RU2169548C2 - Method for treating the cases of rigid ciliary body detachment - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying endolaser coagulation of detached ciliary body on the boundary of detachment zone. The detached ciliary body is cut with erbium-YAG endolaser. The ciliary body is fixed on both sides around the area cut with endolaser coagulator. EFFECT: reduced risk of detachment recurrence; perfect anatomical adjacency of ciliary body.

Description

 The invention relates to medicine, namely to ophthalmology, and can be used to treat ciliary body detachment, prone to relapse due to muscle stiffness of the ciliary body.

 It is known that the cause of the formation of detachment of the ciliary body is the appearance of free communication between the anterior chamber and the suprachoroid space of the eye. The occurrence of serous detachment of the ciliary body and choroid as a result of penetrating wounding of the eye has been described (Hudson A. C. "Serous detachment of the choroid and ciliary body as an accompaniment of perforating lesion of the eyeball." London Ophthalmol. Hosp. Rep., 1913 , V. 19, P. -301-309) and with blunt injury to the eyeball (Collins E.T. "An experimental investigation as to some of the effects, of the hypotomy in rabbits eyes." Trans. Ophth. Soc. UK 1918, V.38. - P. 217-227). In the 70s, the formation of tractional detachments of the choroid and ciliary body was isolated in the late stages after the contusion of the eyeball (Alekseev BN "Echographic diagnosis of detachment of the ciliary body." Vestnik Ophthalmology, 1973, N 4, p.20-27.) confirmed the relationship between the detachment of the ciliary body with the choroid and surgical intervention for cataract extraction or antiglaucomatous surgery (Krasnov ML "Glaucoma Microsurgery", M., 1974).

 To eliminate the detachment of the ciliary body and choroid, coagulation of tissues over the inside of the cyclodialysis fissure was performed through an incision in the limbus and the ciliary body was sutured to the sclera with silk sutures (Vannas M. et al. "On hypotomy following cyclodialisis and its treatment", Acta Ophthalmol., 1952 , V.30, Nl, P.63-64) - this method is taken as the closest analogue. Cyclodialysis was performed under gonioscopic control, followed by diathermocoagulation of the sclera in the limb region until the scleral spur and the iris joined (Shaffer RW et al. "Concerning cyclodialisis and hypotomy". Arch. Ophthalm. 1962, N1, P.25. -31); introduced the practice of cryocoagulator and cryocoagulation of the sclera above the ciliary body and choroid (Barasch K. et al. "Postcyclodialisis hypotomy" Amer. J. Ophthal.l969, N.4, P.644-645). After 20 years of oblivion, the ciliary body was again sutured with fixation to the sclera of the iris root at the level of the scleral spur (Mackenson G. et al. "Verboseness er Eingriff gegen das Hypotonic - Syndrome mit Kammerwin Kelspalf nach cruckensenacuder operation" // Klin. Mbi Augenieie. 1974, Bd.l65, S.696-704.), And also against hypotension (Zheng YZ et al. "Reattachment of the detached ciliary body with suturing for treatment of contusional ocular hypotension", Ophthalm. Surg., 1991, V .22, N.6, P.360-362.).

 An argon laser was used to photocoagulate the ciliary body with ciliary body detachments of postoperative and post-traumatic origin (Joondeph N.C. "Management of postoperative and posttraumatic cyclodialisis cleft with argon laser Phothocoagulation" Ophthalm. Surg., 1980, V.11, N.3, P.3 . 186-188) - the author acted on the visible part of the ciliary body. In addition, transpupilar cyclophotocoagulation was used (Bechetoille A. et al. "La Gonioretraction au laser a argon" // J. Franc. Ophthalmol. - 1985. - V. 8. -N 1. - P. 19-27; Bakutkin BB with co-authors "Laser transscleral surgery of" malignant "glaucoma" // Ophthalmic surgery. - 1990. -N 4, -C. 68-74. and others) using such types of coagulators as argon, ruby, krypton, neodymium, under the control of a three-mirror lens with effects on the ciliary processes. Other authors have chosen the trans-scleral route of exposure to the ciliary body through the sclera to the anterior surface of the ciliary body (Beckman, H. et al. "Transscleral ruby laser cyclocoagulation." // Amer. J. Ophthalmol. - 1984.-V. 98, -N. 6, -P.788-798; Krasnov MM et al. "Morphological studies of the ciliary body in contact transscleral cyclocoagulation in the eyes of humans and rabbits," Vestnik Ophthalmology-1988-T.104-N 5. -P.11 -thirteen).

 He conducted a study and proved the effectiveness of the use of a 10% caffeine solution, which activates the ciliary body and promotes fit with elimination of the detachment of the ciliary body and choroid without surgical intervention V.N.Beglyarbekyan ("Clinic, diagnosis and treatment of post-traumatic eyeball subatrophy", diss Ph.D., M., -1983).

 The well-known methods listed above have proven themselves in the treatment of ciliary body detachment in the early stages. However, in the later stages after the occurrence of detachment of the ciliary body or after relapse of detachment, the fit of the ciliary body is problematic and unlikely. Our method is characterized in that the proposed surgical laser treatment is optimally sparing and is performed with minimal operational impact on the eyeball (without the risk of shells falling out at the time of manipulation), it is strictly dosed under the control of the surgeon and provides a fit with fixation of the ciliary body in the area of anatomical location without drug stimulation, without alien suture on the ciliary body and temperature effects on the outer surface of the sclera.

 The technical result of the proposed method is to achieve the anatomical fit of the rigid ciliary body to the sclera and to reduce the risk of recurrence of detachment of the ciliary body and choroid.

 The technical result is achieved by the fact that the rigid ciliary body is fixed with an endolasercoagulator along the borders of the detachment, followed by its intersection in the Erbium detachment zone: YAG-endolaser and the fixation of these parts of the ciliary body to the sclera using endolasercoagulation.

 The method is as follows.

 After a clinical study and the detection of ciliary body detachment in the late stages or recurrent detachment, the patient is offered surgical treatment. At the moment, the ciliary body is becoming rigid and fitting it to the sclera by conventional methods, in addition to hemming, is actually problematic. In the operating room, against the background of maximum mydriasis, a cycloscopy is performed to visually clarify the height of the detachment of the ciliary body and additional ultrasound examinations (possibly A-, B-, D-scanning) to confirm the height and size of the detachment of the ciliary body. Surgical access is possible in two versions: in the quadrant of the location of the detachment of the ciliary body and in the opposite quadrant. When using an intraocular endoscope, the second option is chosen, but this does not change the tactics of treatment. If an endoscope is not used, then control is carried out through a three-mirror lens. The endolasercoagulator tip (curved at the first access, straight at the second access) is inserted through an incision in the flat part of the limb until the ciliary body is touched in the zone of the end of detachment and prophylactic coagulation of the normal ciliary body is on both sides of the detachment. After the change of lasers is carried out: coagulator on Erbium: YAG. In the detachment zone, the ciliary body crosses and the formed free "ends" are pressed with the tip of the endolaser to the sclera in the adjoining zone. Repeatedly change lasers: Erbium: YAG on the coagulator. The ciliary body is coagulated with fixation of the dissected structure between itself and to the sclera. Then seal the wound by applying 2 to 3 scleral sutures 8/00. With a decrease in turgor, replenishment is made either with physiological saline or with sterile air. The conjunctiva is also sutured with 8/00 suture and an antibiotic solution is administered under it. Bandage.

 Example. A 36-year-old patient was admitted with a diagnosis of OS: recurrent post-concussion detachment of the ciliary body. From the anamnesis - he received a dull injury when a ski stick hit his left eye, the same day he turned to an ophthalmologist at the place of residence, where it was noted: visual acuity OD / OS - 1.0 / 0.4 n / a, IOP OD / OS = 22/20 mm Hg Objectively: OD - irritated, erosion of the cornea and wound of the conjunctiva in the lower quadrant, descemetitis. The anterior chamber is uneven and deeper below, hyphema 2 mm. The pupil is shifted down. The lens is intact in the vitreous body without visible hemorrhage. The fundus reflex is uniform. Appointed and conducted a course of blood-absorbing therapy. Within 3 weeks, the state of the OS returned to normal.

 After 2 months, the patient developed OS hypotension - 16 mmHg, visual acuity decreased to 0.2. The patient was hospitalized for drug treatment according to scheme 1A (to eliminate hypotension). After 3 weeks of active treatment, IOP OS stabilized at 20 mmHg.

 An ultrasound study was carried out only 4 months after the injury, where a high detachment of the ciliary body was noted in the lower-outer quadrant. After another 1 month, subciliary fluid and cryopexy of the sclera were released in the area of the projection of the ciliary body detachment. The eyeball remained calm after surgery for another 4 months.

 At 11 months after the injury, the patient turned for re-examination. Objectively: OD is calm, OS is irritated, pronounced conjunctival injection, conjunctival scar in the lower quadrant, cornea with descemetitis. The anterior chamber of uneven depth, iridodenesis in the lower outer quadrant, with mydriasis, there is a manifestation of a protruding gray formation in the posterior chamber of the eye at 4-5 hours. In the vitreous body, a uniform fine suspension. The fundus without pronounced features. According to ultrasound: in the left eye there is a thickening of the outer membranes, a detachment of the ciliary body in the lower outer quadrant (not extending beyond the quadrant), a diffuse suspension in the vitreous and fixed opacities in the area of the detachment of the ciliary body, no retinal detachment is noted. According to electrophysiology - in the left eye there is an inhibition of the threshold of excitation of the retina. Visual acuity OD / OS = 1.0 / 0.2 n / a, IOP OD / OS = 24/16 mm Hg After analysis of the obtained data, the patient was offered surgical treatment of recurrent ciliary body detachment.

 At the end of 11 months after the injury, the patient was admitted for re-treatment. In the operating room, the patient was anesthetized, the surgical field was prepared. A control ultrasound study confirmed the detachment of the ciliary body in the lower outer quadrant up to 5.5 mm high. Section of the conjunctiva in the upper-inner quadrant and sclera in the flat part of the limb. The endolaser tip was inserted into the wound before contact with the exfoliated ciliary body, and under the control of the endoscope, endolaser coagulation of the ciliary body was made at the border of the anatomical fit to prevent further detachment. The second stage was the change of the endolaser emitter - coagulator to Erbium: YAG, with the help of which the dissection of the exfoliated ciliary body was made. The free ends of the crossed ciliary body were pressed with the tip of the endolaser to the sclera in the area of the anatomical location. In the third stage, the emitter was again changed: from Erbium: YAG laser to coagulator. Without changing the position of the endolaser tip, dissected parts of the ciliary body were fixed by coagulation between themselves and to the sclera. The surgical wound is sealed with scleral sutures 8/00 N 3. The restoration of turgor of the eyeball was not required due to the absence of prolapse of the vitreous body and the outflow of intraocular fluid. Suture 8/00 on the conjunctiva, a solution of gentamicin is introduced under the conjunctiva. Bandage.

 2 days after the operation, the OS condition is satisfactory - slightly irritated, the joints are clean, the cornea is calm and spherical, the anterior chamber is of moderate depth, the iris is calm, the pupil's reaction is satisfactory to light, and the suspension is moderate in the vitreous. Reflex from the fundus is expressed evenly. In the control ultrasound study, the membranes retain a thickening, there is no detachment of the ciliary body. Visual acuity of OS - 0.4 n / a. IOP OS within normal limits.

 3 months after the operation - the OS is calm, the anterior segment without negative dynamics. According to ultrasound, retinal detachment, a ciliary body were not detected, EFI - normalization of the main parameters. Visual acuity OS - 0.6 n / a, IOP OS - 20 mm Hg No relapse of ciliary body detachment was found.

 An indication of the method are cases of detachments of the rigid ciliary body both in the late stages diagnosed and after relapse.

 The method has no contraindications.

 As a result of the application of this method, it is possible to achieve anatomical fit of the detachment of the rigid ciliary body. Preliminary endolaser coagulation of the ciliary body in the adjoining zone and the intersection of the exfoliated ciliary body Erbium: with a YAG endolaser followed by endolaser coagulation of the liberated parts of the ciliary body to the sclera and with each other allows anatomical fit of the ciliary body and fix it to the sclera.

Claims (1)

 A method of treating a rigid ciliary body detachment, including fixing the ciliary body to the sclera, characterized in that the fixation is carried out along the boundaries of the detachment using endolasercoagulation, and then the ciliary body is crossed in the Erbium detachment zone: YAG with a laser, after which the ciliary body is fixed along the sides intersection with an endocoagulator.