How is strabismus surgery done and how effective it is. Surgical treatment of strabismus, surgery, after surgery After surgery for strabismus

Often, strabismus surgery does not immediately return normal vision. Many will agree that it is a pity to look at a mowing young pretty girl or child. Without this cosmetic defect, everything would be fine. In addition, ophthalmologists recommend that before going under the knife, try conservative methods treatment of strabismus.

What is strabismus, or squint

Strabismus is a pathology in which one, both, or alternately the right and left eyes deviate from the normal position when looking directly. When a person looks at an object, the information received by each eye is slightly different, but the visual analyzer in the cortical region of the brain unites everything. With strabismus, the pictures are very different, so the brain ignores the frame from the squinting eye. The prolonged existence of strabismus leads to amblyopia - a reversible functional decrease in vision, when one eye is practically (or completely) not involved in the visual process.

Strabismus can be congenital or acquired. Floating or squinting gaze is common in newborns, especially after a difficult birth. Treatment by a neurologist can relieve or alleviate the appearance of a birth injury. Another cause may be a developmental abnormality or improper attachment of the oculomotor muscles (see Figure 1).

Acquired squint results from:

infectious disease: influenza, measles, scarlet fever, diphtheria, etc.;

somatic diseases;

injuries;

a sharp drop in vision in one eye;

myopia, hyperopia, high and moderate astigmatism;

stress or severe fright;

paresis or paralysis;

diseases of the central nervous system.

How can you get rid of strabismus

Strabismus corrects:

wearing special glasses;

a series of eye exercises;

wearing a bandage that covers one eye;

surgery to correct strabismus.

Intermittent strabismus, when the right or left eye is sometimes squinted, is tried to be corrected by wearing a bandage. Long-term use of specially designed glasses often helps. Exercises to enhance the ability to focus are recommended for almost all patients with strabismus. If all of the above methods have not corrected vision, an operation is performed to correct strabismus. This type of surgery is performed both in infancy and in adulthood.

Types of surgery to correct strabismus

The following types of strabismus are found in children and adults:

horizontal - converging and diverging relative to the bridge of the nose;

vertical;

a combination of the two.

Doctors encounter a convergent strabismus more often than a divergent squint. Along with converging strabismus, the patient may have hyperopia. Divergent squint is usually observed in people with nearsightedness.

During the operation, the following can be performed:

amplifying type operation;

weakening operation.

In loosening surgery, the eye muscles are transplanted a little further from the cornea, which deflects eyeball in the opposite direction.

In the course of augmentation surgery, a small piece of the eye muscle is removed, which leads to its shortening. Then this muscle is sewn to the same place. Surgery to correct strabismus involves shortening and weakening the desired muscles, which restores the balance of the eyeball. The operation is performed on one or both eyes. The microsurgeon determines the type of surgery when the patient is in a completely relaxed state on the operating table.

In some clinics, the operation is performed under local anesthesia only for adults. in others, general anesthesia is given to all patients. Depending on age, health status and other factors, mask (laryngeal), endotracheal anesthesia using muscle relaxants or an alternative type of anesthesia is performed.

It is important that during surgery the eyeball is motionless and there is no muscle tone, because the surgeon performs a special test: he assesses the degree of limitation of eye movements by moving it in different directions.

An adult after surgery can go home on the same day. The child needs preliminary hospitalization. Most often, mothers are in the hospital with the children; they are discharged the next day after the operation. Recovery period takes about 14 days. After discharge, the patient extends the sick leave or certificate in his clinic.

It should be noted that in 10-15% of cases, strabismus is not completely eliminated and a second operation may be necessary. Surgical intervention with adjustable sutures helps to reduce the failure rate. After awakening the patient, the doctor after a while checks the condition of the eyes under local anesthesia. If there are deviations, he tightens the seam knots a little and only then finally fixes them. All types of operations are performed with a fully absorbable suture material.

In adults who have lived for a significant time with strabismus, sometimes double vision after the operation, because the brain has lost the habit of perceiving the binocular picture. If, before the operation, the doctor has established a high likelihood of developing double vision, strabismus is corrected in two stages so that the brain can gradually adapt.

Operation

A few days before surgery, you need to take blood tests, do an EKG and consult with some specialists. Do not eat 8 hours before the operation. If it is scheduled for the morning, you can have dinner, and if in the afternoon, then a light breakfast is allowed. The child and his mother are admitted to the hospital a couple of days before the operation. The procedure is performed under general anesthesia. The operation itself lasts 30-40 minutes, then the patient is taken out of anesthesia and transferred to the ward. All this time, there is a bandage on the eye. After the operated patient has completely recovered from anesthesia, in the second half of the day he is examined by a surgeon. He opens the bandage, checks the eye, instills special drops and closes it again. Adults are then allowed to go home with detailed recommendations: what medications to take, how to bury their eyes and when to come for a second examination. The eye patch is left until the next morning. A week later, you need to come for an examination, where the doctor will assess the speed of healing and the condition of the eye. The final assessment of the position of the eyes is carried out after 2-3 months.

For several weeks after the operation, special anti-inflammatory drops and (if necessary) antihistamines are used. The eye will be red and swollen. Sometimes the eye sticks together the next morning due to accumulated pus. No need to be intimidated: it is washed with warm boiled water or sterile saline. For a couple of days, the eyes will be very watery and sore, and it will also seem that there are motes in the eye. The stitches dissolve on their own after 6 weeks.

Within a month after surgery, you need to carefully protect the eye. Do not swim, stay in dusty rooms or play sports. Children at school are exempted from physical education for six months.

A month after the operation, you need to undergo a course of treatment. To restore the binocular ability to see and recognize the correct picture, you need to undergo special hardware treatment at a medical center. Some clinics have the Amblicor complex, developed by specialists from the Institute of the Brain. Treatment with this device is a computer video training. It helps to overcome the skill of suppressing the vision of one eye. While watching a cartoon or a movie, an EEG of the visual cortex of the brain and indications of eye work are continuously recorded from the patient. If a person sees with two eyes, the film continues, and if only with one, it pauses. Thus, the brain is trained to perceive the picture from both eyes.

The ultimate goal of strabismus surgery is to restore symmetrical (or as close to symmetrical as possible) eye position. Such operations, depending on the situation, can be performed both in adults and in children.

Types of surgery to correct strabismus

In general, strabismus surgery is of two types. The first type of surgery is aimed at weakening an overly tense oculomotor muscle. An example of such operations is recession (the intersection of a muscle at the site of its attachment and its movement in such a way as to weaken its action), partial myotomy (partial excision of a part of muscle fibers), muscle plastic (for the purpose of lengthening). The second type of surgery is aimed at enhancing the action of the weakened oculomotor muscle. An example of operations of the second type is resection (excision of a section of a weakened muscle near the attachment site, followed by fixation of a shortened muscle), tenorrhaphy (shortening of a muscle by forming a fold in the muscle tendon zone), anteposition (movement of the muscle fixation site in order to enhance its action).

Often, during strabismus correction surgery, a combination of the aforementioned types of surgery (recession + resection) is used. If after the surgical intervention there is residual strabismus, which is not leveled by self-correction, a second operation may be required, which is usually performed after 6 to 8 months.

To maximize the effectiveness of strabismus surgery, several basic principles must be followed.

1. Excessive acceleration of the process of surgical correction of strabismus often leads to unsatisfactory results. Therefore, all manipulations should be dosed (if necessary, in several stages).

2. If necessary, weakening or strengthening of individual muscles, dosed surgical intervention should be distributed evenly.

3. During the operation on a particular muscle, it is necessary to maintain its connection with the eyeball.

High-tech strabismus surgery:

Specialists of children's eye clinics have developed a modern high-tech radio wave surgery with the principles of mathematical modeling.

Benefits of high-tech eye surgery:

Operations are low-traumatic, thanks to the use of radio waves, the structures of the eye are preserved.
There are no terrible edema after the operations, the patient is discharged from the hospital the next day.
The operations are accurate.
Thanks to the principles of mathematical calculation, we can ensure the highest accuracy and show a guaranteed result of the operation even before it is carried out.
The rehabilitation period is reduced by 5-6 times.

The result of the operation: highly effective strabismus surgery technologies make it possible to ensure a symmetrical gaze position in various types of strabismus, including those with small and inconsistent angles, to restore the mobility of the eyeball in paralytic strabismus in 98% of cases. This is a unique way to help the patient effectively.

Results of strabismus surgery

Surgical treatment of strabismus allows you to correct a cosmetic defect, which is a strong traumatic factor for patients of any age. However, restoration of visual function (i.e. binocular vision) after surgery requires A complex approach, which includes pleoptic therapy (it is aimed at treating concomitant strabismus amblyopia) and orthopodiploptic therapy (restoration of depth vision and binocular functions).

A one-stage operation to correct strabismus in adults can be performed on an outpatient basis; in the treatment of children, in most cases, hospitalization is necessary. The estimated recovery time after surgery is 1 week, but to recreate full binocular vision, i.e. the ability to see a three-dimensional picture with two eyes at the same time is not enough. During the time a person had strabismus, the brain, figuratively speaking, “forgot how” to combine images from both eyes into a single image, and it will take a long enough time and considerable effort to “teach” the brain this again.

It should be mentioned that, like any operation, surgical correction of strabismus may be accompanied by the development of certain complications. One of the most common complications of strabismus surgery is overcorrection (so-called overcorrection) due to calculation errors. Hypercorrection can occur immediately after the operation, or it can develop after some time. For example, if the operation was performed in childhood, then in adolescence, when the eye grows, the child may again squint. This complication is not irreparable and can be easily corrected with surgery.

This surgical intervention is performed in most ophthalmological centers in Moscow and Russia (both commercial and state). When choosing a clinic for an operation to correct strabismus, it is important to study the capabilities of the clinic, the conditions of stay, the equipment of the clinic with modern equipment and other important points. It is equally important to choose the right doctor for the operation. after all, the prognosis of cure will fully depend on his professionalism.

If you or your relatives have already undergone surgery to correct strabismus, we will be grateful if you leave feedback about the intervention and the clinic where the procedure was performed, as well as the results obtained.

Infantile strabismus

Strabismus in children most often occurs in the presence of hyperopia and astigmatism, less often in congenital and early acquired myopia. Infantile strabismus is not only a cosmetic defect. With this disease, work is disrupted in almost all parts of the visual analyzer.

At birth, a child does not yet know how to look with “two eyes”. The ability for binocular vision develops in a child gradually and lasts up to 4-6 years. All newborns have a hyperopia of about 3 diopters. In this case, the focus is not on the retina, but behind it. As the child grows, the size of the eyeball also increases, as well as the optical focus moves to the retina. Some children, for various reasons, have farsightedness above 3 diopters. To see objects clearly, they have to strain their eyes. This tension is the main prerequisite for the occurrence of convergent strabismus in children, that is, when one of the eyes squints towards the nose. Binocular connections in a child's visual system mature gradually and are therefore easily disrupted. The impetus for the development of childhood strabismus against the background of prerequisites may be a high temperature, physical or mental trauma.

Most often, strabismus in children occurs at the age of 2-3 years. Convergent childhood strabismus is more common than divergent strabismus. With strabismus in children, more often on the squinting eye, a decrease in visual acuity gradually occurs, that is, amblyopia develops. This complication is due to the fact that the visual system, in order to avoid chaos, blocks the transmission of an image of an object to the brain, which is perceived by the squinting eye. This, in turn, leads to a permanent deviation of the eye, in which vision is reduced. Thus, a vicious circle is set in motion.

Treatment of strabismus in children is complex. In the presence of farsightedness or myopia, according to indications, glasses are assigned to the child. Sometimes glasses completely correct a child's squint. However, even with this state of affairs, wearing glasses alone is not enough. With strabismus in children, conservative treatment is carried out using hardware methods. They are aimed at curing amblyopia (if any) and at restoring "bridges" between the eyes, that is, the child is taught to merge images from the right and left eyes into a single visual image. During the treatment of pediatric strabismus, at a certain stage, if indicated, surgery is performed on the muscles of the eye. The operation is aimed at restoring the correct muscle balance between the muscles that move the eyeballs by rotating it in the eye socket. After the operation, conservative treatment of strabismus in children is also mandatory. It is aimed at the complete rehabilitation of visual functions.

There is a statement that with age, strabismus in children can go away on its own. If we are talking about a periodic deviation of the eye in children under 6 months old, then this is a variant of the norm and by 7 months the child's eyes will really stand up straight. If the eye continues to deviate after 7 months or strabismus occurs later, then there can be no question of any independent cure. Strabismus is a medical condition that requires treatment. There are more than 15 types of strabismus and each of them is treated differently. In some cases, rehabilitation takes about 6 months, sometimes up to 3-4 years or more.

In many cases, with strabismus, with the correct management of the child, it is possible to save him from constant spectacle dependence. With high degrees of hyperopia or astigmatism, after curing amblyopia and strabismus, it is possible to use excimer laser correction, which makes it possible to completely rid the child of glasses.

Since the child's visual system is in constant development, in children younger age all the applied methods of treatment are more effective. By school, a child with strabismus should be rehabilitated as much as possible. In older children, it takes much longer to improve visual functions and in some cases it is not always possible to achieve complete recovery.

There are several forms of strabismus in children. Such a friendly squint should be considered horizontal, when one eye deviates either to the nose or to the temple. At the same time, no deviation along the vertical axes is noted. Horizontal strabismus can be with a constant or non-constant angle of deviation. It may depend on optical impairments (farsightedness or myopia), in addition, from a surgical point of view, such a type of horizontal strabismus should be distinguished as strabismus with a small deflection angle. There are features associated with the treatment of certain forms of horizontal strabismus, such as strabismus with an inconsistent angle, periodic strabismus, with a small deviation angle and accommodative strabismus, when the eyes do not squint with glasses, but squint without glasses.

There is a widespread belief that it is preferable not to operate on such forms of strabismus, and conservative treatment can be limited. But experience shows that, as a rule, conservative treatment alone is not enough to get rid of this ailment. The effectiveness of conservative therapeutic treatment without surgical support is temporary and unstable.

Today, new methods of surgery have been proposed that make it possible to effectively operate even those cases of strabismus that were previously considered surgically hopeless. These methods provide for the achievement of the main rehabilitation criteria in the treatment of strabismus: symmetrical position of the eyes, high visual acuity and stereoscopic nature of visual perception.

The fact is that traditional surgical methods are based on two rather outdated principles. First, the traditional operation involves cutting off the oculomotor muscle from the natural place of its attachment and replacing it to the eyeball in a new place. The second is the amount by which the above-mentioned alteration is carried out, is determined empirically experimentally, the revealed frequency of strabismus correction at one or another value of the initial angle.

These principles can be applied to some extent in constant angle strabismus surgery. But what about the cases when the strabismus angle is not constant, or when its value is small, or when there is a combination of strabismus with some impairment of mobility, etc. But such forms of strabismus are found in more than 80% of cases!

The traditional treatment tactics does not offer anything about this, except for long courses of conservative hardware treatment, which is ineffective and has a temporary result and unstable nature. The traditional tactics of treating strabismus does not solve the main issue of horizontal strabismus - the achievement of a stable symmetrical position of the eyes.

It is more effective to use a surgical tactic that allows you not to cut off the muscles from the place of their attachment and not to alter them to a new place. It is very important to note that the dosage takes into account not only the strabismus angle (as in traditional methods), but also the value of other indicators that also affect the position of the eye in the palpebral fissure and, accordingly, affect the effectiveness of the surgical intervention.

And the most important component of this surgical treatment system is the developed technique for dosing the magnitude and volume of intervention, based on mathematical modeling of the operation. It allows you to accurately change the balance between the eye muscles in such a way as to obtain the most symmetrical position of the eyes in the orbits.

There are cases when the deviations of the eyeball occur simultaneously, both along the horizontal and vertical axes. Strabismus is dissociated, in which the movements of the right and left eyes are not associated with each other, but at the same time are performed in all directions of gaze. The tactics of transposition of the oculomotor muscles without cutting off the latter from the attachment site and subsequent reshaping (in contrast to the traditionally used technique) makes it possible to level the vertical component during the surgical operation in the treatment of strabismus. This tactic reduces the number of operations in the patient and allows you to effectively resolve the issue of the vertical component during the surgery of the horizontal component.

In addition, when assessing the nature and causes of the vertical component, the muscle responsible for the vertical deviation of the eye is very scrupulously identified, after which the most optimal, in terms of efficiency, operation is selected individually.

Paralytic strabismus occurs in cases of violation of the innervation of the nerves that provide contraction of the oculomotor muscles. There are three such nerves: the oculomotor nerve, which provides contraction of the muscles that turn the eyeball up and down, and towards the nose; the abducens nerve, which ensures the rotation of the eyeball to the temple, and the blocky nerve, which provides the rotation of the eyeball to the inferior temporal angle.

Violations on the part of one of these nerves leads to a limitation of the mobility of the eyeball in one direction or another and strabismus, which in these cases, in contrast to cases of concomitant and dissociated strabismus, is caused by the arising muscle imbalance associated with the weakness of the muscles innervated by this nerve. The most severe paralytic strabismus is a case of oculomotor nerve palsy. With this form of strabismus, mobility is impaired in almost all directions of gaze.

The eyeballs turn outward, with difficulty turning to the inner part and to the central position. In addition to a cosmetic defect, this condition carries with it severe functional consequences associated with the inability to orient the affected eyeball to the object of fixation, which leads to a serious underdevelopment of the visual system. Conventional methods of traditional surgery cannot solve the problem of these patients - the eyeball remains inactive and its position is not controlled by the patient.

Five years ago in the United States, Professor Kaufman proposed a bold operation that allows, by using one or two remaining normally functioning muscles, to transform the muscle balance in such a way as to ensure the mobility of the eyeball inward. However, despite the solution to the main issue - restoring the mobility of the eye to the inner part, this operation has a very serious drawback - ensuring the movement of the eyeball to the nose, after the operation there is a sharp limitation of the mobility of the eye to the temple.

But it is more effective to use an operation that allows you to either completely restore or significantly improve the mobility of the eyeball to the nose, without losing the possibility of mobility of the eye to the temple! Today this is the only way to radically and highly efficiently help this category of patients. It should be noted that such operations should be carried out as early as possible, given the congenital nature of this strabismus, in order to avoid abnormal development of the child's visual system.

The second complex component in this form of paralytic strabismus is a violation of the mobility of the eye to the temple, and due to a possible imbalance, it deviates to the nose, with difficulty brought to the middle position. In this regard, plastic surgeries are successfully carried out, which make it possible to significantly enhance the action of the muscle that diverts the eye outward and to provide almost complete mobility of the eyeball in all directions of the gaze.

Aznauryan Igor Erikovich

Head of the Clinical Association "Yasny Vzor"

Doctor of Medical Sciences,

Academician Russian Academy medical and technical sciences,

member of the European Association of Pediatric Ophthalmologists,

Member of the European Society of Strabology, Laureate of the Svyatoslav Fedorov.

Strabismus

In pediatric ophthalmology, strabismus (heterotropy or strabismus) occurs in 1.5-3% of children, with the same frequency in girls and boys. As a rule, strabismus develops at the age of 2-3, when the friendly work of both eyes is formed; however, congenital squint may also occur.

Strabismus is not only a cosmetic defect: this disease leads to disruption of the work of almost all parts of the visual analyzer and can be accompanied by a number of visual disorders. With strabismus, the deviation of the position of one or both eyes from the central axis leads to the fact that the visual axes do not intersect on the fixed object. In this case, in the visual centers of the cerebral cortex, the monocular images perceived separately by the left and right eyes do not merge into a single visual image, but a double image of the object appears. To protect against double vision, the central nervous system suppresses the signals received from the squinting eye, which over time leads to amblyopia - a functional decrease in vision, in which the squinting eye is almost or not at all involved in the visual process. Without treatment, strabismus develops amblyopia and vision loss occurs in about 50% of children.

In addition, strabismus adversely affects the formation of the psyche, contributing to the development of isolation, negativism, irritability, as well as imposing restrictions on the choice of profession and sphere of human activity.

Classification of strabismus

According to the timing of occurrence, strabismus is distinguished congenital(infantile - present from birth or developing in the first 6 months) and acquired(usually develops up to 3 years). On the basis of stability of the deviation of the eye, periodic (transient) and permanent strabismus are distinguished.

Given the involvement of the eyes, strabismus may be unilateral ( monolateral) and intermittent ( alternating) - in the latter case, alternately mows one or the other eye.

According to the severity, strabismus is distinguished. hidden(heterophoria), compensated(detected only during ophthalmological examination), subcompensated(occurs only when control is weakened) and decompensated(uncontrollable).

Depending on the direction in which the squinting eye deviates, they emit horizontal. vertical and mixed strabismus. Horizontal strabismus can be convergent (esotropia, converging strabismus) - in this case, the squinting eye is deflected towards the bridge of the nose; and divergent (exotropia, divergent squint) - the squinting eye is deflected to the temple. In vertical strabismus, two forms are also distinguished with an upward displacement of the eye (hypertropia, supraverging strabismus) and downward (hypotropia, infraverging strabismus). In some cases, cyclotropy occurs - torsional heterotropy, in which the vertical meridian is inclined towards the temple (excyclotropy) or towards the nose (inccyclotropy).

From the point of view of the causes of occurrence, there are friendly and paralytic unfriendly strabismus. In 70-80% of cases, concomitant strabismus is convergent, in 15-20% - divergent. Torsional and vertical deviations, as a rule, occur with paralytic strabismus.

With concomitant strabismus, the movements of the eyeballs in different directions are fully preserved, there is no diplopia, there is a violation of binocular vision. Concomitant strabismus can be accommodative, partially accommodative, non-accommodative.

Accommodative friendly strabismus often develops at the age of 2.5-3 years due to the presence of high and medium degrees of hyperopia, myopia, astigmatism. In this case, the use of corrective glasses or contact lenses, as well as hardware treatment, will help restore the symmetrical position of the eyes.

Signs of partially accommodative and non-accommodative strabismus appear in children of the 1st and 2nd year of life. With these forms of concomitant strabismus, the refractive error is far from the only cause of heterotropy, therefore, to restore the position of the eyeballs, surgical treatment is required.

The development of paralytic strabismus is associated with damage or paralysis of the oculomotor muscles due to pathological processes in the muscles themselves, nerves or the brain. With paralytic strabismus, the mobility of the deflected eye towards the affected muscle is limited, diplopia and impaired binocular vision occur.

Causes of strabismus

The occurrence of congenital (infantile) strabismus may be associated with a family history of heterotropy - the presence of strabismus in close relatives; genetic disorders (Cruson's syndrome, Down's syndrome); teratogenic effect on the fetus of some drugs, drugs, alcohol; premature birth and delivery of a low birth weight child; infantile cerebral palsy. hydrocephalus. congenital eye defects (congenital cataracts).

The development of acquired strabismus can be acute or gradual. The causes of secondary concomitant strabismus in children are ametropia (astigmatism, hyperopia, myopia); at the same time, with myopia, divergent squint often develops, and with hyperopia, convergent strabismus. Strabismus can be provoked by stress, high visual stress, childhood infections (measles, scarlet fever, diphtheria, influenza) and general diseases (juvenile rheumatoid arthritis), proceeding with high fever.

At an older age, including in adults, acquired strabismus can develop against the background of cataracts. leukomas (leukoma), atrophy optic nerve... retinal detachment, macular degeneration, leading to a sharp decrease in vision in one or both eyes. Risk factors for paralytic strabismus include tumors (retinoblastoma), traumatic brain injury. paralysis of the cranial nerves (oculomotor, block, abducens), neuroinfections (meningitis, encephalitis), strokes. fractures of the wall and bottom of the orbit, multiple sclerosis. myasthenia gravis.

Strabismus symptoms

The objective symptom of any type of strabismus is the asymmetric position of the iris and pupil in relation to the palpebral fissure.

With paralytic strabismus, the mobility of the deflected eye towards the paralyzed muscle is limited or absent. Diplopia and dizziness are noted, which disappear when one eye is closed, the inability to correctly assess the location of the object. In case of paralytic strabismus, the angle of the primary deviation (squinting eye) is less than the angle of the secondary deviation (of the healthy eye), that is, when trying to fix the point with the squinting eye, the healthy eye deviates to a much larger angle.

A patient with paralytic strabismus is forced to turn or tilt his head to the side in order to compensate for the visual impairment. This adaptive mechanism contributes to the passive transfer of the object's image to the central retinal fossa, thereby eliminating double vision and providing not quite perfect binocular vision. Forced tilt and turn of the head with paralytic strabismus should be distinguished from that with torticollis. otitis.

In case of damage to the oculomotor nerve, ptosis of the eyelid is noted. dilation of the pupil, deviation of the eye outward and downward, there is partial ophthalmoplegia and accommodation paralysis.

Unlike paralytic strabismus, with concomitant heterotropy, diplopia is usually absent. The range of motion of the squinting and fixing eyes is approximately the same and unlimited, the angles of primary and secondary deviations are equal, and the functions of the oculomotor muscles are not impaired. When fixing a gaze on an object, one or alternately both eyes deviate in one direction (to the temple, nose, up, down).

Concomitant strabismus can be horizontal (converging or diverging), vertical (supraverging or infraverging), torsional (cyclotropia), combined; monolateral or alternating.

Monolateral strabismus leads to the fact that the visual function of the deviated eye is constantly suppressed by the central part of the visual analyzer, which is accompanied by a decrease in visual acuity of this eye and the development of dysbinocular amblyopia of varying degrees. With alternating strabismus, amblyopia, as a rule, does not develop or is slightly expressed.

Diagnosis of strabismus

When collecting anamnesis, the timing of the onset of strabismus and its relationship with the past injuries and diseases are specified. During an external examination, attention is paid to the forced position of the head (with paralytic strabismus), the symmetry of the face and eye slits, the position of the eyeballs (enophthalmos. Exophthalmos) are assessed.

Then the visual acuity is checked without correction and with trial lenses. Clinical refraction is examined to determine the optimal correction using skiascopy and computer refractometry. If, against the background of cycloplegia, strabismus disappears or decreases, this indicates the accommodative nature of the pathology. The anterior parts of the eye, transparent media and the fundus are examined using biomicroscopy. ophthalmoscopy.

For the study of binocular vision, a test is carried out with covering the eye: the squinting eye is deviated to the side; using the synoptophora apparatus, the fusional ability (the ability to fusion images) is assessed. The strabismus angle (the deviation of the squinting eye) is measured, the convergence is studied, and the volume of accommodation is determined.

Strabismus treatment

With concomitant strabismus, the main goal of treatment is the restoration of binocular vision, in which the asymmetry of the position of the eyes is eliminated and visual functions are normalized. The interventions may include optical correction, pleoptic-orthoptic treatment, surgical correction of strabismus, pre- and postoperative orthoptodiploptic treatment.

During the optical correction of strabismus, the goal is to restore visual acuity, as well as normalize the ratio of accommodation and convergence. For this purpose, glasses or contact lenses are collected. With accommodative strabismus, this is enough to eliminate heterotropy and restore binocular vision. Meanwhile, spectacle or contact correction of ametropia is necessary for any form of strabismus.

Pleoptic treatment is indicated for amblyopia to increase the visual load on the squinting eye. For this purpose, occlusion (turning off the vision process) of the fixing eye can be prescribed, penalization can be used, hardware stimulation of the amblyopic eye (Ambliokor. The orthoptic stage of strabismus treatment is aimed at restoring the coordinated binocular activity of both eyes. For this purpose, synoptic devices (Synoptophore) and computer programs are used.

At the final stage of strabismus treatment, diploptic treatment is carried out, aimed at developing binocular vision in vivo (training with Bagolini lenses, prisms); gymnastics is prescribed to improve eye mobility, training on a convergent trainer.

Surgical treatment of strabismus can be undertaken if the effect of conservative therapy is absent for 1-1.5 years. Surgical correction of strabismus is optimal at the age of 3-5 years. In ophthalmology, surgical reduction or elimination of the angle of strabismus is often performed in stages. To correct strabismus, two types of operations are used: weakening and strengthening the function of the oculomotor muscles. Weakening of muscle regulation is achieved by transplanting (recession) a muscle or transecting a tendon; enhancing the action of the muscle is achieved by its resection (shortening).

Before and after surgery to correct strabismus, orthoptic and diploptic treatment is indicated to eliminate residual deviation. The success rate of surgical correction of strabismus is 80-90%. Complications of surgical intervention can be overcorrection and insufficient correction of strabismus; in rare cases - infections, bleeding, loss of vision.

The criteria for curing strabismus are the symmetry of the position of the eyes, the stability of binocular vision, and high visual acuity.

Prediction and prevention of strabismus

Treatment of strabismus should be started as early as possible so that the child is sufficiently rehabilitated in terms of visual function by the time school begins. In almost all cases, strabismus requires persistent, consistent and long-term complex treatment. Delayed onset and inadequate correction of strabismus can lead to irreversible loss of vision.

The most successful correction is friendly accommodative strabismus; with late diagnosed paralytic strabismus, the prognosis for the restoration of full-fledged visual function is unfavorable.

Strabismus prevention requires regular examinations of children by an ophthalmologist. timely optical correction of ametropia, compliance with the requirements of vision hygiene, dosage of visual loads. It is necessary to early detection and treatment of any eye diseases, infections, prevention of skull injuries. During pregnancy, adverse effects on the fetus should be avoided.

Strabism rarely needs surgery. Operation on strabismus carried out only for cosmetic purposes, for the formation of binocular vision and in the presence of serious complications.

This article is useful to everyone who suffers from heterotropia and plans to undergo surgery. You will find out what types of surgical intervention exist, how the treatment proceeds, and how long the rehabilitation period lasts.

Need for surgery

The operation to correct strabismus is carried out at any age. In children, less often than in adults, because it is easier to treat.

Also at any age, visual defects in appearance, especially such as strabismus Is a powerful traumatic factor for the psyche that affects self-esteem.

In general, surgical treatment is intended to correct an imbalance in motor activity in all six muscles that control the position of the main ocular axis.

Surgical treatment of pediatric strabismus

The most effective surgical treatment for heterotopia in children is to perform the procedure between the ages of 4 and 5 years. If it is really inevitable and necessary.

Congenital ophthalmic pathology, which is characterized by a significant angle of deviation from the natural position, is treated earlier.

The standard age for this type of surgery was chosen for a reason.

The most effective outcome occurs only if the patient is aware of what is happening. This is necessary because during the rehabilitation period, a person needs to perform a simple series of eye exercises, which will consolidate the effect of the procedure. And, as you know, babies are not capable of such a thing due to unconsciousness.

Important: For all children, regardless of age, eye surgery that cures strabismus performed under general anesthesia. In some cases, even the stipulated short-term hospitalization.

Treatment of strabismus in adults with surgery

In adults, in contrast to children, the operation to eliminate heterotopia takes place on an outpatient basis.

Most doctors say a week is enough for a full recovery from this type of surgery. But binocular vision will take much longer to recover.

Time is needed, because with strabismus, the brain turned off the work of a non-functioning organ and it needs to restore the functionality of the detached channel. To do this, appoint:

eye exercises;
plenoptic therapy;
orthopedic therapy.

One-day surgery for adults is performed under local anesthesia and does not require hospitalization.

Classification of surgical treatments

There are only two main types of operations designed to get rid of strabismus:

debilitating;
reinforcing.

If the reason for the deviation of the pupil from the natural axis is overstrain of the eye muscles, the following methods are used:

recession;
partial myotomy;
plastic surgery of the oculomotor muscle - its partial removal.

For the treatment of weakened muscles, there are surgical procedures such as:

resection;
tenorrhaphy;
Faden procedure;
anteposition.

It rarely happens that the disease occurs due to dysfunction of one muscle. More often than not, several muscles begin to work poorly, and the operation is performed on all of them.

Principles of Surgical Treatment

Important: The principles of the procedure are in the most optimal sequence and combination of preliminary, basic and postoperative measures.

Surgical intervention involves:

Phased approach- relevant for strabismus in both eyes. First, an operation is performed on the first, and after a few months - on the second eye.
Calculating dimensions areas of muscles, with which forced correction work is carried out, is carried out according to established samples.
Muscle shortening / lengthening is carried out evenly on both sides.
Preferably keep a natural connection adjustable muscle with organ.
With significant strabismus it is not recommended to perform surgery on more than two muscles at once one eye.

Some doctors may argue that it cannot be treated with surgery. This is true, but only in relation to the standard methods of conducting such events.

Recently, an exceptional method has been developed to restore the performance of paralyzed oculomotor muscles.

If this type of strabismus is treated with standard methods, the consequences are often unpredictable: the eye moves limitedly, uncontrollably, or after a while it stops moving again.

Indications and contraindications

The operation is carried out exclusively in cases where the therapeutic methods do not bring the desired effect or there is no other way out. Only as a last resort.

Surgery is prescribed only under the following circumstances:

the patient's desire to get rid of a visual defect;
conservative methods are inappropriate;
on the recommendation of an ophthalmologist, who believes that the only way to restore vision is surgery.

Fact: Contraindications to surgical treatment of strabismus can only be the individual characteristics of the patient, which are negotiated with the ophthalmologist when making a decision.

Rehabilitation period

Even after a one-day operation, there is a kind of period during which it is necessary to carry out procedures to improve one's own condition and to restore the work of binocular vision as soon as possible.

Postoperative pain is normal

Immediately after surgery, anesthesia goes away, and the eye will hurt for a while - this is natural.

Attempts or unconscious movements of the corrected organ of vision will only increase the pain syndrome.

The eye itself will be reddened and slightly inflamed, with a temporary slight deterioration in vision.

Fact: Adults often see double vision for a while after surgery.

The restoration of full binocular vision and eye tissues is completed one month after the operation.

Children experience this process faster, but both need to visit an ophthalmologist frequently at this time and perform eye exercises.

Read about what glasses are prescribed for strabismus.

Visual differences before and after surgery on strabismus are visible in the photo below.

Possible complications

No matter how high the price of the operation is, and the chosen clinic does not have a list of recommendations, no one is insured against unforeseen consequences.

Complications from strabismus surgery are not so different as they are dangerous.

Strabismus is a disruption in the work of the oculomotor muscles, which leads to a deterioration in vision.

Doctors in the fight against this disease use both conservative therapy and surgery which has advantages and disadvantages.

Indications for Strabismus Correction Surgery

the presence of visual impairment caused by mismatch in the direction of the visual axes;
Availability cosmetic defect requiring correction;
poor performance application other methods treatment.

Photo 1. Strabismus in one eye in a child. The organ of vision deviates towards the bridge of the nose.

Only individual characteristics patient or the presence of concomitant diseases may be a contraindication to surgical intervention.

How children tolerate surgical treatment: is the procedure going well?

In the presence of a pronounced violation of the work of the oculomotor muscles in children, they are recommended an operative way to get rid of this problem. In pediatric surgery general anesthesia is usually used to reduce stress, but because of this, the time of the baby's stay in the hospital increases.

The optimal age for correction is 5-6 years old. By this time, the degree of visual impairment becomes clear, and the child can actively participate in postoperative rehabilitation.

However, in severe cases, when the angle of deviation of the visual axis is more than 45 °, recommended to conduct the first preparatory stageat 1-2 years old... The therapy allows you to reduce the degree of emerging pathology. The final correction is carried out at the age of 4-5 years.

In the standard scheme treatments will be attended the following steps:

preoperative preparation, which includes both the analysis of the patient's physical readiness for the operation and the psychological preparation for it;
the actual operation;
postoperative period;
rehabilitation period.

Before any surgical procedure appoint a general examination. Usually it includes the delivery of blood and urine tests, an EKG, checking the results of a test for tuberculosis, examination by a pediatrician. These procedures are usually performed on an outpatient basis, in a polyclinic. When using general anesthesia, the baby should not be fed on the day of surgery. Parents should try to calm him down by explaining the meaning of what is happening.

The surgeon determines the tactics of the intervention, choosing the method of correction that will be most effective. With concomitant strabismus two main technologies are applied: strengthening or weakening of individual oculomotor muscles. For strengthening, both excision of a part of the muscle and a change in the place of its attachment can be used.

For weakening, effective methods are: changing the place of muscle attachment, making micro-cuts on it (partial myotomy), lengthening the muscle.

A sterile bandage is applied to the operated eye, which protects against the penetration of infection. Then the baby is transferred to the ward, where he spends some time under the supervision of a medical worker, after which he can be released home.

The rehabilitation period requires special attention. It includes the observation of an ophthalmologist, a set of exercises to strengthen the muscles of the eye, it is also possible to prescribe hardware treatment.

Photo 2. Child before strabismus surgery (top) and after surgery (bottom).

Usually a child quickly recovers both physically and psychologically: elimination of a visible defect improves self-esteem, and the painful sensations from the intervention are forgotten.

As complications bleeding and infectious processes can occur. Due to an erroneous calculation made before the operation, strabismus may reappear in the form of excessive compensation: the eye will deviate in the opposite direction.

Attention! Even if the surgeon is successful, the problem may return after several years, because the growth and development of the organs of vision continues, therefore regular examinations by a specialist are required.

Operation on adults. Reviews after rehabilitation

The principles of surgical treatment of strabismus in adults and children are the same. However, the operation itself in adults goes a little easier: it is performed under local anesthesia.

This shortens the preoperative preparation. But you still have to go through the examination, it will include mandatory fluorography, collection of blood and urine tests, examination by a therapist.

You won't have to stay in the hospital for a long time: the patient is admitted on the day of the operation, and after its successful completion can go home. During the intervention, the patient is injected with local anesthesia, then manipulations are performed.

Important! In the recovery process, the patient himself should take an active part: it is necessary to follow the regimen and follow the doctor's prescriptions.

Possible complications can be related as in violation of the course of the operation, so with non-compliance with recommendations doctor. The most dangerous, as in the case of children, is bleeding or damage to the structures of the eye.

Getting rid of strabismus causes positive emotions in patients. Feedback from one of the patients, who went through this procedure two years ago. Natalia notes that her life has changed significantly: it became easier for her to communicate with people, she ceased to be ashamed of her appearance, she even managed to master a new type of activity - consulting, which previously seemed impossible.

Often, strabismus surgery does not immediately return normal vision. Many will agree that it is a pity to look at a mowing young pretty girl or child. Without this cosmetic defect, everything would be fine. In addition, ophthalmologists recommend trying conservative methods of strabismus treatment before going under the knife.

What is strabismus, or squint

Acquired squint results from:

infectious disease: influenza, measles, scarlet fever, diphtheria, etc.;

somatic diseases;

injuries;

a sharp drop in vision in one eye;

myopia, hyperopia, high and moderate astigmatism;

stress or severe fright;

paresis or paralysis;

diseases of the central nervous system.

How can you get rid of strabismus

Strabismus corrects:

wearing special glasses;

a series of eye exercises;

wearing a bandage that covers one eye;

surgery to correct strabismus.

Types of surgery to correct strabismus

The following types of strabismus are found in children and adults:

horizontal - converging and diverging relative to the bridge of the nose;

vertical;

a combination of the two.

During the operation, the following can be performed:

amplifying type operation;

weakening operation.

In a weakening operation, the eye muscles are transplanted a little further from the cornea, which deflects the eyeball in the opposite direction.

An adult after surgery can go home on the same day. The child needs preliminary hospitalization. Most often, mothers are in the hospital with the children; they are discharged the next day after the operation. The recovery period takes about 14 days. After discharge, the patient extends the sick leave or certificate in his clinic.

Operation

Within a month after surgery, you need to carefully protect the eye. Do not swim, stay in dusty rooms or play sports. Children at school are exempted from physical education for six months.

Types of surgery for strabismus

The main task of any surgical intervention for strabismus should be considered the restoration of the correct balance between the eye muscles responsible for the movement of the eyeball.

When performing a strengthening operation, the eye muscle is shortened due to:

the formation of a special fold in the place of the tendon (tenorrhaphy);

moving the place of attachment of the muscle to the eyeball (anteposition).

Laxative strabismus surgery aims to relieve stress and weaken the eye muscle by:

changes in its place of attachment to the eyeball (recession);

its build-up (plastic);

ineffectiveness of non-surgical treatment carried out for a long time;

very severe strabismus;

non-modding strabismus.

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Each of these periods is of great importance for a favorable outcome of the operation.

The operation itself includes high-tech manipulations by a competent ophthalmologist to regulate the correct balance between the patient's eye muscles in order to restore symmetry in the placement of the eyes. The operation is performed using pain medications.

Postoperative recovery can be a different time period in different patients. It consists in strict observance of all the recommendations of the attending physician for the elimination of:

eye discharge;

double vision, etc.

It is important to understand that in order to eliminate strabismus, the operation must be performed at a strictly defined time, established by the doctor. It cannot be postponed, because the level of vision may decrease significantly. The forcing of events must also not be allowed, which will have a bad effect on its result. In some cases, surgery consists of several necessary stages.

After the elimination of strabismus by surgery, various complications may appear, for the elimination of which additional eye treatment or repeated surgery will be required. The main complications of this kind should be considered:

excessive vision correction;

Strabismus

Types of surgery to correct strabismus

To maximize the effectiveness of strabismus surgery, several basic principles must be followed.

1. Excessive acceleration of the process of surgical correction of strabismus often leads to unsatisfactory results. Therefore, all manipulations should be dosed (if necessary, in several stages).

2. If necessary, weakening or strengthening of individual muscles, dosed surgical intervention should be distributed evenly.

3. During the operation on a particular muscle, it is necessary to maintain its connection with the eyeball.

High-tech strabismus surgery:

Specialists of children's eye clinics have developed a modern high-tech radio wave surgery with the principles of mathematical modeling.

Benefits of high-tech eye surgery:

Operations are low-traumatic, thanks to the use of radio waves, the structures of the eye are preserved.
There are no terrible edema after the operations, the patient is discharged from the hospital the next day.
The operations are accurate.
Thanks to the principles of mathematical calculation, we can ensure the highest accuracy and show a guaranteed result of the operation even before it is carried out.
The rehabilitation period is reduced by 5-6 times.

Results of strabismus surgery

Surgical treatment of strabismus allows you to correct a cosmetic defect, which is a strong traumatic factor for patients of any age. However, restoration of visual functions (i.e. binocular vision) after surgery requires an integrated approach, which includes pleoptic therapy (it is aimed at treating concomitant strabismus amblyopia) and orthopodiploptic therapy (restoration of deep vision and binocular functions).

It should be mentioned that, like any operation, surgical correction of strabismus may be accompanied by the development of certain complications. One of the most common complications of strabismus surgery is overcorrection (so-called overcorrection) due to calculation errors. Hypercorrection can occur immediately after the operation, or it can develop after some time. For example, if the operation was performed in childhood, then in adolescence, when the eye grows, the child may again experience squint. This complication is not irreparable and can be easily corrected with surgery.

The essence of strabismus surgery

General provisions for strabismus operations

Surgery to correct strabismus is often the only effective way to treat it. Strabismus is a disorder of binocular vision. in which, during a straight gaze, the position of one or both eyes can have various deviations to the sides. You can consider in more detail the types of operations performed with strabismus, general provisions their implementation, possible consequences and results.

There are 2 types of strabismus surgery:

reinforcing;
debilitating.
excision of a certain part of it (resection);
excision of part of the muscle fibers (partial myotomy).

Surgical intervention, depending on the situation, can be performed on one or simultaneously on both eyes, any combination of the above types of it can be used. In some cases, a second operation is required.

The ophthalmologist surgeon decides about the surgical intervention after he has established the causes of the indicated visual impairment and carried out a complete diagnosis of the eyes. Indications for the production of surgery to eliminate strabismus can be the following factors:

paralytic strabismus;

It is important to remember that from a cosmetic point of view, these operations can eliminate strabismus completely, but binocular vision is not always restored.

General provisions for strabismus operations

The general scheme of the surgical intervention is as follows:

preoperative preparation;
the actual operation;
postoperative recovery.

Preoperative preparation can last up to 1 year. Its purpose is to rid the brain of the habit of perceiving the wrong image. For this, various electrostimulating techniques can be used, which are prescribed by the doctor depending on the individual characteristics of each patient.

redness of the eyes;
discomfort and pain with sudden movements, in bright light;
various inflammatory processes in the operated areas.

The cosmetic effect after a correctly performed strabismus correction operation will be visible immediately, the restoration of vision will come in 1-2 weeks. In some cases, orthoptodiploptic and pleoptic therapies will be required to restore the binocular functions of the eyes and deep vision.

Thus, surgery to eliminate strabismus in most cases is able to restore normal vision and correct a cosmetic defect in the eyes, thereby returning the patient to a full life.

Treatment of strabismus and its complications

Since strabismus develops against the background of other pathological conditions of the organ of vision, and symptoms are found with an already developed disease, then, quite often, regular visits to an ophthalmologist can avoid the occurrence of strabismus itself and its accompanying complications.

Treatment of strabismus begins from the moment of diagnosis and elimination of the underlying disease, the consequence of which it was. After eliminating the root cause, patients with strabismus undergo complex multistage treatment.

Optical correction

At the first stage, the cause of strabismus is found out, and conditions for normal visual work are created. If a refractive error is detected, its correction is prescribed with correctly selected glasses or contact lenses, which are selected after a multi-day cycloplegia using a solution of atropine in an age-specific concentration. This procedure is necessary to identify the latent part of hyperopia or to exclude the false part of myopia created by the tension of the ciliary muscle, which is responsible for clear near vision (spasm of accommodation).

Pleoptic treatment for strabismus

Pleoptic treatment of strabismus includes a whole range of measures, the purpose of which is to increase and level the visual acuity of both eyes to the age norm. If a functional decrease in vision (amblyopia) is present or is more pronounced in one eye, then occlusion (exclusion from visual work by gluing) is prescribed for the better seeing eye. With constant strabismus, the occlusion mode is alternating, the worse seeing eye is sealed for one day, and the better seeing eye for two or more, depending on the difference in visual acuity. Treatment of amblyopia is a difficult and time-consuming process that uses various types of retinal stimulation to accelerate. At home, these are flashes with the help of a photo flash, perifoveal penalization, training of accommodation reserves. In the conditions of the ophthalmological department, this contingent of patients can be carried out more effective ways- computer techniques, laser stimulation. electrical stimulation. magnetostimulation. pattern stimulation, color therapy, in case of improper fixation - a maculotester, monocular spatial reorientation using Kuppers lighting on a reflex-free ophthalmoscope.

Preoperative Orthotic Treatment

Preoperative orthoptic treatment of strabismus begins after the creation of relative equality of vision in both eyes. The symmetrical position of the eyes is possible only under the condition of correct spatial perception of objects by each eye and the creation of a single visual image by the brain by combining images obtained from each eye. Surgical correction of strabismus leads to an orthophoric position of the eyeballs in the orbit, but for correct perception of the image, the patient must have binocular vision before surgery. First, alternate occlusion is strictly required until strabismus is cured. This avoids the appearance in the brain of pathological mechanisms to combat double vision: functional suppression scotoma and abnormal retinal correspondence. They start with the simplest thing - creating sequential visual images with the help of highlights according to Chermak, as well as with the help of special devices. When treating with a synoptophore, visible objects are placed in eyepieces, which are installed at an angle, equal angle squint. Therefore, a patient with strabismus perceives what he sees as a person with an even eye position. During classes on a four-point color test or when fixing a light source through Bagolini glasses, the asymmetry of the visual axes is corrected by prisms, prismatic compensators or elastic Fresnel prisms. At this stage of treatment, the ability to turn on binocular vision when looking to the sides, from one object to another, is formed, thus developing fusional reserves.

Surgical correction of strabismus

Surgical correction of strabismus is carried out only with insufficient effectiveness of pleopto-orthopto-diploptic treatment of concomitant strabismus. Surgical correction of strabismus in children is best done at the age of 3-4 years, when the child has developed the ability to turn on binocular vision. Early surgical correction of strabismus in children without preliminary orthoptic exercises is shown mainly at large angles of deviation of the eye with congenital strabismus. In adult patients, surgery to correct strabismus can be performed at any time, depending on the patient's wishes.

Surgery to correct strabismus for paralytic strabismus. In case of paralytic strabismus, the indications and timing of surgical treatment are determined only in conjunction with the appropriate specialists (neuropathologist, oncologist, infectious disease specialist).

Prompt correction of strabismus can serve several purposes:

reduction of the angle of strabismus before pleoptic or orthoptic treatment,
prevention of the development of contracture of the external muscles of the eye with a large amount of strabismus,
for the purpose of a functional cure for strabismus,
for cosmetic purposes if it is impossible to improve vision or teach correct binocular vision.

Surgical correction of strabismus is performed by performing two types of operations: strengthening or weakening the eye muscles. Technically, there are many methods of surgical dosage intervention. In order to weaken the muscle, its recession (pushing back), partial myotomy (incomplete dissection of the muscle), tenomyoplasty (lengthening of the muscle) are performed, and for strengthening, resection (shortening) of the muscle-tendon part and proprophy (movement of the muscle anteriorly) are performed.

Classically, in a recession (weakening operation), the place of attachment of the muscle changes, it is transplanted further from the cornea, during resection (augmentation operation), the muscle is shortened by removing a part of it, the place of attachment of the muscle to the eyeball remains the same. The extent of the strabismus correction operation is determined by the strabismus angle. Correct position the eye can be restored in the vast majority of cases. The deviation of the eye remaining after the operation can be further eliminated with the help of orthopto-diploptic treatment. When indicated, a combined surgical correction of strabismus is performed, when one muscle is simultaneously weakened and the other muscle is simultaneously strengthened in one, and then in the other eye.

Postoperative orthoptic treatment

Postoperative treatment of strabismus involves the same principles as preoperative, and is aimed at restoring and developing binocular vision.

At this stage, the symmetrical position of the eyes achieved after the operation is fixed. The child's ability to see binocularly improves, fusion reserves expand, physiological double vision is formed, which is necessary for the correct perception of the distance to the object.

Strabismus treatment is a long-term process that requires a lot of patience from you, strict implementation of the doctor's recommendations, understanding of the stages of treatment. The earlier the pathology is detected and the treatment of strabismus is started, the higher the likelihood of your complete functional recovery.

Surgical treatment of nystagmus

Surgical treatment of nystagmus consists in changing the tone of the horizontal muscles in order to move the position of "relative rest" to the middle position. The operation is performed strictly symmetrically on both eyes and in two stages. At the first stage, a bilateral recession of the muscles associated with the slow phase of nystagmus is performed. The second stage of the operation consists in bilateral resection of the muscles that carry out the fast phase of nystagmus. It is advisable to carry out this stage after the result of the first operation is determined and the nystagmus acquires a stable jerky character. If, after the first stage of the operation, the nystagmus is eliminated or sharply reduced, the second stage is not resorted to.

In conclusion, it should be emphasized that surgical treatment pathologies of the oculomotor apparatus (strabismus, nystagmus) are extremely rarely accompanied by complications, and, as a rule, bring a feeling of great satisfaction to both the ophthalmic surgeon and the patient.

Currently, the generally accepted method of complex treatment of concomitant strabismus, which consists of optical correction of ametropia, measures to combat amblyopia (pleoptics), operations on the eye muscles, and the performance of orthotic and diploptic exercises in the pre- and postoperative periods. The need for surgical treatment of strabismus arises in cases where the constant and long enough (at least a year) wearing correctly prescribed glasses and orthoptic exercises do not lead to the elimination of deviation.

In the process of treating patients before surgery, the main attention should be paid to correcting visual fixation and increasing the visual acuity of the amblyopic eye, developing the ability of the visual analyzer to merge foveal images of objects, obtaining a sufficient fusion width and eye mobility.

The ultimate goal of treating concomitant strabismus is to restore binocular vision. The operation should facilitate, not hinder, the achievement of the specified goal. In this regard, the modern tactics of surgical treatment of strabismus is characterized by the refusal to perform forced interventions, the even distribution of the effect of the operation on several muscles and the use of such types of operations in which the muscle remains in its plane and maintains a reliable connection with the eyeball.

The expediency of adhering to the above principles is confirmed by the results of histological studies, which show that the degree of muscle tension has a great influence on the regeneration process. Both excessively strong and weak tension negatively affects the normal recovery process in the muscle.

The optimal age for performing surgery for concomitant strabismus is considered by most ophthalmologists to be 4-6 years, when the effect of optical correction of refractive errors is already clearly visible and when it is already possible to carry out active orthoptic exercises in the pre- and postoperative periods.

It should be borne in mind that when strabismus occurs in early age(in the first year of life) the development of the binocular visual system occurs incorrectly, from the very beginning it adapts to the asymmetric position of the eyes. In such cases, early and ideally dosed surgery on the eye muscles can create conditions for the formation of normal binocular vision, if there are no contraindications from the retina. Based on these considerations, a number of authors propose to carry out operations for strabismus in early childhood, especially with a very large deviation and the presence of ocular torticollis.

When examining patients before surgery, it is necessary to obtain complete data on visual acuity and visual fixation, eye refraction, strabismus angle, the nature of vision with two eyes open, eye mobility, the ability of the visual analyzer to merge foveal images of objects and fusion reserves at the strabismus angle. Analysis of these data will make it possible to clarify the indications for the operation, determine the rational tactics of its implementation and predict the likely outcome.

If, after active pleoptic treatment, the amblyopic eye retains a low visual acuity (less than 0.3), which prevents the formation of binocular connections, then one should not rush to the operation. If there is a pronounced deviation (more than 10 °), it is still advisable to do it even before the child enters school, but take into account the possibility of reoperation in case of recurrence of strabismus. The parents of the child should be warned about this. It is better to perform such a corrective operation at the age of 10-12 years, when the development of the facial skeleton and orbits almost stops, which, in the absence of binocular vision, can contribute to the deviation of the eyes.

The presence of hypermetrolia in case of converging strabismus and myopia in case of divergent strabismus gives reason to expect the appearance after the operation of "partially accommodative" properties of strabismus. In such cases, optical correction of refractive errors can have a stabilizing effect on the position of the eyes in the postoperative period.

Simultaneous vision indicates a lesser tendency to inhibition of visual perception of the deviated eye than monocular vision. This creates more favorable conditions for the joint activity of both eyes. However, the state of fusion is of paramount importance in this sense. The ability of the visual analyzer to merge foveal images of objects, revealed even before the operation, significantly increases the effectiveness of postoperative orthoptic exercises and the possibility of restoring normal binocular vision. Due to this ability, which acts as a reliable "ally" of the surgeon, even a small angle of strabismus left after surgery can be eliminated.

The more constant the strabismus angle, the better and more stable the results of the operation, as a rule. With a changing angle of strabismus, its average value should be taken into account. If, during the examination of the patient, the deviation periodically disappears and appears, and the range of deviation of the eye is significant, then the operation should not be performed.

At small angles of strabismus, the state of binocular functions should be examined especially carefully. The ability to merge at the zero position of the synoptophore objects and binocular vision detected on a color device indicate that the patient has so-called asymmetric binocular vision. In these cases, which, however, are very rare, the operation does not make sense, since after it either the previous position of the eyes will remain, or persistent double vision will appear.

With enhanced adduction, it is considered advisable to perform an operation in order to weaken the action of the internal rectus muscles. If the adduction is reduced, then the operation should be performed on the external rectus muscle.

With monolateral strabismus, it is more logical first of all to perform an operation on the squinting eye, based on the fact that pathological disorders are usually more pronounced on it. This tactic finds more understanding among the patient and his relatives, therefore, it is justified psychologically.
With alternating strabismus, the question of choosing an eye for the operation naturally loses its meaning, but even in this case it is better to first perform the operation on the eye that has large deviations from the norm (for example, in terms of the degree of mobility or visual acuity).

Based on physiological considerations, preference should be given to operations that enhance the effect of weakened muscles. It is also necessary to take into account the width of the palpebral fissure, remembering that operations that enhance the action of the muscles somewhat narrow the palpebral fissure, and weakening ones somewhat widen it. This recommendation refers to strabismus without local muscle defects (fibrosis, contracture, hypertrophy, anomalies of attachment sites), which in some cases underlie congenital strabismus. In such cases, strengthening the antagonist without prior or simultaneous release of such a strengthened muscle is ineffective.

Even at significant angles of strabismus, operations on more than two muscles should not be performed simultaneously, since this greatly increases the difficulty of dosing and the likelihood of obtaining a hypereffect. If after the first stage of the operation the residual angle of strabismus remains, then the second stage of the operation on another muscle of the same eye or on the other eye is performed after 6-8 months. It is best to warn the patient or his parents about this, otherwise even the first stage of the operation carried out in accordance with the plan, which did not completely correct the strabismus, may be regarded by them as a failure.

When a pronounced horizontal deviation of the eye is combined with a vertical one, it is advisable to first perform an operation on the horizontal muscles, given that vertical deviation can be not only a consequence of muscle paresis, but also a manifestation of vertical phoria, which often disappears in the primary position of the eye. If the vertical deviation is significant and the study of the oculomotor apparatus indicates a predominant lesion of the muscles of vertical action, then an operation should be performed on these muscles.

Types of surgical interventions

To eliminate strabismus, two types of operations are used - strengthening and weakening the action of the muscles.

Enhancing

resection - shortening of a muscle by excising its section at the point of attachment to the sclera and suturing to this place;
tenorrhaphy - shortening by forming a fold from her tendon;
proraphy - an increase in the degree of muscle tension as a result of movement of its tendon anteriorly (with interventions on rectus muscles) or posteriorly (with interventions on oblique muscles) with or without a fold;
twisting - increasing the degree of muscle tension by screwing it around its axis after crossing, followed by suturing to the place of anatomical attachment.

Laxative

free (or complete) tenotomy - the intersection of the muscle tendon at the insertion site without suturing it to the sclera;
tenotomy with a restrictive (safety) suture - fixation of the tenotomized muscle at a certain distance from the site of anatomical attachment using a suture passing through this place and the edge of the transected tendon;
partial tenotomy - applying 2-3 incomplete cuts on the tendon of the muscle from the opposite edges, somewhat spaced from each other;
recession - movement of a muscle, crossed at the site of attachment, posteriorly (with interventions on the rectus muscles) or anteriorly (with interventions on the oblique muscles) with its suturing to the sclera;
prolongation - lengthening the muscle by completely cutting its tendon in different directions and stitching the cut sections;
fadenoperative - fixation of the muscle to the sclera behind the site of the muscle to the eyeball.

To enhance the action of the muscles, resection is usually performed. Tenorrhaphy and proraphy are rarely performed, mainly for interventions on the oblique muscles. Of the operations that weaken the action of the muscles, recession is the most widespread. Prolongation, tenotomy with a safety suture and, especially rarely, partial tenotomy are used much less frequently. Free tenotomy is performed only with some atypical forms of strabismus and with surgery on the oblique muscles.

The methods for carrying out each of these operations are very diverse. However, this applies primarily to technical details and not to the principle of the operation itself. The use of many of these methods is unjustified: they either do not introduce significant changes in the course of the operation, or overly complicate it.

Anesthesia

In children under the age of 10-14 years, operations on the eye muscles should be carried out under anesthesia, giving preference to a mixture of nitrous oxide and fluorothane. In adults and older children, local infiltration and conduction anesthesia is used. It must be remembered that pain usually arise from tension of the oculomotor muscles, which are rich in innervation. To eliminate these sensations, it is necessary to inject an anesthetic into the area of the muscle funnel.

After three times installation, a 0.5-1% solution of dicaine is injected into the conjunctival sac with 1.5-2 ml of a 2% solution of novocaine under the operated muscle, and then, slightly changing the direction of the needle, behind the eyeball. A small amount (0.3-0.5 ml) of novocaine solution should also be injected under the conjunctiva at the site of muscle attachment.

Dosing the effect of the operation

The "question of questions" in strabismus surgery is the correct dosage of the effect of the operation. It was found that there is a high direct correlation between the degree of shortening or movement of the muscle and the obtained value of the change in the angle of strabismus. This suggests that an indicative preliminary plan for dosing the effect of surgery on the oculomotor muscles is possible.

Dosing regimen for converging strabismus according to Avetisov-Makhkamova.

Dev<10° - рецессия внутренней прямой (MRM) = 4 мм
Dev 10 ° - MRM recession + external straight line resection (MRL) = 4-5 mm
Dev 15 ° - MRM recession + MRL resection = 6mm
Dev 20 ° - MRM recession + MRL resection = 7-8 mm
Dev 25 ° - MRM recession + MRL resection = 9 mm
Dev> 30 ° - 2-3 stages of the operation, depending on the initial value of the angle, the presence of residual deviation and the state of binocular functions.

In case of divergent strabismus, on the contrary, MRL recession, MRM resection.

It is advisable to make some dosage adjustments during the operation. If the muscle to be resected looks flabby, then the degree of its expected shortening is increased by 1-2 mm.

It is known that under the influence of narcotic substances the eyes deviate upward and outward, and the magnitude of this deviation varies greatly. In this regard: when carrying out anesthesia, the position of the eyes on the operating table cannot be judged on the effect of the intervention on the eye muscles. Under these conditions, the principle of preliminary dosing of the operation is the only possible one.

The dosing table for strabismus correction should also be used in cases where it is performed under local anesthesia. In this case, it is possible to evaluate the result of the surgical intervention directly on the operating table and make some adjustments to the intended dosage regimen. However, such an assessment is difficult due to the fact that under the influence of novocaine, the strabismus angle also changes within a fairly wide range. It is advisable during the operation to give the patient's eyes a position of some hypereffect.

Tools

To carry out operations on the eye muscles, an eyelid speculum, fixation, anatomical and surgical tweezers, special scissors curved at an obtuse angle, muscle hooks, a measuring device (millimeter ruler, compasses, etc.), a needle holder, blunt scissors for cutting off sutures, a spatula, sharp scleral scraping spoon, needles for muscle ligation and conjunctival sutures, thin curved (preferably atraumatic) needles for episcleral sutures. You may also need muscle clamps, a hook for the superior oblique muscle, and tweezers to fold the muscle.

Thin and strong catgut 1.0 and 2.0, silk 2.0 and 3.0 for the conjunctiva, silk 1.0 for sewing muscles and silk 3.0 and 4.0 are used as suture material for surgical interventions on the muscles of the eye. for ligating a muscle. Biological sutures are also used. Especially convenient are synthetic sutures, which do not need to be removed after surgery.

Postoperative management

After the operation, 1-2 drops of a 30% solution of sulfacyl sodium or other antiseptic are installed in the eye and a bandage is applied, usually binocular. Dressings are done daily. The sutures from the conjunctiva are removed on the 4th-5th day. If silk sutures were applied to the muscle, then they are removed on the 6-7th day.

Orthopedic and diploptic exercises, according to indications, begin as early as possible, as soon as the condition of the eyes allows. These exercises improve eye mobility, help eliminate residual deviation and restore binocular vision. The patients are discharged from the hospital on the 5-7th day after the operation.

Neither before nor after surgery should be prescribed medications, acting on accommodation and indirectly on convergence, for example, atropine solution. Such drugs have a temporary effect on the position of the eyes, sometimes cause a paradoxical effect and create additional difficulties in assessing the effect of the operation.

Better to influence the position of the eyes with a bandage. If, after correcting the converging strabismus, a hypo effect is observed, then it is advisable to leave the binocular bandage for several days. This natural elimination of accommodation also excludes the impulse for convergence, thereby causing a tendency for the divergence of the visual axes. With pronounced hypereffect, it is advisable to leave a monocular dressing to connect accommodation and convergence.

After surgical correction of divergent strabismus, they do the opposite: with hypoeffect, they prefer a monocular dressing, with hypereffect, binocular. Other types of "orthoptic" dressings do not justify themselves.