RU2768188C1 - Method for scleral fixation of two polymeric ophthalmic intracapsular rings with an extensive defect in the ligamentous apparatus of the lens - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. The main corneal incision is made, capsulorhexis (CC), through the incision with the help of an injector, the first polymeric open intracapsular ring (ICR) with a thread is introduced into the capsular bag, at the opposite end of which there is a curved needle (CN). The thread is brought to the outer surface of the sclera through the ciliary sulcus, the capsular sac is centered, the thread is fixed intrasclerally, then the second polymeric open ICC with the thread is implanted into the capsular sac through the main corneal incision, the thread is brought to the surface, similarly to the first ICR. After that, hydrodissection and hydrodelianesis of the lens are performed, cataract phacoemulsification and intraocular lens implantation are carried out. In this case, two identical polymeric ophthalmic ICRs are implanted with a size of 11, or 12, or 13 mm. After performing the main incision and two paracentesis, CC is performed, four additional corneal paracentesis are performed, each of which is equipped with one iridocapsular retractor (ICRr). After removing the lens masses, the capsular bag is filled with a viscoelastic preparation. Then two ICRrs located in the most unstable areas of the ligamentous apparatus of the lens are removed. After that, the end of the thread with CN is cut off, this end is threaded through one of the holes located in the loop of the first ICR, the end of the thread is melted with a thermal cauter until a flange is formed, the size exceeding the hole in the loop of this ICR. After that, this ICR is inserted into the injector so that the loop with the flange is located at the entrance to the injector cavity. Next, this ICR is implanted into the capsular bag in such a way that the loops are located in the most incompetent region of the ligamentous apparatus of the lens. At the same time, the polypropylene thread is left in the main corneal incision, this thread is removed with a hook in the area of ​​the lower paracentesis for calf, forming a loop from the outside. In this case, the end of the thread is left in the anterior chamber. At the next stage, a scleral tunnel is formed in 1/3 of the zone of insolvency of the ligamentous apparatus using a 90° bent needle 27-30G. In this case, the injection is made 2 mm from the limbus, then the needle is passed under the iris into the capsular bag, the second end of the thread is inserted into the needle cavity with the help of microsurgical tweezers and the thread is brought out from the inside out through the sclera. Next, the thread is tightened so that the capsular bag is centered, the thread is cut, leaving 2 mm, and the end of the thread is melted with a thermal cautery, forming a flange, its shape is changed to a “nail head” using microsurgical tweezers, and immersed in the scleral tunnel. Next, the remaining calfs are removed, the second ICR is implanted, a scleral tunnel is formed in 3/3 of the incompetence of the ligamentous apparatus, similarly to the first ICR, the ring is fixed intrasclerally in the region of the ciliary sulcus using a polypropylene thread, passed from the inside outwards with a 27-30G needle bent at 90°.

EFFECT: method enables stabilization of the "IOL-capsular bag" complex in case of violation of the integrity of the ligamentous apparatus of the lens based on the use of a polymeric ophthalmic I ICR CC in cataract surgery.

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Description

The invention relates to ophthalmology and can be used when performing phacoemulsification (PEK) in patients with subluxation of the lens with an extensive defect in the ligamentous apparatus of the lens.

Lens subluxation and weakened or ruptured ligaments of Zinn can be caused by genetically determined diseases such as Marfan's syndrome, Weil-Marchesani syndrome, high myopia, the consequences of glaucoma, pseudoexfoliation syndrome or trauma. The presence of failure of the ligamentous apparatus of the lens is one of the most unfavorable and complicating factors in cataract surgery. Currently, there are many methods for removing cataracts with lens subluxation, each of which has its own advantages and disadvantages.

There is a known method described by Yamane S. and co-authors, according to which a three-part IOL is fixed intrasclerally by melting its haptic elements with a thermal cutter, while the scleral tunnels are formed 1.5-2.0 mm from the limbus using a 27G needle, the haptic elements of the IOL are held with a needle intrascleral from the inside out, then the IOL is centered and flanges are formed, which are then immersed in the scleral tunnel (Yamane, S., Sato, S., Maruyama-Inoue, M., & Kadonosono, K. (2017). Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique, Ophthalmology, 124(8), 1136-1142).

The disadvantages of this technique is the failure of the capsular bag, which means a violation of the anatomical and physiological structure of the eyeball, which can later lead to pathological changes in the fundus, such as macular edema, retinal detachment. There is also a risk of pigmentary glaucoma if there is contact between the IOL and the iris.

The closest analogue is the method of phacoemulsification of cataracts in patients with extensive defects of the ligamentous apparatus of the lens, according to which, before the stage of capsulorhexis (CC) of the lens, the first conjunctival flap is formed in the projection of the zone of the middle of the Zinn ligament defect and the second - in the opposite meridian. Through the main corneal incision with the help of an injector, the first polymeric intracapsular ring (VKK) is introduced into the capsular bag in the form of an open ring with loops at the ends, the diameter of which exceeds the diameter of the capsular bag by 1.5-2 mm, one of the ends of the VKK is bent inward in the form of one round of a flat spiral and to the loop of which a thread is preliminarily fixed, at the opposite end of which there is a curved needle (II), after which the first VKK is positioned in such a way that its bent end is projected in the zone corresponding to the middle of the Zinn ligament defect, then the end with the thread is brought to the surface of the anterior capsules into the area of capsulorhexis, after that, AI is introduced into the anterior chamber and it is sequentially carried out from the inside outward over the capsular bag under the iris and brought to the outer surface of the sclera through the ciliary groove, in the area of the previously separated first conjunctival flap, then, pulling the thread, the capsular bag centered on then the thread is fixed intrasclerally with zigzag stitches. Then, a second ICH, identical to the first one, is implanted into the capsular sac through the main corneal incision and positioned in such a way that its curved end is in the segment opposite to the curved end of the first ICC segment, then the end of the second ICC with a thread is brought to the surface of the anterior capsule in the area of capsulorhexis, then , similarly to the first one, the second ICC is sutured with a thread, which is intrasclerally fixed in the area of the previously separated second conjunctival flap, and then hydrodissection and hydrodelianization of the lens, cataract phacoemulsification and intraocular lens implantation are performed (RF Patent for the invention No. 2458661).

However, at present, this VKK model is not officially registered in the territory of the Russian Federation, which makes it impossible to use it in clinical practice. Also, the disadvantages of this method include the difficulty of performing an intrascleral zigzag suture, the possibility of intraoperative rupture of the capsule during implantation of the ICH, and postoperative inflammatory reactions.

The objective of this invention is to develop an effective, safe and microinvasive method for stabilizing the complex "IOL - capsular bag" in case of violation of the integrity of the ligamentous apparatus of the lens based on the use of polymeric ophthalmic ICC in cataract surgery.

The resulting technical result makes it possible to achieve intraoperative restoration of the stability and integrity of the capsular bag, followed by the possibility of intracapsular implantation of the posterior chamber IOL model and the preservation of the anatomical and physiological structure of the eyeball.

The specified technical result is achieved by scleral fixation using a thermocautery of two polymeric ophthalmic VKKs with sizes of 11, 12, 13 mm, with their intrascleral fixation in areas of greater incompetence of the ligamentous apparatus, this method is achieved as follows, after performing the main incision and two paracentesis, the anterior chamber is filled with viscoelastic preparation, then CC, 4 corneal paracentesis are performed and four iridocapsular retractors (ICR) are installed to stabilize the capsular bag, after removal of the lens masses, the capsular bag is filled and straightened with a viscoelastic preparation, then two CFRs located in the most unstable areas of the lens ligamentous apparatus are removed. After that, the end with II of the 6-0 polypropylene thread is cut off, this end is threaded through one of the holes located in the loop of the first VKK, the end of the thread is melted with a thermal cauter until a flange is formed, the size exceeding the hole in the VKK loop. The next step is to insert this IVC into the injector so that the loop with the flange is located at the entrance to the cavity of the injector, then this IVC is implanted into the capsular bag so that the loops are located in the most insolvent area of the lens ligamentous apparatus, while the polypropylene thread is left in the main corneal incision , with a hook in the area of the lower paracentesis for CFR, the thread is removed, forming an external loop, while the end of the thread is left in the anterior chamber.

The next step is to separate the conjunctival flap or move the conjunctiva to 1/3 of the zone of incompetence of the ligamentous apparatus with microsurgical tweezers of the hummingbird type so that at the end of the operation the area of the scleral tunnel is covered by the conjunctiva, after which, using a 27-30G needle bent by 90 degrees, a scleral tunnel is formed, injecting make 2 mm from the limbus, then the needle is passed under the iris through the capsule and into the capsular bag. Using microsurgical tweezers, the second end of the thread is inserted into the cavity of the needle, in this case the needle is used as a conductor for the polypropylene thread, and the thread is brought out from the inside out through the sclera. Next, the thread is tightened so that the capsular bag is centered, the thread is cut, leaving 2 mm, and the end of the thread is melted with a thermal cautery, forming a flange, its shape is changed to a “nail head” using microsurgical tweezers, and immersed in the scleral tunnel. Next, the remaining two RBIs are removed. Then, the second VKC is implanted in the same way, a scleral tunnel is formed in 3/3 of the incompetence of the ligamentous apparatus, similarly to the implantation of the first VKK, it is fixed intrasclerally in the area of the ciliary sulcus using a polypropylene thread, passed from the inside outward with a 27-30G needle bent at 90 degrees. After that, the posterior chamber IOL is implanted, the remains of the viscoelastic preparation are washed out, the corneal incisions are hydrated, and the conjunctival flap is sutured during its formation. (Polymeric ophthalmic intracapsular rings used in this application are produced by the experimental and technical production of the FGAU "NMIC" MNTK "Eye Microsurgery" named after Academician S.N. Fedorov" of the Ministry of Health of Russia, catalog number No. 10-01, etpmicro.ru).

There is a causal relationship between the set of essential features and the achieved technical result.

Failure of the ligamentous apparatus of the lens can lead to serious complications both intra- and postoperatively, for example, dislocation of the lens or IOL into the vitreal cavity, secondary glaucoma, and uveitis. All these complications force us to look for ways to maintain the stability of the capsular bag with subsequent implantation of the posterior chamber IOL into it to achieve the most physiological position.

This method, based on a microinvasive approach, provides high clinical and functional results already in the early postoperative period and a stable position of the intraocular lens in the capsular bag, which significantly reduces the risk of dislocation of the IOL-bag complex and the development of postoperative complications.

The advantage of the method is the possibility of using a commercially available polymer ophthalmic intracapsular ring, and to stabilize the failure of the ligamentous apparatus of the lens of any extent of the defect.

The method is illustrated by figures 1-7, in Fig. 1 shows the implantation of a 6-0 polypropylene suture into the cavity with a 27-30G guiding needle bent at 90 degrees, FIG. 2, - passing a polypropylene thread from the inside to the outside with the help of a guide needle 2.00 mm from the corneal limbus in the region of the ciliary sulcus, in Fig. 3 - centering of the "VKK-bag" complex, in Fig. 4 - the formation of the flange using a thermocautery for intrascleral fixation "VKK-bag", in Fig. 5 - implantation of the second polymeric ophthalmic ICC using an injector, FIG. 6 - holding a polypropylene thread from the inside to the outside with the help of a guide needle 2.00 mm from the corneal limbus in the area of the ciliary sulcus and centering the second polymeric ophthalmic VKK, in Fig. 7 - the final view of the VKK-bag complex

Position 1 denotes a polymeric ophthalmic intracapsular ring; 2 - guide needle; 3 - polypropylene thread 6-0, 4 - defect zone of the ligamentous apparatus of the lens; 5 - flange, 6 - exit zone of the polypropylene thread to the outside, 7 - thermal cautery, 8 - injector for implantation of polymeric ophthalmic VKK.

The method is illustrated by the following clinical examples.

Example 1

Patient M., 45 years old, diagnosis: left eye - subluxation of the lens of the 3rd degree, both eyes - complicated cataract, high myopia. During the examination: corrected visual acuity (CVA) of the left eye was 0.7 with correction sph - 9.0 cyl -1.0 x 30, the left eye - 0.7 with correction sph -7.0, cyl -1.0 x 150. Intraocular pressure (IOP) was 15 mm. Hg on both eyes. Biomicroscopy of the left eye visualized iridophacodonesis, stretched fibers of the zinn ligament in the upper segment, approximately in the area from 15 to 9 hours, and the upper part of the diffusely clouded lens was also determined in the pupil area. When conducting ultrasonic biomicroscopy (UBM) on the left eye, weakness of the zinn ligament in the meridian from 15 to 9 hours was found with a shift of the lens. Reflex from the fundus in both eyes is uniform. Ophthalmoscopy revealed no pathological changes in the fundus of the eye in the examined areas. The operation according to the claimed method was performed on the patient on the right eye, under local anesthesia after performing the main corneal incision, two paracentesis and QC, four ICRs were installed at 10, 1, 4 and 6 hours, then after removal of the lens masses, two ICRs were removed at 1 and 6 hours. Fixation of the capsular bag with two polymeric ophthalmic ICCs with a diameter of 13 mm was performed in the area of 1/3 and 3/3 of the zone of weakness of the ligamentous apparatus, respectively, to the sclera in the region of the ciliary sulcus, after which a posterior chamber IOL was implanted, the flanges were covered with conjunctival flaps. A 27G needle was used as a guide.

The early postoperative period proceeded with moderate inflammation of the eye, which was stopped by anti-inflammatory therapy. KOZ after 1 month in the left eye was 0.8 with correction sph - 4.0. UBM demonstrated a stable IOL-capsular bag-complex and the passage of a polypropylene thread through the ciliary sulcus.

Example 2

Patient K., 34 years old, diagnosis: traumatic cataract in the left eye. Subluxation of the lens of the 3rd degree, hernia of the vitreous body. NCVA of the left eye 0.2, corrected sph +7.0 cyl +3.75 ax 167°, maximum corrected visual acuity (BCVA) - 0.4. B-scan: membranes are adjacent, destruction of the vitreous body. At biomicroscopy: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, uneven, pronounced iridophacodonesis, mydriasis 5 mm, clouding of the lens nucleus, defects of the zinn ligaments over a long distance in the meridian from 10 to 5 hours, the lens is displaced downward of the pupil, the equator is in the central optical zone, vitreous prolapse into the anterior chamber.

UBM data: rupture of zinn ligaments in the meridian from 10 to 5 hours, for 180-190 degrees with displacement of the lens both in the horizontal and vertical planes.

Given the presence of a vitreous hernia in the anterior chamber, anterior vitrectomy was performed through the main incision. Further, after performing the main corneal incision, two paracentesis and QC, four ICCs were installed at 10,1,4 and 6 hours, then after removal of the lens masses, two ICCs were removed at 1 and 6 hours, then, according to the proposed method, two standard ICCs were implanted 12 mm in diameter each with a flange located above the opening of one of the loops of the VKK, the complexes "VKK-bag" were fixed sclerally as follows: the first VKK at 12 o'clock in the region of 1/3 of the zone of weakness of the Zinn ligament fibers, and the second VKK - at 2 o'clock in the area of 3/3 of the zone of weakness of the ligamentous apparatus. In this clinical case, when the 30G needle was injected, the conjunctiva was moved to the opposite side in order to subsequently immerse the formed flanges. Next, a posterior chamber IOL was implanted and the remaining stages of phacoemulsification were performed. Visual acuity on the first day is 0.8. IOP is normal, IOL is in the correct position, which is confirmed by UBM data.

3 months after surgery, visual acuity is 0.9, IOP is normal, IOL is in the correct position.

Example 3

Patient S., 49 years old, diagnosis: right eye - traumatic cataract, subluxation of the 3rd degree, condition after a contusion eye injury, moderate hypermetropia. From the anamnesis it is known that an eye injury was received six months ago. NCHA of the right eye 0.1. Objectively: the right eye is calm, the anterior chamber is uneven, iridophacodonesis is visualized. The fundus of the eye is not ophthalmoscoped. Applanation tonometry registered intraocular pressure of 19 mm Hg. According to UBM: the absence of the ligamentous apparatus in the lower segment is visualized for 3 to 8 hours.

The patient under local anesthesia underwent the main incision and paracentesis at 2 and 9 hours, after performing capsulorhexis, irido-capsular retractors were installed at 1, 3, 6 and 10 hours. After removing the lens masses and replenishing the volume of the capsular bag with a viscoelastic preparation, according to the claimed method, two IBCs with a diameter of 11 mm were implanted so that the arches and the flange were located on 1/3 and 3/3 of the zones of weakness of the ligamentous apparatus of the lens, the IBCs were fixed by the proposed method to sclera 2 mm from the limbus in the region of the ciliary sulcus. In this case, conjunctival flaps were formed in the area of fixation; at the end of the operation, they were sutured with simple interrupted 8-0 Vicryl sutures. An aseptic bandage was applied to the eye. The early postoperative period was uneventful, the patient received anti-inflammatory therapy. NCHA after 1 week was 0.8. During applanation tonometry, intraocular pressure of 17 mm Hg was registered. According to UBM: a stable IOL-capsular bag - a complex and the passage of a polypropylene thread through the ciliary sulcus.

After 3 months, the NCHA was 0.9. During UBM: IOL is centered, in the correct position.

Claims (1)

A method for cataract phacoemulsification in patients with extensive defects in the ligamentous apparatus of the lens, including the main corneal incision, capsulorhexis (CC), through the incision using an injector into the capsular bag, introducing the first polymeric open intracapsular ring (ICC) with a thread, at the opposite end of which there is a curved needle ( II), bringing the thread to the outer surface of the sclera through the ciliary sulcus, centering the capsular bag, fixing the thread intrasclerally, then a second open polymeric ICC with a thread is implanted into the capsular bag through the main corneal incision, the thread is brought to the surface, similarly to the first ICC, after which hydrodissection is performed and hydrodelianesis of the lens, cataract phacoemulsification and implantation of an intraocular lens, characterized in that two identical polymeric ophthalmic ICCs of size 11, or 12, or 13 mm are implanted, after performing the main incision and two paracentesis, CC is performed, additionally four corneal paracentesis, in each of which one iridocapsular retractor (ICR) is installed, after removing the lens masses, the capsular bag is filled with a viscoelastic preparation, then two CFRs located in the most unstable zones of the ligamentous apparatus of the lens are removed, then the end of the thread with II is cut off, this end is threaded through one of the holes located in the loop of the first VKK, the end of the thread is melted with a thermal cauter until a flange is formed, the size exceeding the hole in the loop of this VKK, then this VKK is inserted into the injector so that the loop with the flange is located at the entrance to the injector cavity , then this ICC is implanted in the capsular bag in such a way that the loops are located in the most insolvent region of the ligamentous apparatus of the lens, while the polypropylene thread is left in the main corneal incision, this thread is removed with a hook in the area of the lower paracentesis for IFR, forming a loop from the outside, while the end I leave threads t in the anterior chamber; at the next stage, a scleral tunnel is formed in 1/3 of the zone of incompetence of the ligamentous apparatus using a 90° bent needle 27-30G, while the injection is made 2 mm from the limbus, then the needle is passed under the iris into the capsular bag, the second end is inserted using microsurgical tweezers threads into the cavity of the needle and bring the thread out from the inside out through the sclera, then tighten the thread so that the capsular bag is centered, cut the thread, leaving 2 mm, and using a thermal cautery melt the end of the thread, forming a flange, change its shape to a “nail head” with microsurgical tweezers and immersed in the scleral tunnel, then the remaining ICS are removed, the second ICC is implanted, the scleral tunnel is formed in 3/3 of the incompetence of the ligamentous apparatus, similarly to the first ICC, the ring is fixed intrasclerally in the region of the ciliary sulcus using a polypropylene thread, passed from the inside to the outside, bent at 90 ° needle 27-30G.

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