RU2486879C1 - Method of surgical treatment of trophic ulcers of cornea and progressive keratitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology and can be applied for surgical treatment of trophic ulcers of cornea and progressive keratitis. Covering of cornea surface is carried out by conjunctiva alloplant, from which circle with diameter 13-14 mm with 3 mm long and 2 mm wide "ears", located in accordance with clock face on 3, 6, 9 and 12 o'clock is cut out. In order to install alloplant 2 mm long cuts of eyeball conjunctiva- in accordance with clockface on 3, 6, 9 and 12 o'clock recesses between conjunctiva and sclera are formed, "ears" of alloplant are put under conjunctiva through cuts into recesses, alloplant is fixed to eyeball conjunctiva by blanket suture with thread 8/0 on the circle perimetre.

EFFECT: method makes it possible to improve healing by reinforcement of revasculisation and stimulation of reparative processes.

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Description

The invention relates to medicine, and more specifically to ophthalmology, in particular to methods for surgical treatment of trophic ulcers of the cornea, in particular after severe burns of the cornea, with Terrien's disease, and progressive keratitis that are not amenable to conservative treatment and threatening perforation.

Eye burns are severe damage to the organ of vision and pose a serious medical and social problem. According to the literature, eye burns account for 6.1-38.4% of all eye injuries. Surgical treatment of patients with severe burn injury is an urgent ophthalmological trauma problem. In solving this problem, more and more importance is attached to surgical treatment methods based on the use of various auto- or allogeneic tissues.

Terrien's disease is known as a slowly progressive thinning of the cornea along the periphery, presumably of autoimmune, endocrine and neurotrophic origin. The need for surgical treatment arises during periods of exacerbation and a high risk of perforation of the cornea - through or integumentary keratoplasty is proposed.

Well-known methods for closing corneal defects with a cadaverous cornea or other allogeneic tissues. (N. A. Puchkovskaya, S. A. Yakimenko, V. M. Nepomnyashchaya. “Eye burns”, “Medicine” publishing house, Moscow, 2001, p. 121-141). In case of corneal ulcers after a burn, layered-through keratoplasty using a mushroom graft is more often used. Technique of operation: a mushroom-shaped graft is cut out from a donor cornea, a mushroom-shaped graft is placed in the recipient’s bed so that its “leg” enters the perforation hole, the edges of the graft are sewn to the limb episcler with interrupted sutures.

However, there are frequent cases of transplant rejection and necrosis due to a deep violation of the microcirculation of their own damaged tissue and the development of an immunological conflict in the recipient's body with donor tissue.

On the other hand, there are difficulties with plastic material - the cadaveric cornea due to the unresolved legal and legal aspects of donation in the Russian Federation.

An effective surgical method of treatment is the use of a biological coating (curative superficial keratoplasty) - for long-term non-healing erosions and ulcers of the cornea, its melting and infiltrates, recurring keratitis, acute keratoconus and other untreatable severe pathological changes in the cornea. (N.A. Puchkovskaya, S.A. Yakimenko, V.M. Nepomnyashchaya. "Eye burns", publishing house "Medicine", Moscow, 2001, p.135-137).

The disadvantage of this method is intolerance to the transplanted cornea, rejection and graft disease.

The treatment coating can also include amnioplasty, i.e. covering the cornea with an amniotic membrane to stimulate reparative processes in the cornea during long-term non-healing trophic erosion and ulceration of the cornea (N. A. Puchkovskaya, S. A. Yakimenko, V. M. Nepomnyashchaya. “Eye burns”, publishing house “Medicine”, Moscow, 2001, p.137).

Intolerance to the transplanted membrane, rejection and graft disease.

The closest is a method for the treatment of purulent keratitis and corneal ulcers, including anesthesia, removal of necrotic tissue, transplantation of a xenograft from the cattle pericardium onto the damaged cornea with transverse conjunctural fixation to the sclera with interrupted sutures. (Patent for invention RU No. 2200521, IPC A61F 9/007, publ. March 20, 2003 - Tereshchenko A.V., Romanenko S.Ya., Golenkov A.K.).

The disadvantage of this method is intolerance to the transplanted xenograft, rejection and graft disease.

The objective of the invention is to improve treatment results through the use of an alloplant conjunctiva, to provide high healing of ulcers or keratitis due to the stimulation of reparative processes in the cornea due to increased vascularization in the absence of allergization.

The task is achieved by the method of surgical treatment of trophic ulcers of the cornea and progressive keratitis, including anesthesia and complete closure of the surface of the cornea. Akinesia is carried out with a 1% solution of lidocaine 8.0 ml and retrobulbar anesthesia with a 1% solution of lidocaine 2.0 ml. Closing the surface of the cornea is performed by the conjunctival alloplant, from which a circle is cut with a diameter of 13-14 mm with “ears” 3 mm long, 2 mm wide, located in accordance with the clock dial at 3, 6, 9 and 12 hours. For the installation of an alloplant, the conjunctiva of the eyeball is cut 2 mm long - in accordance with the hour dial at 3, 6, 9 and 12 hours and pockets are formed between the conjunctiva and sclera. The "ears" of the alloplant are inserted under the conjunctiva through the incisions into the pockets, the alloplant is fixed to the conjunctiva of the eyeball with an 8/0 thread around the circle around the circle.

Novelty of invention

Akinesia is carried out with a 1% solution of lidocaine 8.0 ml and retrobulbar anesthesia with a 1% solution of lidocaine 2.0 ml. Conducting retrobulbar anesthesia can stimulate trophic processes in the cornea due to increased metabolic processes in the ciliary node and moderate vasodilating, antispasmodic action of the anesthetic lidocaine 1% solution.

The corneal surface is closed with a conjunctiva alloplant, from which a circle is cut with a diameter of 13-14 mm with “ears” 3 mm long, 2 mm wide, located in accordance with the clock dial at 3, 6, 9 and 12 hours. The use of conjunctival alloplant promotes tissue healing through special preservation. The material lacks antigenic properties.

The conjunctiva of the eyeball is cut 2 mm long - in accordance with the hour dial at 3, 6, 9 and 12 hours and pockets are formed between the conjunctiva and sclera. The "ears" of the alloplant are inserted under the mucous membrane of the eyeball through the cuts in the pockets, the alloplant is fixed to the conjunctiva of the eyeball with an 8/0 thread around the circle around the circle. The vascularization of the limbal vasculature improves, newly formed vessels appear, trophism improves due to the diffusion of biologically active substances formed in the subconjunctiva of the eyeball. The formation of pockets and the location of the ears in them, the fixation of the alloplant with a twisted seam allows to increase the accuracy of the alloplant installation, the reliability and strength of its fixation, which reduces the healing time.

The technical result of the method consists in the use of conjunctival alloplant, which promotes tissue healing due to special conservation. The material lacks antigenic properties, therefore, immunological incompatibility and transplant rejection are excluded. The vascularization of the limbal vasculature improves, newly formed vessels appear, trophism improves due to the diffusion of biologically active substances formed in the subconjunctiva of the eyeball, which shortens the treatment time. The operation is safe, as the corneal tissue is not removed. The accuracy of alloplant installation, reliability and strength of its fixation are achieved, which reduces the healing time.

The invention is illustrated in figure 1, which shows the alloplant conjunctiva.

A method of surgical treatment of trophic corneal ulcers, for example, against the background of progressive keratitis with ulceration is as follows.

Akinesia of 1% r-rum of lidocaine 8.0 ml and retrobulbar anesthesia of 1% r-rum of lidocaine 2.0 ml are performed. The conjunctiva of the eyeball is cut 2 mm long in accordance with the hour dial at 3, 6, 9 and 12 hours and pockets are formed between the conjunctiva and sclera. From the alloplant of the conjunctiva, a circle 1 is cut with a diameter of 13-14 mm with "ears" 2 3 mm long and 2 mm wide, located in accordance with the hour dial at 3, 6, 9 and 12 hours. The conjunctival alloplant is produced by the Federal State Budgetary Institution “All-Russian Center for Ophthalmic and Plastic Surgery” of the Ministry of Health and Social Development of the Russian Federation. Russia, Bashkortostan, Ufa.

The “ears” 2 are seasoned under the mucous membrane of the eyeball through the incisions. In addition, the alloplant is fixed to the conjunctiva of the eyeball with an 8/0 suture along the circumference of circle 1. In the postoperative period, the instillation of eye drops, antibacterial, keratoplastic preparations, is continued. Infiltration of the cornea completely dissolves, newly formed vessels actively grow through the limb.

Clinical example 1.

Patient K., 36 years old, suffers from recurrent keratitis in both eyes for four years. Currently admitted to the ophthalmology department with recurrence of marginal keratitis in both eyes: photophobia, lacrimation, pericorneal injection of eyeballs, on the corneas along the limb from 4 to 8 hours infiltration to the middle layers of the stroma; in the central sections of the cornea are transparent, the moisture of the anterior chamber is transparent, the irises are calm, the pupils react to light, there are no posterior synechiae. He received intensive antibacterial, anti-inflammatory, symptomatic therapy: cefazolin 3.0 g / day iv 10 days, amoxicillin 1.5 g / day inside 10 days, metranidazole 5 mg / 100 ml iv 2 times a day, 7 days, gentamicin 0.5 ml under the conjunctiva of both eyes for 10 days, calcium chloride 10% 10 ml i / o No. 10, cycloferon 2.0 ml i / m No. 10, ascorbic acid 5% 2.0 ml i / o No. 10; in instillations: ciprolet 0.3% 1 drop 6 times a day, tobropt 0.3% 1 drop 6 times a day, diclof 0.1% 1 drop 4 times a day, tropicamide 1% 1 drop 2 times per day, cornegel 5%, 1 drop 3 times a day; magnetotherapy No. 10 in both eyes, a warming compress 1 time per day No. 10. Given the progressive course of the inflammatory process - increased photophobia, lacrimation, cuts in both eyes, increased hyperemia of the eyeballs and the appearance of conjunctival chemosis in both eyes, the rapid progression of infiltration of the cornea of the right eye around the circumference along the limb from 2 to 10 hours and in depth to the deep layers of the stroma , ulceration of the surface layers of the stroma on the right, on the left, the infiltration persisted from 4 to 8 hours, the absence of positive dynamics in conservative treatment - the patient underwent surgery according to the proposed method - integumentary keratoplasty on the right with the conjunctival alloplant. Akinesia was performed with 1% lidocaine solution 8.0 ml and retrobulbar anesthesia with 1% lidocaine solution 2.0 ml. The conjunctiva of the eyeball was cut 2 mm long - in accordance with the hour dial at 3, 6, 9 and 12 hours, pockets were formed between the conjunctiva and sclera. The cornea is covered with an alloplant in the form of a circle with a diameter of 14 mm, the “ears” of the alloplant are 3 mm long, 2 mm wide are inserted under the mucous membrane of the eyeball through cuts in pockets, in addition, the alloplant is fixed to the conjunctiva of the eyeball with an 8/0 suture thread. In the postoperative period, complex conservative therapy continued: in instillations: tobropt 0.3% 1 drop 6 times a day, boric acid 2% 1 drop 3 times a day, an aqueous solution of chlorhexidine 0.02% 1 drop 3 times a day , cornegel 5%, 1 drop 3 times a day; in injections - emoxipin 1%, 0.5 ml s / c temples No. 10, vitamin B12 at 500u / m No. 10. After 15 days, the alloplant and sutures were removed. The inflammatory process in the eyes stopped, slight photophobia persisted, the conjunctival chemosis resolved, the corneal infiltration of both eyes completely resolved, the defect of the surface layers of the stroma on the right completely epithelized, clouding of the stroma formed at the site of infiltration, and superficial newly formed vessels began to grow through the limb. The patient was discharged for outpatient follow-up care with recommendations: instillation of boric acid in both eyes 2% 1 drop 3 times a day and 5% root preservative 1 drop 3 times a day. When viewed in dynamics after 2 weeks and 1 month, the eyes are calm, there are no signs of inflammation, clouding of the stroma has formed on the corneas along the limb at the sites of infiltration, and superficial newly formed vessels actively grow through the limb. As a result of this method of treatment, there is activation of reparative processes, elimination of further corneal destruction, formation of scar tissue and active corneal vascularization, the drug load on the body has decreased and the treatment time has been reduced.

Clinical example 2.

Patient O., 62 years old, suffers from a progressive trophic ulcer of the cornea of the right eye for 6 months - the stromal defect gradually increased in area, new defects appeared and merged into one, constant photophobia and lacrimation on the right. Currently, she was hospitalized in the ophthalmology department due to the exacerbation of the process - severe photophobia, lacrimation, sensation of a foreign body in the eye, pericorneal injection of the eyeball, presence of a limb uneven in depth of the corneal ulcer at 12-3 hours, infiltration of the edges of the ulcer, single superficial neoplasms vessels grow through the limb. Diagnosed with Terrien's Disease. Outpatient for 1 month was treated with antibacterial and keratoplastic drugs: in instillations of okamistin 1 drop 6 times a day, chloramphenicol 0.25% 1 drop 6 times a day, balarpan 1 drop 4 times a day, cornegel 5% 1 drop 4 times a day. Given the progressive course of trophic corneal ulcers and the absence of positive dynamics in conservative treatment of the patient, the operation was performed according to the proposed method - integumentary keratoplasty on the right with conjunctival alloplant. Akinesia was performed with 1% lidocaine solution 8.0 ml and retrobulbar anesthesia with 1% lidocaine solution 2.0 ml. The conjunctiva of the eyeball was cut 2 mm long - in accordance with the hour dial at 3, 6, 9 and 12 hours, pockets were formed between the conjunctiva and sclera. The cornea is covered with an alloplant in the shape of a circle with a diameter of 13 mm, the “ears” of the alloplant with a length of 3 mm and a width of 2 mm are tucked under the mucous membrane of the eyeball through cuts in pockets, in addition, the alloplant is fixed to the conjunctiva of the eyeball with an 8/0 suture thread. In the postoperative period, complex conservative therapy continued: instillations of chloramphenicol 0.25% 1 drop 6 times a day, balarpan 1 drop 4 times a day, cornegel 5% 1 drop 4 times a day; emoxipin 1% 1.0 ml s / c temple No. 15, vitamin B1 5% 1.0 ml s / c No. 15. After 15 days, the alloplant and sutures were removed. As a result of this method of treatment, the inflammatory process in the eye stopped, photophobia, lacrimation disappeared, infiltration of the edges of the ulcer resolved, the stromal defect was completely epithelized, and the surface vascularization of the ulcer from the limb increased. The patient was discharged for outpatient follow-up with recommendations: instillation of 0.1% diclof drops 1 drop 4 times a day and 5% root preservative 1 drop 3 times a day. When viewed in dynamics after 2 weeks and 1 month, the eye is calm, photophobia and lacrimation are not present, superficial corneal vascularization through the limb at the site of the epithelialized stromal defect intensified - the eye condition canceled the instillation of diclof 0.1% and reduced the frequency of installation of the cornegel 5% to 1 drop 2 times a day.

The proposed method for the surgical treatment of trophic ulcers of the cornea and progressive keratitis promotes complete healing in the area of corneal damage due to increased microcirculation and stimulation of reparative processes in the corneal tissue due to increased vascularization in the absence of allergization; Helps reduce drug loading and reduce treatment time.

Claims (1)

A method for the surgical treatment of trophic ulcers of the cornea and progressive keratitis, including anesthesia, complete closure of the surface of the cornea, characterized in that they carry out akinesia with a 1% solution of lidocaine 8.0 ml and retrobulbar anesthesia with a 1% solution of lidocaine 2.0 ml, closing the surface the cornea is performed with the conjunctiva alloplant, from which a circle is cut with a diameter of 13-14 mm with “ears” 3 mm long, 2 mm wide, located in accordance with the clock dial at 3, 6, 9 and 12 hours; 2 mm long eyeball nactivities - in accordance with the hour dial at 3, 6, 9 and 12 hours and form pockets between the conjunctiva and sclera, the alloplant's “ears” are tucked under the conjunctiva through the incisions into the pockets, the alloplant is fixed to the conjunctiva of the eyeball with an entwining sewing 8/0 around the perimeter of the circle.

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