RU2308253C1 - Method for removing recurrent pterygium - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves removing pterygium body with diamond knife. Radio surgical vaporization is carried out in scleral part and elastoid dystrophy connective tissue filaments abrasion is carried out in corneal part, scleral part and limb zone. Abrasion is carried out with caoutchouc heads and ultrafine diamond grit. The treatment begins with removing coarse connective tissue fibers with head member having large-size fraction of ultrafine diamond grit under rotation speed greater than 7000 rpm and continuously rinsed abrasion-treated surface with physiologic saline. Then, small-sized connective tissue fibers using head member having minimum-sized fraction of ultrafine diamond grit filler. Scleral part of bed is covered with autoconjunctiva flap.

EFFECT: reduced mechanical injury area of healthy eyeball tunics; complete elastoid dystrophy connective tissue filaments removal; accelerated treatment course.

1 tbl

Description

The invention relates to medicine and, in particular, to ophthalmology and can be used to remove recurrent pterygium.

Morphologically, recurrence is caused by elastoid dystrophy of the conjunctival collagen against the background of severe scarring with phenomena of proliferation of the epithelium of non-tumor origin.

There are ways to remove pterygium recurrence using the bare sclera technique by using a strontum applicator (Sr - 90) with a total dose of 1596 to 3870 cGy [Verigo EN, Valsky VV, Borodin Yu.I. Achievements and prospects of ophthalmic oncology // Sat scientific tr scientific and practical. Conf., M. - 2001, p. 1001-103].

The essence of the method is the complete excision of scar-changed tissues of the pterygium zone to the lunate fold, purification of the sclera, coagulation of the vessels of the surgical field and subsequent irradiation for two days with a strontum ophthalmic applicator (Sr -90) with a maximum single dose of 1290 cGy to a maximum total dose of 3870 cGy.

But the disadvantages of this method are:

- the possibility of regional clouding of the cornea;

the possibility of bacterial keratitis due to the accession of the secondary flora in the operating, irradiated field, healing in an open way;

- radiation exposure of the underlying sclera of the ciliary body, with a decrease in the production of intraocular fluid and a violation of the hydrodynamics of the eye, which initiates the development of cataracts;

- the possibility of post-radiation obliteration of the anterior ciliary artery and the inner part of the large arterial circle, limbal vessels of the marginal loop (plexus episckleralis, plexus sckleralis) with the phenomena of chronic ischemia and subsequent neoangiogenesis of proliferating scar tissue, i.e. relapse of pterygium.

There is a method for pterygium radiosurgery using the Surgitron apparatus of Ellman International (USA) [Likhvantseva V.G., Balayan M.L. Radio wave surgery of epibulbar neoplasms of a tumor and non-tumor nature // Bulletin of Ophthalmology No. 4, 2005, p.32-34]. The essence of the method was to remove pterygium by radiosurgical vaporization using various modulations of an electromagnetic wave with a frequency of 3.8 MHz, with power regulation on the cornea and sclera.

The disadvantages of the prototype method are:

- damage to healthy corneal tissue during radiosurgical vaporization to a greater extent than actually during vaporization of elastoid dystrophy due to lower hydrophilicity of the latter;

- gross scarring of the corneal defect with the formation of clouding of the cornea;

- a decrease in visual acuity due to the formation of postoperative astigmatism with a significant component: irregularity due to the formation of paracentral local opacification.

The closest analogue prototype is a method of abrasive microsurgery of the cornea when removing pterygium [Karamyan AA, Ismailov MI, Aliev AG .. // Modern technologies for diagnosis and treatment in ophthalmology Sat. scientific Tr. Makhachkala, 2004. - p.135-137]. The essence of the method is to remove the altered tissue of the sclera and cornea of elastoid dystrophy with a dental boron-tip made of stainless steel with a rotation speed of 4,500 to 8,000 rpm (certificate of the Russian Federation for utility model RU 20454 U1 dated 10.11.2001) with the subsequent closure of the scleral part pterygium bed with allogeneic canned amniotic membrane impregnated with cytostatic -

5-Fluorouracil or mitomycin C, and excimer laser treatment of the corneal part of the pterygium bed in the regime of phototherapeutic keratectomy on the NIDEC TC-5000 device after removing the sutures from the alloplant.

The disadvantages of the prototype method are:

- insufficiently complete removal of keloid dystrophy of the pterygium bed, requiring subsequent use of cytostatic in the scleral part of the bed and excimer laser treatment of the corneal part of the pterygium bed;

- high trauma to healthy layers of the cornea due to the use of steel boron-tip, which has a negative abrasive effect on the cleaned surface of the cornea and sclera;

- the lack of selectivity of exposure to pathological tissues of elastoid dystrophy and intact episcler and cornea tissues during abrasive microsurgery with stainless steel boron;

- long duration of treatment in connection with ongoing inflammatory reactions that occur under the toxic effect of antimetabolites and subsequent photoevaporation of the cornea;

- the toxic effect of cytostatics - antimetabolites, namely 5-fluorouracil or mitomycin C on an already cleaned surface, which prevents physiological gentle healing.

The objective is to propose a method for removing recurrent pterium.

The technical result is a reduction in the area of mechanical trauma to healthy layers of the membranes of the eyeball when small connective tissue fibers of elastoid dystrophy are removed from the bed of pterygium recurrence.

The technical result is achieved by the fact that after removing the head and body of the pterygium with a diamond knife from the surface of the cornea and limbus and vaporizing the body of the pterygium from the sclera with the TA8-van-type electrode-waveguide in the fully rectified waveform (PRF) mode of the Surgitron radiosurgical device, Ellman (USA) ), the bed of pterygium recurrence has a rough surface due to the introduction of conjunctival elastoid dystrophy into the episclera, the limb and the surface layers of the corneal stroma, therefore it is especially important to carefully remove it, with minimal trauma iey healthy layer of the eyeball shell coarse and fine fibers elastoidnoy dystrophy.

For these purposes, use abrasive dental color-coded rubber heads with diamond filling (CGE "Celite" TU 9433-040-10614163-2000). Abrasion is started with a yellow-green, color-coded rubber dental head having a larger fraction of ultrafine diamond chips, at a dental tip with a rotational speed of no more than 7000 rpm with constant irrigation of the abrasive surface with physiological saline. After removal of coarse connective tissue fibers from the bed of relapse of the pterygium, an increase in the ophthalmic surgical microscope is increased and abrasion is continued with a light gray rubber color-coded dental head having the smallest sizes of ultra-dispersed crumbs of diamond filler, which makes it possible to remove small connective tissue fibers from the bed of the pterygium recurrence . In case of abrasion with rubber heads with diamond ultradispersed crumb, “pulling out” of connective tissue fibers of elastoid dystrophy from the cornea and sclera occurs, while the area of deep tissue defects is minimized in the sclera and cornea, because the non-continuous affected layer of the sclera or cornea is removed, only connective tissue fibers that have invaded. Figure 1 The cleaned sclerral bed of the pterygium is treated by cryopexy using liquid nitrogen with an exposure of 1 s, in order to inhibit the processes of excessive scarring in the sclera, limbus. [O.I. Lebedev. Cryopexy in the regulation of reparative processes in glaucoma. // Theses IV Scientific-practical conference. “Human Health in Siberia”, Krasnoyarsk, 1988. - p. 91].

The conjunctival defect over the bed of remote pterygium recurrence is closed with a rotary flap of the autoconjunctiva from the upper or lower conjunctival fornix and fixed to the edges of the defect by conjunctivoscleral nodal sutures - silk 8/0. In the postoperative period, instillations of antiseptic solutions and regenerating drugs that promote epithelization of the corneal surface are used, for example, Kornoregel, Oftagel, Solcoseryl, Actovegin.

The advantages of the proposed method are:

- complete removal of connective tissue fibers of elastoid dystrophy, which have grown in the bed of relapse of pterygium, creating a heterogeneous density, rough surface due to the use of two types of rotating elastic-abrasive rubber heads with diamond ultrafine filler, which allow selective removal of pathological dense fibers;

- preservation of healthy layers of the cornea, sclera due to the elastic rubber base of abrasive heads;

- the preservation of healthy stroma layers of the cornea being cleaned due to the absence of pressure on it, because during rotation, connective tissue fibers of elastoid dystrophy engage in ultrafine diamond chips and break out from the healthy layers of the corneal stroma by rotation forces;

- the conditions of transparent healing of postoperative corneal erosion are fulfilled and the risk of corneal cervical formation is eliminated due to the relatively smaller total area of deep erosion and the absence of the need to use cytostatic antimetabolites to inhibit the processes of excessive scarring and recurrence of elastoid dystrophy;

- eliminates the risk of the formation of postoperative astigmatism and decreased visual acuity due to the ensured ability of the operating area to organotypically regenerate the transparent tissue of the cornea;

- eliminates the risk of recurrence of elastoid dystrophy of the scleral bed due to the complete removal of its connective tissue fibers and subsequent cryopexy of the scleral part of the pterygium bed;

- the absence of neoangiogenesis in the area of remote pterygium due to minimization of surgical injury to the vascular loop of the limb, ciliary arteries, ciliary body, because there is no iatrogenic in the underlying zone of the pterygium bed;

- reduced healing time and postoperative period due to the one-stage surgery.

The proposed method for the removal of pterygium recurrence was used in 34 patients with 52 eyes, while previously operated on - 28 eyes, twice operated - 24 eyes. The results of postoperative observation ranged from 1 to 14 months, an average of 6 months is presented in the table

Table 1 The degree of recurrence of pterygium Number of eyes The degree of astigmatism of the cornea (Dptr), M ± q Aberrometric indicators (Dptr), M ± q Visual acuity II 27 1.84 ± 0.16 1.07 ± 0.28 0.76 ± 0.03 0.83 ± 0.04 0.91 ± 0.23 0.93 ± 0.11 III 21 3.1 ± 0.82 2.71 ± 0.46 0.58 ± 0.09 1.34 ± 0.47 1.73 ± 0.41 0.73 ± 0.05 IV four 3.62 ± 1.08 2.16 ± 0.52 0.49 ± 0.06 1.44 ± 0.42 1.21 ± 0.24 0.68 ± 0.04 Total 52 Note: the numbers in the vertical columns without shading correspond to the indicators of the preoperative period, in the shaded columns to the postoperative indicators. Significance of differences at P <0.001.

Analysis of the data presented in the table indicates the presence of significant deformations of the spherical surface of the cornea with recurrent pterygium, manifested in the form of irregular astigmatism and the associated low resolution of the cornea to focus visual acuity. Surgical treatment, including excision with a diamond knife on the cornea and radiosurgical vaporization - in the scleral part, using the abrasive cleaning technique - cleansing the bed of connective tissue fibers of elastoid dystrophy using dental color-coded rubber heads with ultrafine diamond chips of various sizes, cryopexy bed with liquid nitrogen and autoconjunctival defect plasty, eliminated the risk of recurrence of pterygium, avoided eoangiogenesis of the operative zone, minimize surgical trauma and shorten the postoperative period, increase visual acuity from 0.58 ± 0.09 to 0.73 ± 0.05 and from 0.49 ± 0.06 to 0 at grade III and IV of recurrent pterygium , 68 ± 0.04, respectively, and in 51.9% of the total number of operations performed, restore the physiological optical power of the cornea and visual acuity.

Example 1

Patient N., 48 years old, was admitted to the hospital with DZ: recurrent pterygium of the III degree of the left eye. Pterygium I degree of the right eye.

Earlier, 2 years ago, she was operated on for grade III pterygium using alloplasty of the defect zone of the scleral part of the conjunctiva. The patient reports that in the postoperative period, a constant redness of this part of the eye remained, and then a film directed towards the pupil appeared and progressively increased.

With visometry: visual acuity of the left eye is 0.5, visual acuity of the right eye is 1.0. With fixation topokeratometry of the left eye, corneal astigmatism 2.38 Dptr was detected.

Biomicroscopy on a slit lamp revealed a significant thickening and regidity of the conjunctiva in the inner corner, a large number of newly formed vessels with a developed network of collaterals and microaneurysms. Pterygium with a progressively growing head on the surface of the cornea reaches the outer edge of the pupil, in the surface layers of the corneal stroma there is a perifocal contour of the pterygium cloud-like clouding.

The patient underwent an operation to remove recurrent pterygium by excision with a diamond knife on the cornea and radiosurgical vaporization in the scleral part, then abrasive technique cleansed the pterygium bed from fibers of elastoid dystrophy in the corneal, scleral part and the limb area using dental, color-coded rubber-rubber ultra-fine heads with ultra-fine size , cryopexy of the purified part of the scleral bed with liquid nitrogen was performed. The defect of the conjunctiva of the sclera is closed by a formed rotational autoconjunctival flap from the upper arch, fixed by scleroconjunctival sutures. The postoperative period, lasting 12 days, was accompanied by moderate regressing edema of the autograft, mild corneal syndrome, expressed only by an increase in tear production. Complete corneal epithelization was completed after 8 days with the installation of the Vitabact antiseptic and a regenerating drug for re-epithelialization of the corneal surface. Korneoregel was prescribed 6 times a day and Solcoseryl gel at night. Biomicroscopy revealed restoration of the surface layers of the cornea and a full epithelial coating. Topokerato metrics of 0.75 Dptr indicated a complete correction of irregular astigmatism, which was objectively confirmed by an increase in vision to 0.95 without correction. By the time the conjunctival suture was removed, 14 days after the operation, avascular engraftment of the autograft was biomicroscopically revealed, there were no signs of its hypertrophic inflammation and proliferation, the autograft was translucent with a shiny surface, elastic. With an observation period of 18 months, there are no signs of progression of pterygium, neoangiogenesis, visual functions remain stably high, equal to 0.9 without correction.

Example 2

Patient R., 39 years old, previously operated twice for pterygium, turned in connection with low vision in the right eye, redness of the eyeball in the inner corner. During the examination: visual acuity of the right eye is 0.2, does not correct when selecting spherical and cylindrical glasses.

Visual acuity in the left eye is 0.7, does not correct.

With topokeratometry on the right eye, corneal astigmatism of 3.63 Dptr was detected, an aberrometric indicator was 2.14; on the left eye -2.12 Dptr., the aberrometric indicator - 1.05 Dptr.

Biomicroscopy of the right eye determines hyperemia, hypertrophy and regidity of the conjunctiva and lunate fold of the conjunctiva, massive vascularization, a progressively growing head of the pterygium overlaps the pupil area by 1/2. On the left eye, pterygium grew into the surface layers of the corneal stroma to the level of the pupil girdle of the iris.

Clinical diagnosis: recurrent pterygium IV degree of the right eye, recurrent pterygium III degree of the left eye.

The patient was operated on in the first stage on his right eye using the combined excision of pterygium with a diamond knife on the cornea and radiosurgical vaporization in the scleral part of the pterygium, then abrasion technique cleared the pterygium bed from fibers of the elastoid dystrophy in the corneal, scleral parts and limbus area using dental flower-head with ultrafine diamond chips of various sizes.

Claims (1)

A method for removing recurrent pterygium, including removing the pterygium body with a diamond knife, radiosurgical vaporization in the scleral part and abrasion of connective tissue fibers of elastoid dystrophy in the corneal, scleral parts and the limb area, followed by closing the scleral part of the bed with an autoconjunctival flap, characterized in that the dentist rubber heads with ultrafine diamond chips, begin with the removal of coarse connective tissue fibers with a head having a large fraction of ultrafine diamond crumb, with a rotation speed of not more than 7000 rpm, with constant irrigation of the abrasive surface with physiological saline, then small connective tissue fibers are removed with a head having the smallest size of ultrafine diamond filler crumb.