RU2611939C1 - Method of surgical treatment of pterygium - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to the medicine, particularly, to the ophthalmology, and may be used for the surgical treatment of a pterygium. A pterygium is transected in the limbus area. The conjunctiva and subconjunctival tissue are incised by two aslant-directed cuts with the length of 4 mm each from the edges of the pterygium transection to the sides of the upper and lower conjunctival fornices. The pterygium head is stripped from the cornea to the transection place in the limbus area, and then, removed. The surface of the cornea is leveled by a diamond knife. The conjunctiva is separated from the external surface of the pterygium body covering the area from the upper to the lower aslant-directed cuts up to the semilunar fold and moved towards the medial angle of the eye. The pterygium body is separated from the sclera of the eyeball; the pterygium is transected in the area of the semilunar fold and removed. A wound surface of the sclera is covered with the separated conjunctiva by moving its edge, which was attached to the limbus, towards the upper and the lower conjunctival fornix up to the aslant-directed cut of the conjunctiva, smoothed over the entire area of the removed pterygium body up to the opposite aslant-directed conjunctival cut, and fixed by the interrupted stitches. A relaxation incision of the settled conjunctiva with the length of 5-7 mm is performed in the area of the semilunar fold in parallel to it. The formed wound defect of the conjunctiva is substituted with a conserved amniotic membrane, which is fixed by the interrupted stitches. All interrupted stitches are removed on the 10th day after operation.

EFFECT: method of the increasing of efficiency of the surgical treatment of a pterygium, reduction of the risk of a pterygium relapse, exclusion of the risk of formation of the post-operational astigmatism, preservation of the eye lability, and increasing of aesthetic effectiveness of the operation and quality of life of a patient.

5 dwg, 2 ex

Description

The invention relates to medicine, in particular to ophthalmology, and can be used for surgical treatment of pterygium.

Pterygium is a dystrophic vasoproliferative process in the conjunctiva of the eye, mainly in the subepithelial tissue, which, growing in the optical zone of the cornea, causes a significant decrease in vision and leads to gross cosmetic defects. A recognized radical method of treating pterygium is its surgical removal (Kanski D.D., 2006).

To date, many different traditional operations have been proposed, which are characterized by conjunctival interventions after separation of the pterygium: turning the head and body of the pterygium in the conjunctival pocket (according to Mc Reynolds), counter vertical displacement of square flaps of the mucous membrane after excision of the pterygium (according to Kankrov), unfolding of excised pterygium 180 ° (according to Golovin). The main disadvantage of traditional technologies for surgical treatment of pterygium is the high relapse rate - from 40 to 70% (S.E. Avetisov, E.A. Egorov, 2008).

Currently, preference is given to surgical methods using, after removal of the pterygium, a “barrier” transplant into the wound bed near the limb in the area of the operation of various biological tissues. According to the authors, such a tissue barrier creates a mechanical barrier to the resumption of growth of scar-proliferative tissue in the cornea (A.V. Zolotarev, E.S. Milyudin, 2007).

There is a method of treating pterygium based on autoplasty, which consists in excising the head and body of the pterygium with the subsequent replacement of the bulbar conjunctiva defect with an autograft of the mucous membrane from the lips (Guide to Eye Diseases / edited by N.A. Pletnev - M .: Medicine, 1959).

Disadvantages:

• The formation of additional scars in the oral region;

• Difficulty in the act of chewing in the postoperative period due to iatrogenic wound surface;

• Difficulties in obtaining a flap from the mucosa from the lips due to heavy bleeding;

• The risk of infection of the conjunctiva of the eye with microflora of the oral tissue;

• Antigenic stimulation of the immunocompetent area of the eye is the cause of immunological stress, the clinical manifestation of which is accompanied by an inadequate inflammatory response to surgery with activation of the proliferative process leading to relapse of pterygium;

• aesthetic mismatch of the transplanted tissue of the conjunctival surface of the eye.

A known method of treating pterygium (see Ophthalmology, American Academy of Ophthalmology, Vol. 110, No. 4, April 2003, P. 806), which consists in excising the head and body of the pterygium with the subsequent replacement of the formed wound surface with a free conjunctival flap, cut out from the lower section conjunctival arch

Disadvantages:

• the application of the method is limited only by the small size of the pterygium;

• cicatricial contraction of the conjunctival arch with its subsequent shortening and violation of the physiological outflow of the tear;

• the appearance of additional scars in the aesthetic area of the eye;

• the risk of the formation of symblepharon, which violates the mobility of the eyelid.

There is a method of treating pterygium, which involves excising pterygium and using a specially treated meninges as a homograft to cover the wound defect and create a mechanical barrier in the limb area (Lantukh V.V., Lantukh E.V. RF Patent No. 2150257, publ. 10.06. 2000). Disadvantages:

• a tendency to relapse of pterygium due to activation of antigenic stimulation of the limb by foreign tissue remains;

• a high risk of necrosis, lysis and contraction of the transplant due to the lack of functioning blood vessels in the cerebral flap and the immunological conflict between the transplanted tissue and the own tissues of the eye, requiring repeated surgical interventions to replace the transplant;

• aesthetic color mismatch between the transplanted tissue and the conjunctival surface of the eye;

• difficulties in obtaining donor material due to the lack of licensed eye tissue banks.

A known method of surgical treatment of recurrent pterygium (Latypova E.A., Halimov A.R. Patent of the Russian Federation No. 2354338, publ. 10.05.2009). Separation and excision of the head and body of the pterygium from the cornea and sclera are made, and episcleral vessels are coagulated. The conjunctiva is incised above the crescent fold, detached, wrapped in the direction of the corner of the eye and sew with interrupted sutures to the arches of the eyelids. A graft from a kidney capsule is formed in the bed formed after removal of the pterygium.

Disadvantages:

• there is a risk of pterygium recurrence due to the occurrence of antigenic stimulation in the immunocompetent area of the cornea - in the limb, which is accompanied by an inflammatory reaction to surgery that impedes the development of normal reparative processes;

• high risk of necrosis, lysis and transplant rejection due to the immune conflict of the transplanted tissue antigenically foreign to the surface of the eye, requiring repeated surgery;

• the formation of a coarse, streaming scar in the area of the lacrimal flesh by wrapping the conjunctiva in the direction of the corner of the eye, which entails a low aesthetic result of the operation and is accompanied by impaired eye mobility;

• development of dry eye syndrome due to the removal of a large volume of conjunctiva with goblet cells secreting the components of the tear.

The closest analogue to the prototype is a method of treating pterygium (Zolotarev A.V., Milyudin E.S. Surgical treatment of recurrent pterygium with plastic surgery of the dried amniotic membrane // Bulletin of Ophthalmology. - 2007. - No. 7. - P. 39-42), consisting in separation and excision of pterygium, superficial keratectomy, removal of a pathologically altered conjunctiva with the underlying subconjunctival tissue and replacement of the formed conjunctival defect in the limb with a silicone-dried amniotic membrane with its fixation to epi Clair interrupted sutures.

Disadvantages:

• a high risk of developing pterygium recurrence due to abnormal repair processes due to trauma and inflammation in the limbic zone of the cornea, which performs immunoregulatory and trophic functions;

• peripheral clouding of the cornea in the keratectomy area, resulting from excision of the surface layers of the cornea and the slowing down of reparative processes, violating the transparency of the cornea and causing cosmetic dissatisfaction in patients with the outcome of the operation;

• decrease in visual acuity due to the formation of corneal postoperative astigmatism due to keratectomy, during which the surface layers of the cornea are cut off;

• the risk of exposure of the sclera in the limb in the area of the operation due to the reduction of rigidly-changed remnants of the conjunctiva, stretched at the inner corner of the eye;

• the development of dry eye syndrome due to the removal of a large volume of the conjunctiva with goblet cells secreting the components of the tear;

• with keratectomy, traumatic damage to the limb, an immunocompetent area of the eye, occurs, followed by the development of trophic disorders and inflammatory reactions in the conjunctiva and cornea, which requires repeated surgical intervention;

• aesthetic color mismatch between the transplanted silicone-dried amniotic membrane and the conjunctival surface of the eye.

The objective of the invention is to create an effective method of treating pterygium, which allows to reduce the risk of relapse of the disease and get a good aesthetic result.

The technical result of the invention is to increase the effectiveness of surgical treatment of pterygium, reduce the risk of recurrence of pterygium, eliminate the risk of forming postoperative astigmatism, maintain functional eye mobility, increase the aesthetic effectiveness of the operation and the quality of life of the patient.

The invention is illustrated by drawings:

FIG. 1. Incisions of the pterygium and conjunctiva.

FIG. 2. Separation of the conjunctiva from the outer surface of the body of the pterygium.

FIG. 3. Covering the wound surface of the sclera with a separated conjunctiva.

FIG. 4. The formation of a laxative incision of the laid conjunctiva.

FIG. 5. Replacement of the wound defect of the conjunctiva with an amniotic membrane.

1 - dissection of pterygium in the limb zone.

2 - the head of the pterygium.

3 - the body of the pterygium.

4 - oblique sections.

5 - conjunctiva.

6 - the edge of the conjunctiva adjacent to the limbus.

7 - lunate fold.

8 - the first wound angle.

9 - second wound angle.

10 - nodal seam.

11 - nodal seam.

12 - nodal seam.

13 - laxative incision.

14 - nodal joints.

The technical result is achieved as follows.

After processing the surgical field and local anesthesia, the pterygium in the limb zone 1 is dissected, separating the head of the pterygium 2 from its body 3. Then, the conjunctiva and subconjunctival tissue are cut with two oblique sections 4 4 mm long from the edges of the pterygium dissection towards the upper and lower conjunctival arches (Fig. . one).

The head of the pterygium 2 is captured with serrated forceps and, with a gentle movement of the hand, clockwise, exfoliate it from the cornea to the incision site in the limb zone 1 and remove it. Using a diamond knife, the surface of the cornea is flattened by scraping, removing tissue residues.

Then conjunctiva 5 is separated from the outer surface of the pterygium body with scissors, starting from the edge adjacent to the limb 6, capturing the area from the upper oblique section to the lower oblique section, up to the lunate fold 7 at the inner corner of the eye (Fig. 2). The separated conjunctiva is pushed towards the inner corner of the eye.

Then, with the help of a spatula, the body of the pterygium 3 is cut off in a blunt way from the sclera of the eyeball to the lunate fold 7 at the inner corner of the eye, carefully removing the remaining sections of the subconjunctival tissue and episclera with a spatula. Next, the pterygium is crossed with scissors in the area of the lunate fold and removed.

The next stage covers the wound surface of the sclera with a separated conjunctiva (Fig. 3), displacing its edge, which was adjacent to the limb 6, towards the upper or lower conjunctival arches to the previously made oblique conjunctiva section 4. Such a shift changes the vectors of the vessels and allows the limb zone to be replaced healthy conjunctiva. Next, the first wound angle 8 of the separated conjunctiva is fixed with a nodal suture 10 with silk 8-0 thread to the episcler at the limb, the second wound angle 9 is fixed with a nodal suture 11 with silk 8-0 thread to the edge of the oblique conjunctival incision. The stacked conjunctiva is spread over the entire area of the removed pterygium body and fixed with a nodal suture 12 with 8-0 silk thread to the episclera at the limb in the area of the opposite oblique conjunctival incision.

Then, in the area of the lunate fold, a laxative incision 13 of the laid conjunctiva is formed parallel to the lunate fold 5-7 mm long to eliminate its tension at the inner corner of the eye (Fig. 4).

The last step is to replace the conjunctiva wound defect formed as a result of a laxative incision with a preserved amniotic membrane and fix it with interrupted sutures 14 with 8-0 silk thread (Fig. 5). All interrupted nodal sutures are removed on the 10th day after the operation.

The advantages of the method:

• The risk of developing pterygium recurrence due to the covering of a tissue defect and the limb zone with its own conjunctiva without antigenic properties is excluded.

• The risk of the formation of postoperative clouding of the cornea, astigmatism and decreased visual acuity due to the ensured ability of the operating area to organotypically regenerate is excluded. removal of the head is performed without cutting the surface layers of the cornea;

• There is no risk of rejection of the amniotic membrane, its necrosis, wrinkling due to the good vascular-trophic conditions of engraftment in its own conjunctiva and a small replacement area.

• The exclusion of limb ischemia due to the replacement of the wound bed area with a healthy conjunctiva with intact vascular network, which improves the processes of corneal epithelization and eliminates the risk of corneal clouding;

• Good functional mobility of the eye is maintained due to the lack of tension of the lacrimal muscle conjunctiva;

• The risk of developing dry eye syndrome is eliminated due to the fact that the conjunctiva is not removed and there is no loss of goblet cells secreting the components of the tear;

• High aesthetic effectiveness of the operation: there is no difference in the color of the tissues in the aesthetic area of the eyeball.

The proposed method for the treatment of pterygium was used in 11 patients (11 eyes), aged 52 to 73 years (average age 65 ± 8 years), 7 of them were men, 4 women. With category II pterygium - 6 people, with category III pterygium - 5 people. The postoperative follow-up period was up to 1.5 years. As a result of the operation, no recurrence of the disease was noted in any case, a good aesthetic result was achieved, limitation of the mobility of the eyeball and tension of the lacrimal flesh was not noted. All patients are compensated by the state of the corneal tear film.

Example No. 1. Patient M., 64 years old, was admitted with a diagnosis of pterygium of the III category, induced myopic astigmatism of a weak degree of the right eye. From the anamnesis: the film appeared about 15 years ago, over the past year it began to mark the growth of the film and the appearance of redness in the inner corner of the eye.

The patient underwent surgery to remove pterygium according to the proposed method, and at the stage of covering the wound surface of the sclera with a separated conjunctiva, its edge, which was adjacent to the limb, was shifted towards the lower conjunctival arch to the oblique incision of the conjunctiva located in the direction of the lower conjunctival arch.

After surgery, the patient was prescribed four-fold installations of an antibiotic, anti-inflammatory drug, and root protector for 10 days. Removal of all conjunctival sutures was performed on the 10th day after surgery.

On examination after 1 month: in the area of the operation, there was complete engraftment of the graft, the color of which did not differ from the color of the conjunctival surface of the eye, moderate vascularization of the tissues with the formation of normotrophic scar, tissue disposition of the inner corner and lacrimal was observed on the border between the transplanted amniotic membrane and the conjunctival eye. no lake was noted. During the Schirmer 1,2 and Norn tests, the normal total and basic tear production took place, and the tear film rupture was accelerated up to 5 sec. There was no staining of the cornea with fluorescein; the graft area retained diffuse surface staining.

When examining the patient after 6 months: the cosmetic result was stable; vascularization processes were completely stopped; the normal position of the graft was maintained, which did not differ from the color of a healthy conjunctiva; restriction of eye movement and signs of recurrence were absent. The indicators of the total and basic tear production corresponded to the norm, the tear film rupture was 10 seconds. No staining of the cornea and graft area with fluorescein was noted.

Example 2. Patient I., 76 years old, was admitted with a diagnosis of pterygium II category of the left eye. From the anamnesis: the film appeared about 5 years ago, over the past 2 years it began to note a feeling of discomfort and film growth.

The patient underwent surgery to remove pterygium according to the proposed method, and at the stage of covering the wound surface of the sclera with a separated conjunctiva, its edge, which was adjacent to the limb, was shifted towards the upper conjunctival arch to the oblique incision of the conjunctiva located in the direction of the upper conjunctival arch.

After surgery, the patient was prescribed four instillations of an antibiotic, anti-inflammatory drug, and root protectant for 10 days. All conjunctival sutures were removed on the 10th day after surgery.

In the early postoperative period (up to 10 days), moderate postoperative conjunctival edema was noted, the cornea epithelized on the 4th day, there were no signs of transplant necrosis, and there were no inflammatory reactions.

When viewed 1 month after the operation: in the area of the operation, there was a complete engraftment of the graft, the color of which did not differ from the color of the conjunctival surface of the eye; on the border between the transplanted amniotic membrane and the conjunctiva of the eye, moderate tissue vascularization was observed with the formation of a normotrophic scar; dispositions of tissues of the inner corner and the lacrimal lake were not noted. When conducting a test of Schirmer 1,2 and Norn, there was a normal total and reduced basic tear production; there was an acceleration of the tear film rupture up to 4 sec. There was no staining of the cornea with fluorescein; the graft area retained diffuse surface staining. The patient was prescribed a natural tear preparation 1 drop 3 times a day for a month.

During a dynamic examination of the patient after 6 months: the cosmetic result was stable, the vascularization processes were completely stopped, the transplanted amniotic membrane remained in a normal position, the color of which did not differ from the color of a healthy conjunctiva; restriction of eye movement and signs of recurrence were absent. The indicators of total and basic tear production corresponded to the norm, the tear film rupture was 9 seconds. No staining of the cornea and graft area with fluorescein was noted.

Claims (1)

A method of surgical treatment of pterygium, including separation and excision of the pterygium and replacing the defect with an amniotic membrane, characterized in that the pterygium is dissected in the limb area, from the dissection edges to the sides of the upper and lower conjunctival arches, two oblique sections of the conjunctiva and subconjunctival tissue are made , the head of the pterygium is exfoliated from the cornea and removed, the conjunctiva is separated up to the lunate fold and pushed back, the body of the pterygium is separated, cross they are removed in the area of the lunate fold and removed, the separated conjunctiva is placed on the sclera, shifting it towards the upper or lower conjunctival arch, fixed with interrupted sutures, a laxative incision is made of the laid conjunctiva 5-7 mm long parallel to the lunate fold, and the cannabis conjunctiva formed by the wound defect is replaced amniotic membrane with its fixation by interrupted sutures, which, together with other interrupted sutures, are removed 10 days after surgery.

Images