Method of refractive error correction in nystagmus

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely ophthalmology, and concerns refractive error correction in nystagmus. That is ensured by preoperative transconjunctival injections of the preparation Disport 7-17 Units in muscular sacs of two or four horizontal rectus muscles of both eyes. If observing pendular and pendular jerk nystagmus, Disport is injected in the four horizontal muscles, while jerk nystagmus requires the injections only in the sacs of the two muscles enabling eye turn to a nystagmus relative rest area. In 7-14 days, a standard LASIK or Photorefractive Keratectomy operation follows.

EFFECT: method provides simplified treatment process with higher effectiveness, and decreased number of complications.

3 cl, 3 dwg, 2 ex

 

The invention relates to medicine, namely to ophthalmology, and can be used when performing refractive surgeries (LASIK, PRK) in patients with different refractive errors, combined with nystagmus.

Nystagmus is an imbalance of the oculomotor system, in which the eyes of the patient are in relatively constant, ramp, or jerky movement and line of sight of the patient deviates from the object of fixation. This leads to reduced visual acuity, oscillopsia (the sense of movement in the surrounding environment), compensatory tremor or compensatory rotation of the head. Nystagmus is often combined with various refractive errors. Spectacle correction of ametropy is ineffective, because the visual axis constantly deviates from the optical center eyeglass lenses. Contact correction is barely acceptable, because eye movements lead to the fact that the contact lens is continuously shifted relative to the cornea, touching the edge of the eyelid. The optimal way of correcting refractive errors in the eye is refractive surgery. However, its technical realization requires the state of rest of the eyeballs.

Currently, due to the wide spread surgical methods for correction of refractive errors develop techniques to suppress any who tagma in the preoperative period or when performing refractive surgeries is an important task.

There is a method of suppression of nystagmus when performing photorefractive keratectomy (PRK) for myopia correction by total intravenous anesthesia with sodium thiopental to eliminate swinging movements of the eyeballs during the execution of the excimer laser keratectomy (Buzzards VP, Likhachev D.P., Lanovka SCI, Russian-Bedau .F.// Minoritarians. XII-th: Abstracts. - Odessa, 2001, p.á192).

The disadvantage of this method is the need for General anesthesia, which lengthens the time of surgery and the rehabilitation of the patient, and increases the complexity of the method, because a full anesthesia often is the crowding of the patient's eye upward, as in physiological sleep, which is an additional technical difficulty during the operation.

There is a method of medical treatment of horizontal nystagmus by destination inside of the drug Baclofen at 10-20 mg 3 times a day (Yee R.D., R.W. Baloh, Honrubia V.: Effect of baclofen on congenital nystagmus. In G. Lennerstrand, Zee D.S., E.L. Keller, eds: Functional Basis of Ocular Motility Disorders. Oxford, Pergamon Press: 1982, p.151).

The above-described method of medical treatment of nystagmus has several disadvantages:

1. Treatment is aimed at addressing the symptom and not on pathogenesis;

2. There are numerous side effects on the cardiovascular, digestive, urinary, the Central and peripheral nervous system, including inducing nystagmus;

3. There are many contraindications for the drug.

Closest to the claimed method of the prototype is a method of performing refractive surgery at the eye (patent No. 2337657, publ. 10.11.08), namely, that when krupnoyacheistoy horizontal or rotatory component of the nystagmus in the preoperative period retrobulbarno administering a mixture containing 20-40 mg of lidocaine, 0.4-0.5 mg of epinephrine and 4-6 UNITS lidz; then perform the tuning of the laser illumination of macular reflex followed by the ablation; and when small or srednerossiyskom the nystagmus after cutting the corneal valve when conducting laser in situ Keratomileusis (LASIK) or without cutoff valve of the cornea when performing photorefractive keratectomy (PRK) on the cornea establish a vacuum ring; then when marcorsyscom the nystagmus perform the tuning of tracer, and when srednerossiyskom - tuning of laser illumination of macular reflex; then perform the ablation. However after configuring tracer vacuum ring is removed and the operation is performed in the normal mode under the control of tracer.

However, the known method of performing refractive surgery at the eye has a number of disadvantages:

1. Suppression nastavnicheskij d is igenii eye occurs when small - and srednerossiyskom the nystagmus is already in operation;

2. When krupnoyacheistoy the nystagmus is retro-bulbar anesthesia-akinesia, which leads to dilated pupils, there is a risk of occurrence of acute vascular insufficiency, decreased vision, which is unfavorable for the operation when you want a clear gaze fixation.

An object of the invention is to simplify the known method, increasing its efficiency and reducing side effects.

The goal of the project is achieved by the proposed method lies in the following.

In the preoperative period patient transconjunctival enter drug Dysport dose 7-17 Units in the muscle bags two or four straight muscles of the horizontal action of both eyes, and then, after 7-14 days, perform surgery LASIK or PRK using standard technology.

Vcol needle is made in the conjunctiva 2 mm from the intended anatomical location of the muscle attachment to the sclera, the needle promote 5-7 mm in the distal direction, repeating the sphericity of the sclera (figure 1). Similarly perform the manipulation in the area of projection of the other muscles of the horizontal action of the eyes and the two horizontal muscles on the other eye.

When the ramp type of nystagmus injections are performed in all four muscles of horizontal steps in equal desire the framework (figure 2). When jerky type of nystagmus injections are performed only in bags of two muscles, providing turn eyes towards the zone of relative quiescence nystagmus in equal doses (figure 3). When matacabras-jerky type of nystagmus injections are performed in all four horizontal rectus muscles, with the only difference that in a couple of muscles on the side of the zone of relative quiescence, the drug is administered on 5 Units more.

Schematically in figure 2 and 3 shows the topography of drug Dysport, where

- Extraocular muscle, muscular bag which the drug is administered;

- The direction of the zone of relative calm of the eye.

In the particular case of injection use syringe with needle, 27 G diameter and length of 25-27 mm

The specific dosage administered drug depends on the characteristics of the nystagmus. When marcorsyscom the nystagmus optimal dose 7-10 Units, when srednerossiyskom - 11-14 Units, when krupnoyacheistoy - 15-17 Units.

A significant difference of the proposed method from the prototype is that muscle bags two or four straight muscles of the horizontal action of both eyes transconjunctival injecting enter drug Dysport in experimentally chosen, optimal concentration, component 7-17 Units, which allows to improve the shape stability of the manipulation, to reduce its invasiveness and reduce side effects.

The positive effect of the operation is achieved by the following induced biomechanical changes that are created when running transconjunctival injection drug Dysport in muscle bags:

the relative blocking pathological afferent hyperimmunisation by uncoupling the SYNOPTIC transmission in the eye muscles;

- performing refractive surgery in the relative stability of nystagmus;

secondary reduction of neuromuscular synapses in extraocular direct muscle horizontal actions;

- reduction potential of the torque response of these muscles unchanged Central hyperimmunisation after cessation of chemodenervation.

The combination of the above mechanisms causes a reduction in torque and diametrically indicators of horizontal lines of the muscles, which induces decreased tone of these extraocular muscles. This, in turn, causes a decrease in the oscillations of nystagmus. This creates favorable conditions for refractive surgery, as well as improve visual acuity and quality of life.

The method provides suppression of any form of nystagmus, and also contributes to the decrease in the degree of nystagmus.

Search on the sources of scientific, technical and patent information has not revealed how identical to declare, in connection with which it is possible to draw a conclusion on the conformity of the proposed technical solution the criteria of ”novelty” and ”inventive step”.

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

Example 1.

Patient P., aged 26, arrived in Novosibirsk branch of IRTC "eye microsurgery" with a diagnosis of Mixed astigmatism in both eyes, Srednerussky horizontal nystagmus.

During examination: visual acuity:

OD0,2with Corrsph+1,25DSW-3,50DAh 27°=1,0
OS0,2with Corrsph+1,25DSW-3,50DAh 142°=0,9

Refractometry:

ODsph+1,25DSW-3,50DAh 27°
OSsph+1,25DSW-3,50DAh 142°

Keratometry:

OD41,25DAh 116°38,50DAh 26°
OS41,75DAh 55°39,00DAh 145°

Srednerussky horizontal nystagmus to 15°.

The squint angle is 0°, with a cover uncover-test without installations.

Range of motion is full.

Anterior segment of eye without features. Environment transparent. The fundus of the eye without pathological changes.

7 days before the planned refractive surgery (LASIK) patients were performed injection Dysport by the claimed method. The surgical field was prepared accordingly. The right eye has established vekorasshiriteli, maximized eye slit. At the request of the physician, the patient looked to the right, following the object moved so that the eye was in the position of lead at half the possible amplitude. The eyeball was fixed toothed forceps in this position, by capturing the conjunctiva in the fold in 10 mm distal from the intended anatomical location of attachment of the inner straight muscle to the sclera.

the seat of transconjunctival vcol needle insulin syringe diameter 27G was carried out in 2 mm proximal to the localization of the conjunctiva forceps with subsequent movement of the needle 5 mm in the distal direction. Thus, the needle tip was localized in the muscle bag. Then press the plunger of the syringe was injected Dysport dose of 15 Units.

Similarly performed a manipulation on the outside of the straight muscle of the eye and the inner and outer straight muscle of the other eye with the only difference that vcol needle in the external rectus muscles carried out in 2 mm proximal to the location of the grip tweezers for conjunctival allotted to the outside eye, 14 mm distal from the intended anatomical location of attachment of the outer straight muscle to the sclera.

7 days after the injection operation performed LASIK on standard technology.

14 days after surgery performed control tests:

Visual acuity without correction:

OD of 0.9

OS 0,8

The amplitude of nystagmus decreased to 5° and wore a permanent nature.

Example 2.

Patient K., aged 20, arrived in Novosibirsk branch of IRTC "eye microsurgery" with a diagnosis of Complex myopic astigmatism high degree of both eyes, moderate amblyopia in both eyes, mixed Genesis, Srednerussky horizontal nystagmus.

Visual acuity:

OD0,04with Corrsph-4,00D su-2,00DAh 20°=0,4
OS0,04with Corrsph-4,50Dsu-2,75DAh 165°=0,4

Refractometry:

ODsph-4,50Dsu-2,50DAh 20°
OSsph-4,75DSW-3,25DAh 164°

Keratometry:

OD45,75DAh 106°44,00DAh 16°
OS46,00DAh 76°44,00DAh 166°

Srednerussky mixed (matacabras-jerky) horizontal nystagmus amplitude up to 10°. Zone of relative quiescence in the translation look right, compensatory head rotation to the left by 10°.

The squint angle is 0°, with a cover uncover-test without a moustache is anawak.

Range of motion is full.

Anterior segment of eye without features. Environment transparent. The fundus of the eye without pathological changes.

In the preoperative period patient was performed suppression of nystagmus by subconjunctival injection Dysport by the claimed method as in example 1, except that the dose of drug injected in a couple extraocular muscles on the side of the slow phase of nystagmus (external rectus of the right eye and the internal rectus of the left eye)was 17 Units, and the dose of the drug for a couple extraocular muscles on the side of the fast phase (internal rectus of the right eye and the external rectus of the left eye) - 7 Units.

10 days after the injection operation performed LASIK on standard technology.

14 days after surgery performed control tests:

Visual acuity without correction:

OD0,4n/a
OS0,4n/a

The amplitude melkorazmashistyj mixed (matacabras-jerky) horizontal nystagmus decreased to 5°. Zone of relative quiescence, when averts the right is preserved, compensatory head rotation to the left was reduced to 3-5°.

The squint angle is 0°, with a cover uncover-test without installations.

The amount of movement of the eye is limited by 10-15% compared to preoperative.

The proposed method has several advantages in comparison with known methods.

1. Subconjunctival injection is safe and effective and is performed on an outpatient basis.

2. Stabilization of pathological mobility eyes optimizes refractive surgeon, guaranteed increases the visual effect, eliminating the risk of complications that are possible with other methods of anesthesia.

3. Achieved in the refractive surgery emmetropia has a positive effect on the more stable the position of the eye in combination with paschimottanasana changes in extraocular muscle after termination of botulinum toxin-A.

The proposed method can not only effectively and simply to suppress nystagmus to conduct refractive surgeries, but also to ensure the disappearance or reduction of the amplitude of the oscillatory movements of the eyes.

1. The method of correcting refractive errors in the eye, including preliminary suppression of nystagmus and then performing refractive surgery using the standard method, wherein the patient in the preoperative p is the period transconjunctival enter drug Dysport dose 7-17 Units in the muscle bags two or four straight muscles of the horizontal action of both eyes, when the ramp and matacabras-jerky type of nystagmus injections of Dysport perform in all four muscles of horizontal steps, and when the jerky type of nystagmus injections are performed only in bags of two muscles, providing turn eyes towards the zone of relative quiescence nystagmus.

2. The method according to claim 1, characterized in that when marcorsyscom the nystagmus drug Dysport is administered at a dose of 7-10 Units, when srednerossiyskom-11-14 Units, and when krupnoyacheistoy - 15-17 Units.

3. The method according to claim 1, characterized in that the injection Dysport use a syringe with needle, 27 G diameter and length of 25-27 mm



 

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10 cl, 3 tbl

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely ophthalmology, and can be used for surgical management of retinal detachments if scleral filling appeared to be non-effective. It involves local vitrectomia followed by retinal gas tamponade though the same approach, and transpupillar retinal retention laser coagulation Vitrectomia is performed in the central zone of a vitreous body (VB) with replacing a VB portion by a gas portion of the same volume which is also brought behind the central zone with using a needle attached to a syringe. The single replacement makes 0.3-0.5 ml, while total volume is 1 ml. Before every following removal of the VB portion, a surgeon turns an operated eye away at an angle 15-20°C and holds it in such position to perform vitrectomia, and with every following bringing of the gas portion, the needle is positioned with its outlet section surface upwards.

EFFECT: method ensures a high percentage of retinal attachment, reduces intraoperative injures and length of operation.

3 cl, 2 ex

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