RU2822077C1 - Method for implantation of posterior chamber intraocular lens in case of anterior capsulorhexis inconsistency or defects of lens haptic elements - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions refers to medicine, namely to ophthalmosurgery. According to the first version of the invention, a posterior chamber intraocular lens is implanted by forming a tunnel incision and two paracenteses, anterior capsulorhexis, lens phacoemulsification, intraocular lens (IOL) implantation into a capsular sac are performed. In case of anterior capsulorhexis inconsistency, a posterior capsulorhexis is performed concentrically to the anterior capsulorhexis. Then the optical part of the IOL is brought out through the posterior capsulorhexis behind the posterior capsule, and the haptic elements of the IOL are left in the capsular sac. According to the second version of the invention, upon detecting a defect of the haptic element with preservation of the stump of the second haptic element with a size of not less than 1 mm, the IOL is rotated in the capsular sac and the whole haptic element is positioned at 6 o'clock, and the stump of the second haptic element is positioned at 12 o'clock. Then the posterior capsulorhexis is performed concentrically to the anterior capsulorhexis, then the optical part of the IOL is brought out through the posterior capsulorhexis behind the posterior capsule, and the whole haptic element, like the stump of the second haptic element, is left in the capsular sac.

EFFECT: group of inventions provides centralization and rotational stability of the IOL, reduces the risk of secondary cataract, reduces the risk of developing intra- and postoperative complications in the early and late postoperative period.

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Description

The invention relates to medicine, namely to ophthalmic surgery, and can be used in phacoemulsification of cataracts for fixing a posterior chamber itraocular lens (IOL) in case of failure of the anterior capsulorhexis or defects in the haptic elements of the lens.

Intracapsular centration and fixation of the IOL is quite often difficult due to the failure of the anterior capsulorhexis, ruptures of the posterior capsule of the lens and defects in the haptic elements of the lens.

There is a known method for preventing ruptures of the posterior capsule of the lens with complicated capsulorhexis, which consists of the following. If the edge of the capsulorhexis runs away when performing an anterior capsulorhexis, capsulotomy is continued through paracentesis in the meridian opposite to the radial rupture of the anterior capsule of the lens until the most rounded opening is achieved. After obtaining an anterior intermittent capsulotomy opening with a radial rupture of the edge, many radial incisions are made through paracenteses along the entire perimeter of the capsulotomy opening complicated by a rupture. Then they continue to perform phacoemulsification of cataracts (patent RU 2465874 C1, published on April 19, 2011).

The disadvantages of this method are that it does not provide fixation of the IOL in the capsular bag in case of failure (defect) of the anterior capsulorhexis, as well as maintaining the transparency of the optical axis in the long-term postoperative period. In addition, the lack of support for the anterior capsulorhexis leads to IOL dislocation (tilt) and the development of severe postoperative complications in the form of Elingson syndrome or iris translumination syndrome.

There is a known method of implanting a posterior chamber intraocular lens, which consists in the following. An anterior capsulorhexis is performed in the shape of an ellipse with a major axis of 7.0-7.5 mm along the tunnel incision and a minor axis of 4.0-5.0 mm. The lens masses are removed. Viscoelastic is injected between the layers of the lens capsule. One IOL support element is inserted into the capsular bag until it stops at the opposite equatorial fornix, and the second support element is inserted into the capsular bag by smoothly bending it and rotating the intraocular lens. Centering of the lens is carried out by rotation until the supporting elements of the lens are located perpendicular to the major axis of the capsulorhexis (patent RU 2382624 C1, published 02/27/2010).

The disadvantages of this method are the high risk of IOL dislocation due to fibrosis of the capsule leaves in the projection of the free edge of the anterior capsulorhexis, as well as the possibility of breakthrough of the lens epithelium with the development of secondary cataracts and, as a consequence, a decrease in visual acuity.

There is a known method of implanting an intraocular lens in patients with congenital ectopia of the lens, which consists in the following. A tunnel incision and corneocentesis are formed, an anterior capsulorhexis is performed, the contents of the lens are removed, an intracapsular ring (ICR) is implanted into the capsular bag, and an IOL is implanted. When implanting an IOL, the haptic elements are placed in the ciliary sulcus. Next, a posterior capsulorhexis is performed, concentric to the anterior capsulorhexis. Then, a double capture of the optical part of the IOL is performed in the anterior and posterior capsulorhexis, while the optical part of the IOL is placed behind the capsular bag, the haptic elements remain in front of it, and the aVCK located in the capsular bag is self-fixed in the corner formed by the edge of the IOL and the haptic element. In the case of severe ectopia of the lens, when the distance from the edge of the lens to the center of the pupil is less than 3 mm, suture fixation of the intracapsular ring is performed in the meridian of maximum stretch of the ligaments of Zinn. Next, the threads are tensioned, displacing the intracapsular ring until the IOL is centered (patent RU 2792165 C1, published 03/17/2023).

The disadvantages of this method are the extracapsular location of the haptic elements. The use of only three-part S-shaped IOLs, since monolithic acrylic IOLs with haptic elements located in the ciliary groove provoke the development of Elingson syndrome or iris translumination syndrome. The method is limited to use only in patients with congenital ectopic lens.

The closest to the claimed method (prototype) is a method of IOL implantation for weakened zonular ligaments, defects of the posterior capsule and intraoperative damage to the anterior capsulorhexis, providing for intracapsular fixation of the IOL, characterized by the fact that an elastic IOL is implanted on the iris and moved by pressing one haptic element to the corner anterior chamber, a free haptic element is introduced under the edge of the capsulorhexis, then, moving the IOL along the iris, the rest of the IOL is implanted into the capsular bag, and the haptic elements are introduced into areas free of defects (patent RU 2372883 C1, published on November 20, 2009).

The disadvantages of the prototype are trauma to the angle of the anterior chamber and the root of the iris when introducing an IOL into the capsular bag. Failure of capsular support in the form of free defects creates conditions for IOL dislocation in the late postoperative period with the development of Elingson's syndrome. In addition, through open capsule defects, migration of lens epithelial cells occurs with the development of secondary cataracts and, as a consequence, decreased vision in the postoperative period.

The objective of the invention is to develop a more effective method for intracapsular implantation and fixation of a posterior chamber IOL in the presence of defects in the haptic elements or failure of the anterior capsulorhexis.

Technical result: ensuring centration and rotational stability of the IOL, reducing the risk of developing secondary cataracts, reducing the risk of developing intra- and postoperative complications in the early and late postoperative period.

The proposed method is as follows.

After cataract removal, in the presence of failure of the anterior capsulorhexis, which does not cover the entire optical part of the IOL, a posterior capsulorhexis is performed, concentric to the anterior capsulorhexis, with a diameter of at least 4 mm. In the case of a toric IOL, the lens is positioned according to the toric markings. The IOL optic is then advanced through the posterior capsulorhexis using an iris microhook behind the posterior capsule, and the IOL haptics are left in the capsular bag.

If a defect (separation) of the haptic element is detected with preservation of the haptic stump of at least 1 mm in size, the IOL is implanted into the capsular bag and rotated so that the entire haptic element is at 6 o’clock, and the haptic stump is at 12 o’clock. Then a posterior capsulorhexis is performed, concentrically with the anterior capsulorhexis, then the optical part of the IOL is removed through the posterior capsulorhexis using an iris microhook behind the posterior capsule, while the entire haptic, as well as the stump of the haptic, remain in the capsular bag. The operation is completed by washing out the viscoelastic from the capeal sac and anterior chamber, subconjunctival injection of an antibiotic, and applying a sterile bandage.

The defining differences of the proposed method, compared with the prototype, are:

1) the haptic elements of the IOL are placed in the capsular bag, and the optical part is pinched in the posterior capsulorhexis, which ensures stable fixation of the optical part of the IOL and the absence of displacement around the vertical axis (tilt);

2) the capsular bag and IOL (haptic elements - located in the capsular bag and the optical part of the IOL - pinched in the posterior capsule of the lens) create a durable structure that is resistant to fibrosis and prevents contact of the “capsular bag - IOL” complex with the iris;

3) to prevent secondary cataracts, posterior circular capture of the IOL optics is performed;

4) the method does not require suture fixation of the IOL;

5) the method does not require IOL replacement due to a haptic defect, which eliminates surgical trauma associated with manipulations to remove and reimplant the IOL.

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

Example 1

Patient V., 75 years old. Diagnosis: Overmature age-related cataract of the left eye. Objectively: upon examination - MKO3-pr.l. certae. Pneumotonometry indicators are 14 mm Hg. Art. The anterior segment is unchanged, with the exception of a diffusely cloudy, white lens (milk cataract). Deeper environments are not visible. Ultrasound of the eyeballs without gross pathology.

Surgery was performed on the left eye with fixation of the posterior chamber IOL using the claimed method.

After preparing the surgical field and local anesthesia, the toric axis was marked on the cornea, a main tunnel incision and two paracenteses to the right and left of it were made using a keratome knife. The anterior chamber was filled with viscoelastic. An anterior capsulorhexis was performed. The presence of “milk” cataract, namely intracapsular pressure, contributed to the centrifugal withdrawal of the anterior capsulorhexis, increasing its diameter to 6-7 mm (Fig. 1). The contents of the lens were removed using a phacoemulsifier. The anterior and posterior capsules were carefully polished. An S-shaped toric IOL (Acrysof TORIC IQ SN6AT3+17.5) was implanted into the capsular bag, after which the failure of the anterior capsulorhexis was established, which did not cover the optical part of the IOL and created conditions for rotation and dislocation of the IOL (Fig. 2). A posterior capsulorhexis was performed, concentric to the anterior capsulorhexis, with a diameter of 4 mm. The IOL was positioned according to the toric markings. Next, the optical part of the IOL was brought out through the posterior capsulorhexis using a microhook for the iris behind the posterior capsule, while the haptic elements were left in the capsular bag (Fig. 3). The operation was completed by washing out the viscoelastic from the capsular bag and anterior chamber, subconjunctival injection of an antibiotic, and applying a sterile dressing.

The day after surgery, visual acuity was 1.0 without correction. The IOL maintained its central position, the toric markings corresponded to the calculated ones, and the optical zone was transparent (Fig. 4). The postoperative period was calm. In the postoperative period, standard therapy was used.

Example 2

Patient A., 65 years old. Diagnosis: Immature age-related cataract of the left eye. Objectively: upon examination, visual acuity of the left eye is 0.03 sph-7.0=0.1. Tonometry indicator - 21 mm Hg. Art. The anterior segment is unchanged, with the exception of nuclear opacification of the lens. Deep-lying environments under a thick cover. Ultrasound of the eyeballs without gross pathology.

Surgery was performed on the left eye with fixation of the posterior chamber IOL using the claimed method.

After preparing the surgical field and local anesthesia, a main tunnel incision and two paracenteses to the right and left of it were made using a keratome knife. The anterior chamber was filled with viscose eraser. An anterior capsulorhexis was performed. The contents of the lens were removed using a phacoemulsifier. The anterior and posterior capsules were carefully polished. At the time of polishing, the anterior capsulorhexis ruptured with the formation of an “arrow” in the direction of 2 o’clock. To prevent the rupture from moving to the periphery during IOL implantation, the defect was rounded by grasping the edge of the rupture with capsular forceps and rotating the resulting flap clockwise. An S-shaped IOL (BASIS Z+16.0) was implanted into the capsular bag, after which local failure of the anterior capsulorhexis was established from 1 to 3 o'clock, which did not cover the optical part of the IOL and created conditions for dislocation of the IOL and breakthrough of the lens epithelium in the postoperative period. A posterior capsulorhexis was performed, concentric to the anterior capsulorhexis, with a diameter of 5 mm. Next, the optical part of the IOL was removed through the posterior capsulorhexis using an iris microhook behind the posterior capsule, while the haptic elements were left in the capsular bag. The operation was completed by washing out the viscoelastic from the capsular bag and anterior chamber, subconjunctival injection of an antibiotic, and applying a sterile dressing.

The day after surgery, visual acuity was 1.0 without correction. The IOL maintained its central position. The postoperative period was calm. In the postoperative period, standard therapy was used.

Example 3

Patient G., 65 years old. Diagnosis: Complicated cataract of both eyes. Macular degeneration of both eyes. Objectively: visual acuity of the left eye planned for surgery is 0.05 sph-2.5=0.15, the cornea of the eye is transparent, normal depth of the anterior chamber, nuclear opacification of the lens, the vitreous body is transparent, the fundus of the eye: the optic disc is pale pink, there is a subretinal neovascular membrane in the macula.

Surgery was performed on the left eye with fixation of the posterior chamber IOL using the claimed method. After preparing the surgical field and local anesthesia, a main tunnel incision and two paracenteses to the right and left of it were made using a keratome knife. The anterior chamber was filled with viscoelastic. An anterior capsulorhexis was performed. The contents of the lens were removed using a phacoemulsifier. The anterior and posterior capsules were carefully polished. An S-shaped IOL (RPR-2+22.0) was implanted into the capsular bag. After implantation, a lack of centralization of the IOL and its dislocation in the bag was discovered. During revision of the capsular bag, a detachment of one of the haptic elements of the IOL was discovered and its stump, 1 mm in size, remained intact. A posterior capsulorhexis was performed, concentric to the anterior capsulorhexis, with a diameter of 4 mm. The IOL was rotated in the capsular bag and the entire haptic was positioned at 6 o’clock, and the haptic stump at 12 o’clock, after which the optical part of the IOL was moved out of the posterior capsule using a microhook-centrator, while the entire haptic, as well as the haptic stump, remained in the capsular bag. The operation was completed by washing out the viscoelastic from the capsular bag and anterior chamber, subconjunctival injection of an antibiotic, and applying a sterile dressing.

The next day after surgery, visual acuity was 0.7 cyl+0.75 x 10=0.8. In the postoperative period, standard therapy was used. The observation period was 6 months. Visual acuity was 0.8 uncorrected. The IOL maintained its central position, and the optical zone remained transparent.

The advantages of the proposed method are:

- reducing the risk of complications in the late postoperative period (Ellingson syndrome “uveitis-glaucoma-hyphema”, iris translumination syndrome (pseudophakic iris chafing syndrome));

- ensuring prevention of IOL rotation (rotation), including IOL decentration in the early and late postoperative period;

- ensuring the prevention of secondary cataracts at any period of observation;

- maintaining high visual functions for a long time;

- eliminating the need for repeated surgical interventions;

- IOL replacement is not required for defects in the haptic elements of the lens.

Claims (3)

1. A method for implanting a posterior chamber intraocular lens, including the formation of a tunnel incision and two paracenteses, performing an anterior capsulorhexis, phacoemulsification of the lens, implantation of an intraocular lens (IOL) into the capsular bag, characterized in that if the anterior capsulorhexis fails, a posterior capsulorhexis is performed concentrically with the anterior capsulorhexis, then optical part of the IOL is brought out through the posterior capsulorhexis behind the posterior capsule, and the haptic elements of the IOL are left in the capsular bag. 2. A method for implanting a posterior chamber intraocular lens, including the formation of a tunnel incision and two paracenteses, performing an anterior capsulorhexis, phacoemulsification of the lens, implantation of an intraocular lens (IOL) into the capsular bag, characterized in that when a defect in the haptic element is detected, the stump of the second haptic element is preserved with a size of less than 1 mm, the IOL is rotated in the capsular bag and the entire haptic element is positioned at 6 o’clock, and the stump of the second haptic element is positioned at 12 o’clock, then the posterior capsulorhexis is performed concentrically to the anterior capsulorhexis, then the optical part of the IOL is brought out through the posterior capsulorhexis behind the posterior capsule, and the entire the haptic element, as well as the stump of the second haptic element, is left in the capsular bag. 3. The method according to claim 1 or 2, characterized in that the diameter of the posterior capsulorhexis is at least 4 mm.