RU2309710C1 - Method for treating complicated purulent corneal ulcer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves draining anterior chamber after having penetrating keratoplastic repair done. Proximal end of draining tube is introduced 3-4 mm deep into the anterior chamber along meridiane from 4 to 6 o'clock marks. The distal end is subconjunctivally positioned. Drugs are subconjunctivally introduced in postoperative period in the distal draining tube end. Keratoplastic repair is repeatedly done, cataract is extracted, intraocular lens is implanted and antiglaucoma operation if needed, when penetrating transplant opacity and lenticular opacity occurs in postoperative period with functional eye conditions retained unchanged.

EFFECT: accelerated suppurative process relief, reduced risk of bacterial infection reactivation; increased vision acuity.

2 cl, 3 dwg

Description

The present invention relates to ophthalmology and is intended for the treatment of complicated purulent corneal ulcers, i.e. with severe progressive purulent iridocyclitis (with or without hypertension).

State of the art

The problem of treating purulent corneal ulcers to date has a very important and ever increasing importance in ophthalmology. The relevance of this problem is associated with the severity of this disease and the low effectiveness of the antibacterial drugs used (Kasparov A.A. Infectious inflammatory diseases of the outer eye // Vestn. Ophthalmol. - 1987. - No. 1. - p. 61-62; Ostashevsky V.L. The therapeutic effect of protease inhibitors in suppurative ulcerative keratitis: Diss ... Candidate of Medical Sciences. - Odessa, 1982 - P.98).

The intraocular infection process is very common in the clinic of eye diseases and can be caused by a wide range of bacterial, fungal, viral and parasitic agents. The causes of a purulent infection of the eye (purulent ulcers and purulent iridocyclitis) are: 1) damage to the cornea - microtrauma, injuries, burns, consequences of explosions, etc .; 2) steroid-complicated forms of herpesvirus keratitis - every fifth patient has a mixed infection (virus + bacteria); 3) operations on the cornea with stitches - keratoplasty, cataract extraction with a corneal incision, etc., as well as keratotomy; 4) diseases of the cornea, accompanied by erosion of the cornea - keratitis, superficial dystrophy, bullous keratopathy, dry syndrome, lagophthalmos, etc .; 5) corneal microtrauma when wearing contact lenses 6) local sepsis - blepharitis, dacryocystitis, odontogenic granulomas, sinusitis, sinusitis; 7) common diseases - immunodeficiency, liver disease, alcoholism, drug addiction, etc.

Purulent corneal ulcers in the structure of corneal diseases occupy the second place in prevalence and the first in clinical severity and transience, which can lead to incurable blindness. In connection with the rapid progression of the infectious process in the eye, patients with purulent ulcers need urgent care (J. Hill Use of penetrating keratoplasty in acute bacterial keratitis // Brit. J. Ophtalmol. - 1986. - Vol. 70. N7. - p .502-506).

The development of ophthalmic hypertension on the background of a purulent corneal ulcer complicated by purulent iridocyclitis is caused primarily by leaking trabeculitis due to exposure to infectious agents, as well as blockade of the anterior chamber angle by purulent exudate.

In the treatment of purulent ulcerative keratitis, three main approaches can be distinguished - conservative, surgical and complex.

A conservative method for the treatment of purulent corneal ulcers and purulent iridocyclitis includes intensive local and systemic antibacterial and / or antiviral and / or antifungal therapy (frequent instillations of broad-spectrum antibiotics or antifungal agents in the form of eye drops, subconjunctival, parabulbar and intramuscular injections, also oral administration of antibacterial and / or antifungal drugs), the use of antiseptic (instillation of a solution of chlorhexidine, vitabact), etc. anti-inflammatory (non-steroidal anti-inflammatory drugs in the form of injections or tablets) and detoxification drugs, enzyme inhibitors, immunotherapy (Krasnov ML, Shulpina NB Therapeutic ophthalmology, ed. Medicine, Moscow, 1985, p.127-142; Kanski J. / Clinical ophthalmology - 1999, p.103-108; Yu.F. Maychuk / Vestnik. Ophthalmol. 2003 (5): 23-8).

The widespread introduction of antibiotics into medical practice has led to the emergence of resistant forms of microbes. Currently, there are frequent cases when the conjunctival microflora is resistant simultaneously to 6-8 antibiotics (Volkov VV et al. Prevention of purulent complications with perforated wounds of the eyeball. Ophthalmol. Zhurn. - 1976. - No. 1. - p.12 -16).

Ophthalmologists currently have a large selection of means for conservative treatment of purulent ulcers of the cornea, but many of them are ineffective in treating severe purulent ulcers of the cornea and iridocyclitis, while others cannot be used alone, being only additional means (Hill JC Use of penetratinging keratoplasty in acute bacterial keratitis. Br J Ophtalmol 70: 502-506, 1986).

The lack of reliable conservative agents and the severity of the prognosis for purulent ulcers and iridocyclitis prompts many researchers to use surgical methods of treating this pathology (Y. Naim Yusef, Improving the technology of urgent keratoplasty for inflammatory diseases of the cornea: Diss. ... Candidate of Medical Sciences. - Moscow - 1998. - p. 38).

The surgical method involves the use of early keratoplasty. P. Laibson et al. believe that the progression of the disease 24 hours after the start of conservative treatment is an indication for keratoplasty (P. Laibson, E. Dounefeld. Comeal ulcers related to contact lenses use // Int. Ophtalmol. Clin. - 1986. - Vol. 26, N1 . - p. 3-14).

Through keratoplasty (UPC) with purulent corneal ulcer allows you to completely remove infected tissue and, together with antibacterial therapy, provide more reliable results, minimizing the recurrence of purulent process (Killingsworth DW at all Results of therapeutic penetrating keratoplasty. Ophthalmology 100: 534-541, 1993).

However, even after a radical operation, infectious agents remain in the conjunctival sac, which, under favorable conditions, cause a relapse. In this regard, in the postoperative period, local antibacterial therapy (a combined treatment method) is actively used.

An analogue of the present invention is a method of the same purpose, including the use of annular drainage of the anterior chamber of the eye. The essence of the method is as follows: in the cornea, along the meridians of 5 and 7 hours, departing from the limb by 0.5-1 mm, 2 through cuts are made, concentrically, the limb is 1.5 mm long. The anterior chamber of the eye is washed with a weak antibiotic solution. Through one of the incisions, a supramid thread (4/0) is inserted into the anterior chamber on an atraumatic needle. The needle with thread is removed through the second incision of the cornea. The ends of the thread are tied together so that a ring with a diameter of 5-6 mm is obtained. In this case, part of the thread is located in the anterior chamber, located in the region of the root of the iris, and the node is on the outside. A filament introduced into the anterior chamber in the form of a ring prevents the adhesion of the corneal incisions made, acting as a permanent drainage. The thread remains in the chamber for 5 to 10 days (Mirza-Avakyan II and others. Ring drainage of the anterior chamber of the eye with exogenous purulent iridocyclitis. Methodical recommendations, Yerevan, 1986, p.5).

The disadvantages of the analogue are:

1) Excessive trauma to the cornea with supramide filament in continuous contact with the epithelium, stroma and endothelium of the cornea.

2) The possibility of re (secondary) infection of the corneal incisions (along the supramid drainage) and the rapid spread of infection into the anterior chamber of the eye.

3) The possibility of the occurrence of infiltration and pressure sores of the cornea due to the prolonged presence of the movable supramid suture in its tissues.

4) The lack of therapeutic effect of ring drainage on the existing purulent corneal infiltrate (in cases of purulent corneal ulcer).

5) Ring drainage is not a radical solution to the problem of intraocular hypertension with purulent iridocyclitis. At the same time, a method of shunting the anterior chamber of the eye during anti-glaucomatous operations is known, including the use of tubular drainage with placement of the distal end in the subtenon space behind the eye equator. (Kasparov A.A., Malozhen S.A., Trufanov S.V. Method for shunting the anterior chamber of the eye during anti-glaucomatous operations. RU No. 2168965 dated 04/07/2000). To bypass the anterior chamber, tubular drainage is used with the distal end placed in the subtenon space behind the eye equator. Moreover, the distal end of the drainage is pre-wrapped with a silicone-dried amniotic membrane. The method allows to increase the effectiveness of antiglaucomatous operations. The essence of the method is as follows: in the upper half of the eyeball, along the meridian of 12 hours, a conjunctival flap is separated to the limb. A superficial scleral flap is cut out to 1/2 of its thickness of a rectangular shape, with a base to the limb, 5 × 10 mm in size. The drainage tube is fixed to the sclera in two places with flip seams with the tube pierced through. At the base of the scleral flap, in the trabecular area of the sclera, a through cut is made by a fragment of the blade. The proximal end of the drainage is introduced into the anterior chamber of the eye, and the proximal part of the drainage has a protrusion anteriorly 1-1.5 mm long. A scleral flap covers the drainage tube and 4 nodal sutures are applied to the scleral flap. The distal end of the drainage is pre-wrapped with a silicone-dried amniotic membrane and tightly bandaged with supramide thread around the drainage. Further, the sheltered distal part of the drainage tube is introduced into the subthenon space beyond the equator of the eye. After that, the tenon capsule together with the conjunctiva is carefully sutured with a continuous suture.

This method is an effective treatment for secondary glaucoma, and allows you to reduce intraocular pressure (IOP) through the use of drainage.

The closest analogue of the invention is therapeutic end-to-end keratoplasty for herpesviral corneal ulcers (Kasparov A.A. "Ophthalmogerpes", ed. "Medicine", 1994, pp. 182-183). The essence of the method is as follows: after trepanation of the cornea with a trepan of the corresponding diameter, the corneal disk, including the infiltration zone, and the corneal ulcers are excised. 4 basal iridectomies are performed at 12, 3, 6, 9 hours. Under the corneal visor of its own cornea and on the iris, the Megachrome endothelium protector is applied. From the donor eye, a corneal disk is cut out, in diameter exceeding a cut by 0.5-1 mm, and laid on a prepared bed. The graft is fixed with 4 nodal (nylon 8/0) and continuous sutures (nylon 10/0). The front chamber is washed from the tread and replenished with saline.

The disadvantages of the closest analogue are:

1) The absence of a constant outflow pathway for profuse fibrinous exudate formed during purulent corneal ulcers in the anterior chamber of the eye already in the first hours after keratoplasty.

2) The absence of direct routes of drug delivery directly to the lesion - the anterior chamber of the eye.

Disclosure of invention

The objective of the invention is to improve the treatment of complicated purulent corneal ulcers. The theoretical premise of the invention for purulent complicated corneal ulcers was the idea of creating a constant outflow pathway for exudate (drainage), through which, at the same time, it is possible to deliver drugs to the lesion site (anterior chamber of the eye).

This idea is confirmed by our clinical observations. When treating patients with severe purulent processes in the anterior segment of the eye, in all cases the process was quickly stopped.

In cases of complicated purulent corneal ulcer, a combined operation of end-to-end keratoplasty (SCR) and silicone drainage explantation into the anterior chamber of the eye are performed. Drainage is explanted in the meridian from 4 to 6 hours so that, firstly, the outflow of exudate occurs more efficiently (from the anterior chamber down the drainage), and secondly, for better visualization of drainage during subsequent biomicroscopy in the postoperative period. In addition, subconjunctival injections of drugs (diluted), in the postoperative period, we produce in the lower transitional fold of the conjunctiva, corresponding to the projection area of the distal end of the drainage, which ensures the flow of drugs through the drainage into the anterior chamber.

The technical result of the invention is:

rapid relief of the purulent process with a decrease in the risk of reactivation of a bacterial infection in the anterior chamber of the eye and the rescue of the eye as an organ, as well as an increase in visual acuity. The technical result is achieved due to:

combining removal of the focus of infection (corneal ulcer) with replacing the defect with a healthy cornea with the formation of an active additional pathway for the outflow of exudate from the anterior chamber of the eye and the constant introduction of drug solutions into the distal end of the drainage, which ensures the flow of drugs through the drainage into the anterior chamber of the eye.

In addition, there is an additional technical result in the form of normalization of increased IOP in cases of purulent corneal ulcers and purulent iridocyclitis, accompanied by hypertension due to the newly created outflow path (drainage).

IV. The implementation of the invention:

The method is as follows: processing of the surgical field is usual. Retrobulbar anesthesia and akinesia with a solution of 2% novocaine - 8.0 ml. The upper and lower rectus muscles of the eye are taken on the frenum sutures, an eyelid is inserted. A trepan of the desired size is outlined for a corneal disk, including a zone of purulent corneal infiltration (Figure 1). In the projection of the palpebral fissure, in the lower-outer half of the eyeball along the meridian for 4 hours, a conjunctival flap is removed 11 mm from the limbus up to the limbus. The coagulator conduct hemostasis. Next, they prepare for the drainage of the anterior chamber: the drainage tube is fixed to the sclera in two places with flip seams with the tube pierced through. At the base of the conjunctival flap of the flap, in the trabecular area of the sclera, a non-through incision measuring 1.5-2 mm is indicated by a fragment of the blade. At the previously indicated trepan border, the anterior chamber is opened with a diamond blade and a corneal disc is cut with corneal scissors, including the corneal lesion area. The front chamber is thoroughly washed with a solution of an antibiotic at a dilution, for example, ampicillin (at a dilution of 1:50), organized exudate is removed with tweezers and a hemostatic sponge. 4 basal iridectomies are performed at 12, 3, 6, 9 hours. Under the corneal visor of its own cornea and on the iris, the Megachrome endothelium protector is applied. A corneal disk is cut out from the donor eye, having a diameter exceeding 1-1.5 mm cut out, and laid on a prepared bed. The graft is fixed with 4 nodal (nylon 8/0) and continuous sutures (nylon 10/0). The front chamber is washed from the tread and replenished with saline. Next, proceed to the stage of implantation of drainage into the anterior chamber of the eye. The drainage is a silicone tube, the inner diameter of which is 0.3 mm, the wall thickness is 0.1 mm, so that the external is 0.5 mm. The drainage length is 15 mm. The anterior chamber proximal end is cut off at an angle of 45. The drainage is fixed to the sclera in two places. The distal part of the tubular drainage is sutured with two flanging sutures with supramide sutures (8/0) to the sclera with the tube pierced through: the first suture is applied 5 mm from the limb, the second - 10 mm from the limb, while avoiding narrowing of the drainage lumen, tightening seams do not produce. At the base of the conjunctival flap, in the trabecular area of the sclera, a through cut of 1.5-2 mm is made by a fragment of the blade. The proximal end of the drainage is introduced into the anterior chamber of the eye so that it stands 3-4 mm. Next, the conjunctiva is sutured. In the postoperative period, subconjunctival injections of drugs into the projection area of silicone drainage are performed daily (Figure 2).

The method is illustrated by figures 1, 2 and 3, where 1 is the cornea, 2 is a corneal ulcer, 3 is purulent corneal infiltration, 4 is a hypopion, 5 is an eyelid dilator, 6 is a corneal donor transplant, 7 is a continuous suture, 8 is four basal iridectomies ( colobomas), 9 - the tip of the silicone tubular drainage - in the anterior chamber of the eye, 10 - the subconjunctival "chamber" (the area of drug administration, corresponding to the distal end of the drainage), 11 - conjunctival suture, 12 - a syringe with which to inject drugs into projection area dis cial silicone drainage tube end, 13 - view of the eye after removal of the silicone tubular drainage and removal of the continuous conjunctival suture. Scar of the conjunctiva.

To avoid the "thermostat phenomenon", do not apply a blindfold on the eye, confining itself to sticking a sterile gauze "curtain" on the eyebrow so that the "curtain" covers the eye. After the complete abatement of the inflammatory process, tubular drainage is removed (Figure 3).

We give a clinical example.

Patient Kozich A.V., 67, a resident of Moscow Region, IS No. 2672/04, was admitted to the admission department of the Research Institute of GB RAMS on April 19, 2004 with a diagnosis of the right eye - a purulent corneal ulcer, the threat of perforation, hypopion, beginning endophthalmitis, secondary glaucoma, complicated cataract. The left eye is the initial age-related cataract. The patient complained of intense pain in the right eye, lack of objective vision, swelling of the eyelids and redness of the right eye. From the anamnesis it is known that he first became ill on March 7, 2004. He was hospitalized in an ophthalmologic hospital at the place of residence with a diagnosis of keratitis of the right eye, where for a month they were treated with antibacterial and anti-inflammatory drugs, including dexamethasone, without effect. Twice there was perforation of the cornea and emptying of the anterior chamber OD. He turned to the Research Institute of GB RAMS, where urgent hospitalization was proposed for urgent through therapeutic keratoplasty on the right eye due to the presence of a purulent corneal ulcer complicated by purulent iridocyclitis, secondary uncompensated glaucoma and the threat of repeated perforation of the cornea.

Upon admission to the 2nd surgical department of the Research Institute of GB: vision of the right eye - the correct light projection. Intraocular pressure of the right eye is sharply increased, palpebral fissure narrowed, swelling of the upper eyelid, mixed injection of the eyeball, copious mucopurulent discharge. In the optical zone of the cornea, there is an ulcer with ragged edges, an infiltrated bottom, and in the center of the ulcer, descemetocele. The size of the purulent ulcer was about 5-6 mm. Front camera of medium depth. Hypopion 3-4 mm high, somewhat did not reach the edge of the pupil, the pattern of the iris is fuzzy, the pupil is narrow. Diffuse opacification of the lens of the right eye.

The combined operation was performed: Urgent therapeutic end-to-end keratoplasty with removal of the exudative membrane, rinsing of the anterior chamber with an antibiotic solution and explantation of drainage on OD, as described above.

In the postoperative period, relief of inflammatory phenomena in the eye was noted, vision of the right eye was counted by fingers of the face, intraocular pressure was normalized. OD - a mixed injection of the eyeball, moderate mucous-sucrose discharge, conjunctival chemosis. The joints on the conjunctiva are clean, the edges are adapted. The transplant is transparent, slightly thickened, the sutures are clean, the edges are adapted, the anterior chamber is smaller than the average, the iris pattern is faded, the iris is full-blooded, blood smears on it, basal colobomas at 6, 9, 12 hours, at 4 hours - drainage in the anterior chamber, pupil in the center. On the pupil edge there are posterior synechiae, the pupil is cloudy, there is no reflex from the fundus. The results of bacteriological studies showed the growth of Streptococcus viridae. In the postoperative period, he received active antibacterial, anti-inflammatory, desensitizing therapy. Subconjunctival injections were made in OD, in the projection area of the distal drainage zone, 0.5-1 ml of a solution of the antibiotic ampicillin at a dilution of 1:50. In addition to periocular injections, the patient was given a course of intramuscular injections of broad-spectrum antibiotics, non-steroidal anti-inflammatory, desensitizing drugs.

Then, with clouding of the corneal transplant (as well as swelling or clouding of the lens) in the late postoperative period, the reconstructive and reconstructive stage is performed for optical purposes. This stage is carried out while maintaining the functional characteristics of the eye.

The reconstructive and recovery phase was carried out to the patient A. Kozin. after 4 months. The right eye is the condition after UPC, turbid graft engraftment. Operated secondary glaucoma, complicated swelling cataract. Data of EFI, CSFM: OU - internal layers of the retina and axial bundle of the optic nerve are preserved.

On admission: vision of the right eye: proper light projection, intraocular pressure is normal. OD is calm, the contours of the drainage under the conjunctiva at 4 o’clock, the through graft is cloudy. A membrane was formed in the area of the pupil adjacent to the posterior surface of the graft. The lens capsule was soldered to the descemet sheath of the graft. The anterior chamber is absent in the projection of the through graft; at the periphery, it is slit-like. 09/22/04. In connection with the turbid graft engraftment and swelling cataract, a combined operation was performed: through rekeratoplasty, extracapsular extraction of complicated cataract with IOL implantation, revision of drainage for OD. Upon discharge, the right eye is calm, the transplant is transparent, the suture lies well. The graft has not yet acquired a spherical shape. IOL stands well. Hole in the posterior lens capsule. From the fundus bright pink reflex, intraocular pressure is the norm. VIS OD 0.1 n / a; TENSIO OU-N.

As a result of the first stage of the operation, the following results were achieved: 1) saving the eye as an organ; 2) relief of an acute purulent process in the eye due to excision of a purulent corneal ulcer, washing of the anterior chamber of the eye from purulent exudate and constant outflow of exudate residues through drainage, as well as regular intake of an antibacterial drug in the lesion - the anterior chamber of the eye; 3) the normalization of increased uncompensated intraocular pressure.

The results of the second stage, carried out 4 months after the first stage, carried an optical function, i.e. provided the patient with vision on the right eye due to performed rerectoplasty, removal of the swollen lens and IOL implantation.

The effect of the operation lasts for 10 months, the recurrence of keratitis did not occur, the through graft is transparent, visual acuity increased due to the adoption of a more spherical shape of the graft to 0.3 with correction sph + 3.0 = 0.45.

Claims (2)

1. A method of treating complicated purulent corneal ulcer, including end-to-end keratoplasty (UPC) and drug therapy, characterized in that after UPC, the anterior chamber is drained, the proximal end of the tubular drainage is placed in the anterior chamber of the eye along the meridian from 4 to 6 hours, so that it stands in the anterior chamber by 3-4 mm, and the distal end is placed subconjunctivally, in the postoperative period, drugs are administered subconjunctively in the area of the distal end of the drainage. 2. The method according to claim 1, characterized in that when there is clouding of the through graft and clouding of the lens in the late postoperative period and when the functional parameters of the eye are preserved, rekeratoplasty, cataract extraction and implantation of an intraocular lens (IOL), and, if necessary, an anti-glaucomatous operation are performed .

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