direction of the limb;

FIG. 5 - performing a second injection into the lower part of the sclera in the area of the anatomical site of attachment of the cut muscle in the direction of the limb;

FIG. 6 - localization of the muscle at the corresponding distance of weakening and tying the knot;

FIG. 7 - muscle flashing with suture material Vikril 6.0 (closer to the root of the muscle);

FIG. 8 - hanging threads on the front surface of the circulating tape.

The invention is illustrated by the following examples of specific performance.

Example 1

Patient T., 28 years old, was admitted to the Novosibirsk branch of FSAI "NRC" MTC "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with a diagnosis of Restrictive post-traumatic esotropia of the left eye. Acquired stable axial myopia of a high degree in both eyes.

The patient has a history of comminuted fracture of the medial and lower walls of the right orbit, followed by reconstructive maxillofacial surgery, which caused the appearance of esotropia on the right.

Visual acuity:

OD 0.03 sph -7.75D = 0.9

OS 0.02 sph -8.25D = 0.9

Biometrics:

OD 27.86 mm

OS 28.10 mm

Strabismus angle (in degrees according to Hirschberg with a carpet test):

The mobility of the left eye is sharply limited when assigned to 5 °.

The patient underwent surgical treatment of strabismus in order to reduce the strabismus angle and restore the abduction on the left eye by the claimed method.

During the operation, severe restriction was detected in the area of the rectus medial muscle, which complicated the surgical access to the muscle and the implementation of the traditional recession.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva was performed at 2 and 4 hours with the release of the rectus medial muscle. Then, the direct medial muscle was taken on a muscle hook, it was freed from the anterior ciliary arteries, fascia and adhesions with parabulbar structures. The muscle was stitched with suture material Vikril 6-0. The tendon of the muscle was cut off from the place of attachment, then a distance of 5 mm (the planned location of the rectus medial muscle) was measured on the sclera from the place of attachment of the muscle. The stitched medial muscle was displaced by 5 mm towards the equator. The same needle and thread made the first injection through the sclera into the upper part of the muscle root, then performed the second injection through the sclera into the lower part of the muscle root. The rectal medial muscle was pulled by the thread, localizing to the corresponding attenuation volume of 5 mm. Then the ends of the string were tied with triple multidirectional knots. After making sure the seam was secure, the threads were cut off. The second stage was an intensifying operation - median duplication, by forming a muscle fold in a volume of 7 mm on the rectus lateral muscle. At the end of the operation, nodal sutures were placed on the conjunctiva. In the postoperative period, the squint angle was close to 0 °, the restoration of mobility to the temple increased to 15-17 °, there were no complications, both in the early and in the distant postoperative periods. A follow-up examination after 1, 3 and 6 months showed the stability of the results.

Example 2

Patient T., 38 years old, was admitted to the Novosibirsk branch of FSAI "NRC" MTC "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with a diagnosis of Restrictive exotropia of the right eye. Operated retinal detachment of the right eye. The state after episcleral filling (circulation) on the right. Acquired stable axial myopia of a high degree in both eyes. Difficult myopic astigmatism of the right eye.

History: retinal detachment of the right eye occurred spontaneously.

Visual acuity:

Biometrics:

OD 26.81 mm

OS 26.19 mm

Strabismus angle (in degrees according to Hirschberg with a carpet test):

Limit the mobility of the right eye in all directions of the gaze to 10 °.

The patient underwent surgical treatment of strabismus in the right eye with the claimed method in order to reduce the strabismus angle and increase mobility in all directions of the gaze.

After anesthesia and preparation of the surgical field, a limb-radial incision of the conjunctiva was performed at 7 and 9 hours with the release of the rectus lateralis muscle. Then, the lateral rectus muscle was taken on a muscle hook, it was freed from the anterior ciliary arteries, fascia and adhesions with retrobulbar structures. The muscle was stitched with suture material Vikril 6-0 (Fig. 7). The muscle tendon was cut off from the attachment point (towards the equator), a distance of 10 mm was measured on the sclera. Then, the stitched straight lateral muscle was lowered onto the threads behind the circulating tape 10 mm from the place of muscle attachment, towards the equator. The same needle and thread made the first injection through the sclera into the upper part of the muscle root, then performed the second injection through the sclera into the lower part of the muscle root. The lateral rectus muscle was pulled by the thread, localizing to the corresponding volume of attenuation equal to 10 mm. Then the ends of the string were tied with triple multidirectional knots. The hanging threads of the stitched straight lateral muscle were located on the front surface of the circulating tape, which made it possible to maintain the necessary tight contact of the tape with the sclera (Fig. 8). After confirming the consistency of the seam, the threads were cut off. The second step was an intensifying operation - median duplication, by forming a 6 mm muscle fold on the rectus medial muscle. At the end of the operation, nodal sutures were placed on the conjunctiva. In the postoperative period, the strabismus angle was -5-7 °, mobility in all gaze positions increased to 20 °, there were no complications, both in the early and long-term postoperative periods. A follow-up examination after 1, 3 and 6 months showed the stability of the results.

Example 3

Patient V., 18 years old, was admitted to the Novosibirsk branch of FSAI "NRC" MTC "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with a diagnosis of Paralytic esotropia of the left eye. Operated Dwayne's syndrome of the left eye. Weak hypermetropia in both eyes.

The patient had a history of surgery: recession of the rectus medial muscle in a volume of 5 mm in the left eye.

Visual acuity:

Biometrics:

OD 22.98 mm

OS 23.65 mm

Strabismus angle (in degrees according to Hirschberg with a carpet test):

The mobility of the left eye is limited when assigned to 7 °.

The patient underwent surgical treatment of strabismus in order to reduce the strabismus angle and increase the mobility to the temple in the left eye, taking into account the paralytic component of strabismus by the claimed method.

During the operation, pronounced rigidity of the rectus medial muscle (previously operated according to the traditional technique - recession) was revealed.

After anesthesia and preparation of the surgical field, a limbal-radial incision of the conjunctiva was performed at 2 and 4 hours with the release of the rectus medial muscle. Then, the direct medial muscle was taken onto a muscle hook, it was freed from the anterior ciliary arteries, fascia, and adhesions with retrobulbar structures. The muscle was stitched with suture material Vikril 6-0. The muscle tendon was cut off from the place of attachment, then a distance of 4 mm (planned new location of the rectus medial muscle) was measured on the sclera from the place of attachment of the muscle. The stitched medial muscle was displaced by 4 mm towards the equator. The same needle and thread made the first injection through the sclera into the upper part of the muscle root, then performed the second injection through the sclera into the lower part of the muscle root. The rectal medial muscle was pulled by the thread, localizing to the corresponding volume of attenuation equal to 4 mm. Then the ends of the string were tied with triple multidirectional knots. After confirming the consistency of the seam, the threads were cut off. The second stage was an intensifying operation - median duplication, by forming a 9 mm muscle fold on the rectus lateralis muscle. At the end of the operation, nodal sutures were placed on the conjunctiva. In the postoperative period, the strabismus angle was + 5 °, mobility in all gaze positions increased to 5 °, there were no complications, both in the early and in the distant postoperative periods. A follow-up examination after 1, 3 and 6 months showed the stability of the results.

Example 4

Patient E., 45 years old, was admitted to the Novosibirsk branch of FSAI "NRC" MTC "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with a diagnosis of Non-accommodative exotropia of the left eye. Operated retinal detachment of the left eye. Condition after removing the ribbon strip on the left. Scleromalacia on the left. Acquired stable axial myopia of an average degree of both eyes.

The patient has a history of episcleral filling of the retinal detachment of the left eye, removal of the circulating tape on the left. Scleromalacia under the tendon-muscle part of the rectus lateral muscle in the zone of contact with the circulatory tape.

Visual acuity:

OD 0.3 sph -4.5D = 0.15

OS 0.6 sph-4.25D = 1.0

Biometrics:

OD 25.46 mm

OS 25.78 mm

Strabismus angle (in degrees according to Hirschberg with a carpet test):

Limit the mobility of the right eye in all directions of the gaze to 15 °.

The patient underwent surgical treatment of strabismus in order to reduce the strabismus angle and restore mobility in all directions of the gaze on the right eye of the claimed method.

After anesthesia and preparation of the surgical field, a limb-radial incision of the conjunctiva was performed at 7 and 9 hours with the release of the rectus lateralis muscle. Then, the lateral rectus muscle was taken on a muscle hook, it was freed from the anterior ciliary arteries, fascia and adhesions with retrobulbar structures. The muscle was stitched with suture material Vikril 6-0. The tendon of the muscle was cut off from the point of attachment, then a distance of 9 mm was measured on the sclera (planned new location of the rectus lateralis muscle) from the point of attachment of the muscle. The stitched rectus lateralis was displaced by 9 mm towards the equator. The same needle and thread made the first injection through the sclera into the upper part of the muscle root, then performed the second injection through the sclera into the lower part of the muscle root. The lateral rectus muscle was pulled by the thread, localizing to the corresponding volume of attenuation equal to 9 mm. Then the ends of the string were tied with triple multidirectional knots. After confirming the consistency of the seam, the threads were cut off. The second stage was an intensifying operation - median duplication, by forming a muscle fold in a volume of 8 mm on the rectus lateral muscle. At the end of the operation, nodal sutures were placed on the conjunctiva. In the postoperative period, the strabismus angle was -5 °, mobility in all positions of the gaze increased to 17 °, there were no complications in both the early and long-term postoperative periods. A follow-up examination after 1, 3 and 6 months showed the stability of the results.

The inventive method allows to increase the efficiency of the operation due to a significant decrease in the strabismus angle of friendly, unfriendly and restrictive strabismus on both primary and reoperated oculomotor muscles, especially with a pronounced restrictive component, provides long-term stability of the result of the operation, and also reduces the risk of complications during conducting an operation.

Claims (3)

1. A method of surgical treatment of friendly, unfriendly and restrictive strabismus, including a conjunctival incision in the projection of each operated extraocular muscle, isolation, suturing of the muscle with suture material, cutting it off from the attachment site, fixing the muscle to a new location, followed by suturing of the surgical wound and nodal suturing on the conjunctiva, characterized in that at the first stage, after isolation, stitching and cutting off the muscles from the place of attachment, they are measured on the sclera, towards the equa the torus, the proposed new location of the muscle, then the stitched muscle is displaced by a predetermined distance towards the equator, it is fixed on the sclera with the help of suspending sutures, the muscle is pulled by the thread, localizing at the corresponding weakening distance: with esotropia by 4-5 mm for the rectus medial muscle , with exotropy of 7-9 mm for the rectus lateral muscle, and in the second stage, the strengthening of the rectus lateralis muscle during esotropia by forming a muscle fold in the volume of 7-9 mm or the strengthening of the rectus medial muscle with exotropi by forming folds in the volume of muscle 6-8 mm. 2. The method according to p. 1, characterized in that they produce a limbal-radial incision of the conjunctiva at 7 and 9 hours with the release of the rectus lateralis muscle during exotropy or at 2 and 4 hours with the release of the rectus medialis muscle during esotropia. 3. The method according to p. 1, characterized in that at the end of the circulation when the retina detaches, the hanging threads are placed on the front surface of the circulation tape.

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