RU2836086C1 - Method for removal of fibrosis of capsular bag and retroprosthetic membrane in patients with aphakia and pseudophakia after keratoprosthesis by means of three-port vitrectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions refers to medicine, namely to ophthalmology. According to the first version, fibrosis of a capsular bag (FCB) and a retroprosthetic membrane (RPM) are removed by means of a three-port vitrectomy. Before surgical intervention in patients with aphakia, ultrasonic biomicroscopy and optical coherence tomography are performed, after which three ports 25G are installed at 4 mm from a projection of limb in upper-external, upper-internal and lower-external quadrants. Further, an infusion system, a light guide and a vitreous tube are introduced through the ports, the FCB is removed on the maximum area and the RPM is simultaneously excised behind the optical cylinder with the help of the vitreotome, followed by an anterior vitrectomy, followed by a fundus oculi examination. According to the second version, ultrasound biomicroscopy and optical coherence tomography are performed in the patients with pseudophakia before the surgical intervention, after which three 25G ports are installed at 4 mm from the projection of the limb in the upper-external, upper-internal and lower-external quadrants. Further, an infusion system, a light guide and a vitreous tube are introduced through the ports; the vitreous tube is inserted into the projection of the angle of the anterior chamber and the RPM is excised. Further, the vitreous tube is placed behind the capsular bag and the FCB is removed. Then an anterior vitrectomy is performed, after which the eye ground is examined. In the special case, if there is no pathology of the retina or vitreous body, the operation is completed by removing the ports and applying, if necessary, scleroconjunctival sutures. In a particular case, if there is a pathology of the retina or vitreous body, then vitrectomy and necessary manipulations on the retina are performed; the operation is completed by removing the ports and applying, if necessary, scleroconjunctival sutures.

EFFECT: group of inventions makes it possible to reduce the risk of complications and accelerate the visual rehabilitation of the patient, to remove the RPM and FCB over a long distance without damaging the optical cylinder of the keratoprosthesis and the optical part of the IOL, as well as if necessary, perform endovitrial intervention through the opening of the optical cylinder of the keratoprosthesis.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used to remove retroprosthetic membrane (RPM) and capsular bag fibrosis (CSF) in eyes with pseudophakia or aphakia in the delayed period after the second stage of keratoprosthetics.

Keratoprosthetics is the only effective way to restore visual functions in patients with burn or terminal dystrophic leukomas. Formation of RPM is one of the most common complications that significantly reduces the optical effect of keratoprosthetics.

RPM is formed as a result of an aseptic inflammatory process and is the eye's reaction to surgical trauma with the introduction of a foreign body. RPM is a connective tissue, the main cellular element of which is fibroblasts, whose proliferation leads to a steady increase in the membrane thickness. As it forms, RPM gradually grows along the posterior surface of the cornea and the optical cylinder of the keratoprosthesis, which leads to a significant decrease in visual acuity.

Another factor that reduces visual acuity in patients after the second stage of keratoprosthetics is FKM, the formation of which in patients with pseudophakia or aphakia can occur spontaneously in the late postoperative period, or due to the presence of remnants of cortical masses in the equatorial zone after cataract extraction (CE). As a rule, this is how FKM is formed in patients after the second stage of keratoprosthetics, where CE is required, through the opening of the optical cylinder, 3 mm in diameter.

In case of corneal-prosthetic complex transplantation, accompanied by trepanation of a leukoma with a diameter of more than 8 mm, with one-stage EC, the risk of residual lens masses is minimal, due to the sufficient visualization area. However, the risk of FCM occurrence in this case remains high due to the presence of topographic and anatomical changes in the eye structures associated with a large number of optical-reconstructive interventions and aggressive impact of damaging factors in the anamnesis (thermal, chemical or mechanical).

The closest analogue is the method of RPM and FKM discission (A safe Nd: YAG retroprosthetic membrane removal technique for keratoprosthesis. Cornea. 2010 Oct; 29 (10): 1169-72. doi: 10.1097/ICO.0b013e3181cda001).

The method consists of applying 15-20 YAG laser pulses with a power of no more than 1.2 MJ after the Abraham lens is installed, like “opening a tin can”, with the YAG laser pulses applied clockwise or counterclockwise. The diameter of the discision corresponds to the diameter of the opening of the optical cylinder of the keratoprosthesis.

The disadvantages of this method include: high risk of damage to the optical cylinder and the optical part of the IOL as a result of the action of a high-power laser pulse due to tight contact between the prosthesis optics and the capsular bag or IOL, or due to errors in focusing the laser pulse; risk of developing traction retinal detachment; increased intraocular pressure due to the deposition of fragments of destroyed RPM in the area of the anterior chamber angle; bleeding from the RPM, which in the delayed period leads to fibrin deposition and recurrence of RPM; high risk of damage to the vitreous body due to its immediate proximity to the RPM and the capsular bag; occurrence and chronization of the uveal process.

The main difficulty and disadvantages of this method include the impossibility of discission of RPM and FCM in the late stages of their development due to severe fibrosis and the limitation of the area of laser exposure due to the small diameter of the optical cylinder of the keratoprosthesis.

The objective of the invention is to create a method for discission of RPM and FCM in eyes with pseudophakia or aphakia, used in the delayed period after the second stage of keratoprosthetics using three-port vitrectomy.

The technical result of the method is a reduction in the risk of complications and acceleration of visual rehabilitation of patients, which is achieved by the ability of the vitreotome to remove RPM and FCM over a large area without damaging the optical cylinder of the keratoprosthesis and the optical part of the IOL, and also, if necessary, to perform endovitreal intervention through the opening of the optical cylinder of the keratoprosthesis.

The method is carried out as follows.

The first step before surgery is to perform ultrasound biomicroscopy (UBM) and optical coherence tomography (OCT) to assess the anterior chamber, its angle, determine the location of the capsular bag, the presence of an IOL and its position, as well as the intracorneal position of the keratoprosthesis.

The second stage involves installing three 25G ports 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants. The limbus projection is determined intraoperatively using diaphanoscopy. Then, an infusion system, a light guide and a vitreotome are inserted through the ports, and if the eye is aphakic, then the FCM is removed over the maximum area and the RPM is simultaneously excised behind the optic cylinder using a vitreotome, after which anterior vitrectomy is performed; and in the case of pseudophakia, the vitreotome is inserted into the projection of the anterior chamber angle and the RPM is excised, then the vitreotome is inserted behind the capsular bag, the FCM is removed and anterior vitrectomy is performed.

The next stage involves examining the fundus and, if necessary (pronounced destruction of the vitreous body, retinal pathology), performing an extended vitrectomy and the necessary manipulations on the retina, after which the operation is completed by removing the ports and applying, if necessary, scleroconjunctival sutures.

The method allows for the removal of dense RPM or FKM, in which YAG laser discission is ineffective due to the severity of the fibrous process, close contact of the eye structures with the optical part of the keratoprosthesis, and insufficient visualization area.

The method allows to significantly reduce the risk of damage to the optical cylinder of the keratoprosthesis and the optical part of the IOL, to remove FCM and RPM over the maximum area, which significantly reduces the risk of relapse.

The method allows for access for further manipulations on the fundus after removal of the RPM or FCM, for revision and treatment of concomitant vitreoretinal pathology.

The method is illustrated by the following examples.

Example 1

Patient A., 65 years old. Diagnosis: OU Vascular corneal leukoma. Result of a chemical burn. OD Subatrophy of the eyeball. OS Condition after the second stage of keratoprosthetics. Aphakia. Retroprosthetic membrane.

It is known from the anamnesis that 3.5 years ago there was an acetic acid burn at home. At the place of residence, penetrating keratoplasty with EK was performed on the left eye, without IOL implantation. Due to graft clouding and severe limbal insufficiency syndrome, a decision was made to perform keratoprosthetics of the left eye. In 2023, the first stage of keratoprosthetics was performed, as a result of which a keratoprosthesis support plate was implanted into the thickness of the vascular leukoma. Nine months ago, the second stage of keratoprosthetics was performed at the Scientific and Technical Complex of the Moscow City Hospital - an optical cylinder with aphakic correction was screwed in. The maximum corrected visual acuity at discharge was 0.6.

Biomicroscopy shows a vascularized corneal leukoma in both eyes, left eye: the keratoprosthesis optical cylinder is in the correct, central position, without signs of intraocular fluid filtration. The retroprosthetic membrane is visualized behind the optical cylinder. Deeper media are not ophthalmoscopically visible.

Visual acuity: OD - Visus = 1/∞ proectia lucis incerta; OS - 1/∞ proectia lucis certa. Intraocular pressure (IOP) is normal by palpation in the left eye.

On the OCT of the anterior segment of the left eye, the keratoprosthesis occupies the correct central position. A 134-μm-thick RPM is visualized behind the posterior part of the leukoma.

According to the electrophysiological study (EPS), the presence of gross changes in the right eye and minor changes in the left eye were revealed.

According to B-scan data: left eye membranes are adjacent, destruction of the vitreous body; right eye total retinal detachment, destruction of the vitreous body.

According to the OCT data of the left eye, the supporting plate of the keratoprosthesis is visualized in the thickness of the vascular leukoma, a narrow anterior chamber and a pronounced fibrous retroprosthetic membrane, more than 0.2 mm thick.

Considering the greater potential of visual functions and the presence of dense RPM, a decision was made to perform RPM discission according to the proposed method.

Three 25G ports were installed 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants. Then, an infusion system, a light guide and a vitreotome were inserted through the ports, after which anterior vitrectomy was performed, the capsular bag was removed, and the RPM was dissected with a vitreotome in the projection of the keratoprosthesis optical cylinder opening. The next step was an examination of the fundus: the optic nerve disc (OND) was pale pink, the borders were clear, the macular area (MA) was without visible pathology. The operation was completed by removing the ports without applying conjunctival sutures.

The early postoperative period was uneventful. Moderate edema and hyperemia were noted in the first days. Visual acuity of the left eye was 0.4 with correction. IOP was normal by palpation.

Upon discharge from the hospital on the 7th day: the eye is calm, visual acuity: 0.4 with correction sph -1.0 D = 0.6. IOP is normal by palpation.

When examining the patient 3 months later, the eye is calm, the sutures are sound. Visual acuity: 0.4 with correction sph -1.0 = 0.7. IOP is normal by palpation.

After 6 months, the eye is calm upon examination. According to OCT, the keratoprosthesis occupies the correct central position. Visual acuity: 0.4 with correction sph -1.0 D = 0.7. IOP is normal by palpation.

Example 2

Patient B., 35 years old. Diagnosis: OS Vascular corneal leukoma. Outcome of a chemical burn. Condition after the second stage of keratoprosthetics. Aphakia. Fibrosis of the capsular bag. OD Anophthalmos.

It is known from the anamnesis that 2 years ago he received an industrial burn with lime on both eyes. At the place of residence, the right eye was enucleated immediately after the burn. On the left eye, the first and second stages of keratoprosthetics were performed at the MNTK MG. Visual acuity at discharge was 0.3 with correction sph -3.0 = 0.6

Biomicroscopy of the left eye shows a vascularized corneal leukoma, a centrally located optical cylinder, and FCM. Deeper media are not ophthalmoscoped.

Visual acuity: OS - 1/∞ proectia lucis certa. IOP is normal by palpation.

In OCT of the anterior segment of the left eye, the keratoprosthesis occupies the correct central position, and the FCM is visualized in the posterior chamber.

According to the UBM data of the left eye, elements of the keratoprosthesis are visualized in the thickness of the vascular leukoma, a narrow anterior chamber and FCM.

According to the EFI data, minor changes in the left eye were revealed.

According to B-scan data: the membranes of the left eye are adjacent, destruction of the vitreous body.

Considering the greater potential of visual functions and the presence of dense FCM, a decision was made to perform FCM discission according to the proposed method.

Three 25G ports were installed 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants. Then, an infusion system, a light guide and a vitreotome were inserted through the ports, after which the FCM was removed and anterior vitrectomy was performed. The next step was an examination of the fundus: the optic disc was pale pink, the borders were clear, the medullary tissue was without visible pathology. The operation was completed by removing the ports without applying conjunctival sutures.

The early postoperative period was uneventful. Moderate edema and hyperemia were noted in the first days. Visual acuity of the left eye was 0.1 without correction. IOP was normal by palpation.

Upon discharge from the hospital on the 7th day: the eye is calm, the sutures are sound. Visual acuity: 0.1 with correction sph -2.0 D cyl -1.75 D ax 80=0.3. IOP is normal by palpation.

When examining the patient 3 months later, the eye is calm. Visual acuity: 0.3 with correction sph -2.0 D=0.6. IOP is normal by palpation.

After 6 months, the eye is calm upon examination. According to OCT data, the keratoprosthesis occupies the correct central position at a depth of 2/3 of the stromal layer. Visual acuity: 0.3 with correction sph -2.0 D=0.6. IOP is normal by palpation.

Example 3

Patient P., 46 years old. Diagnosis: OS Vascular corneal leukoma. Outcome of a chemical burn. Condition after the second stage of keratoprosthetics. RPM. Pseudophakia. FKM. OD Anophthalmos.

It is known from the anamnesis that 4 years ago he received an industrial burn with lime on both eyes. At his place of residence, the right eye was enucleated immediately after the burn, and EK with IOL implantation was performed on the left eye. Vision in the left eye was rapidly declining, post-burn corneal opacity of chemical etiology was diagnosed at the place of residence. He contacted the Scientific and Technical Complex of the Moscow City Hospital, where the first stage of keratoprosthetics was performed two years ago, and then 6 months later the second stage of keratoprosthetics. Visual acuity at discharge was 0.05.

Biomicroscopy of the left eye shows a vascularized corneal leukoma, a centrally located optical cylinder, an IOL in the capsular bag in the correct position, and a FCM, mostly of the posterior capsule. The deeper media are not ophthalmoscoped.

Visual acuity: OS - 1/∞ proectia lucis certa. IOP is normal by palpation.

In OCT of the anterior segment of the left eye, the keratoprosthesis occupies the correct central position; in the posterior chamber, the IOL is visualized in the capsular bag in the correct position; FCM, the thickness of the posterior capsule is 98 μm.

According to the UBM data of the left eye, the details of the keratoprosthesis are visualized in the thickness of the vascular leukoma, a narrow anterior chamber and FCM. The IOL occupies the correct central position.

According to the EFI data, minor changes in the left eye were revealed.

According to the B-scan of the left eye: the membranes are adjacent, the vitreous body is destroyed.

Considering the greater potential of visual functions and the presence of a dense posterior lens capsule and signs of FCM, a decision was made to perform FCM discission according to the proposed method.

Three 25G ports were installed 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants. Then, an infusion system, a light guide and a vitreotome were inserted through the ports, after which the RPM and FCM were removed, anterior vitrectomy was performed. The next step was an examination of the fundus: the optic disc was pale pink, the borders were clear, ERM. Then, ERM peeling was performed, after which the operation was completed by removing the ports without applying conjunctival sutures.

The early postoperative period was uneventful. Moderate edema and hyperemia were noted in the first days. Visual acuity of the left eye was 0.1 without correction. IOP was normal by palpation.

Upon discharge from hospital on the 7th day: the eye is calm. Visual acuity: 0.1. IOP is normal by palpation.

When examining the patient 3 months later, the eye is calm. Visual acuity: 0.4 with correction sph -1.5 = 0.9. IOP is normal by palpation.

After 6 months, the eye is calm upon examination. According to OCT, the keratoprosthesis occupies the correct central position. Visual acuity: 0.4 with correction sph -1.5 = 0.9. IOP is normal by palpation.

The proposed method was used in 4 clinical cases. In each of them, it was possible to restore visual functions.

Claims (4)

1. A method for removing capsular bag fibrosis (CSF) and retroprosthetic membrane (RPM) using three-port vitrectomy, characterized in that in patients with aphakia, ultrasound biomicroscopy and optical coherence tomography are performed before surgery, after which three 25G ports are installed 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants; then an infusion system, a light guide and a vitreous cutter are inserted through the ports, the CSF is removed over the maximum area and the RPM is simultaneously excised behind the optic cylinder using a vitreous cutter, after which anterior vitrectomy is performed, and then the fundus is examined. 2. A method for removing capsular bag fibrosis (CSF) and retroprosthetic membrane (RPM) using three-port vitrectomy, characterized in that ultrasound biomicroscopy and optical coherence tomography are performed in patients with pseudophakia before surgery, after which three 25G ports are installed 4 mm from the limbus projection in the upper-outer, upper-inner and lower-outer quadrants; then an infusion system, a light guide and a vitreous cutter are inserted through the ports, while the vitreous cutter is inserted into the projection of the anterior chamber angle and the RPM is excised, then the vitreous cutter is inserted behind the capsular bag and the CSF is removed, then an anterior vitrectomy is performed, after which the fundus is examined. 3. The method according to paragraph 1 or 2, characterized in that in the absence of pathology of the retina or vitreous body, the operation is completed by removing the ports and applying, if necessary, scleroconjunctival sutures. 4. The method according to paragraph 1 or 2, characterized in that in the presence of pathology of the retina or vitreous body, a vitrectomy and the necessary manipulations on the retina are performed, the operation is completed by removing the ports and applying, if necessary, scleroconjunctival sutures.