Way to treat congenital anomalies of the peters children
(57) Abstract:The invention relates to medicine, ophthalmology. Carry the dissection iridocorneal of cicatrices. The dissection is done with the help of the YAG laser at the site of fusion of the iris with a plot of congenital corneal opacities. Cut off the seam shift from the former fixation with blurred laser radiation and medical massage pupil. The method eliminates the dissection of the eyeball, prevents the recurrence of congenital growths. 3 C. p. F.-ly. The invention relates to pediatric ophthalmology and is intended to correct congenital anterior synechia eyes of children with Peters anomaly.The Peters anomaly is a rare congenital disease, Peters described in 1906 and manifested in the presence of congenital corneal opacity in combination with anterior synechia (Dymshits L. A. Fundamentals of ophthalmology childhood, L.: Medicine, 1970, S. 62).Congenital opacities located in the deep layers of the cornea, accompanied by the absence of the endothelium and descemetocele shell in turbidity and strong binding of the modified sections of the cornea with iris and/or the lens.The Genesis of the disease Niki from the cornea in the early stages of embryogenesis, impaired differentiation of mesenchymal cells in the endothelium of the cornea. This eye disease in children is often combined with abnormalities of the hands, feet, the wolf's jaws, the defects of the psyche and the other half of the children anomaly Peters accompanied by secondary glaucoma, leading to blindness.For treatment of this congenital disease in pediatric ophthalmology traditionally used surgical methods: reconstruction of the anterior chamber with surgical dissection of the front of the binding, if necessary in combination with antiglaucoma operations, extraction of congenital cataract, keratoplasty (Kovalevsky, I. E. Eye diseases. The Atlas., 1985, S. 142; Shields, M. C. Textbook of Glaucoma. 1992. P. 245 - 248).The closest analogue of the present invention is a surgical method of post-traumatic dissection of the front binding in the anterior chamber (as a stage of removal of traumatic cataract - Fedorov S. N., Egorova E. C. Surgical treatment of traumatic cataract with intraocular correction. M. : Medicine, 1985, C. 127), which is a microsurgical operation and includes the dissection of the eyeball the limbus corneal incision, dissection iridocorneal the binding of a surgical instrument is her camera the introduction of saline, sealing incision in the imposition of corneal sutures. The disadvantages of this method is the obligation of anesthesia, the need for dissection of the eyeball with the possibility of intraocular infection. Surgical incision of the cornea produced for access to congenital growths in the anterior chamber, is traumatic to the eye, often accompanied by the formation of post-operative binding of the iris with this scar, i.e., an operation aimed at eliminating the binding in the anterior chamber, itself often leads to the formation of new post-operative binding. The forecast recovery of vision and normal anatomic correlations in children's eye with this rare congenital disease so bad that many pediatric surgeons consider surgical treatment of this pathology is required under General anesthesia impractical, generally denying patients in the operation.At the same time is known for the ability to effectively use a YAG laser to cut the front of adhesions of different etiology (trauma, postinflammatory) in adult patients (Fankhauser F. The Q - switched laser: principles and clinical results. Trokel S. L. (ed). YAG laser ophthalmic Made. Appleton-Century - Crofts. - 1983. - P. 101 - 146; Stephanoderis fusion with Peters anomaly have some peculiarities. According to our observations, they are usually voluminous, thick (up to 3 mm), consist of powerful stromal tissue of the iris (not the connective tissue, as in post-traumatic pathology in adults) and are attached to the area of the cornea, generally devoid of endothelium and descemetocele shell from birth. These features do not allow to use the technique and energy parameters YAG laser front Cinematone used for post-traumatic anterior cicatrices in adults.Information about the use of YAG laser for the treatment of anterior cicatrices with Peters anomaly in children are not available.The technical result of the invention is the exception opening the eyeball; the risk of eye infection, damage to surrounding structures; prevention of recurrence of congenital growths and the formation of new post-operative binding.The technical result is achieved due to the use of laser irradiation in combination with medical massage pupil for elimination of congenital anterior cicatrices eyes of children with Peters anomaly, the offset section cut off the seam from the former fixing and holding the peripheral is E. congenital anterior synechia produce non-surgical way and impact directly on them YAG laser (single pulse from 2.0 to 8.9 mj for 1 - 2 session 10 - 100 pulses each). For more accurate focusing and safety be sure to use the contact trehserijnuju lens Goldman.2) Laser cut front binding in the anterior chamber of the produce in 1-1 .5 mm from descemetocele shell (as is done in post-traumatic pathology in order to avoid damage to the corneal endothelium), and directly at the site of adhesions of the iris to the cornea, with focus radiation directly at the site of fixation congenital adhesions of the iris to congenital corneal opacity. This is explained by the peculiarities of the structure of congenital anterior synechia with Peters anomaly. The essence of this congenital anomaly is incomplete splitting of the anterior chamber, neudelane iris from the cornea in the early stages of ontogenesis. So pathogenetically justified not dissection of adhesions at least the thickness of it (as in post-traumatic, postinflammatory pathology), and full cut-off iris tissue congenital adhesions from pathologically modified area of the cornea along the lines of embryonic "indigestion". With congenital absence of the endothelium and on the ri laser action.Accurate focusing and dosed individual selection power mode (pulse energy increases with each pulse, starting with 2 mj and short with long powerful binding - to 8.9 mj) avoids damage to the surrounding tissue (cornea, iris).3) the offset of the clipped seam from the former commit produce a defocused YAG laser radiation and active medical massage pupil (daily shift pupillary edge of the iris on the value of at least 2 to 3 mm). With the proposed method, entirely cut off from the corneal spike, consisting of a powerful tissue of the iris, it remains associated with the main tissue of the iris, and therefore the method of blurred radiation and medical massage pupil is easily displaced from the site of the former fixation and flattens, which is a guarantee of the absence of recurrence of ankylosis.4) insufficient divergence of the ends of the cut growths on the iris to deal an additional 1 to 3 coagulate the Argon laser in the 1 to 2 mm distal to the base of the seam (power pulse of 0.8 - 1.5 W, the exposure time of 0.1 s, focal spot diameter 200 μm) that provides the necessary additional offset the base of the seam.5) When the availability is Rideau 11 and 2 hours in 1 mm from the limbus (2 - 20 pulses at 2 - 6 mj).The proposed laser method does not require anesthesia at the contact of children (more than 60% of cases), while the previously used surgical way all children were necessarily carried out under General anesthesia.The method is as follows.Use, for example, laser installation "Visulas YAG Argon".1) For the main laser interference - YAG laser (yttrium-aluminium garnet activated by neodymium):
the wavelength 1064 nm, pulse energy of 2.0 - 8,9 mj, pulse duration 2 - 3 10-9c, the diameter of the focal spot 30 - 50 microns.2) For additional laser interference - Argon laser: wavelength 514,529 and 488 nm, power output of 0.8 - 1.5 W, pulse duration of 0.1 s, focal spot diameter of 200 microns.After two instillation solution dikaina of 0.5% on the eyes of a sick child contact impose trehserijnuju lens Goldman.stage 1. Beam interference YAG laser radiation is focused directly at the place of fixation of congenital iridocorneal seam to the site of the diseased cornea (from birth devoid of endothelium and descemetocele shell). From the edge of the seam, in naprawa from 2.0 to 8.9 mj) to get the effect of a full dissection of the adhesions. Usually congenital ankylosis of a length of 2-3 mm fully able to dissect 1-2 session 10 - 100 pulses each. Try to avoid leaving residues in the tissue of the iris to the posterior surface of the cornea.stage 2. Shifting the focus confirmation from the dissection of adhesions by 0.5 mm in the direction of the anterior chamber, one or two pulses blurred YAG laser radiation (2 to 3 mj), hydrodynamic shock moisture in the front of the camera to achieve displacement of the end cut off from the cornea of the seam to the side.stage 3. Active medical massage pupil. Pupil dilation is performed by instillation of a solution of mydriacyl 1% (3 times in 5 min). If the pupil is not enough, expanding the iris does not move from the place of the former commit more than 2 mm, then injected under the conjunctiva of 0.2 ml of 1% solution mezatona. The next day, forced by instillation of 1% solution of pilocarpine (up to 6 instillations per hour) to achieve the maximum constriction of the pupil. Such an active massage of the pupil (offset pupillary edge not less than 2-3 mm) are conducted daily for 7-10 days to prevent recurrence of the binding.stage 4. Insufficient divergence of the ends of the cut growths on the iris n,8 -1,5 W, the exposure time is 0.1 s, focal spot diameter 200 μm) that provides the necessary additional offset the base of the seam.stage 5. In the presence of secondary glaucoma produce simultaneously an additional 2 YAG laser peripheral iridotomy in Meridian 11 and 2 hours in 1 mm from the limbus (2 to 20 pulses 2-6 mj).Accurate focusing and dosed individual selection power mode on all laser stages (the pulse energy increases with each pulse, starting with 2 mj and short with long powerful binding to 8.9 mj) avoids damage to the surrounding tissue (cornea, iris).We offer laser method does not require anesthesia at the contact of children (over 60%), while the previously used surgical way all children were necessarily carried out under General anesthesia.Example: the Patient M 14 years old, visually impaired since childhood, which denied reconstructive surgical treatment in connection with a hopeless prognosis.Diagnosis at admission:
Congenital anomaly Peters both eyes, microphthalmos, microcornea 1 degree, amblyopia of obscure origin.Right eye: partial Central corneal opacity, meprednisone cataract.Left eye: partial paracentral corneal opacity, single iridocorneal fusion.Visual acuity: right eye: 0,001, not corrects, the left eye: 0,4+1,5 D= 0,4 -0,5.Intraocular pressure.Right eye: 29 - 30 mm RT. article without drops, 26 -28 mm RT. article with permanent instillation of a solution of artiola 0.25% and pilocarpine 1%-2 times a day,
Left eye: 20 - 21 mm RT.article without instillation.E tonography.Right eye: Ro-25,09; s - 0,12; F - 1,74; SW - 209.Left eye: Po-19,5;-0,20; F-1,91: kV-98.Ultrasound examination.Right eye: PHC: 23 mm Left eye: 21,2 mm Vitreous of both eyes acoustically transparent, retinal detachment is not defined.Keratometry
The diameter of the cornea: the right eye of 10.5 mm, the left eye 10 mmElectroretinogram both eyes: moderate pathological changes in the retina, more pronounced on the right.Gonioscopy. Right eye: anterior chamber angle narrow, is not all over, 2/3 of the circumference of more than half of the trabeculae covered with iris and base iridocorneal of cicatrices. Left eye: anterior chamber angle is open, srednechirchik, the area is quite dif is 3 mm in diameter (with the circle more intense clouding the edge of it and some enlightenment stroma in the center), fused with the fabric of the iris at the pupillary edge five powerful stromal adhesions (meridians 1,4,7,9,11 hours), with a thickness of 2 to 3 mm, the pupil diameter of 2 mm, rigiden, in the lumen guess the point turbidity (less than 1 mm) on the anterior lens capsule, 3/4 pupil clean, fuzzy reflex with fundus ophthalmoscopy impossible.Left eye: congenital paracentral turbidity with a diameter of 1.5 mm along the Meridian 9 hours, spliced with iris isolated single stromal synechia a thickness of 1 mm (9 hours), lens and vitreous body transparent, the fundus of the eye without pathology.Given the severity of concomitant congenital abnormalities of the right eye, later treatment, the age of the child, obscuration amblyopia is high, the prognosis for restoration of visual functions unfavorable, he was denied optical reconstructive surgical treatment. To save the eye as a body, in order to restore the normal anatomic relationships in the anterior chamber, the normalization of intraocular pressure and prevent further progressive increase in eye size, it is necessary dissection congenital almost circular iridocorneal of cicatrices. However tacos the tx2">So the child without anesthesia produced by the YAG laser front Cinematone. For 2 sessions with a break between 1 day YAG laser produced a complete dissection of the almost circular multiple powerful stromal iridocorneal of binding (1,4,7,9,11 hours). 1 session: pulse energy of 5.6 mj, the total energy of 630 mj, the number of pulses 92. 2 session: pulse energy of 8.9 mj, the total energy of 780 mj, the number of pulses 87. For more precise focus and sparing techniques were used contact transitella lens Goldman. Damage to the surrounding tissue is not marked.Result of treatment: conservative achieved, hypotensive, anatomic reconstructive effect. Completely cut all the front seam, restored front camera, almost fully revealed the anterior chamber angle, normalized intraocular pressure (19 - 20 mm RT.cent.), allowing 2 weeks to completely cancel instillation miotikov and beta-blockers. The release of the pupil from binding even increased visual acuity from 0.001 to 0.01; made it possible to examine the fundus of the eye (the optic disc pale pink, border, clear, shift vascular bundle, regional inflection vessels). The observation period of 6 months.
e year will be to address the question of possible partial keratoplasty in the right eye.On the left eye single congenital iridocorneal Union does not yet require intervention, because it does not cause displacement of the pupil, violations of hydrodynamics. The reason for incomplete view (0,5 correction) is a congenital partial clouding of the cornea and amblyopia of obscure origin.Thus, the proposed method combined YAG argon laser treatment in conjunction with medical massage pupil helps to eliminate congenital front seam with Peters anomaly in children without surgery, without opening the eyeball (i.e., without danger of infection of the eye), without the risk of damage to surrounding structures (cornea, iris, lens), can prevent the recurrence of congenital and postoperative cicatrices, restores normal anatomic correlation in the eye that often normalize intraocular pressure without surgery, in some children leads to improved visual acuity (due to the release of the pupil from growths and improve optical conditions) eyes that were considered impaired hopeless, in 60% of cases allows to avoid anesthesia. 1. Way to treat congenital anomalies of the Peters children, including dissection iridicom the plot congenital corneal opacity, then slip clipped fusion from the former fixation with blurred YAG laser radiation and medical massage pupil.2. The method according to p. 1, characterized in that medical massage pupil to carry out daily shift pupillary edge of the iris on the value of at least 2 to 3 mm.3. The method according to p. 1, characterized in that when there is insufficient divergence of the ends of the cut seam additionally on an iris put coagulants argon laser to the periphery from the base of the seam.4. The method according to p. 1, characterized in that in the presence of secondary glaucoma is conducted additionally peripheral YAG laser iridotomy.
SUBSTANCE: method involves introducing 0.1-0.3 ml of photosensitizing gel preliminarily activated with laser radiation, after having removed neovascular membrane. The photosensitizing gel is based on a viscoelastic of hyaluronic acid containing khlorin, selected from group containing photolon, radachlorine or photoditazine in the amount of 0.1-2% by mass. The photosensitizing gel is in vitro activated with laser radiation having wavelength of 661-666 nm during 3-10 min with total radiation dose being equal to 100-600 J/cm2. The gel is introduced immediately after being activated. To compress the retina, vitreous cavity is filled with perfluororganic compound or air to be further substituted with silicon oil. The operation is ended with placing sutures on sclerotomy and conjunctiva areas. Compounds like chealon, viscoate or hyatulon are used as viscoelastic based on hyaluronic acid. Perfluormetylcyclohexylperidin, perfluortributylamine or perfluorpolyester or like are used as the perfluororganic compound for filling vitreous cavity.
EFFECT: excluded recurrences of surgically removed neovascular membrane and development of proliferative retinopathy and retina detachment; retained vision function.
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