RU2848258C1 - Method for surgical treatment of descemet's membrane detachment - Google Patents

Abstract

FIELD: medicine, specifically ophthalmology.

SUBSTANCE: preliminary blood sample is taken from the patient, a corneal paracentesis is formed, the anterior chamber is emptied of intraocular fluid, and the obtained autoplasma is injected into the anterior chamber, followed by the application of a sterile protector and the patient being placed in a face-down position. On the eve of the operation, YAG laser iridotomy is performed at 4 and 8 o'clock through the formed paracentesis using a cannula attached to a syringe, 0.7-1.1 ml of the obtained autoplasma is injected into the anterior chamber, after which the patient is placed in a face-down position for 15-20 minutes. Next, the patient is returned to the supine position, the anterior chamber is emptied through the previously performed paracentesis, sterile air is introduced into the anterior chamber until it is filled, Then, apply flat pressure to the surface of the cornea in the projection of the Descemet's membrane detachment until it adheres to the posterior surface of the corneal stroma. Leave the air in the anterior chamber for 15-20 minutes, after which time part of the air from the anterior chamber is released through the paracentesis. In a particular case, the paracentesis is formed at 3 or 9 o'clock in the limbal zone with a width of 1.0-1.2 mm. In a particular case, the introduction of sterile air into the anterior chamber and flat pressure on the surface of the cornea in the projection of the Descemet's membrane detachment are performed using a curved cannula.

EFFECT: method allows to eliminate Descemet's membrane detachment, including that accompanied by its rupture, accelerate the resorption of corneal stroma oedema, reduce the risk of inflammatory reaction, as well as restore corneal transparency and improve the patient's visual functions.

3 cl, 2 ex

Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used to treat Descemet's membrane detachment.

Descemet's membrane (DM) detachment is a serious and vision-threatening condition that typically occurs after intraocular surgery. The earliest description of DMD in the literature was made in 1927 (Weve H. Separation of the membrane of Descemet after extraction of the lens // Dutch J Med. - 1927. - Vol. 72. - Pp. 398-400). The etiology of DM detachment can be varied. Pathogenetic factors and causes of DM detachment may include: thinning of the DM with age, endothelial dysfunction existing at the time of surgery, improper surgical technique, blunt instruments, and others (Beniwal A. et al. Descemet's membrane detachment: An updated comprehensive review of etiopathogenesis, diagnosis, and management // Indian Journal of Ophthalmology. - 2024. - V. 72. - No. 11. - P. 1560-1568).

Disruption of the relationship between the DM and the corneal stroma leads to fluid accumulation between the detached DM and the stroma, development of stromal and epithelial edema, impaired corneal transparency, and visual impairment. Limited and localized DM detachment outside the optical zone can be treated medically, but more extensive DM detachments require surgical intervention, especially if there is a DM tear and the edges of the tear are twisted.

Descemet's membrane detachment is typically performed first in surgical treatment using air or gas. The first description of the treatment of DM detachment using air injection into the anterior chamber after cataract surgery was published in 1967 (Sparks, G. M., "Descemetopexy: Surgical reattachment of stripped Descemet's membrane" in Archives of Ophthalmology, 1967, Vol. 78, No. 1, pp. 31-34). This method has stood the test of time and is rightfully considered the method of choice when transitioning from conservative treatment to surgical treatment of DM detachment.

A known method for treating Descemet's membrane detachment involves injecting sterile air into the anterior chamber via paracentesis using a cannula to fill 2/3 of the anterior chamber's volume, and then draining fluid from the cavity formed by Descemet's membrane and the corneal stroma through a tunnel incision made in the outer surface of the cornea using a 19G corneal knife. Pressure is then applied to the lower edge of the tunnel incision, gradually withdrawing the knife from the tunnel until the fluid is completely drained from the cavity between Descemet's membrane and the posterior surface of the stroma (patent RU 2703336 C1, published 16.10.2019).

The disadvantages of this method include low efficiency due to the fact that air is quickly absorbed, and its compression effect on the DM weakens and the detachment recurs, which requires repeated introduction of air.

There are known methods for treating Descemet's membrane detachment using gases, such as 2%-14% octafluoropropane (C3F8) and 14%-20% sulfur hexafluoride (SF6), which remain in the anterior chamber longer, providing more effective tamponade for 6-8 weeks and 2 weeks, respectively (Ellis D.R., Cohen K.L. Sulfur hexafluoride gas in the repair of Descemet's membrane detachment //Cornea. - 1995. - V. 14. - №. 4. - P. 436-437.; Sharma A. et al. Perfluoropropane (C3F8) injection for Descemet's membrane detachment in cataract surgery //Nepalese Journal of Ophthalmology: a Biannual Peer-reviewed Academic Journal of the Nepal Ophthalmic Society: NEPJOPH. - 2015. - V. 7. - No. 1. - P. 74-78). The advantage of the method of introducing gas into the anterior chamber over air is that repeated injections are not required.

However, prolonged presence of gas in the anterior chamber carries the risk of increased intraocular pressure and the development of angle-closure glaucoma. In addition, toxic effects of gases on the corneal endothelium have been reported in animal studies (Lee D. A. et al. The ocular effects of gases when injected into the anterior chamber of rabbit eyes // Archives of Ophthalmology. - 1991. - Vol. 109. - No. 4. - Pp. 571-575; Landry H. et al. Corneal endothelial toxicity of air and SF6 // Investigative ophthalmology & visual science. - 2011. - Vol. 52. - No. 5. - Pp. 2279-2286). Although a later in vitro study of human corneal endothelium after exposure to SF6 did not reveal any toxic effects, the authors point out the need for further study of this issue (Schaub F. et al. Influence of 20% sulfur hexafluoride (SF6) on human corneal endothelial cells: an in vitro study //Der Ophthalmologe. - 2016. - Vol. 113. - Pp. 52-57).

Along with air and gases, the use of viscoelastics and mattress sutures is known for fixing the detached DM (Donzis R.B., Karcioglu Z.A., Insler M.S. Sodium hyaluronate (Healon®) in the surgical repair of Descemet's membrane detachment // Ophthalmic Surgery, Lasers and Imaging Retina. - 1986. - Vol. 17. - No. 11. - Pp. 735-737; Amaral C.E., Palay D.A. Technique for repair of Descemet's membrane detachment // American journal of ophthalmology. - 1999. - Vol. 127. - No. 1. - Pp. 88-90). However, these methods have not received recognition due to their low efficiency.

In ophthalmology, the use of platelet-rich plasma (PRP) for the treatment of macular holes is known (Gaudric A, et al. Autologous platelet concentrate for the treatment of full-thickness macular holes. Graefes Arch Clin Exp Ophthalmol. 1995 Sep; 233(9):549-54). When platelet-rich plasma is administered to the area of the hole, platelet aggregates are formed, which are stabilized by fibrin and adhesive glycoproteins.

A further development of PRP technology was the production of autologous conditioned plasma (autoplasma) using a double-syringe centrifugation technique, which involves purifying the plasma from leukocytes, which reduced the likelihood of developing inflammatory processes during the treatment of macular holes (Bikbov M.M. et al. Platelet-rich autoplasma (PLA) - a new "tool" in macular surgery // Point of view. East - West. 2020. No. 2. pp. 33-35).

The closest to the claimed method - the prototype - is a method for treating acute keratoconus, including preliminary blood sampling from a patient, forming a corneal paracentesis, emptying the anterior chamber of intraocular fluid and introducing the obtained autoplasma into the anterior chamber, followed by the application of a bandage, characterized by the fact that a paracentesis is formed at 12 o'clock with a width of 1.0-1.2 mm, the anterior chamber is emptied of intraocular fluid and through the formed paracentesis, using a syringe with a cannula, 0.2-0.3 ml of the obtained autoplasma is introduced into the anterior chamber, after which the patient is transferred to a face down position for 1-1.5 hours (patent RU 2832387 C1, published 12/23/2024).

The disadvantages of the prototype include the low efficiency of the method, since without air tamponade of the anterior chamber, the introduction of autologous plasma into the anterior chamber alone cannot ensure reliable adhesion of the detached DM to the posterior surface of the corneal stroma.

The objective of the invention is to increase the effectiveness of surgical intervention.

The technical result of the method is an increase in the effectiveness of surgical intervention due to a more durable and reliable adhesion of the Descemet membrane to the cornea, as well as due to the acceleration of edema resorption.

The stated task is achieved in the following manner.

Before the operation, biomicroscopy is performed using a slit lamp and optical coherence tomography (OCT) of the cornea, the purpose of which is to determine the extent of the DM detachment, identify and evaluate the shape of the DM rupture, and assess the state of the rupture edge (whether the rupture edge is straightened or twisted).

To prevent pupillary block in case of anterior chamber air tamponade, YAG laser iridotomy is performed one day before surgery.

Blood is collected from the patient using a special “double” syringe (Arthrex ACP® Double-Syringe System) and autologous plasma is obtained using the method described in (patent RU 2832387 C1, published 12/23/2024).

One hour before surgery, a 1% pilocarpine solution is instilled into the conjunctival cavity (three times with a 5-minute interval). Retrobulbar anesthesia is then administered, the eyelids are fixed with an eyelid speculum, and a 1.0-1.2 mm wide corneal paracentesis is created in the limbus area at the 3 or 9 o'clock position. The anterior chamber is emptied of intraocular fluid, and 0.7-1.1 ml of autologous conditioned plasma (autoplasma) is injected into the anterior chamber through a cannula previously attached to a syringe. The eyelid speculum is removed. A sterile plastic protector is applied to the eye to eliminate pressure on the eyeball and prevent contamination of the surgical field. The patient, while on the operating table, assumes a face-down position and remains in this position for 15-20 minutes. After this time, the patient returns to the starting position, and the surgery is resumed. The eyelid speculum is reinserted. The anterior chamber is emptied through the previously performed paracentesis, and sterile air is introduced into the anterior chamber using a curved cannula until it is completely filled with air. Next, using the same cannula, flat pressure is applied to the corneal surface in the projection of the DM detachment until it is completely adhered to the posterior surface of the corneal stroma, as monitored visually through the microscope eyepieces and on the screen of the surgical coherence tomograph (if available). Particular attention should be paid to the twisted edges of the DM tear: they must be completely straightened and fully adhered to the posterior surface of the corneal stroma. Air is left in the anterior chamber for 15-20 minutes. After this time, if necessary, some air from the anterior chamber is released through paracentesis, which prevents pupillary block. The eye is covered with a plastic protector.

The primary goal in treating corneal lamina detachment is its early and effective resolution, facilitated by the compressive action of air and the adhesive properties of autologous plasma, which acts as a "bioglue." Furthermore, autologous plasma helps suppress the inflammatory response and swelling of the corneal stroma, enhancing and accelerating reparation due to the biologically active peptides contained in platelet granules. Platelet alpha granules are known to contain more than 30 cytokines and growth factors that promote tissue reparative processes (Nurden A.T., et al. Platelet sand wound healing. Front. Biosci., 2008, v. 13, pp. 3532-3548).

The invention is illustrated by the following examples of specific implementation.

Example 1

Patient S., 73, presented to the clinic with complaints of decreased vision in her left eye, corneal discoloration, pain, moderate photophobia, and lacrimation. Eleven months earlier, the patient had undergone phacoemulsification of age-related cataracts with implantation of a posterior chamber intraocular lens (IOL). Postoperatively, corneal edema was noted, which was treated with medications, but without clinical benefit. Eight months after surgery, the cornea remained unsatisfactory: stromal edema persisted, and bullous changes appeared in the epithelial layer. Examination revealed a DM detachment in the central cornea. Over the next two months, air was injected into the anterior chamber three times to resolve the DM detachment, but without success.

On admission: moderate lacrimation, photophobia, and blepharospasm on the left. Visual acuity on the left is 0.1, uncorrected. Objectively: the central cornea is opaque, with stromal edema, bullous changes in the epithelial layer, and DM detachment. The DM tear is not visualized. The anterior chamber is deep, with the intraocular lens (IOL) visible in the pupil area. The deeper media are not ophthalmoscopeable. Corneal OCT reveals uneven central corneal thickening, with DM detachment occupying the entire central region and extending to the midperiphery of the cornea. The edge of the DM tear is visible in the midperiphery, in the upper inner quadrant. The edge of the tear is not twisted. The detached DM has several linear, ridge-like, multidirectional consolidations.

Taking into account the anamnesis data, objective examination, and preoperative diagnostics, the following diagnosis was made: detachment of the Descemet membrane with rupture, bullous keratopathy, and pseudophakia on the left.

Surgical treatment of Descemet's membrane detachment was performed using the proposed method on the left eye.

To prevent pupillary block, YAG laser iridotomy was performed at 4 and 8 o'clock one day before the intraocular intervention.

Blood was first drawn from the cubital vein into a special syringe up to the 15 ml mark. Autologous conditioned plasma (autoplasma) was prepared as follows. After the blood was drawn, the syringe was turned upside down and air was removed by gently pressing the syringe plunger. When the first drop of blood appeared from the syringe, the syringe was capped and placed plunger-up in the centrifuge chamber. A counterweight was placed in the opposite chamber. Centrifugation was performed for 5 minutes at 1500 rpm. After the centrifuge stopped spinning, the syringe was carefully removed without inverting or shaking it. The blood separated into two fractions: formed elements and plasma. The supernatant plasma was carefully collected into the inner syringe, then the syringe was unscrewed from the main syringe.

One hour before the operation, a 1% solution of pilocarpine was instilled into the conjunctival cavity (3 times every 5 minutes) to prevent air from penetrating beyond the iridocrystalline diaphragm.

The surgery was performed under local retrobulbar anesthesia. A 1.0 mm corneal paracentesis was created at the 9 o'clock position in the limbus. The anterior chamber was emptied of aqueous humor. 0.7 ml of the obtained autologous plasma was then injected into the anterior chamber through a cannula attached to a previously prepared syringe. A plastic protector was applied. The patient assumed a prone position on the operating table for 15 minutes. After this time, the patient returned to the supine position, and the procedure continued. The eyelid speculum was reinserted. The anterior chamber was partially emptied through the previously created paracentesis, and sterile air was injected into the anterior chamber using a cannula until it was completely filled. The eye was sealed, and intraocular pressure was monitored by palpation. To improve visualization, edematous, opaque epithelium was removed from the previously localized area of DM detachment. Using a cannula as a spatula, pressure was applied to the cornea, along with stroking movements from the detachment edge toward the previously localized DM tear, thereby facilitating the evacuation of fluid from beneath the detached DM. The quality of DM adhesion to the posterior surface of the corneal stroma was visually monitored through the microscope eyepieces. Intraoperative optical tomography was also used to monitor the image. Moderately elevated intraocular pressure was maintained by repeatedly adding sterile air to the anterior chamber. After 15 minutes, to avoid anterior chamber angle block, some of the air was released through paracentesis. A therapeutic contact lens was applied to the cornea. The eye was covered with a plastic protector. A single beta-blocker was instilled 2 hours after the surgery to prevent pressure increases.

The day after surgery: intraocular pressure (palpation control) is normal. Biomicroscopy reveals no DM detachment, and a loose fibrinous film is present in the pupillary region. OCT data shows that the DM is adherent to all parts of the cornea. In the area of the previously existing DM tear, there is optical thickening, apparently due to plasma fibrin deposition between the DM and the corneal stroma. Roll-shaped linear thickening of the DM persists, but is tightly adherent to the underlying corneal stroma.

In the immediate postoperative period, symptoms of ocular irritation (photophobia, lacrimation, blepharospasm) subsided, corneal edema decreased, and corneal transparency increased. Visual acuity on the right side was 0.2, uncorrected.

One month after the intervention, reliable adhesion of the Descemet membrane to the posterior surface of the corneal stroma is observed, symptoms of eye irritation completely disappear, corneal edema further decreases over the entire area, and visual acuity is 0.3, not corrected.

Example 2

Patient D., 71, presented to the clinic complaining of decreased vision in both eyes. Preoperative examination results: Visual acuity: right 0.1 uncorrected; left 0.04 uncorrected. Optical biometry:

Biomicroscopy revealed a clear cornea in both eyes, with extracellular matrix deposition between the corneal endothelium and Descemet's membrane (cornea guttata), a shallow anterior chamber, and clouding of the lens nucleus, more pronounced on the left. Electron biomicroscopy revealed endothelial cell density: 1326/ ^mm2 on the right; 1298/ ^mm2 on the left.

Diagnosis on admission: immature age-related cataract, cornea guttate, anatomically narrow angle, moderate hyperopia, complex hyperopic astigmatism of both eyes.

A planned phacoemulsification of cataract with implantation of an intraocular lens was performed on the left eye.

In the early postoperative period, visual acuity in the left eye is 0.01, uncorrected. Biomicroscopy reveals edematous central corneas, folded DM, clear anterior chamber fluid, correct intraocular lens position, and no deeper visualization. Corneal OCT reveals DM detachment with a rupture in the paracentral zone, with a twisted edge.

Conservative treatment resulted in slight improvement in corneal edema. On the fourth day after cataract removal and IOL implantation, sterile air was injected into the anterior chamber. Over the next two days, OCT showed slight improvement in the area of DM detachment. On the seventh day, sterile air was reintroduced into the anterior chamber. Over the next three weeks, no improvement was observed with conservative treatment, and ocular irritation increased. OCT showed a persistent DM detachment with a rupture.

Surgical treatment was performed on the left eye using the proposed method. To prevent pupillary block, YAG laser iridotomy was performed the day before at the 4 and 8 o'clock positions. Autologous plasma preparation was performed similarly to Example 1.

One hour before the operation, a 1% solution of pilocarpine was instilled into the conjunctival cavity (3 times every 5 minutes).

Retrobulbar anesthesia was administered. After inserting an eyelid speculum at the 3 o'clock position, a 1.2 mm corneal paracentesis was created. The anterior chamber was emptied of intraocular fluid. Then, 1.1 ml of the obtained autologous plasma was injected into the anterior chamber through a cannula attached to a previously prepared syringe. A plastic protector was applied. The patient assumed a prone position on the operating table and remained in this position for 20 minutes. After this time, the patient returned to the supine position, and the procedure continued. The eyelid speculum was reinserted. Through the previously created paracentesis, the anterior chamber was partially emptied, and sterile air was introduced into the anterior chamber using a cannula until it was completely filled. The eye was sealed, and intraocular pressure was monitored by palpation. Using a cannula as a spatula, pressure was applied to the cornea, along with stroking movements from the detachment edge toward the previously localized DM tear to evacuate fluid from beneath the detached DM. The quality of DM adhesion to the posterior surface of the corneal stroma was monitored visually through the microscope oculars and using an in-office optical tomograph. Moderately elevated intraocular pressure was maintained by repeatedly adding sterile air to the anterior chamber. After 15 minutes, to avoid obstructing the anterior chamber angle, some of the air was released through paracentesis. The eye was covered with a plastic protector. Two hours after the surgery, a single beta-blocker was administered to prevent pressure increases.

The day after surgery: intraocular pressure (palpation control) was normal. Biomicroscopy revealed no DM detachment, and a loose fibrinous film was present in the pupillary region. Optical coherence tomography showed the DM was present in all areas of the cornea, including the projection of the DM rupture, where optical thickening was observed, likely due to plasma fibrin deposition between the DM and the corneal stroma.

In the immediate postoperative period, symptoms of ocular irritation (photophobia, lacrimation, blepharospasm) subsided, corneal edema decreased, and corneal transparency increased. Visual acuity on the right side was 0.2, uncorrected.

One month after the intervention, the symptoms of eye irritation have almost completely disappeared, corneal edema has further decreased over the entire area, the DM is tightly attached to all parts of the cornea, and visual acuity is 0.4 and not corrected.

The use of the proposed method will eliminate DM detachment, accelerate the resorption of corneal stromal edema, as well as restore corneal transparency and improve the patient's visual functions.

Claims (3)

1. A method for surgical treatment of Descemet's membrane detachment, including preliminary blood sampling from a patient, forming a corneal paracentesis, emptying the anterior chamber of intraocular fluid and introducing the obtained autoplasma into the anterior chamber, followed by the application of a sterile protector and moving the patient to a face-down position, characterized in that on the eve of the operation, YAG laser iridotomy is performed at 4 and 8 o'clock, through the formed paracentesis using a cannula attached to a syringe, 0.7-1.1 ml of the obtained autoplasma is introduced into the anterior chamber, after which the patient is moved to a face-down position for 15-20 minutes, then the patient is returned to a supine position, through the previously performed paracentesis, the anterior chamber is emptied, sterile air is introduced into the anterior chamber until it is filled, then planar pressure is applied to the surface of the cornea in the projection of the Descemet's membrane detachment until it adheres to the posterior surface corneal stroma, leaving air in the anterior chamber for 15-20 minutes, after which time some of the air from the anterior chamber is released through paracentesis. 2. The method according to paragraph 1, characterized in that the paracentesis is formed at 3 or 9 o’clock in the limbus zone, 1.0-1.2 mm wide. 3. The method according to paragraph 1, characterized in that the introduction of sterile air into the anterior chamber and planar pressure on the surface of the cornea in the projection of the detachment of the Descemet's membrane is carried out using a curved cannula.