Method for astigmatism correction in patients with thin cornea

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly ophthalmology. Considering a degree of astigmatism and patient's age, a nomogram-based topography of corneal incisions is calculated, and a femtosecond laser is programmed that is followed by making corneal incisions referring to the programmed incision parameters with using the femtosecond laser. It is combined with increased the diameter of the corneal incisions by 0.25 mm, decreasing the incision depth by 10% of the corneal thickness in the gicen point, and decreasing the opening angle by 10░ as compared with the nomogram parameters presented in Table 1.

EFFECT: method provides reducing risk of postoperative complications and ensuring higher refraction effect of the surgery.

1 dwg, 1 tbl, 2 ex

 

The invention relates to medicine, in particular to ophthalmology, and can be used for the correction of myopic astigmatism in patients with initially thin corneal layer of the eye, when the elimination of this astigmatism other modern excimer laser means impossible.

There are various ways of treatment of myopia and myopic astigmatism by conducting various types of astigmatic front keratotomy: a longitudinal, tangential, radial and other (Fedorov, S., Durnev CENTURIES Surgical correction of complex myopic astigmatism method front keratotomy". - Ophthalm. journal, 1979, 4, s-213).

However, to resolve a known manner myopic astigmatism completely impossible.

There is a method of surgical correction of myopia and myopic astigmatism high degree, including the application of radial ceratotrichia cuts, in addition to the periphery of the cornea between the cuts cause thermocoagulation at the same angular distance from each other and from cuts of 1 mm from the limbus, and myopic astigmatism treated by applying an additional two thermocoagulation in Meridian, one on either side of the optical center and 0.5 mm from the main thermocoagulation (Patent RU 2160076, publ. 10.12.2000).

The disadvantages of this method are the I complexity, lack of effectiveness and the need for application to the cornea up to 8 radial incisions and 8 thermocoagulation.

There is a method of surgical correction of astigmatism, namely, that on the cornea causing ceratotrichia cuts, additionally between the cuts in the stroma of the cornea to form diametrically opposite blind tunnels at a depth equal to the depth of the incisions. The formation of tunnels produced in the zone of high Meridian. For the formation of tunnels in the middle of one of the cuts imposed tunnel knife and rasclaat corneal stroma in the transverse direction over the entire area between the two incisions. Also on the cornea causing tangential, or radial, or longitudinal cuts (Patent RU 2189804, publ. 27.09.2002).

The disadvantages of this method are the high complexity and the potential risk of adverse complications.

There are clinical situations in which it is practically impossible to carry out the desired optical or contact correction of vision due to severe irregularity the surface of the cornea, as well as to hold excimer laser refractive surgery due to insufficient thickness of the corneal stroma. In this situation, performing astigmatic keratotomy using the femtosecond laser may be the most effective and safe option for the correction.

The most immediate is to the claimed method - the prototype is a method of correction of induced astigmatism that occurs after penetrating keratoplasty and on the intact cornea, namely, that the astigmatic keratotomy performed with the help of femtosecond laser topographic parameters corneal incisions, calculated according to the nomogram developed on the basis of the results obtained when performing a manual ("knife") tangential astigmatic keratotomy (table 1). The calculation of the planned depth of the corneal astigmatic incisions after penetrating keratoplasty performed on 75% of the corneal thickness in this area, and calculation of depth in the intact cornea - 90% (Abbey A, Ide T, Kymionis GD, Yoo SH. Femtosecond laser-assisted astigmatic keratotomy in naturally occurring high astigmatism. Br J Ophthalmol. 2009; 93:1566-1569).

The main disadvantage of this method is the high risk of complications in the form of hypercorrection refraction and induced myopia, because the calculation is performed on the basis of nomograms designed to take into account the results obtained when performing mechanical tangential keratotomy, without regard to biomechanical alterations in the course of the incision of the cornea femtosecond laser and diamond blade.

An object of the invention is to reduce the risk of adverse complications and providing the possibility of the particular operation with a high refractive result.

The goal of the project is achieved by the proposed method lies in the following.

Depending on the size of existing astigmatism and age of the patient, make a calculation of topography causing astigmatic corneal incisions in the form of so-called "arches" on the basis of the nomogram calculation of corneal incisions in the intact cornea (table 1). Then make programming femtosecond laser, which controls all programmed settings corneal incisions with the help of computer programs and sterile disposable aspheric interface. The diameter application corneal incisions, depending on your astigmatism increase by 0.25 mm, the depth of the cuts reduced by 10%, and the angle corneal incisions in the form of "arches" (length of cut) reduce by 10░ in comparison with the characteristics shown in the nomogram presented in the table.

After that make the formation of corneal incisions using a femtosecond laser in accordance with programmed parameters sections. Then a patient under the microscope eyepieces excimer laser (or microscope) and spatula make disclosure of data sections, producing cavitation bubbles. Operation complete the instillation of antibiotic under the conjunctiva and impose aseptic surface is the land code of Ukraine.

Figure 1 shows the monitor femtosecond laser with programmable topographic parameters corneal incisions.

Determining significant difference between the proposed method in comparison with the prototype, is that the programmable parameters of topography causing astigmatic corneal incisions make changes, namely the diameter application corneal incisions increase by 0.25 mm, the depth of the cuts reduced by 10%, and the angle corneal incisions in the form of "arches" (length of cut) reduce by 10░, compared with the parameters used in the nomogram, which reduces the risk of postoperative complications and to improve the accuracy, predictability and safety of refractive surgery to eliminate corneal astigmatism on a thin cornea.

According to the nomogram diameter application corneal incisions on the cornea is 6.5-7,25 mm, standard cutting depth - 90% of the corneal thickness at a given point, and the angle is 60 to 90░, however, thin corneas risk of adverse complications in the form of Microperforation and hyperoffice is very large, therefore, in accordance with the experimentally determined parameters, the depth of programmable corneal incision reduced to 80% of the corneal thickness in this area, the opening angle of the corneal is Azizov reduced by 10░, and the diameter application corneal incisions increase by 0.25 mm from the recommended in the nomogram presented in table 1.

These changes in the calculations of surgery in patients with astigmatism on a thin cornea may reduce risk of intraoperative complications, postoperative induced disorders of refraction (myopia, astigmatism reverse of form) through corneal incisions with a maximum precision of a given diameter, depth, length and shape.

The proposed method meets the criterion of "novelty", as it is unknown at the current level of science and technology. He also meets the criterion of "inventive step"as it is not obvious from the level of science and technology.

The invention is illustrated by the following examples of specific performance.

Example 1

The Century patient, 36 years of age (East. disease No. 289887), asked for advice in the complex NP "eye microsurgery" complaining of low vision in the left eye. From history revealed that the poor vision in the left eye of a patient with 15 years. Spectacle correction is poorly tolerated and has not been used by the patient.

A full eye examination. Diagnosis:

Complex myopic astigmatism of the left eye. Refractive amblyopia is the average degree. Anisometropia. Emmetropia in the right eye. Diagnostically the data before the operation:

Visual acuity: right eye 1.0

left eye with 0.2 Corr. Sph - 0.5 cyl - 4.5 ax 176=0.6

Refractometry: right eye Sph - 0.5 cyl - 0.5 ax 171

left eye Sph - 0.5 cyl - 5.25 ax 176

Keratometry: right eye Wermer. 45.25 ax 84 Gormer. 44.75 ax 174

left eye Wermer. 47.0 ax 88 Gormer. 43.75 ax 175

Pachymetry: left eye 437 mcm

Taking into account each the data of the cornea and existing astigmatism, the patient completed the correction of astigmatism by the claimed method.

The formation of the corneal incisions were done under local anesthesia with the help of femtosecond laser company "Technolas 520F, which uses the radiation of a single-mode optical quantum generator neodymium-glass diode-pumped with a wavelength of 1053 nm, a pulse frequency of 40 kHz, a pulse duration of 500-700 FS. After installation of the vacuum ring made docking (docking console laser through the aspherical interface with the patient's cornea. For easier visualization and centration of the cornea in the process of joining the cornea moistened 2-3 ml of saline. Then made the alignment of the cornea by means of a microscope, where the right integrated screen, giving information about what action you want to perform a surgeon to create the optimum docking. After docking and achieve the necessary compression have closed the vacuum to which ICA, preventing the movement of the interface on the patient's cornea

The calculation and the operation is performed according to the claimed method. Estimates astigmatic incisions: the diameter of the holding sections of 7.25 mm, depth of incisions - 520 microns (80% of the corneal thickness 3.5 mm from the center), the angle (length of cut) - 70░. The location of the top of the corneal incision is 90░, the lower the corneal incision is 270░. Then produced the formation of corneal incisions in accordance with the programmed topographic parameters incisions using a FS laser. Then the patient was transferred under the microscope eyepieces excimer laser and a spatula made the disclosure incisions, producing cavitation bubbles. The operation was completed by instillation of antibiotic under the conjunctiva and applying aseptic bandage.

Visual acuity of the left eye the next day without correction of 0.5.

At 1 month after surgery, the visual acuity of 1.0. Refraction: the field - 0.75, cylinder - 0.75, axis 0 degrees. Complaints patient does not have.

Example 2

Patient S., aged 39 (East. disease No. 292689), went to Novosibirsk branch of IRTC "eye microsurgery" complaining of poor vision. Eyeglass correction tolerated by the patient bad, rigid gas-permeable lenses also cause hypersensitivity cannot use them. A comprehensive evaluation, and the left diagnosis: Complex myopic astigmatism in both eyes. Data before the operation:

Visual acuity: right eye with 0.2 Corr. Sph - 0,5 Cyl - 3,75 ax 15=0.7

left eye with 0.15 Corr. Sph - 0,5 cyl - 2.0 ax 180=0.7

Refractometry: right eye Sph - 0,75 cyl - 3.75 ax 15

left eye Sph - 0,25 cyl - 3.75 ax 161

Keratometry: right eye Wermer. 46.25 ax 101 Gormer. 43.25 ax 11

left eye Wermer. 46.50 ax 73 Gormer. 43.5 ax 163

Pachymetry: right eye 480 microns

left eye 468 Ám

The patient completed the correction of the astigmatism of the proposed method.

The calculation and the operation is performed according to the claimed method. The diameter of performing corneal incisions - 7,25 mm (right eye), 7.5 mm (left eye), the depth of the cuts - 520 microns (80% of the corneal thickness in the 3.5-3.75 mm from the center), the opening angle is 60░. The location of the top astigmatic incisions right eye is 110░, the lower corneal incision - 285░. The location of the top of the corneal incision of the left eye is 75░, the lower corneal incision - 245░.

The formation of the corneal incisions were done under local anesthesia using FS laser, which controls all programmed parameters using the management computer programs and sterile disposable aspheric interface. After installation of the vacuum ring made docking console laser through the aspherical interface with the patient's cornea, with prior instillation of 2-3 ml fiziologicheskogo the solution. Produced concentrations, the vacuum ring is closed. Made the formation of corneal incisions. Under the visual control of the microscope spatula made the disclosure corneal incisions and produced cavitation bubbles. Poured antibiotic under the conjunctiva and put a sterile dressing.

Visual acuity on the next day after the operation:

right eye 0.2 without Corr., left eye 0.3 without Corr

Visual acuity through 7 days after the operation:

the right eye with 0.7 Corr. sph - 0,5=1.0

left eye 0.6 Corr. sph - 0,5=0,8

After 1 month the result is stable. Complaints the patient no.

The use of the proposed method will reduce the risk of operative complications and improve clinical accuracy, safety and efficiency of this method in comparison with the tangential keratotomy, which was performed with a diamond scalpel.

Astigmatism (diopters)*The diameter of the corneal incisions (mm)The depth of the corneal incisions (%)The angle (in deg.)
1.5 to 2.57.259060
2.75 to 3.757.090 70
4.0 to 5.07.09080
5.25 to 6.256.759080
6.5 to 7.56.759090
7.75 to 8.756.59090
*When the patient's age up to 30 years increases the effect of 0.05 diopters; after 30 years reduces the effect of 0.05 diopters;
after 50 years of reduced effect on 0,025 diopters.

The way to correct astigmatism in patients with thin cornea, including calculation of topographic parameters holding corneal incisions in accordance with the nomogram calculation of corneal incisions and applied to the cornea ceratotrichia incisions using a femtosecond laser, characterized in that the diameter application corneal incisions increase by 0.25 mm, the depth of the cuts reduced by 10%, and the aperture angle sections reduced by 10░ in comparison with the characteristics shown in the nomogram presented in table 1.



 

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4 cl

FIELD: medicine.

SUBSTANCE: method involves creating tunnel between sclera and Tenon's capsule in intraocular neoplasm projection. Intraocular neoplasm localization and size is adjusted by applying transscleral diaphanoscopic examination method. 0.1-0.3 ml of photosensitizing gel based on viscoelastic of hyaluronic acid, selected from group containing chealon, viscoate or hyatulon, is transsclerally introduced into intraocular neoplasm structure using special purpose needle in dosed manner. The photosensitizing gel contains khlorin, selected from group containing photolon, radachlorine or photoditazine in the amount of 0.1-1% by mass. Flexible polymer magnetolaser implant is extrasclerally introduced into the built tunnel in intraocular neoplasm projection zone under visual control using guidance beam. The implant has permanent ring-shaped magnet axially magnetized and producing permanent magnetic field of 3-4 mTesla units intensity, in the center of which a short focus scattering lens of laser radiator is fixed. The lens is connected to light guide in soft flexible envelope. The implant is arranged with its north pole turned towards the intraocular neoplasm so that implant laser radiator lens is extrasclerally arranged in intraocular neoplasm projection zone. The implant light guide is sutured to sclera 5-6 mm far from the limb with single interrupted suture. The implant is covered with conjunctiva and relaxation sutures are placed over it. Light guide outlet is attached to temple using any known method. Visual control of intraocular neoplasm cells is carried out by applying fluorescence and fluorescent diagnosis methods. After saturating the intraocular neoplasm with the photosensitizer to maximum saturation level, transscleral intraocular neoplasm laser radiation treatment is carried out via laser light guide and implant lens using divergent laser radiation at wavelength of 661-666 nm. The treatment course being over, the flexible polymer magnetolaser implant is removed and sutures are placed on conjunctiva. Permanent magnet of the flexible polymer magnetolaser implant is manufactured from samarium-cobalt, neodymium-iron-boron or samarium-iron-nitrogen. 0.1-1% khlorin solution as photosensitizer, selected from group containing photolon, radachlorine or photoditazine, is additionally intravenously introduced in 2-3 days at a dose of 0.8-1.1 mg/kg and repeated laser irradiation of the intraocular neoplasm is carried out with radiation dose of 30-45 J/cm2 15-20 min later during 30-90 s.

EFFECT: complete destruction of neoplasm; excluded its further growth.

4 cl

FIELD: medicine.

SUBSTANCE: method involves applying transscleral diaphanoscopic examination method for adjusting intraocular neoplasm localization and size. Rectangular scleral pocket is built 2/3 times as large as sclera thickness which base is turned from the limb. Several electrodes manufactured from a metal of platinum group are introduced into intraocular neoplasm structure via the built scleral pocket. Next to it, intraocular neoplasm electrochemical destruction is carried out in changing electrodes polarity with current intensity of 100 mA during 1-10 min, and the electrodes are removed. Superficial scleral flap is returned to its place and fixed with interrupted sutures. 0.1-2% aqueous solution of khlorin as photosensitizer, selected from group containing photolon, radachlorine or photoditazine, is intravenously introduced at a dose of 0.8-1.1 mg/kg. Visual control of intraocular neoplasm cells is carried out by applying fluorescence and fluorescent diagnosis methods. After saturating the intraocular neoplasm with the photosensitizer to maximum saturation level, transpupillary laser radiation of 661-666 nm large wavelength is applied at a dose of 30-120 J/cm2. the operation is ended with placing sutures on conjunctiva. Platinum, iridium or rhodium are used as the metals of platinum group. The number of electrodes is equal to 4-8. 0.1-1% khlorin solution, selected from group containing photolon, radachlorine or photoditazine, is additionally repeatedly intravenously introduced in 2-3 days at a dose of 0.8-1.1 mg/kg. Visual control of intraocular neoplasm cells is carried out by applying fluorescence and fluorescent diagnosis methods. After saturating the intraocular neoplasm with the photosensitizer to maximum saturation level, repeated laser irradiation of the intraocular neoplasm is carried out with radiation dose of 30-45 J/cm2.

EFFECT: complete destruction of neoplasm; excluded tumor recurrence; reduced risk of tumor cells dissemination.

3 cl, 3 dwg

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