RU2813070C1 - Method of surgical treatment of marginal corneal ulcers, including complicated descemetocele or corneal perforation - Google Patents

Abstract

FIELD: medicine; ophthalmic surgery.

SUBSTANCE: surgical treatment of marginal corneal ulcers is performed, including those complicated by descemetocele or corneal perforation up to 3 mm. Deepithelialization, necrectomy of the ulcerative surface and corneal plastic surgery with an autoconjunctival flap “on a pedicle” are performed. Before autoconjunctival plasty, Alloplant biomaterial for layered keratoplasty with a thickness of 100, 150 or 200 microns, a diameter of 6 to 10 mm is placed on the defect, which is modelled according to the shape of the defect and the receptive bed of the cornea, and fixed with interrupted sutures 8/0 or 10/0 according to periphery "edge to edge". After that, the Alloplant biomaterial for layer-by-layer keratoplasty is covered with an autoconjunctival flap.

EFFECT: improvement of the functional results of treatment by enhancing the regeneration of the thinned area of the cornea in the ulcer area, reducing the period of relief of inflammation to 5–7 days.

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Description

The invention relates to the field of medicine, namely to ophthalmic surgery, and can be used in the treatment of marginal corneal ulcers, including those complicated by descemetocele and corneal perforation.

Corneal ulcers are one of the most complex ophthalmological diseases. They are difficult to treat with medication. The presence of corneal syndrome accompanying a corneal ulcer (injection of the eyeball, photophobia, lacrimation) reduces the visual acuity and “quality of life” of the patient. Complications of this pathology in the form of descemetocele and corneal perforation can lead to the spread of the infectious process into the eye with the development of endophthalmitis or panophthalmitis and complete death of the eye.

The frequency of complications of corneal ulcers with bacterial ulcers varies from 9 to 37%, with immune ulcers it is 19-32%, with eye burns, ulcers and perforations of the cornea are observed in 21-76% of cases [Ivanova I.V., Bobrova N.F., Krovoshein Yu.S. // Ophthalmological Journal. - 1999. - No. 3. - P. 163-170.; Ivanova N.V., Bobrova N.F., Krovoshein Yu.S. // Man and medicine: tes. report VII Russian National Congress. - 2000. - P. 287.], purulent corneal ulcer accounts for 33.2% as a primary and 37.3%) as a secondary infection [Maichuk Yu.F. Pharmacotherapy of inflammatory eye diseases: yesterday, today, tomorrow. Current issues of inflammatory eye diseases. M: 2001; 7-17.].

There is a known method of monolateral autokeratoplasty of the optical zone of the cornea. The essence of the method is to form a flap of autosclera at 1/2 the thickness of the sclera with the base towards the limbus, by excision of a layer-by-layer keratograft with a thickness equal to the depth of the ulcerative defect at 12 o'clock under the upper eyelid with an indentation of 1 mm from the limbus. In this case, the keratograft is placed in a previously prepared bed and fixed with sutures [Tsvetkov A.L., Tsvetkov A.A. Method of monolateral autokeratoplasty of the optical zone of the cornea. Application for invention No. 201812697, 06/13/2018].

There is a known method of surgical treatment of severe burns and deep ulcers of the cornea. The method is used in the treatment of deep corneal ulcers that are not amenable to conservative treatment and threaten perforation. The necrotic corneal tissue is excised. Additionally, a tunnel is formed in the cornea to the base of the pedicle of the autoconjunctival flap. When closing the defect, the conjunctival flap is immersed in the corneal stroma. Fixation is carried out with interrupted sutures edge to edge in the corneal bed and tunnel. The method allows the formation of full-fledged scar tissue by enhancing microcirculation and stimulating reparative processes [Makarov P.V., Gundorova R.A., Boryugovo G.G. Method of surgical treatment of severe burns and deep ulcers of the cornea. RF patent for invention No. 2134561, 08/20/1999].

There is a known method for plastic surgery of perforation of the cornea using an autosclera flap. For plastic surgery of corneal perforation with an autoscleral flap, an autoscleral flap is formed at Vi thickness of the sclera with the presence of a visible vessel, the base is towards the limbus. In this case, the flap is placed on the defect of the cornea and fixed with 6 sutures to the cornea with moderate tension. The scleral defect is closed with a previously separated conjunctiva and Tennon's capsule and their fixation with two interrupted sutures [Tsvetkov A.L., Tsvetkov A.A.: Method of plastic surgery of perforation of the cornea with an autosclera flap. RF patent for invention No. 2692600, 06/25/20019].

There is a known method for plastic surgery of an ulcerative defect of the cornea with its paracentral localization. During the surgical treatment of corneal ulcers of infectious and non-infectious etiology, de-epithelialization of the cornea is performed in the area of the ulcerative defect. Then, two interrupted or one x-shaped suture is applied to the ulcerative defect, depending on the size of the defect, while the nodes are not immersed in the corneal stroma. The conjunctiva is separated along the limbus in the area of the ulcerative defect and a flap is formed from it. The flap is formed by shifting and pulling the conjunctiva to the center of the cornea and covering the ulcerative defect and the infiltration zone. After this, the flap is fixed with a U-shaped suture in the apex area. Additionally, two more sutures are placed on the sides of the formed flap, one on each side. The length of each seam does not exceed 2 mm. The method simplifies the treatment of ulcerative defects of the cornea of both non-infectious and infectious etiology, by eliminating the use of implants, donor material of special surgical instruments and the need to excise a significant part of the corneal tissue [Bakharev A.V., Solovyov Y.A.: Method for plastic surgery of ulcerative defect of the cornea with its paracentral localization. RF patent for invention No. 2644297, 02/08/2018].

There is a known method of surgical treatment of corneal ulcers using an autograft from Tenon's membrane. The method involves cutting out a graft from a Tenon's capsule by separating the conjunctiva and forming the base of the graft (feeding pedicle) and closing the ulcerative defect of the corneal tissue with a cut out Tenon's graft by moving the said graft to the surface of the ulcer, excision of the separated area of the conjunctiva and fixing the graft to the sclera with interrupted sutures [Poromova I. YU. An integrated approach to the treatment of severe ulcerative keratitis: Author: Ferat. dis... cand. honey. Sciences: 14.00.08/Petrozavodsk State University-SPb., 2000. - P. 11-13.].

The closest analogue of the invention is a method of conjunctival keratoplasty, which involves moving an autoconjunctival flap on two or one leg to the damaged area. In this case, the wound surface of the transplanted conjunctival flap should be in close contact with the corneal ulcer, which is devoid of epithelium and Bowman's membrane in the area of the defect. Under local anesthesia, infiltration and regional, a flap of conjunctiva in the form of a strip is removed near the limbus, preferably on the temporal side, since there is more conjunctiva here. The length and width of the flap depend on the location of the defect on the cornea and its size. Epithelization of the cornea occurs within 7-10 days [Oganesyan O.G. Autoconjunctival plastic surgery in urgent surgery of corneal defects. Author's abstract. dis…. Ph.D. honey. Sci. - M., 2002. - 21 p.]

The disadvantage of the prototype is the absence of a collagen substrate, which is a source of regeneration of corneal elements and allows the thinned area of the cornea in the ulcer area to be replaced by a full-fledged regenerate. In addition, the autoconjunctival flap does not adhere tightly to the uneven surface of the corneal ulcer, which in turn can cause displacement of the flap.

The objective of the invention is to develop a method for the surgical treatment of marginal corneal ulcers, including those complicated by descemetocele or corneal perforation up to 3 mm.

The technical result when using the invention is to improve the functional results of treatment by enhancing the regeneration of the thinned area of the cornea in the ulcer area, reducing the period of relief of inflammation to 5-7 days.

The proposed method of surgical treatment of marginal corneal ulcers, including those complicated by descemetocele or corneal perforation, is carried out as follows. Along the periphery of the ulcer, within 2-3 mm of healthy tissue, the cornea is marked and stratified to a depth of 1\2-1\3 using a blade, with the necrotic tissue of the ulcer removed within the intended area. In the area of descemetocele and perforation, de-epithelialization of the cornea is performed carefully, without emptying the moisture of the anterior chamber. The Alloplant biomaterial for layer-by-layer keratoplasty (Registration certificate for a medical device dated December 29, 2021 No. FSR 2011/12012) with a thickness of 100, 150 or 200 microns, with a diameter of 6 to 10 mm, depending on the size of the defect, which is modeled according to the shape, is placed on the resulting defect. receptive bed of the cornea. The graft is fixed with interrupted 8/0 or 10/0 sutures along the edge-to-edge periphery. Alloplant biomaterial should not “sail” and protrude above the surface of the cornea. In the upper or lower sector, closest to the ulcerative surface, an autoconjunctival flap is cut out on a “pedicle”, preserving the feeding blood vessels. The Alloplant biomaterial for lamellar keratoplasty is covered with an autoconjunctival flap relatively freely, without tension. The conjunctival flap is fixed using interrupted 8/0 sutures. The conjunctival defect formed after dislocation of the conjunctival flap is closed with autoconjunctiva from the fornix.

Thus, the use of the Alloplant biomaterial for layer-by-layer keratoplasty and autoconjunctival flap “on a pedicle” with maximum preservation of healthy areas of the cornea ensures complete relief of the inflammatory process within 5-7 days, with the formation of a scar or a full-fledged corneal regenerate within 3-6 months. The alloplant is used as a collagen scaffold to stimulate corneal regeneration. In the postoperative period, as the autoconjunctival flap thins, it becomes possible to visually monitor the process of replacing the Alloplant biomaterial and corneal regeneration. In addition, in the event of reduction or dislocation of the autoconjunctival flap, it is not the ulcerative surface that is exposed, but the allograft for lamellar keratoplasty. Covering the top with an autoconjunctival flap helps protect the biomaterial from the effects of tear enzymes, and promotes a longer and more optimal replacement process, which in turn allows the formation of full-fledged scar tissue.

The essence of the invention is illustrated by the following clinical examples.

Example 1.

Patient S, 77 years old, was undergoing inpatient treatment at the All-Russian Center for Eye and Plastic Surgery.

Diagnosis: OS Regional corneal ulcer complicated by descemetocele.

History: about 1 month ago there were complaints of a feeling of a foreign body in the left eye, pain, discomfort, lacrimation, redness of the left eye, decreased visual acuity, and a cosmetic defect.

On admission:

Visus OD 0.3 - 0.4 s corr. 0.7

Visus OS hand movement near the face is not correct.

Tensio OD 13 mmHg Art.

Tensio OS 17 mmHg Art.

Status localis:

OD: calm, the cornea is transparent, the anterior chamber is of medium depth, transparent, the pupil is round, the photoreaction is normal. Fundus of the eye: optic disc is pale pink, the boundaries are clear, the excavation is physiological, the arteries are narrowed, the veins are wide, full of blood, there is no reflex in the macular area, no pathological foci are found throughout the entire retina.

OS: moderate injection of the conjunctiva in the lower sector. Cornea: in the lower outer sector there is an ulcer with a descemetocele, with unclear boundaries, clouding of the layers of the cornea, transparent from the center of the pupil, the anterior chamber is uneven, the moisture is transparent, the pupil is round, the photoreaction is sluggish. Fundus: not ophthalmoscopically.

Operation OS Keratoplasty conjunctival according to the proposed method. Along the periphery of the ulcer, within 2-3 mm of healthy tissue, the cornea was marked and stratified to a depth of 1/2 using a blade, with necrotic tissue of the ulcer removed within the intended area. In the area of the descemetocele and periphery (the area where the autoconjunctival flap will be placed), deepithelialization of the cornea was performed. Alloplant biomaterial for layered keratoplasty with a thickness of 150 microns and a diameter of 6 mm, which was modeled according to the shape of the receptive bed of the cornea, was placed on the resulting defect. The graft was fixed using interrupted 8/0 sutures along the edge-to-edge periphery. In the lower internal sector, closest to the ulcerative surface, an autoconjunctival flap was cut on a “pedicle”, preserving the feeding blood vessels. The Alloplant biomaterial for lamellar keratoplasty was covered with an autoconjunctival flap. The conjunctival flap was fixed using interrupted 8/0 sutures. The conjunctival defect formed after dislocation of the conjunctival flap was closed with autoconjunctiva from the fornix. Upon discharge:

Visus OD 0.3 - 0.4 s corr. 0.7

Visus OS hand movement near the face is not correct.

Tensio OD 13 mmHg Art.

Tensio OS (half cartridge) TON

Status localis:

OD: no changes.

OS: the cornea in the lower sector is covered with a conjunctival flap, the rest of the area is transparent, moderate injection of an autoconjunctival flap, conjunctival in the lower sector, the anterior chamber in the visible part is uniform, the moisture is transparent, the pupil is round, the photoreaction is sluggish. Fundus: not ophthalmoscopically. In the postoperative period, after 7 days, the inflammatory process was completely stopped, the conjunctival flap covers part of the cornea, is not displaced, under the conjunctival flap the allograft for surgery Alloplant for lamellar keratoplasty has been completely replaced.

The patient was discharged with improvement for outpatient treatment at his place of residence.

After 10 months

Visus OD 0.3 - 0.4 s corr. 0.7

Visus OS hand movement near the face is not correct.

Tensio OD 13 mmHg

Tensio OS (half cartridge) TON

Status localis:

OD: no changes.

OS: the cornea in the lower sector is covered with a conjunctival flap, the rest of the area is transparent, moderate injection of an autoconjunctival flap, conjunctival in the lower sector, the anterior chamber in the visible part is uniform, the moisture is transparent, the pupil is round, the photoreaction is sluggish. Fundus: not ophthalmoscopically.

Example 2.

Patient G., 74 years old, was undergoing inpatient treatment at the All-Russian Center for Eye and Plastic Surgery.

Diagnosis: OS Regional corneal ulcer.

History: 3 months ago there were complaints of a feeling of a foreign body in the left eye, redness, pain, discomfort, lacrimation, decreased visual acuity, was treated on an outpatient basis without effect. On admission:

Visus OD 0.8 sf.+1.0 D cyl.-2.0 D axle 90 gr=1.0

Visus OS counting fingers on the face is not correct.

Tensio OD 17 mmHg Art. Tensio OS (half cartridge) TN

OS: Injection of the eyeball. Cornea: in the internal sector there is an ulcer measuring 6 by 4 mm, oval in shape (about 6 mm), with the optical zone included, the anterior chamber is of medium depth, the moisture is transparent, the pupil is round. Fundus: not ophthalmoscopically. Operation OS-Conjunctival keratoplasty. Corneal plastic surgery was performed using an autoconjunctival flap according to the proposed method. We performed a necrectomy on the surface of the ulcer and removed the corneal epithelium in the area where the autoconjunctival flap will be located. The surface of the ulcer was treated with a 5% iodine solution. An Alloplant for layered keratoplasty with a thickness of 100 microns and a diameter of 10 mm, which was modeled according to the shape of the receptive bed, was placed on the resulting corneal defect. The graft was fixed with interrupted 10/0 sutures. An autoconjunctival flap with a vascular bundle was cut out in the lower internal sector. The pedicle flap was placed on top of the Alloplant biomaterial for lamellar keratoplasty and fixed with interrupted 8/0 sutures without tension.

Upon discharge:

Visus OD 0.8 sf.+1.0 D cyl.-2.0 D axle 90 gr=1.0

Visus OS 0.06 n\k OD: no changes.

OS: moderately irritated, the conjunctival flap is fixed, the Alloplant biomaterial is completely covered with an autoconjunctival flap, the sutures are intact, the optical zone of the cornea is intact, the anterior chamber is of medium depth, the moisture is transparent. Fundus: pink reflex.

In 6 months. OS: the eye is calm, the conjunctival flap is almost transparent, 50% of the replaced Alloplant biomaterial is visible under it, the anterior chamber is of medium depth, the moisture is transparent.

Example 3.

Patient X., 17 years old, was hospitalized at the All-Russian Center for Eye and Plastic Surgery with a diagnosis of OU Regional corneal ulcer, complicated by perforation, tamponed iris. SOP: cerebral palsy, developmental delay.

History: complaints of redness, periodic pain, discomfort, lacrimation, foreign body sensation.

On admission:

Visus OD object vision not corr.

Visus OS light perception is not correct.

Tensio OD (palpable) TN

Tensio OS (palpable) TN

Status localis:

OS: Corneal ulcer, oval, 2.5 mm, in the upper part of the optical zone, complicated by perforation, tamponed iris. The anterior chamber is uneven, the moisture is transparent, the pupil is pulled up. Fundus: not ophthalmoscopically.

Operation under anesthesia:

OS Conjunctival keratoplasty using the proposed method. The superficial layers of the cornea around the ulcer were excised in the form of a strip 1.5-2 mm wide, including healthy areas, to a depth of 1/3-1/2 the thickness of the cornea. The epithelium in the fistula area was carefully removed (without emptying the anterior chamber). An Alloplant for layer-by-layer keratoplasty with a thickness of 200 microns, a diameter of 10 mm, which was modeled according to the shape of the receptive bed, was placed on the de-epithelialized area and fixed with interrupted 8/0 sutures. In the upper-internal sector, an autoconjunctival flap “on a pedicle” was cut out and covered with Alloplant biomaterial for lamellar keratoplasty. Fixed with interrupted 8/0 sutures. The conjunctival defect of the eyeball was closed with autoconjunctiva from the fornix.

Upon discharge: OS - Injection of the eyeball, the conjunctival flap completely covers the ulcer area and Alloplant biomaterial, the sutures are consistent, the anterior chamber is uneven, the moisture is transparent. At the next stage (after 7 months), surgical treatment was carried out: stage I of keratoprosthesis on the left eye, after a year and 9 months - stage II of keratoprosthesis (installation of the optical part).

Due to the presence of a general disease (cerebral palsy, developmental delay) in the patient, determining visual acuity caused difficulties. Approximate visual acuity is 0.1-0.2. Status localis:

OS: The entire cornea is cloudy, uniform in thickness, in the center is the optical part of the keratoprosthesis. The underlying layers are not visible.

Claims (1)

A method of surgical treatment of marginal corneal ulcer, including complicated by descemetocele or corneal perforation up to 3 mm, including de-epithelialization, necrectomy of the ulcerative surface and corneal plastic surgery with an autoconjunctival flap “on a pedicle”, characterized in that before autoconjunctival plastic surgery, Alloplant biomaterial is placed on the defect layered keratoplasty with a thickness of 100, 150 or 200 microns, with a diameter of 6 to 10 mm, which is modeled according to the shape of the defect and the receptive bed of the cornea, and fixed with interrupted sutures 8/0 or 10/0 along the periphery “edge to edge”, after which the Alloplant biomaterial for layered keratoplasty, it is covered with an autoconjunctival flap.