RU2455962C1 - Method of cataract phacoemulcification in case of vast destruction of zonula ciliaris zinni fibres - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmic surgery and can be used for treatment of cataract by method of phacoemulsification in cases of crystalline lens subluxation caused by destruction of zonula ciliaris Zinni fibres. In flat part of ciliary body trocar with calibre 25G is introduced, through corneal tunnel access solution of mydriatic and viscoelastic are introduced into anterior chamber, after that through trocar irrigation cannula is introduced in direction of crystalline lens and viscoelastic is supplied under crystalline lens, with displacement of crystalline lens by means of viscoelastic upwards and its centering by means of cannula crystalline lens is put into natural anatomical position. Through anterior access capsulorexis is performed bimanually, intra-capsule ring is installed and phacoemulsification is performed, during which each time when crystalline lens is displaced backwards, through trocar portion of viscoelastic is supplied, with recovery of natural position of crystalline lens. After removal of sac content, ring is brought outside, capsule sac is removed, IOL is implanted with its further fixation, after which viscoelastic is washed out from anterior chamber, substituting with physiological solution, remains of viscoelastic being removed through trocar.

EFFECT: method makes it possible to carry out phacoemulsification of cataract in case of vast destruction of zonule of Zinni in a non-traumatic way.

4 cl

Description

The invention relates to medicine, and more specifically to ophthalmic surgery, and can be used to treat cataracts by phacoemulsification in cases of subluxation of the lens due to destruction of the fibers of the zinc ligament.

With the extensive destruction of the fibers of the zinc ligament (more than 180), it is not necessary to talk about the preservation of the capsule bag during surgery in order to fix an intraocular lens (IOL) in it, but to remove the lens (contents and capsule) at the current level of technology and technology should be done by microinvasive surgery , i.e. phacoemulsification method.

A number of technologies have been developed to perform cataract phacoemulsification during lens subluxation. One of them is the use of an open intracapsular ring, which is introduced into the equatorial zone of the capsular sac through capsulorexis before the start of phacoemulsification and ensures the expansion and maintenance of the arch of the cataract sac. The ring is inserted into the equatorial zone of the bag completely and remains in this zone in the future. This technique is applied and is effective in situations where the defect of the ligamentous fibers is not extensive.

The authors of the Zaporizhzhya Medical Academy of Postgraduate Education have proposed a more reliable technology for stabilizing the capsule bag during cataract phacoemulsification complicated by subluxation of the lens (article from the collection Zavgorodnaya N.G., Isakova OA, Capsule bag stabilization technique during cataract phacoemulsification complicated by subluxation). MODERN TECHNOLOGIES OF CATARACTAL AND REFRACTION SURGERY. - 2009. - Moscow, 2009. - P.94-98 - PROTOTYPE). The essence of technology is as follows. One end of the intracapsular ring (IAC) is inserted into the bag under the anterior capsule strictly circumferentially from the side opposite to the maximum damage to the fibers of the zinc binder. If necessary, an additional corneal paracentesis is done for this. The second end of the IAC does not start in the capsule bag, it is either installed on the iris or left outside the port (outside the eye) - with a more pronounced degree of lens subluxation. In this case, the lever of the force of action of the intracapsular ring changes in such a way that the capsule becomes stable at the site of separation of the zinc ligaments. Features of the phacoemulsification operation are preliminary vitrectomy (according to indications), sparing hydrodiscissection and hydrodelineation. The rotation of the nucleus was not performed. During phacoemulsification, the “storm and break” method was preferred. After implantation of the artificial lens in the capsule bag, the second end of the ring was inserted into the capsule bag under the front capsule with the location in the equatorial zone.

Technology disadvantages

This technology does not provide sufficient reliability of the fixation of the lens during phacoemulsification, if the violations of the fibers of the zinc ligament are extensive, i.e. there is a high mobility of the lens. In addition, with such mobility, nothing is provided for performing capsulorexis.

The objective of the invention is to develop a more reliable method for atraumatic performing phacoemulsification of cataracts with extensive destruction of the fibers of the zinc ligament with subsequent fixation of the intraocular lens (IOL) outside the capsule bag.

EFFECT: reduction of operational and postoperative complications; the technology gives the surgeon confidence in the implementation of each stage of the operation quickly and atraumatically and ensures the speedy rehabilitation of the patient after the operation.

The specified technical result can be obtained if in the method of phacoemulsification of cataract complicated by lens subluxation, including stabilization of the capsular bag using the intracapsular ring, which is introduced into the equatorial zone of the bag through paracentesis and capsulorexis, while the second end of the ring is left outside the eyes, phacoemulsification and lenses, they begin the operation with lens stabilization using viscoelastic, for this a trocar of feces is installed in the flat part of the ciliary body Ibrom 25G, then through the corneal tunnel access into the anterior chamber, a solution of mydriatic and viscoelastic is injected, then an irrigation cannula is inserted through the trocar in the direction of the crystalline lens and viscoelastic is placed under the lens, displacing the crystalline lens upward by the viscoelastic and centering the cannula, bringing the crystalline to the anatomical position of this, capsulorhexis is performed bimanally by front access, an intracapsular ring is inserted and phacoemulsification is performed, during which each time the lens of the cz is displaced and a portion of viscoelastic is fed through the trocar under the lens, restoring the natural position of the lens, and removing the contents of the bag, the ring is pulled out, the capsule bag is removed, the IOL is implanted, followed by fixation, then the viscoelastic is washed out of the anterior chamber and replaced with saline, after which the residues are removed viscoelastic through a trocar.

Clarifying signs:

- outside the eyes leave the second end of the intracapsular ring 2-3 mm long,

- as a viscoelastic use dispersed viscoelastic - viscose,

- through the trocar, the remains of viscoelastic are removed using a vitreotome.

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

- they begin the operation with lens stabilization using viscoelastic, for this a trocar of 25G caliber is installed in the flat part of the ciliary body,

- then through the corneal tunnel access into the anterior chamber enter a solution of mydriatic and viscoelastic,

- then an irrigation cannula is inserted through the trocar in the direction of the crystalline lens and viscoelastic is placed under the crystalline lens, displacing the crystalline lens upward by the viscoelastic and centering the cannula, the crystalline lens is brought to its natural anatomical position,

- after this, front access bimanally perform capsulorexis,

- set the intracapsular ring,

- carry out phacoemulsification, during which, each time when the lens is displaced posteriorly, a portion of viscoelastic is fed through the trocar under the lens, restoring the natural position of the lens,

- removing the contents of the bag, bring out the ring,

- remove the capsule bag,

- IOL is implanted with its subsequent fixation,

- then the viscoelastic is washed out of the anterior chamber, replacing it with saline,

- after which the remnants of viscoelastic are removed through the trocar.

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

Reception - do not insert the stabilizing ring completely into the capsule bag during phacoemulsification, but leave it partially outside the eye, thereby turning the ring into a lever, for which the focus is the corneal zone, in which the ring path partially lies - a known technique (prototype). However, with the extensive destruction of the fibers of the zinc ligament, this method of stabilization of the capsule bag is not enough. More reliable stabilization of the bag is required when conducting phacoemulsification directly. In addition, due to the high mobility of the lens, it is difficult, and sometimes simply impossible, to perform capsulorexis. According to the invention, the lens is further stabilized using viscoelastic. Viscoelastic is placed in the anterior chamber and behind the lens. This method of fixation of the lens by viscoelastic was used by our authors in the invention (RF Patent No. 2338493). However, in the previous technology, viscoelastic was inserted behind the lens by front access, while the removal of the lens that lost its zonal support was performed by mechanical phacofragmentation. It is known that with mechanical phacofragmentation of the lens, the flows arising in the anterior part of the eye are significantly less than with ultrasonic phacoemulsification. Therefore, having viscoelastic behind the lens and then replenishing its volume with front access during mechanical fragmentation is acceptable. When phacoemulsification is undesirable, because Viscoelastic will have to be wound up more often, therefore, the probability of injury to the iris, corneal endothelium, and access to the anterior chamber increases. The invented invention provides for the supply of viscoelastic for the lens through a 25G trocar, mounted in the flat part of the ciliary body 4 mm from the limbus. Through such a trocar, the 25G irrigation cannula starts well, it is easily guided towards the lens and through it the viscoelastic is fed under the lens. Viscoelastic shifts the lens upward, and the surgeon centers it through the cannula; as a result, the lens is placed in its natural anatomical position (poor contact with the iris). In this case, the lens turns out to be a fixed viscoelastic wound in front of and behind the lens. In such a situation, performing capsulorexis using a bimanual technique is not difficult. The trocar is involved throughout the operation. During phacoemulsification, the volume of viscoelastic behind the lens is easily and atraumatically replenished through it, and after the completion of phacoemulsification and exit from the anterior chamber through it with the help of a vitreotome, the remains of viscoelastic are removed. Then the trocar is withdrawn, with no suturing required. As a viscoelastic, it is proposed to use dispersed viscoelastic - viscose. It holds the volume well, and if a small amount of viscose cannot be removed from under the lens, then complications should not be feared, because it is well absorbed. Viscoelastic stabilizes the lens not only during capsulorexis, but also directly during phacoemulsification: it prevents the capsule bag from moving with the contents in the sagittal plane, and the intracapsular ring prevents the bag from moving in the frontal plane. As a result of two stabilizing techniques, phacoemulsification is fast and atraumatic. Then the ring is pulled out at the end located outside the eye, the capsule bag, which has lost contact with the ciliary body, is removed, and a folding IOL is implanted, fixing it with sutures to the sclera or iris.

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

The method is as follows. In a flat part of the ciliary body 4 mm from the limb, a 25G trocar is installed, a stub is temporarily placed. The main tunnel corneal access is formed with a width of 2.2-2.6 mm and paracentesis. A mydriatic solution is inserted into the anterior chamber (the pupil is dilated), lens mobility is assessed, and the chamber is filled with viscoelastic viscose elastomer, deepening the anterior chamber. Then, through the installed trocar, an irrigation cannula is inserted in the direction of the lens and a viscoelastic (viscot brand) is placed under the lens, displacing the lens upward with viscoelastic and centering it. As a result, the lens is placed in a natural anatomical position. After that, capsulorexis is performed bimanally (using tweezers and a spatula) with front access. Through paracentesis, an intracapsular open polymer ring with a diameter of 12.5 mm is inserted into the equatorial part of the capsule bag, while the second end of the ring is left outside the eye (length 2-3 mm). Perform phacoemulsification (gentle mode), during which each time the lens is displaced posteriorly, a portion of viscoelastic is fed through the cannula under the lens through the trocar, restoring the natural position of the lens. After removing the contents of the bag, the ring is brought out, the capsule bag is removed, the three-part folding IOL is implanted and fixed with sutures to the iris or sclera. After this, viscoelastic is washed out of the anterior chamber, replacing it with saline. No suturing on the tunnel is required (the technology is designed for small access, excluding postoperative astigmatism). Then, through the trocar, the remains of viscoelastic are removed using a vitreotome. Withdraw the trocar. The operation is completed.

Example.

Patient F., 62 years old, came to the clinic with a diagnosis of

Open-angle 3a (operated, laser, on myotics) glaucoma, complicated cataracts, lens subluxation of 3 degrees, pseudoexfoliation syndrome of the right eye.

Myopia of the 1st degree of the left eye.

The diagnosis has been confirmed.

Functional Diagnostic Data:

VOD = 0.25 sph n / a cyl + 1.75 ax 25 = 0.5

VOS = 0.75 sph-1.0 = 0.95

Keratometry OD 44.75 / 43.75 ax 46

OS 44.5 / 44.0 ax 28

IOP OD = 22 mmHg

IOP OS = 19 mmHg

An operation according to the invention was performed on the right eye. After removing the contents of the bag by phacoemulsification through a 2.2 mm front access and exposing the capsule ring and bag to the outside, a three-part Acrysof IOL was implanted and sutured to the iris. As a viscoelastic, a viscot was used, which was successfully removed at the end of the operation (front access and via a trocar).

The postoperative period without features.

Functional diagnostic data on the first day:

VOD = 0.7 sph n / a cyl + 1.0 ax 40-0.9

Keratometry OD 44.75 / 43.50 ax 54

The magnitude of induced astigmatism was 0.25D

IOP OD = 23 mmHg

IOP OS = 21 mmHg

Thus, the presented technology made it possible to rehabilitate a patient with severe ocular pathology and to obtain high functional results.

After 3 months at a second examination, visual acuity of the right eye VOD = 0.8. The value of corneal astigmatism decreased to 0.5D.

The inventive method in our Center operated on 12 patients. All operations were successful, cataract in all cases was removed by phacoemulsification through a small tunnel incision followed by implantation of folding IOLs, the fixation of which was performed using sutures to the iris (8 eyes), to the sclera (4 eyes). The expected high visual acuity was obtained; the magnitude of the induced corneal astigmatism in all patients did not exceed 1D.

Claims (4)

1. A method for phacoemulsification of a cataract complicated by lens subluxation, including stabilization of the capsular bag using an intracapsular ring, which is introduced into the equatorial zone of the bag through paracentesis and capsulorexis, while the second end of the ring is left outside the eye, phacoemulsification and implantation of an intraocular lens) ( that they begin the operation with stabilization of the lens using viscoelastic, for this a trocar of 25G caliber is installed in the flat part of the ciliary body, then through the corneal The mydriatic and viscoelastic solution is injected into the anterior chamber, then an irrigation cannula is inserted through the trocar in the direction of the crystalline lens and viscoelastic is placed under the crystalline lens, the crystalline lens is displaced upward by the viscoelastic and the cannula is centered to bring the crystalline lens into a natural anatomical position, after which the anatomical maxim is open, then , establish the intracapsular ring and carry out phacoemulsification, during which each time the lens is displaced posteriorly through the trocar under the lens under dissolved portion viscoelastic restoring the natural position of the lens, and removing the contents of the bag, is discharged outside the ring was removed capsular bag, the IOL is implanted with subsequent fixation viscoelastic then eluted from the anterior chamber, replacing in saline, whereupon residues viscoelastic outputted through the trocar. 2. The method according to claim 1, characterized in that the outside of the eye leaves the second end of the ring 2-3 mm long. 3. The method according to claim 1, characterized in that the dispersed viscoelastic — viscous — is used as viscoelastic. 4. The method according to claim 1, characterized in that the residues of viscoelastic are removed through a trocar using a vitreotome.