RU2143250C1 - Method for treating patients suffering from a combination of glaucoma and cataract - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves producing superficial scleral flap by means of hammock cut. Intrascleral canals are formed under it. The canals are continued from a zone selected for trabeculectomy to be performed, over scleral flap bed and beyond the latter. Trabeculectomy is carried out behind the place the anterior chamber is accessed after performing phacoemulsification, implantation and rotation of intraocular posterior chamber lens with optical part diameter of 6 mm. EFFECT: improved hypotensive effectiveness; reduced postoperative astigmatism and other complications. 4 dwg, 2 tbl

Description

 The invention relates to medicine, namely to ophthalmic surgery.

 Cataracts and glaucoma are the leading causes of blindness worldwide. Affecting mainly the elderly, both of these diseases are often combined. With the combination of open-angle glaucoma with severe opacities in the lens, combined surgical interventions are indicated. Today, when it is possible to remove a cataract and implant an intraocular lens through a small incision, works appear in which the authors try to combine the advantages of phacoemulsification with various modifications of trabeculectomy (Hansen LL, Hoffmann F., 1987; Pasquale LR, Smith SG, 1992: Wedrich A. et al., 1992; Allan B., Barret GD, 1993: Nelson DB, Donnenfeld ED, 1994).

 Unfortunately, as a result of trabeculectomy performed under the scleral coating, the superficial flap usually comes into close contact with the deep layers of the sclera, as a result of which the newly formed pathways of the outflow of aqueous humor, providing normalization of intraocular pressure (IOP), can overgrow, which in turn leads to repeated increase ophthalmotonus.

 The use of 5-fluorouracil to improve the hypotensive effect when combining phacoemulsification with posterior chamber IOL implantation and trabeculectomy proved to be ineffective (O'Grady J.M. et al., 1993). Skuta G.L. et al., 1992, it was noted that the use of mitomycin C in comparison with 5-fluorouracil was more effective during the intervention. However, despite the high hypotensive effect, the use of mitomycin during combined interventions for cataracts and glaucoma can lead to excessive filtration of aqueous humor in the postoperative period (Costa VP et al., 1993), causing a decrease in visual function due to hypotension and symptomatic maculopathy ( Shields MB et al., 1993).

 A. A. Kugleev et al. (1991) proposed a method for the treatment of open-angle glaucoma, in which nonperforating scleral incisions are made under the scleral flap to ensure a stable hypotensive effect, continuing from the trabeculectomy zone throughout the scleral flap and beyond, which turn into intrascleral "channels" by applying coagulates to the edges of these incisions. However, this operation was used only for the treatment of patients with primary open-angle glaucoma, and if cataract extraction was required, then it was performed by the second stage according to the extracapsular technique.

 Closest to the claimed technical solution is the method proposed by F. M. Gregg (1992). The method consists in combining phacoemulsification with IOL implantation and modified trabeculectomy. After the formation of a 4-6 mm conjunctival flap with the base to the upper arch and corneal paracentesis in the limb in the upper temporal section (for bimanual phacoemulsification), a superficial scleral flap is cut with the base to the limb, 1/2 of the sclera thickness. In this case, the flap height does not exceed 2-2.5 mm, and the width can be 4.5 mm and then the flap has a rectangular shape or 6 mm and then the upper incision is concentric to the limb, and the flap has an L-shape. The anterior chamber is opened using a keratome (3.2 mm), phacoemulsification is performed after capsulorexis, and an IOL from polymethyl methacrylate (PMMA) with an optical diameter of 6.0 mm or 5x6 mm is implanted. IOLs rotate so that the haptic portions are horizontal. Perform trabeculectomy 1.5x3.0 mm and peripheral iridectomy. Impose 10-0 polypropylene sutures on the corners of the scleral flap and suture on the conjunctiva. The disadvantages of this method are: firstly, the low height of the superficial scleral flap, which can lead to the formation of cystic filtering pads in the limb, which provide a poorly dosed reduction in IOP mainly by external filtration of aqueous humor and are easily injured, and secondly, the risk of infection of the neoplasms ways of outflow of aqueous humor due to close contact of the superficial scleral flap with deep layers of the sclera and, thirdly, the possibility of developing severe astigmatism ism in the postoperative period, as the shape of the incision (linear or concentric limbus) with its length of 4.5–6.0 mm, which determines the width of the scleral flap, is 1.5–2 times larger than similar sections used in conventional phacoemulsification. It is known (P.S. Koch, 1992) that with such a length, the best prophylaxis of postoperative corneal astigmatism is the use of the so-called “frown” incision.

 The aim of the present invention is to improve the hypotensive effect, reduce postoperative astigmatism and the elimination of postoperative complications.

 The essence of the method consists in the formation of a superficial scleral flap (using a “hammock” incision), resembling a biconcave lens, under which nonperforating scleral incisions are made, continuing to “fan” from the trabeculectomy zone throughout the scleral bed and extend beyond it by applying coagulates on the edges of the incisions form intrascleral channels, perform phacoemulsification with implantation and rotation of the IOL.

 The method is as follows.

 The operation is performed under local anesthesia. We do not conduct standard akinesia, confining ourselves to the injection of novocaine (or lidocaine) into the orbit. This injection performs not only anesthetic function, but also lowers the tone of the rectus muscles, being, as it were, “intraorbital akinesia”. We introduce 3.0 ml of a 2% solution of novocaine or lidocaine through the lower eyelid, 8-9 mm from its edge, outward from the passage of the lower rectus muscle to a depth of 20 mm. We hold the needle vertically, without changing direction towards the muscular funnel or optic nerve. We introduce another 1.5 - 2.0 ml of anesthetic under the upper edge of the orbit, a few inwards from the passage of the superior rectus muscle. After that, in the eye, for 10 - 15 min, install the Honan oculocompressor, in which we create a pressure of 30.0 mm Hg. Compression leads not only to a decrease in ophthalmotonus, which is highly desirable for combined interventions, but also facilitates the penetration of the anesthetic deep into the orbit, to the location of the ciliary node.

 The operation is performed under an operating microscope with coaxial illumination.

 In FIG. 1 to 4 illustrate the steps of an operation.

 The conjunctiva is cut along the limbus. We form a 6-7 mm conjunctiva flap [1] with the base to the equator. 4 mm from the limb, we carry out a “hammock” incision of the sclera [2], having a length of 5 mm. We cut out the superficial scleral flap [3] on 1/3 of the sclera thickness, having the shape of a biconcave lens. Under the flap, we outline the zone of future trabeculectomy (1x3 mm) [4] and from the lower edge of this zone we draw 3 fan-shaped diverging incisions of the middle and deep layers of the sclera [5], which extend by 1.5 - 2.0 mm beyond the borders of the bed of the scleral flap, to the place of attachment of the superior rectus muscle. Thermocoagulates are applied along the entire length of the edges of these incisions [6], causing a reduction in the sclera in the burn sites and the formation of “channels” in the incisions.

 We carry out corneal paracentesis in the limbus at 2 hours [7]. With the help of a keratome, we open the anterior chamber from under the sclera flap immediately anterior to the area of the future trabeculectomy. Introduce viscoelastic (Ocucoat, Healon, visiton) into the anterior chamber. We perform a continuous circular capsulotomy (capsulorexis). After excision of a portion of the anterior capsule (with a diameter of 5-5.5 mm), we carry out hydrodissection of the nucleus, which is the introduction of saline using a cannula under the flap of the remaining anterior capsule. The purpose of hydrodissection is to separate the nucleus from the cortical masses and facilitate its emulsification. During phacoemulsification, the core, depending on its density, is divided into 2 or 4 parts, in order to reduce the exposure time of ultrasound. Lens masses are removed using an automatic irrigation and aspiration system. We expand the opening zone of the anterior chamber [8] according to the size of the optical part of the IOL (we used the IOL from Storz PMMA — models P328UV with the optical part 5x6 mm and P485UV with the diameter of the optical part 5.0 mm). We implant the lens [9] intracapsularly, rotating it so that the extreme points of the supporting elements [10] are located at 9 and 3 hours and do not put further pressure on the area of trabeculectomy. We excise the previously marked strip of sclera in a place with a trabecula (1x3 mm). We perform basal iridectomy at 12 o’clock [11]. We put the superficial scleral flap into place and fix it with 2 knotted nylon sutures (10-0) [12]. We pull the conjunctiva to the limbus and coagulate with the help of bipolar forceps. Under the conjunctiva, we introduce a solution of dexazone with an antibiotic and apply a monocular dressing.

 Example. Patient A., 72 years old (medical history N 387/96) was admitted with a diagnosis of immature complicated cataract, primary open-angle developed with moderately elevated IOP, under myotics, glaucoma of the left eye. The operation was performed according to the proposed method - phacoemulsification with IOL implantation (P485UV + 17.0D) and trabeculectomy with intrascleral microdrainage. The operation and the postoperative period proceeded without complications. Visual acuity before surgery - 0.01 is not corrected. IOP (according to Goldman) - 26.0 mm Hg 7 days after surgery - 0.7 co sph -1.5D, cyl + 0.75D, ax115. IOP - 18.0 mm Hg. Art. After 6 months, visual acuity was 1.0 co sph -1.5D, cyl + 0.5D, ax11З. IOP - 18.0 mm Hg No filter cushion.

 In total, we performed 12 operations according to the proposed method (11 patients). The distribution of patients by gender and age is presented in table. 1, and the results of combined intervention for each patient are shown in table. 2.

 There were no complications during the operations. In the postoperative period in one patient 81 years old (and / b 5246/96) in the early postoperative period, the appearance of fibrinous exudate on the front surface of the IOL was noted. Using a YAG laser ("Visulas", Carl Zeiss Group), the exudate was destroyed in one session. The pronounced exudative reaction was probably associated with the prolonged use of myotics at the preoperative stage and the need for sphincterotomy during the operation. Ultrasound exposure time during this intervention (in terms of 100% power) was only 58 s.

 In 3 patients, the formation of flat-spilled filtration pads was noted. In other cases, a macroscopically expressed filtration pad was absent.

 Normalization of ophthalmotonus after surgery was achieved in all patients without additional use of myotics and β-blockers. The average astigmatism after the intervention was 0.75 D (from 0.25 to 1.75 D).

Thus, the use of the proposed method for surgical treatment of patients with a combination of cataract and glaucoma in comparison with the prototype method revealed the following advantages:
1) a more pronounced and persistent hypotensive effect is ensured due to the use of intrascleral microdrainage elements along with trabeculectomy;
2) the ophthalmotonus is reduced not so much due to the filtration of aqueous humor under the conjunctiva as due to the formation of an intrascleral depot, as well as the provision of a directed outflow of aqueous humor to the richly vascular area of attachment of the superior rectus muscle in cases when the sclera’s vascular-capillary network does not have time to absorb aqueous humor as it arrives from the front camera. This is a guarantee against the formation of cystic filtration pads;
3) minimized the possibility of developing severe astigmatism in the postoperative period through the use of the most physiological "hammock" incision in the formation of a superficial scleral flap.

Literature
1. Kugleev A. A., Lebekhov P.I., Astakhov S.Yu. A method for the treatment of open-angle glaucoma, autosvid. N 166431 1, Bull. N 27 from 07/23/1991.

 2. Allan D.D., Barret G. D. Combined small incision phacoemulsification and trabeculectomy. J.Cataract Refract. Surg., 1993, v. 19 (1): 97-102.

 3. Costa V.P., Moster M.R. et al. Effects of topical Mitomycin C on primary trabeculectomies and combined procedures. Brit. J. Ophth., 1993, v. 77 (11): 693-7.

 4. Gregg F.M. Phacoemulsification and modified trabeculectomy for managing combined cataracts and glaucoma. J. Cataract Refract. Surg., 1992, v. 18 (7): 362-5.

 5. Hansen L. L., Hoffmann F. Combination of phacoemulsification and trabeculectomy. Results of a retrospective study. Klin. Mbl. Augenheilk., 1987, v. 190 (6): 478-81.

 6. Koch P.S. Converting to Phacoemulsification. 3 Edition. Slack Inc., 1992.

 7. Nelson D. B., Donnenfeld E. D., Small-pupil phacoemulsification and trabeculectomy. International Ophth. Clin., 1994, v. 34 (2): 131-44.

 8. O'Grady J.M., Juzych M.S., Shin D.H. et al. Trabeculectomy, phacoemulsification and posterior chamber lens implantation with and without 5-fluorouracil. Am. J. Ophth., 1993, v. 116 (5): 594-9.

 9. Pasquale L. R., Smith S.G. Surgical outcome of phacoemulsification combined with the Pearce trabeculectomy in patients with glaucoma. J. Cataract Refract. Surg., 1992, v. 18 (5): 301-5.

 10. Shields M. B., Scroggs M.W., Sloop C.M., Simmons R.B. Clinical and histopathologic observations concerning hypotony after trabeculectomy with adjunctive Mitomycin C. Am, J. Ophth., 1993; 116: 673-83.

 11. Skuta G.L., Beeson C.C., Higginbotham E.G. et al. Intraoperative Mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery. Ophthalmology, 1992, v. 99: 438-44.

 12. Wedrich A., Menapace R., Radax U et al. Combined small-incision cataract surgery and trabeculectomy - technique and results. International Ophth., 1992, v. 16 (4-5): 409-14.

Claims (1)

 A method of treating patients with a combination of cataract and glaucoma by forming a scleral flap, performing a trabeculectomy after phacoemulsification, implanting and rotating a posterior intraocular lens with an optical diameter of 6 mm, characterized in that a “hammock” incision is used to form a surface scleral flap, under which an intrasclera is formed channels extending from the zone designated for trabeculectomy throughout the bed of the scleral flap and beyond, and trabeculectomy Follow the important posterior to the opening space of the anterior chamber.

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