RU2746542C1 - Method for eliminating iridodialysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. Conjunctiva is separated from the limbus, dosed - 350 mcm - scleral incision concentrically to the limbus in the iridodialysis projection is performed. Corneocentesis is performed, through which an injection needle of 30 g, bent at an angle of 45°, is inserted with a 10-00 polypropylene thread installed in its cavity. The edge of the iris tear is stitched with a needle and the tip of the needle is punctured into the scleral notch, mobilizing the end of the thread with tweezers. After that, the needle is returned to the anterior chamber in reverse, re-stitching the tear-off edge, and the needle tip is punctured into the scleral notch. A loop is formed from the thread, and the needle is returned back to the anterior chamber. The number of injections and the number of thread loops are determined by the length of the iridodialysis. Then the distal end of the thread is pulled out of the needle cavity and pulled through the loops formed on the sclera. The loops are tightened, the ends of the thread are tied with a triple surgical knot and immersed in the scleral incision, conjunctiva is fixed with a coagulator. After fixation, the pupil is pulled to the place of fixation, to center the pupil and give it a rounded shape, the sliding knot technique is used, and interrupted sutures are applied to the pupillary edge of the iris.

EFFECT: method eliminates iridodialysis and restores the iris diaphragmatic function, ensures high functional results and optimal cosmetic effect.

1 cl, 1 ex, 6 dwg

Description

The proposed invention relates to medicine, namely to ophthalmology, and can be used to eliminate iridodialysis in order to restore the diaphragmatic function of the iris.

Traumatic injuries of the iris and lens are the most frequent and severe consequences of injuries of the eyeball, occupying a leading place in the structure of visual disability in people of working age. Iridodialysis in combination with traumatic cataract is one of the most common consequences of contusion injuries. According to G.E. Venger, N.A. Chudnyavtseva. (1987) traumatic cataracts in 7.6% of cases are combined with iridodialysis. Among the damage to the iris, iridodialysis occupies a special place. The presence, in addition to the pupil, of an additional opening at the site of the iris detachment adversely affects the visual acuity further with the preserved transparency of the optical media and can significantly reduce the functional result of the operation. In most cases, patients complain of light, monocular diplopia, photophobia. If iridodialysis is located in the lower half of the eyeball, this is also a serious cosmetic disadvantage.

Reconstructive operations on the iris in order to restore its diaphragmatic function are one of the leading stages in the complex surgical treatment of post-traumatic pathology of the anterior part of the eyeball and are the most difficult and at the same time promising direction in ophthalmosurgery.

The invention relates to ophthalmic surgery, and can be used to eliminate iridodialysis in order to restore the diaphragmatic function of the iris to achieve high functional results and a satisfactory cosmetic effect.

There is a known method for eliminating iridodialysis, according to which the conjunctiva is separated from the limbus in the projection of iridodialysis, then the eyeball is opened along the limbus, closer to the sclera, the iris is grasped through this incision with tweezers and pulled to the incision. After that, the severed iris root is fixed with a suture to the scleral lip, then sutures are applied to the sclera and conjunctiva. (Skripnichenko Z.M. Ophthalmol. Journal. - 1972. - No. 7 - S. 502-505).

The disadvantages of this method are the need to perform a large incision providing access to the iris, which increases the risk of mechanical damage to the endothelium of the cornea, increases the likelihood of intra- and postoperative complications.

There is also a known method for eliminating iridodialysis, which consists in inserting a 10-00 polypropylene thread into a 26 g needle. The conjunctiva is separated from the limbus in the iridodialysis projection, a scleral visor is formed at the limbus, the needle is inserted through the corneocentesis into the anterior chamber, the tear edge is stitched and the needle is brought out to the sclera, the thread is fixed with tweezers, the needle is returned to the anterior chamber, the edge of the iris tear is re-stitched and the needle onto the sclera, forming a loop. These manipulations are repeated until the final fixation of iridodialysis. After that, the loops formed on the sclera are dissected and the edges of the dissected loops are tightened and tied, thus fixing iridodialysis. (K.V. Ravi Kumar, Video journal cataract and refractive surgery Vol. 32, Issue 4).

The disadvantage of this method is the formation of a large number of nodes on the surface of the sclera, and this requires a lot of additional manipulations with instruments, which increases the duration of the operation.

The closest analogue of the proposed method is a method in which a specially made hollow needle with a hole for a thread at the working end of the needle, with a cannula at the other end, to which an irrigation system is connected, is used. A needle with a thread is inserted into the anterior chamber through a puncture in the limbus region in the meridian opposite to iridodialysis, passed through the anterior chamber to the iridodialysis site, pierced the torn iris root and punctured out through the scleral part of the limbus. The free end of the thread is fixed with tweezers. In the opposite direction, the end of the needle is returned to the anterior chamber, the torn root of the iris is re-punctured and again punctured out through the scleral part of the limbus, and the removed thread duplication is fixed with tweezers. These manipulations are repeated several times, depending on the separation length. The second end of the thread is taken out through the scleral part of the limbus, it is passed through the loop of the thread diplicature, the suture is pulled together and its ends are tied. The operation is carried out with a constant supply of physical. solution to maintain the depth of the anterior chamber. (Wenger G.E. Ophthalmol. Journal. - 1990. - No. 5. - S. 270-272)

The disadvantages of this method are: the need to manufacture a special needle, maintaining the anterior chamber due to the constant supply of physical. solution, which leads to irrigation injury of the corneal endothelium and increases the likelihood of loss of corneal endothelial cells. In addition, after the final fixation of iridodialysis, the pupil is pulled up to the place of fixation and the thread is located on the sclera, which reduces the cosmetic result of the operation.

The objective of the present invention is to provide a method that allows you to eliminate iridodialysis and restore the diaphragmatic function of the iris.

The technical result consists in obtaining high functional results and optimal cosmetic effect.

The specified technical result is achieved due to the fact that all manipulations are performed through corneocentesis, when the anterior chamber is filled with cohesive viscoelastic, that is, practically on the "closed" eye. This allows maintaining a stable depth of the anterior chamber, thereby facilitating manipulation in the anterior chamber during iridoplasty, reducing the risk of damage to the corneal endothelium. The use of a standard 30 g injection needle for fixation of iridodialysis minimizes the trauma of manipulations with the iris and reduces the likelihood of iatrogenic rupture of the iris during suture fixation. The metered scleral incision reduces the thickness of the sclera at the point where the needle is punctured, thereby reducing the effort required to pierce the sclera and reducing the trauma of this stage. After the final fixation of iridodialysis, the entire suture and knot are immersed in the scleral incision, which provides a satisfactory cosmetic result. There is only one needle in the anterior chamber during the iridodialysis elimination process, which greatly reduces the likelihood of contamination. Interrupted sutures at the pupillary edge of the iris in the iridodialysis fixation segment help center the pupil for high functional and cosmetic results.

All this taken together significantly reduces the likelihood of both intra- and postoperative complications.

Among the essential features that characterize the proposed method distinctive are the following:

- performing a dosed scleral incision to facilitate piercing of the sclera during iridoplasty and masking the suture material and knot in the postoperative period;

- using a standard injection needle 30 g, bent at 45 °, with a polypropylene 10-00 thread installed in its lumen for fixing iridodialysis;

- reciprocating movements with one needle, once introduced into the anterior chamber through paracentesis to form a loop of thread during fixation of iridodialysis;

- the formation of one node on the surface of the sclera during the final fixation of iridodialysis;

- the imposition of interrupted sutures on the pupillary edge of the iris in the zone of fixation of iridodialysis to center the pupil.

The proposed method is carried out as follows.

The operation is performed under local anesthesia. The conjunctiva is separated from the limbus in the projection of iridodialysis. With a dosed diamond blade 2 mm from the limbus, a scleral notch with a depth of 350 µm, corresponding to the length of iriddialysis, is performed (Fig. 1). A 10-00 polypropylene thread is passed into the cavity of the 30 g injection needle. For ease of manipulation in the anterior chamber, the needle is bent at approximately 45 degrees. Corneocentesis is performed. The anterior chamber is filled with a cohesive viscoprotector. Through corneocentesis, a 30 g needle with a 10-00 polypropylene thread is inserted into the anterior chamber, the edge of the iris tear is pierced and only the needle tip with the thread is brought out into the scleral notch. The free end of the suture is mobilized and pulled out of the anterior chamber, leaving the entire suture in the needle cavity (Fig. 2). The end of the thread is fixed with tweezers. Then the needle point is returned to the anterior chamber in a reverse motion. At a distance of 2-2.5 mm from the first injection, the edge of the iris tear is re-punctured and the needle point is brought out into the scleral notch. The thread is pulled from the needle, forming a loop (Fig. 3). Hold the loop with knitting tweezers and return the needle point to the anterior chamber. Then, at a distance of 2-2.5 mm from the previous injection, the tearing edge is re-pierced and the needle point is brought out into the scleral notch. Similarly, a loop is formed from the thread on the sclera (Fig. 4). Fix the loop with tweezers and return the needle point to the anterior chamber. Then, the above-described manipulations with the iris are repeated, depending on the length of iridodialysis. After the final stitching of iridodialysis, the distal end of the suture is pulled from the needle cavity through the sclera. The needle is removed from the anterior chamber through the same corneocentesis. Thus, after stitching iridodialysis on the sclera, there are two free ends of the thread and loops between them (Fig. 5). Then the distal end of the suture is passed through the formed loops towards the proximal one, the suture is pulled up and thereby the torn edge of the iris is fixed to the sclera (Fig. 6). The distal and proximal ends of the thread are tied with a triple surgical knot. The knot is immersed in the scleral notch. After fixation of the torn root of the iris to the sclera, the pupil is pulled up to the place of fixation. To center the pupil and give it a rounded shape, interrupted sutures are placed on the pupillary edge of the iris using the sliding knot technique. The conjunctiva is fixed with a coagulator or an interrupted suture 8-00. The viscoelastic is evacuated from the anterior chamber. At the final stage, hydration of corneocenteses is carried out.

The proposed method is applicable not only to eliminate iridodialysis in combination with the simultaneous removal of traumatic cataracts, but also to eliminate iridodialysis in phakic eyes, which is associated with its minimal trauma.

The method is illustrated by the following clinical example.

Patient S., 22 years old. Enrolled in the Irkutsk branch of the IRTC "Eye Microsurgery" them. acad. S.N. Fedorov with complaints of a cosmetic defect, monocular diplopia, light scattering, photophobia of the right eye. History of contusion of the right eye 15 years ago. When viewed OD, the cornea is transparent, the anterior chamber is of medium depth, the pupil is irregularly shaped, 3 mm by 4 mm, displaced upward. Separation of the root of the iris from 4 to 8 hours. The lens is transparent.

In the fundus, there are post-traumatic changes in the macular region. Visual acuity - 0.5 n.c. Direct corneal astigmatism 1.5 diopters. Diagnosis: Post-traumatic iridodialysis, secondary macular degeneration, direct corneal astigmatism of the right eye.

On 05.2018, iridoplasty of the right eye was performed.

Under local anesthesia, the conjunctiva was separated from the limbus in the projection of iridodialysis. A marker concentric to the limbus marks a zone 2 mm from the limbus. A scleral notch with a depth of 350 microns is made with a metered diamond blade according to the marking. On both sides of the iridodialysis, two corneocentesis were performed. The anterior chamber was filled with cohesive viscoelastic. Viscoelastic is also introduced under the iris in the projection of its separation. A 10-00 polypropylene thread is inserted into a 30 g injection needle. The needle is bent at 45 degrees. Through corneocentesis, a 30 g needle with a thread was introduced into the anterior chamber. The edge of the detachment of the iris is punctured with a needle and the tip of the needle is brought out into the scleral notch. The free end of the thread is mobilized, pulled out of the anterior chamber and fixed with tweezers. Then the needle point is returned to the anterior chamber in a reverse motion. At a distance of 2-2.5 mm from the first injection, the edge of the iris tear was re-punctured and the needle tip was brought out into the scleral notch. The thread has been pulled out of the needle and a loop has been formed. While holding the thread with the knitting tweezers in reverse, the needle point is returned to the front chamber. Then, at a distance of 2-2.5 mm from the previous injection, the tear edge was punctured again and the needle point was again brought out into the scleral notch. The second loop is similarly formed on the sclera. The loop is fixed with tweezers and the needle point is returned to the anterior chamber. The above manipulations were repeated until the final fixation of iridodialysis. After the final stitching of iridodialysis, the needle is completely withdrawn from the anterior chamber through the same corneocentesis. The distal end of the suture is pulled out of the needle cavity through the sclera. Then the distal end of the thread is passed through the formed loops towards the proximal one. The thread is pulled up and thus the torn edge of the iris is fixed to the sclera. The distal and proximal ends of the suture are connected by a triple surgical knot. The knot is immersed in the scleral notch. After fixation of the detached iris root to the sclera, the pupil was pulled up to the place of fixation. To center the pupil and give it a rounded shape, 2 interrupted sutures were successively applied to the pupillary edge of the iris using the sliding knot technique. The conjunctiva is fixed with an interrupted suture 8-00. The viscoelastic was evacuated from the anterior chamber with an irrigation-aspiration system bimanually. At the final stage, hydration of the corneocenteses was carried out.

The day after surgery: visual acuity of 0.5 does not correct. Iridoplasty is consistent. The cosmetic effect is satisfactory.

After 1 month. visual acuity 0.5 with cylindrical correction 0.8. Iridoplasty is consistent.

After 6 months. visual acuity 0.7 with cylindrical correction 0.9. Iridoplasty is well-founded, the pupil is centered. The patient is satisfied with the result.

Claims (1)

A method for eliminating iridodialysis, which consists in separating the conjunctiva from the limbus, performing a dosed - 350 μm - scleral notch concentrically to the limbus in the projection of iridodialysis, performing corneocentesis, through which a 30 g injection needle is inserted, bent at an angle of 45 °, with a polypropylene 10 thread installed in its cavity -00, the edge of the iris tear is stitched with a needle and the tip of the needle is punctured into the scleral notch, mobilizing the end of the thread with tweezers, after which the needle is returned to the anterior chamber, re-sewing the tearing edge, and the needle point is punctured into the scleral notch, a loop is formed from the thread, and the needle is returned to the anterior chamber, the number of injections and the number of thread loops are determined by the length of iridodialysis, after which the distal end of the thread is pulled out of the needle cavity and pulled through the loops formed on the sclera, the loops are tightened, the ends of the thread are tied with a triple surgical knot and immersed in the scleral incision, the conjunctiva is fixed with a coagulator; after fixation, the pupil is pulled to the place of fixation, to center the pupil and give it a rounded shape, the sliding knot technique is used, and interrupted sutures are applied to the pupillary edge of the iris.

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