RU2822121C1 - Method for phacoemulsification of cataract, complicated by ligamentous apparatus weakness and dense nucleus of lens, in combination with successive bimanual phaco-fragmentation of lens nucleus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology. Anterior capsule is opened, an anterior capsulorhexis is performed, hydrodissection, phacoemulsification and phacoemulsification of the lens nucleus are performed, followed by removal of lens masses, intraocular lens is implanted. During the operation, after the circular continuous capsulorhexis and achieving the lens nucleus mobility, the anterior chamber of the eye is filled with viscoelastic, two Sinskey hooks are used, which are brought into the anterior chamber through two already existing corneal paracenteses measuring 1.0 mm each at 9 and 14 o'clock at the limb. One hook is brought through the capsulorhexis inside the lens capsule and thereby retained the lens capsule from moving, the second hook is brought under the nucleus of the lens. Both hooks are positioned opposite each other on different surfaces of the lens nucleus. Next step is simultaneous movement of the hooks towards each other through the nucleus of the lens vertically to a penetration depth sufficient for fixation of the hooks in the nucleus of the lens. Then the hooks are moved in different directions in the direction from each other in the horizontal direction, until the lens nucleus breaks into two halves, the hooks rotate the lens nucleus in the capsule in the horizontal direction through 90°, after which the halves of the lens nucleus are broken into two parts in a similar manner, one of the resulting quarters of the lens nucleus is removed from the capsule with hooks to the centre of the pupil in the plane of the iris, after which phacoemulsification of this part of the lens nucleus is performed. Next step is to fill an anterior chamber with a viscoelastic; the other quarter of the lens nucleus is removed from the capsule to the centre of the pupil in the iris plane. Further, phacoemulsification is carried out, all parts of the nucleus of the lens are gradually removed by hooks from the capsule to the centre of the pupil in the iris plane. Then phacoemulsification is carried out until complete removal of lens fragments, then an artificial optical lens is implanted into a capsular sac and the operation is completed.

EFFECT: method enables minimizing the degree of pathological effect on the lens capsule and its ligamentous apparatus, providing stability of the position of the lens capsule during the operation and during implantation of the artificial intraocular lens.

1 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used in surgical interventions for the treatment of cataracts complicated by subluxation and a dense lens core. In the surgical treatment of cataracts, the current “gold standard” is phacoemulsification of the lens using ultrasound energy. A special feature of the operation is the need to maintain the anterior chamber of the eye due to a constant flow of fluid. The balanced salt solution used for these purposes is also necessary for cooling the phaco tip, however, the pressure on the ligamentous apparatus of the lens increases and exceeds normal physiological values. During this operation, the phaco tip is also pressed onto the nucleus of the lens, which in total has an excessive, sometimes negative, effect on the ligamentous apparatus of the lens capsule. In the case of surgery on eyes with complicated cataracts with the presence of weakness of the lens ligaments, rupture of the lens capsule ligaments with subsequent dislocation of the lens into the vitreous body is possible. As a result, there is a need to increase the volume of surgical intervention: lifting the lens from the vitreous cavity with vitrectomy and additional fixation of the artificial lens to the iris or sclera. Prevention of complications that arise during phacoemulsification due to instability of the ligamentous apparatus of the lens requires the use of various devices to stabilize the position of the lens capsule under conditions of increased pressure on it from fluid flows and the phaco tip. One such device is iris retractors.

There is a known method for stabilizing the capsular bag for phacoemulsification of cataracts in patients with extensive defects of the ligamentous apparatus of the lens (patent RU2598643), and 3 iris retractors are used to fix the capsular bag. They are introduced into the anterior chamber of the eye through 3 additional corneal paracentesis, which weakens the frame properties of the cornea, and require their removal after the end of the operation, which increases the operation time.

There are mechanical ways to separate the lens nucleus using special devices such as tweezers and choppers.

A fragmentation tweezer is known (patent RU 2311158) for crushing the lens nucleus, however, when using this device, it is necessary to remove the entire lens nucleus into the anterior chamber of the eye; fragmentation of the nucleus under these conditions carries a high risk of damage to the corneal endothelium. In addition, inserting tweezers into the anterior chamber of the eye and spreading its branches to capture a fragment of the lens nucleus requires a large incision of the cornea or sclera with the need to apply sutures to the wound.

The phaco chopper (patent RU 2341235) is used to separate the soft nuclei of the lens without disturbing its ligamentous apparatus, however, the separation of hard nuclei with pathological mobility of the lens can cause rupture of the ligamentous apparatus with subsequent dislocation of the entire lens.

There is a known method of fragmentation of the lens nucleus during phacoemulsification of cataracts (patent RU2320303), in which grooves are formed in the lens nucleus with a phaco tip without rotation of the nucleus followed by fracture, however, the operation can only be performed on the soft nuclei of the lens. On hard cores with a violation of the ligamentous apparatus of the lens, increased pressure on the lens capsule can lead to rupture of the ligaments and dislocation of the lens into the vitreous body.

The essence of the proposed method is to perform phacoemulsification of cataracts, complicated by weakness of the ligamentous apparatus of the lens and the hard nucleus, characterized in that during the operation, after performing a circular continuous capsulorhexis and achieving mobility of the lens nucleus, the anterior chamber of the eye is filled with viscoelastic, using 2 Sinsky hooks, which are inserted into the anterior chamber through 2 existing corneal paracenteses measuring 1.0 mm each at 9 and 14 o'clock at the limbus. One hook is inserted through the capsulorhexis into the lens capsule and thereby keeps the lens capsule from moving, the second hook is inserted under the lens nucleus. Both hooks are positioned opposite each other on different surfaces of the lens nucleus. The next step is to simultaneously move the hooks towards each other through the lens nucleus vertically to a penetration depth sufficient to fix the hooks in the lens nucleus. Then the hooks are moved in different directions away from each other in a horizontal direction, until the lens core is broken into two halves. Hooks are used to rotate the lens nucleus in the capsule in the horizontal direction by 90°, after which half of the lens nucleus is broken into two parts in a similar manner. One of the resulting quarters of the lens nucleus is removed from the capsule into the lumen of the pupil with hooks, after which phacoemulsification of this part of the lens nucleus is performed. The next step is to fill the anterior chamber of the eye with viscoelastic, use hooks to remove the other quarter of the lens nucleus from the capsule to the center of the pupil in the plane of the iris, after which phacoemulsification of this part of the lens nucleus is performed. All parts of the lens nucleus are gradually removed from the capsule with hooks to the center of the pupil in the plane of the iris, then phacoemulsification is performed until the lens fragments are completely removed. Next, an artificial optical lens is implanted into the capsular bag, the viscoelastic is removed from the anterior chamber, and the operation is completed.

Thus, a step-by-step alternation of phacofragmentation of the lens nucleus with hooks is carried out, followed by their phacoemulsification. With this method, the pressure on the ligamentous apparatus of the lens capsule is minimized, the integrity of the capsule and its normal anatomical position in the posterior chamber of the eye are maintained. The use of additional devices to maintain the stability of the lens capsule when performing the proposed technique is not required. During the operation, phacofragmentation of the lens nucleus is carried out through 1.0 mm paracenteses, there is no outflow of viscoelastic from the anterior chamber, all manipulations inside the eye are carried out with the anterior chamber of the eye filled, and trauma to the corneal endothelium is minimal.

The technique of a step-by-step operation with alternating phacofragmentation and phacoemulsification makes it possible to minimize the degree of pathological impact on the lens capsule and its ligamentous apparatus, ensuring stability of the position of the lens capsule during the operation and during the implantation of an artificial intraocular lens.

The invention is illustrated by the following clinical example.

Example 1. Patient T., born in 1947, was admitted to the ophthalmology department of the Smolensk Regional Clinical Hospital with a diagnosis of complicated brown nuclear cataract, lens subluxation, high myopia of the right eye; pseudophakia, age-related macular degeneration, dry form, left eye. On admission:

visus OD = 0.03 cannot be corrected,

visus OS = 0.4 cannot be corrected,

IOP OD = 19 mm Hg (IOP - intraocular pressure),

IOP OS = 20 mm Hg.

Biomicroscopy of the right eye: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, the pupil is 3.0 mm in diameter, pseudoexfoliation along the edge of the pupil, the lens is diffusely cloudy with a brown tint, iridofacodonesis, the fundus is not ophthalmoscoped, there is no reflex from the fundus.

Biomicroscopy of the left eye: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, the pupil is 3.0 mm in diameter, pseudoexfoliation along the edge of the pupil, posterior chamber pseudophakia, the optic disc is pale pink, the boundaries are clear, the vessels are normal, there are small degenerative lesions in the macula .

The patient was recommended surgical treatment in the following volume: phacoemulsification of complicated cataract with lens subluxation in the right eye.

During the operation using standard preparation, after performing paracenteses of the cornea in the limbus area at 9 and 14 o'clock measuring 1.0 mm, an anterior capsulorhexis of 4.5 mm in diameter was made through the main corneal incision of 2.4 mm at the limbus at 12 o'clock, hydrodissection and hydrodelineation of the lens nucleus using a Simka cannula. When performing capsulorhexis, instability of the capsular bag was revealed; during hydrodelineation, a large size of the lens nucleus in diameter was revealed with an almost complete absence of lens masses. Using two Sinsky hooks, inserted through paracenteses towards each other onto the anterior and posterior surfaces of the center of the lens nucleus, the tips of the hooks were inserted into the center of the nucleus by moving towards each other in the vertical direction. The next movement of both hooks away from each other in the horizontal direction broke the lens nucleus into two equal parts. Using hooks, the resulting halves were rotated horizontally by 90°; in the same way, hooks were used to break one half of the lens into two parts; one of the resulting quarters of the lens was removed from the lens capsule to the center of the pupil in the plane of the iris. Next, phacoemulsification of the two resulting quarters of the lens nucleus was performed alternately through the main incision. The next step was to break half of the lens nucleus into two parts using two hooks through paracenteses, followed by phacoemulsification. As a result of the combined destruction of the lens nucleus, the ligamentous apparatus of the lens was preserved, which made it possible to implant an artificial optical lens into the capsular bag with its subsequent centralization.

Example 2. Patient G., born in 1950, was admitted to the ophthalmology department of the Smolensk Regional Clinical Hospital with a diagnosis of mature complicated cataract, miosis, pupil atony of the right eye; pseudophakia, pupil atony of the left eye. On admission:

visus OD = correct light projection is not corrected,

visus OS = 0.6 cannot be corrected,

IOP OD = 21 mm Hg.

IOP OS = 21 mm Hg.

Biomicroscopy of the right eye: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, the pupil is 2 mm in diameter, there is practically no reaction of the pupil to light, pseudoexfoliation along the edge of the pupil, the lens is diffusely clouded, the fundus is not ophthalmoscoped, there is no reflex from the fundus.

Biomicroscopy of the left eye: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, the pupil is 4 mm in diameter, irregular in shape, slightly retracted at 12 o’clock, there is no reaction of the pupil to light, posterior chamber pseudophakia, the intraocular lens is centered, the optic disc is pale pink, the boundaries are clear, the vessels are normal.

The patient was recommended surgical treatment including phacoemulsification of complicated cataract in the right eye.

During the operation using standard preparation, after performing corneal paracenteses in the area of the limbus at 9 and 14 o'clock measuring 1 mm, an anterior capsulorhexis of 4.5 mm in diameter, hydrodissection and hydrodelineation of the lens nucleus using a Simka cannula. Using two Sinsky hooks, inserted through paracenteses towards each other, the edges of the pupil were shifted to the periphery of the iris in the 3 and 9 o'clock meridian while simultaneously inserting the right hook under the edge of the lens. By moving towards each other in a vertical direction, the tips of the hooks were inserted into the center of the nucleus, and the nucleus with one edge was brought out into the anterior chamber. The next movement of both hooks away from each other in the horizontal direction broke the lens nucleus into two equal parts. Using hooks, the resulting halves were turned horizontally by 90° and finally brought into the anterior chamber. In the same way, using hooks, one half of the lens was broken into two parts, one of the resulting quarters of the lens was removed from the lens capsule to the center of the pupil in the plane of the iris, and then phacoemulsification was performed through the main incision. The next step was to remove the next quarter of the lens nucleus into the anterior chamber of the eye using two hooks through paracenteses and proceed to phacoemulsification with complete removal of the lens fragment. Next, using hooks through paracenteses, the second half of the lens nucleus was broken into two parts, followed by removal into the anterior chamber of the eye and transition to phacoemulsification through the main incision. As a result of the combined destruction of the lens nucleus with subsequent phacoemulsification of the resulting fragments, it was possible to perform the operation under full visual control, avoiding complications. An artificial optical lens was implanted into the capsular bag during surgery.

Claims (1)

A method of phacoemulsification of cataracts complicated by weakness of the ligamentous apparatus and a dense lens nucleus, in combination with sequential bimanual phacofragmentation of the lens nucleus, including opening the anterior capsule, performing anterior capsulorhexis, hydrodissection, phacofragmentation and phacoemulsification of the lens nucleus with subsequent removal of the lens masses, implantation of an intraocular lens, characterized in that that during the operation, after performing a circular continuous capsulorhexis and achieving mobility of the lens nucleus, the anterior chamber of the eye is filled with viscoelastic, two Sinsky hooks are used, which are inserted into the anterior chamber through two existing corneal paracenteses measuring 1.0 mm each at 9 and 14 clock at the limbus, one hook is inserted through the capsulorhexis into the lens capsule and thereby keeps the lens capsule from moving, the second hook is inserted under the lens nucleus, both hooks are positioned opposite each other on different surfaces of the lens nucleus, the next step is to simultaneously move the hooks towards each other each other through the lens nucleus vertically to a penetration depth sufficient to fix the hooks in the lens nucleus, then the hooks are moved in different directions away from each other in the horizontal direction until the lens nucleus breaks into two halves, the hooks rotate the lens nucleus in the capsule in horizontally by 90°, after which the halves of the lens nucleus are broken into two parts in a similar way, one of the resulting quarters of the lens nucleus is removed from the capsule with hooks to the center of the pupil in the plane of the iris, after which phacoemulsification of this part of the lens nucleus is carried out, the next step is to fill the anterior chamber of the eye, the other quarter of the lens nucleus is removed with hooks from the capsule to the center of the pupil in the plane of the iris, then phacoemulsification is carried out, all parts of the lens nucleus are gradually removed with hooks from the capsule to the center of the pupil in the plane of the iris, then phacoemulsification is carried out until the lens fragments are completely removed, then implanted into capsular bag with an artificial optical lens and complete the operation.