RU2753956C1 - Method for surgical treatment of glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmic surgery. A superficial scleral flap is cut out, sinustrabeculectomy is performed. After sinustrabeculectomy, in the upper part of the scleral bed, at a depth of a

part of the sclera, a tunnel incision 2.2 mm wide and 2.0 mm long extending to the scleral surface is made with a disposable 2.2 mm knife. Drainage tape "Glautex" in form of a rectangular flap of 5.0×1.8×0.15 mm in size is introduced through said incision using a spatula until it extends beyond the sclera by 1 mm on one side. Interrupted sutures are applied to the scleral flap and the conjunctiva on the other side.

EFFECT: method allows reducing post-operative complications, reducing the amount of bed days.

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Description

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

The history of the issue of antiglaucomatous operations is a hundred years old. In recent decades, glaucoma surgery has been supplemented by the introduction into the newly formed filtration zone of various biodegradable implants that increase the effect of operations ("New approaches to refractory glaucoma drainage surgery" Russian journal of glaucoma 2016, Vol. 15, No. 4, pp. 82-94).

A known technique and place of installation of biodegradable implants - an open area of the scleral flap (patent RU 2535510 C1). Filtration of chamber moisture occurs in the area close to this flap (intra- and episcleral), which creates a limited filtration cushion in the near-limbal area of the eye. However, over time, it cicatrizes, which negates the effect of the operation. Cicatricial changes occur at the sites of manipulation with the sclera and tenon membrane, due to the development of the subsequent inflammatory process. To limit it, non-steroidal, steroid, cytostatic and other therapy is carried out.

The most radical method of fighting for filtration resistance is to reduce the volume of surgery and create additional filtration zones that are not associated with the limbal zone.

Antiglaucomatous surgeries are of the fistulizing type, which include non-penetrating deep sclerectomy (NDES), as well as penetrating deep sclerectomy (PGE) and the same antiglaucomatous surgeries using various drainage devices, for example, collagen (DKA brand), silicone (Repertable brand), biodegradable materials (Glautex brand), valves, shunts (ExPress brand). (National guidelines on glaucoma / edited by E.A. Egorov Y.S. Astakhov A.G. Shchuko // Moscow. 2008).

The most complete description of the application technique and types of drainage material are described in patent RU 134787 U1 dated 2012.09.05.

The disadvantages of the known interventions include the weak effect of these operations in the terminal stage of glaucoma, good results can be obtained in 1-2 stages of glaucoma. The inability to regulate the degree and rate of decrease in intraocular pressure (IOP) often leads to the development of postoperative ciliochoroidal detachment (CCO), or to an insufficient effect of lowering IOP, which leads to hypertension or to the continued use of antihypertensive drugs after surgery. There is also a high incidence of early cicatricial obliteration of the outflow tract, which develops as early as 1-3 years after surgery.

The closest analogue of the proposed method is patent RU 2535510 C1. The technical essence is as follows. After anesthesia, the conjunctival flap is separated by any means: base to the limbus or from the limbus, 10-12 mm long, then the surface scleral flap is marked and separated, which has the shape of a high trapezoid with dimensions of 5 × 6 mm. Sinustrabeculectomy and cyclodialysis are performed. In the projection of cyclodialysis, a full-layer deep scleral flap of an inverse profile is cut out and a biodegradable material is put on it (like a sleeve), and it is fixed in the same place. Further, the necessary operations are performed depending on the type of antiglaucoma 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 applied regardless of the version of its separation (Dolgiy S.S. Prevention of excessive scarring during antiglaucomatous operations. (Abstract of the thesis ... Ph.D., M., 2012. - P. 13).

However, this method of surgery is complex, contains significant volumes of surgical impact, affecting the ciliary body (cyclodialysis), giving new complications, an increase in hospital stay-days.

The task is to improve the quality of intraoperative manipulations, reduce postoperative complications, and reduce the number of bed-days.

части склеры выходящего на ее поверхность, с дальнейшим проведением через него шпателем дистального отрезка дренажной ленты «Глаутекс» до выхода ее на 1 мм за пределы склеры с одной стороны, а с другой стороны накладыванием узловых швов на склеральный лоскут и конъюнктиву.The task is carried out by performing sinustrabeculectomy, basal iridectomy, forming a tunnel incision with a disposable 2.2 mm knife, 2.2 mm wide, 2.0 mm long in the upper part of the scleral bed at a depth

part of the sclera extending to its surface, with further passing through it with a spatula of the distal segment of the drainage tape "Glautex" until it goes 1 mm beyond the sclera on one side, and on the other side by applying interrupted sutures to the scleral flap and conjunctiva.

The method is carried out as follows.

части склеры, одноразовым 2,2 мм ножом создают тоннельный разрез шириной 2,2 мм, длиной 2,0 мм, выходящий на поверхность склеры. Затем через тоннельный разрез шпателем вводят дренажную ленту «Глаутекс» до выхода ее с одной стороны на 1 мм за пределы склеры, а с другой стороны накладывают узловые швы на склеральный лоскут и конъюнктиву.Preliminarily, the preparation of the implant is carried out: a rectangular flap of the Glautex drainage tape measuring 5.0 × 1.8 × 0.15 mm is cut out with scissors from the standard half of the Glautex drainage. After separating the conjunctiva, with a blade, at 12 o'clock, cut out a superficial scleral flap with the base to the limbus. Sinustrabeculectomy and iridectomy are performed. At the top of the platform and scleral bed, at a depth

parts of the sclera, with a disposable 2.2 mm knife, create a tunnel incision 2.2 mm wide, 2.0 mm long, extending to the surface of the sclera. Then, through the tunnel incision, a drainage tape "Glautex" is introduced with a spatula until it leaves the sclera on one side by 1 mm, and on the other side, interrupted sutures are placed on the scleral flap and conjunctiva.

Clinical example 1.

Patient S., 62 years old, diagnosis: OD primary open-angle I With glaucoma, initial cataract, type 2 diabetes. Visual acuity 0.2 with sph correction. -1.0D = 0.6 Perimetry: widening of the blind spot, single scotomas in the Bjerrum zone. Glaucomatous excavation of the optic nerve head 0.8. Electronic tonography according to Shiotz: Ro = 34; C = 0.02; F = 0.6; Po / C = 1725

The patient underwent an operation: penetrating deep sclerectomy (PGE) using a drainage tape "GLAUTEX" measuring 5.0 × 1.8 × 0.15 mm. Using a disposable 2.2 knife, a tunnel incision 2.2 mm wide and 2.0 mm long was created, which exited onto the scleral surface. Through the tunnel incision with a spatula, a 5.0 × 1.8 × 0.15 mm drainage tape was introduced with a spatula until it protrudes 1 mm beyond the sclera on one side, and on the other side, interrupted sutures were placed on the scleral flap and conjunctiva. An antibiotic and dexamethasone were administered under the conjunctiva. There were no complications in the postoperative period. The patient was discharged on the second day after surgery. 1.5 years after surgery: visual acuity has not changed. Miotics does not receive. According to the computer perimetry data, no narrowing in the visual fields was recorded. The filtration pad in the area of the tunnel puncture exit is wide, the drainage strip under the conjunctival flap has resolved. Coloboma of the iris for 12 hours

Shiotz tonography: Ro = 18; C = 0.25; F = 1.66; K.B. (Po / C) = 72.

Clinical example 2.

Patient F., 65 years old, diagnosis: OS secondary uncompensated glaucoma. Sluggish uveitis in remission. Visual acuity 0.1 s corr. sph. + 1.5D. = 0.5. The field of view is sectorially narrowed by 25 degrees along the nasal meridian. Excavation of the optic nerve head = 0.7.

Electronic tonography according to Shiotz: Ro = 37; C = 0.04; F = 1.12; K.B. (Po / C) = 945;

Performed a PSE operation using a drainage tape "GLAUTEX". A scleral flap 1/2 of the thickness of the sclera is formed with the base to the cornea up to its transparent layers. Standard sinustrabeculectomy and iridectomy were performed. In the upper part of the scleral bed platform, at a depth of 1/2 of the sclera, disposable 2, A 2 mm knife created a tunnel incision 2.2 mm wide and 2.0 mm long, with access to the scleral surface.Drainage tape "GLAUTEX" was inserted into the scleral tunnel with a spatula with a spatula until the drainage strip exits the sclera by 1 mm, and the second edge of the drainage Glautex tapes were pulled with forceps to the site of sinustrabeculectomy. Two interrupted sutures were placed on the scleral flap and on the conjunctiva for complete sealing. The postoperative course is smooth. The patient was discharged on the second day after the operation.

12 months after surgery: the patient's visual acuity did not change. The field of view has expanded by 5 degrees from the nasal side. The filter cushion is flat and wide. The Glautex drainage tape has dissolved. Miotics does not receive. Intraocular pressure according to Maklakov is 19 mm. Hg

Tonography: Ro = 11.4; C = 0.47; F = 2.31; K.B. (Po / C) = 31.

Clinical example 3.

Patient C, 55 years old, diagnosis of OD: primary open-angle IIC operated glaucoma, complicated immature cataract.

Visual acuity: 0.4 n / a. Tonography: Ro = 32; C = 0.04; F = 1.1; K.B. (Po / C) = 825.

The fields of view are narrowed from the nasal side to 45 °. Marginal excavation of the optic nerve head.

Performed the operation of the PSE using the drainage tape "GLAUTEX". A scleral flap 1/2 of the thickness of the sclera is formed with the base to the cornea to its transparent layers. In the upper part of the platform of the scleral bed, at a depth of 1/2 of the sclera, a single-use 2.2 mm knife created a tunnel incision with a width of 2.2 mm and a length of 2.0 mm., with access to the surface of the sclera, a sinustrabeculectomy and iridectomy were performed. Drainage tape "GLAUTEX" was introduced into the scleral tunnel with a spatula, until the drainage strip exits the sclera by 1 mm. The edge of the tape is tightened with tweezers to the place of sinustrabeculectomy, straightened, repositioned the scleral flap. Two sutures were placed on the scleral flap and conjunctiva. The postoperative course was uneventful. The patient was discharged on the third day after the operation.

Dynamic examination 18 months after surgery: visual acuity 0.5 n / a. The field of view has expanded to 50 degrees from the bow. The filter cushion is flat and wide 6 mm from the limb. The drain tape has dissolved. She did not receive antihypertensive therapy. IOP according to Maklakov 21 mm. Hg

Tonography: Ro = 17.5; C = 0.50; F = 2.12; K.B. (Po / C) = 35.

The patient is planned to undergo phacoemulsification of cataract + implantation of an eyepiece lens in the right eye.

The proposed method dramatically reduces the likelihood of developing a cystic filtration cushion in the limbal region, which prevents the development of early postoperative ciliochoroidal detachment. The small size of the surgical site reduces the trauma of significant tissue volumes, which means the development of an inflammatory reaction followed by scarring of the operating bed. The additional filtration zone has a large area and does not undergo obliteration for a long time. The time of the operation is reduced, and the width of the additional tunnel is adjusted by the surgeon for the purpose of optimal and individual discharge of IHF in the early and late postoperative period.

The method of surgical treatment of glaucoma allows to stop the progression of glaucomatous optic neuropathy, to stabilize the normal values of intraocular pressure.

The use of the method of surgical treatment of glaucoma is possible in all ophthalmic medical institutions or departments, which provide operational assistance in the operating room.

Claims (1)

A method for the surgical treatment of glaucoma, including cutting out a superficial scleral flap, performing a sinustrabeculectomy, characterized in that after sinustrabeculectomy, in the upper part of the scleral bed, at a depth

parts of the sclera create a tunnel incision 2.2 mm wide and 2.0 mm long with a disposable 2.2 mm knife, extending to the surface of the sclera, and through it with a spatula, a drainage tape "Glautex" is introduced in the form of a rectangular flap measuring 5.0 × 1.8 × 0.15 mm, until it leaves the sclera on one side by 1 mm, and on the other hand, interrupted sutures are applied to the scleral flap and conjunctiva.