RU2815869C1 - Method of discission of retroprosthetic membrane (versions) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions refers to medicine, namely to ophthalmology. According to first version of invention, discission of retro-prosthetic membrane (RPM) is performed, during the second stage of keratoprosthesis, coagulation of newly formed vessels is performed in the area of projection of optical cylinder hole (OCH). Then the tissues are dissected above the OCH to the plug located between the upper and lower parts of the vascular leukoma, and it is twisted. Then lower part of vascular leukoma is dissected, RPM is visualized, membranotomy is performed crosswise from 12 to 6 o’clock and from 9 o’clock to 3 o’clock. An underwater diathermocoagulator is used to perform single-step coagulation of newly formed vessels and discission along the circumference of the lower base of the OCH with diameter of 3.5 mm according to the “tin opening” type. Extracapsular cataract extraction (CE) is performed, followed by screwing an aphakic optical cylinder and applying interrupted sutures around the optical cylinder. According to the second version of the invention, a phakic optical cylinder is unscrewed after the second stage of the keratoprosthesis and RPM is visualized. Membranotomy is performed crosswise from 12 to 6 hours and from 9 to 3 o’clock. Further, an underwater diathermocoagulator is used to perform single-step coagulation of newly formed vessels and discission along the circumference of the lower base of OCH with diameter of 3.5 mm according to the “tin opening” type. If observing a clouded native lens, CE is performed using an extracapsular technique and the operation is completed by screwing in an aphakic optical cylinder. If CE was performed earlier, the operation is completed by screwing the aphakic optical cylinder and applying interrupted sutures around the optical cylinder.

EFFECT: group of inventions allows to reduce the risk of intraoperative and postoperative complications, as well as maximum complete and sparing cleaning of optical cylinder hole thread, facilitating screwing the optical cylinder and reducing the risk of intraocular fluid filtration from the anterior chamber through the space between the optical cylinder hole thread and the cylinder itself.

2 cl, 3 ex

Description

The invention relates to medicine, and more specifically to ophthalmology, and can be used during optical-reconstructive interventions during keratoprosthetics, in particular for discision of the retroprosthetic membrane at the second stage of keratoprosthesis or in the delayed period after the second stage of keratoprosthesis with simultaneous cataract extraction (EC) or without her.

Keratoprosthetics is the only possible way to restore visual functions in patients with vascular lesions of category 4-5, which are most often a consequence of chemical burns (according to the classification of V.P. Filatov - D.G. Bushmich, 1947). One of the most common complications of keratoprosthesis is the formation of a retroprosthetic membrane (RPM).

RPM is formed as a result of the inflammatory process and is a reaction of the eye to surgical trauma with the introduction of a foreign body. RPM is a connective tissue, the main cellular element of which is fibroblasts; their proliferation leads to a steady increase in membrane thickness. At later stages, vascularization of the RPM occurs, and newly formed vessels appear in it.

As it forms, the RPM gradually grows along the posterior surface of the cornea and the optical cylinder of the keratoprosthesis, which leads to a pronounced decrease in visual acuity, contributes to an increase in intraocular pressure, and also increases the risk of protrusion of the keratoprosthesis.

There is a known method for discision of RPM, which is the closest analogue of the claimed method (https://pubmed.ncbi.nlm.nih.gov/20700050/).

The method is that after installing the Abraham lens, 15-20 YAG laser pulses with a power of no more than 1.2 MJ are applied, like “opening a tin can”, while YAG laser pulses are applied, as a rule, clockwise . The diameter of the discision hole corresponds to the diameter of the optical cylinder (OC) hole.

Disadvantages of the method: high risk of damage to the optical cylinder as a result of the action of a high-power laser pulse or improper focusing of the laser pulse; risk of developing tractional retinal detachment; increased intraocular pressure due to deposition of fragments of destroyed RPM in the area of the anterior chamber angle; bleeding from the RPM, which in the delayed period leads to fibrin deposition and relapse of the RPM; high risk of damage to the vitreous due to its close proximity to the RPM; impossibility of discision of dense RPM due to insufficient laser pulse power; the occurrence and chronicity of the uveal process; impossibility of complete cleaning in the area of the OOC thread.

The objective of the invention is to create two options for RPM discission using an underwater coagulator in patients during the second stage of keratoprosthesis or in the delayed period after the second stage of keratoprosthesis with or without EC.

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

The technical result of the two options is to reduce the risk of developing intraoperative and postoperative complications, which is achieved by the ability of the underwater coagulator to perform RPM discision and simultaneous coagulation of newly formed RPM vessels, as well as the possibility of the most complete and gentle cleaning of the thread of the optical cylinder hole, which will make it easier to screw in the optical cylinder and reduce the risk the occurrence of filtration of intraocular fluid from the anterior chamber of the eye through the space between the thread of the hole of the optical cylinder and the cylinder itself.

The method according to the first option, in which the retroprosthetic membrane is dissected during the second stage of keratoprosthesis, is carried out as follows.

Coagulation of newly formed vessels is performed in the area of projection of the central nervous system. Next, the tissue is dissected above the OOC to a plug located between the upper and lower parts of the vascular cataract. After finding the plug, it is unscrewed using a key that looks like this: a metal cylinder with a diameter of 3.5 mm, a length of 5 cm, on the end parts of which there are 2 metal protrusions 0.2 cm long, congruent with the blind holes in the plug of the keratoprosthesis and the optical cylinder . Next, the lower part of the vascular lesion is visualized, which is dissected using a blade and scissors, after which the RPM is visualized. Using a blade, membranotomy is performed in the direction from 12 o'clock to 6 o'clock, from 9 o'clock to 3 o'clock. Next, using an underwater diathermocoagulator, a simultaneous discision is performed in a clockwise direction like “opening a can” and coagulation of newly formed RPM vessels, while the diameter of the discision hole corresponds to the diameter of the OOC - 3.5 mm. After discision of the RPM, the clouded native lens is visualized and EC is performed using the extracapsular method. The operation is completed by screwing in the aphakic optical cylinder using the key described above and applying interrupted sutures around the cylinder.

The method according to the second option, in which the retroprosthetic membrane is dissected after the second stage of keratoprosthesis, is carried out as follows.

The phakic optical cylinder is unscrewed using the key described above and the RPM is visualized. Using a blade, membranotomy is performed in the direction from 12 o'clock to 6 o'clock, from 9 o'clock to 3 o'clock. Next, using an underwater diathermocoagulator, a one-step clockwise discision is performed, similar to “opening a can,” and coagulation of the newly formed RPM vessels, while the diameter of the discision hole corresponds to the diameter of the OTC - 3.5 mm. In cases where, after discision of the RPM, a clouded native lens is visualized, EC is performed using the extracapsular method; The operation is completed by screwing in the aphakic optical cylinder. In cases where the EC was performed earlier, then after dissection of the RPM, the aphakic optical cylinder is screwed in using a key that looks like this: a metal cylinder with a diameter of 3.5 mm, a length of 5 cm, on the end parts of which there are 2 metal protrusions of length 0. 2 cm, congruent with the blind holes in the keratoprosthesis plug and the optical cylinder.

Significant differences of this method:

the method allows for discision of RPM of different densities and thicknesses, which ensures the creation of the maximum possible discision hole, the diameter of which is equal to the diameter of the OOC - 3.5 mm;

the method allows for discision of the RPM and simultaneous coagulation of newly formed RPM vessels, ensuring the prevention of bleeding during surgery;

The method makes it possible to discriminate the RPM in close proximity to the OOC thread, which leads to more thorough cleaning of the thread from the RPM, thereby facilitating screwing in the optical cylinder and reducing the risk of filtration of intraocular fluid through the space between the OOC thread and the cylinder.

The method is illustrated by the following examples

Example 1

Patient B, 64 years old. Diagnosis: OU Vascular cataract of the cornea. The outcome of a chemical burn. OD Subatrophy of the eyeball. OS Condition after the first stage of keratoprosthesis.

From the anamnesis it is known that 2 years ago there was a burn at home with acetic acid. Six months ago, the first stage of keratoprosthesis on the left eye was performed at MNTK MG.

Biomicroscopy visualizes a vascularized corneal cataract in both eyes. Deep-lying environments are not ophthalmoscopically.

Visual acuity: OD - Visus=1/∝ proectia lucis incerta; OS - 1/∝ proectia lucis certa. Intraocular pressure (IOP) was normal by palpation in both eyes.

Optical coherence tomography (OCT) of the anterior segment of the left eye showed that the keratoprosthesis was in the correct central position. Behind the area of the rear part of the cataract, the RPM is visualized.

According to the electrophysiological study (EPS), the presence of gross changes in the right eye and minor changes in the left eye were revealed.

According to B-scan data: the membranes of the left eye are adjacent, destruction of the vitreous body; of the right eye, total retinal detachment, destruction of the vitreous body.

Taking into account the greater potential of visual functions, the correct central position of the keratoprosthesis and the presence of RPM according to OCT data, it was decided to carry out the second stage of keratoprosthesis with simultaneous discision of the RPM according to the first version of the proposed method.

The early postoperative period occurred without complications. In the first days, moderate swelling and hyperemia were noted, and the sutures were intact. Visual acuity of the left eye was 0.2 without correction. IOP palpation is normal.

Upon discharge from the hospital on the 7th day: the eye is calm, the sutures are intact. Visual acuity: 0.4 with correction sph -1.0 D=0.6. IOP palpation is normal.

When examining the patient after 3 months, the eye is calm, the sutures are intact. Visual acuity: 0.4 with correction sph -1.0=0.7. IOP palpation is normal.

After 6 months, when examined, the eye is calm. According to OCT data, the keratoprosthesis is in the correct central position. Visual acuity: 0.4 with correction sph -1.0 D=0.7. IOP palpation is normal.

The proposed version of the method was used in 9 clinical cases. In each of them, it was possible to achieve restoration of visual functions.

Example 2

Patient A, 31 years old. Diagnosis: OS Vascular cataract of the cornea. The outcome of a chemical burn. Condition after the second stage of keratoprosthesis. Retroprosthetic membrane OD Anophthalmos

From the anamnesis it is known that 3 years ago he received an industrial lime burn on both eyes. At the place of residence, the right eye was enucleated immediately after the burn. Two years ago, the second stage of keratoprosthesis on the left eye was performed at MNTK MG. Visual acuity at discharge 0.3 with correction sph -3.0=0.6

Biomicroscopy of the left eye visualizes a vascularized corneal cataract, a centrally located optical cylinder, and the presence of a vascularized RPM. Deep-lying environments are not ophthalmoscopically.

Visual acuity: OS - 1/∝ proectia lucis certa. IOP palpation is normal.

With OCT of the anterior segment of the left eye, the keratoprosthesis occupies the correct central position, and the RPM is visualized behind the posterior part of the vascular cataract.

According to EFI data, minor changes in the left eye were revealed.

According to B-scan data: the membranes of the left eye are adjacent, destruction of the vitreous body.

Taking into account the potential of visual functions, the correct central position of the keratoprosthesis and the presence of RPM according to OCT data, it is advisable to perform the second stage of keratoprosthesis with simultaneous discision of the RPM according to the second version of the proposed method.

The patient had the phakic optical cylinder unscrewed and the RPM was visualized. Using a blade, a membraneotomy was made in the direction from 12 o'clock to 6 o'clock, from 9 o'clock to 3 o'clock. Next, using an underwater diathermocoagulator, we performed a one-step clockwise discision like “opening a can” and coagulation of the newly formed RPM vessels, while the diameter of the discision hole corresponded to the diameter of the OTC - 3.5 mm. After discision of the RPM, the clouded native lens was visualized, as a result of which EC was performed using the extracapsular method. The operation was completed by screwing in the aphakic optical cylinder.

The early postoperative period occurred without complications. In the first days, moderate swelling and hyperemia were noted. Visual acuity of the left eye was 0.05 without correction. IOP palpation is normal.

Upon discharge from the hospital on the 7th day: the eye is calm, the sutures are intact. Visual acuity: 0.1 with correction sph -2.0 D cyl -1.75 D ax 80=0.3. IOP palpation is normal.

When examining the patient after 3 months, the eye is calm. Visual acuity: 0.3 with correction sph -2.0 D=0.6. IOP palpation is normal.

After 6 months, when examined, the eye is calm. According to OCT data, the keratoprosthesis is in the correct central position. Visual acuity: 0.3 with correction sph -2.0 D=0.6. IOP palpation is normal.

The proposed version of the method was used in 7 clinical cases. In each of them, it was possible to achieve restoration of visual functions.

Example 3

Patient D, 28 years old. Diagnosis: OS Vascular cataract of the cornea. The outcome of a chemical burn. Condition after the second stage of keratoprosthesis. Retroprosthetic membrane. Aphakia OD Anophthalmos

From the anamnesis it is known that 4 years ago he received an industrial lime burn on both eyes. At the place of residence, the right eye was enucleated immediately after the burn. Two years ago, the second stage of keratoprosthesis on the left eye with simultaneous EC was carried out at MNTK MG. Visual acuity at discharge was 0.4 with correction sph -1.5=0.9.

Biomicroscopy of the left eye visualizes a vascularized corneal cataract, a centrally located optical cylinder, and the presence of a vascularized RPM. Deep-lying environments are not ophthalmoscopically.

Visual acuity: OS - 1/∝ proectia lucis certa. IOP palpation is normal.

With OCT of the anterior segment of the left eye, the keratoprosthesis occupies the correct central position, and the RPM is visualized behind the posterior part of the vascular cataract.

According to EFI data, minor changes in the left eye were revealed.

According to B-scan data: the membranes of the left eye are adjacent, destruction of the vitreous body.

Taking into account the potential of visual functions, the correct central position of the keratoprosthesis and the presence of RPM according to OCT data, it is advisable to perform the second stage of keratoprosthesis with simultaneous discision of the RPM according to the second version of the proposed method.

The patient had the phakic optical cylinder unscrewed and the RPM was visualized. Using a blade, a membraneotomy was made in the direction from 12 o'clock to 6 o'clock, from 9 o'clock to 3 o'clock. Next, using an underwater diathermocoagulator, we performed a simultaneous clockwise discision like “opening a can” and coagulation of the newly formed RPM vessels, while the diameter of the discision hole corresponded to the diameter of the OTC - 3.5 mm. After discision of the RPM, the operation was completed by screwing in the aphakic optical cylinder.

The early postoperative period occurred without complications. In the first days, moderate swelling and hyperemia were noted. Visual acuity of the left eye was 0.2 without correction. IOP palpation is normal.

Upon discharge from the hospital on the 7th day: the eye is calm, the sutures are intact. Visual acuity: 0.2 with correction sph -0.5 D cyl -1.0 D akh 80=0.7. IOP palpation is normal.

When examining the patient after 3 months, the eye is calm. Visual acuity: 0.4 with correction sph -1.5=0.9. IOP palpation is normal.

After 6 months, when examined, the eye is calm. According to OCT data, the keratoprosthesis is in the correct central position. Visual acuity: 0.4 with correction sph -1.5=0.9. IOP palpation is normal.

The proposed version of the method was used in two clinical cases. In each of them, it was possible to achieve restoration of visual functions.

Claims (2)

1. A method of discision of a retroprosthetic membrane (RPM), characterized in that during the second stage of keratoprosthetics, coagulation of newly formed vessels is performed in the projection area of the opening of the optical cylinder (OC), then tissue dissection is performed above the OOC to a plug located between the upper and lower parts of the vascular wall. , unscrew it, then dissect the lower part of the vascular cataract, then visualize the RPM, perform a membranotomy crosswise from 12 to 6 o'clock and from 9 to 3 o'clock, then use an underwater diathermocoagulator to perform one-stage coagulation of the newly formed vessels and discision along the circumference of the lower base of the OVC with a diameter of 3.5 mm like “opening a tin can”; Next, cataract extraction (EC) is performed using the extracapsular method, after which the aphakic optical cylinder is screwed in and interrupted sutures are placed around the optical cylinder. 2. A method of discision of the RPM, characterized in that after the second stage of keratoprosthetics, the phakic optical cylinder is unscrewed and the RPM is visualized, a membraneotomy is performed crosswise from 12 to 6 o'clock and from 9 to 3 o'clock, then a single-stage coagulation of the newly formed vessels is performed using an underwater diathermocoagulator and discission is performed around the circumference of the lower OOC bases with a diameter of 3.5 mm, similar to “opening a can”; in the presence of a clouded native lens, EC is performed using the extracapsular method and the operation is completed by screwing in the aphakic optical cylinder; if EC was performed earlier, then the operation is completed by screwing in the aphakic optical cylinder and placing interrupted sutures around the optical cylinder.