RU2277399C2 - Method for fixing transplant in performing perforating keratoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves marking transplant and recipient cornea in circumferential and radial direction after preliminary fixation. Continuous suture is placed in correspondence to the marking. Needle is pierced in- and outwards along radial marks when intersecting the circumferential marks 1 mm far from transplant edge. Needle is pierced in- and outwards 1 mm far from surgical wound boundary when having solid retained recipient cornea rim. The retained rim being not strong, it takes place 2-3 mm far from surgical wound boundary.

EFFECT: enhanced effectiveness of treatment; accelerated operation; uniform and reliable transplant fixation.

2 dwg

Description

The invention relates to medicine, namely to ophthalmic surgery, and is associated with the technical implementation of end-to-end keratoplasty.

A known method of fixation of the graft with end-to-end keratoplasty, in which the graft is pre-fixed with a continuous "delta" suture with three fixation points through 120, after which a continuous suture is applied (1).

The disadvantage of this method is the difficulty of preliminary fixation of the graft, while the main fixation of it by a continuous suture is performed without any special techniques, i.e. on the "eye", which does not allow to ensure the correct suturing and firm fixation of the graft.

There is also known a method of fixation of the graft with through keratoplasty about the thorn, in which the graft is fixed with 4 preliminary interrupted sutures, and then a continuous suture is applied with the stitch length on the transplant 0.7-0.8 mm and the stitch length on the recipient's cornea - 1, 4-1.6 mm (2).

The disadvantage of this method is that it does not take into account the diversity of the corneal pathology, in which through keratoplasty is performed. It is performed not only for cataracts, but also for primary (keratoconus, nodular, ethmoid, Fuchs dystrophy, etc.) and secondary (secondary endothelial-epithelial) corneal dystrophies, as well as keratitis, including purulent, severe corneal burns, in which corneal strength suffers greatly. In addition, in the known method, it remains unclear the calculation of the length of the stitches on the graft and the remaining rim of the cornea of the recipient, there are no techniques that allow you to evenly distribute the stitches among themselves. All these deficiencies can lead to postoperative complications such as the eruption of individual loops of a continuous suture, depressurization and emptying of the anterior chamber of the eye, the formation of a wide border scar ring, impaired graft sphericity and the formation of irregular astigmatism.

The aim of the invention is to reduce the time of the operation, ensuring uniform and durable fixation of the graft with end-to-end keratoplasty performed for various pathologies of the cornea, the exclusion of postoperative complications.

This goal is achieved by the fact that after preliminary fixation of the graft to the recipient’s cornea, annular and radial marking of the graft and the cornea of the recipient is performed, a continuous suture, injection and puncture of the needle are made along the radial marks at the intersection with the ring marks, 1 mm from the edge of the graft and in 1 mm or 2-3 mm from the edge of the surgical wound, depending on the strength of the remaining rim of the cornea of the recipient.

The method is illustrated in graphic material.

Figure 1 shows the fixation of the graft with a continuous suture for through keratoplasty due to corneal pathology, where the strength of the remaining rim of the cornea of the recipient does not suffer, for example, a thorn, corneal dystrophy, including keratoconus.

Figure 2 shows the fixation of the graft with a continuous suture for through keratoplasty due to corneal pathology, where the strength of the remaining rim of the cornea of the recipient, for example, purulent keratitis, thermal or chemical burn of the cornea, suffers greatly.

The method is as follows.

After through trepanation of the cornea of the recipient and removal of the pathologically changed portion of it in the form of a disk, a donor corneal transplant is placed in the trepanation hole and fixed with several provisional nodal sutures. With a scribor moistened with a 1% brilliant green solution on the working surface, radial 1 and ring-shaped 2 marks are applied to the surface of the graft and the remaining rim of the recipient's cornea. A continuous seam (3) is imposed along the radial marks, and the needle is punctured and punctured at the intersection with the ring-shaped ones.

With end-to-end keratoplasty for corneal pathology, where the remaining rim is strong enough (thorn, corneal dystrophy, including keratoconus), the needle and thread are punctured and punctured using radial marks 1 at their intersection with ring-shaped 2, 1 mm from the graft edge and into 1 mm from the edge of the remaining rim of the cornea of the recipient.

With through keratoplasty for corneal pathology, where the strength of the remaining rim of the cornea of the recipient is significantly reduced (purulent keratitis, burns of the cornea), the needle and thread are punctured by radial marks 1 at their intersection with ring-shaped 2, 1 mm from the edge of the graft and 2-3 mm from the edge of the remaining rim of the cornea, capturing the most durable sections of the recipient's tissues.

After applying a continuous seam around the entire perimeter, its loops are evenly pulled (for the convenience of the surgeon, as a rule, up to 12 hours), the ends of the thread are tied and the knot is immersed deep into the surgical wound. Preliminary nodal sutures in the first version of the graft fixation, where the remaining rim of the cornea of the recipient is strong, is removed; in the second variant of graft fixation, where the tissues of the remaining rim of the cornea are fragile, leave them for 10-14 days, after which they are also removed.

The proposed method, in comparison with the known one, takes into account the diversity of the corneal pathology, in which through keratoplasty is performed, it provides uniform and strong fixation of the graft, preserving its sphericity, simplifies the technique of applying a continuous suture, thereby reducing the time of surgery, preventing postoperative complications (eruption of continuous suture loops and emptying anterior chamber, the formation of anterior synechia and a rough annular border scar, corneal astigmatism).

A similar method was operated on for 19 patients with thorn, 5 with nodular and ethmoid dystrophy of the cornea, 8 with keratoconus, 12 with secondary endothelial-epithelial dystrophy of the cornea, 23 with purulent keratitis, 7 with severe stromal herpetic keratitis, 3 with melting cornea due to her burn.

Example 1. Patient K., 53 years old, was operated on for subtotal post-inflammatory left eye sore throat. The right eye is healthy. Visual acuity of the right eye was equal to 1.0, the left - light perception with the correct projection. Objectively: the left eye is calm, the cornea is cloudy almost throughout its length with a moderate number of superficial and deep vessels, in the upper half there is an almost transparent part of the cornea in the form of a crescent moon 2 mm wide ranging from XI hours to I hour, through which the pupil was hardly visible and cloudy lens. Reflex from the fundus was not determined. Intraocular pressure is normal.

After intravenous premedication and local anesthesia with a 2% novocaine solution, a turbid cornea was pierced 8 mm in diameter through the cornea, an extracapsular removal of the turbid crystalline lens was made through the cornea, and a posterior chamber intraocular lens (ZKL) was implanted, and a donor transplanted transplantation hole 8 was placed. , 25 mm and is fixed with 4 knotted provisional sutures. A scribe dipped on the working surface with a 1% solution of brilliant green radial and ring-shaped marks on the surface of the graft and the remaining rim of the cornea of the recipient. A continuous suture of 10/00 was imposed along the radial marks at the intersection with the ring-shaped, and the needle with the thread was injected 1 mm from the edge of the graft, and the puncture was 1 mm from the edge of the remaining rim of the recipient's cornea. The stitch loops were pulled up evenly without tension, where the ends of the thread were tied and the knot was immersed in the surgical wound. Provisional stitches removed. A 20% solution of sodium sulfacyl sodium was instilled into the conjunctival sac, 0.5 ml of dexamethasone and 50 tons of penicillin were introduced under the conjunctiva. An aseptic blindfold is applied to the eye. The postoperative period proceeded with moderate inflammatory phenomena from the side of the eye, which were stopped by anti-inflammatory therapy. The graft grafted transparently, retaining its sphericity, the stitch loops were evenly distributed without tension, not a single loop was cut. The anterior chamber is deeper than the middle, the pupil is round, the ZKL position is correct, behind it is a dense posterior lens capsule, floating opacities in the vitreous. Pathologies in the fundus have not been identified. Visual acuity at discharge was 0.4 n / a. Six months later, the continuous suture was removed, visual acuity increased to 0.6 n / a. Autorefractometric and keratographic phenomena of astigmatism were not detected.

Example 2. Patient S. 35 years old about keratoconus IV Art. of both eyes in turn, with an interval of 6 months, was performed on each eye through keratoplasty with a diameter of 8 mm The graft was fixed with a continuous suture according to the method described above, after applying radial and annular marks to the graft. The needle with the thread was injected 1 mm from the edge of the graft and punctured 1 mm from the edge of the remaining rim of the cornea of the recipient, whose strength was normal. The postoperative period in both eyes proceeded smoothly, eruption of suture loops was not observed, transplants in each eye were transplanted transparently, retaining their sphericity. With a follow-up period of 2 years, the visual acuity of the right eye is 0.3 M 1.5 D = 0.8; visual acuity of the left eye is 0.5 M 0.75D = 1.0. Keratographically, the phenomena of irregular astigmatism were not detected.

Example 3. Patient S., 42 years old, due to a purulent ulcer of the cornea of the left eye, a therapeutic pass-through keratoplasty with a diameter of 7 mm was performed. The graft was fixed in the same way as in the previous examples, after applying provisional nodal sutures and applying radial and annular marks. The needle with the thread was injected 1 mm from the edge of the graft and punctured 2-3 mm from the edge of the remaining rim of the cornea of the recipient, which turned out to be insufficiently strong due to inflammatory infiltration. Provisional sutures at the end of the operation were left in place. In the postoperative period continued antibacterial and anti-inflammatory therapy. Within 3 weeks, the eye calmed down, the position of the stitch loops was correct, not a single loop was cut, provisional stitches were removed on day 10. The graft has survived almost transparently, the anterior chamber is of medium depth, the pupil is moderately dilated, irregular in shape due to posterior synechiae, the lens is partially cloudy, and the fundus is behind the fog. Visual acuity = 0.3 n / k. After 5 months, a continuous suture was removed, visual acuity decreased to 0.2 n / a due to increased opacification of the lens. Autorefractometric and keratographic phenomena of irregular astigmatism were not detected.

INFORMATION SOURCES

1. Copyright certificate No. 1678363, M. Cl. A 61 9/00, 1991

2. Copyright certificate No. 1731213, M. Kl. A 61 9/00, 1992

Claims (1)

A method for fixing a corneal graft with through keratoplasty by preliminary fixing the graft and applying a continuous suture, characterized in that after the preliminary fixation of the graft to the recipient’s cornea, annular and radial marking of the graft and the cornea of the recipient is performed, a continuous suture is applied, and the needle is punctured and punctured at the intersection with annular marks, 1 mm from the edge of the graft and 1 mm or 2-3 mm from the edge of the surgical wound, depending on other awns remaining rim recipient cornea.

Images