RU2290148C2 - Surgical method for treating open angle glaucoma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves forming conjunctival and superficial scleral graft. Deep sclera and cornea layers are excised so that trabecule and Descemet membrane is exposed. Ciliary body-trabecule complex is detached from scleral spur with ciliary body connection to uveal trabecule being retained. The Descemet membrane is detached 1.0 mm deep into the cornea with pocket being formed. Supraciliary space is additionally dilated with explantodraining means which top is placed in Descemet membrane pocket area and its free ends is put into supraciliary space.

EFFECT: improved intraocular fluid discharge conditions; avoided postoperative trabecular apparatus resistance hypotonia.

2 cl, 4 dwg

Description

The invention relates to medicine, specifically to ophthalmology, can be used in the surgical treatment of primary open-angle glaucoma.

The current state of surgery for open-angle glaucoma is associated with the desire to perform interventions that preserve the trabecular network as a factor of natural resistance to the outflow of chamber fluid. This group of interventions includes the sinusotomy proposed by B.N. Alekseev (1978) with refining (purification) of the trabecular network. Sinusotomy with refining of trabeculae provides a reduction in IOP due to the removal of the endothelium and juxtacanical part of the trabeculae in the sinusotomy zone, while maintaining its corneoscleral and uveoscleral layers prevents the development of hypotension.

The most common operation at present is non-penetrating deep sclerectomy (Fedorov S.N., Kozlov V.I., Timoshkina N.T. et al., 1989). It involves the exposure of trabecular tissue and part of the descemetic membrane in the area of operation. The preserved trabecular apparatus provides sufficient resistance to outflow to prevent postoperative hypotension, and filtering the chamber fluid through the anterior part of the trabecula and the descemetic membrane contributes to the hypotensive effect of the intervention. This method is closest to the claimed solution (prototype). It includes the formation of a conjunctival and superficial scleral flap, excision of the deep layers of the sclera and cornea with exposure of the trabecula and descemetic membrane, sclerectomy to the supraciliary space, suture fixation of the superficial scleral and conjunctival flaps.

The disadvantage of this method is the possibility of scarring between the superficial scleral flap and the deep layers of the sclera, which reduces the time of the hypotensive effect of the operation.

The aim of the invention is the stable normalization of intraocular pressure by directing the outflow of intraocular fluid, along with the subconjunctival, directly into the supraciliary space.

The essence of the proposed solution lies in the fact that after the formation of conjunctival and superficial scleral flaps, excision of the deep layers of the sclera and cornea with exposure of the trabecula and descemet membrane, the ciliary body - trabecula complex is detached from the scleral spur, while maintaining the connection between the uveal part of the trabecula and the ciliary body with additional supraciliary space by explant drainage.

Comparative analysis with the prototype shows that the claimed method is distinguished by the presence of new features, according to which the corneoscleral trabecula and the ciliary body are detached from the scleral spur while maintaining the connection of the uveal part of the trabecula and the ciliary body with additional dilatation of the supraciliary space by explant drainage. Thus, the claimed method meets the criterion of "novelty." The novelty of our proposed method indicates the creative nature of the solution, that is, it indicates that the solution meets the criterion of "non-obviousness".

This feature, which distinguishes the claimed method from the prototype, is not identified in other research methods in the study of this field of medicine. In addition, he, in conjunction with other features, contributes to the achievement of the goal and corresponds to the inventive step.

The technical result is expressed in the fact that the proposed method ensures the outflow of intraocular fluid into the supraciliary space not only between the layers of the sclera, where the development of cicatricial processes is possible, but also directly under the scleral spur in the area of cyclodialysis. However, the preservation of the trabecular apparatus provides sufficient resistance to outflow to prevent postoperative hypotension. Thus, the effectiveness of the treatment of open-angle glaucoma is significantly increased.

The practical applicability is proved by the long experience of applying the claimed method at the Department of Eye Diseases of the YAGMA and in the eye departments of the regional clinical hospital of Yaroslavl.

Figure 1-3 shows a diagram of the implementation of the method. Figure 4 shows a diagram of the angle of the anterior chamber of the eye after surgery by the proposed method.

The method is as follows.

Initially, the conjunctiva is separated from the limbus from 10 to 14 hours, it is moved from the limbus, then the superficial scleral flap is cut out and separated by 1/2 thickness of the sclera in the form of a quadrangle 5 × 5 mm in size (1), and it is folded onto the cornea. Then the sclera (5) is deepened and separated to lamina fuska; the deep scleral flap in the form of an isosceles triangle 4 × 4 mm in size. They open a canal, the outer wall of which is in a deep flap and the latter is removed at its base. Then, stupidly with a spatula (6), under the base of the removed flap, the annular ligament in the region of the Schwalbe ring is destroyed and the Descemet's membrane (2) exfoliates 1.0 mm deep into the cornea with the formation of a pocket measuring 3.5 × 1.0 mm (Fig. 1).

Juxtacanalicular tissue is removed from the Schlemm's canal area, then immediately behind the scleral spur (4) a linear section of lamina fuska sclera (5) is made to the ciliary body. An atraumatic cutting needle (7) enters the supraciliary space so that the tip of the needle protrudes at the border of the scleral spur and corneoscleral trabecula (3), being above it, then cyclodialize (3.5 mm long) by sawing the needle to the right and left, those. exfoliation of the ciliary body from the scleral spur (4). Cyclodialysis is carried out without penetration into the anterior chamber by maintaining the anatomical integrity of the uveal part of the trabecular tissue (10) (figure 2). Preservation of the anatomical integrity of the uveal part of the trabecula allows to avoid reducing the depth of the anterior chamber of the eye. Under the scleral spur (4), implant drainage (polyamide thread 4-0) (8) is introduced in the form of a horseshoe, placing its top in the pocket of the descemet membrane (2) at the level of the Schwalbe ring (Fig. 3), and the free ends of the implant are inserted into the supraciliary space (9), thus dilating the latter (Fig. 4). The superficial flap is laid in place, fixing it with three interrupted sutures. Tenon's capsule and conjunctiva are fixed to the limb with two interrupted sutures.

Example 1: Patient I., 79 years old, was admitted to the clinic for primary open-angle glaucoma of the right eye with moderately elevated IOP. The left eye is healthy. Anamnesis: the diagnosis of glaucoma was made 6 years ago, the patient was constantly instilling 0.5% ocupres 2 times a day. On admission: visus OD = 0.08 s +4.5 D = 0.5. Computer perimetry: paracentral absolute scotomas, narrowing of peripheral borders from the nasal side within 20-25 degrees. The cornea is transparent, the anterior chamber is of medium depth, the pupil is round, partial atrophy of the pigment edge of the iris, phacosclerosis. In the fundus: initial glaucomatous excavation. Gonioscopy: the anterior chamber angle is open, moderate exogenous pigmentation. Computer topography: Po = 16.0; c = 0.2; F = 1.21; KB = 78. Contactless tonometry: 24 mmHg Daily tonometry (according to Maklakov): 25-30 mm Hg Surgical treatment was performed according to the method described above. The operation and the postoperative period without complications. 10 days after surgery: visus OD = 0.08 s +4.5 D = 0.5. Biomicroscopic: at 12 o’clock a high spilled filter pad, the cornea is transparent, the anterior chamber is of medium depth. Contactless tonometry: 9 mmHg 1 month after surgery: visus OD = 0.2 s + 4.0 D = 0.6. Pronounced filtration cushion, transparent cornea, anterior chamber of medium depth. Gonioscopy: the trabecular apparatus in the area of the operation is preserved, explant drainage and a gap in the supraciliary space are clearly visible in the layers of the cornea. Field of view without dynamics. Computer tonography: Po = 15.0; c = 0.38; F = 2.18; KB = 41. Non-contact tonometry: 11.0 mmHg 6 months after surgery: visus OD = 0.3 s + 4.0 D = 0.6. Local status and gonioscopic picture without dynamics. Field of view: extension of peripheral borders from the nasal side by 10-15 degrees. Computer tonography: Po = 16.7; c = 0.24; F = 1.84; KB = 34. Non-contact tonometry: 12.0 mmHg

Example 2: Patient P., 54 years old. Diagnosis: primary open-angle initial with high IOP of glaucoma of the right eye. Anamnesis: the diagnosis was made 2 months ago. Buried 0.5% ocupres - no effect. On admission: visus OD = 0.8 n / a. The cornea is transparent, the anterior chamber is of medium depth, the pupil is round, the reaction is live, phacosclerosis. On the fundus: optic nerve disc pale pink, contoured. Gonioscopy: the anterior chamber angle is open, moderately pronounced mixed pigmentation. Computer perimetry: single relative scotomas in the paracentral zone. Computer tonography: Po = 26.8; c = 0.04; F = 0.64; KB = 708. Non-contact tonometry: 30 mmHg Daily tonometry (according to Maklakov): 32-37 mmHg An operation was performed according to the method described above. The operation and the postoperative period without complications. At discharge: visus OD = 0.9. Biomicroscopic: high filtration cushion, transparent cornea, anterior chamber of medium depth. Non-contact tonometry: 9.0 mmHg After 1 month: visus OD = 0.9. The filtration cushion is well defined, the cornea is transparent, the anterior chamber is of medium depth, the pupil is round. Field of view: decrease in the number of paracentral cattle. Computer tonography: Po = 10.0; c = 0.17; KB = 56. Non-contact tonometry: 9.0 mmHg After 6 months: visus OD = 0.9. Local status, field of view - without dynamics. Gonioscopy: the trabecular apparatus in the area of the operation is preserved, drainage is clearly visible in the layers of the cornea, a gap is traced in the area of the operation in the supraciliary space. Computer tonography: Po = 9.15; c = 0.18; F = 0.32; KB = 47. Contactless tonometry: 8.0 mmHg

The proposed method for the surgical treatment of open-angle glaucoma is feasible in an ophthalmic surgical hospital.

Literature.

1. Alekseev B.N. Microsurgery of the inner wall of the Schlemm's canal with open-angle glaucoma // West. ophthalmology. - 1978. - No. 4. - S.14-21.

2. Fedorov S. N., Kozlov V. I., Timoshkina N. T. and other Non-penetrating deep sclerectomy with open-angle glaucoma // Ophthalmic surgery. - 1989. - No. 3-4. - C. 52-55.

Claims (2)

1. The method of surgical treatment of open-angle glaucoma, which consists in the formation of conjunctival and superficial scleral flaps, excision of the deep layers of the sclera and cornea with exposure of the trabeculae and descemetic membrane, characterized in that the ciliary body-trabecula complex is detached from the scleral spur while maintaining communication with the ciliary body with a uveal trabecula, at the same time, the Descemet's membrane is exfoliated 1.0 mm deep into the cornea with the formation of a pocket and the supraciliary space is further dilated eksplantodrenazhom on, the top of which lies in the pocket of the Descemet's membrane, and the free ends tucked into supratsiliarnoe space. 2. The method according to claim 1, characterized in that when detaching from the scleral spur of the complex, the ciliary body-trabecula with the formation of a pocket in the cornea uses an atraumatic cutting needle.

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