RU2241421C1 - Method for correcting intraocular aphakia in the cases of marked lens ligament-capsule apparatus inconsistency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making conjunctiva incisions in oblique meridian, forming triangular scleral flaps at 1/3 of sclera depth, making cornea incision and intracapsular lens extraction. Straight suture needle is bent at an angle of 120° in 2/3 to 1/3 proportion from sharp needle tip. The needle with thread is introduced into anterior chamber near scleral flap base and removed via corneal incision, the needle passes through an orifice in haptic part of intraocular lens and the second pierce is done for bringing the needle back on sclera. The intraocular lens is implanted in posterior chamber by pulling the conducted thread. An intraocular lens of optical force calculated with postoperative anterior chamber depth taken into account, is used. The intraocular lens is fixed in triangular flaps projection. Corneal suture is applied. Anterior vitrectomy is carried out and interrupted sutures are put on the triangular flaps top. Anterior chamber depth is determined from formula AC_slf = 1.85+0.35 AC - 0.4, where AC_slf is the postoperative anterior chamber depth in transscleral lens fixation mode, AC is the anterior chamber depth before operation.

EFFECT: enhanced effectiveness of surgical treatment.

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Description

The invention relates to medicine, more specifically to ophthalmology, and can be used to remove a dislocated or subluxated lens and intraocular correction of aphakia with severe insolvency of the ligament-capsular lens apparatus.

Insufficiency of the ligament-capsular apparatus is a defeat of the zinc ligaments by more than 180 °, which causes a displacement (in either direction) of the lens relative to the conditional line of 3-9 hours.

Currently, spectacle correction, contact correction, and intraocular correction are used to correct vision of patients with severe insolvency of the ligament-capsular lens apparatus. Many authors have proven that the best functional results are achieved by applying the latest technique.

According to the scientific and technical literature from the prior art, a method is known for removing the lens and transscleral fixation of the posterior intraocular lens with the formation of scleral flaps at 3 and 9 hours. At the same time, fixing threads with atraumatic needles at the end, previously tied to the arch of the intraocular lens, were guided by the needle holder through the corneal incision and the pupil (Regillo CD, Tidwell J. A small-incision technique for suturing a posterior chamber intraocular lens, Ophthalmic Surg. Lasers. 1996 Jun. 27 (6), p. 473-475). One of the most significant disadvantages of the method is the formation of scleral flaps at 3 and 9 hours. In the meridian of 3-9 hours, 5-6 mm from the limb, the projection of the external and internal rectus muscles begins, so it is likely that during surgery and in the early postoperative period, you can get a hemorrhagic complication up to hemophthalmus.

As the closest analogue of the claimed method, a method for removing the lens with transscleral fixation of an intraocular lens described in the source: McGuinness R., Kennedy I. Implantation of sutured posterior chamber intraocular lenses, J. Cataract. Refract. Surg., 1995 Jul. 21 (4), p. 373-375.

The known method is as follows. Under local or general anesthesia with a maximally dilated pupil, two triangular scleral flaps with the base facing the limb are formed at 10:30 and 4:30 hours. Then, a standard 25-gauge needle is inserted into the eye through the bed under the scleral flap near the iris. The needle is removed through the ciliary groove in the bed of another triangular flap. The sewing up of the lens is made with polypropylene thread, and a straight needle with thread is passed through the cavity of the 25 gauge needle, after which the 25 gauge needle is removed from the eye. A standard corneoscleral incision is made of sufficient length for the implantation of a polymethylmethacrylate posterior intraocular lens. Through this crochet incision, the thread is pulled from the eye. Intracapsular (using a loop or cryoextractor) cataract extraction is performed, and then anterior vitreectomy is performed using a vitreotome. The lens is inserted into the eye, the thread is tightened so that the lens is hemmed to the sclera on the left under the superficial flap. With a thread with a curved needle, the intraocular lens is hemmed on the other hand, and the second scleral flap is simultaneously closed.

The known method allows to improve visual acuity in patients, however, has a number of the following significant disadvantages:

- in patients 3-6 months after surgery, the triangular scleral flaps are displaced to the side and the emerging polypropylene suture with its rigid ends injures the conjunctiva of the eyeball, and in some cases perforates it;

- Often there are bleeding from the injection site of the needle in the bed of the scleral flap;

- the direct needles used during the operation have a significant drawback: during the first and second injections they go deep enough into the vitreous cavity, which leads to its even greater destruction. In addition, during the second injection with a straight needle, the anatomical structure of the eyeball makes it difficult to get into the projection a triangle prepared in advance;

- when tying the thread, fixing the haptic part of the intraocular lens, it often entangles, which complicates the operation and lengthens its time;

- when performing vitreectomy, an injury to the main corneal suture with the tip of the vitreotome often occurs;

- there is no methodology for calculating the postoperative depth of the anterior chamber of the eye, which is crucial for the subsequent calculation of the optical power of the implanted intraocular lens.

The above disadvantages of the known methods limited the indications for intraocular correction due to the large number of surgical and postoperative complications, as well as insufficiently adequate correction of visual acuity.

The prior art formula is derived based on measuring the depth of the anterior chamber before and after cataract extraction with implantation of an intracapsular posterior intraocular lens (B.N. Alekseev, Yu.K. Shirshikov. Ultrasound diagnosis and surgery in ophthalmology. M., 1980, p. .1250:

PC _art = 2.85 + 0.35; PC + 0.2,

where PC _art is the postoperative depth of the anterior chamber of the artifact eye;

PC - depth of the anterior chamber prior to surgery.

The correction coefficient (0.2) for endocapsular fixation of the intraocular lens arose due to the fact that the front surface of the intraocular lens is slightly farther than the plane of the front surface of the iris. When measuring with ultrasound at a normal pupil width, the distance of the front surface of the intraocular lens from the front surface of the iris resulted in a value of about 0.2 mm, which was taken into account for further calculations.

However, due to transscleral, unlike endocapsular, fixation of the artificial lens, the depth of the anterior chamber changes, and the previous amendment to the well-known formula for calculating the depth of the anterior chamber does not correspond to reality, which leads to an error in postoperative refraction.

The technical result achieved by the invention is to expand the indications for intraocular correction of aphakia with severe insolvency of the ligament-capsular apparatus of the lens.

The essence of the invention is to achieve the mentioned technical result in the method of intraocular correction of aphakia with severe insolvency of the ligament-capsular apparatus of the lens in which the conjunctiva is cut in the oblique meridian, triangular scleral flaps are formed at 1/3 of the sclera depth, a hemostatic sponge is placed on the prepared scleral bed, make additional paracentesis in the horizontal meridian for subsequent vitreoectomy, after which an incision of the cornea and intra capsular lens extraction, then a straight suture needle is bent at an angle of 120 degrees in a proportion of 2/3 to 1/3 of the stitching edge, respectively, this needle with a thread is drawn into the anterior chamber at the base of the scleral flap and it is brought out through the corneal incision, the ends of the thread through holes for fixation in the haptic part of the intraocular lens, implant the intraocular lens with optical power calculated taking into account the postoperative depth of the anterior chamber of the eye, fix it in the projection of triangular flaps, impose corneal stitch, perform anterior vitreoectomy and place nodal sutures on the tops of the triangular flaps, while the depth of the anterior chamber is determined from the formula

PC _sfl = 2.85 + 0.35; PK-0.4,

where PC _sfl is the postoperative depth of the anterior chamber during transscleral fixation of the lens;

PC - depth of the anterior chamber prior to surgery.

The new correction factor (-0.4) in the formula for calculating the depth of the anterior chamber was derived as follows.

A study was conducted to determine the depth of the anterior chamber in artifact patients with endocapsular and transscleral fixation of an intraocular lens, the results of which are set forth in the table. When analyzing the table data, it was concluded that with transscleral fixation of the intraocular lens, the anterior chamber depth is on average 0.6 mm less than with endocapsular fixation of the lens (the difference is statistically significant - p <0.05). This must be taken into account when calculating the optical power of an intraocular lens implanted for intraocular correction of aphakia with transscleral fixation of support elements.

In connection with the foregoing, in the formula for calculating the anterior chamber depth in artifact patients for transscleral fixation of an intraocular lens instead of a correction of +0.2 mm, it is necessary to introduce a correction of -0.4 mm. Ultimately, the formula for calculating the depth of the anterior chamber during transscleral fixation of an intraocular lens takes the following form:

PC _sfl = 2.85 + 0.35; PK-0.4,

where PC _sfl is the postoperative depth of the anterior chamber during transscleral fixation of the lens;

PC - depth of the anterior chamber prior to surgery.

The invention is illustrated by drawings, where figure 1 shows the formation of triangular scleral flaps; figure 2 - removal of the lens using a loop; figure 3 - holding the needle into the front chamber; figure 4 - fixation of the upper and lower supporting elements of the intraocular lens; figure 5 - implantation of an intraocular lens in the posterior chamber; figure 6 - front vitreoectomy.

The method of intraocular correction of aphakia with severe insolvency of the ligament-capsular apparatus of the lens is as follows:

- conjunctival incisions are made in the meridians of 1:30 and 7:30 hours, triangular scleral flaps are formed with the bases to the limb at a distance from the limb of 4-5 mm and 1/3 of the sclera depth, hemostasis is performed with a coagulator and a hemostatic sponge is applied to the prepared scleral bed;

- make a corneal incision along the limb from 10 to 2 hours with additional paracentesis at 9 hours;

- remove the lens using a loop or cryoextractor;

- a straight suture needle with polypropylene yarn 10/0 (model “W-1713” from Ethicon, USA or model “SC-5” from Alcon USA) is bent at an angle of 120 degrees in a ratio of 2/3 to 1/3 from the stitching edge, respectively;

- a needle is bent as described above into the front chamber at the base of the lower scleral flap, it is removed through the corneal incision, the needle is threaded through the hole in the haptic part of the intraocular lens and a second injection is immediately performed to reverse the needle into the projection of the prepared scleral triangle onto the sclera;

- an intraocular lens is implanted in the posterior chamber by pulling the lens support elements by the ends of the thread held earlier;

- with the help of a thread in the projection of triangular flaps, the upper and lower supporting elements of the intraocular lens are fixed. The most commonly used models were “R-366” from Storz USA, US-121 from US-Optics USA or T-26 manufactured by MNTK Eye Microsurgery (all these lenses have a hole in the haptic part fixation). In this case, the postoperative depth of the anterior chamber of the eye to calculate the optical power of the intraocular lens was calculated by the formula:

PC _sfl = 2.85 + 0.35; PK-0.4,

where PC _sfl is the postoperative depth of the anterior chamber during transscleral fixation of the lens;

PC - the depth of the anterior chamber before surgery;

- the ends of the sutures are tied at the base of the scleral flaps;

- impose a continuous supramid suture on the corneal incision (10/0), and nodal sutures (10/0 and 8/0, respectively) on the scleral flaps and conjunctival incision;

- perform anterior vitreectomy through a previously performed incision;

- the operation is completed by the introduction of air into the anterior chamber and subconjunctival injection of corticosteroid and antibiotic solutions.

The method is illustrated by the following clinical examples.

Example 1. Patient T., 75 years old, was admitted with a diagnosis of OS - postoperative aphakia (after intracapsular cataract extraction in another medical institution), destruction and hernia of the vitreous body. Visual acuity (OZ) at admission 0.01, is not corrected. An operation was performed according to the claimed method - secondary implantation of an intraocular lens (model “P-366” of the company “Storz”, USA) with transscleral fixation of support elements and anterior vitreoectomy. In this case, the proposed formula for calculating the depth of the anterior chamber of the eye was used to determine the optical power of the intraocular lens. In the early postoperative period, slight hypertension was noted, which was stopped by appropriate antihypertensive therapy. After 8 days, the patient was discharged from the hospital with Visus (visual acuity) = 0.2 sph (+) 2.0 cyl (-) 4.0 axO = 0.7-0.8. In the remote postoperative period (n / a), no complications were noted.

Example 2. Patient P., 72 years old, was admitted with a diagnosis of OD - dislocation of the intraocular lens into the vitreous body (after an eye injury with a blunt object) and a hernia of the vitreous. Upon receipt, Visus = 0.01 sph (+) 9.0 = 0.2. The removal of a deployed intraocular lens, implantation of an intraocular lens by the proposed method (model “P-366” of the company “Storz”, USA) with transscleral fixation of support elements and anterior vitreoectomy were performed. In this case, the proposed formula for calculating the depth of the anterior chamber of the eye was used to determine the optical power of the intraocular lens. In the early postoperative period, no complications were noted. After 6 days, the patient was discharged from the hospital with Visus –0.3 sph (+) 3.25 cyl (-) 7.0ax20 = 0.6-0.7. In the distant postoperative period, a change in the shape of the pupil was observed.

3. Patient E., 37 years old, was admitted with a diagnosis of OS - traumatic cataract, lens subluxation of the 3rd degree. Visual acuity at admission 0.2 is not corrected. Intracapsular cataract extraction (loop), implantation of an intraocular lens (US-121 model by U.S. Optics, USA) by the proposed method with transscleral fixation of support elements and anterior vitreectomy were performed. In the early postoperative period, no complications were noted. After 6 days, the patient was discharged from the hospital with Visus = 0.2 sph (+) 2.0 cyl (-) 4.0 axО = 0.7-0.8. In the remote postoperative period, no complications were noted. To determine the depth of the anterior chamber, the formula according to the invention was used.

Example 4. Patient B., 70 years old, was admitted with a diagnosis of OD-subluxation of the lens of the 2nd degree, immature cataract. Visual acuity at admission 0.1, is not corrected. Cataract extraction, implantation of an intraocular lens (model “P-366” of the company “Storz”, USA) was performed according to the proposed method with transscleral fixation of support elements and anterior vitreoectomy. The formula according to the invention was used to determine the depth of the anterior chamber. In the early postoperative period (n / a), a flat detachment of the choroid was noted, which, after treatment, on the 5th day, fell into place. After 8 days, the patient was discharged from the hospital with Visus -0.2 sph (+) 3.5 cyl (-) 6.5 ax 170 = 0.6-0.7. In the remote postoperative period, no complications were noted.

5. Patient P., 61 years old, was admitted with a diagnosis of OS - immature cataract. Visual acuity at admission 0.2 is not corrected. During the operation, the inconsistency of the ligament-capsular apparatus of the lens was diagnosed and cataract extraction, implantation of an intraocular lens (model “P-366” of the company “Storz”, USA) with transscleral fixation of supporting elements and anterior vitreoectomy by the proposed method were performed. To determine the depth of the anterior chamber, the formula according to the invention was used. There were no complications in the early postoperative period. After 6 days, the patient was discharged from the hospital with Visus = 0.4 sph (+) 1.0 cyl (-) 3.0 ax0 = 0.8-0.9. In the remote postoperative period, no complications were noted.

The method according to the invention operated on 97 people (99 eyes). No intraoperative complications were observed.

As a result of using the invention, it became possible to correct aphakia in the following groups of patients:

- aphakia after early surgery (during the first year of life) of congenital cataract;

- Severe inconsistency of the ligament-capsular apparatus of the lens (including after previously performed intracapsular cataract extraction);

- injuries of the anterior segment of the eye, excluding the possibility of endocapsular fixation of the artificial lens;

- a combination of degenerate insolvency of the ligament-capsular apparatus and intolerance to contact correction.

Claims (1)

The method of intraocular correction of aphakia with severe inconsistency of the ligament-capsular apparatus of the lens, which consists in making incisions of the conjunctiva in the oblique meridian, forming triangular scleral flaps at 1/3 of the sclera depth, making a section of the cornea and intracapsular extraction of the crystalline lens, then direct bending angle of 120 ° in a ratio of 2/3 to 1/3 of the stitching edge of the needle, respectively, spend this needle with thread in the anterior chamber at the base of the scleral flap, bring it out through the corneal incision, they pass the needle through the hole in the haptic part of the intraocular lens (IOL) and perform a second injection to return the needle to the sclera, implant the IOL into the posterior chamber by pulling on the thread, and IOL is implanted with optical power calculated taking into account the postoperative depth of the anterior chamber of the eye, fix it in the projection of triangular flaps, impose a corneal suture, perform anterior vitrectomy and impose nodal sutures on the top of the triangular flaps, while the depth of the anterior chamber is determined from rmuly PC _sfl = 2.85 + 0.35; PK-0.4, where PC _sfl is the postoperative depth of the anterior chamber during transscleral fixation of the lens; PC - depth of the anterior chamber prior to surgery.

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