RU2786138C1 - Method for scleral flange fixation of a polymer ophthalmological intracapsular ring in failure of the ligamentous apparatus of the lens - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to ophthalmology. A primary incision and two paracenteses are performed; the anterior chamber is filled with a viscoelastic agent. Then capsulorhexis is performed, as well as three or four corneal paracenteses, and three or four iridocapsular retractors (IR) are installed. The capsular bag is filled with the viscoelastic agent after the lens masses are removed. A posterior chamber IOL is implanted; a needle with a double polypropylene thread is passed through one of the loops of the intracapsular ring (ICR), followed by forming a node thereon; the ICR is implanted into the capsule bag through the primary incision, and the loop is located in the area of maximum failure of the ligamentous apparatus of the lens. After the ICR is implanted into the capsular bag, the needle is inserted blunt end first into the anterior chamber and partially removed through the paracentesis located on the side opposite from the area of maximum failure of the ligamentous apparatus of the lens. The conjunctiva is opened, and a radial incision of the sclera is performed to two-thirds of the thickness thereof; the needle is directed towards the area of maximum failure of the ligamentous apparatus of the lens using a needle holder, passing the needle between the anterior capsule of the lens and the posterior surface of the iris into the ciliary sulcus, led into said incision three mm from the limbus onto the sclera, and all IRs are removed. The resulting IOL - capsule bag - ICR complex is centred by tightening the thread, and the thread is cut from the needle, followed by melting the remaining free end of the thread by a thermocautery, forming a flange; washing out the viscoelastic agent, and hydrating the corneal incisions.

EFFECT: possibility of restoring the stability and integrity of the capsular bag intraoperatively, with the future possibility of intra-capsular implantation of a posterior chamber IOL model and preservation of the anatomical and physiological structure of the eyeball.

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Description

The invention relates to ophthalmology and can be used when performing phacoemulsification (PE) in patients with incompetence of the ligamentous apparatus of the lens, namely, with subluxation of 1 or 2 degrees.

The pathology of the ligamentous apparatus of the lens is an urgent problem of modern ophthalmic surgery, which can often lead to various intraoperative complications that make it difficult to carry out subsequent stages of operations or to postoperative complications that directly affect the visual acuity of patients. The search for various ways to improve microsurgical techniques for this kind of pathology is carried out by ophthalmologists around the world, the main of which today is the implantation of an intracapsular ring (ICR) with its suturing to the sclera.

The closest analogue is the method of scleral fixation of polymeric ophthalmic ICC in case of failure of the ligamentous apparatus of the lens, which is the implantation of ICC with loops at the ends measuring 11, or 12, or 13 mm, which is performed after performing three or four corneal paracentesis and installing three or four iridocapsular retractors ( IFR). According to this technique, 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 VKK loops and melted with a thermocauter until a flange is formed larger than the hole in the VKK loop, then the VKK is inserted into the injector so that the loop with flange was located at the entrance to the cavity of the injector, the IFR located in the lower segment is removed, then the ICC is implanted into the capsular bag in such a way that both loops are located in the most insolvent area of the lens ligamentous apparatus, while the free end of the polypropylene thread is left in the main corneal incision, with a hook in the area of the lower paracentesis remaining after the removal of this calf, the thread is removed, 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 zone is insolvent after which a scleral tunnel is formed using a 27 or 30 G needle bent at 90°, 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 capsule and enters the capsular bag, with the help of tweezers the free end of the thread into the cavity of the needle and lead out through the sclera, then a flange is formed, changing its shape to a “nail head”, it is immersed in the scleral tunnel, then the remaining IFR is removed, after that, the posterior chamber IOL is implanted, the remaining stages of phacoemulsification are performed, in case of formation the conjunctival flap is sutured (RF Patent for Invention No. 2770636).

The disadvantages of this method are the technical complexity of its implementation, the rather high difficulty of manipulations in the capsular bag, the risk of complications associated with the puncture of the capsular bag and the possibility of its rupture at the time of puncture.

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.

EFFECT: intraoperative restoration of the stability and integrity of the capsular bag with the subsequent possibility of intracapsular implantation of the posterior chamber IOL model and preservation of the anatomical and physiological structure of the eyeball.

The specified technical result is achieved by scleral flange fixation of a polymeric ophthalmic VKK with two loops at its ends with dimensions of 11 or 12 or 13 mm using a thermal cautery. According to the invention, after performing the main incision and two paracentesis, the anterior chamber is filled with a viscoelastic preparation, then capsulorhexis is performed, three or four additional corneal paracentesis are performed, three or four iridocapsular retractors (ICR) are installed to stabilize the capsular bag, and the main stage of cataract phacoemulsification is performed. After removal of the lens masses, the capsular bag is filled and spread with a viscoelastic preparation. A posterior chamber IOL is implanted. Then a needle with a double polypropylene thread 8-0 is passed through one of the VKK loops and a knot is formed on it. This VKK is inserted into the injector so that this loop with the thread is located at the entrance to the cavity of the injector, then the VKK is implanted into the capsular bag through the main incision and the loop with the thread is placed in the most incompetent area of the lens ligamentous apparatus, while the other end of the polypropylene thread is left mainly corneal incision. The needle with a blunt part with this end of the thread is inserted into the anterior chamber and removed halfway from the paracentesis located in the side opposite from the area of maximum failure of the ligamentous apparatus of the lens. Three millimeters from the limbus, the conjunctiva is opened and a radial incision is made in the sclera for two-thirds of its thickness. With a needle holder, the needle is directed towards the maximum insolvency of the lens ligamentous apparatus, passing it between the anterior lens capsule and the posterior surface of the iris into the ciliary groove, bringing it into an incision three millimeters from the limbus to the sclera, and cutting it off the thread using scissors according to Vannas. After that, all IFRs are removed, the resulting complex IOL - capsular bag - VKK is centered by pulling the thread, the thread is cut off from the needle, leaving 6-7 cm, after which the free end of the thread is melted with a thermocauter to form a flange, the viscoelastic preparation is washed out, the incisions are hydrated, and, if necessary, compare the edges of the conjunctiva using diathermocoagulation.

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 intra- and postoperative complications, for example, decentration of the IOL-capsular bag-VKC complex, its dislocation into the vitreal cavity, secondary glaucoma, hyphema, hemophthalmia, or inflammation. All these complications force us to look for ways to maintain the stability of the IOL-capsular bag-VKC complex in order to achieve the most physiological position of the IOL.

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 IOL in the capsular bag, which significantly reduces the risk of dislocation of the IOL-capsular bag-VKC complex and the development of postoperative complications.

The method is illustrated by the following clinical example.

Example 1

Patient A., 63 years old, applied to MNTK MG with complaints of decreased vision in the left eye, which arose after contusion of the eyeball 3 months ago. Preliminary diagnosis: OS traumatic cataract, subluxation of the lens of the 2nd degree.

On examination, uncorrected visual acuity (UCVA) in the left eye was pr. Certae, intraocular pressure (IOP) - 12 mm Hg. Art. Biomicroscopy: the eye is calm. The cornea is transparent, the anterior chamber is small, uneven, the moisture is transparent, the iris stroma atrophy, the diaphragmatic function of the pupil is impaired, the pupil is 1.5 mm in diameter, the lens is clouded in the nucleus with hydration, iridophacodonesis. With drug-induced mydriasis of 5 mm, the lens equator is visualized at 12 o'clock, the fundus is not ophthalmoscoped. During ultrasonic biomicroscopy (UBM), a convex profile of the iris was detected, the depth of the anterior chamber was reduced to 2.07 mm in the center, a narrow angle of the anterior chamber (in the upper sections - beak-shaped), the lens was dislocated downwards and medially, spherophakia. The operation was performed on the patient's left eye. Under local anesthesia after performing the main corneal incision, three paracentesis at 10, 1 and 6 hours and capsulorhexis in the paracentesis, three ICRs were placed. Fixation of the capsular bag by the loop of the polymeric ophthalmic VKK with a diameter of 12 mm at 12 o'clock to the sclera in the region of the ciliary sulcus was carried out by the proposed method after cataract phacoemulsification and implantation of the posterior chamber IOL into the capsular bag. The edges of the conjunctiva were compared using a diathermacoagulator.

In the postoperative period, anti-inflammatory and antibacterial therapy was performed. The early postoperative period proceeded with moderate inflammation of the eye, which was stopped by anti-inflammatory therapy. After 1 month, when examining the left eye, BCVA was 0.6 sph -0.5 cyl -1.0 ax 125=1.0, IOP 16 mm Hg. At biomicroscopy: the cornea is transparent, the anterior chamber is of medium depth, the moisture is clear, the iris is structural, the pupil is round, the reaction to light is live, the IOL is in the posterior chamber, centered. The reflex from the fundus is pink. UBM demonstrated a stable, central position of the IOL-capsular bag-VKC complex in the posterior chamber of the eye.

Example 2

Patient M., 78 years old, applied to MNTK MG with complaints of decreased vision in the left eye, which arose after contusion of the eyeball 1.5 months ago. Preliminary diagnosis: OS traumatic cataract, subluxation of the lens of the 1st degree.

When examining NCVA in the left eye was 0.05, IOP - 14 mm Hg. Art. Biomicroscopy: the eye is calm. The cornea is transparent, the anterior chamber is shallow, the moisture is transparent, the iris stroma atrophy, the diaphragmatic function of the pupil is impaired, the pupil is 2 mm in diameter, the lens is clouded in all layers, the fundus is not ophthalmoscoped. During UBM, a convex profile of the iris was found, the depth of the anterior chamber was reduced to 2.51 mm in the center, a narrow angle of the anterior chamber, the lens was dislocated upward and outward. The operation was performed on the patient's left eye. Under local anesthesia after performing the main corneal incision, four paracentesis at 2, 7, 10 and 12 hours and capsulorhexis, four ICRs were placed in the paracentesis. Fixation of the capsular bag by the loop of the polymer ophthalmic VKK with a diameter of 13 mm at 5 o'clock to the sclera in the region of the ciliary sulcus was carried out by the proposed method after cataract phacoemulsification and implantation of the posterior chamber IOL into the capsular bag.

In the postoperative period, anti-inflammatory and antibacterial therapy was performed. The early postoperative period proceeded with moderate inflammation of the eye, which was stopped by anti-inflammatory therapy. After 1 month, when examining the left eye, BCVA was 0.8 sph -0.5 cyl -0.5 ax 150=1.0, IOP 18 mm Hg. Art. At biomicroscopy: the cornea is transparent, the anterior chamber is of medium depth, the moisture is clear, the iris is structural, the pupil is round, the reaction to light is live, the IOL is in the posterior chamber, centered. The reflex from the fundus is pink. UBM demonstrated a stable, central position of the IOL-capsular bag-VKC complex in the posterior chamber of the eye.

Claims (1)

A method of scleral flange fixation of a polymeric ophthalmic intracapsular ring (VKK) in case of failure of the ligamentous apparatus of the lens, which consists in making the main incision and two paracentesis, filling the anterior chamber with a viscoelastic preparation, performing capsulorhexis, three or four corneal paracentesis and installing three or four irido-capsular retractors ( IFR), filling the capsular bag with a viscoelastic preparation after removal of the lens masses, implantation of a posterior chamber IOL, passing a needle with a double polypropylene thread through one of the loops of the VKD and forming a knot on it, implanting the VKK into the capsular bag through the main incision and placing the loop in the area of maximum ligamentous incompetence apparatus of the lens, characterized in that after implantation of the ICC into the capsular bag, the needle is inserted with a blunt end into the anterior chamber and partially withdrawn through paracentesis located in the area opposite to the maximum failure ligamentous apparatus of the lens to the side, the conjunctiva is opened and a radial incision of the sclera is made for two thirds of its thickness, with the help of a needle holder, the needle is directed towards the area of maximum insolvency of the ligamentous apparatus of the lens, passing the needle between the anterior lens capsule and the posterior surface of the iris into the ciliary sulcus, leading into this an incision in three millimeters from the limbus to the sclera, and all IFR is removed, the resulting complex IOL - capsular bag - VKC is centered by thread tension, the thread is cut from the needle, after which the remaining free end of the thread is melted with a thermocautery to form a flange, the viscoelastic preparation is washed out, hydrate the corneal incisions.