RU2793217C1 - Method for combined treatment of traumatic cyclodialysis in combination with cataract - Google Patents

Abstract

FIELD: medicine; ophthalmic surgery.

SUBSTANCE: invention can be used for the combined treatment of traumatic cyclodialysis in combination with cataracts. At the first stage, cataract phacoemulsification is performed. Next, the anterior chamber is filled with viscoelastic. To determine the boundary of the separation of the ciliary body, gonioscopy with corneocompression is performed. Apply marks on the limb corresponding to the size of cyclodialysis. The conjunctiva is separated from the limbus within the marks. A continuous suture is applied to fix the exfoliated ciliary body in the region of the ciliary sulcus and sclera in the projection of the scleral spur. The ends of the thread are tucked into the scleral pocket.

EFFECT: invention makes it possible to tightly fix the ciliary body to the sclera in the area of the scleral spur, and reduce the risks of intraoperative complications by minimizing surgical access.

1 cl, 2 ex

Description

The invention relates to medicine, more specifically to ophthalmic surgery, and can be used for the combined treatment of traumatic cyclodialysis in combination with cataracts.

The clinical picture of post-traumatic injuries in case of eye injury is characterized by significant polymorphism of changes. Among the various injuries of the anterior segment of the eye, the most common manifestations are hyphema (98.5%), traumatic cataract (26%), dislocation of the lens (77.6%), iridodialysis (23.2%), traumatic mydriasis and pupillary sphincter ruptures (20 ,9%). In 1-9% of cases, post-concussion cyclodialysis is observed, leading to the development of hypotonic syndrome (Gundorova R.A., Stepanov A.V., Kurbanova N.F. Modern ophthalmotraumatology. M., 2007. - S. 14-20).

Cyclodialysis is a slit-like communication between the anterior chamber and the suprachoroidal space, resulting from the separation of the longitudinal muscle fibers of the ciliary muscle from the scleral spur, provoking pathological activation of the uveoscleral outflow tract of aqueous humor. The consequence is chronic hypotension of the eyeball with the formation of post-concussion hypotonic syndrome: a picture of a pseudocongestive optic nerve develops, swelling of all membranes, accompanied by characteristic tortuosity of all vessels and the formation of characteristic folding in the macular region in the form of a "star figure" - hypotonic maculopathy, decreased visual acuity, subatrophy of the eye apples. Post-concussion cyclodialysis can have a different extent along the arc of a circle, depending on the severity of the contusion, and in 50-88% of cases it is combined with lens opacities of varying degrees.

Various surgical methods for the treatment of cyclodialysis are known, which can be divided into methods using suture fixation, diathermocoagulation and laser coagulation, filling the supraciliary gap with biological tissues, cyclopexy using implants, tamponade of the vitreal cavity.

A known method for the treatment of traumatic cyclodialysis, which uses a continuous stalked suture, from the side of the sclera, the needle is advanced in accordance with its curvature, the ciliary body is pierced, while it is pulled up and fixed with a needle like a hook, after which the needle is punctured through the sclera at a distance of 2-3 mm from the injection site, and again injected into the middle between the first injection and the injection and carried out in a similar way, the ends of the thread are tightened and tied, the manipulations are repeated several times depending on the length of the detachment, with each new injection being made in the middle between the last two injections (patent RU 2447868 , C1, published 04/20/2012).

In this method, a difficultly controlled stage is the moment of piercing the ciliary body and fixing it with a “needle like a hook”, since the advancement of the needle occurs blindly. It cannot be ruled out that the ciliary body was not picked up, or vice versa, the ciliary processes were injured due to a disproportionately deep pickup.

A known method for the treatment of traumatic iridocyclodialysis, which consists in the following: make an incision and separation of the conjunctiva at the site of the alleged localization of iridocyclodialysis. An incision is made in the sclera at the site of the projection of cyclodialysis. When visualizing iridocyclodialysis, the incision is extended to the required length. Localized iridodialysis through a scleral incision is fixed with interrupted sutures to the ciliary body. Next, the ciliary body with the iris sewn to it is fixed with interrupted sutures to the sclera throughout the cyclodialysis. Interrupted sutures are applied to the incision of the sclera and then to the incision of the conjunctiva (Ophthalmology. - 2012. - T. 9 No. 3. - S. 29-32).

This method involves suture fixation when the ciliary body and iris are torn off. Despite the presence of direct visualization of iridocyclodialysis in this method, its significant disadvantages of the method include the fact that the method of fixing the ciliary body is open and with an extended detachment of the ciliary body, the scleral incision should also be sufficiently long, which significantly increases the volume of surgical intervention and surgical risks. . In addition, nodal fixation of the ciliary body is proposed, which does not exclude the existence of cyclodialysis gaps between the applied nodal sutures and may cause the communication between the anterior chamber and the uveoscleral space to remain and require repeated interventions.

Closest to the claimed method - the prototype is a way to eliminate iridodialysis, which consists in the following. After separating the conjunctiva from the limbus, a dosed - 350 μm - scleral incision is performed concentrically to the limbus in the projection of iridodialysis. Corneocentesis is performed, through which a 30 g injection needle is inserted, bent at an angle of 45°, with a 10-00 polypropylene thread installed in its cavity. The edge of the detachment of the iris is stitched with a needle and the tip of the needle is punctured into the scleral notch, mobilizing the end of the thread with tweezers. After that, the needle is returned back to the anterior chamber, re-flashing the edge of the tear, and the tip of the needle is punctured into the scleral notch. A loop is formed from the thread, and the needle is returned back to the anterior chamber. After the required number of loops is formed, the distal end of the thread is pulled out of the needle cavity and pulled through the loops formed on the sclera. The loops are tightened, the ends of the thread are tied with a triple surgical knot and immersed in the scleral notch, the conjunctiva is fixed with a coagulator. After fixation, the pupil is pulled to the place of fixation, the sliding knot technique is used to center the pupil and give it a rounded shape, interrupted sutures are applied to the pupillary edge of the iris (patent RU 2746542 C1, publ. 04/15/2021).

The disadvantages of the prototype are the lack of effectiveness in the treatment of traumatic cyclodialysis in combination with cataracts, a high risk of intraoperative complications.

The objective of the invention is to develop a method for the treatment of traumatic cyclodialysis in combination with a cataract, providing reliable fixation of the ciliary body to the sclera, reducing the risk of intraoperative complications by minimizing surgical access.

The technical result of the invention is to provide the ability to eliminate cataracts and cyclodialysis in the process of combined treatment, the ability to tightly fix the ciliary body to the sclera in the area of the scleral spur, reduce the risk of intraoperative complications by minimizing surgical access.

The task is achieved by determining the maximum size of cyclodialysis intraoperatively, after cataract phacoemulsification, as well as by applying a continuous suture that tightly fixes the ciliary body and the sclera between them, eliminating even minimal cyclodialysis gaps; the possibility of suture fixation of the ciliary body at any length using one or two corneocentesis, previously performed for cataract phacoemulsification.

The proposed method is carried out as follows.

After treatment of the surgical field and anesthesia, the cataract is removed by phacoemulsification according to the standard method, for this purpose accesses are formed - a tunnel incision and two corneocentesis, the anterior chamber is filled with viscoelastic, an anterior capsulorhexis is formed, the contents of the lens are emulsified, the capsular bag is freed from the lens masses, with signs of damage of the ligamentous apparatus, an intracapsular ring (ICR) is implanted, an intraocular lens is implanted. Next, the ciliary body is fixed with a continuous suture within the localization of the cyclodialysis gap. To clarify the localization of the cyclodialysis gap, intraoperative gonioscopy is performed: the anterior chamber is tightly filled with viscoelastic, the boundaries of the cyclodialysis gap are determined using a gonioscope (if there is a choice, preference is given to a straight-type gonioscope), and corneocompression is used to determine the maximum dimensions of the cyclodialysis gap. Using a marker, marks are applied on the limbus corresponding to the dimensions of cyclodialysis, the conjunctiva is separated from the limbus within the marked marks, a line parallel to the limbus 1.5 mm from it, connecting both marks, is marked with a marker. (Tight intraoperative filling of the anterior chamber with viscoelastic helps to avoid hypotension, which often interferes with gonioscopy at the stage of preoperative examination due to the formation of corneal folds. In addition, tight filling of the anterior chamber with viscoelastic in combination with moderate corneocompression makes it possible to determine the maximum dimensions of the cyclodialysis gap, which, in conditions of preoperative hypotension are not always visualized). Next, a 10/0 polypropylene thread is threaded into an injection needle with a diameter of 30g, bent at an angle of 45°, a small amount of viscoelastic is injected under the iris in the ciliary body separation sector, to form a space between the iris and the lens capsule, an injection needle with a threaded thread is inserted under the iris, between the iris and the anterior capsule of the lens, is carried out in the immediate vicinity from the iris to its root, pierced in the projection of the ciliary sulcus, the needle comes out to the surface of the sclera at the starting point of marking, making a small movement with the needle back, the thread is released and the free end is brought out to the surface of the sclera, holding the free end of the thread with knitting tweezers returns the needle with the threaded thread into the anterior chamber, again passes the needle under the iris in the projection of the ciliary sulcus and exits on the surface of the sclera 2 mm from the first puncture on the intended line, holding the thread loop, return the needle to the anterior chamber, the free end of the thread is passed into the loop formed, the next similar movement is made with the needle to form a new thread loop 2 mm from the previous needle prick, the free end of the thread is passed into the newly formed loop, the movement is repeated the required number of times to cover the distance corresponding to cyclodialysis, each puncturing once on the intended line 2 mm from the previous one and passing the first free (proximal) end of the suture thread through the newly formed loop to prevent the loop from slipping. During the completion of the last stitch, the second free (distal) end of the thread is brought to the surface of the sclera, the loops are alternately tightened, reaching a tight tension of the thread, a scleral pocket is formed in the exit meridian of the last stitch from the side of the cornea, the free ends of the thread are inserted into the injection needle, they are alternately brought out into scleral pocket, tied and trimmed. Thus, on the sclera, along the applied marking, the stitches of the thread lie down continuously, the knot is immersed in the scleral pocket. The conjunctiva is tightened with interrupted sutures along the edges of the incision. If the length of cyclodialysis is more than 180°, it is advisable to break the seam into several segments, for ease of manipulation and thread tension.

The defining differences of the proposed method, compared with the prototype, are:

- determination of the maximum size of cyclodialysis intraoperatively, after cataract phacoemulsification, which allows complete suture fixation and avoids the need for repeated surgical intervention;

- the imposition of a continuous suture that tightly fixes the ciliary body and the sclera to each other, which allows for a complete fit of the structures, excluding the preservation of cyclodialysis gaps between interrupted sutures, to exclude even minimal cyclodialysis gaps;

- the possibility of suture fixation of the ciliary body at any length using one or two corneocentesis, previously performed for cataract phacoemulsification.

The invention is illustrated by the following specific examples.

Example 1

Patient V., male, 57 years old, was admitted with a diagnosis of severe contusion of both eyes, on the right: traumatic cyclodialysis, traumatic cataract, traumatic mydriasis, partial hemophthalmos, choroidal detachment, postcontusion retinal dystrophy; on the left: traumatic cataract, tear of the pupillary edge of the iris, post-concussion retinal dystrophy.

Anamnesis: 3 months earlier suffered an injury in a compressor explosion in a personal garage. The result of the injury was a combined craniocerebral injury (severe concussion), trauma to the soft tissues of the face (multiple lacerations of the frontal region), and severe contusion of both eyes. At the time of treatment: visual acuity OD=0.02 n/a, OS=0.1 sph (-) 2.0D=0.2. IOP=8/18 mmHg

The right eye is moderately irritated, slight corneal edema, deep anterior chamber, traumatic mydriasis, focal transillumination of the iris, clouding of the lens; gonioscopy - for 4 to 8 hours, a dark cyclodialysis slit of uneven width is determined in the lower half (during corneocompression, you can see how the boundaries of the cyclodialysis slit expand, but the resulting corneal folds interfere with their accurate determination); according to the ultrasound study in the B-scan mode - detachment of the choroid with a height of 1.5 to 3.0 mm in all quadrants, partial hemophthalmos; according to ultrasonic biomicroscopy (UBM) - partial violation of the integrity of the lens ligaments in the lower sections, cyclodialysis gap in the meridians from 4 to 9 hours; the fundus was viewed with difficulty - one could assume focal changes on the retina in the macular region.

The left eye is outwardly calm, the cornea is transparent, the anterior chamber is of medium depth, a sectoral rupture of the pupillary sphincter at 5-6 hours; slight clouding of the cortical substance of the lens; Ultrasound examination in B-scan mode - detachment of the posterior hyaloid membrane of the vitreous body, the membranes of the eye are adjacent; Gonioscopy - structures of the angle of the anterior chamber (ACC) without features; according to UBM, the anatomical topographic relationships of the iris, lens, and ciliary body are not disturbed. On the fundus, contusion changes in the macular region were determined.

The patient underwent surgical treatment of the right eye by the claimed method.

After treatment of the surgical field and anesthesia, the cataract was removed by phacoemulsification, for which accesses were formed - the main tunnel incision and two auxiliary corneocentesis, anterior capsulorhexis was performed, the contents of the lens were removed, ICC and an intraocular lens were implanted. Further, having filled the anterior chamber with viscoelastic, gonioscopy was performed, with corneocompression, the boundaries of the ciliary body detachment were more than 180 degrees, from 2 to 9 hours. Appropriate markings were made on the limbus, the conjunctiva was separated within the markings, a line was drawn with a marker parallel to the limbus 1.5 mm from it. Then the ciliary body was sutured within the specified marking, breaking the segment into two parts - from 2 to 6 o'clock and from 6 to 9 o'clock, for which purpose a 10/0 polypropylene thread was threaded into an injection needle with a diameter of 30 g, an injection needle with thread was inserted under the iris, pierced at the root, went out with a needle to the surface of the sclera at the starting point of marking, brought the free end of the thread to the surface of the sclera, holding the free end of the thread with knitting tweezers, returned the needle with the thread to the anterior chamber, passed the needle under the iris and came out on the surface of the sclera in 2 mm from the first puncture on the intended line, holding the loop of the thread, returned the needle to the anterior chamber, the free end of the thread was passed into the formed loop, repeated the movement the required number of times reaching 6 hours, formed a scleral pocket, brought the threads into it, tied it, the knot was immersed in pocket. Similarly, the steps of suturing the next segment were repeated using the opposite corneocentesis. Taking into account the presence of a choroidal detachment in the patient and a rupture of the pupillary sphincter, an additional posterior scleral trepanation was performed in the 2 lower quadrants and three interrupted sutures were placed on the pupillary edge of the iris. The conjunctiva was sutured and bandaged.

In the postoperative period, the eye is moderately irritated, the cornea is moderately edematous, the anterior chamber is of normal depth, the IOL is in the correct position, ophthalmohypertension is within 26-28 mm Hg. persisted for 3 days after surgery. According to the B-scan - the fit of the membranes from the first day after the operation. After 7 days - the eye is calm, the cornea is transparent, IOP is 20 mm Hg. Visual acuity of 0.05 - due to contusion changes in the retina. According to the B-scan data, the membranes are adjacent, according to the UBM data, there is no cyclodialysis gap along its entire length. The patient is followed up for 12 months. The condition of the eye is stable.

Example 2

A 42-year-old man was admitted with a diagnosis of severe contusion of the right eye: traumatic cyclodialysis, traumatic cataract, tear of the pupillary edge of the iris, detachment of the choroid. History - 4 months ago, an injury to the right eye during a fight. Within 4 months he was treated at the place of residence, despite the ongoing treatment, hypotension of the right eye remained.

Data objective examination: right eye - visual acuity of 0.1; IOP 12 mm Hg; anterior chamber of normal depth; tear of the sphincter of the pupil at 3-4 hours; diffuse clouding of the lens, the fundus under the veil; gonioscopy - the structures of the angle of the anterior chamber are formed correctly, single deposits of pigment granules, cyclodialysis gap from 2 to 6 hours; according to the ultrasound B-scan - a flat detachment of the choroid up to 2 mm high in the lower quadrants; ultrasonic biomicroscopy confirmed the presence of cyclodialysis in the meridians from 2 to 6 hours.

The patient underwent surgical treatment of the right eye by the claimed method.

After treatment of the surgical field and anesthesia, the cataract was removed by phacoemulsification with implantation of the intracapsular ring and intraocular lens. Next, filling the anterior chamber with viscoelastic, performed gonioscopy, with corneocompression determined the boundaries of the separation of the ciliary body from 2 to 6 hours. The markings were made on the limbus corresponding to the boundaries of cyclodialysis, the conjunctiva was separated, a line was drawn with a marker parallel to the limbus 1.5 mm from it within the markings. Then the ciliary body was sutured from 2 to 6 o'clock, for which a 10/0 polypropylene thread was threaded into an injection needle with a diameter of 30 g, an injection needle with a threaded thread was inserted under the iris, pierced at the root, the needle came out to the surface of the sclera at the starting point of marking, the free end the threads were brought to the surface of the sclera, the needle with the thread was returned to the anterior chamber, again came out on the surface of the sclera 2 mm from the first puncture on the intended line, holding the loop of the thread, the needle was returned to the anterior chamber, the free end of the thread was passed into the formed loop, repeated movement the required number of times reaching 6 hours, a scleral pocket was formed, the threads were brought into it, tied, the knot was immersed in the pocket. Given the patient's choroid detachment and rupture of the pupillary sphincter, an additional posterior scleral trepanation was performed in the 2 lower quadrants and one interrupted suture was placed on the pupillary edge of the iris. The conjunctiva was sutured and bandaged.

A day after the operation, conjunctival hyperemia was noted, the cornea was transparent, the anterior chamber was of normal depth, the shape of the pupil was restored, the IOL was in the correct position, IOP was normal (20 mm Hg), visual acuity rose to 0.5; according to ultrasonic B-scanning, the membranes were adjacent, there was no detachment of the choroid. After 7 days visual acuity was 0.7; IOP remained 20 mm Hg; gonioscopically - the ciliary body was tightly adjacent to the scleral spur, with corneocompression, no cyclodialysis gaps were determined; full adhering of the ciliary body was confirmed by ultrasonic biomicroscopy. The follow-up period for the patient was 3 months. The condition is stable.

The use of the proposed method will allow simultaneous treatment of traumatic cyclodialysis in combination with cataract, provide the ability to tightly fix the ciliary body to the sclera in the area of the scleral spur, reduce the risk of intraoperative complications by minimizing surgical access.

Claims (1)

A method for the combined treatment of traumatic cyclodialysis in combination with cataracts, including the formation of corneocentesis, suture fixation of the detachment of the choroid structure to the sclera, characterized in that at the first stage cataract phacoemulsification is performed, then, to determine the boundaries of the detachment of the ciliary body, the anterior chamber of the eye is filled with viscoelastic, gonioscopy with corneocompression, marks are applied on the limbus corresponding to the dimensions of cyclodialysis, the conjunctiva is separated from the limbus within the marks and a continuous suture is applied to fix the exfoliated ciliary body in the region of the ciliary sulcus and sclera in the projection of the scleral spur, the ends of the thread are tied and tucked into the scleral pocket.