RU2238066C2 - Method for carrying out subtotal vitrectomy - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: about 3-4 d before desired operation one should introduce 0.1 ml isotonic NaCl solution containing 10-15 KU collalysine by 1-2 times at interval of 24-48 h into vitreal cavity through paracentesis of membranes at 4 mm against patient's limbus. Right in the course of operation, before the onset of vitrectomy procedure one should introduce 1.0 ml isotonic NaCl solution containing 30 KU collalysine into vitreous body followed by standard procedure of subtotal vitrectomy. The method suggested enables to decrease the risk for development of jatrogenic retinal detachments at vitrectomy in cases of isolated pathology of vitreous body, decrease the risk for retinal wound, remove vitreous body more completely that, thus, increases the quality in treating vitreoretinal pathology.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to ophthalmology.

A known method for conducting subtotal vitrectomy, which consists in the fact that in the projection area of the flat part of the ciliary body, the sclera is exposed. In the sclera, respectively, the projection of the flat part of the ciliary body 4 mm from the limb, three through punctures are made (2 at 10 and 11 hours, and 1 at 13 hours). An infusion cannula is inserted and sutured into one of the punctures for supplying physiological saline, and the other two are injected with instruments for conducting subtotal vitrectomy - the light guide and the tip of the vitreotome. Through the infusion cannula, physiological saline is continuously fed into the vitreous cavity, the directly removed area of the vitreous body is illuminated with a fiber, and vitrectomy is performed with the tip of the vitreotomy (Abstract of Cand. Diss. P. Lyskin P.V. New surgical methods for treating severe retinal detachments: alloretinoplasty and combined alloretinopexy. ., 1996, p. 14).

The disadvantage of this method is that due to the absorption of small portions of the vitreous body into the tip of the vitreotome and cutting them off at the tip of the vitreotome with a moving rod, followed by elimination, there is a continuous, pulsating, traction effect on the vitreous body, which is transmitted to the retina. With moderate or severe vitreous fibrosis, the traction effect of the vitreotome tip increases on the vitreous and, accordingly, on the retina, which can lead to a number of negative moments during subtotal vitrectomy. With an adjacent retina, due to an increase in the traction effect on the retina, the risk of iatrogenic retinal detachment increases.

When carrying out subtotal vitrectomy, when the retina is detached, the risk of retraction of the retina along with the vitreous body into the tip of the vitreotome and, accordingly, an additional retinal injury, sharply increases. In such cases, the surgeon is forced to intentionally leave a part of the vitreous body undeleted, which accordingly reduces the degree of “subtotality” of the performed vitrectomy and can adversely affect the results of treatment.

And finally, the most complex, unresolved problem: the degree of fibrosis of the vitreous body can be such that the tip of the vitreotome practically does not cut the vitreous body, or cuts it with great difficulty and small fragments, which greatly reduces the effectiveness of the performed vitrectomy, which can be reduced to only partial, which cannot but adversely affect the results of treatment.

The present invention is to give the vitreous body a more fluid state, in which the resistance of the vitreous to cutting is reduced and thus the efficiency of vitrectomy is increased.

The technical result achieved by using the invention is a significant reduction in the degree of fibrosis of the vitreous body, facilitating the process of vitrectomy, reducing the traction effect of the vitreous body on the retina, reducing the risk of iatrogenic retinal detachments, reducing the risk of iatrogenic retinal wounds, expanding the spectrum of indications for vitrectomy, improving the quality of ongoing vitratsgomii.

The technical result is achieved by the fact that 3-4 days before the proposed operation in 1-2 doses, with an interval of 24-48 hours, 0.1 ml of isotonic NaCl solution containing 10- is injected into the vitreous cavity through a puncture of the membranes 4 mm from the limb 15 KE of collalysine, and immediately during the operation, prior to the start of vitrectomy, 1.0 ml of isotonic NaCl solution containing 30 KE of collalysin is injected into the vitreous body.

The introduction of collalizine into the vitreous cavity causes its destruction of the structure of collagen molecules - the main matrix of the vitreous body and the main component of vitreous cords and epiretinal membranes (manifestations of fibrosis of the vitreous). As a result of fragmentation of collagen molecules, the strength characteristics of the vitreous body decrease and its resistance to cutting by the tip of the vitreotome decreases, which facilitates the vitrectomy process itself and allows it to be carried out in cases with gross fibrosis of the vitreous body, which under normal conditions are not amenable to vitrectomy.

The proposed method is as follows. 3-4 days before the proposed operation, an through puncture of the membranes of the eye with the penetration of the injection needle into the vitreal cavity is formed under epibulbar anesthesia 4 mm from the limb. After the expiration of a small amount of the liquid part of the vitreous body and the occurrence of mild hypotension, 0.1 ml of an isotonic solution containing 10-15 KE of collalizine is injected into the vitreous cavity. A similar procedure can be performed the next day or every other day.

The operation of subtotal vitrectomy itself is performed under local and conduction anesthesia, with additional intravenous administration of painkillers and sedatives. In the projection area of the flat part of the ciliary body, the sclera is exposed. In the sclera, respectively, the projection of the flat part of the ciliary body 4 mm from the limb, three through punctures are made (2 at 10 and 11 hours, and 1 at 13 hours). An infusion cannula is inserted and hemmed into one of the punctures to supply physiological saline. The first stage of the operation through one of the scleral punctures in the vitreous body is injected 1.0 ml of isotonic NaCl containing 30 KE of collalysine, the excess liquid part of the vitreous is forced out through the punctures in the sclera. In the other two instruments for subtotal vitrectomy are introduced - the optical fiber and the tip of the vitreotomy. Through the infusion cannula, physiological saline is continuously fed into the vitreous cavity, the directly removed portion of the vitreous body is illuminated with a fiber, and vitrectomy is performed with the tip of the vitreotome.

Example 1

Patient Zh., 57 years old, diagnosis: postoperative aphakia, gross destruction and opacification of the vitreous body, complicated hernia of the vitreous body with fixation of coarse fibrous cords of the vitreous in the iris, its insertion into the corneal surgical scar, total tractional detachment of the retina with multiple peripheral ruptures elements of epiretinal fibrosis. Visual acuity is the correct light projection.

The patient underwent surgical treatment using collalysine. At the first stage, 15 KE of collalysine in 0.1 ml of physiological saline were injected into the vitreous cavity, after a day, 15 KE of collalysin per 0.1 ml of saline was re-injected into the vitreous cavity. Two days after the last injection of the enzyme into the vitreous cavity, the patient underwent a combined surgical intervention: circular sclera depression, after which 30 KE of collalysine were introduced into the vitreous cavity immediately before vitrectomy per 1.0 ml of isotonic solution and subtotal vitrectomy was performed with a simultaneous tamponade gas cavity. At discharge, the retina is fully attached. Visual acuity of 0.1 with correction, gas occupies 1/3 of the volume of the vitreous. When viewed after 3 months, the corrected visual acuity of 0.25, the retina is fully adjacent.

In the process of subtotal vitrectomy, the ease of cutting the vitreous body with the tip of the vitreotome, including its coarse cords, was noted.

Example 2

Patient S., 45 years old. Diagnosis: total retinal detachment with a giant separation of the dentate line by 180 degrees and inversion of the torn edge of the retina, gross destruction and opacification of the vitreous body, high myopia. Visual acuity is the movement of a hand in a face. The patient underwent preoperative and intraoperative effects of collalysine on the vitreous body. 10 KE of collalysin was introduced into the vitreous cavity per 0.1 ml of physiological saline, three days after the enzyme was injected, a subtotal vitrectomy was performed, immediately before which 30 KE of collalysine per 1 ml of saline was injected into the vitreous cavity, then PFOS vitreous cavity tamponade (perfluororganic compound), endolasercoagulation, replacement of PFOS with gas. NV! The operation for detachment was performed without applying an episcleral seal. At discharge, the retina is adjacent, visual acuity is the count of the fingers of the face in the face due to the presence of gas in the vitreal cavity. When viewed after 7 months - the retina is fully diligent, visual acuity of 0.4-0.5 with correction. During vitrectomy, the vitreous needle was easily cut with a vitreoma needle.

Thus, the use of the proposed method allows to achieve anatomical dilution of the retina in the distant postoperative period without the use of episcleral filling and without prolonged tamponade of the vitreous cavity with liquid silicone, which is possible only if the vitreous body is almost completely removed. Using the proposed method of subtotal vitrectomy allows you to achieve similar results.

Claims (1)

A method for conducting subtotal vitrectomy, including three through punctures in the sclera, respectively a projection of the flat part of the ciliary body 4 mm from the limbus, in one of which the infusion cannula is inserted and hemmed to supply physiological solution, the instruments for the subtotal vitrectomy are introduced into the other two - the light guide and the tip of the vitreotome, through the infusion cannula, the physiological saline is continuously fed into the vitreous cavity, the directly removed section of the vitreous is illuminated with a light guide ate, and with the tip of the vitreotome, a vitrectomy is performed, characterized in that 3-4 days before the proposed operation in 1-2 doses and with an interval of 24-48 hours, 10-15 KE are introduced into the vitreous cavity by puncture of the sclera in the projection of the flat part of the ciliary body collalysine in 0.1 ml of an isotonic NaCl solution, and immediately during the operation, its first step is injected into the vitreous body 30 KE of collalysine in 1.0 ml of an isotonic NaCl solution.