RU2310427C1 - Method for treating pseudoexfoliation syndrome patients for cataract using phacoemulsification method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves dilating pupil using tetragonal pupil ring having loop-shaped vertexes. The pupil ring is introduced into the anterior chamber and iris pupil edge is sequentially introduced into each loop by moving the ring circularly in iris plane. Then, continuous circular capsulorhexis which diameter and dilated pupil diameter match each other. Visco-elastic substance is supplied under capsulorhexis edge for lifting the edges. Then, pupil ring loop is pulled towards the pupil center with one instrument, the other one being used for bringing lower arc backward and capsulorhexis edge being in loop projection is introduced into each loop for this purpose.

EFFECT: atraumatic operation; excluded vitreous body prolapse into anterior chamber; retained ligament apparatus and capsule sack integrity.

Description

The invention relates to medicine, in particular to ophthalmology, and can be used in cataract surgery during phacoemulsification in patients with pseudoexfoliation syndrome (PES).

Pseudoexfoliation syndrome is an age-related pathology in which abnormal extracellular fibrillar substance is synthesized and accumulates in most eye tissues. This causes, first of all, the development of severe open-angle glaucoma, closed-angle glaucoma, and also this process leads to insufficient diaphragmatic function of the iris, subluxation of the lens due to degenerative processes in the fibers of the zinc ligament and, as a result, complications during cataract surgery. Such complications include: rupture of the fibers of the zinnic ligament of the lens, rupture of the posterior lens capsule, prolapse of the vitreous humor (CT). The weakness of the fibers of the zinc binder increases the risk of dislocation of the lens or zonulolysis by an average of 10 times. Vitreous prolapse in patients with this syndrome occurs 5 times more often. Insufficient mydriasis causes difficulties during the phacoemulsification procedure, increases the risk of trauma to the iris and its rupture.

There is a method of phacoemulsification of the subluxated lens, when before the emulsion of the lens mydriasis is achieved using hooks (iris retractors). This, however, does not allow the lens to be fixed and can be expected during the operation to break off the ligamentous fibers and dislocation of the lens (Thomas A. Oetting, MD, Luis C. Ompohroy, MD. Iris hooks for phacoemulsification of the subluxated lens // J-Cataract - Refractive Surgery. - 1997. - Nov. - 23 (9). - P.1295-7).

A technique is also known for cataract phacoemulsification, when a polymer pupil ring is used in the eyes with insufficient diaphragmatic iris function (Malyugin B.E., Semikova M.V., Verzin A.A. et al. Comparative results of an experimental clinical study of pupil rings and polymer retractors with phacoemulsification in the eyes with insufficient iris diaphragmatic function. // Ophthalmic surgery. - 2003. - No. 3. - P.18). The pupil ring has a quadrangular shape, where each of the vertices is a loop made in the form of a hinge of the first kind. This method allows you to expand the pupil for atraumatic phacoemulsification, while it does not provide for the fixation of the lens, therefore, the likelihood of complications when performing directly phacoemulsification and implantation of an intraocular lens remains.

To reduce the load on the ligamentous apparatus of the lens in the presence of its weakness or ligament defect, which is characteristic of PES, an intracapsular ring is used, which is inserted through capsulorexis into the equatorial zone of the capsular bag (Ioshin I.E., Egorova E.V., Bagrov S.N. . and others. The intracapsular ring - prevention of complications of cataract extraction with subluxation of the lens // Ophthalmic surgery. - 2002. - No. 1. - P.25-28). The disadvantage of the proposed method when using it in front of eyes with PES is that myosis (narrowing of the pupil) is not eliminated, which also makes phacoemulsification traumatic and there is no intraoperative ability to assess the viability of the ligamentous apparatus after removal of the lens substance.

Known technology proposed by Dr. Yussef N.Yu. et al. (RF Patent No. 2141297 dated November 20, 1999 - prototype), when with a subluxated lens and a poorly expanding pupil or moderate mydriasis, corneal paracentesis is performed at 4 points and continuous circular capsulorexis is performed. Then the iris-fixed hooks fixed on the limb are introduced into the anterior chamber, with the help of which they capture the edge of the capsular window and simultaneously the edge of the pupil is captured along with the edge of the capsule. As a result of the application of the proposed method, simultaneous expansion of the pupil and fixation of the capsule bag over the edge of the capsulorexis are carried out and only then phacoemulsification is performed.

The disadvantages of this technology:

- corneal invasiveness: 4 corneal paracentesis is required for the introduction of iris retractors. Thus, the total number of corneal punctures reaches 6 (the main incision, plus an incision for the phacochipper, plus 4 paracentesis);

- iris retractors do not provide uniform expansion of the pupil, which, in the presence of stenosis of the iris stroma during PES, can lead to tears of the sphincter of the pupil and loss of the diaphragmatic function of the pupil in the postoperative period;

- design features of iris retractors do not exclude the possibility of rupture of the anterior capsule, and then the posterior capsule with prolapse of the vitreous.

The objective of the invention is to develop a reliable and atraumatic method of simultaneous expansion of the pupil and fixation of the capsule bag during phacoemulsification in patients with PES.

The technical result obtained by solving this problem is to reduce surgical and postoperative complications, reduce the time of surgery.

The specified technical result can be obtained if in the method of cataract treatment in patients with pseudoexfoliation syndrome by phacoemulsification, which includes the steps of dilating the pupil and fixing the capsular bag by means of simultaneous mechanical action on the iris and lens, the mechanical effect is exerted through the pupil ring, having a quadrangular shape, where each of the peaks is a loop made in the form of a hinge of the first kind, which lead into the front camera and first with its help expanding t the pupil, for which the pupil edge of the iris is sequentially inserted into each loop by advancing the ring around the circumference in the plane of the iris, then a continuous circular capsulorexis is performed, the diameter of which corresponds to the diameter of the dilated pupil, then a viscoelastic is applied under the edge of the capsulorexis, lifting it, and then into the edge of the capsulorhexis located in the projection of the loop is made up of each loop of the ring; for this purpose, the loop of the ring is pulled to the center of the pupil with one tool, and the lower arc of the loop is drawn back with the other.

Among the essential features characterizing the method, distinctive from the prototype are:

- mechanical effect is exerted through the pupil ring having a quadrangular shape, where each of the vertices is a loop made in the form of a hinge of the first kind;

- the ring is brought into the anterior chamber and, with it, the pupil is dilated first, for which the pupil edge of the iris is sequentially inserted into each loop by moving the ring around the circle in the plane of the iris;

- then perform a continuous circular capsulorexis, the diameter of which corresponds to the diameter of the dilated pupil;

- then serves viscoelastic under the edge of capsulorexis, lifting it;

- then the edge of the capsulorexis located in the projection of the loop is inserted into each loop of the ring, for this purpose, the loop of the ring is pulled to the center of the pupil, and the lower arc of the loop is drawn back with the other.

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

The pupil ring used in the invention was developed by the authors Fedorov S.N., Malyugin B.E. and Semikova M.V. (J. Ophthalmic surgery. - 2003 - No. 3. - S.18-25). It is made of polypropylene and is intended for the so-called mechanical expansion of the pupil. The diameter of the pupil ring is selected and substantiated by the authors and is 6.0-6.5 mm. It is this design of the pupil ring and with such a diameter that has been successfully used in the technology we have developed, where the pupil not only expands the pupil by inserting the pupil edge of the iris between the arches of 4 joints, but also with its help reliably fix the lens, leading between the edges of the hinges also the edge of capsulorexis. In order to make this possible, it is necessary, after the pupil has been enlarged with the help of a ring, to perform a continuous circular capsulorexis and its diameter should correspond to the diameter of the dilated pupil. Otherwise, either the edge of the capsulorexis or the pupillary edge of the iris will slip out of the hinges of the ring (depending on which diameter is larger). After capsulorexis is performed, it is necessary to introduce viscoelastic under the edge of the capsulorexis (i.e., under the anterior capsule of the lens) - this will ensure that the edges of the capsulorexis are separated and more quickly inserted between the arches of each of the 4 hinges. To do this, with one tool they pull the loop of the ring to the center of the pupil, and with the other they take the lower arc of the loop back (the hinge of the first kind has an upper and lower arc), then release the loop and it captures the edge of the capsulorexis. During this action, the pupil edge (it is already inserted between the arches of the loop) will not slip out of the hinge, since the pupil was initially narrow, we artificially expanded it, and when the capsulorexis edge is inserted, the loop is pulled to the center of the pupil, then the edge of the pupil moves together with a loop to the center, tends to take its initial position. At the same time, expanding the pupil and fixing the lens, another term appears atraumatic new technology phacoemulsification in front of eyes with PES. Due to the presence of precisely 4 hinges and the design of the hinges, between the arches of which both the pupil edge and the edge of the capsulorexis are simultaneously clamped, during the process of phacoemulsification, no turbulent flows occur, and they take place, in no way get to the fibers of the zinc bundle (iris and the front lens capsule is tightly connected, and along the entire circumference: 8 contact zones versus 4 in the prototype). Otherwise, they could destroy these fibers, which are already weak due to PES, and a shift of the lens and prolapse of the vitreous body would follow.

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

The method is as follows.

The start of phacoemulsification is traditional. Next, the main section is performed to perform phacoemulsification. Then, through this incision, the pupil ring, folded along with tweezers, is implanted in the anterior chamber, and by rotating the ring around its own axis in the plane of the iris, the pupil edge is inserted into the 4 hinges of the ring. Thus, the pupil is dilated to 5-6 mm in diameter. A continuous circular capsulorexis is performed along the edge of the formed pupil so that the diameter of the capsulorexis corresponds to the diameter of the dilated pupil. Then, under the front capsule, viscoelastic is applied, which ensures the separation of the edges of the capsulorexis. Next, in each of the loops of the ring (there are four of them), the edge of the capsulorexis located in the projection of each loop is inserted. To do this, with one tool they pull the loop of the ring to the center of the pupil, and with the other they take the lower arc of the loop back. Then the loop is released and the edge of the capsulorexis is between the arches of the hinge. Thus, with the help of a ring made of polypropylene, simultaneous expansion of the pupil and fixation of the lens are achieved. Then proceed directly to the ultrasonic phacoemulsification. Next, an intraocular lens is implanted in the capsular bag. Then release the edge of the capsulorexis and the pupillary edge from the hinges of the ring. In the anterior chamber, the pupil ring is dissected at the apex of one of the loops for ease of excretion. The operation of phacoemulsification traditionally ends.

EXAMPLE. Patient L., born in 1929, outpatient card No. 355411, was admitted 2.04 06 with a diagnosis of nuclear cataract, pterygium 2 tbsp., Pseudoexfoliation syndrome of the left eye.

Vision of the left eye = 0.1 s core. Sph.-3.0 = 0.3

Intraocular pressure (Po) = 18.0 mm Hg.

The field of view is within normal limits.

Biomicroscopy of the left eye: growth of the conjunctiva on the limb from the nasal side to 3.0 mm of arcus senilis, pseudoexfoliation along the pupil of the iris and anterior capsule of the lens, pupil reaction to light of 1 degree, in the lens - clouding in the nuclear layers.

The operation for cataracts was performed on April 3, 2006. During the operation after intracameral administration of mydriatic mydriasis, mydriasis was not achieved. A pupil ring is introduced into the anterior chamber, containing four loops located at the same distance from each other and made in the form of hinges of the first kind. The pupillary edge of the iris is inserted into four hinges; as a result, mydriasis of 6 mm is achieved. Then, an anterior continuous circular capsulorexis with a diameter of 6 mm was performed. At the initial stage of the anterior circular capsulorhexis, mobility of the capsular bag was revealed. After capsulorexis was completed and a viscous preparation was inserted under the capsulorexis edge, the capsulorexis edge was inserted into the joints of the pupil ring. Ultrasonic phacoemulsification was performed on an INFINITI apparatus (ALCON, USA), the remains of the lens masses were removed, the IOL model MIOL - 2 was implanted in the capsular bag, and the pupil ring was removed.

On the first day, visual acuity was 0.45 cyl + 2.0 ax 30 = 0.5.

Intraocular pressure = 21 mm Hg.

Biomicroscopy: the cornea is transparent, the pupil 4.0 mm, centered, IOL in the capsular

bag centered.

The fundus is normal.

The inventive method in the EC MTC "Eye Microsurgery" operated on 48 patients (48 eyes). In all cases, for simultaneous expansion of the pupil and fixation of the lens, pupil rings having a quadrangular shape have been successfully applied, where each of the vertices is a loop made in the form of a hinge of the first kind. Mechanical dilatation of the pupil and simultaneous fixation of the lens made it possible to perform all 48 atraumatic operations during cataract phacoemulsification in the eyes with pseudoexfoliation syndrome, to exclude prolapse of the vitreous body, to preserve the ligamentous apparatus, capsular bag, which made it possible to perform intracapsular fixation of the lens. No postoperative complications were observed, the lens occupied a central position.

Claims (1)

A method of treating cataracts in patients with pseudoexfoliation syndrome by phacoemulsification, which includes the steps of dilating the pupil and fixing the capsule bag by means of simultaneous mechanical action on the iris and lens, characterized in that the mechanical effect is exerted through the pupil ring having a quadrangular shape, where each of the vertices is a loop , which is led into the anterior chamber and first with its help the pupil is dilated, for which purpose the pupil edge of the arches by moving the ring around the circumference in the plane of the iris, after which a continuous circular capsulorexis is performed, the diameter of which corresponds to the diameter of the dilated pupil, then viscoelastic is fed under the edge of the capsulorhexis, lifting it, and then the edge of the capsulorexis located in the projection of the loop is inserted into each loop of the ring, To do this, with one tool they pull the loop of the ring to the center of the pupil, and with the other they take the lower arc of the loop back.