RU2712304C1 - Method for reposition and ligation of a single-piece intraocular lens, dislocated together with a capsular sac - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology. Two oblique diametrically opposite corneal paracenteses are intraoperatively performed above a predetermined projection of IOL haptic elements. Through the first paracentesis, 0.1–0.2 ml of the cohesive viscoelastic is introduced into the anterior chamber above the manipulation zone and the dislocated complex IOL – a capsular sac is centered. Then, pupillary edge of iris is displaced towards periphery by 2.0–3.0 mm in four quadrants. Then, the first paracentesis with the needle with the suture is introduced into the anterior chamber, the iris is pierced, the front leaf of the capsule of the lens and passing under the nearest haptic element IOL with the posterior capsule grip, removing the needle by piercing the capsular sac, the iris and the cornea sequentially with the needle, until the needle eye is between the iris and the cornea, wherein the needle prick-out point is displaced relative to the first paracentesis by 90 angular degrees, then, without completely removing the needle from the cornea, the needle is rotated through 90 angular degrees in parallel to the iris and goes over it towards the second paracentesis with its eye forward. Reaching half of the length of the needle through the second paracentesis, the needle is re-turned through 90 angular degrees and a second prick-in is performed in the iris in the projection of the second paracentesis, the front leaf of the lens capsule is pierced and passing under the second haptic element IOL with the posterior capsule grip, needle is withdrawn by puncturing with a needle a capsular sac, an iris and a cornea until the eye of the needle is between the iris and the cornea. Then, the needle is turned through 90 angular degrees in parallel to the iris towards the first paracentesis and, passing above the eyelet forward, the needle is removed from the anterior chamber through the first paracentesis. In the lumen of this paracentesis, a nodular suture is formed and the needle is cut off.

EFFECT: method enables improving the uncorrected visual acuity, preserving the iris diaphragm function, reducing the risk of postoperative inflammatory reactions and quickly rehabilitating the patient.

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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 the failure of the ligamentous apparatus 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 a safe, effective and microinvasive method of reposition and hemming (fixation) of a deployed IOL along with a capsular bag.

The technical result is an improvement in uncorrected visual acuity, preservation of the diaphragmatic function of the iris, a decrease in the risk of inflammatory reactions in the postoperative period, and rapid rehabilitation of the patient.

The technical result is achieved as follows: the day before the operation, the pupil is dilated and the position of the haptic elements of the IOL behind the iris is determined in order to perform corneal paracentesis intraoperatively on the narrow pupil strictly over the projection of the haptic elements of the IOL. For this purpose, the position of the deployed IOL and its haptic elements relative to the iris is plotted on a schematic drawing and a projection of future paracentesis is planned. When viewed from a wide pupil, the integrity and safety of the haptic elements of the IOL, their adhesion to the optical part of the IOL, phimosis of the anterior capsulorhexis, Semmeringer ring, fibrosis of the posterior capsule and the presence of the intracapsular ring are assessed. Intraoperatively under drip anesthesia, without expanding the pupil (on the narrow pupil), two oblique diametrically opposite corneal paracentesis are performed over a predetermined projection of the haptic elements of the IOL with a spear-shaped knife 1.0 mm wide at an angle of 60 ° to the surface of the cornea. When the second paracentesis is performed in its lumen, the knife is rotated around its axis by 10 ° -15 ° and, pressing it on the lower lip of paracentesis, empty the front chamber halfway, in order to raise the deployed IOL in the capsular bag with the vitreous body until it comes into contact with the iris. Then, through the first paracentesis, 0.1-0.2 ml of cohesive viscoelastic is injected into the anterior chamber over the manipulation area and the deployed IOL - capsule bag complex is centered using a rotary hook (Levitsky hook) 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 for the control visualization of the haptic elements and the centering of the deployed complex. Then they go through the first paracentesis with a needle with a thread 10-0 POLYPROPYLENE 20 cm Blue Monofilament Needle 15 mm 1/4 side cut into the anterior chamber, pierce the iris, retreating from the pupil edge 1.5-2.0 mm, the front leaf of the lens capsule and passing under the nearest haptic element of the IOL with the capture of the posterior capsule, the needle is withdrawn by piercing the capsule bag, iris and cornea with a needle until the point where the needle passes into the thread (eye of the needle) is between the iris and the cornea needle puncture is shifted in relation to the first paracentesis of 90 degrees, then, without completely removing the needles from the cornea, turn the needle 90 degrees parallel to the iris and go above it in the direction of the second paracentesis with the ear forward. Having exited half the length of the needle through the second paracentesis, again deploy the needle 90 degrees parallel to the iris and produce a second needle into the iris in the projection of the second paracentesis, pierce the front sheet of the lens capsule and pass under the second haptic element of the IOL with the capture of the posterior capsule, needle, piercing the capsule bag, iris and cornea sequentially with the needle until the needle’s eye is between the iris and the cornea. Then the needle is turned 90 degrees parallel to the iris in the direction of the first paracentesis and, passing above it with the ear forward, the needle is removed from the anterior chamber through the first paracentesis. A nodal suture is formed in the lumen of this paracentesis and the needle is cut off. The formation of the node is carried out with the regulation of the thread tension in such a way as not to deform the iris, but at the same time to reach the contact of the filed deployed IOL in the capsule bag with the back surface of the iris. After fixing the deployed IOL, the thread forms a single purse string suture in the form of a square with a side width of 5.0-5.5 mm. Then, if necessary, for example, with severe fibrosis of the posterior capsule and / or in the presence of complicated vitreous hernia, 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 washed out of the anterior chamber, paracentesis is hydrated with a saline 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. 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 and the application of one purse string suture leads to a decrease in postoperative trauma and the response of the eye to surgery. With fibrosis of the posterior capsule, its dissection reduces higher-order aberrations and increases contrast sensitivity. The developed method is more suitable for monoblock IOLs with a planar shape of the haptic elements of the “boat, shuttle, fish, shovel” type, where there are no holes in the haptic element for stitching with a needle, and puncture of the material with a needle can lead to cracks and teething.

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 patient of 80 years turned to the MNTK with complaints of low vision of the left eye (OS). From the anamnesis: 12 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model AKREOS AO. On examination, Vis OS = 0.3.

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 5.2 mm), the IOL-capsule bag complex is shifted downward in the posterior chamber of the eye, fibrosis of the posterior capsule, the optic edge and the upper haptic element are visualized in the pupil area, 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) 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 15 degrees, 0.2 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 3.0 mm to the periphery, the iris was pierced by 1.5 mm from the pupil edge and vitreotome dissection of the posterior lens capsule was performed. 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 seam on the iris was adapted, the pupil was 3.0 mm, IOL in the center. The patient receives standard postoperative therapy. The next day, Vis OS: 0.2 sph -1.0 cyl -1.0 ax 15 ° = 0.8; IOP OS = 20.0 mm RT. 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 suture on the iris is adapted, IOL in the center. On examination with mydriasis (pupil diameter 5.2 mm), the IOL occupies a central position, an optical window with a diameter of 3.9 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 76-year-old patient turned to the IRTC with complaints of low vision of the right eye (OD), from the anamnesis 17 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model KO-2 NEP-MG.

On examination, Vis OD = 0.1 cyl -2.75 ax55 = 0.2

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. When viewed with mydriasis (pupil diameter 5.0 mm), the deployed IOL complex - capsule bag is displaced downward and located in the anterior third of the vitreous cavity, pronounced fibrosis of the posterior lens capsule and a complicated hernia of the vitreous body is visualized. The optic nerve disc is pale pink, the borders are clear, myopic staphyloma, in the macular region there are multiple dry drusen.

Intraocular pressure (IOP) 20.0 mm Hg. Art. (pneumotometry) Recommended and stitched IOL according to the claimed method, while 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 2.0 mm to the periphery, the iris was punctured in 2 , 0 mm from the pupil margin, 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 surgical wound with adapted edges, the anterior chamber was deep, the moisture of the anterior chamber was transparent, the suture on the iris was adapted, the pupil 3.0 mm, IOL in the center.

The patient receives standard postoperative therapy.

The next day Vis OD: 0.05 shp -3.0 cyl -1.5 ax 80 = 0.35; IOP OD = 20.0 mm RT. Art. (pneumotonometry), conjunctival injection, the cornea is transparent, the anterior chamber is deep, the moisture of the anterior chamber is transparent, Tyndall phenomenon is not noted, the pupil is 3.0 mm, the suture is adapted, the IOL is in the center. On examination with mydriasis (pupil diameter 5.0 mm), the IOL occupies a central position, an optical window with a diameter of 4.2 mm is formed in the posterior capsule of the lens, the optic disc is pale pink, the borders are clear, myopic staphyloma, in the macular region there are multiple dry drusen. The patient was discharged from the hospital.

Example 3

A 75-year-old patient turned to the MNTK with complaints of low vision of the right eye (OD), from a history of 8 years ago, cataract phacoemulsification with implantation with an intraocular lens (FEK + IOL). Model WIOL - CF. When examining Vis OD = 0.02 sph + 10.0 = 0.7.

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. On examination with mydriasis (pupil diameter 4.8 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) 17.0 mm RT. 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, 0.13 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 2.8 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: 0.7, IOP OD = 20.0 mm Hg. Art. (pneumotonometry), conjunctival injection, 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 4.8 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 83-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 LENTIS L-313.

On examination, Vis OS = 0.4.

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. On examination with mydriasis (pupil diameter 5.3 mm), the IOL-capsule bag complex is displaced to the lower temporal 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) 19.0 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, 0.16 ml of viscoelastic was injected, the pupil edge of the iris was displaced by 2.5 mm to the periphery, the iris was pierced by 1.9 mm from the pupil edge, and an uncomplicated vitreous hernia was “tucked” with the help of viscoelastic back into the vitreous cavity at the stage of reposition of the complex. 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 5.3 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, 6 operations were performed according to the proposed method, in all cases the claimed technical result was achieved.

Claims (1)

The method of reposition and hemming of a monoblock intraocular lens deployed together with a capsular bag, including its hemming to the iris, paracentesis in the projection of future suturing and knotting, characterized in that the pupil is dilated before the operation and the position of the haptic elements of the IOL is determined, then intraoperatively on the narrow pupil, two diametrically opposite paracentesis are performed over a predetermined projection of the haptic elements of the IOL, when the second paracent behind in its lumen, the knife is rotated around its axis by 10-15 degrees and, pressing the knife on the lower lip of paracentesis, empty the front chamber halfway, then 0.1-0.2 ml of viscoelastic is introduced into the front chamber above the manipulation zone and with the help of a rotational hook center the deployed IOL complex - capsule bag, then go through the first paracentesis with a needle and thread into the anterior chamber, pierce the iris, retreating from the pupil edge 1.5-2.0 mm, the front leaf of the lens capsule and passing under the nearest haptic element OL with the capture of the posterior capsule, the needle is withdrawn by piercing the capsule bag, iris and cornea with a needle until the needle’s eye is between the iris and the cornea, while the needle puncture site is 90 angular degrees relative to the first paracentesis, then, without completely removing the needles from the cornea, they turn the needle 90 degrees parallel to the iris and go above the iris towards the second paracentesis with the ear forward, going half the length of the needle through the second paracentesis, again unfold the needle 90 degrees parallel to the iris and produce a second needle into the iris in the projection of the second paracentesis, pierce the front leaf of the lens capsule and, passing under the second haptic element of the IOL with the capture of the posterior capsule, withdraw the needle by piercing the capsule bag, the iris the sheath and cornea until the eye of the needle is between the iris and the cornea, then deploy the needle 90 angular degrees parallel to the iris towards the first paracentesis, pass over the iris with the ear forward and withdraw the needle from the anterior chamber through the first paracentesis, in the lumen of the paracentesis, form a nodal suture and cut the needle, paracentesis is hydrated with a saline balanced solution and produce a subconjunctival injection of dexamethasone and an antibiotic.

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