RU2535779C1 - Method for performing capsulorhexis in rigid pupil accompanying phakoemulsification in patients with glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves sparing iris retraction from the pupil to the periphery at 2-3 mm sequentially in four quadrants with the use of a Y-pusher for the IOL implantation; a capulorhexis is performed in the cleared regions with the use of forceps.

EFFECT: method enables reducing injuries and a risk of the pupil residual deformity.

1 tbl, 2 ex

Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the surgical treatment of cataracts in patients with glaucoma with a rigid pupil.

One of the difficulties in performing the surgical stage of capsulorexis during cataract phacoemulsification is the rigid pupil, which is most often found in patients with glaucoma - from 70 to 100%.

The optimal diameter of capsulorexis required for performing phacoemulsification followed by implantation of an intraocular lens is 5.5 mm (Takhchidi H.P., Agafonova V.V., Verzin A.A., Sidenko T.N., Anterior capsulorexis: history of appearance, methods execution and dosing (literature review) // Ophthalmosurgery. - 2010. - No. 5. - P.47-51).

Often in patients with glaucoma, the rigid pupil after narrowing mydriasis medication remains narrow - 3-4 mm, which leads to difficulty in manipulating the iris during capsulorexis due to the impossibility of visual control of the anterior capsule.

The closest analogue (prototype) to the claimed is a method of capsulorexis when performing cataract or FEC extraction in patients with a narrow rigid pupil. It consists in preliminary implantation of a mechanical device in the form of an open ring into the pupil region (B. Malyugin, S. Demyachenko-Shulga, C. Method for cataract extraction with implantation of an intraocular lens with a narrow pupil and device for its implementation. Patent No. 2295941. Publ. March 27, 2007).

The method is implemented by performing corneal paracentesis at 2 and 9 hours, through one of which this device is implanted: first, one end is inserted through paracentesis into the anterior chamber of the eye, then through a second paracentesis, a loop is taken with a micro hook at the end of the open ring and the device is placed 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. A continuous circular anterior capsulorexis is performed. After fragmentation and removal of the lens nucleus, aspiration of the lens masses and implantation of an intraocular lens through paracentesis with a micro hook, the hinges of the first kind of devices for expanding the pupil alternately capture the pupils and release the pupil edge of the iris. Then the device is brought into the anterior chamber and, through paracentesis, it is removed from the anterior chamber of the eye, micro-hooking a loop at one of the open ends.

The disadvantages of the prototype are:

1. A significant increase in the injury rate of the operation, because Before the main stage of cataract phacoemulsification, a mechanical ring, hooks are inserted into the anterior chamber and the device is fixed on the iris - the risk of damage to the iris sphincter, hemorrhagic complications, and the development of postoperative inflammatory reactions. This increases the period of postoperative rehabilitation of patients and may reduce visual function.

2. A high risk of trauma to the cornea, damage to its endothelium, due to the need to remove the used mechanical device from the anterior chamber, which can contribute to field surgical keratopathy, up to epithelial-endothelial dystrophy, reducing visual function and prolonging the patient's postoperative rehabilitation.

3. A significant increase in the duration of the operation due to the need for manipulations related to implantation and subsequent removal of this device from the anterior chamber of the eye.

4. After mechanical expansion of the pupil, incomplete restoration of its shape with permanent deformation of the pupil is possible, which can increase light scattering and reduce visual acuity in the postoperative period.

5. The use of this method requires a special device and material costs for its acquisition.

The task is to propose a method for optimal safe capsulorexis when performing phacoemulsification in patients with glaucoma with a narrow rigid pupil.

The technical result is the provision of visual control of the anterior capsule of the lens for the implementation of capsulorexis during phacoemulsification in patients with glaucoma with a narrow rigid pupil.

The technical result is achieved by the fact that after traditional anesthesia, a corneal incision is performed at 9 hours, paracentesis at 7 and 1 hours, the anterior chamber is filled with viscoelastic. Through paracentesis for 1 h, a fork-shaped pusher is introduced into the anterior chamber for implantation of an intraocular lens (IOL), and through a corneal incision for 9 h - tweezers for conducting capsulorexis. In this case, the surgeon holds the fork-shaped pusher in the left hand, and in the right - tweezers to form capsulorexis. Consistently, in four quadrants, using a fork-shaped pusher for IOL implantation, gentle mechanical displacement of the iris from the pupil to the periphery by 2-3 mm is performed. This provides in each quadrant a sufficient visualization of the liberated part of the anterior capsule, and capsulorhexis is performed at the point of displacement with forceps. Then, in the same manner, capsulorexis is sequentially produced in the remaining three quadrants. Then phacoemulsification is carried out according to standard technology.

The advantages of the proposed method are:

1. Minimizing the risk of mechanical damage to the iris sphincter, due to the absence of rough mechanical effects, reducing the risk of intra- and postoperative complications.

2. There is no risk of corneal damage due to the lack of the need for introducing into the anterior chamber and extracting from it a sufficiently voluminous mechanical device.

3. The proposed method is simple and convenient to perform.

4. The time of the operation is reduced.

5. Does not cause pupil deformities.

6. Does not require a special device and material costs for its acquisition.

A comparative assessment of the clinical efficacy and safety of capsulorexis in various ways was performed in 40 patients with age-related cataracts on the background of primary open-angle glaucoma with normalized intraocular pressure in the presence of a rigid pupil (Table 1).

Formed 2 groups of 20 patients, comparable in age, sex, maturity of cataracts, stages of glaucoma.

In the first group, according to the prototype, a device was used to expand the pupil, and then capsulorexis was performed. During the operation, injuries of the sphincter of the iris were noted in 3 eyes, damage to the corneal endothelium in 2 eyes, which in the postoperative period caused corneal edema, required additional treatment and increased the length of hospital stay. Postoperative inflammatory reactions in the form of single fibrin strands were noted in 3 eyes, which were stopped on the 3rd day by subconjunctival injections of Dexamethasone. This increased the length of hospital stay to 5-6 days.

In the second group of patients, capsulorexis was performed according to the proposed method using a fork-shaped pusher. Technically, all operations were performed in a shorter time, there were no complications in this group of patients, with high functional results.

Example 1

Patient K., 72 g.a. No. 197125. Diagnosis: immature complicated cataract, operating with POAG II A OD.

Upon receipt of a complaint about a low OD.

.

.

IOP: OD - 18 mmHg, without antihypertensive regimen.

Echobiometry: OD-AC - 3.0 mm, L - 4.83 mm, AL - 23.43 mm.

Objectively: OD is calm, the filter pad is spilled, the cornea is transparent, the anterior chamber is of medium depth, moisture is clean, destruction of the pigment pupil border of the iris, pseudoexfoliation along the edge of the pupil and on the surface of the iris, subatrophy of the iris, basal iris coloboma at 12 o’clock, 2 pupil , 5 mm in diameter, maximum drug mydriasis - 3.5 mm (Tropicamide 1%, Irifrin 10%), clouding in the nucleus of the lens of the 3rd degree (according to L. Buratto) and in the cortical layers of the lens, DZN is colorless, ED 1.0 DD , macula and periphery of the retina in children Lyakh not oftalmoskopiruyutsya.

The patient underwent OD surgery according to the proposed method, the Aqua-sens IOL was implanted, and there were no complications during the operation. Postoperative course without complications.

At discharge:

Visus OD - 0.9 n / a

IOP OD - 17 mmHg

OD - Calm, the cornea is transparent, the anterior chamber is of medium depth, the moisture is clean, the pupil is round, the IOL is centered, the posterior capsule is transparent. DZN is decolorized, ED 1.0 DD, the macula and the periphery of the retina without visible focal pathology, the course and caliber of the vessels are not changed.

Example 2

Patient M., 62 g.a. No. 130880. Diagnosis: immature complicated cataract, POAG P A OS.

Upon receipt of a complaint about a low OS.

.

.

IOP: OS-19 mmHg, antihypertensive regimen - Dorzopt-plus 2 times a day.

Echobiometry: OS-AC - 3.1 mm, L - 4.75 mm, AL - 23.48 mm.

Objectively: OS is calm, the cornea is transparent, the anterior chamber is of medium depth, moisture is clean, subatrophy of the pupil girdle of the iris, pseudoexfoliation along the edge of the pupil and on the surface of the iris, the pupil is round, 3.0 mm in diameter, maximum drug mydriasis is 3.5 mm ( Tropicamide 1%, Irifrin 10%), the anterior lens capsule is thinned, clouding of the lens in the nucleus of grade 3 (according to L. Buratto) and in the cortical layers, optic discs are decolorized, ED 0.9 DD, the macula and the periphery of the retina are not ophthalmoscopic in detail.

The patient underwent surgery on the OS according to the proposed method, the Aqua-sens IOL was implanted, and there were no complications during the operation. Postoperative course without complications.

At discharge:

Visus OS - 0.9

IOP OS-18 mmHg

OS - Calm, the cornea is transparent, the anterior chamber is of medium depth, the moisture is clean, the pupil is round, the IOL is centered, the posterior capsule is transparent. DZN is decolorized, ED 1.0 DD, the macula and the periphery of the retina without visible focal pathology, the course and caliber of the vessels are not changed.

Table number 1. Comparison of the effectiveness and safety of capsulorexis in the prototype and the proposed method. Way Number of eyes Capsulorexis diameter Complications The use of a device for the expansion of the pupil in the form of an open ring according to the prototype twenty 5 mm - injury to the sphincter of the iris (3 eyes), - damage to the corneal endothelium (2 eyes), - inflammatory reactions (3 eyes). Perform capsulorexis using a fork-shaped pusher for IOL implantation twenty 5 mm are absent

Claims (1)

A method of performing capsulorhexis with a rigid pupil during phacoemulsification in patients with glaucoma, which consists in mechanical action on the iris, characterized in that in four quadrants, using a fork-shaped pusher for IOL implantation, they sparingly move the iris from the pupil to the periphery by 2 -3 mm and in the liberated areas with forceps, capsulorexis is performed.