RU2362524C1 - Cataract extraction, vitrectomy and intraocular lens implantation technique - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: at first, Gemase solution 0.2-0.3 ml is introduced through a projection of flat ciliary apparatus into vitreal cavity. It is followed with corneal paracentesis on limb and primary tunnel self-sealing corneal incision. Anterior chamber is filled with viscoelastic. Continuous circular capsulorexis of anterior phacocyst, hydrodissection and hydrodelineation of natural crystalline lens, nucleus rotation and phacoemulsification are performed. Cortical mass of crystalline lens is removed. If signs of complete posterior separation of vitreous body are observed, continuous circular capsulorexis and subtotal virectomy are applied. After that an intraocular lens is implanted.

EFFECT: most complete removal of vitreous body, minimised risk of haemorrhage, damage of retina, development of traction syndrome and proliferation.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used in the treatment of combined diseases of the lens and vitreous body with the extracapsular method of cataract extraction (including phacoemulsification) with intraocular implantation (IOL) and vitrectomy.

The vitreous body has a significant role in the pathogenesis of a number of diseases of the posterior segment of the eye (Sdobnikova S.V. Role of removal of the posterior hyaloid membrane (3DM) in transvitreal surgery of proliferative diabetic retinopathy. Dis .... Candidate of Medical Sciences. M., 1997. p. 67- 68). The posterior hyaloid is the outer layer of the vitreous body with a thickness of 100-200 microns. The inner border membrane (VPM) is the basement membrane of the internal processes of the Muller cells of the retina, the thickness of which varies from 10 to 1887 nm depending on the location. Functioning together, ZGM and VPM of the retina carry out transport and barrier functions. In a number of diseases, the adjacent HRM leads to a deterioration in visual functions, because contributes to the progression of macular edema, an increase in hole defect in fevola. Thus, when removing the vitreous, it is important to remove its posterior cortical layers (Eroshevsky T.N., Machekhin V.A. Closed intrectomy in the treatment of patients with hemophthalmia. Bulletin of Ophthalmology. 1984, No. 23, p. 28-30) . But when performing vitrectomy, the greatest difficulty is the removal of ZGM from the VPM. There are methods for separating the ZGM of the vitreous as a mechanical way, in which there is a risk of iatrogenic damage to the retina, retinal vessels, etc. (Banker AS, Freeman WR Vision-threatening complications of surgery for fall-thickness macular holes. Vitrectomy for Macular Hole Study Group. // Ophthalmology. - 1997. - Vol.104, No. 9, p. 1442-1453), and biochemically using chondroitinase, hyaluronidase, vitreosineretics and other drugs that specifically or nonspecifically affect vitreous components and vitreoretinal compounds (Sharafetdinov I.Kh. Experimental and clinical justification for the use of Vitreosineretik for inducing posterior vitreous detachment (3) vitrectomy. Dis ... cand. honey. AUC M. -. 2002 s.15-32). These methods of inducing the posterior vitreous detachment with subsequent vitrectomy are used in vitreoretinal surgery without surgical interventions in the anterior segment of the eye.

Simultaneous surgical treatment of various pathologies is important for the age category of patients, for whom repeated anesthesia is highly undesirable due to the presence of concomitant somatic diseases.

The closest analogue is a method for cataract extraction, vitrectomy and IOL implantation, including corneal paracentesis, a tunnel corneal self-sealing incision, a continuous circular capsulorhexis of the anterior capsule of the natural lens, removal of the natural lens of the eye by phacoemulsification, performing a continuous circular capsulorectomycetaxis Malyugin B.E., Ivannikova T.V. RF Patent No. 2293546 dated 08/02/2005).

The disadvantage of this method is the lack of removal of HGM of the vitreous body and insufficiently complete removal of the vitreous body, which may not lead to a persistent positive anatomical and functional result.

The objective of the proposed method is to develop a safe and effective method for cataract extraction and vitrectomy with IOL implantation.

The technical result, according to the proposed method, is to achieve the most complete removal of the vitreous body, including DGM without performing additional incisions to avoid the risk of bleeding both during surgery and in the early and late postoperative periods, the development of traction syndrome and postoperative proliferation.

The technical result, according to the proposed method, is achieved by the fact that the first step during the operation after anesthesia and sterile treatment of the eye in the projection of the flat part of the ciliary body with the help of an insulin syringe is injected into the vitreous cavity with 0.2-0.3 ml of a Hemase solution, which is a recombinant prourokinase and has specific enzymatic activity. After performing all stages of phacoemulsification, with the appearance of signs of complete ZOSTA, a continuous circular posterior capsulorexis is performed, a subtotal vitrectomy is performed, and then an IOL is implanted.

Gemaza is available in dry form. Before use, the contents of 1 ampoule - 5000 ME - are diluted in 1 ml of physiological saline. To perform the operation by the proposed method, 0.2-0.3 ml of the solution is taken from the obtained volume.

The amount of Hemase depends on the initial state of the vitreous body, the presence or absence of moorings, partial ZOSTA. A volume of injected solution of less than 0.2 ml will be insufficient to obtain the desired effect, a volume of more than 0.3 ml can lead to complications arising from the hyperreaction of the choroid, increasing the permeability of the blood-brain barrier.

After the introduction of the Hemase solution into the vitreous cavity, a cascade of biochemical reactions begins, which lead to the detachment of HMG from the VPM, and the ligation of the mooring line.

According to the invention, performing interventions on the anterior and posterior segments of the eye by access through a corneal incision with the preoperative use of Hemase as an inducer of ZOST allows to achieve the claimed technical result.

The method is as follows. Under local anesthesia, 4 mm is measured from the limbus to the sclera using a surgical compass to determine the projection of the flat part of the ciliary body and 0.2-0.3 ml of a Hemase solution is injected into the vitreous cavity from an injection needle. Next, corneal paracentesis is performed with a width of 1 mm, the main tunnel self-sealing section with a width of 2.2-2.75 mm. The front camera is filled with viscoelastic. A needle inserted through paracentesis produces a continuous circular capsulorexis of the anterior lens capsule, after which the needle is removed. Using a syringe with a thin-walled cannula, hydrodissection and hydrodelineation of the natural lens are performed. Cannula rotate the nucleus. Check the operation of the ultrasonic tip using an artificial front camera. An ultrasonic tip is inserted into the anterior chamber through the main incision. Produce phacoemulsification. The ultrasonic tip is changed to an irrigation tip. The cortical masses of the lens are removed. They are convinced of the presence of complete ZOST (the appearance of the Weiss ring with ophthalmoscopy), which appears after 15-30 minutes. Using tweezers inserted into the cavity of the eye through corneal paracentesis, a continuous posterior circular capsulorhexis with a diameter of 4.5-5.5 mm is performed. After performing capsulorexis, the forceps are removed from the eye cavity. A vitreotome is inserted through the main corneal tunnel incision into the cavity of the eye and through the anterior and posterior continuous circular capsulorexis into the vitreous cavity. The infusion system is introduced into the cavity of the eye through corneal paracentesis. Subtotal vitrectomy is performed. After the vitreous cavity is freed from the clouded vitreous body and posterior hyaloid membrane, the anterior chamber is again filled with viscoelastic and the IOL is implanted into the capsular bag through the main corneal incision. Viscoelastic is washed out of the anterior segment using an automated irrigation-aspiration system, after which the volume of the anterior segment of the eye is filled with saline. Check the tightness of the cuts. The operation is completed by subconjunctival injection of 0.5 ml of a solution of dexazone and gentamicin.

Cataract extraction can also be performed extracapsularly or using laser energy. For extracapsular cataract extraction, it is necessary to perform a corneal incision 7-9 mm long; for laser cataract extraction, a corneal tunnel self-sealing incision is made of the same size as in phacoemulsification.

The proposed method performed 11 operations on the eyes of 11 patients.

Example 1

Patient G., 69 years old. Diagnosis: complicated posterior capsular cataract, vitreous opacification, maculopathy, chronic uveitis in the stage of remission of the right eye. Visual acuity of 0.02 with sph - 5.5 Dptr = 0.1. The field of view is narrowed concentrically by 15 °, intraocular pressure (IOP) 23 mm RT. Art. In B-scan - floating opacities of medium acoustic density, ZOST with fixation to the optic nerve head. Phacoemulsification was performed through a 2.75 mm incision, subtotal vitrectomy and IOL implantation with the preliminary introduction of 0.2 ml of a Hemase solution into the vitreous cavity. Visual acuity after surgery 0.5 with sph correction - 1.25 Dptr = 0.7, the field of view is narrowed from the temple by 10 °, IOP - 22 mm RT. Art. By B-scan - the vitreous cavity is free from the vitreous.

Example 2

Patient P., 72 years old. Diagnosis: complicated cataract, organized hemophthalmus, weak myopia of the right eye. Visual acuity of 0.04 with sph - 2.75 Dptr = 0.8. The field of view is narrowed by 20 ° from the temporal side, by 10 ° from the lower, nasal and upper sides. IOP 19 mm RT. Art. According to B-scanning - turbidity of the average acoustic density, greater severity in the middle layers of the vitreous, partial ZOSTA. Phacoemulsification was performed through a 2.2 mm incision, subtotal vitrectomy, IOL implantation with preliminary introduction of 0.3 ml of a Hemase solution into the vitreous cavity. In the postoperative period, on the 1st day, visual acuity with 0.8 spectacle correction, normal field of view, IOP 20 mm Hg. Art. By B-scan - the vitreous cavity is free from the vitreous.

All patients achieved high and desired functional and anatomical results.

Claims (1)

A method for cataract extraction, vitrectomy and implantation of an intraocular lens (IOL), including performing corneal paracentesis along the limb, the main tunnel self-sealing corneal incision, filling the anterior chamber with viscoelastic, performing continuous circular capsulorexis of the anterior lens capsule, hydrodissection, and nucleotomycetosis removal of the cortical masses of the lens; posterior continuous circular capsulorexis; Ubottal vitrectomy, IOL implantation, characterized in that 0.2-0.3 ml of a Hemase solution is introduced into the vitreal cavity through a projection of the flat part of the ciliary body, cataract extraction is performed, and after 15-20 minutes when signs of complete posterior vitreous detachment appear subtotal vitrectomy, and then IOL implantation.