RU2234298C1 - Method for surgical treatment of dislocated lens with dense nucleus into vitreous body cavity - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: one should perform tunnel incision without lancing anterior chamber and subtotal vitrectomy through transciliary access followed by introduction of perfluoroorganic compound (PFOC) and directing the lens towards iris, then comes sealing the access into vitreous body cavity, filling in anterior chamber with viscoprotector through tunnel access and removal of lens after preliminary mechanical fragmentation. IOL should be implanted, PFOC should be substituted with physiological solution, due to PFOC one should direct the lens towards iris tightly to achieve touching. Lens should be partially, by one fourth or one third, withdrawn into anterior chamber by turning with equatorial plane for 30-50 deg. around the axis located in horizontal plane and coming through the center of lenticular nucleus being perpendicular to incision. Then one should cut off a segment exposed above iris with the help of special pincers, moreover, pincers' branches work in the plane being perpendicular to equatorial lenticular plane. Fragment should be withdrawn outside. Lens should be turned for the angle of 90 deg. in horizontal plane and again one should repeat actions to obtain another equatorial lenticular segment above iris to cut it off by decreasing, thus, the lens by 3-4 times. Central segment should be removed at the last stage. The method enables to atraumatically remove dislocated lens with dense nucleus through minor incision.

EFFECT: higher efficiency of therapy.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for the surgical treatment of a dislocated lens with a dense large nucleus in the vitreous cavity (CT).

A known method of surgical treatment of a dislocated lens in the ST cavity with tunnel scleral-corneal access using liquid perfluororganic compounds (PFOS) and phacoemulsification (RF patent No. 2144809, priority 02.04.97, authors: Zakharov V.D., Ignatiev S.G., Komarova M.G.). However, this method is effective in the treatment of the lens, mainly with a soft nucleus, as the phacoemulsification method is used to remove the lens.

The closest method to surgical treatment of an dislocated lens with a dense large nucleus in the vitreous cavity is a method using a small tunnel incision and liquid PFOS, where a lens loop and phaco chopper are used to fragment the dense lens nucleus (RF patent No. 2192224, priority date 04/26/2001, authors Takhchidi H.P., Kazaykin V.N. - prototype).

The specified method is as follows.

We started with the formation of a small tunnel incision without opening the anterior chamber, then a vitrectomy was performed and liquid PFOS was introduced into the vitreous cavity. The lens, due to a lighter specific gravity, appeared on the surface of PFOS and, as the ST cavity was filled with liquid PFOS, rose to the iris, while a gap of 1-2 mm was left between them. Then the anterior chamber was finally opened, it was filled with a viscoprotector, and through the tunnel incision a lens loop was inserted under the lens, the same access was introduced with a vitreot and a capsule was cut. The capsule bag was opened by a linear section equal to the loop width, and after hydrodissection, the phaco chopper was inserted into the capsule bag between the core and the front capsule and injected into the core for 6 hours. Then, crushing the loop from below and the phaco chopper from above, the loop was pulled out from under the lens and, without interrupting contact with the capsule, the loop was looped into the capsular bag under the core and fragmented by the phaco chopper. Then fragments of the nucleus and capsule bag were brought out, and the IOL was implanted and fixed to the iris or sclera after complete replacement of saline with PFOS.

The disadvantages of the method

1. Through the tunnel access several instruments are introduced simultaneously, which does not allow to reliably maintain the normal tone of the eye, therefore there is a risk of damage to the corneal endothelium.

2. For this technology, a sufficiently large mydriasis is required, which in practice is not always feasible. In cases of insufficient mydriasis, the risk of surgical injury to the iris increases.

3. The lens masses that remain in the posterior chamber between the PFOS bladder and the posterior surface of the iris during nuclear fragmentation are removed by aspiration without sufficient visual control. Therefore, there is a risk of incomplete removal of the lens masses, as a result of which postoperative complications are possible.

The objective of the invention is to develop a simpler and atraumatic technology for the surgical treatment of an dislocated lens with a dense nucleus in the cavity of the vitreous body by removing it through a small tunnel incision.

The technical result obtained by solving this problem is to reduce surgical and postoperative complications.

The specified technical result can be obtained if, in the method of surgical treatment of an dislocated lens with a dense nucleus, into the vitreous cavity, including performing a tunnel incision without opening the anterior chamber, subtotal vitrectomy through transciliary access, followed by the introduction of perfluororganic compounds and bringing the lens to the iris, sealing access vitreous cavity, filling of the anterior chamber with a viscoprotector through tunnel access and removal of the lens after mechanical fragmentation, the implantation of an IOL and the replacement of PFOS with physiological saline, the lens leads to the iris, using PFOS, right up to touching it, it is fragmented in the anterior chamber, and not the core, but the entire lens, for this, with the help of its partially 1 / 4-1 / 3, lead out into the anterior chamber, while unfolding on the equatorial plane 30–50 ° around the axis located in the horizontal plane and passing through the center of the lens nucleus, perpendicular to the section, and “bite” with tweezers-fragmentator a segment above the iris, while the tweezers branches work in a plane perpendicular to the equatorial plane of the lens, bring it out, rotate the lens 90 ° in the horizontal plane and repeat the steps of exposing the next equatorial segment of the lens over the iris and “biting” it, thereby reducing taking the lens 3-4 times, the last segment is removed.

Among the essential features characterizing the method, the distinguishing ones are:

- the lens leads to the iris right up to touching it;

- fragment the lens as a whole, not the core;

- fragment in the anterior chamber;

- for fragmentation, the lens, with the help of a tool, is partially displayed in the anterior chamber, while turning the equatorial plane 30-50 ° around an axis located in the horizontal plane and passing through the center of the lens nucleus, perpendicular to the section;

- “bite” the segment exposed above the iris with tweezers-fragmentator and bring it out;

- when “biting” the lens segment, the branches of the tweezers-fragmentator work in a plane perpendicular to the equatorial plane of the lens;

- then turn the lens in a horizontal plane by 90 ° and again repeat the steps of setting the next equatorial segment above the iris and “biting” it;

- reduce the lens in this manner 3-4 times and the last segment is removed.

As a special case, the central segment of the lens before fragmentation can be further fragmented.

Between the totality of the essential features and the claimed technical result, there is a causal relationship.

The use of PFOS to bring the lens into the pupil area is a well-known technique used by ophthalmic surgeons. Using PFOS in this technology, it is necessary to introduce it until the lens comes close to the iris. As is known, saline PFOS is replaced by saline injected into the ST cavity during vitrectomy, and, therefore, bringing the lens close to the iris will provide maximum filling of the vitreous PFOS cavity and the minimum amount of saline will remain in the posterior chamber. The lens, which does not have a ligamentous apparatus, has high mobility. Thanks to this technology, the lens before fragmentation is firmly fixed in the pupil area. Under the lens is PFOS - a dense, viscous substance, above the lens is a viscous viscoprotector, i.e. media that do not mix and at the same time limit the mobility of the lens, fixing it well in the position that the surgeon gives it. As a result, manipulations with the lens become more controlled.

The next step is the partial removal of the lens with a tool into the anterior chamber. When performing this manipulation, the surgeon has two goals: not to injure the corneal endothelium with the lens and instrument and position the exposed segment so that it can be nibbled comfortably, reliably and atraumatically to the surrounding tissues. To achieve these conditions, the lens is partially ejected into the anterior chamber (by 1 / 4-1 / 3 part), turning the equatorial plane through an angle of 30-50 ° around an axis located in the horizontal plane and passing through the center of the lens nucleus, perpendicular to the section. This angle allows you to come atraumatically to the exposed part of the lens with tweezers-fragmentator. Moreover, the lens expanded and exposed above the iris in this way will be held in this position due, firstly, to the high viscosity of the viscoprotector located in the anterior chamber, and secondly, to PFOS, which does not allow it to fall into the vitreous cavity, and, thirdly, to the pupil the edge of the iris that gripped him. However, if the angle of rotation of the lens, whose diameter is about 9 mm, is greater than 50 °, then the lens will damage the endothelium of the cornea, and if it is less than 30 °, then the iris can be damaged by the fragmentation forceps at the moment the tweezers are inserted and the equatorial part of the lens is bite.

After partial removal of the lens into the anterior chamber, biting of the lens segment exposed above the iris is performed using a tweezers fragmentator (patented by our Center, Patent No. 2194463), while the tweezers branches should work in a plane perpendicular to the equatorial plane of the lens (this technique is atraumatic and increases Efficiency). The inner surface of the working jaws of the tweezers-fragmentator has a wedge-shaped shape with the possibility of contacting with each other by the pointed ends of the wedges, which can smoothly enter the lens from two sides, breaking the capsule, splitting the hard core and pushing apart the fragments. Thus, the entire lens is fragmented, and not just its solid core. The protruding part of the lens protruding above the iris 1 / 4-1 / 3 directly through the capsule is easily bitten off with fragmentation forceps (the action takes place in the pupil plane) and is brought out through the tunnel incision.

Then the remaining part of the lens is rotated by a tool in a horizontal plane 90 ° around the central optical axis of the eye, thereby preparing a new equatorial segment of the lens for partial excretion into the anterior chamber and for subsequent “biting”. After repeating a series of manipulations with the lens (partially removing it with the tool into the anterior chamber, “biting” the equatorial part protruding above the iris and moving it out) 3-4 times, its size decreases. There remains the central part of the lens, which usually resembles a parallelepiped in shape. If we take into account that the diameter of the lens with a dense large nucleus is on average 9.0 mm, and its thickness is 4.0-5.0 mm, then the dimensions of this remaining central part of the lens after three or four fragmentations can be as follows: length 6.0 6.8 mm, width 3.0-4.6 mm, thickness 4.0-5.0 mm. This remaining part of the lens is completely removed with the help of the instrument into the anterior chamber and is removed from the whole eye if the size of this part allows it to be passed through a 5.5 mm wide tunnel without injury to the endothelium. Otherwise, the remaining part of the lens is fragmented with fragmentation tweezers into smaller parts that are easily removed from the eye.

Thus, between the set of essential features of the claimed invention and the achieved technical result, there is a causal relationship.

The method is as follows.

The operation begins with the formation of a tunnel section 5.5 mm wide without penetration into the anterior chamber. Then, a 3-port posterior vitrectomy is performed, the dislocated lens is completely freed from the CT fibers, and liquid PFOS is delivered to the CT cavity from the optic disc. PFOS is applied simultaneously with aspiration of irrigation fluid (balanced saline BSS). Using liquid PFOS, the lens rises from the fundus to the front of the CT cavity. The filling of the ST cavity with liquid PFOS occurs until the lens contacts the posterior surface of the iris.

Then, two sclerotomy sections formed to perform vitrectomy are closed with scleral plugs, the irrigation solution is stopped, and the anterior chamber is opened through the corneoscleral tunnel section made earlier. A viscoprotector is introduced into the anterior chamber to protect the corneal endothelium. All subsequent manipulations are performed in a viscoprotector medium, new portions of which, if necessary, are introduced into the anterior chamber to maintain its depth and normal eye tone.

Through a tunnel incision into the anterior chamber is carried out a cystot, which is then advanced under the iris to the equator of the lens. The cystotome captures the lens in the equator and partially displays it in the anterior chamber, turning the lens in the equatorial plane 30–50 ° around an axis located in the horizontal plane and passing through the center of the lens nucleus perpendicular to the section. The equatorial part of the lens is exposed and pinched in the pupil and, using a piece of tweezers, it is bitten right through the capsule (about 1 / 4-1 / 3 of the lens) and brought out. The remaining part of the lens is rotated in the rear chamber 90 ° around the central optical axis of the eye, and then all the steps to set the next equatorial part of the lens are repeated, reducing the lens 3-4 times with this technique. As a result, the central part of the lens remains, resembling a parallelepiped in shape, one of the smaller sides of which is the equator of the lens. This remaining part of the lens is completely excreted using the cystotome into the anterior chamber and is removed from the whole eye if the size of this part allows it to be passed through a 5.5 mm wide tunnel without injury to the endothelium. Otherwise, the remaining part of the lens is fragmented with fragmentation tweezers into smaller parts. The remains of the lens masses in the anterior chamber are brought out when a new portion of the viscoprotector is introduced. An IOL is then implanted, which is sutured to the iris or sclera (depending on the type of IOL). Then the viscoelastic is removed from the front chamber and the tunnel section is sealed. The flow of the irrigation solution is resumed, the scleral plugs are removed, and then the liquid PFOS is replaced by the irrigation liquid. The operation is completed by suturing the scleral and conjunctival sections.

Example. Patient M., 64 years old. Received November 17, 2002 with a diagnosis of traumatic dislocation of the lens with a dense large nucleus in the cavity of the vitreous body, condition after OS contusion. Visual acuity of the left eye of 0.01 with a spherical corr. +10.5 D = 0.7 field of view within normal limits, IOP = 24 mm Hg. Art.

November 18, 2002, the operation was performed according to the claimed method.

Operation stages

A corneoscleral tunnel incision 5.5 mm wide was formed without penetrating the anterior chamber in the upper sector. A 3-port posterior vitrectomy was performed and, using liquid PFOS, the lens was lifted from the fundus to contact the posterior surface of the iris. Then, two sclerotomy sections were closed with scleral plugs, the irrigation solution was stopped, and the anterior chamber was opened through a tunnel section. A viscoprotector was introduced into the anterior chamber.

The cystotome captured the lens in the region of its equator and partially led into the anterior chamber, while rotating the lens with an equatorial plane 30–50 ° around an axis located in the horizontal plane and passing through the center of the lens nucleus perpendicular to the tunnel section, i.e., passing through 6-12 hours. The equatorial part of the lens exposed and pinched in the pupil was “bitten” by tweezers-fragmentator and brought out. The remaining part of the lens with a cystotome was rotated in the rear chamber 90 ° around the central optical axis of the eye clockwise, and then the steps were repeated. “Biting” of the equatorial part was performed 4 times. The remaining central part of the lens was completely removed by the cystotome into the anterior chamber and fragmented with tweezers-fragmenter into two parts, which were separately removed from the eye. Then they performed implantation of the pupil IOL of the T-19 model, which was hemmed to the iris for 2 arches. After removal of viscoelastic from the anterior chamber, one nodal suture was applied to the tunnel incision. The flow of the irrigation solution was resumed, the scleral plugs were removed and the liquid PFOS was replaced by the irrigation liquid (balanced saline solution). The operation was completed by suturing the scleral and conjunctival sections. On the first day after surgery, when examining the left eye: the cornea is transparent, the anterior chamber is 3.0 mm, the moisture is transparent, the I-T-19 is centered, the fundus is well ophthalmoscopic. Visual acuity of the left eye without correction of 0.4 with a spherical correction of -0.5 D = 0.7; IOP = 23 mm Hg. Art. The patient was discharged on the third day after surgery. Surgical and postoperative complications were not observed.

In the Yekaterinburg Center MNTK "Eye Microsurgery" the claimed method operated on 12 patients whose lens was dislocated into the vitreous cavity with a dense large nucleus (7-9 mm). During all operations, the normal tone of the eye was always maintained, the operations were atraumatic without damage to the endothelium of the cornea, iris and ciliary body. A small tunnel incision, despite the fact that the nuclei were large, made it possible to exclude postoperative astigmatism. Insufficient mydriasis, in some cases, in no way complicated the course of the operation. In the postoperative period, complications were not observed.

Claims (2)

1. A method for surgical treatment of a dislocated lens with a dense nucleus in the vitreous cavity, including performing a tunnel incision without opening the anterior chamber, subtotal vitrectomy through transciliary access, followed by the introduction of perfluororganic compounds (PFOS) and bringing the lens to the iris, sealing access to the vitreous cavity ( CT), filling of the anterior chamber with a viscoprotector through tunnel access and lens removal after preliminary mechanical fragmentation, implantation of the IO L and the replacement of PFOS with physiological saline, characterized in that the lens leads to the iris closely, until it touches it, and it is fragmented in the anterior chamber, not the nucleus, but the entire lens, for this, using its tool partially, by 1 / 4- 1/3, lead to the anterior chamber, while unfolding an equatorial plane 30-50 ° around an axis located in the horizontal plane and passing through the center of the lens nucleus, perpendicular to the section, and “bite” the segment exposed above the iris with a pair of tweezers, jaws n Netseta work in the plane perpendicular to the equatorial plane of the lens, bring it out, rotate the lens 90 ° in the horizontal plane and repeat the steps to set the next equatorial segment of the lens over the iris and “bite” it, reducing the lens 3-4 times with this technique, remove it last central segment. 2. The method according to claim 1, characterized in that the central segment is fragmented before withdrawal.