RU2745280C1 - Method for eliminating secondary regenerative cataract with adamyuk-elschnig pearls in children - Google Patents

Abstract

FIELD: ophtalmology.SUBSTANCE: to eliminate secondary regenerative cataract in the presence of Adamyuk-Elschnig pearls in children, a conglomerate of Adamyuk-Elschnig pearls is mobilized by excising it along the outer edge in the form of a ring using pulsed radiation from a YAG laser, starting from the upper sector, with a gradual increase in the pulse energy from 1.0 up to 3.5 mJ to through perforation of the conglomerate. After that, the mobilized conglomerate is displaced outside the optical zone using single pulses of defocused YAG laser radiation applied over the upper edge of the conglomerate. When localizing the Adamyuk-Elschnig pearls behind the IOL, the opaque posterior lens capsule fused with the conglomerate of pearls is additionally excised. In the presence of vitreocapsular transparent filaments, they are excised by applying an arcuate chain of laser pulses above the upper edge of the conglomerate.EFFECT: method provides restoration of visual acuity while maintaining the regularity of the cornea, that is, without astigmatism, prevention of infection, rapid rehabilitation.3 cl, 3 dwg, 3 ex

Description

The proposed invention relates to pediatric ophthalmology and is intended for Nd-YAG laser removal of secondary regenerative cataract in children. Despite significant advances in ophthalmopediatrics, secondary cataract remains one of the main reasons for a decrease in visual acuity in the long term after cataract removal. Secondary cataract, being an optical obstacle, reduces the visual acuity achieved after cataract removal. In addition to fibrosis of the posterior capsule of the lens, the formation of the so-called regenerative secondary cataract is characteristic of childhood, which is due to the high proliferative-regenerative abilities of the epithelium of the lens capsule in a child. The stratification of Adamuk-Elschnig ball cells on the posterior capsule is a classic type of regenerative secondary cataract.

The formation of a regenerative secondary cataract in children is characteristic of both aphakia and pseudophakia, even despite the use of new IOL models with a rectangular lens edge, while the Adamyuk-Elschnigg balls progressively “grow” from the equatorial zone of the lens, spreading both along the anterior surface of the IOL, and on the back, occupying the optically significant central zone of the IOL - Fig. 1. Even a temporary decrease in the transparency of optical media has a significant effect on the severity of amblyopia.

In recent years, the YAG laser method has been increasingly used to eliminate secondary cataracts. The advantages of the laser method of treatment in comparison with the instrumental-surgical method are obvious: no opening of the eyeball, no danger of infection, postoperative astigmatism, the possibility of outpatient treatment, often without anesthesia, quick rehabilitation and a reduction in the number of complications.

However, the presence of volumetric regenerative masses in the lumen of the aphakic pupil, on the anterior and / or posterior surface of the IOL is considered a contraindication to the laser method in children (Arestova N.N. Secondary cataracts in children. YAG laser surgery. Secondary cataracts in children. YAG laser surgery / / Visual functions in pathological processes in children and methods of their correction / Edited by SE Avetisov et al. - M .: Medicine, 2005. - P. 369-426).

There is a known method of removing secondary cataracts in children by instrumental surgery, in which a posterior capsulectomy and an anterior vitrectomy are performed in the posterior chamber of the eye through paracentesis in the limbus and through peripheral iridotomy without displacement of the IOL in the capsule bag (RU 2705411, 07.11.2019). However, this method is fraught with the possibility of complications, since it involves opening the eyeball with an inevitable risk of intraocular infection, and scarring of the surgical incision leads to astigmatism. This method is adopted as the closest analogue.

The objective of the present invention is to develop a laser method for eliminating secondary regenerative cataract in children with Adamyuk-Elschnig balls.

The technical result of the proposed method is the restoration of visual acuity while maintaining the regularity of the cornea, that is, without astigmatism, prevention of infection, rapid rehabilitation.

The technical result is achieved by mobilizing the conglomerate of balls Adamyuk-Elschnigg using YAG-laser pulsed exposure and displacement of the conglomerate outside the optical zone using defocused laser radiation.

The method is carried out as follows.

The conglomerate of Adamyuk-Elschnig balls is mobilized by excising it along the outer edge in the form of a ring using pulsed radiation of a YAG laser, starting from the upper sector, with a gradual increase in the pulse energy from 1.0 to 3.5 mJ until the through perforation of the conglomerate. After that, the mobilized conglomerate is displaced outside the optical zone using single pulses of defocused YAG laser radiation applied over the upper edge of the conglomerate. When localizing the Adamyuk-Elschnig balls behind the IOL, the opaque posterior lens capsule fused with the conglomerate of balls is additionally excised. In the presence of vitreocapsular transparent filaments, they are excised by applying an arcuate chain of laser pulses above the upper edge of the conglomerate.

Laser surgery is practically painless, only reasonable behavior of the child is required, stable fixation of the gaze, therefore, children over 5 years old are operated under local anesthesia (two-time installation of a solution of oxybuprocaine hydrochloride 0.4% / inocaine / 2-3 minutes before the procedure). Children under 5 years of age and non-contact older children (with CNS pathology, nystagmus) are treated under anesthesia.

As is customary, 20 minutes before laser intervention, 0.2 ml of mezaton solution is injected under the conjunctiva of the eyeball to achieve maximum drug mydriasis. For more accurate focusing, additional immobilization of the eyeball and the safety of the procedure, all laser operations are performed with the obligatory use of special Abraham or Mandelkorn contact lenses.

The developed method of laser elimination of secondary regenerative cataracts makes it possible to completely clear the pupil area (anterior and posterior surface of the IOL) from volumetric layers of volumetric Adamyuk-Elschnigg balls without instrumental opening of the eyeball, without complications, without relapses, with minimal energy parameters of laser radiation, i.e. efficiently and minimally traumatic.

Example 1.

Patient K., 4 years old, was being treated at the N.I. Helmholtz "of the Ministry of Health of Russia with a diagnosis of OD complete secondary regenerative cataract, pseudophakia, moderate obscuration amblyopia, OS healthy.

From birth, a congenital cataract of the child's right eye was revealed. At 4 months. phacoaspiration of congenital cataract with implantation of the Acrysof IOL was performed, a good optical effect was achieved (the anterior and posterior surfaces of the IOL were clean), pleoptic treatment was regularly carried out, by the age of 3 years, visual acuity of 0.3 with correction was achieved, however, in the last year, visual acuity gradually decreased to 0 , 04. Revealed secondary cataract.

Eye condition before laser surgery:

Visual acuity of the right eye 0.04. Intraocular pressure OD 23 mm. Hg The left eye is healthy, visual acuity 1.0; intraocular pressure OD 22 mm. Hg

Right eye. The cornea is transparent, the anterior chamber is middle, the pupil is medically dilated to 7 mm, the iris is not changed, in the area of the pupil there is regenerative cataract - volumetric multilayer Adamyuk-Elschnigg balls completely fill the entire anterior surface of the IOL - Fig. 2., slightly pushing into the anterior chamber (the thickness of the secondary cataract according to ultrasound is 2 mm), there is no reflex from the fundus, ophthalmoscopy is impossible.

On the right eye of the child, YAG-laser removal of the secondary regenerative cataract was performed using the proposed method.

20 minutes before the operation, 0.2 ml of mezatone solution was injected under the conjunctiva of the eyeball (for drug mydriasis). Under anesthesia, a Mandelkorn contact lens was placed on the child's eye. Using pulsed radiation from a YAG laser (YAG YC-1800, NIDEC, USA), a conglomerate of Adamyuk-Elschnigg balls was excised along its outer edge in the form of a ring, starting from the upper sector with a gradual increase in the pulse energy from 1.0 mJ to through perforation of the conglomerate, this required a pulse energy of 2.0 mJ, 70 pulses. The mobilized conglomerate, free from communication with the surrounding structures, somewhat decreased in size ("shrunk"). After that, the mobilized conglomerate was displaced outside the optical zone using single pulses of defocused YAG laser radiation, applied over the upper edge of the conglomerate. It took 6 single pulses at 10, 11, 12 and 14 hours 0.5 mm from the upper edge of the excised conglomerate (pulse energy 2.5 mJ). Having liberated the pupil area, the conglomerate of balls shifted to the lower sector of the anterior chamber, shrinking and flattening, it took the form of a gelatinous strip less than 1 mm thick at 5.30-6.30 hours. did not return to the pupil area - a reliable optical effect was achieved.

Dexazone 0.3 solution was introduced under the conjunctiva; eye drops were installed in the conjunctival cavity: picloxidine 0.05% (vitabact) once; indocollir (indomethacin 0.1%) 4 times an hour twice a day of surgery, then 3 times a day for 1 month.

There were no complications during or after the operation.

Examination 1 year after surgery: Visual acuity of the right eye 0.3 s + 2.0 = 0.4. Intraocular pressure OD 20 mm. Hg The eye is calm, the cornea is transparent, there is no optical obstruction in the pupil area - the anterior and posterior surfaces of the IOL are clean - Fig. 3.

The details of the fundus were well ophthalmoscoped: the optic disc was pink, the boundaries were clear, the vessels of normal caliber, the macula and the periphery were without visible changes.

The condition of the left eye is unchanged.

Continued pleoptic treatment of obscuration amblyopia at the place of residence.

Example 2.

Patient V., 6 years old, was treated at the N.N. Helmholtz "of the Ministry of Health of Russia with a diagnosis of OD partial congenital zonular cataract. OS complete secondary regenerative cataract, fibrosis of the posterior lens capsule, pseudophakia, OI moderate obscuration amblyopia

At 3 years old, incomplete vision of both eyes of the child was revealed, the diagnosis was congenital partial zonular cataract in both eyes. Visual acuity OD 0.7 does not correct. OS: 0.1 does not correct. At the age of 4, the congenital cataract of the left eye was removed with the implantation of the HOYA IOL, a good optical effect was obtained (the anterior and posterior surfaces of the IOL were clean), by the age of 5 years the visual acuity of the left eye 0.7 with correction was achieved, but in the last six months the visual acuity of the left eye was gradually decreased to 0.06 - complete regenerative secondary cataract of the left eye was revealed.

Eye condition before laser surgery:

Right eye: visual acuity 0.8; intraocular pressure OD 20 mm. Hg Given the partial nature of congenital cataract and high visual acuity (0.8), there are no indications for its removal yet.

Left eye: Visual acuity 0.06, does not correct. Intraocular pressure OD 22 mm. Hg The cornea is transparent, the anterior chamber is medium, the iris is not changed, the pupil is medically dilated to 7 mm, the position of the IOL is correct, the anterior surface of the IOL is clean, the posterior surface of the IOL in the pupil area is completely occupied by a multilayer conglomerate of Adamyuk-Elschnigg volumetric balls, there is no reflex from the fundus of the eye, ophthalmic impossible. Shown is laser removal of secondary cataract OS - produced YAG-laser removal of secondary regenerative cataract by the proposed method.

20 minutes before the operation, 0.2 ml of mezatone solution was injected under the conjunctiva of the eyeball (for drug mydriasis). Under local anesthesia (double installation of 0.4% oxybuprocaine hydrochloride solution / inocaine / 2-3 minutes before the procedure), a Mandelkorn contact lens was placed on the child's eye. Using pulsed radiation from a YAG laser (YAG YC-1800, NIDEC, USA), a multilayer volumetric conglomerate of Adamyuk-Elschnigg balls was excised behind the IOL together with the central part of the turbid fibrous-altered posterior capsule of the lens fused to it. Excision was performed within the medically dilated pupil up to 7 mm, annularly, starting from the upper sector with a gradual increase in the pulse energy from 1.0 mJ to through perforation of the conglomerate, which required a pulse energy of 3.5 mJ (85 pulses). The mobilized conglomerate, free of connection with the surrounding structures, immediately decreased in size (“shrunk") and was displaced outside the optical zone using single pulses of defocused YAG laser radiation applied over the upper edge of the conglomerate, which required 8 single pulses per 10 , 11, 12 and 14 hours at 0.5 mm from the upper edge of the excised conglomerate (pulse energy 3.5 mJ). Freeing the pupil area, the conglomerate of balls shifted to the lower sector of the retrocapsular space. When the eyeball moves (in anesthesia, this is checked by vibrating the contact lens up and down), the conglomerate did not return to the pupil area - a reliable optical effect was achieved.

Dexazone 0.3 solution was introduced under the conjunctiva; eye drops were installed in the conjunctival cavity: picloxidine 0.05% (vitabact) once; indomethacin 0.1% (indocollir) 4 times an hour twice a day of surgery, then 3 times a day for 1 month. There were no complications during or after the operation.

Examination 1 year after surgery: Visual acuity of the left eye 0.6 s + 1.5 D = 0.7. Intraocular pressure OD 19 mm. Hg The eye is calm, the cornea is transparent, there is no optical obstruction in the pupil area - the front and back surfaces of the IOL are clean. The details of the fundus were well ophthalmoscoped: the optic disc was pink, the boundaries were clear, the vessels of normal caliber, the macula and the periphery were without visible changes.

The state of the right eye is unchanged.

Continued pleoptic treatment of obscuration amblyopia in both eyes at the place of residence.

Example 3.

Patient F., 1.5 years old, was being treated at the N.N. Helmholtz of the Ministry of Health of Russia with a diagnosis of OD complete secondary regenerative cataract, pseudophakia, moderate obscuration amblyopia; OS complete congenital cataract.

From birth, the absence of object vision in both eyes of the child was revealed - complete congenital cataract in both eyes. At 6 months. a congenital cataract was removed with HOYA IOL implantation on the right eye, a good optical effect was achieved, but by one year, the formation of a complete regenerative secondary cataract was revealed, the mother noticed the appearance of an unstable strabismus in the right eye.

Eye condition before laser surgery:

Visual acuity in both eyes - "counting the fingers of the face", it is difficult to clarify by age, but the visual acuity of the right eye clearly decreased compared to the level achieved after the operation, an unstable converging strabismus appeared (up to 5-10 °), fundus ophthalmoscopy became impossible ...

Right eye. The cornea is transparent, the anterior chamber is middle, the pupil is medically dilated to 6 mm, the iris is not changed, in the area of the pupil there is a regenerative secondary cataract - of uneven density, a conglomerate of Adamyuk-Elschnig balls occupied more than 2/3 of the posterior surface of the IOL, in the rest of the zone dense fibrosis of the posterior capsule is visible. there is no fundus reflex, ophthalmoscopy is impossible.

Shown is the laser removal of the secondary regenerative cataract on the right eye of a child (in the laser operating room) and phacoaspiration of the congenital cataract of the left eye (in the microsurgical operating department) during one anesthesia.

YAG laser removal of the secondary regenerative cataract of the right eye was performed using the proposed method. 20 minutes before the operation, 0.2 ml of mezatone solution was injected under the conjunctiva of the eyeball (for drug mydriasis). Under anesthesia, a Mandelkorn contact lens was placed on the child's eye. Using pulsed radiation from a YAG laser (YAG YC-1800, NIDEC, USA), an irregular density conglomerate of Adamyuk-Elschnig balls was excised together with a section of the turbid fibrous-altered posterior capsule of the lens fused with it. Excision was performed within the medically dilated pupil up to 6 mm, annularly, starting from the upper sector with a gradual increase in the pulse energy from 1.0 mJ to through perforation of the conglomerate, which required a pulse energy of 3.0 mJ (64 pulses). With the movements of the eyeball caused by the oscillatory movements of the contact lens up and down, the excised conglomerate turned out to be inactive - i.e. revealed the presence of almost transparent vitreocapsular filaments of adhesions that fixed the conglomerate. Dissection of the revealed vitreocapsular adhesions was performed by applying an arcuate chain of laser pulses above the upper edge of the conglomerate (it took 17 pulses with a pulse energy of 3.5 mJ). The mobilized conglomerate, free from adhesions with the vitreous body, is displaced from the optical center to the periphery - “drowned” in the lower sector of the retrocapsular space, freeing the optical zone. With the movements of the eyeball (when the contact lens oscillates up and down), the conglomerate did not return to the pupil area - a reliable optical effect was achieved.

Dexazone 0.3 solution was introduced under the conjunctiva; eye drops were installed in the conjunctival cavity: picloxidine 0.05% (vitabact); indomethacin 0.1% (indocollir). There were no complications during and after laser surgery. After the end of the laser operation on the right eye, the child was transported to the microsurgical operating room, where, under continued anesthesia, he underwent phacoaspiration of the congenital cataract of the left eye with IOL implantation. There were also no complications during microsurgical surgery on the left eye.

Inspection after 10 months. after surgery - child 2 years 4 months. Visual acuity of both eyes is not less than 0.1 without correction (it is still difficult to specify by age), Intraocular pressure OD 18 mm. Hg OS 17 mm. Hg Both eyes are calm, the cornea is transparent, the position of the IOL is correct. A good optical effect is achieved - there is no optical obstacle in the pupil area, the front and back surfaces of the IOL are clean. The details of the fundus were well ophthalmoscoped: the optic disc was pink, the boundaries were clear, the vessels of normal caliber, the macula and the periphery were without visible changes. The position of the eyeballs is correct. Continued pleoptic treatment of obscuration amblyopia at the place of residence.

Thus, the developed method of laser elimination of secondary regenerative cataract makes it possible to completely clean both the anterior and posterior surfaces of the IOL in the area of the pupil from the layers of Adamyuk-Elschnig volumetric balls without instrumental opening of the eyeball, without complications, without relapses, with minimal energy parameters of laser radiation - those. effectively and minimally traumatic with a significant increase in visual acuity.

Claims (3)

1. A method for eliminating secondary regenerative cataract in the presence of Adamyuk-Elschnig balls in children, characterized in that a conglomerate of Adamyuk-Elschnig balls is mobilized by excising it along the outer edge in the form of a ring using pulsed radiation of a YAG laser, starting from the upper sector, with a gradual by increasing the pulse energy from 1.0 to 3.5 mJ until the through perforation of the conglomerate, after which the mobilized conglomerate is displaced outside the optical zone using single pulses of defocused YAG laser radiation applied over the upper edge of the conglomerate. 2. The method according to claim 1, characterized in that when localizing the Adamyuk-Elschnig balls behind the IOL, the opaque posterior lens capsule fused with the conglomerate of balls is additionally excised. 3. The method according to claim 1, characterized in that in the presence of vitreocapsular transparent filaments, they are excised by applying an arcuate chain of laser pulses above the upper edge of the conglomerate.

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