RU2801490C1 - Method of cataract extraction and intraocular lens implantation during simultaneous penetrating keratoplasty with partial fixation of trepanned cornea (versions) - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: according to the first variant, the recipient's cornea is trepanned, the remaining bridges are dissected with scissors. Extracapsular cataract removal is performed, the donor graft is placed in the recipient's bed and partially fixed to the recipient's cornea remaining after trepanation, leaving a clearance for the passage of the injector with an elastic intraocular lens (IOL). The anterior and posterior chambers are filled with viscoelastic, the IOL is implanted into the capsular bag, the viscoelastic is removed and the graft is fixed. When cutting the remaining bridges, the bridge is kept at 6 o’clock position and a ligature is applied at 12 o’clock position, and if the clouding of the cornea makes it possible to visualize the anterior chamber, the ligature is fixed to the cornea remaining after trepanation (CRAT). The recipient's trepanned cornea (RTC) is fixed at two points, after which mezaton and viscoelastic are injected into the anterior chamber. Next, circular capsulorhexis, hydrodissection, hydrodeletion are performed, phacofragmentation and aspiration of the lens masses are performed using the phaco-tip. All the instruments for the above manipulations are introduced into the anterior chamber through the space between the two fixation points of the RTC and the operation is completed by removing the viscoelastic and fixing the graft to the CRAT. According to the second option, when dissecting the remaining bridges, the bridge is kept at 6 o’clock position and a ligature is applied at 12 o’clock position, and if the corneal opacification is diffuse and makes it impossible to visualize the anterior chamber, the RTC is lifted by the ligature, creating an angle of 40 degrees between the RTC and the iris, to visualize the structures anterior chamber, after which mezaton and viscoelastic are introduced. Next, circular capsulorhexis, hydrodissection, hydrodeletion are performed, phacofragmentation and aspiration of the lens masses are performed using the phaco-tip, all the instruments for the above manipulations are inserted through the space between the elevated RTC and CRAT, and in the absence of intraoperative complications, after cataract extraction, the operation is completed by removing the viscoelastic and fixing the graft to the CRAT.

EFFECT: group of inventions makes it possible to reduce the number of intraoperative complications, in particular, vitreous prolapse, expulsive hemorrhage, trauma to the posterior lens capsule and anterior hyaloid membrane, which is achieved due to the fact that cataract extraction and IOL implantation are performed in the presence of a relatively sealed anterior chamber or it is possible to control the tightness when presence of diffuse corneal opacity.

3 cl, 3 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for the surgical treatment of various corneal opacities associated with cataracts.

A patent for utility model No. 163774 is known in which, due to the meniscus-shaped form of a keratoprosthesis, with a radius corresponding to the curvature of the cornea and the convex surface of the body, an anterior chamber is created, the presence of which allows one-stage cataract extraction (EC) and penetrating keratoplasty (PKP) without disturbing sealing.

The disadvantages of this method is the technical complexity, as well as a high risk of intraoperative complications.

The closest analogue is the method of implantation of an intraocular lens (IOL) in the simultaneous implementation of the SPC (RF patent 2468773).

The method consists in trepanation of the recipient's cornea, extracapsular removal of the cataract, then the graft is placed in the recipient's bed and partially fixed to the cornea, leaving a gap for the passage of the injector with the IOL, the anterior and posterior chambers are filled with viscoelastic, after which the elastic is implanted using the injector. IOL into the posterior chamber, the viscoelastic is removed and the graft is completely fixed.

The disadvantages of the method: the absence of the anterior chamber when performing EC, the impossibility of rapid sealing when ophthalmohypertension begins, the risk of injury to the posterior lens capsule, the anterior hyaloid membrane and the development of expulsive hemorrhage.

The objective of the invention is to create two variants of EC in the simultaneous implementation of SPC in patients with varying degrees of corneal opacification.

To solve this problem, two versions of the method have been developed.

The technical result of both options is to reduce the risk of intraoperative complications by maintaining a relatively sealed anterior chamber in patients with corneal opacities, in which the anterior chamber is visualized and the ability to change the angle between the recipient's trepanned cornea (TRR) and the iris in patients with diffuse corneal opacification.

The method according to the first variant, in which the clouding of the cornea makes it possible to visualize the anterior chamber, is carried out as follows.

First, the donor cornea is removed from the medium for preserving corneas (corneal storage solution TU No. 9398-013-29039336-2008, produced by LLC NEP Eye Microsurgery, Moscow, Beskudnikovsky 6-r, 59A) and placed on a Barron vacuum cutter. The donor cornea is centered, it is fixed with a vacuum, then the mechanism is closed and the graft of the required diameter is cut out. The graft is placed back into corneal preservation medium. Next, the recipient's cornea is trepanned using a Barron trephine of the required diameter, the remaining bridges are dissected with scissors, keeping the bridge at 6 hours and a ligature is applied at 12 hours, it is fixed to the cornea remaining after trepanation (OPTR), while the TRR is fixed in two points. After that, mezaton and viscoelastic are introduced into the anterior chamber, then circular capsulorhexis, hydrodissection, hydrodelineation are performed, phacofragmentation and aspiration of the lens masses are performed using the phaco-tip. All instruments for the above manipulations are introduced into the anterior chamber through the space between the two TPP fixation points. After EC, the bridge is cut at 6 o'clock and the ligature at 12 o'clock with scissors and the TPP is removed. Next, the graft is placed in the resulting recipient bed and fixed to the OPTR with interrupted sutures, maintaining a clearance for the passage of a manual injector with a size of 2.2 or 2.75 mm, depending on the cartridge used. Next, a cohesive viscoelastic is introduced into the anterior and posterior chambers and the elastic IOL is implanted using a manual injector into the capsular bag. After that, the viscoelastic is removed and the graft is completely fixed to the OPTR.

The method according to the second variant in case of diffuse corneal opacification, in which corneal opacification does not make it possible to visualize the anterior chamber, is carried out as follows.

First, the donor cornea is removed from the medium for preserving corneas (solution for storing the cornea TU No. 9398-013-29039336-2008, produced by NEP Eye Microsurgery LLC, Moscow, Beskudnikovsky 6-r, 59A) and placed on a Barron vacuum cutter. The donor cornea is centered, it is fixed with a vacuum, then the mechanism is closed and the graft of the required diameter is cut out. The graft is placed back into corneal preservation medium. Next, the recipient's cornea is trepanned using a Barron trephine of the required diameter, the remaining bridges are dissected with scissors, keeping the bridge at 6 o'clock, and a ligature is applied at 12 o'clock. The TPP is lifted by the ligature, creating a 40 degree angle between the TPP and the iris. After that, mezaton and viscoelastic are introduced, and cataract extraction begins, circular capsulorhexis, hydrodissection, hydrodelineation are performed, phacofragmentation and aspiration of the lens masses are performed using the phaco-tip. All instruments for the above manipulations are introduced into the space between the TRR and OPTR, and in the absence of intraoperative complications, cataract extraction is completed. Next, the graft is placed in the resulting recipient bed and fixed to the OPTR with interrupted sutures, keeping a clearance for the passage of a manual injector with a size of 2.2 or 2.75 mm, depending on the cartridge used. Next, a cohesive viscoelastic is introduced into the anterior and posterior chambers and the elastic IOL is implanted using a manual injector into the capsular bag. After that, the viscoelastic is removed and the graft is completely fixed to the OPTR.

If intraoperative complications occur, then the TRR is lowered, fixed to the OPTR, and when the eye condition is normal, the TRR is unfixed, and it is again raised at an angle of 40 degrees to the iris. After EC, the bridge is cut at 6 o'clock and the ligature at 12 o'clock with scissors and the TPP is removed. Next, the graft is placed in the recipient's bed and fixed to the OPTR with interrupted sutures, maintaining a clearance for the passage of a manual injector with a size of 2.2 or 2.75 mm, depending on the cartridge used. Next, a cohesive viscoelastic is introduced into the anterior and posterior chambers and the elastic IOL is implanted using a manual injector into the capsular bag. After that, the viscoelastic is removed and the graft is completely fixed to the OPTR.

Significant differences of this method:

the method makes it possible to maintain a relatively stable anterior chamber by bridging and applying a ligature with fixation between TRR and OPTR, which makes it possible to perform EC with a preserved anterior chamber in patients with corneal opacities, making it possible to visualize the anterior chamber;

the method makes it possible to create an angle between the TPP and the iris, which makes it possible to perform EC in patients with diffuse corneal opacities. The method is illustrated by the following examples.

Example 1

Patient A, 64 years old. Diagnosis: OD Keratoconus stage 4. Complicated cataract OS Keratoconus stage 2. Complicated cataract.

From the anamnesis it is known that the diagnosis of keratoconus in both eyes was made 7 years ago at the place of residence, for the last few years he has noted a deterioration in vision in the right eye.

At biomicroscopy, the cornea is transparent, in the optical region there are single opacities, the cornea is aspherical, the optical section is thinned, in the central optical zone, Vogt's striae, the anterior chamber is deeper than the average, the moisture of the anterior chamber is transparent, the iris is structural, the pupil is 3 mm, the lens is diffusely clouded in the nucleus and cortical layers . Deep-lying media are not ophthalmoscoped.

Visual acuity: OD - 0.05, does not correct; OS - 0.2 with correction sph -1.0 D cyl -5.0 D ax 80=0.7. Optical coherence tomography (OCT) of the anterior segment of the right eye visualized the elevation of the posterior surface of the cornea, the thickness of which in the center was 297 µm.

Given the presence of thinning of the cornea and clouding, which makes it possible to visualize the anterior chamber, as well as the presence of cataracts, one-stage penetrating keratoplasty, cataract extraction and IOL implantation with partial fixation of the recipient's cornea were performed according to the first version of the proposed method.

The course of the early postoperative period was uneventful.

In the first days, moderate swelling of the graft, folds of the Descemet's membrane, and rich corneal sutures were noted. The moisture of the anterior chamber is transparent, the pupil's reaction to light is alive, the IOL is in a capsular bag.

At discharge from the hospital on the 7th day: the eye is calm, the graft is transparent, epithelized, well adapted with interrupted sutures, IOL in a capsular bag. Visual acuity of the right eye 0.05 (does not correct). Intraocular pressure - palpation is normal.

When examining the patient after 3 months, there was a positive trend: the operated eye was calm, the graft was transparent, the corneal sutures were consistent, the IOL was in the capsular bag. Visual acuity OD - 0.1 (does not correct). Intraocular pressure - 15 mm Hg.

After 6 months, the examination showed complete transparency of the graft, consistency of the corneal sutures, IOL in the capsular bag. Visual acuity OD - 0.2 with correction sph -1.0 D cyl -4.25 D ax 110=0.8. Intraocular pressure - 16 mm Hg.

Example 2

Patient M, 81 years old. Diagnosis: OD Corneal degeneration. Complicated cataract OS Artifakia

From the anamnesis it is known that a few years ago, inflammation was transferred to the right eye, for which the patient was in the hospital.

Biomicroscopy visualizes diffuse opacification of the cornea, edema, bullousness of the epithelium. Deep-lying media are not ophthalmoscoped.

Visual acuity: OD Visus=l/∞ proectia lucis certa; OS - 0.7.

Optical coherence tomography (OCT) of the anterior segment of the right eye visualizes changes in all layers of the cornea and stroma. The minimum thickness of the cornea in the center is 874 µm.

According to the B-scan, the presence of an enlarged dense lens is determined, which makes it possible to suggest the presence of a cataract.

Taking into account corneal edema, epithelial bullosity and diffuse clouding of all layers of the cornea, as well as the presence of cataracts, it was decided to perform simultaneous penetrating keratoplasty, cataract extraction and IOL implantation with partial fixation of the recipient's cornea in the bridge zone at 6 o'clock and ligation at 12 o'clock, which will make it possible to intraoperatively change the angle between the TPP and the iris, according to the second version of the method

The graft was cut out intraoperatively, then the recipient's cornea with a diameter of 8 mm was trepananized, the remaining bridges were dissected, with the bridge remaining at 6 o'clock, a ligature was applied at 12 o'clock, the TRR was raised by the ligature, creating an angle between the TRR and the iris of 40 degrees, taking into account the absence of intraoperative complications of EC was performed at an angle of 40 degrees between the TRR and the iris, then the graft was placed in the recipient's bed and fixed to the OPTR with interrupted sutures, while maintaining a lumen for the passage of a manual injector of 2.2 mm in size, and after the introduction of cohesive viscoelastic, the IOL was implanted into the capsular bag and completely fixed transplant to OPTR.

The course of the early postoperative period was uneventful. In the first days, moderate swelling of the graft, folds of the Descemet's membrane, and rich corneal sutures were noted. The moisture of the anterior chamber is transparent, the pupil's reaction to light is alive, the IOL is in a capsular bag.

At discharge from the hospital on the 7th day: the eye is calm, the graft is transparent, epithelialized, well adapted nodular, IOL in the capsular bag. Visual acuity of the right eye 0.05 (does not correct). Intraocular pressure - palpation is normal.

When examining the patient after 3 months, there was a positive trend: the operated eye was calm, the graft was transparent, the corneal sutures were consistent, the IOL was in the capsular bag. Visual acuity OD - 0.05 (does not correct). Intraocular pressure - 15 mm Hg.

After 6 months, the examination showed complete transparency of the graft, consistency of the corneal sutures, IOL in the capsular bag. Visual acuity OD - 0.1 with correction sph -2.0 D cyl -3.75 D ax 15=0.7. Intraocular pressure - 14 mm Hg.

Example 3

Patient D, 74 years old. Diagnosis: OD Complicated cataract. Pseudoexfoliative syndrome OS Corneal degeneration. Complicated cataract. From the anamnesis it is known that a few years ago, inflammation was transferred to the left eye, for which the patient was in the hospital.

Biomicroscopy visualizes diffuse opacification of the cornea, edema, bullousness of the epithelium. Deep-lying media are not ophthalmoscoped.

Visual acuity: OD - 0.4 sph -1.0 D cyl -0.75 D ax 94=0.8; OS - Visus=l/∞ proectia lucis certa.

Optical coherence tomography (OCT) of the anterior segment of the right eye visualizes changes in all layers of the cornea and stroma. The minimum thickness of the cornea in the center is 887 µm.

According to the B-scan, the presence of an enlarged dense lens is determined, which makes it possible to suggest the presence of a cataract.

Taking into account corneal edema, epithelial bullosity and diffuse clouding of all layers of the cornea, as well as the presence of cataracts, it was decided to perform simultaneous penetrating keratoplasty, cataract extraction and IOL implantation with partial fixation of the recipient's cornea in the bridge zone at 6 o'clock and ligation at 12 o'clock, which will make it possible to intraoperatively change the angle between the TRR and the iris, according to the second version of the method.

The graft was cut out intraoperatively, then the recipient's cornea with a diameter of 7.5 mm was trepanized, the remaining bridges were dissected, with the bridge remaining at 6 o'clock, a ligature was applied at 12 o'clock, the TRR was raised by the ligature, creating an angle between the TRR and the iris of 40 degrees, and a circular capsulorhexis was performed , hydrodissection, hydrodelineation, and at the time of the introduction of instruments for phacofragmentation of the lens nucleus intraoperatively, an increase in blood pressure occurred, which led to the occurrence of ophthalmohypertension. The instruments were removed from the eye, and the TPP was lowered by the ligature and fixed to the OPTR. The anesthetist administered antihypertensive drugs intravenously, and after the normalization of the eye tone, the ligature was released and the TPP was again raised by 40 degrees, which made it possible to complete the EC. Next, the graft was placed in the recipient bed and fixed to the OPTR with interrupted sutures, while maintaining a lumen for the passage of a manual injector 2.75 mm in size, and after the introduction of a cohesive viscoelastic, the IOL was implanted in the capsular bag and the graft was completely fixed to the OPTR.

The course of the early postoperative period was uneventful. In the first days, moderate swelling of the graft, folds of the Descemet's membrane, and rich corneal sutures were noted. The moisture of the anterior chamber is transparent, the pupil's reaction to light is alive, the IOL is in a capsular bag.

At discharge from the hospital on the 7th day: the eye is calm, the graft is transparent, epithelialized, well adapted nodular, IOL in the capsular bag. Visual acuity of the right eye 0.05 (does not correct). Intraocular pressure - palpation is normal.

When examining the patient after 3 months, there was a positive trend: the operated eye was calm, the graft was transparent, the corneal sutures were consistent, the IOL was in the capsular bag. Visual acuity OS - 0.05 (does not correct). Intraocular pressure - 14 mm Hg. Art.

After 6 months, the examination showed complete transparency of the graft, consistency of the corneal sutures, IOL in the capsular bag. Visual acuity OS - 0.1 with correction sph -3.0 D cyl -4.00 D ax 48=0.7. Intraocular pressure - 14 mm Hg.

Claims (3)

1. A method for cataract extraction and implantation of an elastic intraocular lens (IOL) during simultaneous penetrating keratoplasty, including trepanation of the recipient's cornea, dissection of the remaining bridges with scissors, extracapsular cataract removal, placement of a donor graft in the recipient's bed, and partial fixation to the recipient's cornea remaining after trepanation , leaving a clearance for the passage of the injector with the IOL, filling the anterior and posterior chambers with viscoelastic, implanting the IOL into the capsular bag, removing the viscoelastic and fixing the graft, characterized in that when cutting the remaining bridges, the bridge is kept at 6 hours and a ligature is applied at 12 hours, and if clouding of the cornea makes it possible to visualize the anterior chamber, then the ligature is fixed to the cornea remaining after trepanation (OPTR), while the recipient's trepanned cornea (TRR) is fixed at two points, after which mezaton and viscoelastic are introduced into the anterior chamber, then circular capsulorhexis, hydrodissection are performed , hydrodeletion, phacofragmentation and aspiration of the lens masses are performed using the phaco-tip, while all the instruments for the above manipulations are introduced into the anterior chamber through the space between the two fixation points of the TPP and the operation is completed by removing the viscoelastic and fixing the graft to the OPTR. 2. A method for cataract extraction and elastic IOL implantation during simultaneous penetrating keratoplasty, including trepanation of the recipient's cornea, dissection of the remaining bridges with scissors, extracapsular cataract removal, placement of the donor graft in the recipient's bed and partial fixation to the recipient's cornea remaining after trepanation, leaving a gap for passage of the injector with the IOL, filling the anterior and posterior chambers with viscoelastic, implanting the IOL into the capsular bag, removing the viscoelastic and fixing the graft, characterized in that when cutting the remaining bridges, the bridge is kept at 6 hours and a ligature is applied at 12 hours, and if the corneal opacification is diffuse and does not make it possible to visualize the anterior chamber, then the TPP is lifted by the ligature, creating an angle of 40 degrees between the TPP and the iris, to visualize the structures of the anterior chamber, after which mezaton and viscoelastic are injected, then circular capsulorhexis, hydrodissection, hydrodeletion are performed, phacofragmentation is performed using the phaco-tip and aspiration of the lens masses, all the instruments for the above manipulations are introduced through the space between the elevated TRR and OPTR, and in the absence of intraoperative complications, after cataract extraction, the operation is completed by removing the viscoelastic and fixing the graft to the OPTR. 3. The method according to claim 2, characterized in that in the event of intraoperative complications, TPP is lowered by the ligature, fixed to the OPTR, and after normalization of the eye condition, the ligature is released, TPP is raised, restoring the angle of 40 degrees, and after cataract extraction, the operation is completed by removing viscoelastic and fixation of the graft to the OPTR.