RU2801866C1 - Method of the treatment of combined pathology of the early stage of primary endothelial dystrophy of the cornea fuchs and cataracts with femtolaser support - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: main surgical access is formed from the temporal side and additional paracentesis, after which phacoemulsification is performed through the main surgical access and an intraocular lens is implanted into the posterior chamber. Through paracentesis, a cohesive viscoelastic is introduced into the anterior chamber, descemetorhexis is performed, the viscoelastic is aspirated, the anterior chamber is restored with a balanced saline solution, and the incisions are sealed. At the same time, three notches are first applied to the endothelium in the region of the Descemet's membrane and tissue bridges are left between the notches. Notches are applied in such a way as to mark a fragment of the Descemet's membrane with a diameter of 7.5–8.5 mm, capsulorhexis is performed, phacofragmentation is performed and the main surgical access is formed 2.5 mm wide from the temporal side. Then two paracentesis are performed at 90° and 270° each 1.2 mm wide, after which phacoemulsification is carried out through the main incision and an intraocular lens is implanted, a cohesive viscoelastic is introduced into the anterior chamber through one of the paracentesis, and three bridges are cut through one of the paracentesis and the Descemet's membrane is removed through the main access. After that, the main surgical access is expanded to 4 mm, the cohesive viscoelastic is removed from the anterior chamber through paracentesis, an additional paracentesis is performed by 180° and a collet forceps is inserted through it, which is removed through the main surgical access, the donor endothelial material is captured and implanted into the anterior chamber, which is subsequently fixed to the cornea with air, the volume of the anterior chamber during implantation of the material is maintained using a catheter of the irrigation system inserted through paracentesis at 90° and 270°. The incisions are sealed with 10-0 interrupted sutures, while surgical access, paracentesis, descemetorhexis, phacofragmentation and capsulorhexis are performed simultaneously using a femtolaser. In a particular case, notches are applied at 110°, and bridges are left 10°.

EFFECT: method allows to increase the accuracy of manipulations and reduce the risk of tissue injury.

2 cl, 2 ex, 3 tbl

Description

The invention relates to medicine, in particular to ophthalmology, and in particular to a method for the treatment of combined pathology of the early stage of primary endothelial dystrophy of the cornea Fuchs and cataracts with femtolaser accompaniment and endothelial keratoplasty.

To date, there are three main methods of treating patients with Fuchs' dystrophy and cataracts:

- implementation of isolated phacoemulsification with implantation of an intraocular lens (IOL);

- staged treatment: phacoemulsification with IOL implantation and delayed transplantation of donor material from Descemet's membrane;

- simultaneous phacoemulsification with IOL implantation and transplantation of donor material from Descemet's membrane.

A known method of endothelial keratoplasty of the Descemet's membrane with phacoemulsification (Bruno Lovaglio Cancado Trindade et al. Toric IOL in Combined DMEK and Cataract Surgery, Clin Ophthalmol. 2021 Apr 13; 15:1511-1516. doi: 10.2147/OPTH.S293086. eCollection 2021., DOI: 10.2147/OPTH.S293086), during which the main incision is made to a width of 2.2 mm and the anterior chamber is filled with viscoelastic, capsulorhexis is performed with a diameter of 4.8-5.0 mm, and phacoemulsification is performed. The IOL is then implanted. After that, descemetorhexis is carried out in the anterior chamber and the graft is cut out. Moreover, the diameter of the removed Descemet's membrane is chosen to be 0.25 mm larger than the size of the proposed graft. Next, two lateral paracentesis are created for convenient deployment of the graft. The graft is introduced into the anterior chamber using a cartridge, after which it is oriented in the desired position and fixed with air.

The method of transplantation of the desecemetic membrane (method of transplantation of the desecemetic membrane: Patent RU 2600158, Russian Federation, Application RU 2016145088, announced 2016.17, 10.20.20), including the determination of the necessary diameter of the required diameter of the deseceutal membrane (DM), trepanation of the DM DM, the DM, the RU RU. donor cornea, staining with DM, separation of DM from the posterior layers of the corneal stroma with subsequent complete exfoliation of the DM, removal of the DM of the recipient, introduction of the DM of the donor with an injector into the anterior chamber of the recipient, straightening of the DM of the donor and fixing it to the posterior layers of the stroma of the recipient with air, characterized in that that the DM of the donor is separated from the stroma along the circular notch 1-2 mm to the center, after which the separated edge is captured with tweezers and, pulling the DM towards the center of the cornea, the DM is peeled off to half of the cornea, the detached half of the DM is placed in its original place, in a similar way capture the edge of the DM in the opposite meridian and peel off the second half of the DM, after complete peeling of the DM, it is additionally stained from the side of the stroma, an orienting marginal notch is cut out on the periphery of the DM in the form of an isosceles triangle, a thin strip of viscoelastic is applied in the center on the endothelial surface of the exfoliated DM, after which using tweezers, DM is folded in half, the DM folded in half is placed in a disposable injector, advanced into the tip of the injector with a needle or spatula; before DM implantation, the recipient is iridectomy for 6 hours, the donor DM is implanted through the injector using a jet of balanced saline solution with the endothelial layer facing inward, the air fixing the DM is left in the recipient's anterior chamber until complete physiological resorption. Moreover, this method of DM transplantation is performed after phacoemulsification.

The disadvantages of the above methods include the possibility of tissue damage, due to the fact that the formation of the rexis of the DM is carried out mechanically using a special tool, the Sinskey hook.

There is a known method for performing posterior layered keratoplasty using a femtosecond laser (Method for performing posterior layered keratoplasty using a femtosecond laser: patent RU 2758028, Russian Federation, application RU 2021106713, application 16.03.2021, publ. 25.10.2021), during which the formation of femtosecond laser programmed intrastromal planar and vertical incisions of the donor cornea (DR) through a single-stage resection. In this case, the donor corneal graft is formed using a femtosecond laser with a wavelength of 1053 nm, with a pulse duration of 200-350 ms, a pulse duration of 200-550 f/s, and a maximum laser pulse power of 12 mW. To do this, the native corneoscleral disc of the donor is fixed in the holder of the artificial anterior chamber (IPC) with the endothelial side up. Then, using a continuous supply of a balanced salt solution (BSS), the IPC is filled with this solution under a pressure of 50 mm Hg. Next, a solution of dispersive viscoelastic - 1% solution of hydroxypropyl methylcellulose is applied to the endothelium of the DR immediately before the application of the laser interface, incubated for 30-60 seconds. Next, the laser handle is fixed to the IPC, then, by rotating the threaded ring, the DR is smoothly contacted with the laser head, using intraoperative optical coherence tomography, the contact of the DR and the laser head is monitored, and with tight continuous contact, a donor corneal graft with a thickness of 125-130 μm and a diameter is formed with a laser. 7.0-8.5 mm. In this case, the first cut is carried out in the vertical direction from the endothelium deep into the stroma. Further, by rotating the ring in the opposite direction, the laser head and the DR are smoothly separated. Then the laser handle is removed from the IPC surface, after interruption of the contact of the DR with the laser head, the cornea with the viscoelastic on it is stained with methylene blue, the stained viscoelastic is washed off. Then, the same dye is applied to the surface of the DR, and when the DR endothelium is stained for less than half of its area, the DR is evaluated with a suitable graft. After that, the graft is separated from the underlying stroma with a stratifier and transferred to the funnel of the glide, with the endothelium upwards, having previously washed off the dye from the DR, a strip of a cohesive viscoelastic preparation - 1% sodium hyaluronate is applied to the surface of the endothelium through a tunnel sclerocorneal incision (TSPP) under constant maintenance of the volume of the anterior chamber of the recipient's eye with an irrigation flow, tweezers inserted through the corneal paracentesis opposite to TSPP, the graft is pulled into the anterior chamber of the patient's eye and fixed to the posterior layers of its own cornea with an air bubble or gas-air mixture.

The disadvantages of the above method include the fact that it does not imply simultaneous femtodescemetorhexis, femtokeratotomy incisions, femtocapsulorhexis and femtophacofragmentation, as well as a high risk of tissue damage, due to the fact that the formation of rexis DM is carried out mechanically using a special tool - a Sinskey hook, as well as By implanting DM with a part of the stroma, the recipient has lower visual results compared to implanting DM alone.

Closest to the claimed invention is a method for the treatment of combined pathology of the early stage of primary endothelial dystrophy of the cornea of Fuchs and cataracts (Method for the treatment of combined pathology of the early stage of primary endothelial dystrophy of the cornea of Fuchs and cataracts: patent RU 2630035, Russian Federation, application RU 2016145088, application 17.11.2016 , publ. 09/05/2017), during which the main surgical approach is formed from the temporal side with a width of 2.0 mm and one additional paracentesis at 1 or 11 o'clock for the right and left eyes, respectively, with a width of 1.0 mm. Next, phacoemulsification is performed with implantation of a posterior chamber hydrophobic IOL with capsular fixation. From the side of the corneal epithelium, a circular mark with a diameter of 4 mm is applied, a cohesive viscoelastic is introduced into the anterior chamber through a paracentesis, descemetorhexis is performed at the specified mark with a microhook, a monolayer of modified corneal endothelial cells is removed, after which the viscoelastic is aspirated, the anterior chamber is restored with a balanced saline solution, and the paracentesis is sealed. The method makes it possible to increase visual functions, eliminate the need to use donor material, and reduce the duration of manipulations.

The disadvantages of this method include a high risk of tissue injury and a relatively low functional (visual) rehabilitation of patients. This is due to the fact that a number of patients develop edema and clouding in the central optical zone of the cornea (26% of patients after central descemetorhexis required transplantation of the Descemet's membrane).

The technical problem is the need to develop an effective method for the treatment of combined pathology of the early stage of Fuchs primary endothelial corneal dystrophy and cataracts with femtolaser accompaniment, devoid of the above disadvantages.

The technical result consists in increasing the accuracy of manipulations and reducing the risk of tissue injury.

The technical result is achieved by the fact that in the method of treating the combined pathology of the early stage of primary endothelial dystrophy of the Fuchs cornea and cataracts with femtolaser accompaniment, during which the main surgical access is formed from the temporal side and additional paracentesis, after which phacoemulsification is performed through the main surgical access and an intraocular lens is implanted into the posterior chamber, and through paracentesis, a cohesive viscoelastic is introduced into the anterior chamber, descemetorhexis is performed, a layer of modified cells is removed, the viscoelastic is aspirated, the anterior chamber is restored with a balanced saline solution and the incisions are sealed, according to the invention, three notches are first applied to the endothelium in the region of the Descemet's membrane and left between tissue bridges with notches, while the notches are applied so as to mark a fragment of the Descemet's membrane with a diameter of 7.5-8.5 mm, capsulorhexis is performed, phacofragmentation is performed and the main surgical access is formed with a width of 2.5 mm from the temporal side, then two paracentesis at 90° and 270° 1.2 mm wide, after which phacoemulsification is performed through the main incision and an intraocular lens is implanted, a cohesive viscoelastic is introduced into the anterior chamber through one of the paracentesis, and three bridges are cut through one of the paracentesis and removed through the main access Descemet's membrane, after which the main surgical approach is expanded to 4 mm, the cohesive viscoelastic is removed from the anterior chamber through paracentesis, then an additional paracentesis is performed at 180° and collet tweezers are inserted through it, and a catheter of the irrigation system is inserted through paracentesis 90° and 270° to hold the anterior chamber, after which a guide spatula is passed through the main surgical access for implantation of the corneal endothelium with donor material, which is captured with collet tweezers and straightened, after which the instruments are removed and the incisions are sealed with interrupted sutures 10-0, while the surgical access, paracentesis, descemetorhexis, capsulorhexis and phacofragmentation are performed using a femtolaser.

The above technique provides an increase in the accuracy of manipulations and a decrease in the risk of tissue injury, including a decrease in the risk of complications at the stage of capsulorhexis and phacofragmentation, a decrease in the risk of damage to the corneal stroma during descemetorhexis, as well as a decrease in induced astigmatism during tunnel incision and paracentesis. In this case, in the most preferred embodiment of the invention, the notches are applied at 110°, and the bridges are left at 10°. Moreover, a donor graft is implanted, consisting of a Descemet's membrane and stroma.

The inventive method is carried out as follows.

First, using a femtolaser, three notches are applied to the endothelium in the region of the Descemet's membrane and tissue bridges are left between the notches, while the notches are applied so as to mark a fragment of the Descemet's membrane with a diameter of 7.5-8.5 mm. Preferably, the notches are applied at 110°, and the bridges are left at 10°. Next, capsulorhexis is performed, phacofragmentation is performed and the main surgical access is formed with a width of 2.5 mm from the temporal side, then two paracentesis are performed at 90° and 270° with a width of 1.2 mm. After that, phacoemulsification is carried out through the main incision and an intraocular lens is implanted. A cohesive viscoelastic is introduced into the anterior chamber through one of the paracentesis. Then, through one of the paracentesis, three bridges are dissected and the Descemet's membrane is removed through the main access. Then the main operational access is expanded to 4 mm. Viscoelastic is removed from the anterior chamber through paracentesis and an additional 180° paracentesis is performed and collet tweezers are inserted through it. Through paracentesis 90° or 270°, a catheter of the irrigation system is inserted to maintain the anterior chamber, after which collet tweezers are inserted through the paracentesis opposite to the main incision and removed through the main surgical access, donor endothelial material is captured and implanted into the anterior chamber. After that, the donor material is straightened and fixed with air. The incisions are then sealed with 10-0 interrupted sutures.

At the same time, surgical access, parecentesis, descemetorhexis, phacofragmentation and capsulorhexis are performed using a femtolaser. In a preferred embodiment of the invention, the above steps (operative access, parecentesis, descemetorhexis, phacofragmentation and capsulorhexis) are performed using a Ziemer Femto LDV Z8 laser using a liquid interface and low vacuum. The use of a femtolaser in such a combined multi-stage operation makes it possible to perform the stage of detachment of the pathologically altered Descemet's membrane with endothelium more precisely, often in one fragment, and also to avoid ruptures and the spread of this zone to the periphery. In the future, such precision descemetorhexis allows more precise positioning of the endograft and, accordingly, ensures its better fit. A more dosed and sparing femto-assisted descemetorhexis will also significantly reduce the traumatization of the corneal stroma. Preferably, Elder's glide is used for implantation of the graft.

The claimed invention is illustrated by examples.

Example 1

Patient F., aged 69 years, was admitted with complaints of pain in the right eye and gradual deterioration of vision in the right eye.

As a result of the primary diagnostic measures, the following parameters were obtained:

After the examination, the diagnosis was Fuchs's Dystrophy 3 tbsp. Complicated initial cataract. O.D.

According to the diagnostic results, it was decided to carry out the treatment according to the claimed method. In this case, a pre-prepared donor graft from the Descemet's membrane and stroma was used.

First, three notches were made on the endothelium in the region of the Descemet's membrane and tissue bridges were left between the notches, while the notches were made so as to mark a fragment of the Descemet's membrane with a diameter of 7.5 mm. Next, capsulorhexis was performed, phacofragmentation was performed, and the main surgical approach was formed with a width of 2.5 mm from the temporal side and two paracentesis at 90° and 270° with a width of 1.2 mm. Through the main incision, phacoemulsification and implantation of the intraocular lens were performed, and through one of the 90° paracentesis, a cohesive viscoelastic was introduced into the anterior chamber, and three bridges were cut through the 270° paracentesis, and the Descemet's membrane was removed through the main access. After that, the main surgical access was expanded to 4 mm, and the cohesive viscoelastic was removed from the anterior chamber through paracentesis. Then, through an additional paracentesis at 180° using collet tweezers, a donor material was implanted through the main incision, which was subsequently fixed to the cornea with air. The volume of the anterior chamber during the implantation of the material was maintained using a catheter of the irrigation system inserted through the paracentesis at 90°. The incisions were sealed with 10-0 interrupted sutures, while surgical access, paracentesis, descemetorhexis, phacofragmentation, and capsulorhexis were performed simultaneously using a femtolaser.

The operation and postoperative period were successful without complications.

Example 2

Patient K., aged 68, was admitted with complaints of low vision and pain in the left eye.

As a result of primary diagnostic measures, the following data were obtained:

Additionally, as a result of diagnostics, the following data were obtained (Table 1). Tab. 1 - diagnostic results before treatment

According to the diagnostic results, it was decided to carry out the treatment according to the claimed method. In this case, a pre-prepared donor graft from the Descemet's membrane and stroma was used.

First, three cuts were made on the endothelium in the area of the Descemet's membrane, leaving bridges of tissue between the cuts, while the cuts were made so as to mark a fragment of the Descemet's membrane with a diameter of 8.5 mm. Next, capsulorhexis was performed, phacofragmentation was performed, and the main surgical approach was formed with a width of 2.5 mm from the temporal side and two paracentesis at 90° and 270° with a width of 1.2 mm. Through the main incision, phacoemulsification and implantation of an intraocular lens were performed, and a cohesive viscoelastic was introduced into the anterior chamber through a 270° paracentesis, and three bridges were cut through a 90° paracentesis, and the Descemet's membrane was removed through the main access. After the main surgical access was expanded to 4 mm, the cohesive viscoelastic was removed from the anterior chamber through paracentesis. Then an additional 180° paracentesis was made and collet forceps were inserted through it, and a catheter of the irrigation system was inserted through the 270° paracentesis to maintain the anterior chamber.

Then, through an additional paracentesis at 180° using collet tweezers, a donor material was implanted through the main incision, which was subsequently fixed to the cornea with air. The volume of the anterior chamber during the implantation of the material was maintained using a catheter of the irrigation system inserted through the paracentesis at 90°. The incisions were sealed with 10-0 interrupted sutures, while surgical access, paracentesis, descemetorhexis, phacofragmentation, and capsulorhexis were performed simultaneously using a femtolaser.

In table. 2 shows the results of diagnostics on the 1st day after the operation.

In table. Figure 3 shows the patient's diagnosis data at discharge.

The obtained clinical results indicate an increase in the effectiveness of treatment using the proposed method by improving the accuracy of manipulations and reducing the risk of tissue injury.

Claims (2)

1. Method for the treatment of combined pathology of the early stage of primary endothelial dystrophy of the cornea Fuchs and cataracts with femtolaser support, during which the main surgical approach is formed from the temporal side and additional paracentesis, after which phacoemulsification is performed through the main surgical access and an intraocular lens is implanted into the posterior chamber, and through paracentesis, a cohesive viscoelastic is introduced into the anterior chamber, descemetorhexis is performed, the viscoelastic is aspirated, the anterior chamber is restored with a balanced saline solution and the incisions are sealed, characterized in that first three incisions are made on the endothelium in the region of the Descemet's membrane and bridges of tissue are left between the incisions, while the incisions applied so as to mark a fragment of the Descemet's membrane with a diameter of 7.5-8.5 mm, capsulorhexis is performed, phacofragmentation is performed and the main surgical access is formed 2.5 mm wide from the temporal side, then two paracentesis are performed at 90° and 270° 1 wide .2 mm, after which phacoemulsification is performed through the main incision and an intraocular lens is implanted, a cohesive viscoelastic is introduced into the anterior chamber through one of the paracentesis, and three bridges are cut through one of the paracentesis and the Descemet's membrane is removed through the main access, after which the main surgical access is expanded up to 4 mm, the cohesive viscoelastic is removed from the anterior chamber through paracentesis, an additional 180° paracentesis is performed and collet tweezers are inserted through it, which are removed through the main surgical access, they capture the donor endothelial material and implant it into the anterior chamber, which is subsequently fixed to the cornea with air, the volume of the anterior chamber during implantation of the material is maintained using a catheter of the irrigation system inserted through paracentesis at 90° and 270°, the incisions are sealed with interrupted sutures 10-0, while surgical access, paracentesis, descemetorhexis, phacofragmentation and capsulorhexis are performed at the same time using a femtolaser. 2. The method according to p. 1, characterized in that the notches are applied at 110°, and the bridges are left at 10°.