RU2485920C1 - Method of phacoemulsification of eyes with narrow pupils - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology and can be applied for phacoemulsification on eye with narrow pupil. Paracenteses on 12, 2, 5 and 9 o'clock are performed. Hooks-iris-retractors are introduced on 12, 5 and 9 o'clock, pupil edge of iris is stretched to give it rectangular shape and phacoemulcification is performed, before carrying out irrigation-aspiration iris-retractor on 9 o'clock is removed and said paracentesis and papacentesis on 2 o'clock is used for irrigation-aspiration.

EFFECT: method makes it possible to reduce operation time, reduce risk of hemorrhage, reduce risk of vitreous body falling out.

2 cl, 2 ex

Description

The present invention relates to ophthalmology and is intended for phacoemulsification in the eyes with a narrow pupil.

Currently, the most advanced methods for removing the natural lens of the eye, both with cataract and with refractive purpose, are methods that use small incisions, which led to a decrease in postoperative inflammation, and therefore, reduced the recovery time for vision after surgery.

Various methods are known for phacoemulsification of the lens of the eye with IOL implantation, including opening the eyeball, conducting continuous circular anterior capsulorhexis, hydrodissection, phacoemulsification inside the capsular bag, removal of the crystalline masses, implantation of the IOL and suturing.

With a narrow pupil, the implementation of methods using small incisions increases the risk of intraoperative and postoperative complications: tearing of the zinc cords, rupture of the posterior lens capsule, hemorrhage of the iris, damage to the pupil edge of the iris with impaired sphincter function, postoperative iridocyclitis, corneal edema, etc.

The problem of reducing intra- and postoperative complications in the surgical treatment of cataracts complicated by a narrow pupil is relevant. Often, degenerative changes in the tissue of the iris are combined with dystrophy of the zinc ligaments. With insufficient diaphragmatic function of the iris, a subluxation of the lens occurs. Phacoemulsification with a narrow pupil and weakness of the zinc cords is fraught with the occurrence of complications such as trauma to the iris, rupture of the posterior capsule, luxation of the crystalline lens in the vitreous body, etc.

For phacoemulsification, maximum dilatation of the pupil is necessary (William F Maloney. An approach for beginning phaco surgeons. Implants in Ophthalmology. - 1989. - Vol.3. - No. 4. - P.96-101). The presence of a narrow rigid pupil is a serious contraindication to the operation due to the impossibility of visual monitoring of the tip of the phacoemulsifier relative to the lens, its posterior capsule and zinc ligament using an operating microscope.

During the phacoemulsification procedure in the eyes with a narrow pupil, insufficient mydriasis causes technical difficulties, increases the risk of injuring the iris and getting it ruptured. In accordance with this, various methods of phacoemulsification in the presence of a narrow pupil are proposed.

A known method of removing the lens with a narrow pupil, in which two corneal paracentesis is done at 3 and 9 hours, through one of them perform continuous circular capsulorexis. Then, the phacoemulsifier irrigation tip is introduced into one of the paracentesis, and the aspiration tip is introduced into the other and the lens masses of the anterior cortical lens layer, peripheral lens masses and posterior lens masses are removed. Next, the suction tip is brought under the lens nucleus, and the irrigation tip is placed above the core and by moving towards each other, the core is divided into parts. Extend one of the paracentesis for the introduction of an ultrasonic tip, carry out phacoemulsification of the lens and implant IOL (RU 2284807, 10.10.2008). However, the disadvantages of the method include the fact that capsulorexis is performed with a narrow pupil, as a result of which there are difficulties in performing capsulorexis (especially in glaucoma eyes). Since capsulorexis itself is small in size, it is difficult to remove cataracts of density 3 and 4 through it, in addition, there is a risk of damage to the edge of capsulorexis by the phacochopper and a high risk of prolapse of the vitreous. It should be noted that phacodonesis is poorly visualized, pseudo-exfoliation (PES) is not visualized, and in hyperopters with a small anterior chamber, manipulation is difficult, since endothelial damage is possible.

A known method of cataract extraction with a narrow pupil, providing for the formation of an anterior circular capsulorexis and phacoemulsification of the lens nucleus with core fragmentation in the center of the pupil in a vertical plane in the projection of capsulorexis formed along the edge of the pupil without mechanical expansion (RU 2317052, 02.20.2008). The disadvantages of the method are associated, as in the previous method, with poor visualization of phacodonesis, lack of visualization of pseudo-exfoliations (PES), difficulties in performing capsulorexis (especially in the eyes of glaucoma), the risk of damage to the edge of capsulorexis by phacocopper, high risk of vitreous prolapse, endothelial damage in hypermetropes in the presence of a shallow camera.

A known method of cataract extraction with a narrow pupil by phacoemulsification under visual control using an endoscope that is inserted into the posterior chamber at an angle of 45-60 ° or into the vitreous at an angle of 60-75 °, while in the process of phacoemulsification the nucleus is advanced around its axis c subsequent phacoemulsification of its edges (RU 2177286, 12.27.2001). The disadvantages of the method are the need to use expensive equipment, the risk of endophthalmitis when the endoscope is inserted into the vitreous body, the use of monomanual cataract phacoemulsification technology, the presence of a narrow field of view through the endoscope, with the ensuing consequences.

A known method of treating cataract patients with pseudoexfoliation syndrome (PES), which consists in expanding the pupil using the pupil ring, having a quadrangular shape, where each of the vertices is a loop. The pupil ring is inserted into the anterior chamber and the pupil edge of the iris is sequentially inserted into each loop by advancing the ring around the circumference in the plane of the iris. Next, a continuous circular capsulorexis is performed, the diameter of which corresponds to the diameter of the dilated pupil. Under the edge of the capsulorexis, viscoelastic is served to raise its edge. After that, with one tool, the loop of the pupil ring is pulled to the center of the pupil, the other is taken away from the lower arc of the loop posteriorly and the edge of capsulorexis located in the projection of the loop is brought into each loop (RU 2310427, 11/20/2007). However, it is technically difficult to place the edge of capsulorexis in 4 loops of the pupil ring. In addition, in the presence of PES, the capsulorexis edge can tear during manipulations, and in hyperopia with a small camera, manipulations are difficult, which leads to the risk of damage to the endothelium.

A known method of cataract extraction with a narrow pupil, which consists in carrying out corneal paracentesis at 2 and 9 hours and implanting through one of them a device for expanding the pupil in the form of an open ring: first, one end is introduced through paracentesis into the anterior chamber of the eye, then through the second paracentesis with a micro hook grab a loop at the end of an open ring and place the device in the anterior chamber of the eye, on the iris. The pupil edge of the iris is sequentially fixed with a micro-hook in the first-kind hinges and the pupil is dilated. Continuous circular anterior capsulorexis (NKPK) is performed, the edge of the NKPK is fixed in these hinges of the first kind, and the arcs between the hinges of the first kind are brought under the edge of the capsulorexis from the inside. Hydrodissection, fragmentation and removal of the lens nucleus, aspiration of the lens masses are performed. IOL is implanted through one paracentesis, and through the second paracentesis, microhooks successively capture the hinges of the first kind of pupil expansion device and release the pupil edge of the iris and the edge of capsulorexis from them. The device is brought out to the anterior chamber and through the same paracentesis the device is removed from the eye by micro-hooking a loop at one of the open ends (RU 2295941, 03/27/2007). However, when performing the method, it is technically difficult to insert the edge of capsulorexis into 3 loops of the pupil ring. In addition, in the presence of PES, capsulorexis can tear during manipulation, which will lead to corresponding complications - prolapse of the vitreous body, and with a large gap - prolapse of the crystalline masses into the vitreous body, which, in turn, can lead to phacogenic uveitis.

A known method of dilating the pupil during ophthalmic surgery, in which a ring is made into the anterior chamber of the eye, into the pupil region, made of a material having the property of swelling and provided with a groove along the outer edge, in which the pupil edge of the iris is fixed, the dimensions of the groove correspond to the thickness of the iris along it pupillary edge (RU 2102952, 01/27/98). The disadvantages of the method are the need for a large incision and suturing, which leads to postoperative induced astigmatism, in the long term - to the need to remove postoperative sutures, the selection of complex astigmatic glasses (glasses), in addition, there are difficulties with manipulation in the capsule bag and the anterior chamber, especially when the “body” falls out.

There is a method of phacoemulsification of the subluxated lens, when before the emulsion of the lens mydriasis is achieved using hooks (iris retractors). (Thomas A. Oetting, MD, Luis C. Ompohroy, MD. Iris hooks for phacoemulsification of the subluxated lens // J-Cataract - Refractive Surgery. - 1997. - Nov. - 23 (9). - P.1295-7 )

There is a method of dilating the pupil using 4 hooks, which are inserted into the anterior chamber through 4 additional (2-3 mm) corneal incisions (A.P. Posazhennikov. Methods of mechanical expansion of the pupil in surgery of soft and membranous cataract. Bulletin of Ophthalmology.-1988. - T. - 104. - No. 3. - C.22-24). The disadvantages of this method are its invasiveness and frequent ruptures of the sphincter of the pupil with a sufficiently strong stretching, which can lead to bleeding. With this stretching, the pupil does not restore or partially restores its shape after removal (removal) of iris retractors. This method is taken as the closest analogue.

The task of the invention is to improve the method of phacoemulsification with a narrow pupil.

The technical result of the proposed method is to reduce the time of phacoemulsification, the absence of ruptures of the sphincter of the pupil edge and bleeding from this zone, the absence of rupture of the capsulorhexis and the posterior lens capsule, as a result of which the vitreous prolapse occurs, while maintaining satisfactory visualization during phacoemulsification.

The technical result is achieved by reducing the number of paracentesis for irradiation and the use of one of the paracentesis intended for irradiation for irrigation-aspiration.

While in the closest analogue 4 paracentesis is carried out for the introduction of iris tractors and two additional ones for irrigation-aspiration, in the proposed method the number of paracentesis is reduced to 3 and one additional, moreover, one of the three is also used for bimanual aspiration-irrigation. When using three iris refractors to stretch the iris, a triangular hole is formed. A smaller number of paracentesis (instead of 6 paracentesis - 4: at 12, 2, 5 and 9 hours) provides a lower risk of inflammation, as well as the generation of induced astigmatism resulting from impaired limbal strength. With the expansion of the pupil, its central zone should not exceed 5-6 mm, while there are no ruptures of the sphincter of the pupil edge, there is no bleeding from them.

The proposed method phacoemulsification with a narrow rigid pupil was performed in 45 patients. Observations in the near and distant postoperative period showed that with a fairly satisfactory visualization, all stages of phacoemulsification are performed atraumatically, which allows to achieve the maximum possible visual results.

The method is as follows. The patient undergoes conventional anesthesia. Five-time instillation of Alkain with an interval of 5 minutes between instillations is used as epibulbar anesthesia. Diamond microknives with a blade width of 1.0 mm produce corneal paracentesis directly at the limb at 4 points at 12, 2, 5, 9 hours. In the presence of posterior synechiae, they are removed through one of the paracentesis. Through one of the paracentesis, the anterior chamber is filled with a viscoelastic preparation. The iris-fixed hooks fixed on the limb are introduced through paracentesis openings at 12, 5, 9 hours at 12, 5, the pupil edge of the iris is grasped, the pupil edge of the iris is stretched to give it a triangular shape. Using special capsular forceps, capsulorexis is formed with a diameter of 5-6 mm. After hydrodelineation and hydrodissection using the ultrasonic tip of the phacoemulsifier, emulsification is carried out. When switching from phacoemulsification to bimanual irrigation-aspiration, the iris retractor is removed at 9 o’clock and bimanual irrigation-aspiration of soft residues of cortical masses is carried out through paracentesis at 2 and 9 o’clock. The anterior chamber and capsular bag are filled with a viscoelastic preparation. Using an injector, a soft silicone intraocular lens is implanted into the capsular bag through a corneal incision. The pupil edge is released from the iris-irrector hooks at 12 and 5 hours. Using a suction-irrigation tip, a viscoelastic preparation is removed from the capsular bag and the anterior chamber. Under the conjunctiva, 0.3 ml of dexazone is administered, monocular gluing is applied. The method is feasible both when carrying out only phacoemulsification, and as part of a combination with antiglaucomatous surgery.

EXAMPLE 1. Patient V., born in 1944, and / b No. 1980, was admitted with a diagnosis of immature cataract, operated (by laser) open-angle glaucoma II AB of the left eye. Vis OS = 0.05 sph. - 11.0 = 0.1. Intraocular pressure (Po) = 24.3 mm Hg (on mysticism - fotil - 2 r / d). PZO OS-23.81 mm

Keratometry: OS - 98 ° - 44.35

8 ° - 45.61

Biomicroscopy of the left eye: the cornea is transparent, the anterior chamber is of medium depth, the pupil is round, 2.5 mm in diameter, clouding in the nucleus and under the posterior lens capsule, fundus behind the fleur - details are not visible.

A combined operation for subcompensated glaucoma and phacoemulsification by the proposed method. Processing the operating field. Anesthesia: Alkaina solution is epibulbar, novocaine solution 2% -2.0 retrobulbar. Vekorashiritel. A linear incision of the conjunctiva on the watch is 7 mm from the limb 1.5 cm long. A rag of the surface layers of the sclera of rectangular shape 5 × 7 mm is cut and separated with the base to the limb. Under the superficial scleral flap, a triangular-shaped flap from the deep layers of the sclera is dissected. Then we proceeded to cataract removal. Formed paracentesis at 12, 2, 5 and 9 hours. After paracentesis, iris tractors were introduced at 12, 5, and 9 hours, which captured the edges of the pupil and stretched. The pupil stretched out in the form of a triangle. The hooks were fixed at the limb, after which capsulorexis, hydrodelineation and hydrodissection were performed, then phacoemulsification was performed. In the transition from phacoemulsification to bimanual irrigation-aspiration, the iris retractor was removed at 9 o’clock and bimanual irrigation-aspiration of soft residues of cortical masses was performed through paracentesis at 2 and 9 o’clock. The anterior chamber and capsular sac were filled with viscoelastic. Using an injector, a soft silicone intraocular lens was implanted into the capsular bag through a corneal incision. Spent the release of the pupil edge from the iris-irrector hooks at 12 and 5 hours. Using a suction-irrigation tip, viscoelastic was removed from the capsular bag and the anterior chamber. Then they again switched to anti-glaucoma surgery. The outer wall of the Schlemm's canal was removed. A moderate flow of intraocular fluid from the Schlemm's canal appeared. Decreased turgor of the eye. The scleral flap was fixed with 2 8-0 interrupted sutures. Continuous suture on the conjunctiva. R-solution of Dexamethasone 0.3 + r-gentamicin 20 mg s / w. Aseptic dressing.

On the first day, visual acuity was 0.2 sf-1.0 = 0.6.

At discharge (on day 5), visual acuity was 0.4 sf-1.0 = 0.8.

Intraocular pressure = 18 mm Hg.

Biomicroscopy: filter bag for 12 hours, the cornea is transparent, the pupil is 4.0 mm in the center, the IOL in the capsule bag is centered.

The fundus without negative dynamics.

Carrying out phacoemulsification by the proposed method allowed avoiding ruptures of the sphincter of the pupil edge and bleeding from this zone, ruptures of the capsulorexis and the posterior lens capsule, as a result, no vitreous prolapse was noted.

In this case, removal of an immature cataract on the operated eye was shown with the presence of subcompensation of intraocular pressure. Drug antihypertensive treatment without effect. The pupil did not expand due to the rigidity of the pupil, which made it difficult to conduct capsulorexis and further removal of the lens according to standard methods. Removal of immature cataracts with a narrow pupil by the above method allowed to avoid both intraoperative and postoperative complications, reduce the duration of phacoemulsification. At the same time, satisfactory visualization was maintained during phacoemulsification.

EXAMPLE 2. Patient U., born in 1937, and / b No. 9293, was admitted with a diagnosis of mature cataract, operated (laser) narrow-angle glaucoma II A of the right eye. Vis OD = Correct light projection. Intraocular pressure = 14 mm Hg. PZO OD-23.05 mm

Keratometry: OD-32 ° - 42.35

122 ° - 42.72

Biomicroscopy of the right eye: the cornea is transparent, the anterior chamber is of medium depth, the pupil is round, 2.5 mm in diameter, posterior synechiae, iridotomy opening for 12 hours, clouding in all parts of the lens, the fundus is not ophthalmoscopic.

30 minutes before the operation, a subconjunctival injection of a solution of mesatone 1% - 0.3 ml was performed in order to achieve mydriasis. Mydriasis was not achieved due to rigidity of the pupil and the presence of posterior synechiae. During the operation after intracameral administration of mydriatic, mydriasis was not achieved. After paracentesis for 2 hours with a spatula, the posterior synechiae were broken. Through paracentesis for 12 hours, 5 hours, and 9 hours, iris refractors were introduced, which captured the edges of the pupil and stretched. The pupil is stretched in the form of a triangle. The hooks were fixed at the limb, after which capsulorexis, hydrodelineation and hydrodissection were performed, then phacoemulsification was performed. In the transition from phacoemulsification to bimanual irrigation-aspiration, the iris retractor was removed at 9 o’clock and bimanual irrigation-aspiration of soft residues of cortical masses was performed through paracentesis at 2 and 9 o’clock. The anterior chamber and capsular sac were filled with viscoelastic. Using an injector, a soft silicone intraocular lens was implanted into the capsular bag through a corneal incision. Spent the release of the pupil edge from the iris-irrector hooks at 12 and 5 hours. Using a suction-irrigation tip, viscoelastic was removed from the capsular bag and the anterior chamber. R-solution of Dexamethasone 0.3 + r-gentamicin 20 mg sc / w. Aseptic dressing.

On the first day, visual acuity was 0.5-0.6 n / corr.

Intraocular pressure = 15 mm Hg.

Biomicroscopy: the cornea is transparent, the pupil is 4.0 mm in the center, the IOL in the capsular bag is centered.

The fundus without negative dynamics.

In this case, the removal of mature cataract on the operated eye with the presence of posterior synechia was shown. Before surgery, the patient underwent pupil dilation with a 1% mesatone solution under the conjunctiva before surgery and its introduction into the anterior chamber during surgery. However, the pupil did not expand due to the presence of posterior synechia, which made it difficult to conduct capsulorexis and further removal of the lens according to standard methods. Removal of mature cataract with a narrow pupil and the presence of posterior synechia by the above method allowed to avoid both intraoperative and postoperative complications.

Thus, the proposed method of phacoemulsification with a narrow rigid pupil is less traumatic and is not accompanied by intraoperative damage.

Claims (2)

1. A method of phacoemulsification in the eyes with a narrow pupil, including paracentesis and stretching of the pupil edge of the iris with iris retractors, characterized in that paracentesis is performed at 12, 2, 5 and 9 hours, through paracentesis at 12, 5 and 9 hours iris retractor hooks, the pupil edge of the iris is stretched to a triangular shape and phacoemulsification is performed, while prior to irrigation-aspiration, the iris retractor is removed for 9 hours and this paracentesis and paracentesis are used for 2 hours for irrigation-aspiration . 2. The method according to claim 1, characterized in that in the presence of posterior synechiae, they are removed after paracentesis.