RU2180536C2 - Method for removing encapsulated magnetic foreign body from eyeball tunic - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing argon endolaser retina coagulation around the encapsulated splitter in posterior tunics of the eyeball. Foreign body capsule is destroyed by means of argon endolaser coagulation. Splitter-revealing zone is mechanically enlarged by moving endolaser end piece. The endolaser capsule coagulation is repeated when needed. The naked foreign body is removed with endolaser end piece combined with U-shaped magnetic end piece. EFFECT: accelerated surgical intervention process; reduced risk to loose the foreign body; reduced risk of hemorrhages and retina detachment.

Description

 The invention relates to medicine, namely to ophthalmology, and can be used to remove intraocular encapsulated foreign bodies located in the membranes of the eyeball.

 It is known that difficulties with the removal of a foreign body arise when the latter is located in the posterior segment of the eye or in the projection of the ciliary body and often leads to retinal detachment and hemophthalmia (R. Gundorova - Prevention, early diagnosis, clinic and treatment of post-traumatic complications associated with long-term stay in the eye of chemically active foreign bodies. // Diss. Doctor of Medical Sciences, - M., - 1968. - P. 88-101). In this regard, it was concluded that it is better to leave it than to remove it from the eye if the position of the foreign body relative to the retina allows (Gundorova R.A. - Eye injuries. // M., - Medicine, - 1986. - P. 116-123). According to another point of view, it is advisable to leave foreign bodies in the eye if there are no signs of metallosis and the fragment itself is covered with a dense fibrinous capsule (V. Neroev - Rational management and treatment tactics for patients with intraocular foreign bodies of the posterior part of the eye. // Dios. Cand. Honey sciences, - M., - 1987. - S. 112-134).

 However, a splinter, which has been inside the eye for a long time, causes a formidable complication - metallosis of the eyeball tissues: among this disease, siderosis occurs - up to 80% of the cases are due to the effects of iron oxidation products and in 20% of cases - chalcosis in copper-containing foreign bodies (R. Gundorova, A.A. - Prevention, early diagnosis, clinic and treatment of post-traumatic complications associated with prolonged exposure to chemically active foreign bodies in the eye // Diss. Doctor of Medical Sciences, - M., - 1968. - P. 103-134).

 A known method of exposing an encapsulated foreign body, including dissecting the capsule using a Gref knife, Sato and removing it with collet tweezers or a magnet probe (R. Gundorova et al. - Eye injuries. // M., - Medicine, - 1986. - S. 112-145).

 Also known is a method of removing encapsulated fragments localized in the membranes of the posterior part of the eye, in which a foreign body is "exposed" with the help of a vitreophage, after which it is captured with collet tweezers and removed. However, during the execution of these manipulations, complications arise in the form of traction retinal detachments and hemorrhages (Lagua N. - Extraction of an encapsulated of foreign bodies by means of pars plana vitrectomy. // Klin. Mbl. Augenheilk, - 1979, - Bd. 174, - H. 4, - S. 542-547).

 To remove the encapsulated fragment from the posterior pole of the eye, tweezers are used to expose the fragment, and to prevent retinal detachment, a circlet with transscleral cryopexy is used (Slusher MM et al. - Management of intraretinal foreign body. // Trans. Amer. Acad. Ophthalmol. And Otolaryng. , - 1982, - V. 89, - 4. - P. 369-373).

 A tactic for removing an intraocular foreign body with a localization of a fragment behind the retina of the eye has been developed. After performing a vitreotomy: an elastic tip, put on the cannula, is brought to the foreign body behind the retina. The foreign body is moved by the cannula to a gap in the retina and fixed with tweezers, which then remove the foreign body. After this, endolasercoagulation is carried out around the retinal rupture (Joondeph BC et al. - Management of subretinal foreign bodies with a cannulated extrusion needle. // Amer. J. Ophthalmol., - 1990, - V. 110, - 3. - P. 250- 253).

 It is known that powerful stationary electromagnets and more dimensional permanent hand magnets are used to remove magnetic foreign bodies, the size and shape of their tips have polymorphism and depend on the functions that they perform. Some authors propose using blunt and short tips to remove shallowly localized intraocular foreign bodies, since they have more attractive force (Brodsky B.S. Magnetic operations to extract metal fragments from the eye. // Collection of reports of scientific and practical conf., - M., - 1963. - S. 132-143). Others consider thin straight tips to be most effective in transvitreal or deep operations (Hager G. - Besonderheiten bei der Extraction von Eisensplittern aus den Augeninnein. // Klin. Augenheilk, - 1971, - Bd. 158, - 5, - H. 622-627 )

 There are a large number of modifications of permanent permanent magnets. Currently, a model of a permanent cobalt-samarium magnet with a set of straight-line tips of various thicknesses and lengths has become widely used (Bykov V.P. - Intraocular microsurgery of the consequences of penetrating fragmentation wounds. // Abstract of diss. Candidate of medical sciences, - M., - 1980, - 14 p.).

 A known method of removing magnetic fragments using a pointed injection needle, when it is introduced through a wound to a foreign body and after contact of the needle an electromagnet is brought to it. At the end, the needle is removed from the wound channel along with a fragment fragmented to it (Ganchev N. - The extraction small foreign body located with-in the deep Rayers of the cornea. // Ophthalmologica (Sophia), - 1971, - V. 72, - 2. - P. 85-89).

 There is a method of transvitreal removal of magnetic foreign bodies localized in the posterior part of the eye, including preliminary preventive barrier argonlasercoagulation to prevent tractional detachment of the retina during surgical removal of a foreign body and subsequent YAG laser treatment of a foreign body capsule in the form of a dissection of the capsule itself to expose a fragment. After opening the capsule over the fragment, the patient is taken to the operating room, where the tip of the permanent magnet is inserted through the incision in the flat part of the ciliary body and the foreign body is removed (SU 1451912, - 1988). This method is taken as the closest analogue.

 Known methods have proven themselves when removing foreign bodies from the back of the eyeball. However, almost all of them are traumatic in relation to the retina and can cause complications in the form of bleeding or detachment of the retina. In some cases, it is not technically possible to violate the integrity of a dense capsule with neovascularized vessels above a foreign body, even with the help of a shock YAG laser, and replacing instruments at the time or before removing a foreign body can lead to a “loss” of a foreign body or increase the risk earlier listed complications.

 The proposed method is based on the fact that argon endolaser coagulation of newly formed vessels and capsules with its destruction, exposure of a foreign body is carried out with one tool - the endolaser tip. In addition, immediately after exposure of the foreign body, the magnetic fragment is removed without changing the intraocular instrumentation with the same endolaser tip combined with the magnet.

 The technical result of the method is to reduce the risk of retinal detachment and bleeding at the time of surgery.

 The technical result is achieved by conducting intraocular intervention with prophylactic argonlasercoagulation of newly formed vessels and the retina around the bed of a foreign body, breaking the capsule and removing a magnetic foreign body from under it with only one tool - the tip of the endocoagulator combined with a magnet.

 The method is as follows.

 After a clinical study confirming the presence of a foreign body under the retina during x-ray localization, ultrasound scanning and ophthalmoscopy, the patient is prepared for surgery to remove a foreign body.

 Against the background of maximum mydriasis and under local anesthesia in the operating room, sclera tissue is opened in the area of the flat part of the ciliary body and the tip of the endolaser argon coagulator is inserted into the vitreous body. Under the control of the fundus lens, the tip is led to the encapsulated fragment and endolaser argon coagulation of the retina around the bed of the foreign body in 2-3 rows and staggered, and then on the surface of the capsular bag and neovascular vessels covering the capsule. In the process of exposure to coagulation violate the integrity of the capsule bag. The resulting gaps are diluted with an endolaser tip until the foreign body is completely exposed. At the moment of contact of the foreign body and the endolaser tip, a magnet with a grip-shaped tip is brought to the endolaser tip outside the eye to improve contact with the endolaser. The wound is sutured, and antibiotics are administered under the conjunctiva. Bandage.

 Example. A 36-year-old patient was admitted to the inpatient ophthalmology department with a diagnosis of OD-penetrating corneoscleral scar, post-traumatic aphakia, an intraocular foreign body hammered in the posterior pole of the eyeball, covered with a dense capsule with neovascular vessels on the surface of the capsule. Visual acuity OD / OS: 0.02 / 0.6; IOP OD / OS: 22/22 mm Hg. Art. According to EFI, inhibition of the activity of the retina OD by 1.5 times; according to x-ray studies, the foreign body in the posterior part of the eye (according to the conditional scheme, partially in the shells of the eye), according to the ultrasound scan, the foreign body is in the posterior part of the eye in the membranes and hammered.

 From the anamnesis: five years ago, he received a penetrating wound to the eyeball with the introduction of a metal magnetic fragment during the processing of the part with a sledgehammer. On the day of injury at the place of residence, the primary surgical treatment of a corneal wound was performed with the extraction of a traumatic cataract and a negative attempt to remove a foreign body. After conservative treatment, visual acuity of the right eye with aphakic correction reached 0.3-0.4; IOP OD within 22-24 mm RT. Art.

 In connection with the deterioration of visual acuity and a change in the color of the iris, the patient turned to an ophthalmological institution where they diagnosed the presence of an encapsulated fragment with the effects of metallosis. The patient is offered the removal of an intraocular foreign body. However, upon examination, the presence of a dense capsule above the fragment with pronounced neovascular vessels on the surface of the capsule is noted. Given the likelihood of bleeding during dissection of the capsule and tractional movement of the retina due to the dense capsule, it is proposed to use YAG laser dissection of the capsule over a foreign body with preliminary barrier argon coagulation of the retina of the bed of a foreign body.

 Against the background of maximum mydriasis, OD produce an argon laser barrier coagulation 4 mm from the foreign body in a staggered pattern in three rows around the foreign body in the amount of 131 coagulate. 5 days after argon exposure, YAG laser dissection of the retina over a foreign body is used. The foreign body is not exposed. There was almost no bleeding from the neovascular vessels of the capsule. After 10 days, due to the absence of changes on the capsule side over the fragment in the operating room under local anesthesia, the sclera is opened in the area of the flat part of the ciliary body of the upper quadrant and the tip of the endolaser coagulator is introduced into the incision to strengthen the barrier coagulation of the retina around the foreign body and create a denser capsule above the fragment (due to the lack of effect from the YAG laser dissection of the capsule, the foreign body decided not to remove). Under the control of fundus lenses, initial endolaser coagulation of the capsule neovascular vessels is performed. As a result of repeated exposure, a violation of the integrity of the capsule bag was noted. The endolaser tip mechanically enlarged the gaps between the sites of endolaser argon coagulation. As a result, the foreign body was completely exposed. In view of the sufficient exposure of the fragment, it was proposed to remove the foreign body. However, when examining the area of occurrence of the fragment there is doubt about the successful removal of a foreign body when replacing the endolaser with a magnet due to the sharply increased caliber of the newly formed vessels. There is a risk of bleeding, and in this state they bring the tip of the magnet, specially curved in the form of a grip shape for better contact, to the tip of the endolaser and the foreign body is removed along with the tip of the endolaser. Bleeding and prolapse of the vitreous into the surgical wound was not observed. Impose 2 interrupted sutures on the sclera and a continuous suture 8-00 on the conjunctiva. An antibiotic solution is administered under the conjunctiva. Bandage.

 2 days after surgery, the state of OD is satisfactory: slightly irritated, the sutures are clean, the cornea is calm, a single suspension in the vitreous body. On the fundus: the bed of a foreign body is clean, surrounded by pronounced laser coagulates. There are no phenomena of hemorrhage and retinal detachment. Visual acuity of OD - 0.08, IOP OD - 24 mm RT. Art. According to ultrasound, there are no changes.

 3 months after surgery - OD is calm, the sutures are removed. The anterior segment is unchanged, except for a partial restoration of the color of the iris. In the vitreous body, a moderate suspension. The fundus of the eye is a pale pink optic nerve disc, the vessels are calm, in the area of surgical intervention, the retinal area is surrounded by pigmented laser coagulates. The retina is everywhere. Visual acuity of OD from sph. + 11.0 = 0.4; IOP OD - 22 mm RT. Art.

 The indications of the method are operations associated with the removal of the encapsulated foreign body and with the risk of retinal detachment and bleeding.

 The method has no contraindications.

 As a result of the application of this method, it is possible to remove a foreign body using an endolaser tip combined with a grip-shaped magnet tip, and to avoid traction on the retina when the capsule is dissected over a foreign body and when foreign bodies located in the membranes of the eye are removed from bleeding from blood vessels.

Claims (1)

 A method for removing an encapsulated fragment from the membranes of the eyeball, including its preliminary barrier laser coagulation of the retina around the bed of the fragment and releasing the foreign body from the capsule, characterized in that the release is effected by alternately coagulating and mechanically exposing the capsule to an argon endolaser tip followed by magnetic removal of the body the same tip combined with a magnet.