RU2600149C1 - Method for surgical treatment of patients with concomitant pathology of anterior segment of eyeball: aniridia, corneal clouding of various degree of manifestation, pathology of lens and ligamentous apparatus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology, and can be used for surgical treatment of congenital and traumatic aniridia, combined with decreased corneal clouding of various degree of manifestation and cataract. Femtosecond laser is used to make a blind circular incision on recipient's cornea with diameter of 7-9 mm concentrically to limb at a depth of 2/3 thickness and an affected cornea at given depth, then surface layers are removed to transparent layers, leaving deep corneal disk, especially in optical zone, creating a surgical bed. Cataract phacoemulsification is performed, then through incision of cornea on circular arc of 80-90 degrees, while continuing through incision. Through prepared incision iridolenticular diaphragm is implanted on surface of anterior capsule with support in area of ciliary furrow without application of fixing sutures. From anterior chamber viscoelastic is washed out. Along circumference is excised remaining part of deep corneal disk of recipient, donor cornea is removed from medium for preservation and placed on Barron vacuum trepan with endothelium upwards. Through trepanation of donor cornea is made, a transplant of required diameter is cut out. Obtained graft is laid with endothelium down in prepared operational bed on cornea of recipient, donor cornea is fixed in four meridians with interrupted sutures, then a continuous blanket suture, after that, fixing interrupted sutures are removed, operation is finished by introducing under conjunctiva dexason solution and an antibiotic.

EFFECT: method enables to reduce number of possible postoperative complications, such as loss of endothelial cell density in early postoperative period, prevent turbidity of corneal graft, as well as higher visual acuity and improves aesthetic effect.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of congenital and traumatic aniridia, combined with clouding of the cornea of varying severity and cataract.

A known method of surgical treatment of aniridia (RF patent for the invention No. 2129851).

The method includes conducting through corneal incisions through half its thickness, delaminating along this thickness along the ring to the central optical zone, then an open intracorneal diaphragm is implanted into the corneal pocket. The method allows to reduce the invasiveness of surgical intervention.

The closest analogue is the method of surgical correction of total aniridia combined with aphakia in the single-chamber eye (RF patent for the invention No. 22427,546).

The method consists in implanting an artificial implant inside the eye, previously on the sclera after incisions and separation of the conjunctiva in the meridians 2-30, 6-30, and 10-30 form scleral flaps. Under the flaps in the middle of their bases, sections of the remaining layers of the sclera and the flat part of the ciliary body are cut. Then, through the corneal incision, an artificial eye implant (iridocrystalline diaphragm) is introduced into the cavity of the eye, consisting of two components. The first component is a positive lens, in the body of which 3 flexible support elements are fixed. The second component is an artificial iris. Loops are located at the ends of the support elements, each of which is successively brought out through previously formed incisions in the sclera and is sutured to the edges of the incisions under scleral rags.

The disadvantage of this method is that suture fixation of the iridocrystalline diaphragm (IHD) may be ineffective due to the possibility of resorption and eruption of sutures, changes in the position of the artificial eye implant, and also due to the fairly frequent intraoperative bleeding from the vessels of the ciliary body. The disadvantage of this method is that it cannot be used for clouding of the cornea of varying severity.

The objective of the invention is to provide an effective method of surgical treatment of aniridia in combination with clouding of the cornea of varying severity, which allows to increase the safety of surgical intervention, as well as reduce the morbidity of surgical intervention, reduce the number of possible postoperative complications, increase visual acuity after surgery and improve the cosmetic effect.

The technical result of the invention is to reduce the number of possible postoperative complications, such as loss of density of endothelial cells in the early postoperative period, preventing clouding of the corneal transplant, reducing the rehabilitation of patients, as well as increasing visual acuity and improving the cosmetic effect.

The technical result is achieved by the fact that in the method of surgical treatment of aniridia, including the corneal incision and implantation of the ICD, according to the invention, a non-through circular incision of the recipient’s cornea with a diameter of 7 to 9 mm concentrically limbus to a depth of 2/3 of the thickness is performed using a femtosecond laser and the lesion is stratified the cornea at a given depth, after which the surface layers are removed to transparent layers, leaving a deep corneal disc, especially in the optical zone, creating an operating bed, after this cataract phacoemulsification is carried out, then a corneal incision is made through an arc of a circle of 80-90 degrees, continuing a non-through incision, an iridocrystal diaphragm is implanted through the prepared incision onto the surface of the anterior capsule, resting on the ciliary sulcus without fixing sutures, then the viscoelastic is washed out of the anterior chamber after this, the rest of the recipient’s deep corneal disc is excised around the circumference, the donor cornea is removed from the preservation medium and placed in a vacuum I take Barron trepan upwards with endothelium, perform through trepanation of the donor cornea, cut out the graft of the required diameter, then put the transplant into the prepared operating bed on the recipient’s cornea with the endothelium down, fix the donor cornea in four meridians with interrupted sutures, then apply a continuous, after-closure suturing nodal sutures, the operation is completed by the introduction of a dexazone solution and an antibiotic under the conjunctiva.

Among the essential features characterizing the method, the distinguishing ones are:

- carrying out a non-through circular incision to a depth of 2/3 of the cornea thickness and its delamination at a given depth using a femtosecond laser allows to ensure the exact size of the corneal disk and the minimum risk of corneal tissue damage;

- non-through cutting of the corneal disc allows you to perform a significant part of the operation on the closed eye, thereby eliminating the possible intra- and postoperative complications associated with the risk of surgery according to the type of "open sky";

- implantation of the iris lens diaphragm on the surface of the lens capsule with support in the area of the ciliary sulcus without fixing sutures eliminates the resorption and eruption of sutures, the position of the irid lens lens diaphragm, as well as bleeding from the vessels of the ciliary body;

- simultaneous keratoplasty with restoration of the structures of the anterior segment of the eyeball and implantation of the iris lens diaphragm can reduce the trauma of the endothelium of the donor transplant many times;

- the implantation of the iris lens diaphragm simultaneously with keratoplasty allows you to restore the structure of the anterior segment of the eyeball and improve their visualization. This will allow you to correctly implant the iridocrystalline diaphragm and to avoid loss of density of endothelial cells in the early postoperative period, and as a result, to prevent clouding of the corneal transplant in the postoperative period;

- it is possible to control optical reconstructive interventions and accurately perform capsulorexis, as well as to place supporting elements of the iridocrystalline diaphragm in case of capsular support, and it is possible to implant intracapsularly controlling the capsular edge.

Thus, between the set of essential features and the claimed technical result, there is a causal relationship.

The combination of signs provides a reduction in intra- and postoperative complications, the terms of rehabilitation of patients, allows to achieve the maximum possible visual acuity, elimination of cosmetic defects, provides simultaneous "closed" phacoemulsification and implantation of the iris lens, which corresponds to the achievement of the technical result of the invention.

The method is as follows:

The treatment of the surgical field is carried out with a 0.5% chlorhexidine solution twice. Alcain and vitabact are instilled into the conjunctival cavity. The operation is performed under local anesthesia and intravenous anesthesia. First of all, a vacuum ring is installed, which fixes the patient's eye. After that, a programmed, through a femtosecond laser, non-through circular incision of the cornea at the recipient is performed concentrically to the limb, the diameter of the trepanation incision is selected depending on the initial size of the cornea of the recipient, to a depth of 2/3 of the thickness of the cornea, when calculating the depth of the cut, proceed from the recipient's pachymetry performed optical coherence tomography and stratification of the cornea at a given depth. Then the surface layers, which are composed of epithelium and superficial stroma, are removed. In this case, it is necessary to strive to achieve transparent layers, especially in the optical zone, leaving a deep corneal disc of the recipient, thereby preparing the operating bed (circular opening of the cornea of the recipient). After creating a bed, making sure that, if possible, all damaged layers have been removed, the next step is phacoemulsification of cataracts, which includes performing the main corneal two-stage self-sealing tunnel incision and corneal paracentesis, introducing viscoelastic into the anterior chamber, and performing continuous circular capsulorhexis with a diameter of 5 mm using micro forceps carrying out hydrodissection and hydrodelineation of the lens, phacoemulsification. After that, with a round corneal scissors, continuing a non-through incision, a through incision of the cornea is made along an arc of a circle of 80-90 degrees. Through the prepared incision, an iris lens diaphragm is implanted with tweezers onto the surface of the lens capsule with support in the area of the ciliary groove without the application of fixing sutures. Then, viscoelastic is washed out of the anterior chamber with balanced saline. After that, a deep corneal disc of the recipient, which consists of the deep part of the stroma, descemet shell and endothelium of the cornea, is excised with round corneal scissors around the circumference. The donor cornea is removed from the canning medium, prepared, for example, according to the patent of the Russian Federation No. 2069951 Borzenka-Moroz and consisting of the following components, taken in wt. %: medium M-199 25, medium F-10 25, chondroitin sulfate 2.7, dextran-40 2.0, gentamicin sulfate 0.00014, amphotercin B 0.00015, medium Dyulbekko-Igla - the rest. The donor cornea is placed on the vacuum trepan of Barron with the endothelium upward, through the trepanation of the donor cornea is performed, the graft of the required diameter is cut out, then the transplant is transferred to the prepared bed on the recipient’s cornea, fixing anchor sutures are applied in four meridians (8.0 silk) and then continuous twisted seam (nylon 10-0), fixation nodal joints (silk 8-0) are removed. The operation is completed by the introduction of a conjunctiva of a solution of dexazone and an antibiotic in a volume of 1.0 ml.

The method is illustrated by the following example:

Example 1:

Patient A., 35 years old. Diagnosis: OS - Post-traumatic corneal scar. Endothelial-epithelial dystrophy of the cornea. Traumatic mydriasis. Traumatic cataract. OU - Axial myopia of moderate degree. Condition after refractive surgery (LASIK).

Visus OS - pr. Certae

OD - 1.0

Ophthalmometry:

OS 44.75-175 48.75-85 OD 41, 25-15 41.50-105

Density of endothelial cells: the data device does not produce

Through the keratoplasty, the front 2/3 layers of the affected recipient cornea were removed on the left eye of the patient, according to the invention, cataract phacoemulsification, implantation of the iris-crystalline diaphragm was performed, then the remaining deep layers of the cornea were removed, followed by transplantation of the donor cornea.

The operation and the postoperative period proceeded without complications.

1 month after surgery:

OS - 0.1

When examining the OS: the eye is calm, the graft is transparent, lies correctly, the edges are adapted, the corneal suture is clean, adapted, the iris-lens diaphragm is in the correct position.

Thus, in case of combined lesions of the iris, lens and cornea, carrying out a simultaneous operation of donor corneal transplantation and implantation of the iridocrystal diaphragm can increase the safety of surgical intervention, as well as reduce the morbidity of surgical intervention and reduce the number of possible intra- and postoperative complications, eliminate a cosmetic defect, and increase the severity patient vision.

Claims (1)

A method for the surgical treatment of patients with combined pathology of the anterior segment of the eyeball: aniridia, clouding of the cornea of varying severity, pathology of the lens and its ligamentous apparatus, including the corneal incision and implantation of the iris-lens diaphragm, characterized in that a femtosecond laser carries out a non-passive circular incision with a diameter of 7 to 9 mm concentric to the limb to a depth of 2/3 of the thickness and exfoliate the affected cornea at a given depth, after which superficial layers are removed to transparent layers, leaving a deep corneal disc, creating an operating bed, then cataract phacoemulsification is carried out, then continuing through a non-through incision, a corneal incision is made through an arc of a circle of 80-90 degrees, an iris-lens diaphragm is implanted on the surface of the anterior capsule through the prepared incision. with support in the area of the ciliary sulcus without fixing sutures, then viscoelastic is washed out of the anterior chamber, after which the rest is excised around the circumference I’m part of the recipient’s deep corneal disk, the donor cornea is removed from the preservation medium and placed on the Barron vacuum trepan with the endothelium upward, through-trepanation of the donor cornea is performed, the graft of the required diameter is cut out, then the resulting transplant is laid down with the endothelium into the prepared surgical bed on the cornea of the recipient they are fixed in four meridians by interrupted sutures, then a continuous twisted seam is applied, then fixing interrupted sutures are removed, ation end subconjunctival administration deksazona solution and antibiotic.