RU2743218C1 - Method of surgical correction of presbyopia of middle-aged and elderly people - tissue-preserving lasik - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: cornea is moistened before the operation, and laser ablation is performed using the LASIK method. At the same time, 7 days before the operation, the surface of the cornea is treated daily with moisturizing preparations containing sodium hyaluronate (hereinafter - SH), such as: Vizmed, 2 drops 3 times a day, or Okvis, 2 drops 2 times a day. Directly on the operating table, a triple instillation of 0.5% alcaine is carried out, 2 drops every 30 seconds. Before applying the vacuum ring, the moisturizing preparation Vizmed-gel is instilled. In the process of patch formation, a constant irrigation of the BSS solution is carried out at a rate of 1 ml per second per blade during the movement of the microkeratome head. Before lifting the patch, the remains of SH are removed from the edges of the patch first with an irrigation jet of BSS solution at a speed of 0.5 ml per second, in the direction from one edge of the patch leg to the other. Then, with a wet swab, soaked in 0.5 ml of BSS, in two movements in the same direction, using a spatula, the patch is folded back on the conjunctiva, folded in half with a duplicate, and laser ablation is performed. After performing eximerlaser ablation, the stromal bed is washed with 2 ml of BSS with simultaneous removal of the corneal cells remains with swab, moistened with BSS, the patch is laid in place, and the interface is washed with a BSS solution at a rate of 0.5 ml per second. Next, the patch is smoothed with a wet swab, moistened with BSS solution, in three longitudinal movements: from the patch leg to the periphery, from the center to the right edge, from the center to the left edge.

EFFECT: method allows increasing the organ preservation of the cornea and the organ of vision, preventing operational and postoperative complications in the form of erosion, epitheliopathy, ingrowth of the epithelium, formation of scarring changes along the edge of the patch and occurrence of dry eye syndrome.

1 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used as a method of surgical correction of presbyopia in middle-aged and elderly people.

Complaints about blurred vision at close range is one of the most common complaints of patients after 40 years of age at an appointment with an ophthalmologist. This condition is called presbyopia. This occurs as a result of a decrease in the elasticity of the lens, which leads to a decrease in its accommodative abilities. The main symptom of presbyopia (the wrong common name is farsightedness) is the vagueness of small objects at close range. In the absence of correct correction of presbyopia, asthenopic complaints appear, which are expressed in the fusion of letters and lines, a feeling of tension and dull pain in the upper halves of the eyeballs, eyebrows, bridge of the nose, less often in the temples (sometimes up to nausea), mild photophobia and lacrimation. Most often, presbyopia begins to develop at the age of 40-45 and ends by 60 years. But there is a group of patients in whom involutional processes in the lens begin earlier at the age of 35-40 years.

The optimal and well-known way to eliminate the painful symptoms of presbyopia and restore visual performance is the appointment of spectacle correction for near. But not all patients are satisfied with this method of correction. Many do not want to use glasses, or the use of several pairs of glasses for distance, near and when working at a computer leads to discomfort and a decrease in the quality of life.

In addition to the appointment of spectacle correction, there are other methods of correction, for example, the implantation of multifocal lenses with a refractive purpose. This method of correction is not suitable for all patients; many do not dare to replace their own lens. Recently, more and more attention has been attracted by laser vision correction, the possibilities of which are expanding more and more.

The closest analogue is the use of laser intrastromal keratomileusis "Laser Assisted in Situ Keratomileusis" - LASIK (LASIK). The essence of this method is laser evaporation of the corneal stroma after incomplete cutting and retraction towards the superficial flap (J. Refract. Corneal Surg.-1990. - Vol. 10, No. 5. - P. 498-510).

In the classical version, the technique of performing the operation is as follows: half an hour before the operation, an anesthetic is installed every 5 minutes, then 2-4 ml of lidocaine hydrochloride at a concentration of 20 mg / ml is injected peribulbar.

At the first stage, using a microkeratome, a surface flap of the cornea with a diameter of 8-9 mm and a thickness of 150-160 microns is cut so that from the nasal or upper side (depending on the type of microkeratome) the flap remains fixed on the base of the cornea with a “neck” 3-5 mm.

After the cut is completed, the flap is turned to the side, the laser beam is centered, focused on the stromal bed of the cornea, and the optical disk of a given thickness is evaporated according to a special program. The stroma is cleared of evaporation products, washed and the flap is placed in place. Then an antibiotic, non-steroidal anti-inflammatory drugs are instilled. (Balashevich L.I. Refractive surgery. - SPb., 2002. - S. 111-124).

In the described embodiment, no drops are prescribed to moisturize the cornea before the operation. Anesthesia is performed 30 minutes before surgery. The corneal protectors are not buried before the vacuum ring is applied. No BSS solution is irrigated during flap formation. There are no additional measures (flushing of the corneal surface) before flap lifting. The corneal flap does not fold into duplicate on the conjunctiva. Smoothing of the flap is performed without precise recommendations.

After the operation, an eye examination is carried out; drip installations of corneal protectors are not carried out. In the early postoperative period, corticosteroids and antibiotics are usually prescribed; corneal protectors are not mandatory.

This method of correcting presbyopia has the following significant disadvantages: the age-related features of the cornea associated with increased looseness and a tendency to epitheliopathy are not taken into account. The prevention of operational and postoperative complications in the form of erosion, keratopathy, epithelial ingrowth is not carried out. There is no treatment and prevention of dry eye syndrome.

The technical result of the proposed method for correcting presbyopia is to increase the organ preservation of the cornea and the organ of vision, to prevent operational and postoperative complications in the form of erosion, epitheliopathy, epithelial ingrowth, the formation of cicatricial changes along the edge of the flap and the occurrence of dry eye syndrome.

The technical result is achieved by the fact that in the method of surgical correction of presbyopia in middle-aged and elderly people, which consists in moisturizing the cornea before the operation, carrying out laser ablation using the LASIK method, according to the invention, 7 days before the operation, the surface of the cornea is treated daily with moisturizing preparations containing sodium hyaluronate (GN) which are used as: Wizmed, 2 drops 3 times a day, or Okvis, 2 drops 2 times a day, three times installation of 0.5% alkaine is carried out directly on the operating table, 2 drops every 30 seconds, before applying a vacuum ring instill in the moisturizing preparation Wizmed-gel, during the formation of the flap, a constant irrigation of the BSS solution is carried out at a rate of 1 ml per second on the blade while the head of the microkeratome is moving, before lifting the flap, the remnants of HN are first removed from the edges of the flap with a BSS irrigation stream at a rate of 0.5 ml in second, in the direction from one edge of the flap to the other , and then with a wet swab soaked in 0.5 ml of BSS, with two light movements in the same direction, using a spatula, the flap is thrown onto the conjunctiva, folded in duplicate, laser ablation is performed, after performing eximer laser ablation, the stromal bed is washed with 2 ml of BSS with simultaneous removing the remnants of corneal cells with a moistened BSS swab, the flap is placed in place, the interface is washed with BSS solution at a rate of 0.5 ml per second, the flap is smoothed with a wet swab moistened with BSS solution in three longitudinal movements: from the flap stem to the periphery, from the center to the right edge , from the center to the left.

The inventors have developed a set of essential distinctive features that are necessary and sufficient to achieve the claimed technical result. The proposed method is carried out as follows. 7 days before the correction, drip moisturizing preparations containing hyaluronic acid (HA) are prescribed, since HA is a glycosaminoglycan produced by the epithelial cells of the cornea, and as a component of the lacrimal fluid, it is responsible for its viscosity, elasticity and the normal functioning of the mechanisms of hydration of the ocular surface.

The physicochemical property of binding water molecules contributes to its slow evaporation from the HA solution and the therapeutic effect is lengthened. The efficacy and good tolerability of HA is due to its physical similarity to mucin. This allows it to adhere well to the mucin layer of the precorneal film, and this protective coating remains for a long time.

As moisturizing drugs, medicines containing sodium hyaluronate (HN) are used, while 7 days before the operation they use: Wizmed, 2 drops 3 times a day, or Okvis, 2 drops 2 times a day. These preparations are a viscoelastic solution containing hydroxyethyl cellulose (0.3 g) and chondroitin sulfate (0.0005 g) and a balanced salt solution of BSS, which causes a moderate anti-inflammatory, desensitizing effect on the cornea and forms an additional protective film on the epithelium. The drug remains on the cornea for 12 hours, which distinguishes it from other corneal protectors.

Anesthesia is performed on the operating table by instilling 0.5% alkaine three times, 2 drops every 30 seconds.

Before applying the vacuum ring, 2 drops of Wizmed-gel (0.3% sodium hyaluronate) are dripped onto the cornea, which creates the effect of additional lubrication on the cornea.

In the process of flap formation, the BSS solution is continuously irrigated from a syringe at a rate of 1 ml per second onto the blade during the movement of the microkeratome head, which additionally moisturizes the epithelium and prevents its injury. BSS - Balanced Saline Solution, developed by Merrill, is a physiological and isotonic ophthalmic irrigation solution, has a stable acid-base balance, pH 7.5 to 8.2, and contains the five main ions sodium, potassium, calcium, magnesium and chlorine.

Before lifting the flap, the remains of GN are removed from the edges of the flap first with an irrigation stream of BSS at a rate of 0.5 ml per second, in the direction from one edge of the flap head to the other, and then with a wet swab dipped in 0.5 ml of BSS in two light movements in the same direction. The central superficial part of the flap remains moist with the remnants of GN, which protects the epithelium during excimer laser ablation.

Using a spatula, the flap is folded back onto the conjunctiva, folded in half to prevent overdrying of the inside of the flap.

After performing excimer laser ablation, the stromal bed is washed with 2 ml of BSS while removing the remnants of corneal cells with moistened 0.5 ml of BSS tupfer. The flap is placed in place, the interface is washed with 3 ml BSS solution at a rate of 0.5 ml per second. The flap is smoothed in three longitudinal movements: from the leg of the flap to the periphery, from the center to the right edge, from the center to the left edge with a wet 0.5 ml BSS swab. The wet swab becomes soft, does not scratch the corneal epithelium and does not shift the flap. Drying the flap for 3 minutes, as in the standard method, is not carried out.

Then the patient is examined after 45 minutes, when the primary adhesion of the flap to the corneal stroma occurs and the edema of the corneal tissues decreases. Instill drops of Tobradex 0.1 ml and 0.1 ml of Okvis 0.3%.

In the postoperative period, a combined antibiotic preparation with a corticosteroid Tobradex is prescribed, 2 drops for 6 days in a decreasing pattern: 1 day - 4 times a day, the 2nd day - 3 times a day, the 3rd day - 2 times a day and 4 -th day - once a day. Without fail, all patients are prescribed in drops the corneal protector Okvis 0.3%, 2 drops 2 times a day for one month.

All of the above measures are aimed at preliminary preparation of the eyeball of middle-aged and elderly patients for performing correction using the LASIK method. The latter implies a mechanical effect of a microkeratome on the corneal epithelium. As a result of exposure to various exogenous and endogenous factors, the corneal epithelium, in patients after 40 years of age, has a less strong adhesion to the underlying layers of the cornea. Preoperative instillation of drops Okvis, Vismed moisturizes the cornea, eliminates microdefects of the epithelium, reduces the phenomenon of dry eye syndrome. The proposed technique additionally protects the corneal epithelium during the operation, creating a surface film during flap formation, which avoids the occurrence of intraoperative complications. In the postoperative period, additional installations of OKvis allow avoiding the appearance of epitheliopathy, dry eye syndrome, accelerating the healing process of the postoperative corneal wound, and reducing the likelihood of cicatricial changes along the flap edge.

The method is illustrated by the following clinical examples.

Example 1

A 42-year-old patient L. came to the Eye Clinic of Doctor Belikova with complaints of poor vision in both eyes, far and near, intolerance of spectacle and contact correction.

On examination:

Visual acuity of the right eye:

distance 0.4 with sphere correction + 3.50 diopters = 1.0;

near 0.1 with the correction sphere + 4.50 diopters = 1.0.

Left eye visual acuity:

distance 0.3 with sphere correction + 3.25 diopters = 1.0;

near 0.1 with correction sphere + 4.25 diopters = 1.0. \

Autorefractometry data:

right eye: sphere + 3.75 diopters, cylinder + 0.25 diopters, axis 90 °

left eye: sphere + 3.50 diopters, cylinder + 0.50 diopters, axis 80 °

Objectively: The anterior segment of the eye and glaucoma media are without pathology.

Diagnosis: Moderate hyperopia, presbyopia in both eyes.

7 days before the operation, the following were used as moisturizers:

Wizmed 2 drops 3 times a day daily.

In both eyes, laser vision correction was performed using the LASIK method according to the invention. No complications were recorded.

The patient was examined by a surgeon 45 minutes after the operation. No complaints.

Objectively: both eyes are slightly irritated, the corneas are transparent, the flap is adapted, the interface is clean. Deep environments: no negative dynamics.

Examination the next day after correction: no complaints.

Objectively: Both eyes are calm, the corneas are transparent, shiny, the wound areas are fully adapted, the interface is clean, the deep environments are not changed.

Visual acuity:

right eye: distance 0.5 with sphere correction - 1.00 diopters = 1.0;

close to 0.6. left eye: distance 0.6 with sphere correction - 0.75 diopters = 1.0; close to 0.6.

Autorefractometry data:

Right eye: sphere - 1.50 diopters, cylinder - 0.50 diopters, axis 180 °

Left eye: sphere - 1.25 diopters, cylinder - 0.50 diopters, axis 10 °

Examination on the 7th day after correction:

No complaints.

Objectively: both eyes are calm, the corneas are transparent, shiny, the wound areas are fully adapted, the interface is clean, the deep environments are not changed.

Visual acuity:

right eye: distance 0.8 with sphere correction - 0.50 diopters = 1.0; near 0.6

left eye: distance 0.8 with sphere correction - 0.50 diopters = 1.0; close to 0.6;

Autorefractometry data:

Right eye: sphere - 0.50 diopters, cylinder - 0.25 diopters, axis 180 °

Left eye: sphere - 0.75 diopters, cylinder - 0.50 diopters, axis 10 °

Examination 1 month after correction:

No complaints. I am satisfied with the result of the operation.

Objectively: both eyes are calm, the corneas are transparent, shiny, the interface is clean, the deep environments are not changed.

Visual acuity:

right eye: distance 1.0; near 0.6

left eye: distance 1.0; close to 0.6.

Example 2

Patient K., 58 years old, turned to the "Eye Clinic of Dr. Belikova" with complaints of poor distance vision in the right eye, which has worried him since childhood. The left eye has always seen well. Discomfort has appeared over the past two years. Contact lenses and glasses cannot be tolerated.

On examination:

Visual acuity

right eye: 0.1 with sphere correction - 4.25 diopters cylinder - 0.75 diopters axis 125 diopters = 1.0.

left eye = 1.0.

Autorefractometry data:

right eye: sphere - 4.5 diopters, cylinder - 0.25 diopters, axis 170 °

left eye: sphere - 0.5 diopters, cylinder - 0.25 diopters, axis 5 °

Objectively: the anterior segment of the eye and glaucoma media are without pathology.

When examining the fundus of the right eye: myopic horse, peripheral moderate retinal dystrophy. Prophylactic retinal laser coagulation is not indicated.

Diagnosis: Anisometropia. Moderate myopia with astigmatism of the right eye. Presbyopia in both eyes.

7 days before the operation, the following were used as moisturizing agents: Okvis, 2 drops 2 times a day, daily.

On the right eye, laser vision correction was performed using the LASIK method according to the invention. No complications were recorded.

The patient was examined by a surgeon 45 minutes after surgery. No complaints.

Objectively: the right eye is slightly irritated, the cornea is transparent, the flap is adapted, the interface is clean. Deep environments: no negative dynamics. The day after the correction: no complaints.

Objectively: The right eye is calm, the cornea is transparent, shiny, the wound area is fully adapted, the interface is clean, the deep environments are not changed.

Visual acuity

Right eye: distance 0.7 with sphere correction - 0.5 diopters = 1.0; close to 0.4

Autorefractometry data:

Right eye: sphere - 0.5 diopters, cylinder - 0.5 diopters, axis 180 °

On the 7th day after correction: no complaints.

Objectively: the right eye is calm, the cornea is transparent, shiny, the wound area is fully adapted, the interface is clean, the deep environments are not changed.

Visual acuity:

right eye: distance 0.8 with sphere correction - 0.25 diopters = 1.0; near 0.3

Autorefractometry data:

right eye: sphere - 0.25 diopters, cylinder - 0.25 diopters, axis 175 °

1 month after correction: no complaints, the result of the operation is satisfied.

Objectively: The right eye is calm, the cornea is transparent, shiny, the interface is clean, the deep environments are not changed.

Visual acuity:

right eye: distance 1.0; near 0.2

Autorefractometry data:

right eye: sphere - 0.25 diopters, cylinder - 0.25 diopters, axis 178 °.

Thus, the use of the proposed method makes it possible to increase the organ preservation of the cornea and the organ of vision, to prevent operational and postoperative complications in the form of corneal erosion, epitheliopathy, epithelial ingrowth, the formation of cicatricial changes along the edge of the flap and the occurrence of dry eye syndrome.

Claims (1)

A method of surgical correction of presbyopia in middle-aged and elderly people, including moisturizing the cornea before the operation, carrying out laser ablation using the LASIK method, characterized in that 7 days before the operation, the surface of the cornea is treated daily with moisturizing preparations containing sodium hyaluronate (GN), as which are used: Vizmed 2 drops 3 times a day or Okvis 2 drops 2 times a day, three times instillation of 0.5% alkaine is carried out directly on the operating table, 2 drops every 30 seconds, before applying a vacuum ring, a moisturizing preparation Vizmed is instilled gel, in the process of flap formation, continuous irrigation of the BSS solution is carried out at a rate of 1 ml per second on the blade during the movement of the microkeratome head, before lifting the flap, the remnants of GN are removed from the edges of the flap first with an irrigation stream of BSS at a rate of 0.5 ml per second, in the direction one edge of the leg of the flap to the other, and then with a damp swab dipped in 0, 5 ml of BSS, with two movements in the same direction, using a spatula, the flap is thrown onto the conjunctiva, folded in half with a duplication, laser ablation is performed, after performing ekimerlaser ablation, the stromal bed is washed with 2 ml of BSS while removing the remnants of corneal cells with a moistened BSS tupfer place, the interface is washed with BSS solution at a rate of 0.5 ml per second, the flap is smoothed with a wet swab moistened with BSS solution in three longitudinal movements: from the flap leg to the periphery, from the center to the right edge, from the center to the left edge.