RU2548513C1 - Method of microinvasive nonpenetrating deep sclerectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmological surgery, and can be applied in the microinvasive surgical treatment of open angle glaucoma. For this purpose a conjunctival 2 mm long cut is made. A superficial scleral flap with penetration into surface layers of the cornea is cut out. The base of the surface flap constitutes 2 mm, the height is 2 mm. Then a deep 2 mm high scleral flap, with the base of 2 mm near the limb, top of 1 mm, is excised. The said flap is excised together with peripheral layers of the cornea and an external wall of the Schlemm's canal with exposing the zone of the trabecula and the Descemet's membrane. The sclera is completely excised to the ciliary body in 1 mm from the apex of the surface sclera flap bed. After that two-three applicates are applied by means of a button electrode backwards from the scleral spur. The scleral bed is formed by a diode laser with a wavelength of 810 nm, exposure of 5 s and power of 300-400 mW. The scleral bed is filled with the Healaflow implant. The scleral flap is laid with the application of interrupted sutures. The conjunctiva is reinforced by one interrupted suture.

EFFECT: method provides prolonged hypotensive effect in the postoperative period due to the formation of intrascleral and extrascleral paths of the liquid outflow without the formation of sclera-scleral and sclera-conjunctival adhesions in the intrascleral cavity and subconjunctival space.

2 ex

Description

The invention relates to medicine, namely to the field of ophthalmology, and can be used to increase the effectiveness of surgical treatment of open-angle glaucoma.

The closest analogue is a method for the surgical treatment of glaucoma, including anesthetic support, the formation of a conjunctival flap in the upper segment of the eyeball with separation of 1-2 mm from the limbus, the formation of a superficial scleral flap with an entry into the transparent layers of the cornea by 1-2 mm, the formation of a deep triangular, a rectangular or trapezoidal flap and the subsequent removal of a deep scleral flap, complete excision of the sclera at the apex of the scleral flap to the surface of the ciliary body, removal of the outer wall of the Schlemm's canal and corneoscleral tissue to a depth until the trabecula and descemetic membrane are exposed, laying the superficial scleral flap with its fixation to the sclera with 1-2 interrupted sutures, applying one nodal suture to the conjunctiva with injection under the conjunctiva of dexason with antibiotic and then applying monocular (A method for the surgical treatment of primary open-angle glaucoma using the method of microinvasive non-penetrating deep sclerectomy (RF patent for the invention No. 2405512). However, the effect of the above method is limited by the fact that in some cases a cicatricial restriction of the filtering pad and intrascleral cavity is formed with the development of intraocular fluid retention under the conjunctiva and, as a result, increased intraocular pressure (IOP) after surgical treatment of open-angle glaucoma in the postoperative period.

The technical result of the invention is to achieve a prolonged antihypertensive effect in the postoperative period due to the formation of intrascleral and extrascleral fluid outflow pathways with the formation of a fluid depot in the intrascleral cavity (ICP) and a spilled filtration pad (AF).

The technical result is achieved by the fact that in the microinvasive method of surgical treatment of open-angle glaucoma, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of an intrascleral bed and a spilled filter pad, conducting a conjunctival incision 2 mm long, cutting out a superficial scleral flap, the base of which is 2 mm, height 2 mm with entry into the surface layers of the cornea, followed by excision of a deep scleral flap 2 mm high, 2 mm base of the limb, with a vertex of 1 mm, together with the peripheral layers of the cornea and the outer wall of the Schlemm canal with exposure of the trabecula and descemetous membrane, complete excision of the sclera to the ciliary body at a distance of 1 mm from the top of the bed of the surface flap, according to the invention, is applied posterior to the scleral spur with a button electrode two or three applicates, then form the scleral bed with a diode laser, using subthreshold laser pulses with an exposure of 5 seconds and a power of 300-400 mW, the scleral bed is filled with a Heala implant flow, then lay the scleral flap with the imposition of nodal sutures and strengthen the conjunctiva with one nodal suture.

A distinctive feature of the method from the closest analogue is that during microvasive non-penetrating deep sclerectomy, diathermotrabeculospasis is performed by applying two to three applicates with a button electrode behind the scleral spur, the intrascleral bed is formed by a diode laser with a wavelength of 810 nm using 5 sub-threshold laser values seconds and with a power of 300-400 mW, the scleral bed is filled with a 0.2 ml Healaflow implant, which has the properties of preserving the shape, volume and lends itself to modeling.

The positive aspect of the proposed method is that during the operation they form an intrascleral bed uniformly filled with an implant, which eliminates the possibility of adhesion of the scleral flap with the intrascleral cavity after surgery due to the presence of the implant, which has the properties of preserving shape, volume and modeling. In addition, the presence of an implant in the intrascleral bed promotes the formation of a fluid depot in the intrascleral space, which contributes to the formation of extrascleral and intrascleral outflow pathways of the intraocular fluid without the formation of sclero-scleral and scleroconjunctival adhesions in the intrascleral cavity and subconjunctival space. After trabeculospasis, the trabecular network expands, and the outflow of intraocular fluid improves. All these actions, ultimately, lead to the prolongation of the hypotensive effect of the operation.

The proposed method is carried out by the following sequence of steps.

The processing of the surgical field, anesthesia, akinesia of the eyeball, and the application of an eyelid extender are performed. In the upper segment concentric limbus at a distance of 2 mm produce a conjunctival incision 2 mm long. A superficial scleral flap is cut out by a surface incision at ½ thickness of the sclera with access to the surface layers of the cornea with a base of 2 mm and a height of 2 mm. Then a deep scleral flap is cut and removed to 1/3 of the sclera thickness, 2 mm high, with a 2 mm base at the limb and a 1 mm vertex together with the outer wall of the Schlemm canal and the site of the corneoscleral tissue anterior to the Schlemm canal with exposure of the corneoscleral trabecula and the periphery of the descemet shell to obtaining pronounced filtration of intraocular fluid. 1 mm from the top of the bed of the superficial scleral flap, the remaining scleral layers 0.5x0.5 mm are removed to the ciliary body. To the back of the scleral spur, with a button electrode of a diathermocoagulator with a power of 10 W, exposure time one second is applied two or three applicates. A scleral bed is formed by a diode laser with a wavelength of 810 nm using sub-threshold values of laser pulses with an exposure of 5 seconds and a power of 300-400 mW, then the scleral bed is filled with a Healaflow implant.

The Healaflow implant is made of chemically cross-linked hyaluronic acid. It has the properties of preservation of shape, volume, can be modeled and resistant to resorption.

Then put the scleral flap with the imposition of nodal sutures and strengthen the conjunctiva with one nodal suture.

The method is confirmed by the following clinical examples.

Example 1. Patient K., 60 years old, was admitted to the Eye Microsurgery FSBI with a diagnosis of Primary open-angle glaucoma, advanced stage (III), with moderately elevated IOP (B) of the right eye.

Visual acuity of the right eye = 0.6; intraocular pressure 28 mm Hg The coefficient of ease of outflow of 0.04. During biomicroscopy: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, opacities in the cortical layers of the lens. Fundus: optic disc gray, excavation 0.9 disc diameter.

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method with the application of two applicates during trabeculospasis. We used laser pulses with an exposure of 5 seconds and a power of 300 mW.

In the early postoperative period, no clinical signs of an inflammatory reaction were noted: the cornea maintained its transparency, the anterior chamber was of a uniform depth of 2.8 mm without a tendency to crush, and the diaphragmatic function of the iris was preserved. During biomicroscopy, a spilled AF of 6 × 12 mm in size was visualized with light pastiness and a prominence of up to 2.0 mm in the center. In the subsequent periods, some flattening was noted with a prominence of not more than 1.5 mm without encapsulation.

The IOP on the first day after surgery was 8 mm Hg, followed by a gradual increase by 3 months to 13 mm Hg. without antihypertensive therapy.

When examining by the method of ultrasonic biomicroscopy (UBM) "SONOMED" (USA) on the first day after the operation, AF was determined, the height of which was 0.98 mm. The scleral flap (SL) was hydrated with an acoustic density of 60-70%. Thickness averaged 0.27 mm. An optically negative cavity in the form of a narrow gap with a width of up to 0.1 mm without inclusions was viewed between the AF and SL. ICP was an acoustically negative space without inclusions in the form of an irregular oval. The height was 0.59 mm. The width of the trabeculo-descemet membrane (TDM) was 0.82 mm; its thickness was 0.07 mm. The acoustic density of the membrane was 40%. By 7-14 days after the operation, the structures of the drainage system created by the operation retained the same parameters.

By 1-3 months, the AF was clearly visualized, the AF height was 1.1 mm. The AF content retained pronounced hypoechoicity with acoustic density fluctuations of 30-40% without microcavities.

The safety of the acoustically negative gap between the AF and SL up to 0.05 mm was noted. The thickness of the SL increased, amounting to 0.39 mm due to hydration with the preservation of low acoustic density of 50-90%. The boundaries of the SL were clearly visualized. The formation of a hypoechoic tunnel emerging from under the SL and connecting the ICP with the subconjunctival space was noted. The height of the ICP was 0.69 mm. The interface has a clear outline. The absence of inclusions in COI is noted.

TDM parameters did not change compared with earlier follow-up periods. The width was 0.82 mm; its thickness was maintained at 0.07 mm. The acoustic density of the membrane remained stable, amounting to 30-50%. TDM had a direct profile without prominence.

Example 2

Patient M., 55 years old, was admitted to the Eye Microsurgery FSBI with a diagnosis of Primary open-angle glaucoma, advanced stage (II), with moderately elevated IOP (B) of the right eye.

Visual acuity of the right eye = 0.8; intraocular pressure 30 mm Hg The coefficient of ease of outflow of 0.07. During biomicroscopy: the eye is calm, the cornea is transparent, the anterior chamber is of medium depth, opacities in the cortical layers of the lens. Fundus: optic disc is decolorized, excavation is 0.7 times the diameter of the disc.

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method with the application of three applicates during trabeculospasis. We used laser pulses with an exposure of 5 seconds and a power of 400 mW.

In the early postoperative period, no clinical signs of an inflammatory reaction were noted: the cornea maintained its transparency, the anterior chamber was of a uniform depth of 3.0 mm, and the diaphragmatic function of the iris was preserved. During biomicroscopy, a spilled AF of 5 × 10 mm in size with a light pastiness in the center was visualized.

The IOP on the first day after surgery was 9 mm Hg, followed by a gradual increase by 3 months to 16 mm Hg. without antihypertensive therapy.

When examining by the method of ultrasonic biomicroscopy (UBM) "SONOMED" (USA) in the first days after the operation, AF was determined, the height of which was 0.93 mm. SL was hydrated with an acoustic density of 50%. Thickness averaged 0.24 mm. Between AF and SL, an acoustically negative cavity was seen in the form of a narrow gap with a width of up to 0.1 mm without inclusions. ICP was an acoustically negative space without inclusions in the form of an irregular oval. The height was 0.55 mm. The width of the TDM was 0.81 mm; its thickness was 0.06 mm. The acoustic density of the membrane was 50%.

By 7-14 days after the operation, the structures of the drainage system created by the operation retained the same parameters.

In terms of 1-3 months, the AF was clearly visualized, the AF height was 1.20 mm. The AF content retained pronounced hypoechoicity with acoustic density fluctuations of up to 30-50% without microcavities.

The safety of the acoustically negative gap between the AF and SL up to 0.05 mm was noted. The thickness of the SL increased, amounting to 0.32 mm. Its density maintained an uneven hypoechoicity of 50-90%. The boundaries of the SL were clearly visualized. The formation of a hypoechoic tunnel emerging from under the SL and connecting ICP with the emerging intrascleral pathways was noted. ICP parameters slightly increased compared to earlier periods: the ICP height was 0.63 mm, the interface acquired a clear outline. The absence of inclusions in COI is noted.

The width of the TDM was 0.81 mm; its thickness was maintained at 0.07 mm. The acoustic density of the membrane remained stable at 50%. TDM had a direct profile without prominence.

Claims (1)

A microinvasive method for surgical treatment of open-angle glaucoma, which consists in creating intrascleral pathways for the outflow of intraocular fluid with the formation of an intrascleral bed and a spilled filter pad, conducting a conjunctival incision 2 mm long, cutting out a superficial scleral flap with a base of 2 mm, a height of 2 mm and entering the surface layers cornea, followed by excision of a deep scleral flap 2 mm high, 2 mm base at the limb, 1 mm apex, together with peripheral layers of the cornea and the outer wall of the Schlemm's canal with exposure of the trabecula and descemetic membrane, complete excision of the sclera to the ciliary body at a distance of 1 mm from the top of the bed of the surface flap, characterized in that two or three applications are applied behind the scleral spur with a button-shaped electrode, then form a scleral the bed with a diode laser with a wavelength of 810 nm, using subthreshold values of laser pulses with an exposure of 5 s and a power of 300-400 mW, the scleral bed is filled with a Healaflow implant, then the scleral ones are placed th flap with the imposition of nodal sutures and strengthen the conjunctiva with one nodal suture.