RU2535510C1 - Method for surgical treatment of glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: superficial scleral flap is cut out with its base facing the limb. Sinus trabeculectomy and cyclodialysis are performed. A full deep inverted scleral flap is cut out within the cyclodialysis area in a projection of the superficial scleral flap. A cuff made of a biodegradable material is put on the flap and fixed in the previous place.

EFFECT: method provides stable intraocular pressure reduction by the formed intraocular fluid outflow tract.

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Description

The present invention relates to ophthalmology and is intended for the surgical treatment of glaucoma.

In recent years, domestic and foreign researchers began to distinguish a special clinical form of glaucoma - refractory glaucoma (RG). A distinctive feature of this type of glaucoma is a persistent increase in intraocular pressure (IOP) that is not amenable to traditional methods of therapeutic and surgical treatment.

The basis of the pathogenesis of WG are pronounced changes in the drainage system of the eye, which greatly complicate or make it impossible for the outflow of intraocular fluid (HPW). In far-reaching and terminal stages of the disease with severe pain syndrome, repeated operations are required repeatedly, since in this case it is practically not possible to obtain an adequate result in treatment using traditional medications, laser methods and surgical procedures. Conservative treatment of RH is characterized by low efficiency and plays only an auxiliary role. As for the surgical treatment of glaucoma, a huge number of different interventions have been used. And at present, ever new methods and their modifications are constantly being offered.

The following types of surgical treatment for glaucoma are distinguished:

1) cyclodestructive interventions;

2) reconstructive interventions;

3) standard filtering interventions using cytostatics;

4) drainage methods (Nizov A.V. Explantodrainage in the treatment of refractory post-traumatic glaucoma. Diss. ... candidate of medical sciences, M., 2011. - S.23-24).

For the treatment of refractory glaucoma, drainage methods are recognized as the most effective. The use of drainage implants provides an opportunity for the outflow of intraocular pressure in conditions of pronounced fibroplastic activity of tissues. Among the used drains, three main types can be distinguished: 1) translimbal seton drains; 2) shunt tubes; 3) shunt devices.

The first works were carried out back in 1906 by M. Rollett, and in 1912 A. Zorab, who used silk thread for implantation and suggested introducing it into the sclerotomy opening in order to activate the outflow of the intraocular fluid from the anterior chamber under the conjunctiva and to prevent scleral fistula overgrowth. However, in the distant period, the formed outflow paths were healed. Among drainages from heterogeneous materials, glaucoma drainages from lyophilized collagen of porcine sclera are most common. Such drainage is completely resorbed within 6–9 months and is replaced by a newly formed loose connective tissue, while a tunnel is preserved in the sclera through which the outflow of HPW is carried out. (Kozlov V.I. et al., Non-penetrating deep sclerectomy with collagenoplasty / Ophthalmic surgery. - 1990. - No. 3. - P.44-46). Subsequently, the xenoplat collagen drainage was developed from highly purified collagen type 1 of animal origin, saturated with sulfated glycosaminoglycans. The structure of this porous material in structure is similar to the histological structure of trabecular tissue, therefore, its use helps to restore the outflow of MIC (Anisimova S.Yu. et al. Long-term results of surgical treatment of RG using biodegradation-resistant collagen drainage // Glaucoma. - 2010. - No. 2 - S. 28-33).

The closest analogue of the present invention is a method for the surgical treatment of glaucoma, the technical essence of which is as follows: after anesthesia, the conjunctival flap is removed by any means: with the base to the limbus or from the limbus, then the surface scleral flap, having the form of a high trapezoid, is marked and separated. After the formation of a superficial scleral flap, a drainage is put on it (like a sleeve), followed by the necessary operations, depending on the type of anti-glaucoma intervention (penetrating or non-penetrating option). Fixation of the scleral flap with the drainage put on it is carried out with 1-2 interrupted sutures. Sutures on the conjunctiva are imposed, regardless of the option of its separation, in order to achieve good adaptation (Dolgiy S.S.Prevention of excessive scarring during anti-glaucomatous operations. Abstract. Diss. ... Ph.D., M., 2012. - P.13 [p.24]).

The disadvantages of this method are:

1. The use of only one outflow activation mechanism based on the formation of a fistula sclera under the surface flap in the area of the trabecula and Schlemm's canal, which ensures the drainage of intraocular fluid into the conjunctival filter pad.

2. Surface implantation of Glautex drainage above and below the superficial scleral flap to prevent scarring of the filter pad. In the early postoperative period due to swelling of the drainage under the influence of the intraocular fluid filtered from the anterior chamber, this leads to a displacement of the conjunctival flap and disruption of the formation of the filtration pad.

3. In addition, the swelling of Glautex drainage in the early postoperative period and the displacement of the conjunctival flap is accompanied in some cases by the divergence of the edges of the operative incision of the conjunctiva.

The task of the invention is to develop a combined method for the surgical treatment of glaucoma using biodegradable material.

The technical result of the invention is a persistent decrease in intraocular pressure in a severe category of patients.

The technical result is achieved by simultaneously forming two outflow pathways of the intraocular fluid: expanding the uveoscleral tract using biodegradable drainage and additional outflow of intraocular fluid from the drainage zone of the anterior chamber angle into the formed conjunctival filter pad using a microfistulizing operation.

The developed combined intervention, which provides, along with the microfistulizing mechanism of sinusotrabeculectomy (STE), additional activation of the uveoscleral outflow of intraocular fluid, is ensured by implantation of biodegradable drainage simultaneously into the suprachoroidal space and between the scleral layers to form a new outflow pathway, moreover, it is also excluded conjunctival flap in the postoperative period due to deep drainage implantation. The essence of the method consists in the fact that after cutting out the surface scleral flap and sinusotrabeculectomy, cyclodialysis is carried out, then a full-layer deep scleral flap of the inverse profile is projected in the projection of the surface scleral flap in the cyclodialysis zone, a sleeve from the biodegradable material is put on it and fixed in place. Thus, the base of the deep scleral flap is in the opposite position from the base of the superficial scleral flap, that is, it has a reverse profile, which provides two ways for the outflow of intraocular fluid.

The method is as follows.

As is customary, the patient undergoes a comprehensive ophthalmologic examination in the preoperative period, including visometry, pneumotonometry, biomicroscopy, ophthalmoscopy, ultrasound A and B scans, ultrasound biomicroscopy, and optical coherence tomography of the anterior segment of the eye.

Preoperative preparation and anesthesia are common. A frenum suture is applied to the superior rectus muscle. In the presence of previous interventions, the conjunctiva is incised in a quadrant intact from previous operations, 10-12 mm long. The sclera is exposed, starting from the limbus and to the zone 6 mm from it. A U-shaped sclera flap 5 × 6 mm in size is formed with the base to the limb 1/2 of its thickness. Sinus trabeculectomy and cyclodialysis are performed. In the area of cyclodialysis in the projection of the superficial scleral flap, a full-layer deep scleral flap of the reverse profile is cut out, a sleeve of biodegradable material is put on it and fixed in its original place. The superficial flap of sclera is put into place and fixed with interrupted sutures. Impose a continuous seam on the conjunctiva. Saline and air are injected into the anterior chamber. The operation is completed by subconjunctival administration of a solution of dexamethasone 0.4% 0.3 mg and gentamicin 0.3 mg. An aseptic monocular dressing is applied.

Clinical example.

Patient S., 58 years old. He was hospitalized with a diagnosis of OS - post-traumatic glaucoma III-IV c, penetrating corneoscleral scar of the cornea, artificial iridocrystal diaphragm (IHD). At the time of hospitalization: Vis OS = hand movement in the face, Vis OD = 0.8 n / a. IOP OS = 34 mm Hg OD = 14 mm Hg The orbit without pathological changes. The position of the eye is correct, the movement in full. The cornea is edematous, in the central zone of the bulla, penetrating corneoscleral scar, anterior chamber of medium depth. IHD is shifted inwards. The fundus behind the fleur. The length of the axis of the eyeball according to ultrasound biometry: OD - 22.5 mm, OS - 23.6 mm. According to the results of a comprehensive study, including UZBM and OCT, the thickness of the cornea is 0.66 mm (in the center). ICD decentered, shifted to the inner corner of the eye. In 3 quadrants (upper, inner, and partially lower), the anterior chamber angle is obturated due to the fusion of the cornea with the remains of the iris root.

Preoperative premedication was performed, including diphenhydramine 0.1 mg / kg, relanium 0.15-0.2 mg / kg, seduxen 0.2 mg / kg. The operation was performed under local anesthesia. Conducted normal processing of the surgical field. Installed blepharostat. After conducting pterygo-orbital anesthesia with 2% lidocaine solution and drip anesthesia with alkaine solution, a bridle suture was placed on the superior rectus muscle. The conjunctiva was cut in a preselected quadrant along the meridian for 6 hours. Carried out hemostasis. We made a U-shaped section of the sclera with a 5 * 6 mm base to the limbus and formed a superficial scleral flap 1/2 of the thickness of the sclera within this section. A fragment of trabecula 1 * 5 mm was excised under its base. Cyclodialysis was carried out with a spatula towards the equator within the bed of the scleral flap. On the scleral flap bed, 2 through sections of the deep layers of the sclera were made, starting from the trabeculectomy zone in the direction of the equator parallel to the edge of the bed. A U-shaped flap was formed from the deep layers of the sclera with a size of 4 * 5 mm of an inverse profile with respect to the superficial scleral flap. Having turned away a deep flap, the ciliary body was exposed. Glautex drainage was put on a deep flap. The scleral deep flap was fixed with two interrupted sutures to the deep scleral layers within the bed of the superficial flap, preserving the window formed at the beginning of the operation in the trabecula zone. The sclera superficial flap was put in place and fixed with interrupted sutures. Imposed a continuous seam on the conjunctiva. Saline and air were introduced into the anterior chamber. Under the conjunctiva, an injection of a solution of dexamethasone 0.4% 0.3 mg and gentamicin 0.3 mg was made. An aseptic monocular dressing was applied.

In the postoperative period, there were no complications. When discharged after 5 days, Vis OS = 0.01 does not correspond. Down at the limb for 6 hours. conjunctival filtration pad is formed. The cornea is transparent. Front camera of medium depth. ICD in the same position as before the operation. The fundus reflex is pink; details are poorly visible. IOP OS = 15 mmHg

When viewed after 3 months, a pronounced conjunctival filtration pad was formed. The cornea is transparent. Front camera of medium depth. The position of the IHD has not changed. On the fundus expressed glaucomatous excavation of the optic disc. Vis OS = 0.01 not corr. IOP OS = 17 mm Hg A steady decrease in IOP can be noted.

Thus, the proposed method provides a stable hypotensive effect due to the combined intervention, which provides, along with the microfistulizing mechanism of sinusotrabeculectomy (STE), additional activation of the uveoscleral outflow of intraocular fluid.

Claims (1)

A method for the surgical treatment of glaucoma, including cutting a superficial scleral flap with a base to the limb and performing a sinusotrabeculectomy, characterized in that after sinusotrabeculectomy, cyclodialysis is performed, a full-layer deep scleral flap of the reverse profile is inserted into the cyclodialysis area in the projection of the superficial scleral flap, and put on it with a biofeedback fixed in the same place.