Corneal reinnervation method

Abstract

FIELD: ophthalmology.SUBSTANCE: incision is made in the skin of the upper eyelid along the palpebral fold, and the fibers of the orbicularis muscle in the medial half of the incision are bluntly separated until the branch of the supratrochlear nerve is visualized. Then, the orbicularis muscle is separated along the branch of the supratrochlear nerve to the anterior edge of the upper eyelid, and a subconjunctival tunnel is formed using blunt technique from the superior conjunctival fornix to the limbus. The branch of the supratrochlear nerve is sutured with 7 / 0 absorbable thread at the anterior edge of the upper eyelid and cut off below the suture. Next, the cut nerve is passed through the formed subconjunctival tunnel and fixed with a nodal suture at the limbus; the orbicularis muscle and the incision in the skin of the upper eyelid are sutured with continuous non-absorbable 6 / 0 sutures.EFFECT: achievement of stable corneal epithelialization and improvement of its sensitivity with minimal duration and trauma of the operation.1 cl, 1 ex

Description

[0001] The invention relates to medicine, namely to ophthalmology, and can be used to treat a number of patients with neurotrophic keratitis.

[0002] Neurotrophic keratitis (NK) is a rare degenerative corneal disease caused by disruption of its innervation due to various etiologies and leading to persistent, treatment-resistant epithelial and stromal defects, including corneal perforation. It occurs in 1.6–11.0 cases per 10,000 people.

[0003] Previously, it was believed that the occurrence of NK was caused only by a disruption of corneal innervation as a result of damage to the nuclei of the trigeminal nerve, the central trunk, or the trunk of the first branch of the trigeminal nerve. Currently, a number of pathological processes affecting the ciliary nerves are attributed to the causes of NK development (Dua HS, Saida DG, Messmer EM, Rolando M., Benitez-Del-Castillo MG, Hossain PN, et al. Neurotrophic keratopathy. Progr Ret Eye Res. 2018;66: 107-131. Versura P, Giannaccare G, Pellegrini M, Sebastiani S, Campos EC Neurotrophic keratitis: current challenges and future prospects. Eye Brain. 2018;10:37-45). Peripheral causes of NK may include local mechanical injuries, thermal and chemical burns, keratorefractive surgeries, prolonged wearing of contact lenses, herpetic keratitis, etc.

[0004] The goal of treatment of neurotrophic keratitis is to restore or increase the sensitivity of the cornea, as well as to achieve its complete epithelialization.

[0005] The modern algorithm for the treatment of NK involves the use of both conservative (tear substitutes, keratoprotective, metabolic therapy, recombinant human nerve growth factor preparations) and surgical methods that have a symptomatic (blepharorrhea, biological covering of the cornea with a tenoconjunctival flap, amnion, etc.) and pathogenetic focus (corneal reinnervation).

[0006] A method for corneal reinnervation is known (Russian Federation Patent for Invention No. 2803270). A coronal incision is made, dissecting the skin and subcutaneous fat along a designated line in the temporoparietal regions from one auricle to the other down to the periosteum. The temporoparietal flap is separated from the periosteum, reaching the superficial plates of the temporal fascia, and is reflected to the anterior side. The periosteum is incised, retreating 8-11 cm from the superior orbital margins. Next, the periosteum is peeled back on both sides from the frontal bone to the superior orbital margins and the bony pyramid of the nose and reflected along with the temporoparietal flap to the anterior side. On the healthy side, the exit sites of the supraorbital and / or supratrochlear nerves from the orbit are visualized and released. On the healthy side, 4-8 branches of the supraorbital and / or supratrochlear nerves are isolated from the temporoparietal flap.Next, the distal end of one of the branches of the supraorbital or supratrochlear nerves on the healthy side is sutured to the majority of the supraorbital nerve on the affected side at its end-to-side exit from the orbit. Next, on the affected side, a tunnel is formed in the reflected temporoparietal flap from the superior conjunctival fornix of the upper eyelid to the periosteum of the superomedial orbital rim. The branches of the supraorbital and / or supratrochlear nerves of the healthy side are passed from the periosteum of the superomedial orbital rim to the superior conjunctival fornix of the upper eyelid on the affected side. The temporoparietal flap is put back in place. On the affected side, tunnels are formed around the corneal limbus to pass the branches of the supraorbital and / or supratrochlear nerves of the healthy side. 3-5 perilimbal incisions are made in the conjunctiva and Tenon's capsule around the corneal limbus, 2-4 mm away from it. Next, tunnels are formed in the episcleral space, connecting the incisions together.Next, corneoscleral tunnels are created in the sclera around the corneal limbus at the sites of the conjunctival and Tenon's capsule incisions. Three to five 2-4 mm wide scleral incisions are made parallel to the corneal limbus, through a layer 1 / 3 to 1 / 2 of its thickness. The scleral and corneal tissues are dissected from the limbus toward the center of the cornea by 1-2 mm. Next, from the previously formed tunnel in the temporoparietal flap, terminating in the superior conjunctival fornix of the upper eyelid on the affected side, a tunnel is formed under Tenon's capsule and conjunctiva, using blunt and sharp dissection, to the nearest perilimbal conjunctival incision. The branches of the supraorbital and / or supratrochlear nerves are carried out in the formed tunnels in the temporoparietal flap and in the episcleral space, divided into fascicles and fixed in the formed corneoscleral tunnels.

[0007] The disadvantages of this method are the high trauma of the operation, the need for a wide surgical approach, general anesthesia, collaboration with maxillofacial surgeons, and the risk of impaired sensitivity in the surgical area.

[0008] A method for corneal reinnervation is known (Russian Federation Patent for Invention No. 2823733). The supraorbital nerve is isolated, a donor nerve is sutured to it, and the latter nerve is brought to the cornea on the affected side and sutured. An autologous sural nerve graft no more than 30 cm long is used as the donor nerve. Subbrow incisions are made on the healthy and paralyzed sides of the face, and the supraorbital nerve is isolated on the healthy side. The subbrow incisions are connected, forming a subcutaneous tunnel, and the sural nerve is brought through the subcutaneous tunnel. Next, an epineural window is created in the supraorbital nerve on the healthy side, and an end-to-side epineural suture is made between the sural nerve and the supraorbital nerve.The conjunctiva and Tenon's membrane are then separated circumferentially around the limbus. The end of the sural nerve is inserted under the conjunctiva through a lateral incision and divided into four fascicles, which are inserted into the formed corneoscleral canals at the 3, 6, 9, and 12 o'clock positions. The edges of the corneoscleral canals are secured with interrupted sutures. In this particular case, the sural nerve is sutured to the supraorbital nerve with interrupted sutures using 9 / 0 nylon. The edges of the corneoscleral canals are secured with 8 / 0 silk. The conjunctiva is sutured over the sural nerve with separate interrupted sutures using 8 / 0 silk.

[0009] The disadvantages of this method are the high trauma of the operation, the need for a wide surgical approach, and the collection of an autoneuronal graft, which complicates and prolongs the rehabilitation process for patients.

[0010] The use of these methods is possible in cases of cerebral palsy resulting from damage to the trigeminal nerve nuclei, central trunk, or trunk of the first branch of the trigeminal nerve. Treatment of cerebral palsy caused by local, peripheral causes using such traumatic methods is inappropriate.

[0011] The applicant is not aware of the closest analogue of the proposed invention.

[0012] The objective of the proposed invention is to create a method for reinnervation of the cornea in NC caused by peripheral damage to the ciliary nerves of various etiologies, which makes it possible to restore or improve the sensitivity of the cornea, to achieve its epithelialization with minimal surgical trauma and duration of the operation.

[0013] The technical result is a reliable improvement in corneal sensitivity according to esthesiometry data, achieving complete corneal epithelialization.

[0014] The method is as follows:

[0015] An upper eyelid skin incision is made along the palpebral fold. Blunt dissection is used to separate the orbicularis oculi muscle fibers in the medial half of the incision until the branch of the supratrochlear nerve is visualized. The orbicularis oculi muscle is separated along the branch of the supratrochlear nerve to the anterior edge of the upper eyelid. A subconjunctival tunnel is created using blunt dissection from the superior conjunctival fornix to the limbus. The branch of the supratrochlear nerve is sutured with 7 / 0 absorbable suture at the anterior edge of the upper eyelid and divided below the suture line. The severed nerve is passed through the formed subconjunctival tunnel and secured with an interrupted suture at the limbus. The orbicularis oculi muscle and the upper eyelid skin incision are closed with continuous 6 / 0 non-absorbable sutures.

[0016] The method allows for achieving stable corneal epithelialization and improving its sensitivity with minimal duration and trauma of the operation.

[0017] The method is illustrated by the following clinical example:

[0018] Patient K., 48 years old, diagnosis: OD Neurotrophic keratitis. Consequences of radiation treatment (brachytherapy) for conjunctival lymphoma. Pseudophakia.

[0019] Complaints: decreased vision, constant redness of the eyeball.

[0020] History: According to the patient's medical records and reports, conjunctival lymphoma was diagnosed in 2013 at the OD. Brachytherapy was performed with stabilization of the process. After treatment, severe dry eye syndrome was noted, and since 2014, frequent exacerbations of keratitis have been observed, which are difficult to treat with conservative methods. In 2021, the patient underwent fluoroscopy and intraocular lens (IOL) at the OD. She regularly uses tear substitutes and keratoprotective agents.

[0021] Upon admission:

[0022] Visual acuity:

[0023] OD 0.05 n / k

[0024] OS 0.850 sph 1.50 = 1.00

[0025] Objective: OD The eyelids are in the correct position, with complete closure. There is pronounced pericorneal injection. The cornea is deepithelialized, stains with fluorescein over the entire surface, and is rough. The cornea is diffusely opacified and edematous in all layers, and is vascularized. The anterior chamber is of medium depth and the aqueous humor is transparent. The pupil is round, 3 mm. The posterior chamber IOL is centered. Details of the fundus are visible behind the veil.

[0026] According to corneal esthesiology data, corneal sensitivity in the right eye was absent in three sectors (central, inferior, and nasal), and significantly decreased in two sectors (superior and temporal) (0 and 1 on the Cochet & Bonnet esthesiometer scale, respectively). Corneal sensitivity in the left eye was 5 on the Cochet & Bonnet esthesiometer scale in all sectors.

[0027] The sensitivity of the skin of the eyelids and forehead is preserved, symmetrical on both sides.

[0028] The patient underwent corneal reinnervation using the proposed method.

[0029] The patient had no complaints the day after surgery. Minor swelling and subconjunctival hemorrhage were noted. The skin sutures were intact, and the wound edges were adjusted.

[0030] Postoperative examination and skin suture removal were performed on the seventh day. The patient has no complaints. Objectively: there is no tissue swelling in the surgical area, and the subconjunctival hemorrhage is resolving.

[0031] At the follow-up examination 6 months after the operation, visual acuity was:

[0032] OD 0.1 n / k

[0033] OS 0.850 sph 1.50 = 1.00

[0034] Objective: OD The eyelids are in the correct position, with complete closure. The eye is calm. The cornea is diffusely opacified and vascularized. Corneal epithelialization is complete (no areas of fluorescein staining). The anterior chamber is of medium depth and the aqueous humor is clear. The pupil is round, 3 mm. The posterior chamber IOL is centered. Details of the fundus are visible behind the veil.

[0035] According to esthesiometry data, sensitivity was restored in all five sectors of the cornea of ​​the right eye (in the superior and temporal - 5, in the central, inferior and nasal - 4 on the Cochet & Bonnet esthesiometer scale).

Claims

A method of corneal reinnervation characterized in that an incision is made in the skin of the upper eyelid along the palpebral fold, the fibers of the orbicularis oculi muscle are bluntly separated in the medial half of the incision until the branch of the supratrochlear nerve is visualized, then the orbicularis oculi muscle is separated along the branch of the supratrochlear nerve to the anterior edge of the upper eyelid, a subconjunctival tunnel is formed bluntly from the superior conjunctival fornix to the limbus, the branch of the supratrochlear nerve is sutured with 7 / 0 absorbable thread at the anterior edge of the upper eyelid and cut off below the suture, then the cut nerve is passed along the formed subconjunctival tunnel and fixed with an interrupted suture at the limbus, the orbicularis oculi muscle and the incision of the skin of the upper eyelid are sutured with continuous 6 / 0 non-absorbable sutures.