RU2770636C1 - Method for scleral fixation of polymer ophthalmological intracapsular ring in case of failure of the ligamentous apparatus of the lens - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely ophthalmology. The main corneal incision, capsulorrhexis (CCC), is carried out, one end of the thread is passed in the area of the ciliary furrow using a guide needle, and the second end of the thread is passed through the loop of the stabilizing device and the formation of a flange. Next, centering of the stabilizing device is carried out, cutting off the end of the thread located at the sclera, heating the end of the thread with the formation of a flange using a thermal router. As a stabilizing device, an open polymer ophthalmic intracapsular ring (ICR) with loops at the ends with dimensions of 11, or 12, or 13 mm is used. After performing three or four corneal paracentesis, three or four iridocapsular retractors are installed. After removal of the lens masses, the capsule bag is filled with a viscoelastic preparation. After that, the end of the polypropylene thread is threaded through the hole of one of the ICR loops and melted with a thermoscauter to form a flange larger than the hole in the ICR loop. Then the ICR is inserted into the injector so that the loop with the flange is located at the entrance to the cavity of the injector, remove the iridocapsular retractor located in the lower segment. Next, the ICR is implanted into the capsule bag in such a way that both loops are located in the most dehiscent area of the ligamentous apparatus of the lens. In this case, the free end of the polypropylene thread is left in the main corneal incision, the thread is removed with a hook in the area of the lower paracentesis remaining after the removal of this iridocapsular retractor, forming an outer loop, while the free end of the thread is left in the anterior chamber. Then, the conjunctival flap is separated or the conjunctiva is moved away with microsurgical tweezers in the projection of the dehiscence zone of the ligamentous apparatus of the lens, after which a scleral tunnel is formed using a 27 or 30 G needle bent by 90°. The injection is made 2 mm from the limb in the area of the ciliary furrow, then the needle is passed through the equator of the capsule and gets into the capsule bag, using tweezers, the free end of the thread is inserted into the needle cavity and removed through the sclera. Next, a flange is formed, changing its shape to a “nail cap”, it is immersed in the scleral tunnel, then the remaining iridocapsular retractors are removed. After that, the posterior chamber IOL is implanted, the remaining stages of phacoemulsification are performed, in the case of the formation of a conjunctival flap, it is sutured.EFFECT: method makes it possible to achieve intraoperative restoration of the stability and integrity of the capsule sac, followed by the possibility of intra-capsule implantation of a posterior chamber IOL model and preserve the anatomical and physiological structure of the eyeball.1 cl, 4 dwg, 3 ex

Description

The invention relates to ophthalmology and can be used when performing phacoemulsification (PEK) in patients with lens subluxation.

The closest analogue is a method for stabilizing a capsular bag using an intracapsular segment (VCS) made of polymethyl methacrylate, which is a 120 degree arc with two loops at the ends and one loop located in the center of the segment and bent upward and outward perpendicular to the segment itself. This model has two radii of curvature 4.5 and 5.0 mm and is used for intrascleral suturing in case of defects of the ligamentous apparatus and lens subluxations. According to this technique, after phacoemulsification, sclerotomy is performed at a distance of 2 mm from the limbus in the area of zonular weakness using a 26 G needle, then the needle is injected intrasclerally, the needle passes into the anterior chamber between the anterior capsule and the posterior surface of the iris, then one end of the polypropylene thread is placed with tweezers 5-0 into the cavity of the needle through the main corneal incision, then the needle, as a conductor of one end of the polypropylene thread, returns through the sclera to the outside and brings out the end of the thread. After that, one end of the polypropylene thread is visualized in the sclera area 2 mm from the limbus, and the other end of the thread is in the main corneal incision. Next, the second end of the thread is passed through the hole of the VKS loop located in the center of the VKS and bent up and outward, and a flange is formed using a thermocautery, then the VKS-thread complex is placed in the capsule in the area of weakness of the ligamentous apparatus, the capsular bag is centered, and the end of the thread , located at the sclera, is cut, heated and shaped into a flange using a thermocautery. As a final step, the flange is dipped into the scleral tunnel, an intraocular lens (IOL) is implanted, and the following cataract phacoemulsification steps are performed (Canabrava, S., Canedo Domingos Lima, A.C., Arancibia, A.E.L., Bicalho Dornelas, L.F., & Ribeiro, G. ( 2020. Novel double-flanked technique for managing Marfan syndrome and microspherophakia, Journal of Cataract and Refractive Surgery, 46(3), 333-339.

The disadvantages of this method is the unavailability of this model of VCL in the territory of the Russian Federation, and this VCL does not provide uniform tension of the capsular bag, so it is almost always used in combination with additional intracapsular rings (VKK).

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 thermocauter of a polymer ophthalmic VKK with dimensions of 11 or 12 or 13 mm, according to the invention, after performing the main incision and two paracentesis, the anterior chamber is filled with a viscoelastic preparation, then capsulorhexis (CC), three or four corneal paracentesis and three or four irido-capsular retractors (ICR) are installed to stabilize the capsular bag, after removing the lens masses, the capsular bag is filled and straightened with a viscoelastic preparation, then one ICR located in the lower segment is removed. After that, the end with a curved needle is cut off at the 6-0 polypropylene thread (II), this end is threaded through the hole of one of the VKK loops, the end of the thread is melted with a thermal cauter until a flange is formed with a size exceeding the hole in the VKK loop. this VKK is inserted into the injector so that the loop with the flange is located at the entrance to the cavity of the injector, then the VKK is implanted into the capsular bag and the loops are placed in the most incompetent area of the lens ligamentous apparatus, while the polypropylene thread with the other end is left in the main corneal incision, with a hook in area of the lower paracentesis for CFR, after its removal, 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 in the weakest area of incompetence of the ligamentous apparatus with microsurgical tweezers of the hummingbird type so that in the future the area of the scleral tunnel is covered by the conjunctiva, after which a scleral tunnel is formed using a 90-degree bent needle 27 or 30 G, an injection is made 2 mm from the limbus in the region of the ciliary sulcus, then the needle is passed through the equator of the capsular bag and enter its cavity. Using tweezers, the second end of the thread is inserted into 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. At the final stage, the thread is tightened so that the capsular bag is centered, the end of the thread is cut off, 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. After that, the remaining three IFRs are removed, the posterior chamber IOL is implanted, the viscoelastic preparation is washed out, the corneal incisions are hydrated, and the conjunctival flap, if it has been formed, is sutured with simple interrupted 8-0 Vicryl sutures. (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 common polymeric ophthalmic VKK and stabilizing the failure of the ligamentous apparatus of the lens by microinvasive access.

The method is illustrated by figures 1-4, figure 1 shows the implantation of a 6-0 polypropylene thread into the cavity with a 27 or 30 G guide needle bent at 90 degrees, fig. 2 - carrying out a polypropylene thread from the inside to the outside with the help of a conductor 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 - formation of the flange with the help of a thermocauter for intrascleral fixation 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 - zone where the polypropylene thread comes out, 7 - thermal cautery.

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, complicated cataract, high myopia. On examination: corrected visual acuity (CVA) of the left eye 0.7 with correction sph -8.0. Intraocular pressure (IOP) was within normal limits. Biomicroscopy visualized iridophacodonesis and stretched Zinn ligament fibers in the upper segment. When conducting ultrasound biomicroscopy (UBM), weakness of the ligamentous apparatus in the meridian from 11 to 14 hours was found with a downward displacement of the lens.

The reflex from the fundus is uniform. Ophthalmoscopy revealed no pathological changes in the fundus in the examined areas. The operation in the described manner was performed on the patient on the left eye. The patient under local anesthesia after performing the main corneal incision, two paracentesis and capsulorhexis were placed four CRIs at 10, 1, 4 and 6 hours, then after removal of the lens masses, two CRIs were removed at 1 and 6 hours. Fixation of the capsular bag for polymeric ophthalmic VKK with a diameter of 13 mm at 12 o'clock to the sclera in the region of the ciliary sulcus was carried out by the proposed method, after which the posterior chamber IOL was implanted. In the area of the scleral tunnel, a conjunctival flap was separated, followed by covering the formed flange with it, the flap was sutured with a simple interrupted suture with 8-0 Vicryl thread. 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 on the left eye 0.8 with correction sph -3.0. IOP 15 mm. Hg A stable "IOL-capsular bag" complex was visualized on UBM, and the location of the polypropylene thread corresponded to the zone of the ciliary sulcus.

Example 2

Patient S., 49 years old, diagnosis: left 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 a year ago. Uncorrected visual acuity (UCVA) of the left eye 0.05. Objectively: the left eye is calm, the anterior chamber is uneven, iridophacodonesis is visualized, the lens is clouded in all layers, the fundus 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 4 to 7 hours.

The patient under local anesthesia underwent the main incision and paracentesis at 2 and 9 hours, after performing capsulorhexis, three ICRs were installed at 12, 4 and 8 hours. After removal of the lens masses and replenishment of the volume of the capsular bag with a viscoelastic preparation, an ICH with a diameter of 11 mm was implanted so that the arches and the flange were located at 6 o'clock, the IVC was fixed by the proposed method to the sclera at 6 o'clock, 2 mm from the limbus in the region of the ciliary sulcus. In this case, a conjunctival flap was formed in the area of fixation; at the end of the operation, it was 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 3 months was 0.9. During applanation tonometry, intraocular pressure of 19 mm Hg was registered. According to UBM: the complex "IOL-capsular bag" is stable, the IOL is centered, in the correct position, the thread in the area of the ciliary sulcus and the flange are consistent.

Example 3

Patient S., 49 years old, diagnosis: right eye - traumatic cataract, subluxation of the 3rd degree, condition after a contusion eye injury. From the anamnesis it is known that six months ago an eye injury was received. 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 14 mm Hg. According to UBM: the absence of the ligamentous apparatus in the upper segment is visualized for 9 to 1 hour.

The patient under local anesthesia underwent the main incision and paracentesis at 2 and 9 hours, after performing capsulorhexis, four ICRs were installed at 11, 3, 5 and 8 hours. After removal of the lens masses and replenishment of the volume of the capsular bag with a viscoelastic preparation, according to the claimed method, a 12 mm ICH was implanted, the arches and a flange were placed at 12 o'clock in the zone of greatest weakness of the ligamentous apparatus of the lens, the IVC was fixed by the proposed method to the sclera 2 mm from the limbus in the region of the ciliary sulcus. In this case, the conjunctiva was moved back in the area of fixation so that at the end of the operation, the flange was completely covered by the conjunctiva. An aseptic bandage was applied to the eye. The early postoperative period was uneventful, the patient received anti-inflammatory therapy. NCHA after 1 month was 0.8. Applanation tonometry registered intraocular pressure of 17 mm Hg. According to UBM: the IOL is in the correct position, centered, the capsular bag is consistent, the thread passed through the ciliary sulcus is adapted, the flange is consistent.

Claims (1)

A method for cataract phacoemulsification in patients with incompetence of the ligamentous apparatus of the lens, including the main corneal incision, capsulorhexis (CC), passing one end of the thread in the area of the ciliary sulcus with a guide needle, passing the second end of the thread through the loop of the stabilizing device and forming a flange, then centering the stabilizing device , cutting the end of the thread located at the sclera, heating the end of the thread with the formation of a flange using a thermal cautery, characterized in that an open polymer ophthalmic intracapsular ring (VKK) with loops at the ends measuring 11, or 12, or 13 mm is used as a stabilizing device, after performing three or four corneal paracentesis, three or four iridocapsular retractors (ICRs) are installed, after removing the lens masses, the capsular bag is filled with a viscoelastic preparation, after which the end of the polypropylene thread is threaded through the hole of one of the loops VKK and melted with a thermal cautery until a flange is formed with a size exceeding the hole in the VKK loop, then the VKK is inserted into the injector so that the loop with the flange is located at the entrance to the injector cavity, the IFR located in the lower segment is removed, then the VKK is implanted into the capsular bag in such a way that so that both loops are located in the most insolvent area of the ligamentous apparatus of the lens, while the free end of the polypropylene thread is left in the main corneal incision, the thread is removed with a hook in the area of the lower paracentesis remaining after the removal of this calf, forming an external loop, while the free end of the thread is left in the anterior chamber, then the conjunctival flap is separated or the conjunctiva is pushed back with microsurgical tweezers in the projection of the incompetence zone of the ligamentous apparatus of the lens, after which a scleral tunnel is formed using a 90 ° bent needle 27 or 30 G, the injection is made 2 mm from the limbus in the region of the ciliary sulcus, then the needle is passed through the equator of the capsule and enter the capsular bag, with the help of tweezers, the free end of the thread is inserted into the cavity of the needle and taken out through the sclera, then a flange is formed, changing its shape to a “nail head”, immersed in the scleral tunnel, then the remaining IFR is removed, after that implantation of the posterior chamber IOL is carried out, the remaining stages of phacoemulsification are performed, in the case of the formation of a conjunctival flap, it is sutured.

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