RU2180539C2 - Surgical method for treating the cases of open angle glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves additionally separating and removing radial uveal layer of trabecula fibers in carrying out non-penetrating sinusotrabeculectomy. Hemostatic collagen sponge plate is placed over the so created operative bed. The plate completely covers the formed filtering membrane and fills the whole subepiscleral space. EFFECT: enhanced effectiveness of surgical treatment. 3 dwg

Description

 The invention relates to medicine, in particular to ophthalmic surgery, and can be used in microsurgical treatment of glaucoma.

 A widespread method for the treatment of open-angle glaucoma is non-penetrating deep sclerectomy - NSES [1]. Modifications of this method are known aimed at enhancing and prolonging the hypotensive effect. So, the authors of [2] developed a non-GSE with collagenoplasty using artificial drainage from cross-linked lyophilized collagen, which creates an intrascleral cavity for the outflow of intraocular fluid, filtered through a trabecular network and a descemetic membrane.

 Known drainage from a copolymer of collagen with monomers of the acrylic series, having a high moisture permeability, which over time increases even more with the absorption of collagen [3]. The latter in the form of a rectangular plate is placed under the superficial scleral flap in the bed, formed at the site of removal of the triangular sclera flap with the outer wall of the Schlemm canal and the area of the corneal tissue of the limb to the descemet membrane. But at the same time, only part of the formed filtration membrane is covered with drainage and not the entire volume of the formed subepiscleral bed is filled. Over time, in the postoperative period, the unclosed portion of the filtration membrane and the unfilled volume of the subepscleral space begin to fill with fibrous and scar tissue, which leads to a decrease in the hypotensive effect, which is a disadvantage of the known method.

 The closest in technical essence and the effect obtained is an operation called non-penetrating sinus strabeculectomy [4, 5], according to which, after performing NSES, in order to increase the filtration efficiency, the Schlemm's canal endothelium, juxtacanalicular tissue and the following layers are removed: corneoscleral and uveal meridional fibers trabeculae before exposure of the layer of uveal radial fibers (descemetociliary layer) trabeculae. However, in this case, it is not possible to create a sufficiently high level of filtration of intraocular fluid through the formed filtration membrane, and in connection with the proliferation of scar tissue under the episcleral flap, it is impossible to ensure the duration of the hypotensive effect of the operation.

 The objective of the invention was to develop an effective method for the treatment of open-angle glaucoma, which provides a sufficiently high and persistent antihypertensive effect with low morbidity and non-penetrating nature of the surgical intervention.

 The essence of the invention lies in the fact that after performing HSE, removal of the Schlemmm canal endothelium, juxtacanalicular tissue, layers of corneoscleral and uveal-meridional fibers, the uveal-radial layer of trabecula fibers is additionally removed, retaining only the rudimentary comb ligament covering the inner surface of the trabecular network On the formed operating bed, a plate of hemostatic collagen sponge is placed, which completely covers the filtration membrane and is filled the entire volume of the subepiscleral space.

The technical result obtained by using the present invention is expressed in the following:
- a filtration membrane is formed for the intraocular fluid, consisting of a naked descement membrane and a rudimentary comb ligament of the trabecula;
- the hemostatic collagen sponge, in contact with the intraocular fluid, increases in volume, completely closes the filtration membrane and completely fills the subepiscleral space, protecting them from filling with scar tissue;
- in the early postoperative period, the hemostatic collagen sponge inhibits hyperfiltration through the filtration membrane;
- filtration is carried out through the entire volume of the implant, which is ensured by its porous structure.

 The proposed method for the surgical treatment of glaucoma is as follows.

 After traditional anesthesia, the conjunctiva is dissected in the upper segment 4-5 mm from the limbus and it is separated in the direction of the limb, exposing a portion of the sclera sufficient for the operation. Then the superficial scleral flap is separated by 1/3 of the sclera thickness of the trapezoidal shape with dimensions of 0.5 • 0.7 • 0.3 cm with a wide base to the limb with approach to the peripheral part of the cornea up to 2-2.5 mm. The next step separates a deeper scleral flap 1/3 of the thickness of the sclera of a triangular shape with the base to the limb. Further (see Fig. 1), when separating the deep scleral flap with a single block anterior to the scleral spur 1, the outer wall of the Schlemm canal and the peripheral part of the corneal tissue are removed, while the cavity of the Schlemm canal is opened and the Descemet sheath 2 is exposed at a distance of 1.0-1, 5 mm anterior to the Schwalbe boundary ring 3.

The main stage of the operation is microsurgical separation of the layers of trabeculae fibers: in the area of the opened Shlemmov canal after removal of the endothelium 4 and juxtacanalicular tissue 5, the layers of corneoscleral 6 and uveal-meridional fibers of trabecula 7 are removed, then the uveal-radial fibers are completely separated in separate sections of the trabecula 8. Only the rudimentary comb ligament 9 covering the inner surface of the trabecular network remains intact. As a result of exposure of the descemet casing and layer-by-layer separation of the fibers of the trabecular network (see Fig. 2), a filtration membrane 10 with a low liquid filtration resistance is formed. On the formed filtration membrane (Fig. 3) and in the area of the removed deep scleral flap, a plate of hemostatic collagen sponge 11 is placed with dimensions corresponding to the sizes of the operating bed. Upon contact with intraocular fluid, the sponge increases in volume, completely closes the filtration membrane and completely fills the subepiscleral space, protecting them from filling with scar tissue. At the end of the operation, the superficial scleral flap 12 is repositioned and a continuous suture is placed on the conjunctiva. The proposed method for the treatment of open-angle glaucoma is illustrated by the following examples,
Example 1

 Patient Serzhanov Y.N., born in 1925, outpatient card 82464.

 He applied to TF GU MNTK "MG" with a diagnosis of open-angle glaucoma 2 stage "C" of the left eye.

 Visual acuity of 0.7 n / a, the magnitude of the intraocular pressure of 32 mm RT. Art.

 The nature of the changes in the visual field corresponds to the stage of developed glaucoma.

 The patient underwent antiglaucomatous surgery in accordance with the proposed method of treatment.

On the 5th day after surgery: visual acuity of 0.25, with a correction of 0.7; the magnitude of the intraocular pressure of 14 mm RT. Art., the field of view expanded concentrically by 10-15 ^o , decreased the area of the central cattle.

 After 0.5 years after surgery, visual acuity of 0.7 n / a, the magnitude of the intraocular pressure of 16 mm RT. Art., narrowing of the visual fields is not marked.

 Example 2

 Patient Tipikina A.F., born in 1929, outpatient card 82089.

 Turned to TF GU MNTK "MG" with a diagnosis of open-angle glaucoma 3 stage "C" of the left eye.

 Visual acuity of 0.06, with a correction of 0.55, the value of intraocular pressure - 43 mm RT. Art.

 The nature of the changes in the visual field corresponds to the stage of advanced glaucoma.

 The patient underwent antiglaucomatous surgery according to the proposed method.

On the 5th day after surgery: visual acuity of 0.06, with a correction of 0.5: the value of intraocular pressure of 15 mm RT. Art., the field of view expanded concentrically by 20-30 ^o , decreased the area of the central cattle.

 0.5 years after surgery: visual acuity of 0.05, with a correction of 0.6; the magnitude of the intraocular pressure of 17 mm RT. Art., narrowing of the field of view was not observed.

 1.5 years after the operation: the visual acuity of the operated eye remained at 0.05, with a correction of 0.45; the magnitude of the intraocular pressure of 16 mm RT. Art., narrowing of the field of view is not marked.

 Example 3

 Patient Zubakin V.A., born in 1927, outpatient card 85167.

 He turned to TF MNTK "MG with a diagnosis of open-angle glaucoma 2 stage" C "of the right eye.

 Visual acuity of 0.125, with a correction of 0.9. The magnitude of the intraocular pressure of 35 mm RT. Art.

 The nature of the changes in the visual field corresponds to the stage of developed glaucoma.

 The patient underwent antiglaucomatous surgery according to the proposed method.

On the 5th day after surgery: visual acuity of 0.125, with a correction of 0.7. The magnitude of the intraocular pressure of 14 mm RT. Art. The field of view expanded concentrically by 10 ^o , the area of the central cattle decreased.

 0.5 years after surgery: visual acuity of 0.125; with correction - 0.8; the magnitude of the intraocular pressure of 18 mm RT. st .; narrowing of the field of view is not marked.

 1.5 years after surgery: visual acuity remained at the level of 0.125; with correction - 0.8; the magnitude of the intraocular pressure of 20 mm RT. st .; narrowing of the field of view is not marked.

Sources of information
1. S. N. Fedorov, V. I. Kozlov and others. Ophthalmosurgery, 3-4, 1989, p. 52.

 2. V.I. Kozlov, S. N. Bagrov, S. Yu. Anisimov et al. Ophthalmic surgery, 1990, 3, p. 44-46.

 3. N. T. Timoshkina, E. Yu. Neresov, M. L. Zenina and other Ophthalmic surgery, 4, 1998, p. 16.

 4. RF patent 2097010, IPC A 61 F 9/007, op. 11/27/97, BI 33 (prototype).

 5. V.M. Malov, A.V. Zolotarev. In the book. "Eroshevsky readings." Samara, 1997, with. 189-190.

 6. G. A. Nikolayev, A. V. Zolotarev. In the same place, with. 236.

Claims (1)

 A method of surgical treatment of open-angle glaucoma, which involves performing a non-penetrating sinus strabeculectomy, characterized in that the uveal-radial layer of trabeculae fibers is further separated and removed, after which a plate from a hemostatic collagen sponge is placed on the formed surgical bed, which completely covers the formed filtration membrane and fills the entire sub space .

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