RU2770635C1 - Method for performing transplantation of half of descemet's membrane and endothelium in the treatment of primary endothelial of fuchs corneal dystrophy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely ophthalmology. Half of Descemet’s membrane (DM) and endothelium are transplanted. Corneal tunnel incision and removal of the recipient’s DM, trepanation of the donor cornea DM, staining and separation of DM from the posterior layers of the donor cornea stroma are performed. The graft is also straightened, centered and fixed by air tamponade of the anterior chamber. The separated DM is cut in half on the donor cornea, on each of the received transplants a marginal orientation mark is made in the form of an non-isosceles triangle. In the meridian of 6 hours, a coloboma of the iris is made, the corneal tunnel incision is sealed. Next, intraoperative optical coherence tomography is performed and the fit of the graft to the recipient’s stroma is evaluated. In a particular case, in the presence of diastasis, an additional air tamponade of the anterior chamber is performed.EFFECT: method makes it possible to reduce injuries of endothelial cells of the donor DM at all stages of surgery, as well as to restore the transparency of the cornea.1 cl, 1 ex

Description

The invention relates to the field of medicine, namely to ophthalmology, and relates to the technique of transplantation of half of the Descemet's membrane (DM) and endothelium in the treatment of Fuchs primary endothelial corneal dystrophy.

Fuchs endothelial corneal dystrophy (EDRF) is a bilateral genetically determined pathology characterized by thickening of the DM, deposition of extracellular matrix (gutta) and progressive loss of endothelial cells and, as a consequence, the development of endothelial dysfunction.

площади роговицы от подлежащей стромы и под нее вводили 0,06% раствор трипанового синего для окрашивания ДМ. Корнеосклеральный диск с отсепарованной, но прилежащей ДМ высекали с эндотелиальной стороны трепаном нужного диаметра (8,0-9,5 мм). Далее ДМ пинцетом отсепаровывали полностью в пределах остальной

площади роговицы от подлежащей стромы. Отсепарованную ДМ переносили на стерильную мягкую контактную линзу. Далее контактную линзу с расположенной на ней ДМ кератомическим ножом рассекали на 2 части. Сформированные трансплантаты помещали в раствор BSS для последующей трансплантации. На глазу реципиента производили роговичный тоннельный разрез шириной 1,8 мм в меридиане 12 ч. Через единственный парацентез в меридиане 10 ч обратным крючком Синского при заполненной воздухом передней камере осуществляли десцеметорексис в намеченных пределах. ДМ реципиента удаляли через тоннельный разрез. Десцеметотрансплантат имплантировали в переднюю камеру через тоннельный разрез с помощью адаптированного инжектора. Расправление трансплантата осуществляли ab externo. После расправления трансплантата его фиксировали к строме реципиента в пределах оптического центра при помощи воздушной тампонады передней камеры. (Оганесян О.Г., Макаров П.В., Грдиканян А.А., Гетадарян В.Р., Милаш С.В. Частичная трансплантациядесцеметовой мембраны с эндотелием (

и

DMEK). Российский медицинский журнал. 2018; 24(2): 78-82.)The closest analogue is the method of partial transplantation of DM, which was performed under installation anesthesia. A corneoscleral disc 17–18 mm in diameter was fixed with the endothelium upwards in a cornea suction fixator. With an ophthalmosurgical scraper, the DM was separated from the Schwalbe ring for 180° along the circumference and from the stroma by 1-2 mm to the center. DM tweezers were separated within

area of the cornea from the underlying stroma and under it was injected with a 0.06% solution of trypan blue for staining DM. The corneoscleral disc with separated but adjacent DM was excised from the endothelial side with a trephine of the required diameter (8.0–9.5 mm). Next, the DM was completely separated with tweezers within the rest

area of the cornea from the underlying stroma. The separated DM was transferred to a sterile soft contact lens. Next, the contact lens with the DM keratomy knife located on it was dissected into 2 parts. The formed grafts were placed in BSS solution for subsequent transplantation. A corneal tunnel incision 1.8 mm wide was made in the recipient's eye in the 12 o'clock meridian. Descemetorhexis was performed within the intended limits through a single paracentesis in the 10 o'clock meridian with the anterior chamber filled with air. The recipient's DM was removed through a tunnel incision. The descemetograft was implanted into the anterior chamber through a tunnel incision using an adapted injector. The graft was straightened ab externo. After the graft was straightened, it was fixed to the stroma of the recipient within the optical center using an air tamponade of the anterior chamber. (Oganesyan O.G., Makarov P.V., Grdikanyan A.A., Getadaryan V.R., Milash S.V. Partial transplantation of the Descemet's membrane with endothelium (

and

DMEK). Russian medical journal. 2018; 24(2): 78-82.)

The disadvantage of this method is the increased manipulation of instruments during the division of DM using its transfer, which can lead to significant injury to endothelial cells. Also, the absence of any marks on the graft does not exclude the possibility of inverse orientation of the DM and its adherence to the cornea with the endothelial side up.

The technical result of the proposed method is a significant reduction in trauma to the endothelial cells of the donor DM at all stages of surgery, as well as restoration of the transparency of the cornea.

The method is carried out as follows.

Produced standard eyelid akinesia according to Van Lindt and instillation of anesthetic into the conjunctival cavity. The corneal epithelium was removed with a scraper within 8.0 mm. Conducted circular approximate marking with a diameter of 8.0 mm. A corneal tunnel incision was made at 12 o'clock, a 1.0 mm wide paracentesis was positioned at 3 or 9 o'clock for the right and left eyes, respectively. In the meridian of 6 hours, an iris coloboma was formed using a disposable 25G needle bent upwards and a Sinsky microsurgical hook. A circular descemetorhexis with a diameter of 8.0 mm was performed with a blunt microhook (with a reverse profile), followed by removal of the DM with tweezers, after which the viscoelastic was aspirated (preliminarily introduced into the anterior chamber) and the anterior chamber was restored with a balanced saline solution. For further manipulations, the donor cornea was placed and fixed with the endothelium upwards in an artificial anterior chamber. The DM and endothelium of the donor, located to the periphery of the trepanation zone, were separated using corneal tweezers with blunt jaws. Using a thin spatula, the edge of the DM was separated along the notch by 1–2 mm towards the center. Next, the DM of the donor cornea was separated using corneal tweezers. They grabbed the edge of the DM and pulled it towards the center of the cornea, separated it to half, and then laid it in its original position. Using the same technique, the opposite edge of the DM was separated. During separation, regular installations of 0.15% trepan blue solution were used for contrasting. The formed transplant with a diameter of 8.0 mm was cut in half using a sterile disposable microblade. For the correct orientation of the graft in the anterior chamber during the spreading of the donor DM, using micro-scissors (according to Vannas) on each of the grafts, an approximate marginal mark was formed in the form of an isosceles triangle. The formed graft was placed in a conservation medium. For implantation of the graft, a straight glass pipette was used, connected by a tube to a 5.0 ml syringe containing saline. After implantation, the correct orientation of the DM graft and endothelium was verified using an edge mark in the form of an isosceles triangle. Next, the corneal tunnel incision was sealed by applying one interrupted suture (nylon 10/0). The graft was straightened and centered ab externo by stroking the outer surface of the cornea with a 30G cannula and a spatula. The vertical location of the graft in the anterior chamber was preferred. Anterior chamber air tamponade was used to fix the graft. Intraoperative optical coherence tomography (iOCT) was performed to assess the fit of the graft to the stroma of the recipient.

Among the significant distinguishing features of this method of treatment are:

- The formed graft is cut in half directly on the donor cornea, which reduces the time of instrument manipulation when transferring the DM to a sterile soft contact lens, reducing the likelihood of mechanical damage to the DM and endothelium;

- The presence of marginal indicative marks in the halves of the DM (in the form of non-isosceles triangles), made during cutting out, allows you to control the correct orientation of the grafts in the anterior chamber, which reduces the frequency of inverse positioning of the DM;

- The formation of the iris coloboma allows you to completely leave the air in the anterior chamber, thereby increasing the duration of the mechanical contact of the graft with the stroma of the recipient;

- Conducting iOCT of the anterior segment of the eye makes it possible to assess the fit of the graft to the stroma of the recipient throughout its entire length after the introduction of air.

The method is confirmed by the following example:

Example 1

Patient O., 60 years old, applied to the Federal State Budgetary Institution "NMIC" MNTK "MG" with complaints of decreased visual acuity, fogging in the morning, photophobia. Visual acuity OS 0.4 uncorrected. Objectively: the cornea is edematous, cornea guttatae. The anterior chamber is of medium depth, the iris is structural, initial lens opacities in the cortical layers, the optic disc is pale pink, the boundaries are clear, the macular area is without visible pathology. Taking into account the data of preoperative diagnostics and objective examination, the diagnosis was made: OS Fuchs endothelial corneal dystrophy. Primary age cataract. Surgical treatment for OS included transplantation of a half of the Descemet's membrane and endothelium; iOCT was also used to control the fit of the graft to the stroma of the recipient according to the proposed method.

The claimed method operated on 6 patients with EDRF. Transparent graft engraftment was observed in 100% of cases.

Claims (2)

1. A method for transplanting half of the Descemet's membrane (DM) and endothelium, including making a corneal tunnel incision and removing the recipient's DM, trepanation of the DM of the donor cornea, staining and separation of the DM from the posterior layers of the stroma of the donor cornea, and also straightening, centering and fixing the graft by air tamponade anterior chamber, characterized in that the separated DM is cut in half on the donor cornea, on each of the obtained grafts a marginal indicative mark in the form of a non-isosceles triangle is made, an iris coloboma is made in the meridian of 6 hours, the corneal tunnel incision is sealed, intraoperative optical coherence tomography is performed and evaluated adherence of the graft to the stroma of the recipient. 2. The method according to claim 1, characterized in that in the presence of diastasis, an additional air tamponade of the anterior chamber is performed.