RU2146117C1 - Combined surgical method for treating primary glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves forming integral rectangular flap with two pedicles at the flap apex, from superficial sclera layers taking 1/3 or 1/2 of its thickness. The scleral flap is bent over the cornea. Penetrating incision is made in the deep layers of the sclera in the pedicle base projection area to reach suprachoroid space all over the whole width of the scleral flap. Deep layers of the filtering zone are exsected near limb together with sinus and trabecula in the form of triangle. Basal iridectomy is carried out through the triangular access hole built. Both scleral pedicles are pushed with spatula into the suprachoroid space through linear incision. The central part of the flap apex is sutured to convex sclera part with single U-shaped suture so that the canal provides free circulation of the intraocular fluid from the anterior part under the flap and into the posterior part. The superficial flap is attached to the surrounding sclera. EFFECT: reduced risk of traumatic complications; stable hypotensive action. 4 dwg

Description

 The invention relates to medicine, namely to ophthalmology, and is intended for the surgical treatment of patients with primary glaucoma.

 Known surgical methods for the treatment of primary glaucoma, aimed at enhancing the outflow of intraocular fluid mainly along the anterior drainage system of the eye, for example trabeculectomy, / J. E. Cairns, American J. Ophthalmology, 1968, v. 66, No. 4, p. 673-679 /.

 Along with this, there are operations that activate the outflow of intraocular fluid along the posterior, uveoscleral pathway, which are less traumatic, do not cause a pronounced drop in intraocular pressure and avoid early postoperative complications and achieve a more stable hypotensive effect / S.N. Fedorov. Bulletin of Ophthalmology, 1982, N 4, p. 6-10 /.

 Recently, there has been a tendency to develop combined operations that combine the positive aspects of both the first and second types of interventions.

 The prototype of the invention is a combined operation of the filtering iridocycloretraction / A.P. Nesterov. Primary Glaucoma, 2nd Edition. M.: Medicine, 1982 /, which consists in the formation of two surface strips of the sclera with the base to the limb and conducting them into the supraciliary space through a T-shaped incision in the anterior drainage system of the angle of the anterior chamber with subsequent excretion through the second incision at the top of the scleral bed - the posterior section eyes.

 Thus, the T-shaped incision implements the idea of activating the outflow of intraocular fluid along the anterior drainage system of the eye, and conducting scleral flaps into the supraciliary space with their subsequent excretion in the posterior part of the eyeball contributes to the activation of the outflow of intraocular fluid along the posterior, uveoscleral pathway.

 The disadvantages of this method are the need to cut out two separate flaps, significant invasiveness of the operation associated with conducting the obtained flaps into the supraciliary space, scarring of the T-shaped incision associated with a snug fit of the tissues of the scleral flaps and the deep layers of the sclera, and this, in turn, leads to reducing the outflow of intraocular fluid from the angle of the anterior chamber to the posterior part of the eye.

 The aim of the invention is to reduce the morbidity of the operation, obtaining a stable hypotensive effect due to the activation of the outflow of intraocular fluid along the anterior drainage and posterior, uveoscleral path.

 This goal is achieved by creating a fistulizing element in the anterior drainage system and draining the suprachoroidal space of the eye under a single scleral flap.

 In FIG. 1, 2, 3, 4 depicts a method of combined surgical treatment of primary glaucoma.

 The method is as follows. In the lower-outer sector of the eyeball, 6 mm from the limbus and parallel to it, a conjunctiva incision is made, 8-10 mm long, after which it is separated together with the subconjunctival tissue to the limbus. On the lower and outer rectus muscles of the eyeball, suture-holders are applied. After preliminary hemostasis from the surface layers of the sclera, one third or half of its thickness forms a single rectangular flap 1 13-15 mm long, 7-8 mm wide, with two legs 2 at the top of the flap, 2x7 mm / fig. 1/.

 The scleral flap is bent onto the cornea, in the deep layers of the sclera, in the projection of the base of the legs / about 7 mm from the limb /, a through incision 3 is made to the suprachoroidal space for the entire / Fig. 3/ scleral flap width under the control of a spatula / Fig. 2/. In the limb, the deep layers of the filtering zone are excised together with the sinus and trabeculae in the form of a triangle 4 after preliminary determination of the projection of the Schlemm's canal. The dimensions of the excised section of the drainage zone 2.5x2.5 mm. In all cases, a basal iridectomy 5 is performed through the obtained triangular access. Then both scleral legs 2 are tucked with a spatula into the suprachoroidal space through a linear incision 3 / Fig. 4/. Being spacers for the incision, they open it for the directed current of intraocular fluid from the fistulizing opening of the anterior chamber angle to the posterior section - the suprachoroid space. The central part of the flap apex is sutured to the convex part of the sclera with one U-shaped suture (Fig. 4/) so that a channel for free circulation of intraocular fluid from the anterior section under the flap 1 to the posterior suprachoroid space is formed under the flap.

 Two additional sutures are applied about 3-4 mm from the limb to fix the surface flap 1 to the surrounding sclera / Fig. 4/. The conjunctival wound is sutured with a continuous suture.

 Example. Patient K., 60 years old, with a diagnosis of the right eye - open-angle far-reaching, uncompensated glaucoma. The left eye is open-angle, terminal, uncompensated glaucoma. The right eye was previously operated on for glaucoma. An antiglaucomatous operation was performed twice on the left eye. Visual acuity at admission: the right eye is 0.04, the left eye is the movement of the hands of the face.

Fields of vision on the right eye for a total of 8 meridians - 220 degrees, the left eye - are not determined. Intraocular pressure: right eye - 45 mm RT. Art., left - 35 mm Hg Electrotonography data: the right eye P _about - 35.6 mm Hg, C - 0.02 mm ³ / min / mm Hg F - 0.46 mm ³ / min. Left eye: P _about - 25.2 mm Hg, C - 0.08 mm ³ / min / mm Hg, F - 0.84 m ³ / min. Electrophysiological examination: right eye - electrical sensitivity - 660 μA, electrical lability - 37 Hz; left eye - thresholds are not determined.

 In January 1994, a two-chamber drainage was performed on the right eye, after 3 months on the left eye. Operations were performed in the lower external sectors of the eyeball. The conjunctiva was cut parallel to the limb with a length of 10 mm, after preliminary separation of it and the application of suture-holders on the lower and external rectus muscles, hemostasis of the scleral vessels was made. A single rectangular sclera flap was formed and cut into one third of the thickness 14 mm long, 7 mm wide, with two legs on the top of the flap, 2x7 mm in size. The scleral flap is folded back onto the cornea, near the limb the deep layers of the filtering area are excised together with the sinus and trabecula in the form of a triangle, 2.5x2.5 mm. Through triangular access, a basal iridectomy was performed.

 Then, both scleral legs are tucked into the suprachoroidal space through a linear incision. The central part of the top of the flap is sewn to the convex part of the sclera with one U-shaped suture. Two additional sutures were placed 4 mm from the limb for fixing the superficial and deep layers of the sclera. The conjunctival wound is sutured with a continuous suture.

The operation and the postoperative period proceeded without complications. The patient was examined after 1 year. Visual acuity remained the same. The field of view of the right eye expanded to 290 ^o , the left - 25 ^o . Intraocular pressure stabilized - the right eye - 20 mm Hg, left - 22 mm Hg Electrotonography of the right eye: P _about - 17.1; C 0.27; F - 1.87. Left eye: P _about - 18.6; C 0.29; F - 2.57.

After 3 years, visual acuity was observed in both eyes. The field of view of the right eye expanded to 320 ^o , the left eye - preserved. Intraocular pressure was stably compensated in both eyes; on the right - 21 mm RT. Art., on the left - 19 mm RT. Art.

 The positive effect of the operation is to cut out a single superficial scleral flap and lay most of it in the formed bed of the deep layers of the sclera, which significantly reduces the invasiveness of the operation. The formation of a triangular trabeculectomy in the corner of the anterior chamber, supplemented by basal iridectomy, the introduction of a single scleral flap into the suprachoroidal space of the posterior part of the eyeball, the creation of a channel for direct and directed intraocular fluid flow from the anterior chamber to the posterior section under a single scleral flap provides a stable hypotensive effect of the operation.

Claims (1)

 A method for the combined surgical treatment of primary glaucoma by forming a superficial scleral flap and introducing it into the subscleral space, creating an outflow of intraocular fluid along the anterior and posterior uveoscleral pathways, characterized in that a single rectangular scleral flap is formed from the limbus to the posterior segment of the eye with two legs at its apex , at the base of the projection of the legs, a linear incision is made of the deep layers of the sclera to the suprachoroidal space, at the limb they perform a trabeculect In the form of a triangle, basal iridectomy is performed through the obtained access, the legs of the single scleral flap are inserted into the suprachoroidal space in the form of spacers through a linear section of the deep layers of the sclera to form the canal and create sclera under the rag, free circulation of intraocular fluid from the anterior to the posterior, then the scleral the flap is fixed in a bed with three interrupted sutures.

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