RU2777742C1 - Method for treatment of acute keratoconus by transcorneal suture fixation of descemet membrane - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: for the treatment of patients with acute keratoconus, local installation anesthesia is performed, as well as paracentesis of the cornea in the limbic zone, introduction of a sterile air bubble into the front chamber (hereinafter – FC), and subsequent suture fixation of Descemet membrane (hereinafter – DM) and endothelium. Localization of DM detachment is identified, using intraoperative optical coherent tomography (hereinafter – iOCT). Viscoelastic is introduced into FC directly at an input to paracentesis. Sutures in a number from 2 to 5 are passed along previously applied marks through the entire thickness of the cornea. In a linear DM rupture, sutures are passed perpendicular to this rupture. In the absence of rupture, sutures are passed in the form of a grid or crosswise. Then, sutures are tied up, and knots are displaced to a place of a needle injection to the cornea. Next, the air bubble is substituted with a balanced salt solution, and the final control is carried out, using iOCT.

EFFECT: method accelerates the resorption of edema, as well as allows for the restoration of corneal transparency, and improvement of visual functions of a patient.

1 cl, 4 ex, 2 dwg

Description

The invention relates to medicine, namely to ophthalmology, and can be used for the treatment of acute keratoconus.

Acute keratoconus is characterized by the occurrence of edema of the corneal stroma due to the penetration of moisture from the anterior chamber due to rupture of the Descemet's membrane (DM). Acute keratoconus, as a rule, occurs suddenly, accompanied by a sharp pain syndrome and severe corneal edema. The zone of edema and clouding of the stroma can be different - from local clouding in the center of the cornea to its total edema. A number of authors believe that since this condition can resolve spontaneously, it does not require active treatment. On the other hand, since the resolution of the process can take up to 3-4 months, a number of ophthalmologists consider it expedient to adhere to a more active treatment tactics. In particular, perform surgical interventions, including the introduction of blood into the anterior chamber of the eye (hemo-filling), an air or gas bubble, coagulation of the cornea, its bandage strengthening, and a number of others. There is an opinion about the expediency of performing emergency penetrating keratoplasty, however, this increases the risk of corneal graft opacification. Active drug therapy to relieve inflammation and achieve faster clinical calm of the eye is generally considered to be appropriate.

объема, который оставался на длительный срок (Н Yahia Cherif, J Gueudry, M Afriat, A Delcampe, P Attal, H Gross, M Muraine. Efficacy and safety of pre-Descemet's membrane sutures for the management of acute corneal hydrops in keratoconus. Br J Ophthalmol 2015 Jun; 99(6): 773-7).The closest in technical essence is the method proposed by Yahia et al. (2015). The operation was performed under local anesthesia. First, the epithelium was mechanically removed, then paracentesis was performed, and sterile air was introduced into the anterior chamber for better visualization of the rupture in the DM. After that, using a thread of 10-0 nylon, the authors applied non-penetrating pre-Descemet sutures in an amount from 3 to 7 perpendicular to the rupture of the DM. Then, at the end of the operation, sterile air was re-introduced into the anterior chamber, filling it for

volume that remained for a long time (H Yahia Cherif, J Gueudry, M Afriat, A Delcampe, P Attal, H Gross, M Muraine. Efficacy and safety of pre-Descemet's membrane sutures for the management of acute corneal hydrops in keratoconus. Br J Ophthalmol 2015 Jun; 99(6): 773-7).

The disadvantages of this method are the imposition of non-penetrating pre-Descemet sutures and filling PC with sterile air, which was left for a long time. Non-penetrating pre-Descemet sutures prevent complete applanation of the cornea, which increases the period of edema resorption. Prolonged exposure to air in the PC can cause pupillary block, as well as Urrets-Zavalia syndrome.

The technical result of the method is to accelerate the resorption of edema, as well as restore the transparency of the cornea and improve the visual functions of the patient.

The technical result is achieved by the fact that the method according to the invention includes the application of 2 to 5 interrupted sutures through the entire thickness of the cornea with penetration into the anterior chamber along pre-applied marks in the affected area. The suture itself flattens the cornea, bringing its stroma closer to the area of the detached DM, and the section of the thread passing inside the anterior chamber, behind the cornea, serves for direct applanation of the DM to the posterior surface of the stroma. In this case, if there is a visible DM rupture site, the sutures are applied perpendicular to its length, and in the absence of a DM rupture site, crosswise or in the form of a lattice. The method is performed under the control of intraoperative optical coherence tomography (IOCT).

The method is carried out as follows.

The operation is performed under local installation anesthesia. In the area of the limbus, a paracentesis 1-1.2 mm wide is made, which is necessary for access to the anterior chamber at 9 or 3 o'clock. A bubble of sterile air is introduced into the anterior chamber to prevent emptying of the chamber at the time of suturing. Then, 0.1 ml of dispersive viscoelastic (VE) is introduced into the paracentesis, placing a drop of it in the anterior chamber (PC) directly at the entrance to the paracentesis. The VE serves to prevent the release of an air bubble from the PC at the time of suturing.

Next, iOCT is performed and the boundaries of the DM detachment are determined, which are marked with a marker on the anterior surface of the cornea. These marks will serve as a guide for the subsequent puncture of the cornea with a needle during sutures. A curved needle (needle 15 mm long, 1/4 bend of the needle tip) with a polypropylene thread (10-0) is injected along the outer border of the mark, it is passed through the cornea through the anterior chamber, and the puncture is made outside the mark in the opposite meridian. The thread is tied, and the suture knot is shifted to the point where the needle enters the cornea. If necessary, air is added to the anterior chamber, iOCT is performed, and the next suture is applied. Next, release the air bubble as much as possible and replace the volume of PC with a balanced salt solution. The operation is completed with an injection of dexamethasone and an antibiotic under the conjunctiva.

The method is illustrated in Fig. 1, 2, which show suturing. Position 1 indicates the cornea, 2 - the place of corneal edema, 3 and 4 - interrupted sutures in the form of a lattice (horizontal and vertical), 5 - crosswise interrupted sutures.

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

- the imposition of through interrupted sutures in the amount of 2 to 5 (horizontally and vertically or crosswise), simultaneously promotes corneal applanation with its flattening (impact force from outside to inside) and pressing the DM to the stroma (impact force from inside - outwards);

- the introduction of air is used only at the stage of suturing, then it is removed, which is the prevention of pupillary block and the development of the Urrets-Zavalia syndrome;

- IOCT of the anterior segment of the eye makes it possible to assess the prevalence and magnitude of DM detachment, as well as to control the volume and depth of corneal tissue suturing, as well as the fit of DM to the posterior layers of the cornea;

- the implementation of suture transcorneal fixation contributes to the restoration of normal anatomical and topographic ratios of the layers of the cornea, ensures the restoration of the function of the DM and endothelium, providing rapid resorption of edema and restoration of the transparency of the cornea.

The invention is illustrated by the following examples:

Example 1

Patient K., 35 years old, applied to the Federal State Budgetary Institution National Research Center “MNTK “MG” with complaints of a sharp decrease in visual acuity, pain, photophobia, and lacrimation. From the anamnesis: at the age of 30, she was diagnosed with OU Keratoconus stage 3. When contacting visual acuity OD 0.05 is not corrected. Objectively: the cornea is changed in the form of a cone, the center is displaced downward and outward, there is a sharp edema of all layers, the cornea is cloudy, including the superficial layers of the stroma, no DM rupture is detected, detachment of the DM and endothelium from the posterior layers. The anterior chamber is deep, the iris is structural. Deep-lying media are not ophthalmoscoped. Taking into account the data of the anamnesis (previously established diagnosis), preoperative diagnosis and objective examination, the diagnosis was made: OD Acute keratoconus. Surgical treatment according to the proposed method for OD included paracentesis for 9 hours, transcorneal suture fixation of the DM and endothelium to the posterior layers of the cornea in the form of a lattice using a 10-0 polypropylene thread, in the amount of 5, of which 2 horizontal interrupted sutures and 3 vertical, according to previously applied parallel marks, using iOCT to control the volume and depth of stitching.

Example 2

Patient O., 38 years old, applied to the Federal State Budgetary Institution "NMIC" MNTK "MG" with complaints of a sharp decrease in visual acuity, pain, photophobia. From the anamnesis: at the age of 33, she was diagnosed with OD Keratoconus stage 2, OS Keratoconus stage 3. Visual acuity of OS 0.01 is not corrected during treatment. Objectively: the cornea is changed in the form of a cone, the center is displaced downward and outward, there is a sharp edema of all layers, the cornea is cloudy, including the superficial layers of the stroma, the DM rupture is not visualized, detachment of the DM and endothelium from the posterior layers. The anterior chamber is deep, the iris is structural. Deep-lying media are not ophthalmoscoped. Taking into account the data of the anamnesis, preoperative diagnostics and objective examination, the diagnosis was made: OS Acute keratoconus. Surgical treatment according to the proposed method on OS included paracentesis for 3 hours, cruciform suture transcorneal fixation of the DM and endothelium to the posterior layers of the cornea using a 10-0 polypropylene thread, in the amount of 2, according to pre-applied parallel marks, using iOCT to control the depth of stitching .

Example 3

Patient C, 28 years old, applied to the Federal State Budgetary Institution "NMIC" MNTK "MG" with complaints of a sharp decrease in visual acuity, soreness, photophobia, and lacrimation. From the anamnesis: 2 years ago, OU Keratoconus stage 3 was diagnosed at the place of residence. Visual acuity of OS 0.02 is not corrected during treatment. Objectively: the cornea is changed in the form of a cone, the center is displaced downward and outward, there is a sharp edema of all layers, the cornea is cloudy, including the superficial layers of the stroma, a linear rupture of the DM is visualized, detachment of the DM and endothelium from the posterior layers. The anterior chamber is deep, the iris is structural. Deep-lying media are not ophthalmoscoped. Taking into account the data of the anamnesis, preoperative diagnostics and objective examination, the diagnosis was made: OS Acute keratoconus. Surgical treatment according to the proposed method on OS included paracentesis for 3 hours, transcorneal fixation of the DM and endothelium perpendicular to the length of the rupture to the posterior layers of the cornea using a 10-0 polypropylene thread, in an amount of 3, according to pre-applied parallel marks, using to control the depth of stitching iOCT.

Example 4

Patient D., 27 years old, applied to the Federal State Budgetary Institution National Research Center “MNTK “MG” with complaints of a sharp decrease in visual acuity, pain, photophobia, and lacrimation. From the anamnesis: at the age of 25, a diagnosis of OD Keratoconus stage 3 was made. OS Keratoconus stage 1. When contacting visual acuity OD 0.03 is not corrected. Objectively: the cornea is changed in the form of a cone, the center is displaced downward and outward, there is a sharp edema of all layers, the cornea is cloudy, including the superficial layers of the stroma, no DM rupture is detected, detachment of the DM and endothelium from the posterior layers. The anterior chamber is deep, the iris is structural. Deep-lying media are not ophthalmoscoped. Taking into account the data of the anamnesis (previously established diagnosis), preoperative diagnosis and objective examination, the diagnosis was made: OD Acute keratoconus. Surgical treatment according to the proposed method for OD included paracentesis for 9 hours, transcorneal suture fixation of the DM and endothelium to the posterior layers of the cornea in the form of a lattice using a 10-0 polypropylene thread, in the amount of 4 (2 horizontal interrupted sutures and 2 vertical), pre-applied parallel marks, using iOCT to control the volume and depth of stitching.

Six patients with acute keratoconus were operated on in a similar way. There were no intra- or postoperative complications in any of the cases.

Claims (1)

A method for treating patients with acute keratoconus, including local installation anesthesia, performing corneal paracentesis in the limbus zone, introducing a sterile air bubble into the anterior chamber (AC) and subsequent suture fixation of the Descemet's membrane (DM) and endothelium, characterized in that intraoperative optical coherence tomography is performed (iOCT) to identify the localization of the detachment of the DM, viscoelastic is injected into the PC directly at the entrance to the paracentesis, 2 to 5 sutures are passed through the entire thickness of the cornea, while in case of a linear rupture of the DM, the sutures are carried out perpendicular to this rupture, and in the absence of a rupture - in in the form of a lattice or crosswise, the sutures are tied, and the knots are displaced to the place where the needle was injected into the cornea, after which the air bubble is replaced with a balanced saline solution and a final control is carried out using iOCT.

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