RU2644297C1 - Method of filling ulcerous defect of cornea in its paracentral distribution - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical ophthalmology. In the surgical treatment of corneal ulcers of infectious and non-infectious etiology in the zone of an ulcertive defect, epithelial debridement of cornea is made. Then two nodular or one x-weld is applied to the ulcerative defect, depending on the size of the defect, and the nodes are not immersed in the corneal stroma. Along peripheral rim in the zone of the ulcerative defect, conjunctiva is separated and graft from it is formed. Graft is formed by shearing and pulling the conjunctiva to the center of the cornea and covering it with ulcerative defect and an infiltration zone. After this, the graft is fixed with a p-shaped seam in the zone of height. In addition, two more sutures are applied to the sides of the formed grap, one on each side. Length of each joint does not exceed 2 mm.

EFFECT: method simplifies the surgical treatment of corneal ulcerous defects, both non-infectious and infectious etiology, by excluding the use of implants, donor’s material, special surgical instruments, and the need to excise a large part of the corneal tissues.

1 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, namely to surgical ophthalmology, and can be used in the surgical treatment of corneal ulcers of infectious and non-infectious etiology.

Corneal injuries and diseases occupy from 7.4% to 25% among the causes of blindness and low vision (V.M. Klementyev, 1983; E.S. Libman, 1988).

Corneal ulcer is a serious eye disease, spreading deeper than the bowman's membrane, with the development of an extensive inflammatory process and the presence of ulcerative formations, purulent infiltrate, the result of which is loss of vision until the eye is removed (Seemoreat: http://euroasia-science.ru/medicinskie- nauki / sovremermye-aspekty-lecheniya-yazvennyx-porazhenij-rogovicy / # sthash.PS6IluTT.dpuf). Moreover, a crater-shaped defect is formed on the surface of the cornea.

This pathology is always accompanied by corneal syndrome, that is, clouding of the cornea, a significant decrease in visual acuity, pain.

The cornea of the human eye has a rather complex structure. It consists of five layers: epithelial tissue, Bowman's membrane, stroma, Descemet's membrane, endothelium. With the formation of an ulcer, damage to the epithelial layer occurs, which extends inward to the bowman membrane and even deeper.

Corneal ulcers are considered one of the most serious ophthalmic diseases. They are quite difficult to treat and often cause loss or significant decrease in visual acuity.

The severity of the course of the disease depends on the location of the area in which the ulcer appears, the depth of the lesion, and if the disease originates in the central part of the cornea, the prognosis will be less favorable than with other options for the location of the primary lesion.

Corneal ulcer can occur in both chronic and acute form.

Depending on the cause of the development of corneal ulcers, the latter are divided into infectious and non-infectious. The causative agents of infectious ulcers are:

- viruses (herpes, chickenpox);

- bacteria (Pseudomonas aeruginosa, tuberculosis mycobacteria, pneumococci, streptococci, diplococci, staphylococci);

- mushrooms;

- parasites (chlamydia, acanthameba).

Corneal ulcers of non-infectious origin most often occur against the background of corneal dystrophy (primary or secondary), dry eye syndrome, and some autoimmune diseases.

Predisposing factors for the development of ulcerative lesions of the cornea are:

- non-compliance with the rules of wearing and disinfection of contact lenses;

- long-term therapy of the patient with antibiotics, corticosteroids and some other drugs;

- the use of eye drops and ointments infected with pathogens;

- non-compliance with the rules of aseptic and antiseptic when performing various ophthalmic procedures;

- some eye diseases (keratitis, eyelid inversion, trichiasis, dacryocystitis, blepharitis, trachoma, conjunctivitis) and the nervous system (damage to the trigeminal and / or oculomotor cranial nerves);

- A number of systemic diseases (diabetes mellitus, atopic dermatitis, rheumatoid arthritis, Sjogren's syndrome, polyarteritis nodosa);

- hypo - and vitamin deficiencies;

- general exhaustion.

Often corneal ulcers are formed as a result of eye burns, foreign bodies getting into them, mechanical injury, and photoophthalmia.

According to the depth of the lesion and the nature of the course, corneal ulcers are divided into perforated and non-perforated, superficial and deep, chronic and acute. Depending on the location of the ulcer defect, a central, paracentral and marginal (peripheral) form of the disease is distinguished.

Typically, a corneal ulcer is characterized by a unilateral lesion. Its very first sign is the appearance of severe pain in the affected eye, which, as the disease progresses, intensifies and becomes unbearable. In addition, patients complain of blepharospasm, eyelid edema, photophobia (photophobia), profuse lacrimation.

The degree of visual impairment depends on the location of the defect and is most pronounced with central ulcers. The outcome of the ulcerative process is always the formation of a scar (from small and thin to cataract).

Diagnosis of corneal ulcers is based on the characteristic clinical symptoms of the disease. To clarify the diagnosis, the eye is examined using a biomicroscope (slit lamp). If necessary, fluorescein preparations are applied to the cornea, causing the staining of the ulcer in a bright green color. This diagnostic method allows you to see even very small ulcers in area, as well as accurately assess the depth and extent of the lesion.

Conservative methods for the treatment of complicated corneal ulcers in the initial stages of the disease, as well as in addition to surgical intervention include extracorporeal therapy, plasmapheresis [Polyanskaya N.K. Tactics for the treatment of patients with corneal ulcers on the background of severe somatic pathology. Clinical Ophthalmology. - 2007. - T. 8, No. 1. - S. 14-16]. With the complication of the form of the disease (for example, with a late diagnosis and inefficiency of conservative treatment, the threat or completion of perforation), surgical methods of treatment are forced to be used.

Despite significant advances in the medical treatment of corneal lesions, the problem of urgent therapeutic keratoplasty remains equally relevant, in particular with deep ulceration of the cornea, descemetocele and perforation, penetrating wounds of the cornea with tissue deficiency, and burn injury to the eyeball (Popov M.Z. , 1942; Polozova N.A., 1980; Gorgiladze T.U., 1983; Gundorova R.A., et al., 1983; Puchkovskaya N.A., 1983; Kasparov A.A., 1987; Hirst LW, 1982 ; Kenyon RK 1992).

The main goal of therapeutic keratoplasty is to preserve the eyeball by removing the pathological area of the cornea and restoring its defect (Barraquer, 1961).

, 1970; Thoft R.A., 1979; Tseng S.C. 1998; Azuara, 1999).In order to eliminate defects in the cornea, various materials are used: cornea, sclera, amnion, alloplant, dura mater and others (Kalfa S.F., 1945; Polyak B.L., 1948; Kasparov A.A., 1975; Muldashev E .R., 1987; Batmanov Yu.E., 1990; Gundorova R.A., 1996; Krasyuk E.Yu., 1997; Safonova T.N., 2000; Gundersen T., 1958, 1967; 1968;

, 1970; Thoft RA, 1979; Tseng SC 1998; Azuara, 1999).

However, the possibilities for the widespread provision and use of allogeneic biografts are limited by organizational, economic, legislative, national-religious and other reasons. As a result, in situations requiring urgent repair of corneal defects, it is not always possible to carry out surgical treatment.

A known method of surgical treatment of complicated immunopathological ulcers of the cornea of peripheral localization, which consists in removing sections of the conjunctiva with the affected vessels (conjunctivectomy) and bringing to the formed defect of the perilimbal zone of the full vessels of the unchanged conjunctiva [Kudryashova Yu.I. The effectiveness of the treatment of conjunctival vasculitis in combination with peripheral localized corneal ulcers. Modern technologies in the diagnosis and treatment of vascular pathology of the organ of vision. - Krasnodar, 2002. - S. 202-203]. However, this surgical intervention is quite time-consuming, associated with increased trauma and risk.

In complicated forms of corneal ulcers (banal, creeping peripheral), which have a high risk of perforation of the cornea, keratoplasty with special synthetic materials is used for prophylactic purposes [Polyanskaya N.K. Tactics for the treatment of patients with corneal ulcers on the background of severe somatic pathology. Clinical Ophthalmology. - 2007. - T. 8, No. 1. - S. 14-16] [1].

A known method of treating complicated corneal ulcers, including preparing the surgical field for keratoplasty of the affected corneal areas, keratoplasty of the latter is carried out by applying and fixing to the prepared surface bed on the site of the cornea of the sheet implant from permeable-porous titanium nickelide, cut and molded by anthropometry of the bed surface and anthropometrically formed (RU 2570346 C1, 12/10/2015).

There is a method of treating a deep corneal defect, in which it is filled with collagen gel with cultured allogeneic postnatal or embryonic fibroblasts included in it, then the defect is closed with a soft contact lens with allogeneic postnatal or embryonic epithelial cells deposited on the inner surface (RU 2177284 C1, 12/27/2001 )

Known methods for closing defects of the cornea with a cadaveric cornea (Killingsworth DW etall. Resultsoftherapeuticpenetratingkeratoplasty. // Ophthalmology., 1993 Apr., 100 (4) P. 534-41), own conjunctiva (Gundorova R.A. et al. Autoconjunctival corneal plastic surgery of choice for sealing non-infectious defects of the cornea. // Abstracts of the scientific and practical conference "Theoretical and clinical studies as the basis of medical and surgical treatment of injuries of the organ of vision. Moscow, 2000, pp. 45-47), alloplants (Muldashev E.R. Alloplants in ophthalmic surgery. // Ufa, 1987, pp. .-80).

However, obtaining a cadaveric cornea is associated with certain difficulties: additional examination of the corpse of the donor for the presence of various infections, obtaining the consent of relatives of the deceased to take the material, etc. There are also frequent cases of transplant rejection and necrosis due to a deep violation of the microcirculation of their own damaged tissue, the development of mechanisms of immunological conflict in recipient organism with donor tissue (Tazetdinova N.R. Clinical and immunological substantiation of pathogenetically oriented about medical and surgical treatment of burn eye disease. // Diss. Candidate of Medical Sciences. M., 1989, p. 26 .; Legeza GV and other Errors in the tactics of treating severe eye burns in the early stages and their causes. // Eye burns and their consequences, materials of scientific and practical conference. Moscow, 1997. - pp. 23-24 .; Kuckelkorn R. et al, Retrospektive Betrachtung von schweren Alkaliveratzungen der Augen // Klin. Mbl. Augenheilkd. - 1993. - Bd. 203, H. 6. - S. 397-402). When engraftment takes place, a rough clouding of the cornea is formed with a significant decrease in the visual acuity of the injured eye.

As the closest analogue (prototype), the known keratoplasty method was selected, in which the borders of the removed area of the corneal tissue are marked with a trepan or blade, and the latter is removed layer by layer with a round stratifying knife or blade within the unchanged corneal tissue. On the intact area of the conjunctiva of the eyeball, in the nearest meridian to the lesion, perilimbal, a conjunctiva flap is cut on one leg. Further, from the edge of the bed, a bed channel is formed to the base of the leg of the conjunctival flap by layerwise excision of corneal tissue (both damaged and intact, including the surface layers of the limb within the bed channel). The conjunctival flap is laid on the cornea and fixed with interrupted sutures in the entire canal bed edge to edge. The defect of the epibulbar conjunctiva is not sutured (Oganesyan O.G., Autoconjunctival plastic surgery in urgent surgery of corneal defects, Abstract of dissertation, candidate of medical sciences, M., 2002).

In contrast to the known method, the proposed invention has a number of fundamental differences:

- excision of only superficial epithelium, as a necessary minimum for adherence of the flap, in the prototype - excision of corneal tissue within healthy tissue;

- the conjunctiva flap is simply pulled up like a blanket; in the prototype, the conjunctiva flap is on the leg, i.e. a bridge disconnected from one shore;

- in the prototype in place of the flap remains a defect, which, as the author emphasizes, is not sutured, in the proposed method, this defect is absent;

- in the prototype, from the place of the excised corneal tissue to the base of the flap, a canal is also cut out, where the flap is placed and sewn; in the proposed method, no channel is additionally cut out.

The stage of fixing the formed flap in more detail:

the conjunctival flap is displaced over the ulcer defect towards the center of the cornea with coverage of the infiltration zone.

The U-shaped submersible suture is performed as follows: by injecting a needle into the cornea, pulling the thread longitudinally in the thickness of the cornea, the needle is pulled out from under the conjunctiva, piercing the conjunctiva through to the outside, then the thread is pulled over the conjunctiva, the needle is injected through the conjunctiva under it and there knot with the other end of the thread. Thus, the node is located inside between the cornea and the conjunctival flap.

The technical result of the method consists in successful and fairly technically uncomplicated surgical treatment of corneal ulcer defects of both non-infectious and infectious etiology without the use of any implants and the need to excise a significant part of the corneal tissue, which leads to a decrease in the possibility of developing postoperative complications, provides for the possibility of monitoring the state of internal environments, leaves extensive possibilities of combination with other therapeutic methods, creates favorable conditions for further surgical intervention, in the event of need, and all this ensured we developed the technique of closing the corneal ulcer defect.

The method is as follows.

In the area of a peptic ulcer, corneal de-epithelization is performed (Fig. 1). Then, two nodal (Fig. 2) or one x-shaped suture (Fig. 3) is applied to the ulcer defect, depending on the size of the defect. In this case, the nodes are not immersed in the stroma of the cornea. The conjunctiva is separated along the limb in the area of the ulcer defect and a flap is formed from it (Fig. 4). The flap is formed by moving and pulling the conjunctiva to the center of the cornea and covering it with a peptic ulcer and an infiltration zone. After that, the flap is fixed with an u-shaped seam in the region of the apex. Additionally, two more seams are placed on the sides of the formed flap, one on each side (Fig. 4). The length of each seam does not exceed 2 mm.

The method is illustrated by the following drawings:

1. De-epithelialized corneal ulcer defect - FIG. one

2. Nodal seams for volumetric ulcer defect - Fig. 2

3. X-shaped suture for a small ulcer defect - FIG. 3

4. Closure of a peptic ulcer by conjunctival flap - FIG. four

The following positions are indicated in the drawings:

1 - cornea

2 - conjunctiva

3 - peptic ulcer

4 - corneal sutures

5 - the area of the limb where the conjunctiva is separated

6 - U-shaped seam

7 - additional seams.

Example 1

Patient B., 60 years old, was treated in the 29th eye department of Clinical Hospital No. 1 named after N.I. Pirogov.

Diagnosis: corneal ulcer with perforation of the left eye.

Anamnesis: according to words, vision decreased about a week ago, 1 month ago, the removal of a foreign body of the cornea.

Upon enrolment:

VISOD = 0.3 IOP = 18 mmHg VISOS = 0.01 n / a IOP = palp norm

Right eye: calm, the cornea is transparent, p / camera is of medium depth, moisture is transparent, pupil 3.5, phacosclerosis. The fundus of the eye: the optic nerve disc is pale pink, the borders are clear, in the ML and the visible periphery without focal pathology, the vessels are within normal limits.

Left eye: mixed injection, deep corneal infiltration paracentrally, descemetitis, medium-sized p / chamber, hypopion 3 mm, pupil 2.5, reaction reduced, phacosclerosis, fundus: not visible in details.

Operation 09/14/15: Kunt conjunctival plastic surgery.

In the middle period, a dislocation of the conjunctival flap, perforation of the ulcer were revealed.

Operation 09/25/15: plastic corneal ulcer of the proposed method.

Concomitant treatment was carried out in accordance with the Moscow city standards of medical care.

At discharge:

VISOD = 0.3 IOP = 18 mmHg VISOS = 0.01 n / a IOP = palp norm

Left eye: moderately irritated, corneal ulcer under the conjunctival flap, infiltration in the resorption stage, anterior chamber of medium depth, moisture transparent, pupil 3 mm, reaction reduced, phacosclerosis. fundus: reflex pink, details behind the fleur.

Right eye: as received.

The patient was discharged with improvement for outpatient monitoring at the place of residence. Conservative treatment recommended.

Example 2

Patient L., 77 L, was treated in the 29th ophthalmic department of City Clinical Hospital No. 1 named after N.I. Pirogov from 06/20/14 to 06/27/14

Diagnosis: perforated corneal ulcer of the right eye, immature cataract of both eyes.

Anamnesis: according to the words, 2 months ago, redness appeared, was treated on an outpatient basis. Sent to the hospital with a scheduled admission to the IOSCR.

Upon enrolment:

VIS OD = 0.1 IOP = N p / p VIS OS = 0.05 IOP = N p / p

Right eye: pericorneal injection, clouding of the cornea along the limb, ulcerative defect for 7-8 hours at the limb with perforation, the edges are clean, the camera is uneven, the iris is in the wound, the pupil is pulled up to the wound, the lens is clouded in the cortical layers, details of the eye day are beyond fleur, reflex weakened.

The left eye: calm, the cornea is transparent, the anterior chamber is of medium depth, moisture is transparent, the pupil is 3 mm in the center, the lens is clouded in the cortical layers. Fundus: details behind the fleur, reflex weakened.

Operation 06/23/14: plastic ulcer on the right.

The treatment was carried out in accordance with the Moscow city standards of medical care.

At discharge:

VIS OD = 0.09-0.1 IOP = N p / p VIS OS = 0.05 IOP = N p / p

Right eye: moderately irritated, ulcerative defect covered by conjunctival flap, sutures consistent, anterior chamber of medium depth, moisture transparent, iris subatrophic, pupil 3 mm, opacification of the lens in the cortical layers, fundus - details behind the fleur, reflex is reduced.

Left eye: as received.

The patient is discharged with improvement for outpatient observation by an oculist at the place of residence, conservative therapy is recommended.

Claims (2)

1. The method of plastic surgery of a corneal ulcer defect during its paracentral localization, characterized in that corneal de-epithelialization is performed in the area of the ulcer defect with the subsequent application of the ulcer defect, depending on its size, two nodal sutures or one x-shaped, without immersing nodes in the stroma the cornea, then along the limb in the area of the ulcerative defect, the conjunctiva is separated and a flap is formed from it, moving it and pulling it to the center of the cornea, covering the conjunctiva with the ulcer defect and the infiltration zone, after which kut fixed inner p-stitch in the top, then further formed on the sides of two superposed flap seam, one on each side, wherein each suture length is less than 2 mm. 2. The method according to p. 1, characterized in that for suturing the corneal ulcer, use nylon 9-0 or 10-0.

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