RU2348384C1 - Method of cornea surface reconstruction in patients suffering from monocular burn leukomas - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: surgical treatment of patients suffering from burn corneal leukoma in remote period after the injury is combined with conjunctiva peritomy backwards from the limb distanced 4 mm. Fibrovascular pannus is excised from cornea surface. On pair eye, conjunctiva is separated from Tenon's membrane. Thereafter two sector limb-conjunctival transplant flaps sized 4×4 mm are cut out in upper sector so that to provide intact limb 2-3 mm positioned 12 o'clock. Flaps are positioned 6 and 12 o'clock on the operated eye herewith fixed to limb and sclera. Conjunctiva is fixed to sclera in a circumferential direction. After that cornea surface is covered with soft contact lens, e.g. silicone hydrogel lens of diameter 13.8 mm. Two conjunctival defects of donor eye are taken in separately.

EFFECT: provides secured stable growth of epithelial cells on burnt eye cornea surface, and further stable state of eyes; lower postoperative complications and improved cosmetic effect on donor eye.

2 cl, 2 ex

Description

The invention relates to medicine, more specifically to ophthalmic surgery, and can be used in the surgical treatment of patients with burn corneal sore throats in the long term after an injury.

The inventive method is based on the technology for the treatment of patients with burn sores, developed by K.R. Kenyon and S.G. Tseng in 1989. The essence of this technology is as follows. First, the conjunctival peritomy is performed posterior to the limbus at a distance of 2 mm. Then, the fibrovascular pannus is excised from the surface of the cornea using a Martinez spatula or bluntly tweezers. The next stage is harvested two sectoral conjunctival-limbal (CL) graft on a healthy eye. Transplants are cut out at 6 and 12 hours (in the lower and upper sectors). On the circumference, each graft graft has a length of about 4 hours, while the graft cuts out beyond the limb, toward the central region of the cornea by 0.5 mm and towards the bulbar conjunctiva behind the limb by 2 mm. Thus, the size of each of the 2 graft flaps is 3 × 10 mm. Then the grafts are placed on the operated eye anatomically identically in the upper and lower sectors, after which 10-0 nylon sutures are placed on the corneal edge and 8-0 Vicryl sutures are placed on the conjunctival edge. To protect and strengthen the grafts, a soft bandage contact lens is used that covers the wound surface (Kenneth R. Kenyon, MD, Scheffer C. G. Tseng, PhD, MD. Limbal Autograft Transplantation for Ocular Surface Disorders // Ophthalmology. - 1989. - No 96. - P.709-723).

The disadvantages of the method.

The sizes of the prepared grafts are significant, which increases the risk of iatrogenic limbal-cell insufficiency in the donor eye and, as a result, the occurrence of a postoperative inflammatory process in a single functionally active eye.

The objective of the invention is to reduce the injury to the eye of the donor.

The technical result obtained by solving this problem is to reduce postoperative complications in the donor eye, the best cosmetic effect of this eye and the guaranteed result of stable growth of epithelial cells on the surface of the cornea of the burned eye, and further stable eye condition.

The specified technical result can be obtained in the method of reconstructing the surface of the cornea in patients with monocular burn sore throats by using conjunctival-limbal graft flaps, including performing conjunctival peritomy posterior to the limb, excising the fibrovascular pannus from the corneal surface, and cutting out two paranomal lumbar-conjunctival oculi of the two sectors grafts-grafts and their location at 6 and 12 hours of the operated eye with fixation to the limbus and sclera, after which they are fixed A soft contact lens is applied to the sclera of the conjunctiva with separate sutures along the circumference and then on the surface of the cornea, after which two conjunctival defects on the donor eye are sutured separately, while corneal peritomy is performed posterior to the limbus at a distance of 4 mm, and conjunctival limbal flaps are paired. the eye is cut out in the upper sector, 4 × 4 mm in size, so that between them there remains 2-3 mm of the intact limbus at 12 hours, while the flaps in the conjunctival area are cut out, having previously separated the conjunctiva from the ten a new shell.

It is proposed to use a 13.8 mm diameter Selikon-hydrogel lens as a soft contact lens.

Among the essential features characterizing the method, the distinguishing ones are:

- peritomy of the cornea is performed posterior to the limbus at a distance of 4 mm,

- conjunctival-limbal flaps on the paired eye are cut out in the upper sector, 4 × 4 mm in size, so that between them there remains 2-3 mm of the intact limbus at 12 hours,

- flaps in the conjunctival area are cut out, after separating the conjunctiva from the tenon membrane.

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

The developed method is intended for the surgical treatment of patients with monocular burn sores of the cornea in case of total limbal cell failure.

By performing conjunctival-limbal transplantation, the problem of restoring the corneal epithelial layer and its further stable state on the burned eye is solved. As our practice has shown, transplantation of autoconjunctival-limbal flaps that are cut out from a pair of healthy eyes is optimal for solving this problem. The CL fence of the flaps in the upper sector of the donor eye is cosmetically advantageous (the zone is under the upper eyelid). Both flaps were taken in the upper sector, however, 2-3 mm of the intact limb should be left between them. This value is necessary and sufficient for subsequent normal growth of epithelial cells on the surface of the cornea of the donor eye. By reducing the length of the transplants, each is 2.5 times, thereby ensuring the early healing of the CL of the donor eye zone, while complications are minimized. In the conjunctival zone, the flaps are cut out without a tenon membrane, which is pre-peeled off by introducing lidocaine into this zone. This eliminates the contraction of the conjunctival arch when suturing the donor eye. The use of CL flaps with a shorter length as transplants for the affected eye, as our practice has shown, is a quite acceptable solution that allows for active epithelization of the corneal surface, while the percentage of long-term stability of the formed epithelial layer remains high, at the level of analogues. After the application of CL grafts grafts with a size of 4 × 4 mm, the regeneration result, as we already noted, was positive, although, of course, slightly longer in time than the prototype. This moment was taken into account, and the conjunctival peritomy was proposed to be performed posterior to the limb at a distance of 4 mm, and not 2, as in the prototype. This allowed, despite a slightly slowed down process of regeneration of the surface layer of the cornea, in comparison with the prototype, to prevent the growth of conjunctival epithelial cells on the cornea. The pathway of the conjunctival epithelial cells to the cornea increased (4 mm), and it took more time to overcome it, and when the conjunctival epithelial cells were near the cornea, the peripheral part of the cornea was already covered with corneal epithelial cells. Which was required.

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

The method is as follows.

The operation was performed under general anesthesia, which is associated with the duration of the procedure. On the damaged eye, the patient underwent circular conjunctival peritomy at a distance of 4 mm from the limbus. The fibrovascular membrane (pannus) was exfoliated and dissected from the surface of the entire cornea.

On the healthy eye of the patient, two conjunctival-limbal flaps 4 × 4 mm in size were marked in the upper sector so that between them there remained 2-3 mm of the intact limbus at 12 hours. A notch was cut along the corneal area of the marked flap with a diamond knife to a depth of 200 μm along the limb, departing from the last 0.3 mm towards the center of the cornea. Under the conjunctival part of the flap was introduced 2% lidocaine in a volume of 0.1 mm to exfoliate from the underlying tenon membrane. The conjunctival part of the flap was cut out with scissors, the limbal part was cut with a diamond delaminator. Cut out CL flaps were transferred and fixed at 6 and 12 hours to the limbus and sclera with separate interrupted sutures. The own conjunctiva was also fixed along the circumference with separate sutures to the sclera 4 mm from the limbus to limit its displacement to the limb at the stage of restoration of the epithelium on the surface of the cornea. The surface was superimposed with a silicone hydrogel soft contact lens Night Day (Cuba Vision) with a diameter of 13.8 mm with high oxygen permeability. After that, two conjunctival-limbal defects were sutured separately in the upper sector on the paired eye.

EXAMPLE 1. Patient M., card No. 314390, born in 1968, contacted the EC MTC “Eye Microsurgery” with a diagnosis of the consequences of a chemical burn OD: vascular corneal sore throat. When examining visual acuity without correction, OD = 0.01, visual acuity with correction is 0.05; OS = 1.0. An operation was performed according to the claimed method with autotransplantation of two conjunctival-limbal flaps. Surgery was performed 39 months after the burn. The patient was in hospital for 10 days. Duration of epithelization is 15 days. Duration of wearing a contact lens is 15 days. The duration of dexamethasone instillation is 4 weeks, 4 times a day. Sutures were removed after 15 days.

Visual acuity without correction (OD) = 0.25, with a correction of 0.4; OS = 1.0. There is no inflammatory process on the donor eye, and a cosmetic defect is not visually detected on it.

When viewed after six months and a year, the result is positive, visual acuity OD = 0.5. OS = 1.0.

EXAMPLE 2. Patient S., card No. 300316, born in 1978, contacted the EC MNTK “MG” with a diagnosis of the consequences of an alkali burn OD: vascular corneal cornea. On examination: visual acuity OD 0.02sph n / a; OS = 1.0. The patient underwent an operation - reconstruction of the surface of the cornea with autotransplantation of two conjunctival-limbal flaps according to the claimed technology. Surgery was performed 23 months after the burn. The patient was in hospital for 8 days. The terms of epithelization are 12 days. The term of wearing MKL is 12 days.

The duration of the use of dexamethasone installations is 13 weeks, 4 times a day. Sutures were removed after 12 days. Visual acuity without correction OD = 0.35 does not correct; OS = 1.0. There is no inflammatory process on the donor eye (OS), and also a cosmetic defect is not visually detected on it.

When viewed after six months and a year - the result is positive, visual acuity OD = 0.45; OS = 1.0.

Thus, this technology made it possible to reduce the trauma caused to the donor eye, and at the same time ensure the restoration of the corneal epithelial layer on the burned eye, and ensure its further stable condition and good visual functions.

In the EC MNTK “Eye Microsurgery”, 12 people were operated on in this way, no complications were observed, the method confirmed its reliability.

Claims (2)

1. A method of reconstructing the surface of the cornea in patients with monocular burn sores by using conjunctival limbal graft flaps, including performing conjunctival peritomy posterior to the limb, excising the fibrovascular pannus from the corneal surface, cutting two sectoral conjunctival-limbal loci from the paired eye them for 6 and 12 hours of the operated eye with fixation to the limbus and sclera, after which they are fixed to the sclera of the conjunctiva with separate sutures along the circumference and then a soft contact lens is applied to the surface of the cornea, after which two conjunctival defects on the donor eye are sutured separately, characterized in that the corneal peritomy is performed posterior to the limbus at a distance of 4 mm, and the conjunctival-limbal flaps on the paired eye are cut out in the upper sector, 4 × 4 mm in size so that between them there remains 2-3 mm of the intact limbus for 12 hours, while the flaps in the conjunctival area are cut out, after separating the conjunctiva from the tenon membrane. 2. The method according to claim 1, characterized in that a silicone-hydrogel lens with a diameter of 13.8 mm is used as a soft contact lens.