RU2548795C1 - Method for performing minimally invasive deep sclerectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: conjunctival incision is made. A surface scleral flap is formed. A deep scleral flap is formed, and a ciliary body is exposed at its apex. The deep scleral flap is excised. The surface scleral flap is placed back. A hydrogel drain tube 2×3 is placed under the surface scleral flap into the formed intrascleral cavity backwards the scleral spur in parallel with the limb to fill the intrascleral bed. A distal end of the drain tube is immersed into a scleral coloboma between the ciliary body and sclera. The scleral flap is fixed with one interrupted suture in the centre. That is followed by making a corneal 3-o'clock paracentesis, which is used to fill an anterior chamber with RROVISK viscoelastic 0.2 ml by means of a cannula. Healaflow drainage implant 0.1-0.2 ml is administered by means of the cannula into the subconjunctival space. The conjunctival incision is sealed with uninterrupted suture.EFFECT: method provides creating the intrascleral passages for intraocular fluid outflow by using the hydrogel drainage of optimum size, as well as preventing excessive filtration, ensures the smooth intraoperative and early postoperative stabilisation of intraocular pressure and hydrodynamics by administering Healaflow drainage implant into the subconjunctival space and preventing milling the anterior eye chamber, contacting the iris root and the anti-glaucomatous surgery by filling the anterior eye chamber with PROVISK viscoelastic.2 dwg, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used in microinvasive surgery of glaucoma.

Surgical treatment of glaucoma is one of the most pressing problems of ophthalmic surgery. Unfortunately, to date, there is a relatively high risk of intra- and postoperative complications, usually leading to decreased vision.

Currently, non-penetrating antihypertensive operations are a promising area in open-angle glaucoma surgery. Despite the low invasiveness of non-penetrating surgeries and the low incidence of intraoperative and postoperative complications, such operations have their own specific features and complications, such as intraoperative excessive filtration of intraocular fluid through a formed trabeculo-descemetic membrane (TDM) and microperforation of the descemetic membrane (in 2-30 % of cases) at the time of the formation of TDM. Due to excessive filtration and microperforation of the descemet membrane, there is a sharp discharge of intraocular moisture with a corresponding sharp drop in intraocular pressure. Due to a sharp pressure drop, a hydraulic shock occurs, simultaneously affecting all internal structures of the eye, the hemodynamics of the eye are disturbed, the membrane permeability is disturbed, the choroid swelling appears before the choroid detachment.

The combination of small sizes of TDM (length 2-3 mm) and excessive filtering can lead to pulling the iris root with an excess current of intraocular fluid, and then blocking the area of operation and thereby reduce the hypotensive effect.

The closest analogue is the method of surgical treatment of open-angle glaucoma (RF patent No. 2344796), which consists in the formation of a superficial conjunctival incision and its separation, the formation of a superficial and deep scleral flaps, with access to the transparent layers of the cornea up to 3.0 mm wide, with bases facing the limb, isolation of the trabeculo-descemetic membrane and removal of the deep scleral flap together with the outer wall of the Schlemm's canal and strip of corneoscleral tissue, until the descemetic m is completely exposed membranes, reposition of the superficial scleral flap and comparison of the conjunctival incision, the introduction of 0.2-0.3 ml of viscoelastic into the conjunctival incision, before it is sutured, and under the tenon membrane towards the arch of the eye. Then, at 3 or 9 hours, the anterior chamber is transclerally opened at the limb, and with the help of an irrigation cannula, a 0.1 ml sterile air bubble is introduced, then 0.3-0.4 ml of balanced saline is injected through the same cannula.

However, this method has some disadvantages: the air introduced into the anterior chamber of the eye quickly dissolves (within one day), which can lead to grinding of the anterior chamber of the eye and does not sufficiently stabilize the hemo- and hydrodynamics of the eye in the postoperative period. This method does not take into account the possibility of microperforation of TDM and tightening the iris to the area of operation.

The objective of the invention is the creation of a microinvasive method of non-penetrating deep sclerectomy, allowing you to correct excessive filtering.

The technical result of the invention is to ensure the correct anatomical ratio of the structures of the anterior segment of the eye, preventing excessive filtering during surgery and the early postoperative period, smooth stabilization of ophthalmotonus and hydrodynamics during surgery and in the early postoperative period, prevention of grinding of the anterior chamber of the eye, prevention of contact of the iris root with the zone anti-glaucomatous surgery.

The specified technical result is achieved by the fact that in the method of conducting microinvasive non-penetrating deep sclerectomy, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a filtration conjunctival pad, starting with a conjunctival incision and the formation of a superficial scleral flap, the formation of a deep triangular scleral flap with its tops, which are excised, according to the invention under the superficial scleral A flap in the formed intrascleral cavity, posterior to the scleral spur, a 2 × 3 mm hydrogel drainage is placed parallel to the limb, thus filling the intrascleral bed, the scleral flap together with the hydrogel drainage is fixed with one nodal suture in the center, corneal paracentesis is performed for 3 hours, through which, using a cannula, the anterior chamber is filled with 0.2 ml of PROVISC viscoelastic, 0.1-0.2 ml of a Healaflow drainage implant is inserted into the subconjunctival space using a cannula and the operation is completed ju sealing of the conjunctival incision.

Hydrogel drainage - a translucent elastic plate of hydrophilic hydrogel with dimensions of 2 × 3 mm and a thickness of 0.15 mm, manufactured by the ETF FSBI MNTK Eye Microsurgery named after Acad. S.N. Fedorova, Russia, is intended for the prevention of scarring and obliteration created by the operation of the outflow pathways of the intraocular fluid, a large percentage of water of 85% with the presence of a water-buffered shell on its surface, higher elasticity and biocompatibility with the surrounding tissues of the eye. Hydrogel drainage does not resolve, and therefore is not replaced by connective tissue.

The Healaflow drainage implant (Anteis, Switzerland) consists of non-animal origin reticular sodium hyaluronate. Due to the relatively dense consistency, Healaflow allows you to simulate its volumetric parameters and use it as a filler in the intrascleral space, preventing excessive filtering during surgery and in the early postoperative period, maintains a sufficient volume of the intrascleral cavity and eliminates the possibility of contact of the TDM with a superficial scleral flap. The Healaflow drainage implant preserves the space between the filter pad and the scleral flap, maintains the depth of the intrascleral cavity, does not cause cell infiltration, and contributes to the uncomplicated flow of intraocular fluid.

To fill the volume and create the depth of the anterior chamber through paracentesis, Viscoelastic Provis (Alcon, USA) - 1% sodium hyaluronate is introduced. This viscoelastic has a high molecular weight, has relatively strong compounds of molecular chains among themselves, due to which the drug behaves as a single mass, maintains volume. Sagging, introduced into the anterior chamber of the eye, performs the necessary volume of the anterior chamber and prevents its crushing and postoperative fit of the iris root due to increased filtration through the formed TDM. Within 5-7 days after the operation, the Provisk gradually dissolves and is replaced by intraocular fluid from the anterior chamber to the operation area.

The proposed drugs do not cause an increased reaction of the surrounding eye structures. The cornea, lens and vitreous body retain their transparency.

The invention is illustrated in figures 1-2, figure 1 shows the stage of implantation of hydrogel drainage into the intrascleral bed with immersion of the distal end of the drainage in the coloboma of the sclera between the ciliary body and sclera. Figure 2 shows the position of the HealaFlow drainage implant in the subconjunctival space.

The method is as follows.

After local anesthesia, a conjunctival incision 4 mm wide at a distance of 2 mm from the edge of the limb 1 is performed at 12 hours. After separation of the conjunctiva and tenon membrane, a surface scleral flap 2 3 × 3 mm in size is inserted sequentially into the transparent layers of the cornea. From the underlying layers, the sclera forms a deep scleral flap of a triangular shape, with the base facing the limb, with the ciliary body exposed at its apex. Next, a deep scleral flap is removed together with the outer wall of the Schlemm canal and a strip of corneoscleral tissue until the descemet membrane is completely exposed 3. With excessive filtration or microperforation of the TDM under the superficial scleral flap, a hydrogel drainage 2 in size 2 × is placed parallel to the scleral spur 4 parallel to the limbus. 3 mm 5, the intrascleral bed is filled, immersing the distal end of the drainage in the sclera coloboma zone between the ciliary body and sclera, the superficial scle Theeral flap 2 is fixed with one nodal suture in the center, then the corneal paracentesis is performed for 3 hours, through which 0.2 ml of viscoelastic - Provisk is injected into the anterior chamber using a cannula. After that, 0.1-0.2 ml of the Healaflow 5 drainage implant is introduced into the subconjunctival space using the cannula and the operation is completed by sealing the conjunctival incision with the formation of a spilled filter pad 4.

The method is characterized by the following clinical examples.

Example 1. Patient I., 70 years old, diagnosis: Primary open-angle II In glaucoma of the left eye.

Glaucoma was detected in 2009, the patient complains of blurred vision in front of the left eye. At the moment, Azarga is dripping 2 times a day and Xalatan 0.005% 1 time per day.

There were no operations, no eye injuries. Somatically - ischemic heart disease, hypertension of the II degree.

Inspection data: the eye is calm, the optical media are transparent, pseudoexfoliation along the edge of the pupil, the pupil's reaction to light is positive.

Gonioscopically - the angle of the anterior chamber is open, medium width, pigmentation II tbsp. Fundus: pink reflex, optic nerve disc - pale, glaucomatous excavation 0.7.

Instrumental examination data: Visual acuity with correction - 0.7. Topography: Po = 30; C = 0.06; F = 0.98; Po / C = 500. Perimetry: the field of view is concentrically narrowed by 25 degrees along the upper and lower nasal meridian.

The operation of the left eye was performed according to the invention, since after the formation of TDM, excessive filtration of intraocular fluid and grinding of the anterior chamber were noted. Before suturing the conjunctival incision, 0.1 ml of the Healaflow drainage implant was introduced through the cannula into the subconjunctival space, the conjunctival incision was sealed with a continuous suture.

In the postoperative period, complications were not observed. Intraocular pressure 4 hours after surgery - 12 mm Hg, after 1 day - 10 mm Hg, and on day 2 - 9 mm Hg. According to the B-scan, there is no edema and detachment of the choroid, the membranes are adjacent. According to the data of optical coherent tomography (OCT) of the anterior segment 1 day after the operation: the anterior chamber angle is 12 ° - 28 °, the root of the iris is in the correct position, the blockade of the trabeculo-descemet membrane (TDM) is not the root of the iris, and the filter pad (AF) , 1.56 mm high, cellular structure. Scleral flap thickness averaged 0.27 mm. Between AF and SL (scleral flap), an optically negative cavity was seen in the form of a narrow gap with a width of up to 0.1 mm without inclusions. COI was a space without inclusions in the form of an irregular oval. The hydrogel drainage partially filling the ICP was visualized. The height was 0.5 mm. TDM had an even profile, its width was 0.82 mm, and the thickness was 0.06 mm.

The patient was discharged on the second day after surgery. Discharge pressure - 9 mmHg (pneumotonometer), visual acuity with correction - 0.7.

1 month after surgery:

Inspection data: the eye is calm, the optical media are transparent, pseudoexfoliation along the edge of the pupil, the reaction to light is positive.

Gonioscopically - the angle of the anterior chamber is open, medium width, pigmentation II tbsp.

Fundus: pink reflex, optic nerve disc - pale, glaucomatous excavation 0.7.

The filter cushion is flat, spilled.

Instrumental examination data:

Visual acuity has not changed. According to computer perimetry, no changes in the fields of vision were recorded.

Topography: Po = 13; C = 0.34; F = 1.32; Po / C 38.23.

According to the OCT of the anterior segment 1 month after the operation: the anterior chamber angle is 12 ° - 30 °, the root of the iris is in the correct position, the blockade of the trabeculo-descemet membrane (TDM) is not the root of the iris, the AF was clearly visualized, its height was 1.27 mm FP has a cellular structure without microcavities. The thickness of the SL increased, amounting to 0.35 mm due to hydration. The boundaries of the SL are clear, an optically negative gap between the AF and SL was visualized. The height of the ICP was 0.56 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 0.06 mm. TDM had a direct profile without prominence. The formation of intrascleral and subconjunctival outflow tracts was noted.

As a result of the operation, the patient had the correct anatomical ratio of the structures of the anterior segment of the eye, the anterior chamber angle remained open during all observation periods, smooth stabilization of the ophthalmotonus was achieved during the operation and the early postoperative period, prevention of grinding of the anterior chamber of the eye, contact of the iris root with the zone anti-glaucomatous surgery.

Example 2. Patient S., 65 years old, diagnosis: Primary open-angle I In glaucoma of the left eye.

Glaucoma was detected in 2011, the patient complains of blurred vision in front of the left eye. At the moment, Ganfort is dripping 2 times a day.

There were no operations, no eye injuries. Somatic - hypertension 1 tbsp.

Inspection data: the eye is calm, the optical media are transparent, the destruction of the pigment border of the iris, the pupil's reaction to light is positive.

Gonioscopically - the angle of the anterior chamber is open, medium width, pigmentation I art. Fundus: pink reflex, optic nerve disc - pale, glaucomatous excavation 0.6.

Instrumental examination data: Visual acuity with correction - 0.6. Topography: Po = 27; C = 0.09; F = 0.93; Po / C = 300. Perimetry: the field of view is concentrically narrowed by 8 degrees along the upper nasal meridian.

The operation of the left eye was performed according to the invention, since microperforation occurred at the time of the formation of the TDM. Before suturing the conjunctival incision, 0.2 ml of the Healaflow drainage implant was inserted through the cannula into the subconjunctival space, the conjunctival incision was sealed with a continuous suture.

In the postoperative period, complications were not observed. Intraocular pressure 4 hours after surgery - 13 mm Hg, after 1 day - 12 mm Hg, and on day 2 - 10 mm Hg. According to the B-scan, there is no edema and detachment of the choroid, the membranes are adjacent.

According to the data of optical coherence tomography (OCT) of the anterior segment 1 day after the operation: the anterior chamber angle is 12 hours at 24 °, the root of the iris is in the correct position, the blockade of the trabeculo-descemet membrane (TDM) is not the root of the iris, AF, the height of which was 1.16 mm. Scleral flap thickness averaged 0.30 mm. Between AF and SL (scleral flap), an optically negative cavity was seen in the form of a narrow gap with a width of up to 0.12 mm without inclusions. ICP was a space without inclusions in the form of an irregular oval, hydrogel drainage was visualized. The height was 0.65 mm. TDM had an even profile, its width was 0.95 mm, and the thickness was 0.07 mm.

The patient was discharged on the second day after surgery. Pressure at discharge - 10 mmHg (pneumotonometer), visual acuity with correction - 0.6.

3 months after the operation: Inspection data: the eye is calm, the optical media are transparent, the destruction of the pigment border of the iris, the reaction to light is positive.

Gonioscopically - the angle of the anterior chamber is open, medium width, pigmentation I art.

Fundus: pink reflex, optic nerve disc - pale, glaucomatous excavation 0.6.

The filter cushion is flat, spilled.

Instrumental examination data: Visual acuity has not changed. According to computer perimetry, no changes in the fields of vision were recorded.

Topography: Po = 15; C = 0.25; F = 1.25; P / C = 60.

According to OCT data of the anterior segment 1 month after the operation: the anterior chamber angle is 12 ° - 27 °, the root of the iris is in the correct position, the blockade of the trabeculo-descemet membrane (TDM) is not the root of the iris, the AF was clearly visualized, its height was 1.31 mm FP has a cellular structure without microcavities. The thickness of the SL increased, amounting to 0.34 mm due to hydration. The boundaries of the SL were clearly visualized. The height of the ICP was 0.76 mm. The absence of inclusions in COI is noted. Hydrogel drainage was visualized without signs of encapsulation. TDM parameters did not change compared with earlier follow-up periods. The width was 0.95 mm; its thickness was maintained at 0.07 mm. TDM had a direct profile without prominence. Outflow paths are visualized well.

As a result of the operation, the claimed technical result was achieved.

According to the proposed method, 15 patients were operated on, in all cases the claimed technical result was achieved.

Claims (1)

The method of conducting microinvasive non-penetrating deep sclerectomy, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a spilled filter pad, in this case, they begin by performing a conjunctival incision and forming a superficial scleral flap, forming a deep triangular scleral flap with exposure of the ciliary body at its apex, and the superficial scleral flap is laid in its original place, the conjunctival incision is sealed with a continuous a weld seam, characterized in that under the superficial scleral flap, a 2 × 3 mm hydrogel drainage is placed parallel to the scleral spur in the formed intrascleral cavity, back to the scleral spur, filling the intrascleral bed, immersing the distal end of the drainage in the scleral coloboma between the ciliary body and sclera, the flap is fixed with one nodal suture in the center, corneal paracentesis is performed for 3 hours, through which, using a cannula, the anterior chamber is filled with viscoelastic PROVISC in an amount of 0.2 ml, using anyuli administered 0.1-0.2 ml Healaflow drain implant into the subconjunctival space and the sealing operation is completed conjunctival incision.

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