RU2230535C2 - Surgical method for treating the cases of traumatic cataract aggravated by iridodialysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making double-stage self-sealing tunnel incision and carrying out phacoemulsification. U-shaped iridoscleral sutures are applied. To make sutures, paracentesis and scleral incision are carried out. Curved needle with a thread are introduced into anterior chamber through the scleral incision to catch detached iris edge. The needle with a thread is brought out through the paracentesis. The needle with thread are introduced into anterior chamber through the paracentesis 5 mm far from the first pierce place and brought out through the scleral incision. Interrupted sutures are applied. Iris detachment reaching 45є, paracentesis and scleral incision are produced in iridodialysis projection. Iris detachment reaching 45 to 120є, 1-2 additional scleral incisions are produced in iridodialysis projection and paracentesis is made in a segment located opposite to iridodialysis. Several U-shaped sutures are applied over each of the scleral incisions.

EFFECT: stable improvement of vision acuity; reduced scale of tissue injuries.

3 cl, 3 dwg

Description

Traumatic injuries of the iris and lens are the most frequent and severe consequences of eyeball injuries, which occupy a leading place in the structure of visual disability in people of working age. Traumatic cataracts complicated by iridodialysis are most often found after concussion injuries. It is known that traumatic cataracts in 7.6% of cases are combined with iridodialysis. Among the lesions of the iris, iridodialysis (separation of the iris from the root) occupies a special group. The presence of an additional opening in addition to the pupil at the place of separation of the iris adversely affects visual acuity, even if the transparency of optical media is intact and can significantly reduce the functional result of the operation. In most cases, patients complain of overexposure, monocular diplopia, photophobia. If iridodialysis is located in the lower half of the eyeball, this is also a serious cosmetic drawback.

A known method for the correction of iridodialysis, according to which the conjunctiva is separated according to the limb, is performed in the projection of iridodialysis. Next, the eyeball is opened in the limbus, closer to the sclera. Through this incision, the iris is captured with tweezers and pulled to the incision. The torn root of the iris is fixed with a suture to the scleral lip, then the incision is sealed with a suture on the conjunctiva and sclera (Skripnichenko Z.M. Operations on the iris with traumatic eye injuries and their consequences. // Ophthalm. Journal - 1972. - No. 7. - C. 502-505).

The closest is the surgical method for the treatment of traumatic cataract complicated by iridodialysis, in which, in case of limited iridodialysis localized in the lower segment of the eyeball, cataract is removed through a corneoscleral incision in the upper segment of the eyeball, after which the surgical incision is sealed with 2-3 sutures. Then, through an additional surgical incision, carried out according to iridodialysis, the severed iris is sutured to the scleral lip with interrupted sutures, after which the additional incision is sutured (Fedorov S.N., Egorova E.V. Surgical treatment of traumatic cataracts with intraocular correction. M .: Medicine. - 1985. - S.166-171).

However, to perform these methods, a large incision is required to provide access to the iris. A large incision makes it difficult to maintain a constant anterior chamber depth necessary for iridoplasty. This, in turn, increases the risk of mechanical damage to the corneal endothelium during manipulation with a surgical instrument during surgery. Wide surgical access causes depressurization of the eyeball, increases the likelihood of intraoperative complications, increases the healing time of the surgical wound, leads to the formation of postoperative induced astigmatism, which ultimately reduces the functional results of the operation and increases the terms of social rehabilitation of patients.

The technical result of the proposed method is to achieve the maximum possible visual acuity, reducing surgical and postoperative complications and the timing of rehabilitation, eliminating cosmetic defects.

What is new in achieving the technical result is that they form a corneal two-stage self-sealing tunnel incision; after phacoemulsification of the cataract, iridodialysis is eliminated by applying U-shaped rainbow-scleral sutures.

Also new is that for suturing, paracentesis and scleral incision are performed, a curved needle with a thread is inserted into the anterior chamber through a scleral incision, they capture the edge of the iris and the needle and thread are removed through paracentesis, then a needle with a thread is inserted into the anterior chamber through paracentesis, they capture the edge of the separation of the iris at a distance of 5 mm from the first injection and withdraw the needle through an incision in the sclera, then knots are tied.

Also new is that when the iris is torn off to 45 degrees, paracentesis and scleral incision are performed in the projection of iridodialysis.

Also new is that when the iris is torn from 45 to 120 degrees, 1-2 scleral incisions are additionally formed in the projection of iridodialysis, paracentesis is performed in the segment opposite to iridodialysis, several U-shaped sutures are made through each of the scleral incisions.

The exclusion of suturing on the cornea does not induce postoperative astigmatism, which ensures the achievement of high visual acuity.

The application of U-shaped iris-scleral sutures with a distance of 5 mm ensures reliable fixation of the iris, which, in turn, reduces the risk of postoperative complications and provides complete rehabilitation in a short time and the elimination of cosmetic imperfections.

Making incisions in the sclera and paracentesis facilitates surgical procedures, reduces surgical trauma, promotes rapid rehabilitation of the patient, maintains a constant depth of the anterior chamber of the eye, due to which there is no prolapse of the iris into the surgical wound or collapse of the eyeball, and the risk of damage to the corneal endothelium is reduced.

Comparative analysis with the prototype shows that the proposed method is characterized in that they form a corneal two-stage self-sealing tunnel incision. After phacoemulsification of cataracts, iridodialysis is eliminated by applying U-shaped rainbow-scleral sutures, paracentesis and scleral incision are performed to suture, a curved needle with a thread is inserted through a scleral incision in the anterior chamber, the edge of the iris is removed and the needle with thread is removed through paracentesis , then the needle with the thread is inserted into the anterior chamber through paracentesis, capturing the edge of the iris at a distance of 5 mm from the first injection and the needle is brought out through an incision in the sclera, then knotted sutures; when the iris is torn off to 45 degrees, paracentesis and scleral incision are performed in the iridodialysis projection, and when the iris is torn from 45 to 120 degrees, 1-2 scleral incisions are additionally formed in the iridodialysis projection, paracentesis is performed in the opposite iridodialysis segment, several U-shaped sutures are inserted through each from scleral incisions. All this meets the criterion of "novelty."

A new set of features ensures the achievement of the maximum possible visual acuity, reduction of surgical and postoperative complications and terms of patient rehabilitation, elimination of cosmetic defects, does not require special tools and needles, provides simultaneous phacoemulsification and “closed” iridoplasty through a small surgical incision, which meets the criterion of “industrial applicability” "

The proposed method is illustrated by the following drawings, where Fig. 1 shows the sequence for eliminating iridodialysis when the iris is torn off up to 45 degrees, where A is the needle injection through the scleral incision, the capture of the iris separation edge and the puncture through paraceitis; B - needle return; In - tying a nodal seam. In Fig.2 - the sequence of elimination of iridodialysis with the separation of the iris with a length of 45 degrees to 120 degrees, where A is the separation of the iris, B is the injection of the needle through the scleral incision, the capture of the edge of the separation of the iris and puncture through paracentesis in the opposite segment, B is the return needle , G - tying a nodal suture, D - completion of iridoplasty. Figure 3 shows the pulling of the pupil edge to the place of fixation of the separation of the iris and the centering of the pupil.

The method is as follows.

The operation is performed under local and neuroleptanalgesia. The upper rectus muscle is not taken on the stitch-holder. A corneal two-stage self-sealing tunnel incision is formed with a length of 3.2 mm, which is performed, if possible, taking into account keratotopography data. Then cataract phacoemulsification is carried out, the technique of which depends on the degree of density of the lens nucleus. For implantation, an IOL from a collagen copolymer of the RSP-2 model is used. The elimination of iridodialysis is carried out at the final stage of the operation by applying U-shaped rainbow-scleral sutures. For this, incisions are made in the sclera and additional corneal paracentesis. The number of incisions in the sclera is due to the length of the separation of the iris. With the separation of the iris with a length of up to 45 degrees, one U-shaped fixing seam is applied. To do this, in the projection of iridodialysis, an incision is made in the sclera. Through it, an Alcon curved needle with a nylon thread 10-00 is inserted into the anterior chamber of the eye. The needle captures the edge of the separation of the iris and remove it through an additional paracentesis performed in the projection of iridodialysis. Next, the needle is inserted into the anterior chamber through the same paracentesis, re-capture the edge of separation at 5 mm from the first injection. The needle is removed from the anterior chamber through a previously made scleral incision. Tie 3-4 nodal sutures, which are immersed in the scleral incision (figure 1). The ends of the thread are cut with scissors Vannas. When the iris is torn from 45 to 120 degrees, iridodialysis is eliminated using a straight needle from Alcon with a thread of propylene 10-00.

The number of U-shaped sutures depends on the length of the separation of the iris. To do this, perform 2 or 3 scleral incisions in the projection of iridodialysis. In the opposite segment, paracentesis is performed. The needle is inserted into the anterior chamber through an incision in the sclera. Through paracentesis, a spatula is introduced towards the needle, with the help of which the edge of the separation is strung onto the needle. The needle is removed from the anterior chamber using a cannula inserted into paracentesis, then through the same paracentesis the needle is re-introduced into the anterior chamber, it grabs the separation edge at a distance of 5 mm from the first injection and leads it out through an incision in the sclera. Tie 3-4 knots, which are immersed in the scleral incision. The ends of the thread are cut with scissors Vannas. A similar manipulation is repeated until iridodialysis is eliminated. To do this, use one paracentesis and different incisions in the sclera (figure 2). When iridodialysis is 120 degrees after fixing the torn iris root to the sclera, the pupil is pulled up to the fixation site. To center the pupil and give it a rounded shape in this case, additional nodal sutures are placed on the pupil edge (Fig. 3). A straight needle is inserted into the anterior chamber of the eye through paracentesis, the edge of the coloboma is captured and the puncture is carried out through the cornea in the opposite segment. The free end of the thread is left in paracentesis. The hook through paracentesis from the anterior chamber leads the other end of the thread left in the paracentesis, the ends of the thread are stretched in opposite directions, tying a knot. The knot is tied three times.

To prevent mechanical damage to the corneal endothelium at all stages of the operation, viscoprotectors are used (visited). At the end of the operation visited from the anterior chamber is removed. The anterior chamber is restored with saline. Sutures on the corneal incision do not impose. The operation is completed by subconjunctival injection of a solution of dexazone and gentamicin.

The proposed method is illustrated by the following clinical examples.

Clinical example 1.

Patient I., born in 1978, was admitted to the Irkutsk branch of the State Scientific and Technical Center “Eye Microsurgery” on 10.11.2000 with a diagnosis of Traumatic cataract, iridodialysis OD. On admission:

Visual acuity: OD 0.08-0.1 n.k.

OS 1.0

IOP: OD 21 mmHg

OS 19 mmHg

Echobiometry: OD 23.58 mm

OS 24.03 mm

Keratophthalmometry: OD 42.35 ax 171

43.09 ax 81

OS 42.65 ax 170

42.95 ax 80

St.localis:

OD is calm. The cornea is transparent. Front camera uniform up to 3.0 mm. In the segment of 6-8 hours (45 degrees) iridodialysis. The pupil is 3.0-3.5 mm irregular in shape due to a slight displacement to the side opposite to iridodialysis. The reaction to light is lively, uneven. Plane synechia with anterior lens capsule in the projection of iridodialysis. In the lens of clouding in the nuclear-cortical layers. Details of the fundus are not ophthalmoscopic.

11.11.2000, an operation was performed on OD phacoemulsification of traumatic cataract with implantation of IOL, iris plastic.

The operation was performed under local and neuroleptanalgesia. The stitch-holder on the upper rectus muscle was not superimposed. A corneal two-stage self-sealing tunnel incision with a length of 3.2 mm was formed, which was performed, if possible, taking into account keratotopography data. The spatula made the separation of planar synechia in the segment of 6-8 hours. Through this incision, traumatic cataract was removed by phacoemulsification. The front camera is full of visitors. An elastic IOL from the RSP-2 model collagen copolymer was implanted into the capsular bag. At 7 o'clock an incision was made in the sclera. Through it, an Alcon curved needle with a 10-00 nylon thread was inserted into the anterior chamber of the eye. The needle captures the margin of separation and the needle is withdrawn from the anterior chamber through additional paracentesis performed in the projection of iridodialysis (7 hours). Next, the needle was inserted into the anterior chamber through the same paracentesis, and at the distance of about 5 mm from the first injection, it re-captured the separation edge. The needle is removed from the anterior chamber through a previously made incision in the sclera. Tied 3 knotted sutures that are immersed in the scleral incision. The ends of the thread are cut with scissors Vannas. Visit has been removed from the front camera. The anterior chamber is restored with physiological saline. No sutures were made on the corneal incision. A subconjunctival solution of gentamicin and dexazone was administered. The postoperative period was uneventful. Conducted standard anti-inflammatory therapy. The visual acuity of the right eye on the 5th day was 0.9 and remained stable during the observation period of up to 1.5 years. Keratotopograph data indicate the absence of induced postoperative astigmatism. Iridoplasty and cosmetic effect remained stable throughout the observation period.

Clinical example 2.

Patient R., born in 1963, was admitted to the Irkutsk branch of the State Scientific and Research Center “Eye Microsurgery” on October 15, 2001 with a diagnosis of Traumatic cataract, iridodialysis OD.

On admission:

Visual acuity: OD-pr.1.certa.

OS 1.0.

IOP: OD 22 mmHg

OS 19 mmHg

Echobiometry: OD 24.12 mm

OS 24.05 mm

Keratophthalmometry: OD 42.25 ax 18

43.05 ax 108

OS 43.21 ax 31

44.01 ax 121

St.localis:

OD is calm. The cornea is transparent. Front camera up to 3.0 mm. In the segment of 6-10 hours (100 degrees) the separation of the iris from the root. Irregular pupil 2.5 mm to 3.5 mm, displaced by 3 hours. The reaction to light is uneven due to planar synechia in the projection of iridodialysis. The lens is diffusely cloudy. The fundus is not ophthalmoscopic.

10/16/2001, an operation was performed on OD - phacoemulsification of traumatic cataract with implantation of IOL, iris plastic.

The operation was performed under local and neuroleptanalgesia. The stitch-holder on the upper rectus muscle was not superimposed. A corneal two-stage self-sealing tunnel incision with a length of 3.2 mm was formed, which was performed, if possible, taking into account keratotopography data. The spatula made the separation of planar synechia in the segment of 6-10 hours. Through this incision, traumatic cataract was removed by phacoemulsification. The front camera is full of visitors. Elastic collagen copolymer is implanted into the capsular bag. At 7-30 and 9 hours, incisions were made in the sclera, at 2 hours, corneal paracentesis. Through an incision in the sclera at 7-30 and a needle of the Alcon firm with a thread propylene 10-00 is inserted into the anterior chamber. A spatula was introduced to meet her through paracentesis at 2 hours, with the help of which the edge of the separation was strung on a needle. The needle is removed from the anterior chamber through paracentesis over a spatula. Through the same paracentesis, the needle was again inserted into the anterior chamber, and it seized the separation edge at a distance of 5 mm from the first injection. The needle is removed from the anterior chamber through an incision in the sclera at 7-30. 3 knotted sutures are tied, the ends of the thread are cut off with Vannas scissors, the knot is immersed in a scleral incision. A similar manipulation was performed through an incision in the sclera at 9 hours and the same paracentesis at 2 hours. Thus, the separation of the iris to the sclera is fixed. After that, to center the pupil, a nodal suture was placed along the pupillary edge in the meridian of 8 hours. For this, a straight needle is inserted into the anterior chamber of the eye through paracentesis, the edge of the coloboma is captured, and a puncture is made through the cornea in the opposite segment. The free end of the thread is left in paracentesis. The hook through the paracentesis from the anterior chamber leads the other end of the thread, forming a loop, which is captured by suture forceps and 2 times wound on the branches of the second suture forceps. The free end of the thread, left in paracentesis, is captured, the ends of the thread are stretched in opposite directions, thereby tying a knot. The knot is tied three times.

Visit has been removed from the front camera. The anterior chamber is restored with physiological saline. No sutures were made on the corneal incision. A subconjunctival solution of gentamicin and dexazone was administered. In the postoperative period, a hyphema of up to 0.5 mm was observed, which resolved on day 2 against the background of the standard anti-inflammatory and resolving therapy. The visual acuity of the right eye on day 5 was -0.8 and remained stable during the observation period of up to 7 months. Keratotopograph data indicate the absence of induced postoperative astigmatism. Iridoplasty and cosmetic effect remained stable throughout the observation period.

Thus, the proposed method allows to obtain high visual acuity in patients of working age, to ensure their full rehabilitation in a short time, to use all the advantages of a small incision in the surgery of traumatic cataracts complicated by iridodialysis.

Claims (3)

1. A method of surgical treatment of traumatic cataract complicated by iridodialysis by removing cataracts, implanting an IOL and eliminating iridodialysis, characterized in that they form a corneal two-stage self-sealing tunnel incision, after phacoemulsification of the cataract, iridodialysis is eliminated by superimposing U-shaped rainbow-scleral sclerotomy for suturing, paracentesis and scleral incision are performed, through the scleral incision, a curved needle with a thread is inserted into the anterior chamber, grab th separation iris and output the needle thread through paracentesis, and then the needle with the thread is introduced into the anterior chamber paracentesis after capturing iris region separation distance of 5 mm from the first puncture, and outputting the needle through an incision in the sclera, then knotted nodal joints. 2. The method according to claim 1, characterized in that upon separation of the iris up to 45 °, paracentesis and scleral incision are performed in the projection of iridodialysis. 3. The method according to claim 1, characterized in that when the iris is torn from 45 to 120 °, 1-2 scleral incisions are additionally formed in the projection of iridodialysis, paracentesis is performed in the segment opposite to iridodialysis, several U-shaped sutures are made through each of the scleral incisions.

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