RU2367389C1 - Vitreoretinal surgery technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: offered invention refers to ophthalmology and aims at vitreoretinal surgery. At first, an endoilluminator port is spaced 3-4 mm from limb. It is followed with corneal paracentesis wherever and a tunnel corneal incision in a meridian opposed to a pathological zone of vitreous body and/or retina. Through the tunnel incision, there are carried out anterior circular capsulorhexis of maximum diametre, phacoemulsification or phacoaspiration, intracapsular ring grafting in capsular sac, posterior circular capsulorhexis with its centre displaced towards the tunnel incision. Through anterior and posterior capsulorhexises, vitreous body and/or retina are operated.

EFFECT: technique allows free intraocular manipulation with any surgical tools to enable adequate surgical intervention, possibility of low-injury removal of intraocular foreign bodies Besides, the technique provides to prevent development of complicated and secondary cataract, to reduce injuries of operative intervention and risk of retinal and ciliochoroidal detachment, to prevent development of postoperative hypotonia.

2 ex, 8 dwg

Description

The present invention relates to medicine, namely to ophthalmology, and is intended for vitreoretinal intervention.

The prior art.

Vitreoretinal interventions are performed for hemophthalmia and opacification of the vitreous body of various origins, diabetic retinopathy, proliferative vitreoretinopathy, central retinal ruptures, complicated rheumatic and traction retinal detachments, post-traumatic eye pathology, and the presence of intraocular foreign bodies.

In most cases, at the time of surgery, the patient has a cataract of varying degrees of density, which impedes visualization of intraocular structures and significantly complicates manipulations near the retina.

Vitreoretinal intervention at the present stage includes the mandatory removal of the vitreous body (vitrectomy) in a subtotal or total volume for the prevention of the vitreoretin proliferative process and the formation of a mooring line. An important point of each operation is the surgical effect on the pathological focus in the vitreous body and / or retina. In most cases, this process captures both structures and represents a site of preretinal fibrosis, sometimes with neovascularization, and, accordingly, a section of tractional retinal detachment, a second time changed, contracted retina. In case of shrapnel wounds of the eye, this area includes a foreign body and a mooring formed along the wound channel, going to the place of entry. The impact on the pathological focus is produced by collet instruments of various designs, vitreoretinal spatulas, endolasers and diathermocoagulators using intraoperative liquid perfluororganic compounds, and postoperative long or short-term endotamponads with liquid or gaseous organofluorine compounds, silicone oil.

There are several ways to perform vitreoretinal intervention.

The classic way is a three-port vitreoretinal intervention of 20 Gauge (G) through the flat part of the ciliary body (Zakharov V.D. Vitreoretinal surgery. M., 2003, p.60-66). For this, two sections of the conjunctiva are performed: the first - in the meridian of 10-11 hours, 2 mm from the limb with a length of 5.0-6.0 mm, the second, much larger - in the meridian of 12 ³⁰ -14 ³⁰ with a length of 12.0-15.0 mm 2 mm from the limb. At the edges of the incisions, laxative incisions are usually made towards the conjunctival arch 2.5-3.0 mm long. After this, diathermocoagulation of the vessels in the area of future sclerotomy is carried out. The first is the incision for the infusion cannula in the meridian of 2 hours at 4.0 mm from the limb parallel to it. At the site of the alleged sclerotomy, a mattress suture (4-5 mercilene) is applied to fix the infusion cannula. The length of the cut should be equal to 1.4 mm so that a cannula with a diameter of 0.9 mm could pass through it. A sclerotomy is carried out, an infusion cannula is inserted into it and fixed by tightening the previously applied suture. Then two more punctures are made to enter the instruments. They are also located 4.0 mm from the limb and have a length of 1.4 mm. One of them is usually performed in the meridian of 10-11 hours, the second in the meridian of 13 hours in the immediate vicinity of the infusion cannula. An optical fiber is introduced through one cut at 13 hours, and a vitrector is introduced through another at 10 hours. Perform vitrectomy. The last step of the operation is removing the tools and suturing with silk 8-0. The infusion cannula is removed last and the sclerotomy is sutured. Conjunctival sections are closed with interrupted sutures, 8-0 silk is used.

The disadvantages of this method are high trauma, intraoperative bleeding into the vitreous cavity from sclerotomy zones, postoperative astigmatism due to scleral deformity during suturing, the risk of cataracts, prolonged surgery, long-term rehabilitation of patients, the difficulty of stopping expulsive hemorrhage, the risk of retinal detachment for due to pronounced traction on the part of the ciliary body, the development of ciliochoroidal detachment.

A known method of two-port vitreoretinal intervention of 20 G through the flat part of the ciliary body (Shishkin MM, Kasatikova EV Modern technologies for the treatment of vitreoretinal pathology - 2008, M., 2008. Bimanual access as one of the options for sparing 20 G vitreoretinal intervention, with . 207-209), which consists in the fact that instead of three sclerosis, two are formed at a distance of 3-4 mm from the limbus, each is as close as possible to the meridian corresponding to the upper edge of the horizontal rectus muscles in order to provide the largest sector for the vitr Otomo on the extreme periphery. A vitrector 20 G and an endolighter with an irrigation channel of 20 G are introduced into the vitreous body cavity. After vitrectomy, a sclerotomy and conjunctival incision are sutured.

The disadvantages of this method are high invasiveness, intraoperative bleeding into the vitreous cavity from sclerotomy zones, postoperative astigmatism due to scleral deformity during suturing, the risk of cataracts, the duration of surgery, long-term rehabilitation of patients, the difficulty of stopping expulsive hemorrhage, the risk of retinal detachment due to retinal severe traction on the part of the ciliary body, the development of ciliochoroidal detachment, intraoperative hypotension of the eye with ne Yemen tool places.

A known method of vitreoretinal intervention (Gundorova R.A., Bykov V.P. Modern technologies for the treatment of vitreoretinal pathology - 2008, M., 2008. Anterior vitrectomy with primary trauma and the consequences of penetrating eye injuries, pp. 48-51). The method is characterized in that the eyeball is opened by making corneal incisions in the limbus with the formation of a conjunctival flap or limbus for active instruments and an infusion cannula, then a lens-rectrectomy is performed. The operation is completed by hydroobturation of incisions or suturing.

The disadvantage of this method is the poor visualization of intraocular structures due to the formation of intraoperative corneal astigmatism, the high invasiveness of surgery, the impossibility of intracapsular fixation of an artificial intraocular lens (IOL) after a lensectomy, the exit of the endotamping substance into the anterior chamber, the difficulty in removing the vitreous in full due to limited mobility instruments, the risk of damage to the iris by the vitrector, postoperative hypotension.

The closest analogue of the invention is a method of three-port vitreoretinal intervention through the flat part of the ciliary body using seamless technology. To do this, three ports 23 or 25 G are placed at 3.0-4.0 mm from the limb. The first installed port is used for irrigation, the other two are used to introduce active instruments into the vitreous cavity. Typically, ports for the right eye correspond to 7 ³⁰ , 1 ³⁰ , 10 ³⁰ hours, for the left - 4 ³⁰ , 10 ³⁰ , 1 ³⁰ hours. After removing the ports, suture sealing of scleral and conjunctival punctures is not performed. (Takhchidi Kh. P. Modern technologies for the treatment of vitreoretinal pathology - 2007, M., 2007. Vitreoretinal surgery 25 G: possibilities and prospects, pp. 9-16).

The disadvantage is the inability to use collet instruments of a larger diameter, which excludes the use of several types of instruments that have no analogues for 23 and 25 G vitreoretinal intervention, the inability to remove intraocular foreign bodies using this technology, the risk of developing cataracts, postoperative hypotension.

Disclosure of the invention.

The objective of the invention is to develop a universal method of seamless vitreoretinal intervention.

The technical result of the invention is the possibility of free manipulation of any surgical instruments inside the eye for adequate surgical intervention, the possibility of less traumatic removal of intraocular foreign bodies, the prevention of complicated and secondary cataracts, less trauma of surgical intervention with a reduced risk of retinal detachment and ciliochoroid detachment, the absence of postoperative hypotension.

The technical result is achieved due to free access to the vitreous cavity through the tunnel incision of the cornea and the holes in the lens capsules, removal of the lens with the implantation of the IOL into the capsular bag, the use of a single port installed using seamless technology in the projection of the flat part of the ciliary body.

The method is illustrated by the following drawings (figures 1-11), where 1 is the conjunctiva, 2 is the cornea, 3 is the iris, 4 is the lens, 5 is port 23 or 25 G, 6 is the corneal paracentesis of 0.9 mm, 7 is a tunnel incision 2.75 mm, 8 - rexis of the anterior lens capsule, 9 - intracapsular ring, 10 - rexis of the posterior lens capsule, 11 - irrigation cannula, 12 - end illuminator 23 or 25 G, 13 - vitrector, 14 - vitreoretinal instrument, the dimensions of which exceed the internal port diameter, 15 - soft IOL.

The method is carried out in the following way:

Transconjunctival at 3-4 mm from the limb set port (5) (figure 1).

Produce paracentesis of the cornea of 0.9 mm (6) anywhere and a tunnel incision of the cornea of 2.75 mm (7) in the meridian, opposite the location of the pathological process (figure 2).

The lens is removed while preserving the capsules. To do this, first produce anterior capsulorexis (8) with a maximum diameter (Fig. 3), phacoaspiration or phacoemulsification.

Through the tunnel incision of the cornea (7), an intracapsular ring (9) is implanted into the capsular bag (9) (Fig. 4) and circular rexis of the posterior lens capsule (10), 2-3 mm in diameter, shifted towards the corneal tunnel incision is performed (2-3) (Fig. 5).

Vitreoretinal intervention is carried out under visual control, the volume of which is determined individually depending on the type and amount of intraocular pathology. Perform vitreomy (Fig.6). The introduction into the cavity of the vitreous body of instruments whose size exceeds the diameter of the port inlet (5) is made through a tunnel incision of the cornea (7), through openings in the lens capsules (Fig. 7).

The port (5) is removed, a soft IOL (15) is implanted into the capsule bag through the tunnel incision (Fig. 8).

Hydroobturation of paracentesis and tunnel incision is performed, ophthalmotonus is regulated.

The proposed method makes it possible to freely manipulate any surgical instruments inside the eye for adequate surgical intervention, less traumatic removal of intraocular foreign bodies, prevention of complicated and secondary cataracts, reduces the morbidity of surgical intervention, minimizing the risk of retinal detachment, ciliochoroid detachment and postoperative hypotension.

Example 1

A 35-year-old patient was admitted to a specialized ophthalmologic department with a diagnosis of the left eye - penetrating treated scleral wound, hemophthalmus, intraocular foreign body. Visual acuity OD // OS = 1,0 // rr. 1. certa; IOP OD // OS = 20 // 18 mm Hg From the anamnesis 10 days ago, an everyday injury - when working with a hammer on an iron structure, a splinter flew off and fell into the left eye. Vision decreased immediately. Primary surgical treatment was performed at the place of residence. Sent to the SRI them. Helmholtz Rosmedtehnologii for vitrectomy and removal of the intraocular foreign body.

According to the X-ray data, a foreign body of metal density measuring 2.5 × 2 × 1 mm is located in the meridian 3 ⁰⁰ -3 ²⁰ , the distance from the limb is 19-20 mm, from the anatomical axis - 5-6 mm. Anteroposterior eye size 22 mm.

After the examination, the patient is offered surgery according to the proposed method.

In the operating room, under general anesthesia, port 25 G was installed transconjunctively 3-4 mm from the limbus.

A 0.9 mm corneal paracentesis was performed at 6 o’clock and a 2.75 mm corneal tunnel incision was made in the meridian opposite the localization of the foreign body at 3 o’clock.

They performed anterior capsulorexis with maximum diameter, phacoaspiration. Through the tunnel incision of the cornea, implantation into the capsule bag of the intracapsular ring was performed and the proxis of the posterior lens capsule 3 mm in diameter shifted towards the corneal tunnel incision was performed.

An irrigation cannula was installed in the corneal paracentesis, an end illuminator was introduced through the port into the vitreous cavity, and a vitrector was introduced through the tunnel incision of the cornea.

Under visual control, vitrectomy was performed in a subtotal volume.

Through the tunnel incision of the cornea, the holes in the lens capsules introduced into the cavity of the vitreous body 20 G the tip of the Alkom-01 diode endolaser 810 nm. Produced under visual control prophylactic endolasercoagulation of the retina around a foreign body. Through a tunnel incision, a magnet was brought to a foreign body. Magnetic test is negative.

Removal of the intraocular foreign body was performed with collet forceps to remove foreign bodies through the tunnel incision of the cornea.

The port was removed, a soft IOL + 22.5 ^d from Nidek was implanted into the capsule bag through a tunnel incision.

Hydroobturation of paracentesis and tunnel section was performed. Palpation normotonia. Subconjunctival 0.5 gentamicin solution.

2 days after the operation, the OS is a little annoyed, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent. Drug mydriasis. IOL in the correct position. DZN is pale pink, the borders are clear. The course of blood vessels is not changed. The retina is adjacent in all places, in the place of occurrence of a foreign body, a section of retinal atrophy with a gap without retinal detachment, surrounded by pale laser coagulates. Visual acuity OS = 0.9; IOP OS = 22 mm Hg

3 months after surgery, the OS is calm, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent. Drug mydriasis. IOL in the correct position. DZN is pale pink, the borders are clear. The course of blood vessels is not changed. The retina is adjacent in all places, in the place of occurrence of a foreign body, a section of retinal atrophy with a gap without retinal detachment, surrounded by pigmented laser coagulates. Visual acuity OS = 1.0; IOP OS = 22 mm Hg

The method made it possible to perform vitrectomy using a seamless technology, freely manipulating surgical instruments of various calibers and designs inside the eye to conduct adequate surgical intervention, to remove the intraocular foreign body with less trauma, to prevent complicated and secondary cataracts, to reduce the risk of retinal detachment, ciliochoroid detachment and postoperative hypotension to a minimum by installing only one port.

Example 2

A 45-year-old patient Zh was admitted to a specialized ophthalmological department with a diagnosis of left eye - diabetic proliferative vitreoretinopathy, hemophthalmus, tractional retinal detachment in the lower section. Visual acuity OD // OS = 0.8 // rr. 1. certa; IOP OD // OS = 20 // 18 mm Hg From the anamnesis, he suffers from type I diabetes for 12 years. Vision decreased 10 days ago. Sent to the SRI them. Helmholtz Rosmedtehnologii for high-tech surgical treatment.

After the examination, the patient is offered surgery according to the proposed method.

In the operating room, under general anesthesia, port 25 G was installed transconjunctively 3-4 mm from the limbus.

A 0.9 mm corneal paracentesis was performed at 6 hours and a 2.75 mm corneal tunnel incision was made in the meridian opposite to the location of the traction retinal detachment.

They performed anterior capsulorexis with maximum diameter, phacoaspiration. Through the tunnel incision of the cornea, implantation into the capsule bag of the intracapsular ring was performed and the proxis of the posterior lens capsule 3 mm in diameter shifted towards the corneal tunnel incision was performed.

An irrigation cannula was installed in the corneal paracentesis, an endoluminator was introduced into the vitreous cavity through the port. Through the tunnel incision of the cornea - vitrector.

Vitrectomy was performed in a subtotal volume. The retina was visualized. In the lower part on the middle periphery of the retina along the lower temporal arcade, preretinal fibrosis with neovascularization, causing traction retinal detachment with partial capture of the macular region.

An endodiothermocoagulator was introduced into the vitreous cavity through a tunnel incision of the cornea and the holes in the lens capsules, neovascular vessels were coagulated to prevent hemorrhage.

Vertical collet scissors and retinal spatulas of various designs partially exfoliated preretinal fibrosis, partially removed it with dissection at the sites of traction.

Through the tunnel incision of the cornea, the holes in the lens capsules introduced into the cavity of the vitreous body 20 G the tip of the Alkom-01 diode endolaser 810 nm. Produced under visual control prophylactic endolasercoagulation of the retina around the remains of fibrous tissue.

The port was removed, a soft IOL + 22.5 ^d from Nidek was implanted into the capsule bag through a tunnel incision.

Hydroobturation of paracentesis and tunnel section was performed. Palpation normotonia. Subconjunctival 0.5 gentamicin solution.

2 days after the operation, the OS is a little annoyed, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent. Drug mydriasis. IOL in the correct position. DZN is pale pink, the borders are clear. The course of blood vessels is not changed. The retina is adjacent in all places, in the place of localization of the pathological process, the retina is adjacent, part of the fibrous tissue is surrounded by pale laser coagulates. Visual acuity OS = 0.7; IOP OS = 22 mm Hg

3 months after surgery, the OS is calm, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent. Drug mydriasis. IOL in the correct position. DZN is pale pink, the borders are clear. The course of blood vessels is not changed. The retina is adjacent in all places, in the place of localization of the pathological process, the remains of fibrous tissue surrounded by pigmented laser coagulates. Visual acuity OS = 0.9; IOP OS = 22 mm Hg

The method made it possible to perform vitrectomy using a seamless technology, freely manipulating surgical instruments of different caliber and design inside the eye to conduct adequate surgical intervention, prevent complicated and secondary cataracts, reduce the risk of retinal detachment, ciliochoroid detachment and postoperative hypotension to a minimum by installing only one port .

Claims (1)

A method for vitreoretinal intervention, including vitrectomy and removal of the lens, characterized in that the port is first set up for endolumination 3-4 mm from the limbus, then corneal paracentesis is performed and a corneal tunnel incision is made in the meridian on the opposite side of the pathological area of the vitreous body and / or retina through which the anterior circular capsulorexis is successively produced with a maximum diameter, phacoemulsification or phacoaspiration, implantation in the capsular mesh to the intracapsular ring, the posterior circular capsulorexis with the center shifted to the side of the tunnel incision, and through it intervene on the vitreous body and / or retina.

Images