RU2421201C1 - Method of treating congenital cataracts with congenital fibrosis of posterior capsule of lens in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to paediatric ophthalmology, and aims at treating congenital cataract with congenital fibrosis of a posterior capsule of lens in children. Cataract is extracted, and an intraocular lens (IOL) is implanted. The posterior capsule is exposed later than 7 days after the operation by cross perforations with creating an optical window of the diameter 3 mm and smaller with using a pulse YAG-laser at pulse energy 0.2-1.8 mJ, 20-40 pulses.

EFFECT: method provides optimum optical and functional effects, and prevents the development of macular oedema, IOL disposition, retinal detachment.

2 ex

Description

The invention relates to medicine, namely to pediatric ophthalmology, and is intended for laser microsurgical treatment of congenital cataracts with congenital fibrosis of the posterior capsule, taking into account their clinical features, leading to increased efficiency and reduced morbidity of treatment in children.

The closest analogue of the invention is a method of the same purpose, including instrumental microsurgical circular posterior capsulorexis, with anterior vitrectomy, performed during the extraction of congenital cataracts. Capsulorexis is carried out using a disposable needle (cystotome) or capsule tweezers, cutting a round flap of the posterior lens capsule with a diameter of up to 4 mm, and then partially removing the front part of the vitreous in the area of the formed hole using a vitrector (Bobrova N.F. Features of surgical treatment of cataracts in children. // Cataract. - Kiev .: Book plus / Under the editorship of Veselovskaya ..., 2002. - p.173-202). With this method of simultaneous cataract extraction with instrumental posterior capsulorexis, a high risk of complications remains: prolapse of the vitreous body in the anterior chamber and surgical incision. Anterior vitrectomy in children is fraught with the formation of vitreocorneal adhesions with decentralization and dislocation of the IOL, the development of macular retinal edema, and macular degeneration. The lack of integrity of the capsular bag significantly complicates the implantation of the IOL, which can lead to the dislocation of the IOL into the posterior chamber of the eye.

Disclosure of invention

The objective of the invention is to improve the method of treatment of congenital cataracts with congenital fibrosis of the posterior lens capsule in children accompanying cataracts.

The technical result of the invention is to obtain optimal optical and functional results (within the limit of the functional capabilities of the optic-nervous apparatus for this congenital pathology) and to prevent the development of macular edema, IOL dislocation, and retinal detachment.

The technical result is achieved by extraction of a congenital cataract with implantation of an intraocular lens, preserving the integrity of the fibro-altered posterior lens capsule and delayed YAG of the laser posterior capsulotomy, with the formation of an optical window with a diameter of not more than 3 mm, produced within no earlier than 7 days after the operation by applying perforations in the form of a cross using pulsed radiation from a YAG laser with an energy per pulse of 0.2-1.8 mJ, 20-40 pulses.

The need for a delayed capsulotomy is due to the task of preserving the entire posterior lens capsule after removing the lens masses during the extraction of congenital cataracts in children, even with congenital fibrotic changes in the posterior capsule to prevent complications (prolapse of the vitreous body in the anterior chamber and surgical incision, vitreous corneal fusion, macular edema, macular edema, macular edema, macular edema ) that occur with instrumental posterior capsulotomy performed simultaneously with IOL implantation, and providing g Ranta intracapsular implanting the IOL (the IOL prevent dislocation in the posterior chamber).

Therefore, it is advisable to perform posterior capsulotomy not by the instrumental but by the YAG laser method delayed, which reduces the risk of dislocation of the IOL of the prolapse of the vitreous body, preserves its integrity, since the presence of the IOL performs a barrier function.

For YAG laser excision of dense fibrous pupil membranes, the spiral method is usually used (pulse energy 2.0-4.0 mJ, number of pulses 20-80 - Stepanov A.V. Laser reconstructive ophthalmosurgery. // Diss. ... doctor of medical sciences . - M., 1991. S.222-223 and 226), which however requires high energy costs to form a sufficiently large optically clean window in the back capsule and is possible only if there is a safe distance between the back capsule and the IOL due to the high risk damage to the optically active central part IOL (Hamidov A.A., Bolshunov A.V. Laser microsurgery of pupillary membranes. Illustrated guide. - M.: Monuments of historical thought, 2008. P.37-39). In addition, these options are designed for adult patients. At the same time, the features of congenital fibrosis of the posterior capsule in children (pronounced density, large diameter of fibrosis of the posterior capsule and its planar fusion with the posterior surface of the IOL (Kruglova TB, Kononov LB, Features of the technique for the extraction of congenital cataract with IOL implantation) in children of the first year of life with congenital cataracts. Russian Pediatric Ophthalmology Journal. No. 4, 2008, pp. 32-35), make the spiral-shaped technique unsuitable for laser surgery of congenital fibrosis of the posterior capsule in children, since Large energy regimes are used, which can lead to irreversible damage to the retina.Although the cruciform technique (cross-shaped opening of the changed capsule followed by cutting off the four formed flaps from the base and aligning the edges of the formed optical opening) is usually used in adults for thin translucent membranes, fibrosis of the posterior capsule I- II Art (pulse energy 1.5-2.5 mJ, the number of pulses 4-60 - Stepanov A.V. Laser reconstructive ophthalmosurgery. // Diss ... Doct. honey. sciences. - M., 1991. S. 222-223 and 226). However, this technique is used in adults on thin membranes and with a large energy regime, which cannot be used in children, since such regimes can lead to irreversible damage to the retina. In our observation, a complete cross-shaped dissection of the conglomerate in 80-90% of cases leads to a pronounced divergence of the edges of the capsulotomy sections due to the special elasticity of the posterior capsule in children. The resulting 4 triangular flaps of the posterior capsule immediately diverge to the sides, forming a sufficiently large optically clean window with a diameter of not more than 3 mm, to prevent the dislocation of the IOL in children, in the center of the pupil. Therefore, excision of these flaps is not required, which significantly reduces the energy costs of laser surgery and the risk of complications.

A feature of the cruciform technique for performing YAG laser posterior capsulotomy in children with congenital fibrosis are:

- lower energy parameters of the operation in children: pulse energy from 0.2 to 1.8 mJ; the number of pulses is from 20 to 40 (in adults, the pulse energy is 1.5-2.5 mm, the number of pulses is 4-60 (see above Stepanov A.V., ibid.);

- capsulotomy window size limit - no more than 3 mm in diameter with artifact (in adults 5 mm)

- delayed YAG laser posterior capsulotomy is performed in the absence of signs of an inflammatory reaction of the eye.

The method is as follows.

In the operating room, under conditions of anesthesia, the eyelids and eyeball are immobilized. The palpebral fissure is dilated using an eyelid extender. Immobilization of the eyeball is provided by the application of the frenum suture on the superior rectus muscle. A corneal incision is made in the area of 12 hours with a diamond blade, then with a 2.75 mm fako cutter (Alcon) they form a corneal tunnel incision. A 0.1 ml Mesaton solution is introduced into the anterior chamber in a dilution of 0.5 ml of a balanced solution of BSS (Alcon) or 0.9% NaCl to achieve drug-induced mydriasis. The front capsule is stained with methylene blue. After filling the anterior chamber of the eyeball with viscoelastic (Provisc, Viscoat), an anterior continuous circular capsulorexis with a diameter of 5.5 mm is produced using a disposable needle (cystotome) or capsule tweezers. Paracentesis is formed at 3 or 9 hours of 2.0 mm. Lens masses are removed by phacoaspiration (Megatron, Millenium, Legassi, etc. phacomachines) or by manual aspiration-irrigation technique using a Simco cannula and a syringe connected by a silicone tube.

A flexible acrylic IOL is implanted in a capsular bag using an injection technique or tweezers (with an increase in incision with a 3.75 mm implant knife), the residues of viscoelastic are washed out. The posterior capsule with congenital fibrosis is left intact. Instillation (3 times) of Pilocarpine solution 2%. The anterior chamber is restored with a balanced solution (BSS, 0.9% NaCl) and sterile air. The operation is completed by applying an immersion suture to the main corneal incision. Subconjunctival solution of Dexazone 0.4, Gentamicin 0.3 is administered. The conjunctival sac is washed with Vitabact solution, with the laying of an ointment (Tetracycline 1%) for the lower eyelid. In the absence of an inflammatory reaction of the eye to the operation, which takes place no earlier than 7 days after the operation, a YAG laser posterior capsulotomy is performed.

A neodymium YAG laser was used (for example, a Visulas-YAG-Argon-II apparatus from Carl Zeiss, Germany). Energy modes: depending on the density of congenital fibrosis of the posterior capsule: from 0.2 to 1.8 mJ (the denser the capsule, the higher the power); the number of pulses from 20 to 40; open the back capsule by applying perforations in the form of a cross. Complete the operation with forced instillations of the Naklof 0.1% solution. For children under 5 years of age and non-contact older children, laser intervention is performed under general anesthesia.

Examples

Example 1. Patient K-va A., 9 months. She was undergoing treatment at the Helmholtz Scientific Research Institute for GB with a diagnosis of OD-congenital atypical cataract. Secondary divergent strabismus (dev-div 3-5 gr) OS-healthy (age norm). On OD, cataract extraction with implantation of IOL (ZKL) + 21.0D was performed. During the operation, a partial dense congenital fibrosis of the posterior lens capsule D 5 mm was revealed, the posterior lens capsule was kept intact. The child was discharged after standard medical treatment in a hospital with the corresponding standard recommendations for outpatient treatment. Taking into account the reactive postoperative course after cataract removal, YAG was performed after 17 days of laser posterior capsulotomy by applying perforations in the form of a cross using pulsed radiation from a YAG laser (pulse energy 1.2 mJ, number of pulses 35) with the formation of an optical window with a diameter of 3 mm. The state of OD at discharge is calm, the cornea is transparent, the anterior chamber is uniform, medium depth, moisture is transparent, the pupil is round in center, artifact, the position of the IOL is correct, the optics of the IOL is transparent, the optically clean window in the fibrously altered posterior capsule is 3 mm, the fundus is ophthalmoscopically well , without pathology. Visual acuity at discharge is not lower than 0.05 (it is impossible to specify by age), the child has become sighted, is well oriented, takes toys. With further outpatient monitoring for 1 year, no complications were noted, the position of the eyes was correct, the optical media were transparent, which indicates optimal optical and functional results and the absence of complications.

Example 2. Patient A. 2 g 6 months. She was undergoing treatment at the Helmholtz Research Institute of GB with a diagnosis of OS-congenital atypical cataract. Secondary divergent strabismus (dev-div 15-25g) OD-healthy (age norm) OS performed cataract extraction with implantation of IOL (ZKL) + 14.0D. During the operation, subtotal congenital fibrosis of the posterior lens capsule of uneven density was detected, the posterior lens capsule was left intact. The child was discharged after standard inpatient drug treatment, with the corresponding standard recommendations for outpatient treatment. Considering the uncomplicated postoperative course, YAG was performed on the OS after 7 days - laser posterior capsulotomy with the formation of an optical window with a diameter of 3 mm (pulse energy 1.1 mJ, number of pulses 28) by applying perforations in the form of a cross using pulsed radiation from a YAG laser. The state of OS at discharge is calm, the cornea is transparent, the anterior chamber is uniform, medium depth, moisture is transparent, the pupil is round in center, artifact, the position of the IOL is correct, the optics of the IOL is transparent, the optically clean window in the center of the back capsule is round in shape, 3 mm, along the edge pupil remains of the posterior capsule, which does not impede detailed ophthalmoscopy. Visual acuity at discharge is not lower than 0.05 (it is impossible to determine by age), the child plays with small toys. With further outpatient observation for 1 year, no complications were noted, the position of the eyes was correct, the optical media were transparent.

Thus, the proposed method provides optimal optical and functional results (within the limit of the functional capabilities of the optic-nervous apparatus in this congenital pathology) without complications during the operation, in the short and long term after it.

Claims (1)

A method of treating congenital cataracts with congenital fibrosis of the posterior lens capsule in children, including cataract extraction, IOL implantation and opening of the posterior lens capsule, characterized in that the opening of the posterior capsule is performed no earlier than 7 days after surgery by applying perforations in the form of a cross, with the formation optical window with a diameter of not more than 3 mm, using a pulsed YAG laser with an energy per pulse of 0.2-1.8 mJ, 20-40 pulses.