RU2692617C1 - Method of monolateral auto keratoplasty of cornea optical zone - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to ophthalmology. For monolateral auto keratoplasty of the cornea optical zone, an auto sclera flap is formed 1/2 of the scleral thickness by the base to the limb by excising the layer-by-layer keratotransplant in the thickness equal to the depth of the ulcerous defect on 12 o'clock under the upper eyelid with 1 mm from the limb. Keratotransplant is placed in a previously prepared bed and fixed with sutures. Peripheral defect of cornea on 12 o'clock is closed by a prepared auto sclera flap by turning it through its base and laying on the cornea with suturing fixation to cornea by 6 sutures and closing conjunctival defect 2 with interrupted sutures.EFFECT: method eliminates threatening of corneal perforation, by means of reliable closing of optical zone, by means of front layer keratoplasty of cornea, enables reducing length of rehabilitation of patients and eliminating corneal syndrome.1 cl, 5 dwg, 2 ex

Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used for layered autokeratoplasty. The method is implemented as follows.

Trephine with a small diameter of 2.5 mm is carried out through penetration within the healthy tissue of the cornea to the posterior border membrane of the cornea after measuring the depth of the ulcer. Opposite the prepared bed for layered keratotransplant under the upper eyelid, an incision of the conjunctiva and the tennon membrane is carried out at the limbus. The flap is made up of autosclers with a size sufficient to close the planned corneal defect 1/2 of the thickness of the sclera with the base to the limbus. Excision of keratotransplant strata, the thickness equal to the depth of the ulcer, is performed with a trepan of the same size for 12 hours under the upper eyelid 1 mm from the limb. The keratotransplant prepared in this way is laid in the previously prepared bed and fixed with sutures. At 12 o'clock, the peripheral defect of the cornea is closed by autoscalers with a previously prepared flap, turning it through its base and laying it on the cornea with suture fixation to the cornea 6 with sutures, after which the conjunctival defect is sutured with 2 interrupted sutures.

Injuries and diseases of the cornea has always occupied a leading place among the causes of blindness and low vision. Treatment of the cornea in various pathologies is caused by a high percentage of disability in this group of patients [1].

Causes of corneal pathology are extremely diverse, these include: injuries of the cornea (toxic lesions, traumatic and radiation injuries), various diseases of the cornea: herpes and bacterial diseases, fungal lesions, trophic disorders, epithelial-endothelial dystrophy, dry keratoconjunctivitis and much more [2, 3, 4]. In almost all of the above cases, damage to the integrity of the corneal epithelium occurs to varying degrees [2, 5, 6].

The most severe lesions of the cornea, of course, include those cases when the cornea is perforated; in such situations, plastic cornea is often used with Kunt autosclera, or corneal plastic with amniotic membrane or umbilical cord tissue of the fetus. The keratoplasty of silica-gel-dried cornea, cryo-frozen or fresh donor cornea is used less frequently [7, 8, 9, 10].

The known method of end-to-end autokeratoplasty [11]. It lies in the fact that before the operation, they perform a mirror microscopy of the endothelium of all the transparent zones of the cornea around the opacities and determine the number of cells in them. Choose the zone with the highest cell density. After the zone is selected, trephinemaids cut out an autograft, which captures the cloud zone and the transparent zone, after which the graft is rotated and the cloud zone is transferred from the dorina line to the periphery. The graft is strengthened with a blanket stitch. However, this method does not allow to eliminate one of the complications of autokeratoplasty, namely the amount of postoperative corneal astigmatism.

The closest technical solution is the method of layer-by-layer keratoplasty [12]. The method consists in the fact that after removal of the area of the pathologically changed, thinned cornea, it is split along the edge of the trephination bed to a depth of 1-3 mm, a layer-by-layer corneal graft is placed at a center thickness of 0.4-0.5 mm and along the edge of the back surface to 0 , 2-0.3 mm, width 1-3 mm around the perimeter and fix the graft to the recipient's cornea with interrupted sutures.

The disadvantages of the method include: additional examination of the donor's corpse for the presence of various infections in it, obtaining the consent of the relatives of the deceased to take the material, etc. Also cases of graft rejection and necrosis due to a deep violation of the microcirculation of the own damaged tissue, the development of the mechanisms of the immunological conflict in the recipient’s organism with the donor cloth [13, 14, 15]. In addition, after the operation, the configuration of the central parts of the cornea is changed, which leads to insufficient visual acuity.

The task of the invention is the creation of an effective way monolateral autokeratoplasty optical zone of the cornea.

The technical result of the proposed method is to achieve higher visual functions, elimination of the threat of corneal perforation, by reliably closing the optical zone, by means of anterior corneal keratoplasty, as well as shortening the rehabilitation time for patients and eliminating corneal syndrome.

The method is implemented as follows.

With a trephine of small diameter of 2.5 mm, blind penetration is performed within the healthy tissue of the cornea to the posterior border membrane of the cornea after measuring the depth of the ulcer (Fig. 1). Opposite the prepared bed for layered keratotransplant under the upper eyelid, an incision of the conjunctiva and the tennon membrane is carried out at the limbus. The flap is made of autosclers with a size sufficient to close the planned corneal defect 1/2 of the thickness of the sclera with the base to the limbus (Fig. 2). Excision of keratotransplant strata, the thickness equal to the depth of the ulcer, is performed with a trepan of the same size at 12 o'clock under the upper eyelid 1 mm from the limbus (Fig. 3). The keratotransplant prepared in this way is placed in the previously prepared bed and fixed with sutures (Fig. 4). At 12 o'clock, the peripheral defect of the cornea is closed by autoscalers with a previously prepared flap, turning it through its base and laying on the cornea with suture fixation to the cornea 6 with sutures, after which the conjunctival defect is sutured with 2 interrupted sutures (Fig. 5).

The advantage of the proposed method:

- the implementation of the front layer of keratoplasty of the cornea allows you to securely close the optical zone with the exception of the threat of perforation and in some cases to increase the patient's vision;

- in case of the threat of rejection of the layer-by-layer keratotransplant, it is possible to take the second peripheral fragment of the cornea under the upper eyelid;

- suture fixation of the flap by autosclers above the zone of the cornea defect under the upper eyelid allows to obtain an aseptic course of the process;

- the location of the zone of taking the layered keratotransplant under the upper eyelid does not impair the cosmetic appearance of the operated eye.

The proposed method allows to achieve high clinical and functional results, which is confirmed by the following clinical examples.

Clinical example 1.

Patient M., 70 years old, was operated on January 22, 2016, diagnosis: ulcer of the cornea of the left eye. Anamnesis: was treated on an outpatient basis after traumatic erosion of the optical zone of the cornea of the left eye. On the sixth day, observe a sharp deterioration in the vision of the left eye. Independently applied to the ophthalmology department. During the initial examination: visual acuity OS = 0.02 does not correct. The eye is hypotonic. In the optical zone of the cornea, there is an ulcer of the cornea with a diameter of about 2 mm, with a protruding desceamer membrane. Front camera saved. The lens without visible pathology. The fundus of the eye is not ophthalmoscopically. On an emergency basis, due to the absence of a donor cornea, a method of plasty of the cornea with a flap of its own cornea was applied. After the incision of the conjunctiva and the Tennon membrane, at 12 o'clock under the upper eyelid, the marking of the flap of the autosclers was carried out. Then, the depth of the corneal center ulcer was determined, which was 400 microns. Trepan 2.5 mm. with a dosed blade feed of 400 microns, partial trepanning was performed around the ulcerative defect of the cornea, the altered corneal tissues were carefully removed. A 400-micron pre-cut corneal layered disk was installed in a prepared bed and fixed with 6 interrupted sutures. Then, with the flap of autosklerae, the kerato graft area with suture fixation to the cornea was closed, 2 sutures were attached to the conjunctiva. Surgery and postoperative periods were uneventful. In the postoperative period, broad-spectrum antibiotics, non-specific anti-inflammatory drugs, keratoplasty were used. When discharged from the department on the 16th day after admission, the OS-eye is moderately irritated. Corneal flaps and autosklery securely fixed to the cornea sutures. Visual acuity OS = 0.2 does not correct.

Clinical example 2. Patient M., 60 years old, was operated on February 12, 2017, diagnosis: purulent cornea of the right eye. Anamnesis: was treated on an outpatient basis by an ophthalmologist for chronic keratoconjunctivitis with antibiotics and keratoplasty. She applied to the ophthalmology department on her own due to a sharp deterioration in the vision of the right eye. During the initial examination: visual acuity OD = 0.02 does not correct. Severe pericorneal injection. In the center of the cornea is a corneal ulcer up to 2 mm in diameter filled with pus. Hypopion up to 1 mm, iris rubeosis. Conducted active treatment with the use of broad-spectrum antibiotics locally and intravenously, antihistamines and desinsibilizing drugs, non-specific anti-inflammatory drugs, steroids, keratoplasty. When relieving signs of inflammation: the disappearance of the hypopion, the signs of iridocyclitis, the cleansing of the ulcer defect for 20 days, the patient was discharged from the outpatient department. Visual acuity OD = 0.03 does not correct. The eye is almost calm, normotonia. In the center of the cornea of the right eye there is a deep defect of the cornea with a gray turbidity. The lens without pathology, the fundus of the eye is within normal limits. After 3 months, the patient again turned for a consultation. When viewed visual acuity OD = 0.04 does not correct. The eye is almost calm, normotonia. In the center of the cornea of the right eye is the same deep defect of the cornea with a gray turbidity. In view of the urgent request of the patient and her refusal to queue up for layer-by-layer keratoplasty, she was offered an operation using a new technique. After obtaining consent, the method of plastics of the cornea was applied using the flap of the cornea. After the incision of the conjunctiva and the Tennon membrane, at 12 o'clock under the upper eyelid, the marking of the flap of the autosclers was carried out. Then the depth of the corneal center ulcer was determined, which was 450 microns. Trepan 2.5 mm. With a dosed blade feed of 450 microns, partial trepanning was performed around the ulcerative defect of the cornea, and altered corneal tissues were carefully removed. A 450-micron pre-cut corneal layered disk was installed in a prepared bed and fixed with 6 interrupted sutures. Then, the keratotlant graft with suture fixation to the cornea was closed with a flap of prepared autoscleers, 2 sutures were applied to the conjunctiva. Surgery and postoperative periods were uneventful. In the postoperative period, broad-spectrum antibiotics, non-specific anti-inflammatory drugs, keratoplasty were used. At discharge from the hospital on the 15th day after admission, the OD-eye is moderately irritated. Corneal flaps and autosklery securely fixed to the cornea sutures. Visual acuity OD = 0.25 does not correct.

Information sources

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Claims (1)

The way monolateral autokeratoplasty of the optical zone of the cornea, including the formation of a flap autoskelera 1/2 thickness of the sclera base to the limb, by excision of layered keratotransplanta thickness equal to the depth of the ulcer at 12 hours under the upper eyelid with a margin of 1 mm from the limb, and different keratotransplant is placed in a previously prepared bed and fixed with stitches, while the peripheral defect of the cornea is closed at 12 o'clock by a previously prepared autosclera flap, by turning and it through its base and laying on the cornea with suture fixation to the cornea 6 stitches and suturing the conjunctival defect 2 interrupted sutures.

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