RU2699535C1 - Method for intraoperative fixation of a subluxated lens in phacoemulsification or laser extraction with intraocular lens implantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. For ultrasonic phacoemulsification or laser extraction of the subluxated lens with intraocular lens implantation (IOL) in the presence of detachment of the anterior hyaloid membrane from the posterior surface of the lens, a corneal tunnel and paracentesis are performed, and the anterior chamber is completely emptied. Then, irrigation-aspiration tip is inserted into anterior chamber, irrigation mode is switched on in phacomatic machine or cataract laser extractor, wherein the sterile air from the tip under the head of the saline balanced solution enters the anterior eye chamber, and the excessive volume of air penetrates through the defect of the Zinn's zonules under the crystalline lens into retrolental space. Then, air is removed from anterior chamber by tip with aspiration mode. That is followed by phacoemulsification or laser extraction of the lens, air is removed from retrolental space, almost pressed down with IOL tip. Then corneal tunnel and paracentesis is hydrated with salt balanced solution and subconjunctival injection of dexamethasone and antibiotic is performed.

EFFECT: method improves the uncorrected visual acuity, reduces the risk of postoperative inflammatory reactions, reduces the length of the surgical intervention and the rehabilitation period.

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Description

The invention relates to ophthalmology and is intended for ultrasonic phacoemulsification (PE) or laser extraction (LE) of a subluxated lens with implantation of an intraocular lens (IOL) in the presence of detachment of the anterior hyaloid membrane from the posterior surface of the lens.

Seamless corneal incision, continuous circular capsulorexis, phacoemulsification and placement of an elastic IOL in a capsular bag are the gold standard for cataract surgery. However, to apply this technique, a certain initial state of eye structures is required, in particular, the safety and strength of the ligamentous apparatus of the eye. In 5-15% of patients with cataracts, a violation of the integrity of these structures is initially observed (Egorov V.V., Tonkonogy S.V., Danilov S.V., Danilov O.V. Ultrasonic biomicroscopy in the preoperative diagnosis of weakness of zinc ligaments in patients with a combination of age-related cataracts and pseudoexfoliation syndrome // New technologies for the diagnosis and treatment of diseases of the organ of vision in the Far East region: Collection of scientific papers. - Khabarovsk, 2013. - P. 142-147).

Lens subluxation is a factor significantly complicating the conduct of PE or LE cataract, in connection with this, the task of developing new methods for cataract surgery of the subluxated lens remains relevant.

The closest analogue of the method is the method of intraoperative fixation of the subluxated lens. The method consists in the fact that first the central parts of the vitreous are removed, air is introduced on the sides of the posterior pole of the lens, and after cataract extraction, an intraocular lens is implanted in a capsular bag or posterior chamber. (RF patent for the invention No. 2180541).

The disadvantage of this method is the need to dissect the conjunctiva and tenon membrane 4-5 mm from the upper limb to perform a meridional section of the sclera and the flat part of the ciliary body with a diamond knife 1.5 mm long or to puncture these membranes with a needle; then the vitreotome requires a partial vitrectomy of the central parts of the vitreum to Tn-1 or insert a sharp intramuscular needle into the vitreum cavity and aspirate 0.1-0.2 ml of the vitreous body. All these manipulations can increase the risk of developing intraoperative hemorrhagic and postoperative inflammatory complications. Another disadvantage is extracapsular cataract extraction when phacoemulsification is not possible, which implies the stitching of surgical access and a longer rehabilitation period for the patient.

The objective of this method is to create a method for intraoperative fixation of a subluxated lens with PE or LE, which allows for a more stable position of the native lens.

The technical result is an improvement in uncorrected visual acuity, a decrease in the risk of inflammatory reactions in the postoperative period, a reduction in the time of surgery and a quick rehabilitation period.

The technical result is achieved as follows: intraoperatively under application anesthesia, a corneal tunnel is performed at 10 hours, corneal paracentesis is performed at 2 hours and the anterior chamber is completely empty. Then, through the main access, 0.1 ml of adhesive viscoelastic is injected directly into the anterior chamber cavity into the anterior chamber to ensure tightness and prevent the iris from falling into the corneal tunnel. They enter the anterior chamber with a coaxial irrigation-aspiration tip with a silicone sleeve and thereby seal the anterior chamber of the eye. Using the pedal of a phacomachine or a laser cataract extractor, they switch on the irrigation mode and sterile air from the irrigation-aspiration tip under the pressure of a salt-balanced solution enters the anterior chamber of the eye, and then penetrates through the defect of the zinc ligaments under the lens into the retrolental space, replacing the intraocular fluid from the posterior chamber of the eye, which left when the eye was empty after paracentesis. Next, the aspiration mode is turned on and air is removed from the anterior chamber, and an air bubble in the posterior chamber stabilizes the position of the lens. Through previously performed paracentesis, an adhesive viscoelastic is introduced into the anterior chamber with simultaneous cessation of irrigation supply and an irrigation-aspiration tip is removed on the deep anterior chamber, continuous circular capsulorexis is performed, hydrodissection and hydrodelineation are performed.

Since air, like any gas, is compressed, the air in the retrolental space will acquire an ellipsoidal shape and surrounds the lens below. This not only serves as an additional support for the lens, but also squeezes the fibers of the vitreous body from the zone of defect of the zinc cords and the posterior capsule of the lens, which prevents the vitreous from falling out into the anterior chamber in subsequent stages of the operation.

Then, PV or LE of the lens, leaching of the cortical masses, polishing of the posterior capsule, introduction of cohesive viscoelastic and implantation of the IOL are performed. Since air always tends to rise upward, at the stage of leaching of viscoelastic, it is easy to remove it from the retro-lental space: for this, the IOL is pressed a little against the posterior capsule, which allows you to remove air from the eye cavity. The corneal tunnel and paracentesis are then hydrated with a balanced salt solution, and at the end of the operation, a subconjunctival injection of 0.2 ml of dexamethasone and 0.2 ml of antibiotic is performed.

If there are fibers of the vitreous in the anterior chamber prior to the lens removal step, then anterior vitrectomy is performed first - a vitreotome is entered through the corneal tunnel and all vitreous fibers are removed from the anterior chamber.

This method allows to provide intraoperative additional support for the subluxated lens, reduce the load on the remaining zinc ligaments, prevent the vitreous fibers from falling out into the anterior chamber during lens removal, thereby reducing the surgical trauma.

The method is illustrated by the figure, which shows a diagram of the method: the position 1 denotes a coaxial irrigation and aspiration tip; 2 - a crystalline lens; 3 - iris; 4 - zinc bundles; 5 - air; 6-vitreous.

Example 1

Patient K., 75 years old, turned to the diagnostic department of the polyclinic of the Federal State Autonomous Institution Scientific Research Center for Scientific and Medical Research "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with complaints of decreased vision of the left eye, fog in front of the eye. When collecting the anamnesis, the patient indicated a gradual decrease in vision over several years, no operations were performed on the part of the eye pathology.

On examination, Visus OS = 0.4

Intraocular pressure (IOP) 19.0 mm. Hg (pneumometry)

OS: the eye is calm, the cornea is transparent, the anterior chamber is uneven, the iris is subatrophic, the lens is clouded in the nuclear-cortical layers, phaco-iridodenesis, the optic nerve disk is pale pink, the borders are clear, the macular zone is behind the fleur.

Diagnosis: OS Complicated cataract, lens subluxation of 2 degrees. Recommended and conducted phacoemulsification of cataracts according to the claimed method.

Examined 2 hours after surgery. The patient notes an improvement in vision. During biomicroscopy: the cornea is transparent, the accesses are hermetic, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the pupil is 5.0 mm, the IOL in the capsular bag is centered. The patient receives standard postoperative therapy.

The next day, Visus OS: 0.9; IOP OS = 18.0 mm. Hg (pneumometry). During biomicroscopy: the cornea is transparent, the accesses are tight, the medium-depth chamber, the moisture of the anterior chamber is transparent, the pupil is 3.0 mm, the IOL is in the correct position, the optic disc is pale pink, the borders are clear, the macular area is without features. The patient was discharged from the hospital.

Example 2

Patient M, 68 years old, turned to the diagnostic department of the polyclinic of the Federal State Autonomous Institution Scientific Research Center for Scientific and Medical Research "Eye Microsurgery" named after Acad. S.N. Fedorova »Ministry of Health of Russia with complaints of decreased vision of the left eye, fog in front of the eye. When collecting the anamnesis, the patient indicated a gradual decrease in vision over several years, no operations were performed on the part of the eye pathology.

On examination, Visus OS = 0.2

Intraocular pressure (IOP) 21.0 mm. Hg (pneumometry)

Objectively: OS: the eye is calm, the cornea is transparent, the anterior chamber is uneven, the iris is subatrophic, the lens is cloudy in the nuclear-cortical layers, phaco-iridodenesis, vitreous fibers are visible at 5 o’clock, details of the fundus are not visualized. Diagnosis: OS Complicated cataract, lens subluxation of 2 degrees.

Recommended and conducted phacoemulsification of cataracts according to the claimed method in combination with anterior vitrectomy, while vitrectomy was performed before removal of the lens.

Examined 2 hours after surgery. The patient notes an improvement in vision. During biomicroscopy: the cornea is transparent, the accesses are hermetic, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the pupil is 5.0 mm, the IOL in the capsular bag is centered. The patient receives standard postoperative therapy.

The next day, Visus OS: 0.8; IOP OS = 18.0 mm. Hg (pneumometry). During biomicroscopy: the cornea is transparent, the accesses are tight, the medium-depth chamber, the moisture of the anterior chamber is transparent, the pupil is 3.0 mm, the IOL is in the correct position, the optic disc is pale pink, the borders are clear, the macular area is without features. The patient was discharged from the hospital.

Example 3

Patient K., 59 years old, turned to the diagnostic department of the polyclinic of the Federal State Autonomous Institution Scientific Research Center for Scientific and Medical Research "MTC" Eye Microsurgery "named after Acad. S.N. Fedorova »Ministry of Health of Russia with complaints of decreased vision of the right eye for several years, fog in front of the eye. When collecting an anamnesis, the patient indicated that he had been using glasses since childhood to correct visual acuity, no operations were performed on the part of the eye pathology.

On examination, Visus OD = 0.1

Intraocular pressure (IOP) 19.0 mm. Hg (pneumometry)

Ultrasonic A-method: eye length 25.3 mm

Objectively: OD: the eye is calm, the cornea is transparent, the anterior chamber is uneven, the iris is subatrophic, the lens is clouded in the nuclear-cortical layers, phaco-iridodenesis, details of the fundus are not visible. Diagnosis: OD Complicated cataract, lens subluxation of 2 degrees, moderate myopia. Recommended and laser extraction of cataracts by the claimed method.

Examined 2 hours after surgery: the patient notes an improvement in vision. During biomicroscopy: the cornea is transparent, the accesses are hermetic, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the pupil is 4.0 mm, the IOL in the capsular bag is centered. The patient receives standard postoperative therapy.

The next day, Visus OD: 0.9 IOP OD = 18.0 mm. Hg (pneumometry). During biomicroscopy: the cornea is transparent, the accesses are tight, the medium-depth chamber, the moisture of the anterior chamber is transparent, the pupil is 3.0 mm, the IOL is in the correct position, the optic disc is pale pink, the borders are clear, the myopic cone, the macular area without features. The patient was discharged from the hospital.

Example 4

Patient K., 72 years old, turned to the diagnostic department of the polyclinic of the Federal State Autonomous Institution Scientific Research Center "Scientific and Research Center" Eye Microsurgery "named after Acad. S.N. Fedorova »Ministry of Health of Russia with complaints of decreased vision of the right eye for several years, fog in front of the eye. When collecting an anamnesis, the patient indicated that there were no operations on the part of the eye pathology.

On examination, Visus OD = 0.05

Intraocular pressure (IOP) 23.0 mm. Hg (pneumometry)

Objectively: OD: the eye is calm, the cornea is transparent, the anterior chamber is uneven, the iris is subatrophic, the lens is clouded in the nuclear-cortical layers, phaco-iridodenesis, vitreous fibers are visualized for 8 hours, details of the fundus are not visible.

Diagnosis: OD Complicated cataract, lens subluxation of 2 degrees. Recommended and performed laser extraction of cataracts according to the claimed method in combination with anterior vyrectrectomy, while vitrectomy was performed before removal of the lens.

Examined 2 hours after surgery: the patient notes an improvement in vision. During biomicroscopy: the cornea is transparent, the accesses are hermetic, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the pupil is 4.0 mm, the IOL in the capsular bag is centered. The patient receives standard postoperative therapy.

The next day, Visus OD: 0.7 IOP OD = 18.0 mm. Hg (pneumometry). During biomicroscopy: the cornea is transparent, the accesses are tight, the medium-depth chamber, the moisture of the anterior chamber is transparent, the pupil is 3.0 mm, the IOL is in the correct position, the optic disc is pale pink, the borders are clear, the macular area is without features. The patient was discharged from the hospital.

Claims (1)

A method for intraoperative fixation of a subluxated lens during cataract extraction with implantation of an intraocular lens (IOL), including the introduction of sterile air, performing capsulorexis, lens extraction and implantation of an IOL, characterized in that the corneal tunnel and paracentesis are performed first, completely empty the anterior chamber, then with an aspiration tip into the front chamber, include irrigation mode on a phacomachine or laser cataract extractor, while sterile air from the tip when under the pressure of a saline balanced solution it enters the anterior chamber of the eye, and an excess volume of air penetrates through the defect of the zinc ligaments under the lens into the retrolental space, then air is removed from the anterior chamber with a tip in the aspiration mode, then phacoemulsification or laser extraction of the crystalline lens is performed, air is removed from the retrolental spaces, slightly pressing down with the tip of the IOL, then the corneal tunnel and paracentesis are hydrated with a balanced salt solution and produce a subconjuncture tival injection of dexamethasone and an antibiotic.

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