Method for correcting restrictive strabismus in endocrine ophthalmopathy
The method addresses limitations in surgical treatment of restrictive strabismus by using remote sutures and intermuscular fascia fixation to enhance muscle weakening and eye mobility, minimizing complications and improving surgical accuracy.
Patent Information
- Authority / Receiving Office
- RU · RU
- Patent Type
- Patents
- Current Assignee / Owner
- FEDERALNOE GOSUDARSTVENNOE BYUDZHETNOE NAUCHNOE UCHREZHDENIE NAUCHNO-ISSLEDOVATELSKIJ INSTITUT GLAZNYKH BOLEZNEJ IM M M KRASNOVA (FGBNU NIIGB IM M M KRASNOVA)
- Filing Date
- 2025-12-29
- Publication Date
- 2026-06-30
AI Technical Summary
Existing surgical methods for treating restrictive strabismus in endocrine ophthalmopathy face challenges such as limited muscle weakening effect, inaccurate postoperative results, technical difficulties in creating scleral flaps, increased risk of complications like deformation and perforation, and cosmetic defects due to scleral thinning.
The method involves recession and lengthening of extraocular muscles using remote sutures and suturing the intermuscular fascia to the eyeball, with specific suture placement to prevent muscle detachment and reduce eye movement restrictions.
This approach enhances surgical effectiveness by preventing complications, improving eye mobility, and ensuring accurate muscle fixation, while reducing the risk of intraoperative and postoperative issues.
Smart Images
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Abstract
Description
[0001] The invention relates to medicine, namely to ophthalmology, and can be used to correct restrictive strabismus in endocrine ophthalmopathy.
[0002] Endocrine ophthalmopathy (EOP) is known to be often accompanied by specific inflammation of the extraocular muscles, which results in fibrosis, impaired muscle fiber extension, and, consequently, restrictive strabismus with severe limitation of ocular mobility in the direction opposite to the action of the affected extraocular muscle. The first stage of surgical correction of strabismus associated with EOP involves weakening procedures—muscle recessions. Given that the deviation angles of the eye in this extraocular muscle disorder are often large (more than 25 degrees), and eye mobility from the initial position is significantly limited (or absent), a large (forced) recession of the fibrously altered muscle is necessary.In turn, such rectus muscle recession is associated with displacement of its attachment point to the sclera far beyond the equator of the eyeball, which inevitably leads to a change in the leverage of the eyeball and a decrease in its mobility in the direction of the recessed muscle during contraction. To prevent this undesirable effect, it is more appropriate to perform muscle lengthening in combination (or without) with its recession(s). However, the site of attachment of the muscle tendon to the prolonging (lengthening) material subsequently undergoes adhesion to the surface of the eyeball, creating an additional point of muscle attachment to the eye in the retroequatorial zone, which can also reduce the range of eye movement in the direction of the operated muscle.
[0003] A known method for the surgical treatment of concomitant, inconsistent, and restrictive strabismus consists of the following: in the first stage, the weakened muscle, after being suturing with suture material and dissected from its attachment site, is fixed to its original attachment site on the sclera using suspender sutures at a distance of 4-5 mm from the muscle attachment site for esotropia for the medial rectus muscle or 7-9 mm for exotropia for the lateral rectus muscle. In the second stage, a median duplication of the lateral rectus muscle is performed for esotropia in a volume of 7-9 mm or a duplication of the medial rectus muscle in a volume of 6-8 mm for exotropia (Patent RU 2705041, 01.11.2019).
[0004] The disadvantages of this method are:
[0005] - a small amount of recession, has a limited weakening effect in restrictive strabismus, which is manifested by a weak improvement in eye mobility in the direction opposite to the recessed muscle.
[0006] - performing a single-stage reinforcing operation (duplication) reduces the accuracy of predicting postoperative results.
[0007] The closest approach to the claimed method is for treating restrictive strabismus associated with endocrine ophthalmopathy. This involves first lengthening the inferior rectus muscle using a 2-8 mm long trapezoidal flap, extracted from the sclera toward the equator, which becomes a continuation of the tendinous portion of the muscle. In the second stage, which is performed if the patient is not satisfied with achieving orthoposition of the eyes in a straight line and if double vision occurs when shifting the gaze upward, the superior rectus muscle, which is the contralateral antagonist in the healthy eye, is fixed to the sclera with two cross-sutures, 12-16 mm from its physiological attachment site in the area behind the equator of the eyeball. The thickness of the scleral flap being cut is 1 / 3 of the scleral thickness. When cutting a scleral flap longer than 2 mm, its lateral edge is distally shifted 1-3 mm temporally.Sutures are placed on the sclera, covering 1 / 3 of its thickness, with a stitch length of 2-3 mm (Patent RU 2313319, December 27, 2007). The disadvantages of the prototype are:
[0008] - The need for a scleral flap. Accessing the muscle tendon and cutting a scleral flap of the required thickness are technically challenging given the large angles of strabismus and the lack of passive eye movements from the initial position.
[0009] - Too thin a scleral flap increases the risk of deformation, cutting through, and even detachment from the base due to significant muscle tension in patients with severe restriction associated with endocrine myopathy.
[0010] - Too thick a U-shaped scleral flap contributes to a significant weakening of the supporting and protective function of the remaining thickness of the sclera in the area of flap formation.
[0011] - In the area of thinning of the sclera (formation of the scleral flap), translucency of the choroid is observed, which is a cosmetic defect.
[0012] - Adhesions form in the flap formation area, significantly complicating repeat surgical interventions in this area. The risk of eyeball perforation during procedures increases.
[0013] - The formation of large flaps (greater than 6.5 mm) leads to displacement of the muscle attachment point (scleral flap) into the retroequatorial space, which reduces the range of eye movement in the direction of the weakened muscle. In cases of vertical restrictive strabismus correction, gaze misalignment may occur, manifesting as diplopia.
[0014] The objective of the invention is to create a method that increases the effectiveness of surgical intervention.
[0015] The technical result of the invention is the prevention of possible intraoperative and postoperative complications, such as disruption of muscle fixation (rupture) in the calculated place to the sclera, perforation of the eyeball during surgery or in the postoperative period as a result of thinning of the sclera; prevention of a decrease in the amplitude of movement of the eyeball.
[0016] The technical result is achieved through recession and lengthening of the straight extraocular muscles using remote sutures and suturing the intermuscular fascia to the eyeball.
[0017] The method can be used both as a single stage of surgical treatment and in combination with various options for interventions on extraocular muscles, enhancing their effect.
[0018] The method is illustrated in Fig. 1, where 1 is the limbal incision of the conjunctiva, 2 are the radial relaxing incisions of the conjunctiva, 3 is the tendon of the rectus extraocular muscle, 4 is the ligature suture, 5 is the place of attachment of the tendon of the rectus muscle to the sclera, 6 is the place of the first stitch (the point of insertion and removal of the needle) through the sclera in the direction of the cornea, 7 is the place of the second stitch (the point of insertion and removal of the needle) through the sclera in the direction of the cornea, 8 is the triple fixing knot of the ligatures, 9 is the inner leaf of the fascial sheath of the muscle and the intermuscular fascia, 10 are the nodal sutures fixing the inner leaf of the fascial sheath of the muscle and the intermuscular fascia to the sclera, 11 is the limbus, 12 is the equator of the eyeball.
[0019] The method is carried out as follows.
[0020] To correct restrictive strabismus in endocrine ophthalmopathy, first make a conjunctival incision concentric with the limbus in the meridian of the operated muscle. Additionally, make two relaxing conjunctival incisions toward the fornix. The edges of the rectus tendon are sutured with non-resorbable ligatures. A complete tenotomy is performed. The sclera is sutured with the same ligatures in the pre-equatorial zone using return sutures, each consisting of two scleral stitches in the direction of the limbus. The first stitch is placed at the calculated location posterior to the original attachment site in the projection of the corresponding edge of the muscle tendon, with the distance between the first punctures corresponding to the width of the muscle tendon. The second stitch is placed 2-3 mm posteriorly and more centrally relative to the first stitches. The length of the sutures is adjusted according to the calculated length and the free ends of the ligatures are fixed together using a triple knot.The inner leaflet of the fascial sheath of the corresponding rectus muscle and intermuscular fascia are placed under the muscle and ligature sutures and fixed in two places with interrupted resorbable sutures to the sclera.
[0021] Clinical Example 1
[0022] Patient L., 50 years old. Visited the Federal State Budgetary Scientific Institution "M.M. Krasnov Research Institute of City Hospital" in January 2024. She has been under the observation of an endocrinologist for hypothyroidism since 2018. In August 2021, symptoms of EOP appeared: eyelid edema, and since December 2021 - diplopia. In January 2022, pulse therapy with prednisolone was performed (total dose 7800 mg). In February 2022 - orbital radiation therapy. In July 2023, radioiodine therapy was performed, and L-thyroxine was prescribed. TSH has been normal since January 2024. The patient does not smoke. At the time of presentation, the main complaint was double vision, downward deviation of the right eye.
[0023] Preoperative examination result:
[0024] Vision pattern: diplopia (in all directions of gaze). The left eye is dominant. The upward mobility of the right eye is limited in adduction and especially in abduction - Fig. 2.
[0025]
[0026]
[0027] According to the CT scan of the orbits from March 19, 2024, an increase in the size of the inferior rectus muscle of the right and left eyes (OD>OS) is noted.
[0028] The patient is scheduled for surgery on her right eye using the proposed method, covering a volume equivalent to an 8.0 mm inferior rectus muscle recession. After combined (intravenous and local) anesthesia, a 3-4 mm limbal conjunctival incision is made at the 6 o'clock meridian. Radial relaxing incisions are made in the conjunctiva toward the inferior fornix. The inferior rectus tendon is isolated and secured with a hook. Interrupted ligature sutures (6 / 0 polyester) are placed on the tendon edges. After preliminary coagulation of the muscle vessels, the muscle tendon is dissected from its attachment to the sclera anterior to the ligature sutures. Using an ophthalmic caliper, the location of the future fixation of the sutures to the sclera was marked 4.0 mm posterior to the original site of attachment of the tendon to the eyeball.Each needle and ligature were used to suture the sclera toward the limbus: the first stitch was placed at the marked location on the sclera (4.0 mm from the original attachment site), the second stitch was placed 2 mm posteriorly and 2 mm more centrally (in the direction of the opposite ligature). The suture length from the first stitch (fixation to the sclera) to the muscle tendon suturing site was set at 4.0 mm. This positioned the edge of the inferior rectus tendon behind the equator of the eyeball. The ends of the sutures were tied together with a triple knot. Using fixation forceps, the inner layer of the fascial sheath of the inferior rectus muscle and intermuscular fascia was inserted under the muscle and suture ligatures. Two interrupted 7 / 0 Vicryl sutures were used to secure the sheath to the sclera, 1-2 mm posterior to the suturing site (first stitch). The conjunctiva was closed with interrupted 7 / 0 Vicryl sutures.
[0029] Result of follow-up examination 3 months after surgery:
[0030] Vision in natural conditions and under color haploscopy: binocular, stable. Maddox distance test results: exophoria 6-7 PD, infrahyperphoria 3 PD. The right eye has almost full upward mobility in adduction and abduction, and full downward mobility - Fig. 3.
[0031]
[0032] Clinical Example 2
[0033] Patient X., 50 years old, consulted the M.M. Krasnov Research Institute of City Hospital in April 2023. Diagnosis: OU - Endocrine ophthalmopathy. Binocular diplopia. History: manifestations of endocrine ophthalmopathy (OU exophthalmos, strabismus, double vision) since 2022. Pulse therapy with systemic glucocorticosteroids was performed. In 2023, transnasal endoscopic bilateral orbital decompression, lateral bone decompression of the right and left orbits, and thyroidectomy were performed. Since 2023, the patient has been on replacement therapy with euthyrox.
[0034] The main complaint is double vision, alternating deviation of the eyes towards the nose.
[0035] Preoperative examination result:
[0036] Vision pattern: diplopia (in all directions of gaze). Alternating. Most often, the patient fixates with the left eye. Mobility of the right and left eyes is limited outward and upward in adduction and abduction - Fig. 4.
[0037] Vis OD=1.0.
[0038] Vis OS=1.0.
[0039] Synoptophore data:
[0040]
[0041] The patient is scheduled to undergo surgical intervention on the right and left eyes using the proposed method in a volume equivalent to a recession of each internal rectus muscle by 8.5 mm.
[0042] Description of surgical intervention on the right eye:
[0043] After combined (intravenous and local) anesthesia, a 3-mm limbal conjunctival incision was made in the medial sector. Radial relaxing incisions were made in the conjunctiva in the medial direction. The tendon of the internal rectus muscle was isolated and secured with a hook. Interrupted ligature sutures (6 / 0 polyester) were applied to the edges of the tendon. After preliminary coagulation of the muscle vessels, the muscle tendon was dissected from its attachment to the sclera anterior to the applied ligature sutures. Using an ophthalmic caliper, the site of future suture fixation to the sclera was marked 5.0 mm posterior to the original site of tendon attachment to the eyeball. Each needle with a ligature was used to stitch the sclera in the direction of the limbus: the first stitch was made at the place marked on the sclera (5.0 mm from the original attachment site), the second stitch was made 2 mm posteriorly and 3 mm more centrally (in the direction of the opposite ligature).The suture length from the first stitch (fixation to the sclera) to the muscle tendon insertion site was set at 3.5 mm. The edge of the inferior rectus tendon was thus positioned behind the equator of the eyeball. The ends of the sutures were tied together with a triple knot. Using fixation forceps, the inner leaflet of the fascial sheath of the internal rectus muscle and the intermuscular fascia was inserted under the muscle and suture ligatures. Two interrupted 7 / 0 Vicryl sutures were used to secure the suture to the sclera 1-2 mm posterior to the insertion site (first stitch) using scleral ligature sutures. The conjunctiva was closed with interrupted 7 / 0 Vicryl sutures.
[0044] A similar intervention was performed on the left eye.
[0045] Result of follow-up examination 4 months after surgery:
[0046] Vision in natural conditions and under color haploscopy: binocular, stable. Maddox test result (distance): orthophoria. Torrington test (near): orthophoria. Limited upward mobility of the right and left eyes remains. Outward mobility of the OU is full - Fig. 5.
[0047] Vis OD=1.0.
[0048] Vis OS=1.0.
[0049] Synoptophore data:
[0050]
[0051] Clinical Example 3
[0052] Patient Ch., 51 years old, consulted the M.M. Krasnov Research Institute of City Hospital in May 2023. Her medical history reveals that the first signs of EOP appeared in 2018: eye pain, lacrimation, and double vision. In 2019, she was diagnosed with diffuse toxic goiter. The patient received systemic glucocorticosteroids (prednisolone) orally. A thyroidectomy was performed. Medicinal euthyroidism was achieved. In July 2023, she underwent correction of the convergent component of strabismus associated with endocrine ophthalmopathy in the right eye (RecRM 5.0 mm + PlicRL 5.0 mm).
[0053] In this case, the main complaint is double vision (images tilt in different directions and vertical displacement), which intensifies when looking up; forced (tilted) head position, limited upward gaze.
[0054] Preoperative examination result:
[0055] Vision pattern: diplopia with straight ahead gaze, sideways gaze, and upward gaze. Binocular vision when looking down. The dominant eye fixes with the left eye. Upward mobility of the right and left eyes is limited in adduction and especially in abduction. Infrahypertropia is observed with dextroversion, and suprahypotropia with sinistraversion. Fig. 6.
[0056]
[0057]
[0058] The patient is scheduled to undergo surgical intervention on the right and left eyes using the proposed method in a volume equivalent to a recession of each inferior rectus muscle by 9.0 mm.
[0059] Description of surgical intervention on the right eye:
[0060] After administering combined (intravenous and local) anesthesia, a 3-mm limbal conjunctival incision was made at the 6 o'clock meridian. Radial relaxing incisions were made in the conjunctiva toward the inferior fornix. The tendon of the inferior rectus muscle was isolated and secured with a hook. Interrupted ligature sutures (6 / 0 polyester) were applied to the edges of the tendon. After preliminary coagulation of the muscle vessels, the muscle tendon was dissected from its attachment to the sclera anterior to the applied ligature sutures. Using ophthalmic calipers, the site of future suture fixation to the sclera was marked 4.5 mm posterior to the original tendon attachment to the eyeball. Each needle with a ligature was used to stitch the sclera in a zigzag pattern in the direction of the limbus: the first stitch was made at the place marked on the sclera (4.5 mm from the original attachment site), the second stitch was made 2 mm back and 3 mm more centrally (in the direction of the opposite ligature).The suture length from the first stitch (fixation to the sclera) to the muscle tendon suturing site was set at 4.5 mm. This positioned the edge of the inferior rectus tendon behind the equator of the eyeball. The ends of the sutures were tied together with a triple knot. Using fixation forceps, the inner leaflet of the fascial sheath of the internal rectus muscle and the intermuscular fascia was inserted under the muscle and suture ligatures. Using two interrupted 7 / 0 Vicryl sutures, the suture was secured to the sclera 1-2 mm posterior to the suturing site (first stitch) using scleral ligature sutures. The conjunctiva was closed with interrupted 7 / 0 Vicryl sutures.
[0061] A similar intervention was performed on the left eye.
[0062] Result of follow-up examination 4 months after surgery:
[0063] Vision type: binocular, stable. Maddox distance test results: exophoria 5 PD, infrahyperphoria 2 PD. Upward mobility of the right and left eyes has significantly improved in adduction and abduction, and downward mobility is full (Fig. 7).
[0064]
[0065] Synoptophore data:
[0066]
[0067] Thus, the method allows for increasing the effectiveness and functionality of the treatment of restrictive strabismus with EOP, improving the accuracy and convenience of dosing the amount of weakening (recession with lengthening using remote sutures) of the muscle; simplifying the technique and reducing the duration of the operation, preventing possible intraoperative and postoperative complications, such as disruption of muscle fixation (rupture) at the calculated site to the sclera, perforation of the eyeball during surgery or in the postoperative period as a result of thinning of the sclera; as well as reducing the amplitude of eyeball movement.
Claims
A method for correcting restrictive strabismus in endocrine ophthalmopathy, including recession of the rectus muscle of the eye using remote ligature sutures, characterized in that first an incision is made in the conjunctiva concentrically to the limbus in the meridian of the location of the operated muscle, in addition 2 relaxing incisions of the conjunctiva are made towards the fornix, the edges of the tendon of the rectus muscle are sutured with non-resorbable ligatures, a complete tenotomy is performed, the sclera is sutured with the same ligatures in the preequatorial zone using return sutures, each consisting of two scleral stitches in the direction of the limbus, wherein the first stitch is made at the calculated location posterior to the original attachment site in the projection of the corresponding edge of the tendon of the muscle with a distance between the first punctures corresponding to the width of the tendon of the muscle, the second stitch is made posteriorly by 2-3 mm and more centrally in relation to the first stitches,The length of the sutures is adjusted in accordance with the calculated length and the free ends of the ligatures are fixed together using a triple knot; the inner leaflet of the fascial sheath of the corresponding rectus muscle and intermuscular fascia are placed under the muscle and the ligature sutures and fixed in two places with interrupted resorbable sutures to the sclera.