RU2313321C1 - Method for destroying subconjunctival brittle foreign body - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying short 0.5-3.0 mJ pulse Neodymium YAG-laser radiation to the foreign body via conjunctiva. The treatment is carried out as long as it is required for transforming the body into homogeneous mass.

EFFECT: eliminated irritating action of foreign body without injuring eye tunics and dystrophic changes caused.

Description

The present invention relates to ophthalmology and is intended to eliminate a fragile inert foreign body located under the conjunctiva of the eyeball and causing discomfort to the patient's eye.

The level of technology. It is known that removal of a foreign body from under the conjunctival membrane of the eyeball is an surgical intervention performed using a microsurgical instrument either under a slit lamp or in an operating room (E. Vilshansky. On the question of the need for reconstructive interventions in patients with traumatic eye injuries and its appendages. // Reconstructive ophthalmosurgery. - M., - 1979, - S.163-165).

There is a method of removing a subconjunctival, including a fragile foreign body, including instrumental dissection of the conjunctiva above the foreign body: under local anesthesia, the conjunctiva is fixed and the forceps are fixed with tweezers over the foreign body with a knife, a blade or scissors open the conjunctiva. If bleeding occurs, hemostasis is performed, after which, if necessary, the conjunctiva is dissected until the foreign body is adequately exposed. A foreign body is removed either with tweezers or a magnet, depending on the nature of the foreign body (Gundorova R.A. Eye injuries. M .: Medicine, - 1986, - 310 p.).

With the mobility of a foreign body under the conjunctiva along the wound canal along the sclera surface or with a sharp restriction of mobility in cases of getting into the subconjunctival "pocket", the removal of a foreign body with the introduction of a magnet or tweezers into the wound canal may not be achieved. Fixation of the conjunctiva and its elevation above the sclera can cause further displacement of the foreign body along the sclera. Conducting hemostasis under a slit lamp is difficult, since it is necessary to plug and dissect conjunctival tissue at the same time.

An important factor is the nature of the removed foreign body. In cases where foreign objects that are fragile are diagnosed - in the form of a plate of glass, gunpowder; villous, tissue materials of small sizes, etc., which do not irritate the conjunctival tissue, but cause uncomfortable conditions in the patient’s eye due to the tension of the conjunctival tissue and protruding above the surface in the form of a tuber, surgical removal of such a foreign body will cause a much greater negative process on the part of the conjunctiva, than its non-removal, since the scars of the conjunctiva will remain. In addition, during manipulations with a brittle substance, its unexpected destruction can occur with an unadapted fragment displacement and the development of the corresponding dystrophic processes of the eyeball tissue.

The disadvantages of this method, in our opinion, are: the difficulty of finding a foreign body among the bleeding vessels and conjunctival tissue, invasiveness, the need to use additional techniques and materials, the inability to control the process and complications during surgery, and most importantly, the ability of a foreign body to move in tissues conjunctiva or destroyed by the manipulation of surgical instruments.

However, in the prior art there is no information regarding the possibility of targeted destruction of a fragile foreign body without damaging the integrity of the outer membranes of the eye.

Disclosure of the invention.

The objective of the invention is to develop such a method for the treatment of the elimination of fragile subconjunctival foreign bodies or its destruction, in which the integrity of the eye membranes is not violated.

The proposed method is based on the fact that the destruction of a foreign body is performed without dissecting the conjunctiva with a short-pulse neodymium YAG laser with its transformation into a homogeneous mass, which will be in the subconjunctival space previously formed by the fragment itself and will not exert a pressure on the conjunctiva from the inside, but in a patient with this discomfort disappears.

The technical result of the proposed method is to eliminate the irritating effect of a foreign body on the membranes of the eye without surgical damage with the prevention of dystrophic changes due to both the pressure of the foreign body and possible surgical intervention.

The technical result is achieved by reducing the size of a foreign body under the conjunctiva without violating its integrity and turning it into a homogeneous mass, acting on it with radiation from a short-pulse neodymium YAG laser in a certain mode.

Due to its physical properties, short-pulse neodymium YAG laser allows you to destroy a foreign body without violating the integrity of the conjunctival membrane, turning it into many small foreign bodies or a homogeneous mass, thereby allowing you to reduce the effect on the conjunctival tissue from the inside and straighten the elastic tissue of the conjunctiva over the foreign body.

The implementation of the invention.

The method is as follows: under local anesthesia on a slit lamp, combined with a laser unit in a mode sufficient to destroy or destroy a foreign body (0.5-3.0 mJ - pulse energy), a short-pulse neodymium YAG laser effect on a foreign body is produced . In this case, the laser exposure mode is selected, starting from the minimum value of the pulse energy, when it reaches the beginning of fragmentation, it is continued in this mode. The exposure time is determined by the conversion of a foreign body into a homogeneous mass.

The laser focus is directed to the surface or body of a foreign body under the conjunctiva. A foreign body is destroyed until it turns into a uniform, homogeneous mass that can flatten.

Example 1. A 27-year-old Ta-shin patient turned to a specialized ophthalmology department with the diagnosis: OD - conjunctival wound, foreign body under the conjunctiva. Visual acuity OD / OS: 0.5 / 0.8; IOP OD / OS: 22/22 mmHg According to EFI - inhibition of the activity of the retina, OD is not observed; according to x-ray studies - a foreign body in the anterior part of the eye (according to a conventional x-ray scheme, a foreign body is partially in the scleral membranes of the eye), according to U3-scan - a foreign body outside the shells of the eyeball.

From the anamnesis - he received an eyeball wound in an explosion of a home-made firework with the introduction of a foreign body of unknown etiology (presumably gunpowder-shaped powder). In connection with bleeding from the eye, the patient turned to a specialized ophthalmological institution. They diagnosed the presence of a fragment under the conjunctiva. The patient is offered the removal of a foreign body from under the conjunctiva. However, upon examination, a significant displacement of the foreign body from the input wound of the conjunctiva was noted. The foreign body showed a negative magnetic probe. However, the reverse movement of a foreign body under the conjunctiva along the wound channel was not noted, since it turned out to be fixed in a subconjunctival "pocket". The introduction of tweezers into the wound channel caused bleeding from the conjunctival vessels. In such a situation, it was proposed to dissect the conjunctiva above the fragment and remove the foreign body. The conjunctiva was fixed with tweezers and raised above the sclera. As a result of this action, a pronounced subconjunctival hematoma was formed, and when the conjunctiva was cut with scissors, bleeding was noted, which did not allow further intervention. After hemostasis, carried out by mechanical stretching of the conjunctiva with dilated jaw scissors, marked changes in blood vessels and the thickness of the conjunctiva above the fragment were noted. However, with this condition of the foreign body, further intervention is postponed. 2 weeks after the blood-absorbing therapy, the foreign body is easily visualized. Irritation from the conjunctiva is not revealed. The patient does not notice irritation from the damaged eye, however, large vessels were found around the foreign body, and it was considered dangerous to remove such a fragment. But the patient complains of a pulling sensation in the zone of localization of a foreign body. The patient was invited to further eliminate a foreign body to conduct a short-pulse neodymium YAG laser. After laser fragmentation with a pulse energy of 2.5 mJ, the foreign body was destroyed to 1/3 of the volume, but the newly emerged weak bleeding did not allow to complete the manipulation. After the elimination of reactive irritation, it was noted that the foreign body was partially flattened by reducing its diameter. The patient felt much calmer after the partial destruction of a foreign body. Given the calm state of the conjunctiva, 2 days after the first operation, complete fragmentation of this foreign body was performed by laser fragmentation with an energy of 2.5 mJ.

After 2 weeks, the state of OD is satisfactory, there are residual phenomena of subconjunctival hemorrhage, there are no wounds of the conjunctiva, beneath it there is a gray homogeneous mass that moves easily upon palpation, the cornea is calm, and a single suspension in the vitreous body. Visual acuity of OD - 0.5, IOP OD - 24 mm Hg According to the ultrasound - no changes.

3 months after the operation - OD is calm: the anterior segment is unchanged, the mucous membrane is transparent, the mucous membrane without a scar in the area of laser intervention, only under the conjunctiva there is a dark spot, as with hyperpigmentation (destroyed mass of powder), which does not cause concern to the patient.

Example 2. After receiving some positive result in a previous clinical case, a patient, 32-year-old, contacted us, who received multiple pieces of glass from glasses in his left eye. After several surgical removal of glass fragments from the deep layers of the cornea, the state of the left eye stabilized: the visual acuity of the OS corresponded to 0.8, the IOP was normal, and there were no deviations from the norm with instrumental research methods. There were also negative X-ray studies both by conventional methods and by skeletal images. A year after the injury, the patient noted constant pain, more pronounced in the inner corner of the left eye. An ophthalmoscopy revealed: a cyst-like formation of the mucous membrane in the inner corner of the left eye, where among the transparent contents a foreign body was contoured up to 1 mm across and shaped like a plate.

The patient abstained from surgery. In addition, the conjunctival scar was located next to the glass fragment, which had sufficient neovascularization and caused conjunctival tension in this zone. All these factors predicted difficulties in removing a foreign body - a lengthy search among the sacred blood, possible displacement of a foreign body in any direction.

It is proposed to use a neodymium short-pulse effect for the destruction of a glass fragment. Under local anesthesia of a 1% aqueous solution of dicain, the first pulses were produced in the energy regime up to 1.0 mJ. At the same time, the fragment partially shifted and was fixed in the zone directed to the scar of the conjunctiva. By increasing the pulse energy to 2.0 mJ, they achieved fragmentation into halves of a fragment, and further destruction did not occur at this energy. With a repeated increase in energy to 3.0 mJ, the fragmentation of a foreign body into 8 fragments was achieved, which was immediately distributed over the sclera in the cavity, where there was a whole glass fragment before laser exposure.

After 2 weeks during the examination, visual function did not deteriorate, and the condition of the conjunctiva stabilized. The mucous membrane is calm everywhere, the vessels are not enlarged. The fragments during biomicroscopy are not at all noticeable, merging with the mucosa. The patient does not show any complaints to the left eye.

The method is applicable for fragile foreign bodies in the form of glass, gunpowder, filamentous materials. Thus, the proposed method provides a non-invasive effect on a brittle foreign body of various nature with the prevention of inflammatory complications from the membranes of the eye.

Claims (1)

A method for destroying a subconjunctival fragile foreign body, characterized in that the foreign body is transconjunctually fragmented by irradiating it with a short-pulse neodymium YAG laser with a pulse energy of 0.5-3.0 mJ for a time sufficient to turn it into a homogeneous mass.