Method of surgical prevention of intraocular lens dislocation in case of weakness of crystalline lens ligaments

Abstract

FIELD: medicine; ophthalmology.SUBSTANCE: after performing phacoemulsification, linear incisions are made in the anterior capsule from the edge of the capsulorhexis to the vault of the capsular bag in opposite meridians, forming a 1 mm wide flap. Next, the flap is removed and pinched in the previously formed coloboma of the iris. In a particular case, if necessary, the flap is additionally pinched in the paracentesis, after which the paracentesis is sutured.EFFECT: reliable fixation, a sufficient level of tension and anatomically correct position of the IOL, and preventing its rotation, ensuring the absence of refractive shift.2 cl, 10 dwg, 2 ex

Description

[0001] The invention relates to medicine, in particular to ophthalmology, and can be used for surgical prevention of intraocular lens (IOL) dislocation in case of weakness of the ligamentous apparatus of the lens.

[0002] Weakness of the lens ligament apparatus is one of the leading factors for intraoperative complications. Causes may include trauma, congenital connective tissue malformations, and pseudoexfoliation syndrome.

[0003] There are a large number of classifications of changes in the physiological position of the lens, one of which is the classification of lens dislocations according to N.P. Pashtaev in 1986.It is customary to divide subluxations into: the first degree, where slight displacements of the lens along the optical axis without lateral displacement, iridodonesis, change in the depth of the anterior chamber are allowed, which indicates a partial rupture of the fibers of the zonular ligament; the second degree - lateral displacement of the lens towards the preserved fibers of the zonular ligament, with a pronounced rupture of the ligament, the equator of the lens is visible on a narrow pupil; uneven deepening of the anterior chamber; pronounced phacoiridodonesis; light rays pass through the peripheral parts of the lens, while a myopic shift of refraction is observed; the third degree - the zonular ligament is ruptured more than half of its circumference, the edge of the lens is displaced beyond the optical axis of the eye, can deviate significantly into the vitreous body; aphakic refraction is observed. [Faizrakhmanov R.R., Shishkin M.M., Konovalova K.I., Karpov G.O., Transscleral IOL fixation: from complex to simple. Ufa: Bashk. Encycl, 2020; 12-15 s].

[0004] Currently, phacoemulsification techniques with subsequent fixation of the intraocular lens to the sclera or iris are being improved, and there are also special devices that help surgeons preserve the capsular bag during cataract surgery. Such devices as the intracapsular ring (Morcher GmbH, Stuttgart, Germany; Ophtec, Netherlands) and the Ahmed intracapsular segment (Morcher, FCI Ophthalmics, MarshfieldHills, MA) are known. [Chang D., Phaco-chop and other modern cataract surgery techniques. Options for complicated cataract surgery strategies: a manual / trans. D. Jaber; ed. B.E. Malyugin. - Moscow: Oftalmologiya, 2019.317-328].

[0005] In addition to standard intracapsular rings (ICR), the Cionni capsular ring is used in practice, which ensures reliable fixation of the capsular bag to the sclera, as well as its stability [Cionni RJ, Osher RH, Marques MV etal. Modified capsular tension ring for patients with congenital loss of zonular support / / J. Cataract Refract. Surg. - 2003. - Vol. 29, No. 9. - P. 1668-1673.].

[0006] However, such a device is difficult to implant at the stage before the lens is removed; it is possible that the cortical fibers at the equator of the lens may be pinched during the aspiration stage.

[0007] A technique for temporary or permanent fixation of IOL is known, namely the Ahmed segment, which is a part of the capsular ring with an opening. [Iqbal Ike K. Ahmed; Sylvia H. Chen; Christoph Kranemann; David T. Wong. (2005). Surgical Repositioning of Dislocated Capsular Tension Rings., 112(10), 0-1733.doi:10.1016 / j.ophtha.2005.05.006]. Due to the smaller size of the device, it is easier to manipulate.

[0008] The disadvantages of the implant are its limited use in cases of extensive defects of the ligamentous apparatus, due to which there is no complete equatorial support of the sac, and there is also a need to insert a standard intracapsular ring for more stable fixation.

[0009] In turn, Malyugin B.E. proposed a device that is an alternative to the Zionni ring in the form of an open ring, one end of which is spirally bent inward for more convenient fixation with a suture to the sclera. [Malyugin, B.E., Golovin, A.V., Uzunyan, D.G., Isaev, M.A. Features of the technique and results of microinvasive phacoemulsification using an original model of an intracapsular ring in patients with extensive defects of the ligamentous apparatus of the lens / / Ophthalmosurgery. - 2011. - No. 3]. This makes it possible to insert the ring using an injector through a 2-millimeter incision.

[0010] The disadvantage is the displacement of the IOL-VKK-capsular bag complex towards the site of scleral fixation, as well as hemorrhagic complications.

[0011] Be that as it may, the scope of the interventions described above is often excessive, associated with an increase in the operating time, the risk of intraoperative complications, increased anesthetic support, and requires special skills and experience of the surgeon, therefore, the development of an improved method for the prevention of this pathology remains a pressing task at the present time.

[0012] The aim of the invention is to develop a method for preventing postoperative dislocation of the IOL in case of weakness of the ligamentous apparatus of the lens.

[0013] The technical result of the invention consists in stable fixation of the anterior capsule flap, eliminating the risk of its displacement with the development of IOL dislocation in the postoperative period.

[0014] The specified technical result is achieved in a method for surgical prevention of intraocular lens dislocation in case of weakness of the ligamentous apparatus of the lens, in which, after performing phacoemulsification, linear incisions or one incision of the anterior capsule are made from the edge of the capsulorhexis to the vault of the capsular bag in opposite meridians with the formation of flaps or one flap 1 mm wide, brought out into the previously formed coloboma of the iris, and, if necessary, further into paracentesis, the paracentesis is sutured.

[0015] Thus, the essence of the method is to form an anterior capsule flap, perform longitudinal iridotomy and fix the flap in the coloboma of the iris or paracentesis, and close the paracentesis with a 10-0 nylon interrupted suture.

[0016] The method is explained by Figs. 1-6, which show a diagram of the operation, where: In Fig. 1 - Position of the capsular bag of the lens after phacoemulsification; In Fig. 2 - Insertion of collet scissors and linear opening of the anterior capsule; In Fig. 3 - Scissors are inserted through the main paracentesis to form the iris coloboma; In Fig. 4 - Using a pusher, collet tweezers or viscoexpression, the formed flap is brought out into the coloboma area, and, if necessary, further into the paracentesis; In Fig. 5 - the flap is inserted into the iris coloboma, In Fig. 6 - The paracentesis is sutured with 10-0 nylon. Designations in the diagram: 1 - anterior capsule flap, 2 - iris coloboma.

[0017] And also Fig. 7-10, which show optical coherence tomography (OCT) images, where:

[0018] In Fig. 7 - Patient 3. The lens capsule flap is fixed in the coloboma of the iris;

[0019] Fig. 8 - Patient 3. Optical coherence tomography (OCT) of the anterior segment. The fibrous flap of the anterior capsule is fixed to the edge of the coloboma;

[0020] In Fig. 9 - Patient G. The anterior capsule flap of the lens is brought out through the iris coloboma in paracentesis;

[0021] In Fig. 10 - Patient G. Gonioscopy of the area of ​​fixation of the capsule flap to paracentesis.

[0022] The method is carried out, for example, as follows.

[0023] After phacoemulsification, linear incisions are made in the anterior capsule from the edge of the capsulorhexis to the fornix of the capsular bag in opposite meridians, creating flaps approximately 1 mm wide. Next, a hilar coloboma of the iris is formed with scissors through the previously performed paracentesis. The capsular flap is advanced into the formed coloboma using a pliers, pusher, or viscoexpression. In cases of severe laxity of the lens ligament apparatus, the flap is pinched in the paracentesis, which is sutured with a single interrupted 10-0 nylon suture. Postoperatively, fibrosis of the capsular flap-iris complex occurs, reducing the risk of IOL dislocation.

[0024] The method is supported by the following clinical examples.

[0025] Example 1. Patient 3, born in 1958, was admitted to the eye microsurgery department with a diagnosis of OS immature cataract, grade 1 lens subluxation. OU pseudoexfoliation syndrome (Fig. 7). At the time of admission, the patient complained of decreased vision and a fog in front of the left eye. Visual acuity at the time of admission: VisOS=0.02 uncorrected.

[0026] Phacoemulsification with IOL implantation in combination with iridocapsular sutureless fixation was performed using the stated method (the anterior capsule flap was brought out into the coloboma of the iris, Fig. 8).

[0027] The result has been stable for three months; pseudophacodonesis was absent, and no capsular flap displacement or IOL dislocation was detected. Visual acuity at discharge: Vis OS=0.9, uncorrected.

[0028] 2. Patient G., born in 1948, was admitted to the eye microsurgery department with a diagnosis of OD incipient cataract. Grade 2 lens subluxation and OU pseudoexfoliation syndrome. He complained of a gradual decrease in vision and blurred vision. Visual acuity at admission: VisOD=0.1 sph - 2.0 D=0.3. The patient underwent sutureless iridocapsular fixation using the stated method with a capsular flap delivered via paracentesis, Fig. 9.

[0029] For three months, the result was stable: there was no pseudophacodonesis, no displacement of the capsular flap or IOL dislocation was detected, visual acuity at the time of discharge: VisOD=0.2 sph - 3.0 D=0.9 (Fig. 10).

[0030] The proposed method was applied to four patients. Technical results were achieved in all cases.

[0031] Thus, the method ensures reliable fixation, sufficient tension level and anatomically correct position of the IOL, and also prevents its rotation.

[0032] The method improves the effectiveness of surgical treatment by reducing the likelihood of IOL displacement, enables intracapsular implantation of standard IOL models; ensures the absence of refractive shift; low probability of intraoperative complications; does not require the use of additional devices or implants; does not require enhanced anesthesia.

Claims

1. A method for surgical prevention of intraocular lens dislocation in case of weakness of the ligamentous apparatus of the lens, characterized by the fact that after performing phacoemulsification, linear incisions are made in the anterior capsule from the edge of the capsulorhexis to the vault of the capsular bag in opposite meridians with the formation of a 1 mm wide flap, after which the flap is removed and pinched in the previously formed coloboma of the iris.

2. The method according to paragraph 1, characterized in that, if necessary, the flap is additionally pinched in the paracentesis, after which the paracentesis is sutured.

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