RU2830362C1 - Method for reposition of “iol-capsular sac” complex dislocated in vitreal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology. Performing vitrectomy with introduction of perfluoroorganic compound (PFOC) on macular area. Then forceps are inserted into the vitreous cavity through the port and the “IOL-capsular sac” complex is held with the help of the forceps; the capsular sac is dissected from one side of the IOL perpendicular to the longitudinal axis of the IOL in the direction of the centre of the optical part of the IOL. Then, on the other side of the IOL, a vitreotome is used to form two holes in the capsular sac along the edges of the middle part of the haptic elements, as in Fig. 3, at 1.5 mm from the edge of the haptic elements. Further, the IOL is intercepted with forceps through the access in the capsular sac with the IOL fixation by the optical part and the “IOL-capsular sac” complex is positioned behind the iris so as to visualize one of the haptic elements and the first formed hole in the capsular sac, after which in a projection of a haptic element, a needle with a suture is inserted translimbally, the needle is brought to the iris, and at distance of 2 mm from the pupillary edge and 1.5 mm from the edge of the haptic element, the first iris puncture is made from outside to inside. Further, a suture with a needle is passed through the formed hole in the capsular bag, then under the haptic element, and on the other side, a second puncture is made from the inside to the outside in the capsular bag, and a second iris puncture is made at distance of 1.5 mm from the edge of the haptic element and 2 mm from the pupillary edge and needle pricking out translimbally. Then, in the middle between the iris punctures in the cornea, a paracentesis is performed, where the ends of the sutures are brought out, which, when held together, are pulled up, suture ends are cut and fused by means of a bipolar thermocoagulator to form a single spherical formation – a flange, which is filled through a paracentesis into the anterior chamber. Further, the second haptic element is sutured to the iris in a similar way, after which the PFOC is removed and the operation is completed.

EFFECT: method enables reducing the volume of the surgical intervention with minimizing the mechanical traumatisation of the macular region and increasing the reliability of fixation of the “IOL-capsular sac” complex deployed in the vitreous cavity.

1 cl, 2 ex, 3 dwg

Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used for repositioning and fixing an IOL-capsular bag complex dislocated in the vitreous cavity, where the IOL has S-shaped haptic elements.

A method for repositioning an intraocular lens dislocated in the vitreous cavity is known (patent RU 2662426, filed 10.08.2017, published 25.07.2018), in which, after vitrectomy and removal of the port at 10 o'clock, the branches of tweezers are inserted through the sclerostomy into the vitreous cavity, the IOL arch is grasped with them and the arch is brought out through the sclerostomy to the outside, tied with a 10/0 nylon thread with a 3/8 curved needle at the other end of the thread and the thread is tightened with a surgical knot; after this, the IOL arch is repositioned into the posterior chamber of the eye. Next, the port in the 4 o'clock meridian is removed and a similar manipulation is performed with the opposite IOL arch. Then, the curved needles with the thread are inserted one by one through the sclerostomies at 10 and 4 o'clock, respectively, followed by their puncture 1.5-2.0 mm from the limbus in the same meridians, the threads are pulled outward, alternately pulling both threads, the IOL is centered relative to the pupil, each thread is fixed with an intrascleral Z-shaped suture and the ends of the threads are cut.

The disadvantages of this method are:

- technical complexity of manipulation with a possible risk of mechanical detachment of the haptic elements from the optical part of the IOL, associated with its subsequent replacement;

- the need to extract haptic elements from the eye cavity, which increases the risk of postoperative complications;

- the impossibility of using this technique with an intact capsular bag, which will lead to an increase in the duration of the operation - excision of the capsular bag, associated with a high degree of surgical trauma to the eye;

- the risk of mechanical damage to the macular area when the IOL arch is captured by the tweezers, since PFOS is not used;

- a large volume of manipulation through the sclerostomy, which may require the application of additional sutures to the sclera to avoid filtration.

The closest analogue accepted as a prototype is the method described in patent RU 2427353 C1 (declared 04.03.2010, published 27.08.2011), in which after vitrectomy, tamponade of the vitreous cavity is performed with a perfluoroorganic compound (PFOC) before placing the IOL behind the iris. The IOL is centered. The first needle with the first thread is taken, the first needle with the first thread is passed from the outside along the sclera and inside the eye behind the posterior surface of the IOL in such a way that a figure symmetrical relative to the longitudinal and transverse axes is obtained from the first thread, while the sections of the thread located inside the eye are crossed with each other in the center of the IOL, and the outer sections of the thread are parallel to each other and to the longitudinal axis and are at the same distance from it. Then take the second needle with the second thread and pass it outside along the sclera and inside the eye behind the first thread so that the outer sections of the second thread are perpendicular to the outer sections of the first thread. As a result, a rectangular figure is obtained from the second thread, and the figure is symmetrical relative to the longitudinal and transverse axes. Then the PFOS is removed and the operation is completed.

The disadvantages of this method are:

- instability of the anatomical position of the IOL, since it simply lies on the threads, without additional fixation, as a result of which there is a high risk of decentration or dislocation of the IOL in the postoperative period;

- the need to use PFOS to fill the vitreous cavity, which increases the cost of the operation;

- a large volume of surgical intervention due to the need to use PFOC, associated with a high degree of surgical trauma to the eye;

- long duration of the operation;

- technical complexity of manipulations when forming four injections and four needle punctures with its passage inside the eye through the entire anterior diameter of the eyeball;

- the need for fourfold intraoperative traumatic compression with a needle on the scleral capsule of the eye during its insertion and removal when passing the needle through the entire diameter of the eyeball through the ciliary body;

- increased risk of excessive traction on the retina and ciliary body;

- the risk of mechanical damage to the pigment layer of the iris by the anterior surface of the IOL due to constant oscillatory movements of the IOL, since the IOL is not fixed.

The problem of the claimed invention is the creation of a low-traumatic method of repositioning and reliable fixation of the IOL-capsular bag complex dislocated in the vitreous cavity.

The technical result of the claimed invention is an increase in the effectiveness of surgical treatment during repositioning of the IOL-capsular bag complex dislocated in the vitreous cavity: a decrease in the volume of surgical intervention with minimization of mechanical trauma to the macular region and an increase in the reliability of fixation of the IOL-capsular bag complex dislocated in the vitreous cavity.

In order to achieve the claimed technical result in the method of repositioning the IOL-capsular bag complex dislocated in the vitreous cavity, including performing a vitrectomy, suturing the IOL, according to the invention, vitrectomy is performed with the introduction of a perfluororganic compound (PFOC) to the macular region, then tweezers are inserted into the vitreous cavity through the port and the IOL-capsular bag complex is held with it, while on one side of the IOL, the capsular bag is dissected with a vitreous cutter perpendicular to the longitudinal axis of the IOL in the direction of the center of the optical part of the IOL, then on the other side of the IOL, two openings are formed in the capsular bag along the edges of the middle part of the haptic elements with a vitreous cutter, as in Fig. 3, retreating from the edge of the haptic elements by 1.5 mm, then the IOL is intercepted with tweezers through an access in the capsular bag with fixation of the IOL by the optical part and the IOL-capsular bag complex is positioned behind the iris in such a way as to visualize one of the haptic elements and the first formed opening in the capsular bag, after which a needle with a suture thread is inserted translimbally in the projection of the haptic element, the needle is brought to the iris, and at a distance of 2 mm from the pupillary edge and 1.5 mm from the edge of the haptic element, the first puncture of the iris is performed from the outside to the inside, then the thread with the needle is passed through the formed opening in the capsular bag, then under the haptic element and on its other side, a puncture is performed from the inside to the outside in the capsular bag, and at a distance of 1.5 mm from the edge and at a distance of 2 mm from the pupillary edge, the second puncture of the iris is performed and the needle is inserted translimbally, then a paracentesis is performed in the middle between the punctures of the iris in the cornea, where the ends of the threads are brought out, which are held together and pulled up, the ends of the threads are cut and melted using bipolar thermocoagulator with the formation of a single spherical formation - a flange, which is inserted through paracentesis into the anterior chamber, then the second haptic element is stitched to the iris in a similar manner, after which the PFOS is removed and the operation is completed.

The use of a small amount of PFOS contributes to: reducing the duration of the operation and reducing the risk of the presence of PFOS bubbles in the eye in the postoperative period.

Reliable fixation of the IOL to the optical part using tweezers through access in the capsular bag reduces the risk of mechanical damage to the iris during surgery and reduces the risk of repeated dislocation at the time of IOL suturing.

Forming additional holes in the capsular bag simplifies the process of suturing the fibrous capsular bag.

The method allows to restore the architecture of the eye by preserving the capsular bag.

The technique of flange connection of the thread allows stable fixation of the IOL-capsular bag complex, precise dosing of the loop length, eliminates deformation of the iris, preserves the diaphragm function and round shape of the pupil.

The invention is illustrated by drawings.

Fig. 1 - Method of repositioning the IOL-capsular bag complex,

dislocated in the vitreous cavity, suturing of the complex.

Fig. 2 shows the same thing, forming a flange.

Fig. 3 shows the same thing, the IOL-capsular bag complex sewn to the iris.

The method is carried out as follows.

Subtotal vitrectomy is performed using 25G technology. Three standard transscleral ports are installed. Vitrectomy is performed with temporary administration of 1.5-2 ml of perfluoroorganic compound (PFOC) to the macular area. Through The branches of the tweezers are inserted into the vitreous cavity through the port and the IOL-capsular bag complex is held in place by them to prevent movement along the vitreous cavity. Using a vitreotome on one side of the IOL 1, an access 3 is formed in the capsular bag 2, cutting the capsular bag 2 perpendicular to the longitudinal axis 4 of the IOL 1 in the direction of the center of the optic part, then using a vitreotome on the other side of the IOL 1, two openings 5, 6 are formed along the edges of the middle part of the haptic elements 7, 8, 1.5 mm away from the edge of the haptic elements. Then, using tweezers, the IOL 1 is intercepted through the access in the capsular bag 2, fixing the complex with the branches of the tweezers by the optic part. Then the IOL 1 is placed behind the iris 9 and the complex is shifted so as to visualize one of the haptic elements 7 and the formed first opening 5 in the capsular bag 2. In the projection of the haptic element, a translimbal injection of a needle with a monofilament thread 10 polypropylene 9-0 is performed. Next, the needle is brought to the iris 9, and at a distance of 2.0 mm from the pupillary edge and 1.5 mm from the edge of the haptic element, the first puncture 11 of the iris 9 is made from the outside to the inside, the thread 10 with the needle is passed through the first opening 5 in the capsular bag 2, then under the haptic element 7, and on its other side from the inside to the outside, a puncture 12 is made in the capsular bag 2 and a second puncture 13 of the iris 9 is made at a distance of 1.5 mm from the edge of the haptic element and at a distance of 2.0 mm from the pupillary edge. The total length of the tie is 2.5-3.5 mm. The needle is also punctured translimbally. Then, in the middle between the punctures of the iris 9 in the cornea, a paracentesis 14 is performed, where the ends of the thread 10 are successively brought out using a micro hook and ligature tweezers, which are held together by means of the first ligature tweezers, the threads are tensioned, and the second ligature tweezers are used to intercept the threads at the paracentesis, so that the length of the threads from the iris to the ligature tweezers is equal to the length of the initial tie (2.5-3.5 mm). Moreover, the tips of the tweezers should be directed perpendicular to the limbus in order to hold the threads as close to each other as possible. Then the threads above the ligature tweezers are cut so that the ends are about 5 mm long. Then, using a bipolar thermocoagulator, the threads are melted to the ligature tweezers, forming a single spherical formation – flange 15. The tips of the tweezers protect the cornea from thermal effects. Then, using a spatula, flange 15 is inserted into the anterior chamber. The loop should not tighten the iris, the visible part of the loop above the iris should be equal in length to the part of the loop behind the iris, without sagging or tightening the latter. The second haptic element 8 is sutured in a similar manner. Then the PFOS is removed and the operation is completed.

This method allows for stable fixation of the IOL-capsular bag complex dislocated in the vitreous cavity, achieving a stable anatomical and functional result, reducing the time of surgery with minimization of surgical trauma to the eye, thereby reducing the risk of postoperative complications, preventing the need for repeated surgical interventions, and eliminating the need for IOL replacement during surgery.

Example 1. Patient D., 85 years old. On admission: complaints of a sharp decrease in vision in the right eye after a fall. Anamnesis: Phacoemulsification of cataract with implantation of the AcrySof Natural IOL in the right eye in 2010. Vitrectomy with air-gas mixture tamponade for a through-and-through macular hole in the right eye in 2015.

At the time of contact:

Visometry: OD 0.01 sph +11.0 = 0.55 cyl n/c

Refractometry: OD sph +11.0 cyl +0.5 Ax 105

IOP (Pi) OD = 11 mm Hg.

Ophthalmostatus of the right eye:

The eye is calm. The cornea is unremarkable. The anterior chamber is deep, the aqueous humor of the anterior chamber is transparent. The pupil is of regular shape, the pupil's reaction to light is weakened, the iris is subatrophic, pseudoexfoliation along the pupillary margin. The IOL is not visualized in the projection of the pupil. With reverse ophthalmoscopy, a dislocated mobile IOL is visualized in the lower sections in the capsular bag. Fundus: the optic disc is pale pink, the contours are clear, the profile of the macular region is smoothed, the edges of the macular hole are closed, the periphery is unremarkable.

The diagnosis was: Dislocation of the IOL-capsular bag complex into the vitreous cavity, avitria, operated macular rupture of the right eye.

A 25G endovitreal intervention was performed, with repositioning of the IOL-capsular bag complex using the claimed method.

After surgery: Visual acuity OD sph -1.0 cyl -1.0 Ax 60 = 0.25. The eye is moderately irritated. Slight edema and hyperemia of the conjunctiva. The cornea is transparent. The position of the IOL in the lumen of the pupil is correct, the IOL is sutured by 2 arches to the iris, the sutures are consistent. Avitria. The retina is adjacent in all quadrants. IOP 10 mm Hg.

Examination after 1 month: the position of the lens is stable, visual acuity OD 0.2 sph -1.0 = 0.5 cyl n/c IOP (Pi) OD = 15 mmHg.

Example 2. Patient P., 65 years old. On admission: complaints of a sharp decrease in vision in the left eye after blunt eye trauma. Anamnesis: Phacoemulsification of cataract with implantation of the Hanita IOL in the left eye in 2012.

At the time of contact:

Visometry: OS 0.04 sph +10.0 = 0.8 cyl n/c

Refractometry: OS sph +10.0 cyl +0.75 Ax 65

IOP (Pi) OS = 12 mm Hg.

Ophthalmostatus of the left eye:

The eye is calm. The cornea is unremarkable. The anterior chamber is of medium depth, the aqueous humor of the anterior chamber is transparent. The pupil is of regular shape, the pupil's reaction to light is weakened, the iris is subatrophic, the pigment border of the iris is atrophied, pseudoexfoliation along the pupillary margin. In the projection of the pupil, the IOL is not visualized, with reverse ophthalmoscopy in the lower sections, a dislocated IOL is visualized in the capsular bag. Fundus: the optic disc is pale pink, the contours are clear, the macular area is unremarkable, the periphery is unremarkable.

Diagnosis: Condition after contusion, dislocation of the IOL-capsular bag complex into the vitreous cavity of the left eye.

A surgical intervention was performed with repositioning of the IOL-capsular bag complex using the claimed method.

After surgery: Visual acuity OS 0.6 sph -0.75 cyl -0.5 Ax 75 = 0.8. The eye is moderately irritated. Slight edema and hyperemia of the conjunctiva. The cornea is transparent. The position of the IOL in the lumen of the pupil is correct, the IOL is sutured by 2 arches to the iris, the sutures are consistent. Avitria. The retina is adjacent in all quadrants. IOP 9 mm Hg.

Examination after 1 month: the lens position is stable, visual acuity OS 0.75 sph -0.5 cyl -0.5 Ax 75 = 0.9. IOP (Pi) OS = 11 mmHg.

Claims (1)

A method for repositioning the IOL-capsular bag complex dislocated in the vitreous cavity, including performing a vitrectomy, suturing the IOL, characterized in that vitrectomy is performed with the introduction of a perfluororganic compound (PFOC) into the macular area, then tweezers are inserted into the vitreous cavity through a port and the IOL-capsular bag complex is held with them, while on one side of the IOL, the capsular bag is dissected with a vitreous cutter perpendicular to the longitudinal axis of the IOL in the direction of the center of the optic part of the IOL, then on the other side of the IOL, two openings are formed in the capsular bag with a vitreous cutter along the edges of the middle part of the haptic elements, as in Fig. 3, stepping back from the edge of the haptic elements by 1.5 mm, then the IOL is intercepted with tweezers through an access in the capsular bag with fixation of the IOL by the optic part and the IOL-capsular bag complex is positioned behind the iris shell in such a way as to visualize one of the haptic elements and the first formed opening in the capsular bag, after which a needle with a suture thread is inserted translimbally in the projection of the haptic element, the needle is brought to the iris, and at a distance of 2 mm from the pupillary edge and 1.5 mm from the edge of the haptic element, the first puncture of the iris is performed from the outside to the inside, then the thread with the needle is passed through the formed opening in the capsular bag, then under the haptic element, and on its other side, a puncture is performed from the inside to the outside in the capsular bag, and at a distance of 1.5 mm from the edge of the haptic element and 2 mm from the pupillary edge, the second puncture of the iris is performed and the needle is inserted translimbally, then a paracentesis is performed in the middle between the punctures of the iris in the cornea, where the ends of the threads are brought out, which, holding together, are pulled up, the ends of the threads are cut and melted using bipolar thermocoagulator with the formation of a single spherical formation - a flange, which is inserted through paracentesis into the anterior chamber, then the second haptic element is stitched to the iris in a similar manner, after which the PFOS is removed and the operation is completed.