Method of treating squint with atypical innervation of extraocular muscles

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely ophthalmology and may be used to treating spastic squint and atypincal squint accompanying type 1 Duane syndrome. It involves exposing a lateral end of an internal rectus muscle, further at 2-3 mm from an attachment point of the muscle to sclera a needle is inserted in an end face of the lateral muscle; the needle is moved at 8-10 mm along the muscle in a distal direction at an angle from the lateral end of the muscle to its middle axial border, and the preparation Disport 15-20 units is introduced. The incisional wound is closed. The similar method is used for surgical manipulations on the internal rectus muscle of the other eye, if the patient suffers from spastic squint and double Duane syndrome.

EFFECT: method provides reduced dynamometric functions of the internal rectus muscles and compensated optimal balance in the oculogyric system.

2 dwg, 2 ex

 

The invention relates to medicine, namely to ophthalmology, and can be used in the treatment of spastic strabismus and atypical strabismus syndrome Dwayne (type 1).

As you know, spastic strabismus is a state of the oculomotor system, in which the internal rectus muscles are sent regular hyperimmunity due to neurological diseases, accompanied by General hypertonicity of the entire nervous system.

When you first type of syndrome Duane cause of strabismus is pathological cross-redistribution innervation of the inner and outer straight muscles, the internal rectus receives nerve impulses from the eye and from lateral nerve.

Symptoms of spastic strabismus are: no or drastically reduced abstraction eyeballs out, expressed convergent strabismus, often simultaneous bilateral not alternating. When you first type of Duane syndrome is marked one - or two-sided limitation of abduction of the eye, convergent strabismus, retraction of the eye and narrowing of the palpebral fissure when you try to lead the eye. In both cases, the violations are functions of mono - and binocular vision, accompanied by severe physical discomfort and exclusion of patients in the domestic and social sphere.

is swesty different methods of surgical treatment of spastic strabismus and strabismus syndrome Dwayne the first type, the essence of most of them is to perform a weakening domestic direct muscle and (or) partial or full lateral transposition of the vertical muscles of the action.

Known, for example, a method of surgical treatment of strabismus in the first type of Duane syndrome and spastic strabismus, namely, that to increase the amplitude of the eye movement of the outer parts of the upper and lower straight muscle is stitched respectively to the upper and lower parts of gipoallergennoy outer muscles (Jensen C.D.F. Rectus muscle union: A new operation for paralysis of the rectus muscle // Trans. Pacific Coast Ophthalmol. Soc. 1964, Vol.45, p.359).

The known method allows you to restore some degree of mobility of the eye towards the outer straight muscle. However, the known method has a number of disadvantages.

1. You gain contradictious muscles without weakening the muscles, which increased and are a major causal factor in strabismus.

2. The extent of surgical intervention due to the large tissue trauma and compression of anterior ciliary arteries leads to significant swelling of the conjunctiva and ischemia of the anterior eye segment.

3. Intervention on the vertical straight muscle creates the risk of lung of these anomalies, narrowing of the palpebral fissure and the emergence of vertical strabismus.

WPI the walls of the treatment of strabismus with atypical innervation extraocular muscles by performing the recession, domestic direct muscle (Von Noorden G.K., Campos Y.S. Binocular vision and ocular motility: theory and management of strabismus. - 6th ed., 2007, p.587-588), which are as follows. After selecting the capture muscle muscle hook at its upper and lower edge as close as possible to the scleral attachment impose two knotted suture using vicryl 6-0. The muscle is cut with scissors and is stitched to the sclera in 4-10 mm distally. Surgical wound is sutured.

The proposed method leads to a metered weakened contractility of the interior direct the muscles and helps to reduce the magnitude of strabismus.

However, the proposed method reduce the effects of internal direct muscle has a number of disadvantages.

First, the recession implies a change in the static performance of the muscles, and spastic strabismus and abnormal hyperinnervation when the first type of Duane syndrome increases its dynamics.

Secondly, bilateral recession in physiological amounts, is unable to correct the deviation, and the increase in the volume of transactions leads to the secondary constraint casts and reduced convergence.

Thus, the weakening of the domestic direct muscle is achieved through changes diametrically indicators extraocular muscles. When the recession is changing the point of application of the lever, but hyperinflate still call the characteristic hypermagnesemia domestic direct muscle.

The most closest to the claimed method of the prototype is a method of treatment of paralytic strabismus, including the introduction of the drug Dysport dose of 10-20 Units in extraocular ipsilateral muscle antagonist paralyzed extraocular muscles, in addition, depending on the type of paralysis carry out the introduction of the drug in one or more muscles, which is contralateral synergistic paralyzed muscles (patent RU 2257914 C1, 10.08.2005). The method is as follows. Formed in verkhneingulskoe space put muscle hook without limiter, turn the hook 180° (when the tip slides over the sclera), grab the muscle at its attachment. Hook slip to 3-4 mm distal from the insertion along the muscles and raise above the sclera of 1.5-2 mm Under the muscle slid the spatula-mirror width 4 mm Muscle hook is removed. The conjunctiva and tenon shell shift to the private zone of radial access edge muscles with tweezers and slid over the edge of a spatula mirrors. After that, departing at 5 mm from the point of insertion of the muscle to the sclera distally along the muscles, produce vcol needle 27 G in the middle part of the muscle bag, move the needle 5 mm along the muscles in the distal direction, then in a muscular bag enter drug Dysport dose of 10-20 Units. About erational the wound is sutured. In a similar way to perform surgical procedures on extraocular muscle, which is the contralateral synergist paralyzed muscles. If paralysis involving two or more extraocular muscle, the drug is injected in the appropriate extraocular muscles of the contralateral synergist.

The method reduces the risk of malnutrition paralyzed muscles and the development of hypertrophy her antagonist, causing the contracture condition between these muscles and to eliminate the likelihood of hyperthyroidism contralateral synergist muscles.

The disadvantages of this method are:

- the complexity of the number of technical manipulation of the surgical instruments before performing the injection: offset hook 3-4 mm distal from the insertion along the muscles, pripodniatii muscles above the sclera of 1.5-2 mm, the institution under the muscle spatula-mirrors 4 mm wide;

- introduction of a needle into the muscle bag, departing 5 mm from the point of insertion of the muscle to the sclera, is complicated when the contracture of this muscle;

- introduction of a needle into the middle third of the muscle bags confidently localize the drug only in its namiseom space.

An object of the invention is to simplify the known method and effectiveness of treatment is.

The goal of the project is achieved by the claimed method consists in the following.

After preparation of the surgical field and retro-bulbar (or intravenous balanced multi-component) anesthesia free lateral edge of the inner straight muscle (lateral access to the internal direct extraocular muscle) to render it without highlighting it. Then, after 2-3 mm from the point of insertion of the muscle to the sclera, produce vcol needle into the end of the lateral edge of the muscle, the needle slip on 8-10 mm along the muscles in the distal direction at an angle from the lateral edge of the muscle to its average axial boundary and injected 15-20 Units of Dysport (figure 1). Surgical wound is sutured. In a similar way to perform surgical procedures on internal straight muscle of the other eye if the patient spastic strabismus and bilateral Duane syndrome (figure 2).

Schematically in figure 2 presents the topography of drug Dysport, where

Internal rectus, which is the target for chemodenervation.

The required amount of drug Dysport to achieve effective induced paralysis internal direct muscle depends on the size of strabismus, limited mobility of the eye outwards and the patient's age. The minimum dose of 15 units of naznachen the Xia in the presence of one of the following conditions: the value of strabismus of less than 15°, limiting the mobility of the eye up to 50% from age norms and age of the patient up to 2 years. In other cases, the dosage is 20 Units. Dosage of 15-20 Units sufficient for the maximum off extraocular muscle in which you inject, and to achieve secondary esotropia. During the existence of induced paralysis in the ophthalmic portion extraocular muscles responsible for its contractility that occurs secondary malnutrition, and the number of newly formed neuromuscular synapses is less than before the injection. Thus, the contractile response of the muscle to a pathological hyperimmunisation becomes smaller, which symptomatically is reflected in the decrease of value of strabismus and increase the motility of the eye outwards.

A significant difference of the proposed method from the prototype is that the injection Dysport perform side-only access to the affected muscle, the muscle does not produce and does not raise above the sclera, which allows to simplify the method and provide a more complete distribution of the drug in the muscle bag and achieving the most effective, richly innervated part of the muscles, which in turn makes it possible to reduce the contractile response of the muscle on the unchanging hyperimmunization.

Execution inye the tion of the drug Dysport in extraocular muscle paralytic strabismus (Patent RU 2257914 C1, 10.08.2005) have a different functional purpose, namely to prevent the development of hypertrophy and contracture of the antagonist of the affected muscles and creating conditions for a more full recovery and avoid the possibility of secondary imbalance in the oculomotor system.

The positive effect of the proposed method of drug Dysport in the internal rectus muscles is achieved by creating the following modulated biomechanical mechanisms:

- creates a secondary malnutrition orbital part extraocular muscles responsible for muscle contraction, as a result decreasing the amount of strabismus;

- as a result of reinnervation is detected occurs fewer nerve-muscle synapses, resulting in decreased contractility of the internal direct muscle in response to the constant hyperimmunisation;

- creation of secondary esotropia gives the possibility of orthotropy in the stage regression induced paralysis with intact binocular vision;

- no diametrically change broadens the scope of possible surgical procedures as subsequent stages of the treatment of strabismus.

The combination of these artificially created biomechanical conditions reduces the torque of the internal direct muscle and ur evasive optimal balance in the oculomotor system.

The search for 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 implementation method.

Example 1.

Patient K., 2 years. Diagnosis: Spastic convergent strabismus.

During examination:

1. The angle of strabismus:

The direction of gazeRight eyeLeft eye
When you look to the rightto +60°> +60°
When looking straight+45°+45°
When you look to the left> +60°to +60°

2. Mobility:

The direction of gazeRight eyeLeft eye
Cast50°50°
Allocated to the e 10°

The patient was put Dysport by the claimed method. After multicomponent balanced anesthesia and processing operating margins introduced vekorasshiriteli maximally exposing the eyeball. Next, to provide direct access to the internal muscle of the right eye with tweezers captured the conjunctiva for 3 hours and took the eyeball. Conjunctival spring scissors were made by one radial incision of the conjunctiva and tenon's capsule length of 10 mm along the Meridian 4 hours. Scissors were useprofile the tenon capsule from episclera in ninanajna quadrant. Formed in ninanajna space put muscle hook with stop, the tip of the hook is thus directed away from the sites of proposed insertion of the muscle. Turn the hook 180° (when the tip slides over the sclera), invaded the muscle at its attachment. Took my eyes. The conjunctiva and tenon shell shifted to the private zone of radial access edge muscles with tweezers. Thus, the beginning of muscular abdomen was allocated in the area of the conjunctival incision, muscle bag remained intact. Then, after 2-3 mm from the point of insertion of the muscle to the sclera, made vcol needle 27 G in the end of the lateral edge of the muscle, the needle sweep and 8-10 mm along the muscles in the distal direction at an angle from the lateral edge of the muscle to its average axial boundary and injected 20 Units of Dysport. The needle was extracted from the muscle of the handbags, the reverse movement, the pre-pressing place of vcol cotton swab. Making sure that from a place of vcol not put out a drug taken muscle hook from under the muscle. Edge of the cut conjunctival and tenon's membrane closed. The wound left the house taking with absorbable thread 7-0. Anchor suture was placed on the middle portion of the radial slit.

Under the conjunctiva was injected with 0.3 ml of 1% solution of Dexasone and peppered with dry Sulfacetamide. Removed vekorasshiriteli and put a sterile dressing.

Then proceeded to perform an operation on my left eye on the above technologies in internal direct muscle. This changed only the Meridian radial incision at the access to the operated extraocular muscles - 9 hours.

In the postoperative period in the conjunctival cavity both eyes have installed the solution of Cipromed 4 times a day for 7 days.

During examination of the patient after 6 months the following has been discovered.

The angle of strabismus:

+12°
The direction of gazeRight eyeLeft eye
When you look to the right+15°+10°
When looking straight+12°
When you look to the left+10°+15°

Mobility:

The direction of gazeRight eyeLeft eye
Cast45°45°
Abstraction55°50°

Thus, significantly decreased the amount of strabismus. However strabismus from spastic condition became friendly state.

Abstraction in both eyes grew to the age norm.

Example 2.

The patient Including, for 6 years. Diagnosis: Bilateral Duane syndrome type 1.

During examination:

The angle of strabismus:

The direction of gazeRight eyeLeft eye
When you look to the right+30°Not defined
When looking straight+17°+15°
When you look to the leftNot defined+35°

Mobility:

The direction of gazeRight eyeLeft eye
Cast30°30°
Abstraction

The patient injections were performed by the claimed method as in example 1 except that the dosage of the drug Dysport was 17 Units.

10 months after treatment when conducting follow-up examination revealed the following.

The angle of strabismus:

The direction of gazeRight eyeLeft eye
When you look to the right+15°Not defined
When looking straight
When you look to the leftNot on the determined +15°

Mobility:

The direction of gazeRight eyeLeft eye
Cast30°30°
Abstraction25°25°

Thus, there has been a steady position of the eyes in the primary position of gaze, expanded the field of binocular vision sufficient for a normal life.

The proposed method is simple in execution, allows injection Dysport only in the affected muscle side access, to eliminate the labor-intensive stages of the operation, which provides better distribution of the drug in the muscle bag and achieving the most effective, richly innervated part of the muscle.

Method for the treatment of strabismus, abnormal innervation extraocular muscles, including the release of direct access to the internal muscle, highlighting the latest and drug Dysport, characterized in that the free lateral edge of the inner straight muscles, then departing at 2-3 mm from the point of insertion of the muscle to the sclera, produce vcol needle in the butt lateraling the edge of the muscle, the needle slip on 8-10 mm along the muscles in the distal direction at an angle from the lateral edge of the muscle to its average axial border and enter drug Dysport dose of 15-20 Units.



 

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