RU2712300C1 - Method for reposition and lining of intraocular lens, deployed together with capsular sac - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. One corneal paracentesis – the first paracentesis – is intraoperatively performed for reposition and lining of the intraocular lens. Then the knife is rotated in the lumen of this paracentesis by 10–15 degrees, and pressing the knife on the lower lip of the paracentesis, half the anterior chamber is emptied; then 0.1–0.2 ml of the viscoelastic is injected into the anterior chamber above the zone of the supposed iris puncture. Dislocated intraocular lens is centered by means of a rotary hook. Further, by the same hook, the pupil edge of the iris is translationally displaced by 2–3 mm to the periphery in the four quadrants. First paracentesis with a needle with a suture comes into an anterior chamber. Iris is pierced 1.5–2.0 mm from the pupillary border and the frontal capsule of the crystalline lens capsule passing under the haptic element of the intraocular lens closest to the first paracentesis with a posterior capsule grip. Needle is removed by piercing the cornea until the point of needle transfer into the suture is between the iris and the cornea. Needle prick-out point is the first prick out, displaced relative to the first paracentesis by 90 angular degrees. Then, not completely removing the needle, go over the iris in the reverse direction and withdraw the needle with the suture through the first paracentesis and in its lumen forming a nodular suture. Needle is cut off. That is followed by performing a second paracentesis diametrically opposite the first paracentesis, and the above sequence of needle and needle actions is repeated in a similar manner.

EFFECT: method enables improving the uncorrected visual acuity, preserving iris diaphragm function, reducing the risk of postoperative inflammatory reactions, and reducing the length of the surgical intervention.

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Description

The invention relates to ophthalmology and is intended for reposition and hemming of a deployed intraocular lens (IOL) together with a capsular bag due to insolvency of the ligaments of the lens located within the posterior chamber of the eye or within the anterior third of the vitreous cavity.

The dislocation of the posterior intraocular lens is a serious complication of cataract surgery. According to the literature, the dislocation frequency of posterior chamber IOLs is from 0.2% to 3.0% of cases (Yang S, Nie K, Jiang H, Feng L, Fan W (2019) Surgical management of intraocular lens dislocation: A meta-analysis. PLoS ONE 14 (2): e0211489. Https://doi.org/10.1371/journal.pone.0211489).

The closest analogue of the method is a method of reposition of a monoblock intraocular lens, deployed together with a capsular bag. The method consists in the fact that through the flat part of the ciliary body, an injection needle is inserted under the block, with which the block is first centered, and then, pressing the block up, the location of the supporting elements is detected and, using an atraumatic curved suture needle, a sequential, in one approach, application is performed transkornalny fixing sutures on one, and then on the other supporting elements at a distance of 2.5-3.5 mm from the edge of the pupil, after which the thread passing from the outside between the sutures is dissected, and the ends of the threads are brought into paracentesis, you completed in the projection of suturing, and knot knots, characterized in that after the block is centered and the support elements are located, the injection needle is directed under the more remote supporting element to the place of its future fixation to the iris, the injection needle is moved further from this zone towards the equator and, continuing press the block upwards with the needle, the suture is applied, and the injection needle is seized in the seam, and after the needle is punctured, the injection needle is removed from the seam and sent to the place of future fixation of the second o the support element, where again, by performing a suture, the injection needle is captured in the seam, and after the needle is punctured, it is brought out (RF Patent for the invention No. 2527912).

The disadvantage of this method is: the need to pierce the scleral membrane of the eye with an injection needle through the flat part of the ciliary body to center the deployed IOL complex - the capsule bag and squeeze the block up to visualize the haptic elements through the iris, which can increase the risk of inflammatory and hemorrhagic reactions from the iris shell and posterior segment of the eye.

The objective of the invention is to develop an effective, safe and microinvasive method of reposition and hemming (fixation) of a deployed IOL along with a capsular bag.

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

side cut в переднюю камеру, прокалывают радужную оболочку, отступая от зрачкового края 1,5-2,0 мм, передний листок капсулы хрусталика и, проходя под ближайшим гаптическим элементом ИОЛ с захватом задней капсулы, выводят иглу, прокалывая иглой последовательно капсульный мешок, радужную оболочку и роговицу до тех пор, пока место перехода иглы в нить не окажется между радужной оболочкой и роговицей, затем, не извлекая полностью иглы, идут над радужной оболочкой в обратном направлении и выводят через тот же парацентез. При этом место выкола иглы смещено по отношению к парацентезу на 90 градусов. Формирование узла производят внутри парацентеза с регулированием натяжения нити таким образом, чтобы получился широкий стежок, который не будет деформировать радужную оболочку, но вместе с тем позволит достичь соприкосновения подшиваемого комплекса к ее задней поверхности. Далее отрезают иглу и указанную последовательность действий иглой с нитью повторяют зеркально симметрично со вторым гаптическим элементом, предварительно выполнив второй парацентез диаметрально противоположно первому. После двусторонней фиксации дислоцированной ИОЛ, места вколов и выколов нити в радужную оболочку образуют квадрат с шириной стороны 5,0-5,5 мм. При выраженном фиброзе задней капсулы и/или при наличии осложненной грыжи стекловидного тела через один из парацентезов вводят витреотом и рассекают заднюю капсулу хрусталика и/или дополняют передней витрэктомией. Неосложненную грыжу стекловидного тела возможно просто «заправить» с помощью вискоэластика обратно в витреальную полость на этапе репозиции комплекса. Далее удаляют вискоэластик из передней камеры методом промывания: через один парацентез нагнетают ирригационный раствор, а через второй парацентез он пассивно вымывается, парацентезы гидратируют солевым сбалансированным раствором и в конце операции производят субконъюнктивальную инъекцию 0,2 мл дексаметазона и 0,2 мл антибиотика.The technical result is achieved as follows: intraoperatively under application anesthesia, without expanding the pupil (on the narrow pupil), perform the first corneal oblique paracentesis for 10 hours with a spear-shaped knife 1.0 mm wide at an angle of 60 degrees to the surface of the cornea, rotating the knife in the lumen of the paracentesis by 10 ° -15 °, press it on the lower lip of paracentesis and empty the anterior chamber by half to lift the IOL-capsule bag complex upwards with the vitreous body until it contacts the iris. Then, 0.1-0.2 ml of cohesive viscoelastic over the manipulation zone is injected into the anterior chamber and, using the rotational hook (Levitsky hook), they are centered inside the capsule bag of the IOL, using the stored anterior hyaloid membrane as a support for this complex. Next, the pupil edge of the iris is progressively displaced to the periphery by 2.0-3.0 mm with the same rotational hook in four quadrants to visualize the haptic elements and the state of the capsular bag. When examining a deployed IOL along with a capsular bag, attention is paid to the safety and integrity of the haptic elements, their adhesion to the optical part of the IOL, the presence of the Semmering ring, phimosis of the anterior capsulorexis and the severity of fibrosis of the posterior lens capsule. Having determined the projection of the haptic elements of the intraocular lens under the iris, they go through paracentesis with a needle with a thread 10-0 POLYPROPYLENE 20cm Blue Monofilament Needle 15 mm

side cut into the anterior chamber, pierce the iris, retreating from the pupil edge 1.5-2.0 mm, the front sheet of the lens capsule and passing under the nearest haptic element of the IOL with the capture of the posterior capsule, remove the needle by piercing the capsule bag, the iris the membrane and the cornea until the point of transition of the needle into the thread is between the iris and the cornea, then, without completely removing the needles, go over the iris in the opposite direction and out through the same paracentesis. In this case, the needle puncture site is offset by 90 degrees with respect to paracentesis. The formation of the knot is carried out inside paracentesis with the regulation of the tension of the thread so that a wide stitch is obtained that will not deform the iris, but at the same time it will allow the hemmed complex to come into contact with its back surface. Next, the needle is cut off and the indicated sequence of operations with the needle and thread is repeated mirror symmetrically with the second haptic element, after having performed the second paracentesis diametrically opposite to the first. After bilateral fixation of the deployed IOL, the places of injections and punctures of the thread into the iris form a square with a side width of 5.0-5.5 mm. With severe fibrosis of the posterior capsule and / or in the presence of a complicated hernia of the vitreous, a vitreotome is introduced through one of the paracentesis and the posterior lens capsule is dissected and / or supplemented with anterior vitrectomy. An uncomplicated vitreous hernia can simply be “tucked” using viscoelastic back into the vitreal cavity at the stage of complex reposition. Next, viscoelastic is removed from the anterior chamber by washing: through one paracentesis, the irrigation solution is injected, and after the second paracentesis it is passively washed, the paracentesis is hydrated with a salt-balanced 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.

Reposition and hemming of the deployed IOL together with the capsular bag on the narrow pupil excludes the formation of its irregular oval shape in the postoperative period and does not violate the diaphragmatic function of the iris. Hemming with two wide stitches makes it possible to firmly fix the IOL-capsule bag complex to the iris and preserve the natural hydrodynamics of the eye without obturating the pupil area with the hemmed IOL-capsule bag complex. Manipulations with IOL in the anterior chamber are minimal, which reduces the risk of inflammatory reactions in the postoperative period. Performing only two corneal paracentesis leads to a decrease in postoperative trauma and the response of the eye to surgery. Surgical intervention time is reduced due to fewer needle and thread manipulations in the anterior chamber. With fibrosis of the posterior capsule, its dissection reduces higher-order aberrations and increases contrast sensitivity.

The method is illustrated in the figure, which shows a diagram of the method: position 1 indicates the first paracentesis; 2 - the first injection of the thread into the iris; 3 - the first puncture of the thread from the iris; 4 - second paracentesis; 5 - the second injection of the thread into the iris; 6 - the second puncture thread from the iris; 7 - IOL.

Example 1

A 78-year-old patient turned to the ISTC with complaints of low vision of the left eye (OS). From the anamnesis: 10 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model Alcon IQ SN60WF.

On examination, Vis OS = 0.2.

Objectively: OS: calm. The cornea is transparent, the anterior chamber is of medium depth, moisture is transparent, the pupil is round, 3.0 mm in diameter. When viewed with mydriasis (pupil diameter 5.0 mm), the IOL-capsule bag complex is biased downward in the posterior chamber of the eye, pronounced fibrosis of the posterior capsule, the optic edge and the upper haptic element are visualized in the pupil region, the anterior hyaloid membrane is preserved. The optic nerve disc is pale pink, the borders are clear, the macular region is without features.

Intraocular pressure (IOP) 22.0 mm Hg. Art. (pneumotometry)

The IOL was repositioned and stitched according to the claimed method, and the knife was rotated in the lumen of paracentesis by 10 degrees, 0.1 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 3.0 mm to the periphery, the iris was punctured in 1.5 mm from the pupil edge and vitreotome dissection of the posterior lens capsule. The patient was examined 2 hours after the operation, conjunctival injection was noted, the cornea was transparent, the area of the surgical wound with adapted edges, the chamber was of medium depth, the moisture of the anterior chamber was transparent, the sutures on the iris were adapted, the pupil was 3.0 mm, IOL in the center. The patient receives standard postoperative therapy.

The next day, Vis OS: 0.08 sph -1.75 = 0.7; IOP OS = 19.0 mm Hg. Art. (pneumotonometry), conjunctival injection decreased, the cornea is transparent, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the Tyndall phenomenon is not marked, the pupil is 3.0 mm, the sutures are adapted, the IOL is in the center. When viewed with mydriasis (pupil diameter 5.0 mm), the IOL occupies a central position, an optical window with a diameter of 4.0 mm is formed in the posterior lens capsule, the optic disc is pale pink, the borders are clear, the macular region is without features. The patient was discharged from the hospital.

Example 2

A 63-year-old patient turned to the MNTK with complaints of low vision of the right eye (OD), from the anamnesis 3 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model Alcon IQ SN60WF.

When examining Vis OD = 0.03.

Objectively: OD: calm. The cornea is transparent, the anterior chamber is deep, moisture is transparent, the pupil is rounded, 3.0 mm in diameter. The IOL in the capsular bag is shifted down, the edge of the optics is visualized in the pupil. On examination with mydriasis (pupil diameter 5.3 mm), the IOL-capsular bag complex is displaced downward and located in the anterior third of the vitreous cavity, pronounced fibrosis of the posterior lens capsule, a complicated vitreous hernia is also visualized. The optic nerve disc is pale pink, the borders are clear, the macular region is without features.

Intraocular pressure (IOP) 20.0 mm Hg. Art. (pneumotometry)

Reposition and hemming of the IOL according to the claimed method was recommended and performed, while the knife was rotated in the lumen of paracentesis by 15 degrees, 0.2 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 2.0 mm to the periphery, the iris was punctured in 2.0 mm from the pupil edge, an anterior vitrectomy and dissection of the posterior lens capsule were performed by a vitreotome. The patient was examined 2 hours after the operation, conjunctival injection was noted, the cornea was transparent, the area of the operative wound with adapted edges, the anterior chamber was deep, the moisture of the anterior chamber was transparent, the sutures on the iris were adapted, the pupil 3.0 mm, IOL in the center.

The patient receives standard postoperative therapy.

The next day, Vis OD: 0.8, IOP OD = 22.0 mm Hg. Art. (pneumotonometry), conjunctival injection decreased, the cornea is transparent, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the Tyndall phenomenon is not marked, the pupil is 3.0 mm, the sutures are adapted, the IOL is in the center. On examination with mydriasis (pupil diameter 5.3 mm), the IOL occupies a central position, an optical window with a diameter of 4.5 mm is formed in the posterior capsule of the lens, the optic disc is pale pink, the borders are clear, the macular region is without features. The patient was discharged from the hospital.

Example 3

A 70-year-old patient turned to the MNTK with complaints of low vision of the right eye (OD), from an anamnesis 8 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model Alcon NATURAL SN60AT.

On examination, Vis OD = 0.05 sph + 10.0 = 0.8

Objectively: OD: calm. The cornea is transparent, the anterior chamber is deep, moisture is transparent, the pupil is rounded, 3.0 mm in diameter. The IOL in the capsular bag is shifted down, in the area of the pupil, the edge of the optics and the haptic element of the IOL are visualized. When viewed with mydriasis (pupil diameter 6.0 mm), the IOL-capsular bag complex is displaced downward, and a complicated vitreous hernia is visualized in the upper segment. The optic nerve disc is pale pink, the borders are clear, the macular region is without features.

Intraocular pressure (IOP) 18.0 mm Hg. Art. (pneumotometry)

Reposition and hemming of the IOL according to the claimed method was recommended and performed, while the knife was rotated in the lumen of paracentesis by 13 degrees, 0.12 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 2.5 mm to the periphery, the iris was punctured in 1.7 mm removal of the complicated vitreous hernia from the pupil edge and vitreotome.

The patient was examined 2 hours after the operation, conjunctival injection was noted, the cornea was transparent, the area of the surgical wound with adapted edges, the anterior chamber was of medium depth, the moisture of the anterior chamber was transparent, the sutures on the iris were adapted, the pupil 3.0 mm, IOL in the center. The patient receives standard postoperative therapy.

The next day, Vis OD: 0.8, IOP OD = 21.0 mm Hg. Art. (pneumotonometry), conjunctival injection decreased, the cornea is transparent, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the Tyndall phenomenon is not noted, the pupil is 3.0 mm, the sutures on the iris are adapted, IOL in the center. On examination with mydriasis (pupil diameter 6.0 mm), the IOL occupies a central position, the optic disc is pale pink, the borders are clear, the macular region is without features. The patient was discharged from the hospital.

Example 4

A 82-year-old patient turned to the ISTC with complaints of low vision of the left eye (OS). From the anamnesis: 7 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model Alcon SN60AT.

On examination, Vis OS = 0.5.

Objectively: OS: calm. The cornea is transparent, the anterior chamber is of medium depth, moisture is transparent, the pupil is rounded, 2.8 mm in diameter. When viewed with mydriasis (pupil diameter 5.5 mm), the IOL-capsule bag complex is displaced into the lower nasal segment of the posterior chamber of the eye, the optic edge, the upper haptic element and the uncomplicated vitreous hernia are visualized in the pupil area. The optic nerve disc is pale pink, the borders are clear, the macular region is without features.

Intraocular pressure (IOP) 21.0 mm Hg. Art. (pneumotometry)

Reposition and hemming of the IOL according to the claimed method was recommended and performed, while the knife was rotated in the lumen of paracentesis by 12 degrees, 0.17 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 2.8 mm to the periphery, the iris was pierced by 1.9 mm from the pupil edge, an uncomplicated vitreous hernia was “tucked” with the help of viscoelastic back into the vitreous cavity at the stage of complex reposition. The patient was examined 2 hours after the operation, conjunctival injection was noted, the cornea was transparent, the area of the surgical wound with adapted edges, the chamber was of medium depth, the moisture of the anterior chamber was transparent, the sutures on the iris were adapted, the pupil was 2.8 mm, IOL in the center. The patient receives standard postoperative therapy.

The next day, Vis OS: 0.6 sph -1.5 = 0.8; IOP OS = 19.0 mm Hg. Art. (pneumotonometry), conjunctival injection decreased, the cornea is transparent, the chamber is of medium depth, the moisture of the anterior chamber is transparent, the Tyndall phenomenon is not marked, the pupil is 2.8 mm, the sutures are adapted, the IOL is in the center. When viewed with mydriasis (pupil diameter 5.5 mm), the IOL occupies a central position, the optic disc is pale pink, the borders are clear, the macular region is without features. The patient was discharged from the hospital.

In total, the proposed method performed 35 operations, in all cases the claimed technical result was achieved.

Claims (1)

The method of reposition and hemming of an intraocular lens (IOL), deployed together with a capsular bag, including hemming it to the iris, performing paracentesis in the projection of future sutures and tying knots, characterized in that the first corneal is performed intraoperatively under application anesthesia without expanding the pupil paracentesis at 10 o'clock at an angle of 60 °, then rotate the knife in the lumen of this paracentesis by 10-15 degrees and, pressing the knife on the lower lip of paracentesis, empty the anterior chamber by half, then in ednyuyu chamber administered 0.1-0.2 ml viscoelastic over the intended puncture area of the iris; with the help of a rotational hook, the deployed IOL is centered, then the pupil edge of the iris is progressively shifted by 2-3 mm to the periphery in four quadrants with the same hook to visualize the haptic elements and the state of the capsular bag, having determined the projection of the haptic elements of the IOL, they go through the first paracentesis with a needle and thread into the anterior chamber, pierce the iris 1.5-2.0 mm from the pupil edge and the front sheet of the lens capsule and passing under the haptic element of the IOL closest to the first paracentesis with a grip m of the posterior capsule, the needle is withdrawn by piercing the cornea until the place where the needle passes into the thread is between the iris and the cornea, while the place of the first needle puncture is 90 angular degrees relative to the first paracentesis, then without completely removing the needle go over the iris in the opposite direction and withdraw the needle with the thread through the first paracentesis and form a nodal suture in its lumen and cut the needle; after this, the second paracentesis is performed diametrically opposite to the first paracentesis and the indicated sequence of operations with a needle and thread is repeated in the same way, the viscoelastic is removed from the anterior chamber by washing, the paracentesis is hydrated with a salt-balanced solution and at the end of the operation a subconjunctival injection of dexamethasone and an antibiotic is performed.

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