RU2184514C1 - Surgical microinvasive method for forming the cases of glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making intrascleral intraocular fluid discharge paths in an ill eye with filtration conjunctiva cushion formed. The operation begins with incision in conjunctiva and forming conjunctival and scleral flaps that are placed at their initial place after excising deep sclera layers. The 1.5-2 mm long incision in conjunctiva is carried out along the limb 0.5-1 mm apart from it. The 2.5x2.5 mm large scleral flap is cut out. To do it, operation zone is selected under conjunctiva by temporary displacing the conjunctiva by means of an instrument. Episcleral blood vessels are coagulated by means of coagulator device having end face working area. EFFECT: enhanced effectiveness of treatment; accelerated healing process; enabled multiple repeated surgical interventions.

Description

 The invention relates to medicine, namely to ophthalmology, and can be used in the microsurgical treatment of glaucoma.

 Experience with the treatment of glaucoma shows that drug and laser treatment of glaucoma often give only a temporary effect. A radical way to normalize elevated intraocular pressure is surgical treatment, and the most successful results in the last decade have been obtained using filtration-type operations with the creation of intrascleral outflow pathways of intraocular fluid (IVC) and the formation of a filtration conjunctival pillow. Such operations include trabeculectomy, transscleral drainage of the posterior chamber (TDZK), non-penetrating deep sclerectomy (NGSE) and several others. They found a combination of technologies for various anti-glaucoma surgeries, but the only thing is that the formation of outflow filtration pathways begins with a conjunctival incision and separation of the conjunctival flap, cutting out a superficial scleral flap, and then (with the exception of trabeculectomy technology) they cut a deep scleral flap, which is subsequently dissected. Further actions depend on the type of operation: during NGSE, the Descemet's membrane is exposed and a portion of the corneal tissue with the outer wall of the trabeculae is removed (A.S. 1565484), with TDZK, a fistula is formed in the posterior chamber (RF patent 2128490), and a portion of the sclera with trabeculae is removed during trabeculectomy ( RF patent 2071748).

 In recent years, especially in Russia, there has been a continuous improvement of such operations; operations of a non-penetrating type are especially actively being improved. The modernization concerns the modeling of the scleral bed, the prevention of scarring of the postoperative outflow tract (various types of drainage are created), new ideas are being developed to prevent a secondary increase in IOP, etc. (RF patent 2097010, 2150255, 2160574). However, evolution did not concern the geometric dimensions of the surgical intervention. Basically, the conjunctiva was cut 6-7 mm from the limbus, sometimes closer, but everywhere its length was quite long and amounted to 8 mm (RF patent 2160574), 7 mm (RF patent 2097010), 7-10 mm (RF patent 2142764) . The conjunctiva 6 · 6 mm in size was separated (V.I. Kozlov et al. Types of conjunctival incisions in glaucoma microsurgery and methods for its sealing // Collection of scientific articles: Promising directions in the surgical treatment of glaucoma.- M., 1997, p.63- 66). Scleral flaps (superficial and deep) were traditionally cut out with a size of 5 • 5 mm or 6 • 6 mm (RF patent 2157678, 2142764).

 As a prototype, i.e. the closest analogue, the most advanced technology to date has been taken - NGSE protected by the USSR copyright certificate 1565484 (authors Fedorov S.N., Kozlov V.I., Timoshkina N.T. et al.), in which they form a conjunctival and superficial scleral flap , a deep scleral flap above the ciliary body is outlined and separated, which is removed together with the outer wall of the Schlemm canal and the adjacent strip of corneoscleral tissue, thus opening the transition zone of the descemet membrane in the projection of the Schwalbe line, after four surface of the scleral flap is fixed in the same place interrupted sutures and continuous suture is applied to the conjunctiva. In this case, the conjunctival incision is performed 6-7 mm from the limb, 8 mm long, and the superficial scleral flap is cut out with a size of 5 • 5 mm.

 The disadvantage of this method is the relatively large area of surgical intervention, therefore, a large invasiveness of tissues, as well as the possibility of the formation of a rough scar tissue at the site of the incision, which is a threat to a stable outflow of intraocular fluid.

 The objective of the invention is to reduce the invasiveness of the operation and to obtain a stable hypotensive effect in the postoperative period by reducing the area of surgical intervention and the formation of a filter cushion from an intact conjunctiva and subconjunctiva (tenon membrane).

 The technical result obtained by solving this problem is to increase the effectiveness of anti-glaucomatous surgery, accelerate healing processes and, therefore, reduce the time of rehabilitation. An additional technical result consists in the possibility of repeated repeated intervention in areas not injured during a previous operation.

 The specified technical result can be obtained if, in the method of surgical treatment of glaucoma, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a filtration conjunctival pillow, which begins with a conjunctival incision and the formation of a superficial scleral flap, according to the invention, the conjunctival incision is performed along the limb at a distance of 0 , 5-1 mm from it and a length of 1.5-2 mm, and the superficial scleral flap is cut out with a size of 2.5 • 2.5 mm, for this operation the ionic zone under the conjunctiva is liberated by temporarily moving the conjunctiva with a tool, and the coagulation of the episcleral vessels is performed by a coagulator with an end working platform.

Among the essential features characterizing the method, the distinguishing ones are:
- a conjunctival incision is made 0.5-1 mm from the limb, 1.5-2 mm long along the limb;
- superficial scleral flap cut out with a size of 2.5 • 2.5 mm;
- the operating area under the conjunctiva is released by temporarily moving the conjunctiva using a tool;
- coagulation of episcleral vessels is performed by a coagulator with an end platform.

 Between the totality of essential features and the achieved technical result, there is a causal relationship.

 The modern development of anti-glaucoma microsurgery creates high requirements for eye tissue incisions. The invasiveness of tissues should be minimal. We have proposed a microinvasive method for the surgical treatment of glaucoma: a conjunctival incision is not 6 mm, but only 1.5-2 mm; the scleral flap is not 5 • 5 mm, but only 2.5 • 2.5 mm, thereby reducing the invasiveness of the operation (less damage to the vessels and directly to the conjunctival tissue and sclera). With the size of the scleral flap being cut out 2.5 · 2.5 mm (versus 5 • 5 mm), the volume of coagulation of the episcleral vessels decreases, and the volume of coagulation decreases, the likelihood of the formation of fibrovascular membranes decreases, therefore, the amount of scar tissue is the main danger of a stable IOP maintenance process normal in the postoperative period.

 A conjunctival incision made at a distance of 0.5-1 mm from the limb and a length of 1.5-2 mm allows you to form a filter cushion of an intact conjunctiva around the scleral flap (the node after suturing the conjunctiva will be located above the flap, or rather, near the limb), which will also work on the stability of the outflow of intraocular fluid. Thus, the microinvasive approach significantly reduces the invasiveness of anti-glaucoma surgery, and by eliminating the formation of scar tissue around the scleral flap, the reliability of the operation increases.

 Indeed, the method is gentle and effective, but requires a certain technology, which allows a large scleral flap to be cut out through a small incision (1.5-2 mm) (2.5 • 2.5 mm). Own mobility and elasticity of the conjunctiva allows it to be moved with the tool in the right direction, providing access to the underlying structures for further non-invasive operations, but it is important to link the size ratio so that the surgeon’s actions are non-invasive. It is a section of the conjunctiva with a length of 1.5-2 mm that allows the atraumatic movement of the conjunctiva and cutting out a scleral flap measuring 2.5 • 2.5 mm. If the conjunctiva is cut less than 1.5 mm, then it will not be possible to cut out a scleral flap measuring 2.5 • 2.5 mm, and cutting out a smaller scleral flap is fraught with significant technical difficulties today. If the conjunctival incision is performed more than 2 mm, then the positive effect of the claimed technology is lost. Another condition for the noninvasive performance of microinvasive anti-glaucoma surgery is the use of a coagulator to coagulate the episcleral vessels with only the end site, otherwise the conjunctiva will be injured (burn damage) by the side walls of the coagulator.

 Thus, between the set of essential features and the achieved technical result, there is a causal relationship.

 The method is as follows.

 After traditional anesthesia, the conjunctiva is dissected in the upper segment along the limb at a distance of 0.5-1 mm from it, 1.5-2 mm long and, if necessary, is separated to the periphery. Then, with the Mira 4000 high-frequency diathermocoagulator, which has an end platform with a diameter of 0.2 mm, the sclera vessels are coagulated along the perimeter of the scleral flap planned for cutting (2.5 • 2.5 mm). The coagulation procedure is performed only after the coagulation site is free of the conjunctiva, and for this, using a tool, such as tweezers, the surgeon shifts the conjunctiva from the working area for coagulation time and holds it in this position until coagulation is performed and the coagulator will not be removed. Then a scleral flap of 2.5 • 2.5 mm is cut out, while the conjunctiva is also displaced with tweezers and held in this position, freeing access to the desired area of the sclera. The subsequent stages of the operation are traditionally performed according to the stages of the NSES or TDZK or trabeculectomy without any features, only the area of surgical intervention is smaller, because it is given by the dimensions of the superficial scleral flap, namely 2.5 • 2.5 mm, and further stages of the operation are carried out within these limits. At the end of the operation, a continuous suture is applied to the conjunctiva, a knot is tied, which is located above the scleral flap at the limb.

 Example 1. Patient M., 61 years old.

 Diagnosis: open-angle glaucoma of the left eye. Visual acuity of 0.8. The field of view is narrowed by 10-15, IOP 40 mm Hg. using timolol 0.5% (two instillation).

 The optic nerve disc is pale pink, E / D 0.6.

 The operation of NGSE according to the claimed method was performed using microinvasive access: conjunctival incision 1.5 mm along the limb at a distance of 0.5 mm from it, superficial scleral flap 2.5 • 2.5 mm; further stages are traditionally according to the stages of NSES within the size of a cut scleral flap.

 The postoperative period was uneventful. On the 2nd day after the operation, the eye is calm, IOP 20 mmHg, Vis 0.8.

 3 months after the operation: IOP 22 mm Hg, Vis 0.8; there is a spilled conjunctival filtration pad.

 When viewed after 6 months: IOP 21 mm Hg, Vis 0.8.

 Example 2. Patient D., 58 years old.

 Diagnosis: closed-angle far-reaching uncompensated glaucoma of the right eye. Visual acuity of 0.7 with correction, IOP 54 mm Hg, the cornea is transparent, the anterior chamber is shallow.

 Gonioscopy: the anterior chamber angle is closed around the perimeter to the Schwalbe ring. Fundus reflex pink, fundus: marginal glaucomatous excavation of the optic disc. The field of view from the nasal side is narrowed to 8 degrees.

 On the right eye, an operation was performed - transciliary drainage of the posterior chamber (TDZK), where the filtration hole in the posterior chamber was formed by pulsed exposure to laser radiation. The initial stages of the operation had the following parameters: conjunctival incision 2 mm along the limb at a distance of 0.5 mm from it; the conjunctiva was separated; then a superficial scleral flap with a size of 2.5 x 2.5 mm was excised with the base to the limb half the thickness of the sclera; Further, the operation was continued according to TDZK technology.

 The operation and the postoperative period proceeded without complications. In the postoperative period (1st day): over the limb in the upper sector, a spilled filter pad formed, IOP 17 mm Hg, Vis 0.6 with correction, the anterior chamber deepened, the iris took a concave profile.

 One month after the operation, IOP 21 mm Hg, Vis 0.7 with correction.

 6 months after IOP surgery, 22 mmHg, Vis 0.7 with correction.

 To date, more than 200 anti-glaucoma surgeries have been performed in the clinic of EC MTCA by the claimed microinvasive method. This method of surgical treatment of glaucoma has established itself as more reliable and less traumatic in comparison with previously used technologies, where the surgical field was twice as large in area.

Claims (1)

 A method for the surgical treatment of glaucoma, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a filtration conjunctival pillow, in this case, they begin by performing a conjunctival incision and forming a superficial scleral flap, which, after excision of the deep layers of the sclera, is laid in its original place, characterized in that the conjunctival incision is performed along the limb, at a distance of 0.5-1 mm from it and a length of 1.5-2 mm, and a superficial scleral flap is cut out with a size of 2.5x2.5 mm, To do this, the operating area beneath the conjunctiva release by temporarily moving the tool through the conjunctiva and coagulation episcleral vessels coagulator operate with the end of the working platform.