RU2736914C1 - Method for surgical removal of corneal pterygium with defect repair by intact bulbar conjunctiva - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology and plastic surgery. For surgical removal of cornea pterygium with defect plasty by intact bulbar conjunctiva, conjunctiva is marked on body border of pterygium and intact bulbar conjunctiva. Then head of pterygium is separated from cornea. A body of the pterygium is excised along a line of marking and removed by forming a wound defect of the bulbar conjunctive and a bare wound surface of the rectangular episcleras. Further, in the middle one-third of long edges of the wound defect of the bulbar conjunctive, two linear incisions are made: the first incision is directed towards the lower arch of the conjunctiva, the second incision is directed towards the upper arch of the conjunctiva. Two flaps of intact bulbar conjunctiva on a wide base on upper and lower vaults of conjunctive are respectively shifted relative to each other, lower flap towards upper edge of wound defect of bulbar conjunctiva, and upper flap - towards lower edge of wound defect of bulbar conjunctiva as shown in Fig. 1h. Each flap is fixed with one interrupted suture to episclera, besides, the lower flap is fixed near the edge of the upper border of the wound defect of the bulbar conjunctiva, and the upper flap is located at the edge of the lower border of the wound defect of the bulbar conjunctiva.

EFFECT: method provides complete replacement of degenerate changed bulbar conjunctiva for normal and complete closure of postoperative wound defect of conjunctiva and episclera.

1 cl, 1 ex, 1 dwg

Description

The invention relates to medicine, namely to ophthalmology and plastic surgery, and can be used to remove the corneal pterygium.

There is a known method of transplanting pterygium according to McReynolds (A. Kalakhan "Surgery of eye diseases", Medgiz, 1963, pp. 161-163, (Surgery of the eye diseases. Alston Callahan, BA, MS (Ophth.). MD, FACS Birmingham , Alabama), which includes several stages of moving the body and the head of the pterygium separated from the cornea under the conjunctiva in the direction of the lower fornix.This method does not give a good cosmetic result, since the pterygium is not excised, but moves entirely under the bulbar conjunctiva, which is a factor of negative psychoemotional reactions of the patient ...

There is a known method of removing the pterygium by its complete excision within the intact bulbar conjunctiva. Then the resulting defect is covered with an autoconjunctiva cut out in the region of the lower transitional fold. (A. Kalakhan "Surgery of eye diseases", Medgiz, 1963, pp. 163-164, (Surgery of the eye diseases. Alston Callahan, BA, MS (Ophth.). MD, FACS Birmingham, Alabama). The known method is quite laborious in execution, additional areas of the bulbar conjunctiva are affected, which is a factor of additional trauma and a longer period of patient's convalescence.

The known method of Demara (AF Rumyantsev "Eye Surgery", second edition, State Medical Publishing House of the Ukrainian SSR, Kiev-1959, pp. 214-215). The pterygium is separated and an additional incision downwards, parallel to the limbus. The head is completely cut off, after separating the body of the pterygium, it moves into a lateral incision and is strengthened with one interrupted suture, and the resulting defect is closed by pulling the conjunctival strip separated between the incision and the limbus.

The known method of operation Knapp (AF Rumyantsev "Eye Surgery", second edition, State Medical Publishing House of the Ukrainian SSR, Kiev-1959, p. 215). The head of the pterygium is separated with its complete cutting off, then the body of the pterygium is separated and cut into two halves, each of which is transplanted into two lateral incisions of the bulbar conjunctiva parallel to the limbus, and reinforced with one interrupted suture, and the resulting defect is closed by pulling the band of the conjunctiva separated between cut and limb.

A known method of removing the pterygium according to Chermak (AF Rumyantsev "Eye surgery", second edition, State Medical Publishing House of the Ukrainian SSR, Kiev-1959, p. 216). The head and body of the pterygium are separated, then the head is cut off, and the body of the pterygium is moved to the semilunar fold, temporally from it, several interrupted sutures are applied to the conjunctiva.

All of these methods have one main drawback - the body of the pterygium is preserved, which is transplanted under the bulbar conjunctiva, and this leads to a poor cosmetic effect.

There is also known a method of treating pterygium (see Ophthalmology, American Academy of Ophthalmology, Vol. 110, No. 4, April 2003, P. 806), consisting in excision of the head and body of the pterygium, followed by replacement of the formed wound surface with a free conjunctival flap cut out from the lower department of the conjunctival fornix.

Disadvantages of the known method:

- the application of the method is limited only by the small size of the pterygium;

- cicatricial contraction of the conjunctival fornix, followed by its shortening and violation of the physiological outflow of tears;

- the appearance of additional scars in the aesthetic zone of the eye;

- the risk of the formation of simblepharon, which disrupts the mobility of the eyelid.

There is a method for the treatment of pterygium, involving excision of the pterygium and the use of a specially treated meninges as a homograft in order to cover the wound defect and create a mechanical barrier in the limbus area (RF patent No. 2150257, IPC A61F 9/007, publ. 10.06.2000).

Disadvantages of the method:

- there is a tendency to recurrence of pterygium due to activation of processes of antigenic stimulation of the limbus by foreign tissue;

- high risk of necrosis, lysis and contraction of the graft due to the absence of functioning blood vessels in the meninges flap and an immunological conflict between the transplanted tissue and own eye tissues, requiring repeated surgical interventions to replace the graft;

- aesthetic discrepancy in color between the transplanted tissue and the conjunctival surface of the eye;

- Difficulties associated with obtaining donor material due to the lack of licensed eye tissue banks.

There is also known a method of surgical treatment of recurrent pterygium (RF patent No. 2354338, IPC A61F 9/007, publ. 05/10/2009), in which the head and body of the pterygium are separated and excised from the cornea and sclera, episcleral vessels are coagulated. The conjunctiva is incised over the lunar fold, it is separated, wrapped towards the corner of the eye and sewn with interrupted sutures to the arches of the eyelids. A graft from the kidney capsule is placed in the bed formed after the removal of the pterygium.

Disadvantages of the method:

- the risk of recurrence of pterygium remains due to the occurrence of antigenic stimulation in the immunocompetent zone of the cornea - at the limbus, which is accompanied by an inflammatory response to surgical intervention, which prevents the development of normal reparative processes;

- high risk of necrosis, lysis and rejection of the graft due to the immune conflict of the transplanted tissue antigenically foreign to the surface of the eye, requiring repeated surgery;

- the formation of a rough, prominant scar in the area of the lacrimal meatus due to the wrapping of the conjunctiva towards the corner of the eye, which entails a low aesthetic result of the operation and is accompanied by impaired eye mobility;

- the development of dry eye syndrome due to the removal of a large volume of the conjunctiva with goblet cells secreting tear components.

Also known is a method of treating pterygium with a silicone-dried amniotic membrane (Zolotarev A.V., Milyudin E.S. Surgical treatment of recurrent pterygium with plastics with a silicone-dried amniotic membrane // Bulletin of Ophthalmology. - 2007. - No. 7. - P. 39-42), which consists of in separating and excising the pterygium, superficial keratectomy, removing the pathologically altered conjunctiva with the underlying subconjunctival tissue and replacing the formed conjunctival defect at the limbus with a silicone-dried amniotic membrane with its fixation to the episclera with interrupted sutures.

Disadvantages of the method:

- high risk of pterygium recurrence due to abnormal repair processes due to trauma and inflammation in the limbal corneal zone, which performs immunoregulatory and trophic functions;

- peripheral corneal opacities in the area of keratectomy, resulting from excision of the surface layers of the cornea and slowing down of reparative processes, disrupting the transparency of the cornea and causing cosmetic dissatisfaction in patients with the outcome of the operation;

- decreased visual acuity due to the formation of postoperative corneal astigmatism due to keratectomy, during which the surface layers of the cornea are cut off;

- the risk of exposure of the sclera at the limbus in the operation area due to the reduction of rigidly altered remnants of the conjunctiva, stretched at the inner corner of the eye;

- the development of dry eye syndrome due to the removal of a large volume of the conjunctiva with goblet cells secreting tear components;

- with keratectomy, traumatic damage to the limbus - the immunocompetent zone of the eye occurs with the subsequent development of trophic disorders and inflammatory reactions in the conjunctiva and cornea, which requires repeated surgical intervention;

- aesthetic discrepancy in color between the transplanted silicone-dried amniotic membrane and the conjunctival surface of the eye.

The objective of the claimed invention is to develop a simple affordable way to eliminate corneal pterygium at minimal cost, without the need for auto- and allografts, prevention of recurrence and a quick rehabilitation period.

The technical result of the proposed method is a complete replacement of the degeneratively altered bulbar conjunctiva with a normal one, and complete closure of the postoperative wound defect of the conjunctiva and episclera.

The specified technical result is achieved by the proposed method, which consists in the following.

A marker is used to mark the conjunctiva at the border of the body of the pterygium and the intact bulbar conjunctiva, then with a microsurgical scalpel, the head of the pterygium is separated from the cornea and removed by excision of the head and body of the pterygium along the marking line within the intact bulbar conjunctiva with microsurgical scissors. As a result, a wound defect of the bulbar conjunctiva and a bare wound surface of the episclera in the shape of a rectangle not larger than 5 × 4 mm in size appear. Further, in the middle third of the long edges of the wound defect of the bulbar conjunctiva, two linear incisions are made using microsurgical scissors: the first incision is towards the lower fornix of the conjunctiva, the second incision is towards the superior fornix of the conjunctiva, receiving flaps of the intact bulbar conjunctiva on the wide base from the side of the superior and inferior arches of the conjunctiva, respectively. The two flaps are then slid against each other. The lower flap is directed towards the upper edge of the wound defect of the bulbar conjunctiva, and the upper flap is directed towards the lower edge of the wound defect of the bulbar conjunctiva, and each flap is fixed with one interrupted suture to the episclera. The lower flap is fixed at the very edge of the upper border of the bulbar conjunctival wound defect, and the upper flap is fixed at the very edge of the lower border of the bulbar conjunctival wound defect.

The inventive method is shown in the drawing, where FIG. 1 (a, 6, c, d, e, f, g, h, i) schematically shows the stages of sequential performance of a surgical intervention with the following designations:

1 - marking line along the border of the pterygium and intact bulbar conjunctiva,

2 - the head of the pterygium,

3 - pterygium body,

4 - microsurgical scalpel,

5 - microsurgical scissors,

6 - a wound defect of the bulbar conjunctiva and a bare area of episclera that arose after removal of the pterygium, in the form of a rectangle measuring 5 × 4 mm,

7 - the upper fornix of the conjunctiva,

8 - the lower fornix of the conjunctiva,

9 - linear section of the intact bulbar conjunctiva in the direction of the superior fornix of the conjunctiva 3 mm long,

10 - linear section of an intact bulbar conjunctiva in the direction of the lower fornix of the conjunctiva 3 mm long,

11 - upper flap of intact bulbar conjunctiva on a broad base,

12 - lower flap of an intact bulbar conjunctiva on a broad base,

13 - the upper edge of the wound defect of the intact bulbar conjunctiva,

14 - the lower edge of the wound defect of the intact bulbar conjunctiva,

15 - interrupted suture fixing the bulbar conjunctiva flap to the episclera.

The method of surgical removal of the corneal pterygium with plastic defect using an intact bulbar conjunctiva is as follows.

Starting from the inner limbus, a marker is used to mark the conjunctiva at the border of the body of the pterygium and the intact bulbar conjunctiva (see Fig. 1, a). Then a microsurgical scalpel is used to separate the pterygium head from the cornea (see Fig. 1, b). Then, the head and body of the pterygium are excised with scissors, along the marking line within the intact bulbar conjunctiva (see Fig. 1, c). As a result, a wound defect of the bulbar conjunctiva and a bare wound surface of the episclera not larger than 5 × 4 mm (see Fig. 1, d) appear. Further, in the middle third of the long edges of the wound defect of the bulbar conjunctiva, two linear incisions are made with microsurgical scissors: the first incision is towards the lower fornix of the conjunctiva, the second is towards the superior fornix of the conjunctiva, each 3 mm long (see Fig. 1, e ). As a result, flaps of intact bulbar conjunctiva are obtained on a broad base (see Fig. 1, e). Then two flaps are shifted relative to each other, the lower one - towards the upper edge of the wound defect of the bulbar conjunctiva, and the upper one - towards the lower edge of the wound defect of the bulbar conjunctiva (see Fig. 1, g), the direction of displacement of the flaps in the diagram is shown by arrows. FIG. 1, h shows the final location of the upper flap 11 of the intact bulbar conjunctiva on a broad base at the lower long edge 14 of the wound defect of the bulbar conjunctiva and the final location of the lower flap 12 of the intact bulbar conjunctiva on the wide base at the upper long edge 13 of the wound defect of the bulbar conjunctiva. Each flap is fixed with Vicryl 8.0 suture material with one interrupted suture to the episclera. The lower flap is at the very edge of the upper border of the bulbar conjunctival wound defect, and the upper flap is at the very edge of the lower border of the bulbar conjunctival wound defect (see Fig. 1, i). As a result of these manipulations, the bare area of the episclera is completely closed and the integrity of the bulbar conjunctiva is restored.

According to the claimed method, 25 surgical interventions were performed with good clinical and cosmetic results. The technique and the final result of corneal pterygium removal by the claimed method are shown on the example of one patient.

Example 1. Patient C. is presented, pterygium of the right eye 10 years old. In March 2018, the patient was operated on using the claimed method. Marker was used to mark the border of the pterygium and the intact bulbar conjunctiva. Under local infiltration anesthesia: lidocaine 2% 2.0 ml + mesatone 1% 0.3 ml with a microsurgical scalpel, the head of the pterygium was separated from the cornea and the head and body of the pterygium were removed by excision with scissors, along the marking line within the intact bulbar conjunctiva. As a result, a wound defect of the bulbar conjunctiva and a bare wound surface of the episclera in the shape of a rectangle 5 × 4 mm in size appeared. Further, in the middle third of the long edges of the wound defect of the bulbar conjunctiva, two linear incisions were made using microsurgical scissors, the first one towards the lower fornix of the conjunctiva, the second one towards the upper fornix of the conjunctiva, each 3 mm long. As a result, flaps of intact bulbar conjunctiva on a broad base were obtained. The first flap - from the side of the upper fornix of the conjunctiva, the second - from the side of the lower fornix of the conjunctiva. Then the obtained flaps were shifted relative to each other. Lower - towards the upper edge of the wound defect of the bulbar conjunctiva, and the upper - towards the lower edge of the wound defect of the bulbar conjunctiva, and each flap was fixed with Vicryl 8.0 suture material with one interrupted suture to the episclera, at the very edge of the upper and lower border of the wound defect of the bulbar conjunctiva ... When examining the patient one month after the surgical removal of the pterygium, the cornea is clean, epithelialized, the conjunctival flaps lie correctly, no traces of the operation are visible. When examining the patient two years after the surgery, the cosmetic result was consistently good, and there were no signs of relapse.

The advantage of this method is the simplicity of the operation, low cost, short operation time (15 minutes) and a quick rehabilitation period of seven days. The result of this operation is complete closure of the bulbar conjunctival defect with a good cosmetic effect, and excision and complete removal of the pterygium and closure of the defect of the intact conjunctiva is a reliable way to prevent recurrence of the pterygium. Also, the advantage of this method is the absence of the need for transplantation of auto and allografts.

Claims (1)

A method of surgical removal of the corneal pterygium with plastic defect using an intact bulbar conjunctiva, characterized by the fact that, first, a surgical marker is used to mark the conjunctiva along the border of the pterygium body and the intact bulbar conjunctiva, then the head of the pterygium and the cornea are separated from the cornea with a microsurgical scalpel with a microsurgical scalpel, the head of the pterygium and the cornea are separated from the cornea using a microsurgical scalpel. pterygium and remove it, forming a wound defect of the bulbar conjunctiva and a bare wound surface of a rectangular episclera not more than 5 × 4 mm in size, then in the middle third of the long edges of the wound defect of the bulbar conjunctiva, microsurgical scissors perform two linear incisions 3 mm long each: the first incision - towards the lower fornix of the conjunctiva, the second incision - towards the upper fornix of the conjunctiva, two flaps of the intact bulbar conjunctiva on a wide base from the side of the upper and lower fornix of the conjunctiva, respectively, are shifted from each other relative to the other, the lower flap towards the upper edge of the bulbar conjunctival wound defect, and the upper flap towards the lower edge of the bulbar conjunctival wound defect as shown in Fig. 1h, and each flap is fixed with one interrupted suture to the episclera, and the lower flap is fixed at the very edge of the upper border of the bulbar conjunctival wound defect, and the upper flap - at the very edge of the lower border of the bulbar conjunctival wound defect.

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