RU2168965C1 - Method for making anterior eye chamber in performing antiglaucoma operations - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves using tubular drainage with distal end positioned in subtenon space outside of eye equator. The distal end of the drain tube is wrapped in advance with amniotic membrane dried with silicon. EFFECT: improved quality of glaucoma treatment. 1 dwg

Description

 The invention relates to medicine, namely to ophthalmology, to the surgical treatment of secondary glaucoma and the treatment of primary refractory glaucoma, which are not amenable to traditional methods of surgical treatment.

 There is a method of surgical treatment of secondary glaucoma, which consists in the formation of a new path of outflow of intraocular fluid through a tubular drainage passing from the anterior chamber beyond the equator of the eyeball into the subthenon space, with fixation of drainage by two sutures (Kabanov IB, Abstract of Cand. Science.- M., 1986). The main disadvantage of this method is the frequent development in the postoperative period of obstruction of the distal end of the drainage in the subtenon space, with a violation or complete cessation of the outflow of intraocular fluid through it, which is accompanied by a again increase in intraocular pressure.

 A known method of surgical treatment of glaucoma with the formation of a new path of outflow of intraocular fluid through a tubular drainage from the anterior chamber of the eye behind its equator into the subtenon space, in which the distal end of the drainage is carried out under a silicone explant 12-15 mm long, fixed with two U-shaped sutures to the sclera ( Kasparov A.A., Malozhen S.A., Vet.Ophthalmol. - 1993.- T. 109, N 1. - S. 6-8). Sheltering the distal end with an explant made of spongy silicone rubber hollow inside, it would seem, should in a certain way protect it from obstruction by the surrounding tissues of the operated eye. However, with long-term follow-up of patients - more than 1 year, in some patients (2 eyes), 15 patients were operated on (15 eyes), infection of a spongy silicone explant with its subsequent eruption outside the conjunctiva was noted of different genesis. This formidable postoperative complication required repeated surgery to remove the explant. The subsequent obstruction of the distal end of the drainage that developed led to a violation of the outflow of intraocular fluid and an increase in intraocular pressure. At the same time, the infection is highly likely to penetrate through the drainage cavity into the anterior chamber cavity or into the fiber surrounding the eyeball, i.e., the use of a silicone explant to cover the distal end of the drainage threatens to develop a situation that can result in complete death of the eye.

 The aim of the invention is to increase the reliability and effectiveness of antiglaucomatous bypass surgery of the anterior chamber of the eye - preventing obstruction of the lumen of the drainage in the postoperative period.

 This goal is achieved by the fact that the distal part of the tubular drainage is preliminarily wrapped with a canned amniotic membrane with an epithelial surface outward, with the edge of the coating projecting 4-6 mm beyond the end of the drainage, and the covered part is introduced into the subtenon space beyond the eye equator.

 The use of an amniotic membrane in ophthalmology is known in the treatment of conjunctival defects, with burns of the cornea, keratitis, with scleroplasty, with recurrent aseptic erosion of the cornea with ulceration. The amniotic membrane is a fairly common material, available, widely used in ophthalmology.

 The drawing shows a diagram of the operation of shunting the anterior chamber of the eye according to the proposed method.

 The method is illustrated by the following clinical examples.

 Example 1

 Patient I., 52 years old, IB N 1965, was admitted to the hospital with a diagnosis of mesodermal dystrophy of the iris of the left eye, secondary operated uncompensated glaucoma, immature complicated cataract. From the anamnesis it is known that the diagnosis of mesodermal dystrophy of the iris was established in 1978. In 1989, due to secondary glaucoma with a sharp increase in intraocular pressure (up to 37 mm Hg. According to Maklakov), a sinusectomy was performed on the left eye, due to the lack of compensation for the level of intraocular pressure, in 1994 a trabeculectomy was made, on a drug regimen intraocular pressure remained subcompensated. At the beginning of 1998, intraocular pressure increased, pains appeared in the left eye, and on 10.06.98 a trabeculectomy was performed with silicone drainage explantation (2 hours along the meridian). 1 month after surgery, an increase in intraocular pressure and the appearance of pain in this eye were again noted.

2.07.98, the patient was admitted to the clinic for surgical treatment. The visual acuity of the left eye at admission was equal to the movement of the hand in the face (correct light projection). The field of view, when determined by a 4 / V object on a sphere perimeter, is narrowed by 20 ^° from the nasal and temporal sides, and by 15 ^° from the bottom. Intraocular pressure was determined by the OTM-01 microdeformation tonometer in the supine position, on the left eye it was 34 mmHg. During biomicroscopic examination, drainage contours were observed under the conjunctiva of the eyeball along the meridian of 2 hours. Ribbon-like degeneration of the surface layers of the corneal stroma. The anterior chamber is of medium depth, its moisture is transparent. The iris is subatrophic, its pattern is faded, at 2 o’clock - a basal coloboma, the pupil is shifted down. Diffuse opacification of all layers of the lens. The fundus reflex is very weak, ophthalmoscopy fails.

The patient underwent an antiglaucomatous operation of shunting the anterior chamber of the left eye according to the proposed method. The operation was carried out as follows. Processing of the surgical field is common. Retrobulbar anesthesia and akinesia with a solution of 2% novocaine - 6.0 ml. The upper rectus muscle was taken on the frenum suture, an eyelid was inserted. In the upper half of the eyeball, along the meridian of 12 hours, a conjunctival flap was separated to the limb. A superficial scleral flap was cut out to 1/2 of its thickness of a rectangular shape with a base to the limb measuring 5x10 mm. The drainage (see drawing) was a silicone tube 1, the inner diameter of which was 0.3 mm, the wall thickness was 0.1 mm, so that the external was 0.5 mm. The drainage length was 22 mm. Anterior chamber - the proximal end is cut off at an angle of 45 ^o and facing the posterior epithelium (endothelium) of the cornea on the wall opposite to the cut, at an distance of 0.8 mm from its end there is an additional hole with a diameter of 0.5 mm. The canned amniotic membrane, dried and stored on silica gel, 10 × 15 mm in size, was pre-soaked in a disinfectant solution - 50 ml - 0.02% aqueous solution of chlorhexidine + 80 mg gentamicin + 500000 IU ampicillin with an exposure of 7 minutes, after which it was placed for the same time in 0.9% isotonic sodium chloride solution. The drainage tube was fixed to the sclera in two places with flanging sutures with a piercing through the tube (supramide 8/0) - the first suture was applied 6 mm from the limb, the second - 12 mm from the limb. At the base of the scleral flap, in the trabecular area of the sclera, a 1.5 mm long through section was made with a fragment of the blade. The proximal end of the drainage was introduced into the anterior chamber by beveling to the corneal endothelium. A scleral flap covered the drainage tube and 4 nodal sutures (Supramid 8/0) were placed - 2 sutures on its tops and 2 sutures in the middle of each of the sides. The distal part of the tubular drainage was pre-wrapped with a prepared amniotic membrane (2, see drawing) so that its surface covered with epithelium was turned outward (to the surrounding tissues of the eye). At the same time, the part of the amniotic membrane wrapped around the tube was tightly tied with supramide thread (8/0) at a distance of 10 mm from the distal end of the tube, and the rest of the membrane, also wrapping the drainage, was positioned more freely so that the edge of the amniotic membrane overlapped the distal end of the drainage tube by 5 mm. The sheltered distal part of the drainage tube was introduced into the subthenon space beyond the equator of the eye. After that, the tenon capsule together with the conjunctiva was carefully sutured with a continuous suture (supramide 8/0). The operation was completed by administering an antibiotic and steroid in the solution under the conjunctiva, after which the frenum suture and eyelid were removed. Monocular bonding was applied. Surgery went without complications.

 The postoperative period was uneventful and on the 7th day the patient was discharged from the clinic. At discharge, intraocular pressure was determined, equal to 19 mm Hg on the operated eye. (when measured with an OTM-01 tonometer), the boundaries of the field of view and visual acuity remained the same as when they were received. 2 weeks after surgery, the conjunctival suture was removed. Subsequently, every 2 months the patient underwent control functional studies - the level of intraocular pressure, the boundaries of the visual field remained stable. 18 months after surgery, complete compensation of the level of intraocular pressure in the left eye was maintained = 20 mm RT. Art., the boundaries of the field of view and visual acuity remained at the same level. During biomicroscopic examination under the conjunctiva, the presence of 2 tubular drainages along the meridians of 12 and 2 hours, tape-like degeneration of the cornea, anterior chamber of medium depth, the anterior chamber end of drainage along the meridian of 12 hours, dystrophy of the iris and peripheral coloboma, diffuse opacification of all crystal layers were determined. The patient was preparing for cataract extraction surgery on this eye.

 Thus, the successful operation of bypass surgery of the anterior chamber of the eye according to the proposed method, with the normalization of intraocular pressure for 1.5 years, allowed the patient to perform cataract extraction surgery with increased visual acuity.

 Example 2

 Patient B., 70 years old, information security N 897, was admitted to the hospital for repeatedly operated uncompensated angle-closure glaucoma, the condition after end-to-end peripheral keratoplasty, and artifact on the right eye.

 From the anamnesis it is known that for the first time in 1992, angle-closure glaucoma was revealed on the right eye, for which laser iridectomy was performed in December this year. In October 1995, an operation was performed on this eye for cataract extraction with implantation of an intraocular lens, and in November of the same year, anterior vitrectomy was performed. The intraocular pressure of the right eye began to increase, in the drug regimen - arutimol 0.5% - 3 times a day, intraocular pressure = 49 mm Hg. (when measured with an OTM-01 microdeformation tonometer) and in October 1996, a trabeculectomy was performed on this eye with basal iridectomy, dissection of the anterior synechia, and explantation of a hydrogel insert. In the postoperative period, there was a lack of compensation for the level of intraocular pressure and there was a thinning of the cornea in the area of the postoperative scar (scar after cataract extraction) and its protrusion with the formation of staphyloma of the corneal-scleral region with a diameter of about 6.5 mm - as a result of an increase in intraocular pressure. For this reason, in January 1998, a through therapeutic peripheral corneal transplant was performed with silicone drainage explantation, the latter was placed in the anterior chamber along the meridian for 12 hours. 2 months after the operation, an increase in intraocular pressure was again noted in a very strong medication regimen: fotil - 2 times and trisopt - 2 times a day in the right eye. In March of the same year, trabeculectomy was again performed with the explantation of a hydrogel insert in this eye. The day after the operation, the appearance of a total hyphema with staining of the cornea with blood pigment was noted. Subsequently, in a medication regimen - optimol 0.5% - 2 times in the right eye, intraocular pressure remained subcompensated. However, in early 1999, signs of decompensation of intraocular pressure reappeared: there was a prominence of a transplanted corneal transplant and severe pain in this eye.

03.03.99, the patient was admitted to the clinic for surgical treatment. The visual acuity of the right eye upon admission equaled the correct light projection from three sides and was absent from above. The field of view of this eye, when determined by a 4 / V object on a sphere perimeter, is narrowed from above to the fixation point, from the nose to 20 ^o , from the temporal side to 50 ^o , from below to 10 ^o . When determining the intraocular pressure with a microdeformation tonometer (OTM-01), it was 37 mmHg. Biomicroscopy determined the severity of a translucent peripheral transplant; it was not possible to determine the drainage under the conjunctiva at the upper limb. The cornea is translucent, with traces of yellow blood pigment in the thickness of the stroma, with the ingrowth of newly formed superficial and deep vessels. The anterior chamber is of medium depth, on the endothelium of the cornea pigment deposition. The iris is atrophic, the pupil is oval. An intraocular lens is contoured in the posterior chamber. The fundus reflex is weakly pink. Ophthalmoscopy is not possible. The patient underwent an antiglaucomatous operation to shunt the anterior chamber of the eye according to the method described above with preliminary removal of the previous tubular drainage. Surgical field treatment, anesthesia, akinesia were performed as usual. A conjunctiva was opened above the projection site of the previous drainage and the conjunctival flap was separated to the limbus. The distal end of the drainage was isolated from cicatricial adhesions, while no outflow of intraocular fluid was noted along it, the attempt to flush the drainage failed, the fluid did not pass through it into the anterior chamber. After that, it was concluded that both ends of the drainage are impassable. Above the proximal part of the drainage a superficial scleral flap was cut with dimensions of 5x9 mm along the meridian of 12 hours. The drainage was removed from the anterior chamber and completely removed. In its place was placed a new tubular drainage made of silicone rubber with an inner diameter of 0.3 mm, a wall thickness of 0.15 mm, an outer diameter of 0.6 mm and a length of 21 mm. Further, the operation with respect to the proximal part of the drainage was performed as described in example 1. In this case, the distal part of the tubular drainage was pre-wrapped with a pre-prepared canned amniotic membrane 12x15 mm in size so that its epithelial surface was facing outward and the free part of the membrane protruded beyond the end of the drainage by 4 mm. The amniotic membrane wrapped around the tube at a distance of 9 mm from its distal end was ligated with nylon thread (8/0). After that, the sheltered part of the drainage was introduced into the subthenon space beyond the equator of the eye and the operation was completed. The operation was uneventful, the postoperative period was uneventful and a week later the patient was discharged from the hospital. Visual acuity and the boundaries of the field of vision at discharge remained the same as at admission, the intraocular pressure of the operated eye was determined = 18 mmHg. (when measured with an OTM-01 tonometer). 2 months after the operation, the figures for intraocular pressure remained stable within normal limits, as well as in subsequent control measurements every 2 months. 1 year after the operation, full compensation of the level of intraocular pressure in the right eye was maintained = 21 mmHg, visual acuity and the boundaries of the field of vision did not change. In a biomicroscopic examination of the upper limb under the conjunctiva, drainage contours were determined, the peripheral corneal graft was almost cloudy, the cornea was generally translucent, and the number of newly formed vessels in it decreased. The anterior chamber is of medium depth, along the meridian of 12 hours, the proximal end of the drainage is well seen, the iris is subatrophic, the pupil is oval. The fundus reflex is weakly pink.

 Thus, it would seem that a simple method of covering the distal part of the tubular drainage with a preserved amniotic membrane, applied in the proposed manner, allowed us to normalize the increased intraocular pressure with significant tissue deformation after numerous previous antiglaucomatous operations and to avoid physical death of the eye.

 Example 3

 Patient P, 36 years old, IB N 1960, was admitted to the hospital on 05/12/99 with a diagnosis of epithelial ingrowth into the anterior chamber of the left eye, secondary operated subcompensated glaucoma, and artifact. From the anamnesis it was found that in June 1998 he received severe contusion of the eyeball, complicated by hemophthalmus. After that, secondary glaucoma developed on this eye and an antiglaucomatous operation was performed. In October of the same year, a traumatic cataract was extracted with implantation of an intraocular lens. In December 1998 - laser dyscision of secondary cataract. In the drug antihypertensive regimen - arutimol 0.5% - 3 r, a subcompensation of intraocular pressure was noted per day. In the last weeks before entering the clinic in the left eye appeared severe undecreased pain.

 The patient was admitted to the hospital clinic for the surgical treatment of glaucoma. The visual acuity of the left eye at admission was 0.01, not corrected. The field of view of this eye, when determined by a 4/3 object on a sphere perimeter, is almost normal. When determining the intraocular pressure with an OTM-01 microdeformation tonometer, it was 33 mmHg. (lying down). Biomicroscopy noted congestive injection of the conjunctiva of the eyeball. In the cornea along the upper limb there is a scar with the presence of an X-shaped suture, moderate swelling of the epithelium and superficial stromal layers, along the posterior surface of the cornea, the growth of a translucent membrane occupying 2/3 of its upper part, with clear borders in the form of “tongues”, in its lower third single brown small precipitates on the endothelium. The anterior chamber was determined by uneven depth; the anterior synechia was measured along the meridians from 1 to 2 hours. The iris along the meridians from 10 to 11.30 h was absent, the pupil is very wide (traumatic mydriasis), irregular in shape. An intraocular lens rotated along the horizontal axis was determined in the posterior chamber, followed by the remains of a dense translucent posterior lens capsule. Rough floating opacities in the vitreous. During ophthalmoscopy, it was found that the optic disc is bright pink, its borders are clear, the vascular bundle is almost in the center, the retinal vessels are narrowed. The antiglaucomatous operation of shunting the anterior chamber of the eye in its main part was performed according to the method described above, as in Example 1. The proximal part of the tubular drainage was fixed to the deep layers of the sclera with two flap sutures (nylon 8/0) under the scleral flap and through an incision in the trabecular scleral zone introduced into the front camera. The proximal part of the drainage towards its distal end continued as a tube (i.e., a part of the drainage system was represented by a silicone tube with an inner diameter = 0.3 mm, wall thickness = 0.15 mm, an outer diameter = 0.6 mm, length - 13 mm), and ended in a cavity of a silicone hemisphere with a diameter of 9.0 mm, a height of 2.0 mm, with a wall thickness of 0.15 mm, with through holes on the rear side surface with a diameter of 0.1 mm, having on its front facing to limb 2, small protrusions with holes for fixing. The distal part of this tubular drainage system, represented by a hollow inside the silicone hemisphere, was inserted into the subthenon space beyond the equator of the eye, placed on the exposed sclera and sutured to it by two interrupted sutures (nylon 8/0) passing through holes in two front protrusions of the hemisphere. Then, a canned amniotic membrane soaked in a disinfectant solution, as in Example 1, was placed on top of a fixed hemisphere, with the epithelial part of the membrane facing outward, so that the free edges of the amniotic membrane protruded 1.5 mm beyond the hemisphere along the perimeter. Then they carefully covered both parts of the drainage system with a tenon capsule along with the conjunctiva and carefully sutured them with a continuous suture (nylon 8/0). The operation was completed by administering an antibiotic and steroid under the conjunctiva in solution, after which the frenum suture and eyelid were removed. Monocular bonding was applied.

 In the postoperative period, prolonged hypotension was noted. From the anamnesis it was known that the first standard antiglaucomatous operation, carried out as early as the fall of 1998, was also accompanied by persistent and prolonged hypotension. In our case, neither clinical data nor ultrasound revealed a ciliochoroidal detachment. After 10 days, the patient was discharged from the clinic. The visual acuity at discharge was 0.01, it is not corrected, the boundaries of the visual field, as at admission, are normal. Intraocular pressure of the left eye with tonometry (OTM-01) = 12 mm Hg After 2 months after the operation, the intraocular pressure was completely normalized, when measured with an OTM-01 tonometer = 19 mmHg. and kept at this level during subsequent dynamic observation. 10 months after surgical treatment, the visual acuity of the left eye = 0.08, is not corrected, the boundaries of the visual field are normal. When measuring intraocular pressure, it was 20 mmHg. Biomicroscopic examination revealed the absence of edema of the epithelium and the surface layers of the corneal stroma, its optical section was of normal thickness, and the translucent membrane grown into the anterior chamber of the epithelium did not increase in area of the lesion of the posterior corneal surface. On the meridian of 2 hours, the anterior chamber part of the drainage was well viewed. The front camera is also generally uneven. The iris is atrophic, from 10 to 11.30 hours. A defect in its tissue, the pupil is wide, irregular in shape. An intraocular lens was determined in the posterior chamber, rotated, with the remains of a translucent posterior lens capsule behind it. In the vitreous body, the amount of rough floating turbidity slightly decreased. During ophthalmoscopy, the optic nerve disc was pink, with clear boundaries, and the central location of the vascular bundle. The macular region was not determined in detail.

 Thus, the claimed method made it possible to achieve not only the normalization of intraocular pressure on the operated eye for a long (up to 10 months) observation period, but also to increase its functionality by increasing visual acuity by 8 times.

 Despite the apparent simplicity of the claimed technical solution, the feasibility of covering the distal end of the tubular drainage with a preserved amniotic membrane to prevent obstruction of its channel is not obvious to a highly qualified ophthalmologist surgeon. This operation was performed by us for the first time. It eliminates the use for these purposes of complex and expensive special designs of drains and significantly improves long-term results of treatment.

 The proposed simple and new technical solution was the result of a long research work and a practical search for a reliable way to shunt the anterior chamber of the eye with secondary and primary glaucoma, refractory to traditional surgical methods of treatment. The method is technically easy to carry out, does not require scarce materials and can be applied directly according to the present description in the conditions of any ophthalmic surgical hospital. The claimed method has important medical, economic and social significance.

Claims (1)

 A method of shunting the anterior chamber of the eye during antiglaucomatous operations, including the use of tubular drainage with the distal end placed in the subtenon space behind the eye equator, characterized in that the distal end of the drainage is pre-wrapped with a silicone-dried amniotic membrane.