RU2150921C1 - Method for performing transscleral fixation of posterior chamber intraocular lens - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves doing hammock incision by 1/2 of sclera thickness at 12 o'clock position. Sclera flaps are cut out at 9 and 3 o'clock position. Prolene thread on two needles is brought by means of guiding needle making entrance and exit punctures under sclera flaps 0.5-.75 mm from the limbus. The middle portion is brought out to haptic members of the intraocular lens. The lens is implanted and fixed in ciliary sulcus. The needles are additionally conducted through the sclera and the sutures are tied. EFFECT: facilitated introduction of the intraocular lens; reduced risk of postoperative traumatic complications.

Description

 The invention relates to medicine, namely to ophthalmic surgery.

 Intraocular lens implantation (IOL) has become the standard in the surgical rehabilitation of patients with cataracts and aphakia. Until recently, in the absence of the posterior lens capsule, anterior chamber lenses were widely used, the supporting elements of which are located in the area of the iris-corneal angle (RRU) or iris-clip lenses (ICL). Unfortunately, anterior chamber lenses often lead to damage to the trabecular skeleton, prolonged inflammatory processes in the eye and the development of corneal dystrophy (Apple DJ et al., 1984; Waring GO et al., 1987, 1988; Speaker MJ et al., 1988; Cohen EI s et al., 1988). The main problem associated with the use of iris-clip lenses is their dependence on the size of the pupil and the state of the iris. It is known that medication mydriasis is a prerequisite for performing phacoemulsification or extracapsular cataract extraction. The insufficient elimination of mydriasis at the final stages of the operation, the use of prolonged action myriatics to prepare the eyeball for surgery are factors predisposing to the dislocation of ICL into the anterior or vitreous chamber with all the ensuing consequences. S.N. Fedorov and E.V. Egorova (1985) rightly noted that the dislocation of ICL or its supporting elements is a specific complication of the postoperative period due to the presence of such a lens in the eye.

 In recent years, works have been published abroad on the implantation of the most physiological - posterior chamber IOLs for patients who do not have a posterior lens capsule. A number of authors (Apple D.I. et al., 1989; Davis R.M. et al., 1991) propose fixing the posterior lens to the iris. Others (Spigelman A.V. et al., 1988; Stark W.J. et al., 1988; Holland E. J. et al., 1992; Heidemann D.J., Dunn S.P., 1992) prefer transscleral fixation of the haptic portion of the IOL using polypropylene sutures. We prefer the latter because transscleral fixation of the posterior chamber IOL, in contrast to iris fixation, does not affect the possibility of pupil dilatation in the postoperative period, can be used in eyes with severe atrophy of the iris stroma and less often leads to the development of cystic macular edema (DGHeidemann, SP Dunn, 1992). Potentially, transscleral fixation lenses can cause a variety of complications, ranging from the possible development of hemophthalmus or retinal detachment due to gross manipulations during sutures through the ciliary body and ending with the possibility of externalization of fixing sutures (Lubniewski A.J. et al., 1990). However, the improvement of transscleral fixation techniques (S. Eguchi, 1992), the emergence of special IOL models ("Alcon" - CZ70BD, "Storz" - P366UV) with the presence of "ears" for the precise conduct of special threads ("Alcon" PC-9 10-0 Polypropylene, "Ethicon" CS-160-6 and CTC-6, 10-0 Prolene) led to the fact that these complications now practically do not occur.

 Closest to the claimed technical solution is the method of S. Eguchi (1992), which served as the basis for the creation by Alkon of polymethylmethacrylate (PMMA) lenses of the CZ70BD series and PC-9 needles with loops of 9-0 or 10-0 polypropylene yarn. In the original method, the method is carried out on the aphakic eye with the complete absence or failure of the posterior capsule. Start with a 7 mm corneal-scleral incision, vitrectomy (if necessary) and anterior chamber replenishment with viscoelastic. Then at 4 and 10 hours the conjunctiva is cut along the limb and 2 triangular sclera flaps are formed into 1/2 of its thickness, with the base to the limb. Through the "ears" available in the haptic part of the IOL (the diameter of its optical part is 7 mm and the total length is 12.5 mm), loops of polypropylene thread are carried out sequentially for the upper and lower supporting elements. Needles with the same threads are passed through these loops and a lens (fixed on two threads with two needles) is placed in a position suitable for implantation. An injection needle of the 26th or greater caliber is passed through the sclera from under the flap at 4 hours. For convenience, the needle is mounted on a syringe or a special handle. A PC-9 needle is inserted into the lumen of this injection needle, from which there is a thread tied to the lower arch of the IOL, and both of these needles are brought back from under the scleral flap. A similar procedure is repeated from under the sclera flap for 10 hours. IOLs are implanted into the ciliary sulcus and pulled by the threads fixed to the supporting elements and brought out under the scleral flaps. Cut one of the threads forming a loop, pass the PC-9 needle through the sclera and tie the ends of the threads together at first at 4, and then at 10 o’clock. The resulting nodules are covered with prepared scleral flaps, fixing them and the conjunctiva with sutures from any material.

 The disadvantages of this method are: 1) greater trauma when trying to perform an operation through a narrow pupil (expanding the pupil, firstly, is not always possible, and secondly, expanding it is undesirable in the absence of the posterior lens capsule, since it can cause additional loss of the vitreous body); 2) the inconvenience of holding the needle with the thread through the injection needle acting as a conductor in the inner compartment, especially in patients with deep-set eyes or a large nose; 3) the possibility of developing severe astigmatism due to the use of a 7-mm incision, a concentric limb.

 The aim of the present invention is to reduce the morbidity of trans-scleral fixation of the IOL and facilitate its implementation.

 The essence of the method lies in the fact that from under two surface scleral flaps cut at 9 and 3 hours, using a conductor needle, a polypropylene thread is carried out on two needles, the middle part of which is pulled out with a hook out of 12 hours, the thread is cut in half, the formed ends are tied to the "ears" on the haptic part of the IOL, the lens is implanted in the back chamber; the needles are additionally passed through the sclera and knotted sutures, which are covered with scleral rags and conjunctiva.

 The method is as follows.

 The operation is performed under local peribulbar anesthesia using an operating microscope with coaxial illumination.

 In FIG. 1-4 depict the steps of the operation.

After conjunctival sections along the limbus, we make a “hammock” incision 1/2 of the sclera thickness [1] 6.5-7.0 mm long (depending on the diameter of the optical part of the IOL) at 12 hours. At 9 and 3 o'clock we cut out two superficial triangular scleral flaps [2, 3], with the base to the limb. In the horizontal meridian, 0.5-0.75 mm from the limb, from under the flap [2] at 9 o’clock we draw a needle with 10-0 prolene thread on two needles [4] (type Prolene 10-0 CS-160- 6, CTC-6 "Ethicon"). The needle should be brought out from the inside out under the flap [3] at 3 o’clock 0.5-0.75 mm from the corneal-scleral limb. This distance was determined based on a study by RGDuffey et al. (1989), which showed on enucleated eyes that for proper fixation of the haptic part of the IOL in the ciliary sulcus, sutures should not be extended further than 1 mm per limb. To accurately localize the area of the ciliary sulcus and in order to avoid possible (primarily hemorrhagic) complications that may arise when trying to make a shot from the inside out blindly, we use a guide needle [5], which can be made from a regular injection needle (injection needle 25th caliber must be bent at the border of the lower and middle third at an angle close to 90 ^o ). As a handle we use a regular insulin syringe. We draw a conductor needle from under the flap [3] towards the needle with prolene thread. In the area of the pupil, insert the needle with the thread into the lumen of the conductor needle. Since the needle with the thread is bent, it is enough to introduce it into the lumen of the conductor, which in this case acts as a “lock”, and withdraw it together with the conductor through an injection under the flap [3]. After holding the thread on two needles, we open the front chamber in the area of the incision prepared for 12 hours [1], introduce a viscoelastic and, using the Kuglen hook or a regular hook for the iris, pull the middle part of the thread out of the pupil area. Next, we cut the thread in half, tie the formed ends to the “ears” [6] on the haptic part of the IOL [7] and implant the lens into the posterior chamber. For the needles, the thread (and with it the IOL) is tightened. We additionally hold the needles under the flap through the sclera and tie the seams. After this, the superficial scleral rags are put in place and fixed with absorbable (or any other) sutures [8].

Example. Patient A., 58 years old (medical history N 21322/96) was admitted with a diagnosis of aphakia of the right eye, artifakia of the left eye, myopia of the middle degree of both eyes. In September 1995, extracapsular cataract extraction of the right eye was performed, during which the posterior capsule was torn with the prolapse of the vitreous body, and anterior vitrectomy was performed. This patient first came to us in April 1996 (medical history N 6782) with a diagnosis of immature complicated cataract of the left eye. Given the relatively young age of the patient and the intolerance of contact lenses, it was decided to perform phacoemulsification with IOL implantation in the left eye, followed by secondary implantation of the IOL in the right eye. 04/18/1996, phacoemulsification was performed with IOL implantation (Storz P328UV, + 16.0D) intracapsularly. There were no complications during the operation and in the postoperative period. On the day of receipt for secondary IOL implantation in the right eye, its visual acuity was 0.02 with sph + 8.0 D, cyl - 0.5 D, ax 90 ^o = 0.7; visual acuity of the left eye is 0.4 with sph -1.25D, cyl is 1.0D, ax 19 ^o = 0.8. 12/18/1996, the operation was performed according to the proposed method. A posterior chamber IOL (+ 17.0 D) from Storz P366UV was implanted; 10-0 Prolene was used on two needles from Ethicon for transscleral fixation. The operation and the postoperative period proceeded without complications. Visual acuity at discharge on the 4th day after the intervention 0.5 s cyl - 1.0D = 0.8, ax 124 ^o , after 4 months - 0.6 sph -1.5D, cyl - 0.75D, ax 125 ^o = 1.0.

 In total, we performed 7 transscleral fixation operations of the IOL according to the proposed method. In 4 cases, the operation was performed in the second stage: IOLs were implanted in aphakic eyes. In 3 other cases - at the same time: 1 - with intracapsular extraction of the subluxated lens; 2 - with the replacement of the deployed iris-clip lenses; and 3 - with extensive rupture of the posterior capsule with loss of the vitreous body during extracapsular extraction. All patients achieved high visual acuity (0.5 and above). The observation period is 3-12 months. In no case was IOL bias detected.

Thus, the use of the proposed method of transscleral fixation of the posterior chamber IOL in the absence of the posterior lens capsule using the needle-conductor we proposed in comparison with the prototype method revealed the following advantages:
1) the possibility of IOL implantation in patients with a narrow rigid pupil is provided;
2) a simpler and more accurate way of holding the thread for fixing the haptic parts of the IOL in the ciliary sulcus, regardless of the structural features of the patient’s facial skull, is provided;
3) with secondary implantation, the possibility of developing severe astigmatism in the postoperative period is minimized by using the most physiological “hammock” incision and the formation of a scleral tunnel before opening the anterior chamber.

LITERATURE:
1. Fedorov S.N., Egorova E.V. Surgical treatment of traumatic cataracts with intraocular correction. - M .: Medicine, 1985, p. 280-287.

 2. Apple DJ., Mamalis N., Lothfield K, Googe J.M., Novak L.C., Van Norman D., Brady S.E., Olson R.J. Complications of intraocular lenses. A historical and histopathological review. Surv. Ophthalmol., 1984, 29: 1.

 3. Apple D. J., Price F.W., Gwinn T., Imkamp E., Daun M., Casanova R., Hansen S., Carlson A.N. Sutured retropupillary posterior chamber intraocular lenses for exchange or secondary implantation. The 12th annual Binkhorst lecture, 1988. Ophthalmology, 1989, 96: 1241.

 4. Cohen E.I., Brady S.E., Leavitt K., Lugo M., Speaker M.G., Laibson P. R., Arentsen J. J. Pseudophakic bullous keratopathy. Am. J. Ophthalmol., 1988, 106: 264.

 5. Davis R.M., Best D., Gilbert G.E. Comparison of intraocular lens fixation techniques performed during penetrating keratoplasty. Am. J. Ophthalmol., 1991, 111: 743.

 6. Duffey R.J. Holland E.J., Agapitos PJ., Lindstrom R. L.: Anatomic study of transsclerally sutured intraocular lens implantation. Am. J. Ophthalmol., 1989, 108: 300.

 7. Eguchi S. Suturing the implant: The Audiovisual J. Cat. Implant Surg. , 1992, v. VI.

 8. Heidemann D.G., Dunn S.P .: Transsclerally sutured intraocular lenses in penetrating keratoplasty. Am. J. Ophthalmol., 1992, 113: 619-625 (7).

 9. Holland E.J., Daya S.M., Evangelista A., Ketcham J.M., Lubniewski A. J., Doughman D.J., Lane S.S. Penetrating keratoplasty and transscleral fixation of posterior chamber lens. Am. J. Ophthalmol, 1992, 114 (2): 182-187.

 10. Lubniewski A.J., Holland E.J., Van Meter W.S., Gussler D., Parelman J., Smith M.E. Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses. Am. J. Ophthalmol., 1990, 110: 237.

 11. Spigelman A.V., Lindstrom R. L., Nichols B. D., Lindquist T. D., Lane S. S. Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg. 1988, 19: 396.

 12. Stark W.J., Goodman G., Goodman D., Gottsch J. Posterior chamber intraocular lens implantation in the absence of posterior capsular support. Ophthalmic Surg., 1988, 19: 240.

Claims (1)

 The method of transscleral fixation of the posterior chamber intraocular lens (IOL), including the formation of two opposite sclera flaps with the bases to the limb, the stitching of the IOL support elements with a thread on two needles and the fixation of these threads under the prepared sclera flaps after implantation of the IOL into the ciliary sulcus, characterized in that a hammock "incision 1/2 of the sclera thickness at 12 o’clock, sclera rags are cut out at 9 and 3 o’clock, after which the prolene thread on two needles is carried out using a conductor needle with an injection and Using a scleral flap 0.5 - 0.75 mm from the limb, through the sclera incision, the middle part of the thread is removed, cut in half, the formed ends are tied to the haptic elements of the IOL, which they implant, pulling it by the threads, after which the needles are additionally carried out through the sclera and stitches are knotted.

Images