RU2196555C2 - Surgical method for treating glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying non-penetrating deep sclerectomy. Pharmaceutical composition is additionally administered under superficial sclera flap and on the sclera surface in the antiglaucoma operation zone. The composition has cytostatic agents in the amount of 0.001-2.5 mas. %; and viscoelastic filler, the balance. EFFECT: prevented intraocular fluid hyperfiltration; prolonged operation result. 1 dwg

Description

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

 A known method of surgical treatment of open-angle glaucoma, including cutting out a superficial scleral rectangular flap with the base facing the limb to the transparent layers of the cornea, forming inside the formed bed a triangular flap from the middle layers of the sclera, excising the corneoscleral strip including the outer wall of the Schlemm canal and the peripheral layers of the corneal stroma, with exposure of the limbal edge of the descemet membrane without opening the anterior chamber (SU 1565484, 05.29.1990).

 The disadvantage of this method is, in some cases, excessive scarring of the surgical area and, as a consequence, insufficient and short-term effect of the operation.

 The objective of the method is to prolong the hypotensive effect of antiglaucomatous surgery, subject to the maximum safety of the treatment.

 The technical result achieved by using the invention is the prolongation of the hypotensive effect of antiglaucomatous surgery.

 The technical result is achieved by the fact that in the method of surgical treatment of open-angle glaucoma, including non-penetrating deep sclerectomy according to the invention, a pharmaceutical composition containing cytostatics and viscoelastic is additionally administered under the superficial scleral flap and on the sclera surface under the mucous membrane of the eye with the following components in wt. %: cytostatics 0.001-2.5; viscoelastic rest.

 The pharmaceutical composition as viscoelastic may contain 0.1-3.0% sodium hyaluronate and / or 0.1-6.0% chondroitin sulfate and / or 0.1-6.0% water-soluble cellulose derivatives in isotonic saline with pH 7.0-7.5.

 The pharmaceutical composition as a cytostatic may contain mitomycin-C 0.001-0.01 wt. % (antitumor antibiotic isolated from Streptomyces caespitosus), 5-fluorouracil 0.1-2.5 wt.% (antimetabolite, pyrimidine analog), bleomycin 0.1 mg / ml 2.5 wt.% (antitumor antibiotic, waste product fungus Str. verticillus).

 It should be noted that when using the proposed method, viscoelastic begins to play the role of a depot for the accumulation of cytostatic. The gradual resorption of these drugs from viscoelastic causes a longer and more pronounced antiproliferative effect compared with the use of cytostatic drugs during surgery without viscoelastic. This circumstance makes it possible to reduce the concentration of toxic cytostatics introduced into the surgical area, therefore, the percentage of complications associated with their use is reduced.

 The non-penetrating nature of the intervention creates resistance to fluid flow at the level of its exit from the anterior chamber into the subscleral space. Due to this, the intraocular pressure is greater than the pressure under the superficial scleral flap. This circumstance makes it possible to exclude the ingress of the cytostatic agent into the anterior chamber; therefore, the toxic effect of the cytostatic agent on the cornea and uveal tract is excluded.

 The method also helps to prevent complications associated with hyperfiltration of intraocular fluid (shallow anterior chamber syndrome, choroid detachment, etc.) by creating adequate resistance to the outflow of intraocular fluid and additional sealing of the filtration zone.

 The prolongation of the hypotensive effect of antiglaucomatous surgery is carried out by creating adverse conditions for the development of excessive scarring of the surgical area. This occurs due to the deterioration of the adaptation of the superficial scleral flap to its bed, as well as due to the antiproliferative effect of cytostatics added to the composition to viscoelastic. At the same time, a gel-like drainage is formed under the superficial scleral flap, consisting of a composition of viscoelastic and cytostatics, dosing the outflow of intraocular fluid from the anterior chamber into the subtenon space and resolving in the early postoperative period, when the primary pathways of the outflow of intraocular fluid are formed.

 Thus, the method allows to prolong the hypotensive effect of the operation, as well as to more effectively prevent the postoperative complications.

 The invention is illustrated in the drawing, which shows a diagram of the operation: superficial scleral flap - 1; ciliary body - 2; trabecula - 3; front camera - 4; pharmaceutical composition viscoelastic with cytostatic - 5; the mucous membrane of the eye - 6; cornea - 7; lens - 8.

 The method is as follows.

 Under local anesthesia, a conjunctiva and tenon capsule is incised 6 mm from the limbus. A superficial scleral flap is cut out (1) with a base at the limb at 1 / 3-2 / 3 of the sclera thickness with entry into the transparent layers of the cornea. A triangular deep scleral flap with a base to the limb is outlined and cut out under it until partial exposure of the surface of the ciliary body (2). They open the Schlemm canal, exposing the trabecula (3) along the entire base of the deep scleral flap. After this, a deep scleral flap, including the outer wall of the Schlemm's canal, is removed with exposure of the area of the Descemet sheath adjacent to the trabecula. The front camera (4) remains unopened. Under the superficial scleral flap, 0.1-0.3 ml of the pharmaceutical composition of viscoelastic with a cytostatic agent is introduced (5). Next, the superficial scleral flap (1) is fixed with sutures to the side walls of its bed, from 0.1 to 1.0 ml of the pharmaceutical composition of viscoelastic with a cytostatic agent is introduced onto its surface (5). A continuous suture is applied to the mucous membrane of the eye (6). The operation ends with the introduction of a conjunctiva of a solution of dexazone and an antibiotic.

 Example 1

 Patient K., 52 years old, with a diagnosis of primary open-angle operated PS glaucoma of the right eye. Received with complaints of decreased visual acuity in the right eye. Instills 3 times 1% pilocarpine solution in the right eye. It is known that 2 years ago at the place of residence an anti-glaucomatous operation was performed on the right eye. An increase in ophthalmotonus up to 30 mm Hg. Art. notes 1 month after surgery.

 Right eye. IOP = 34.5 mm Hg. Art. Visual acuity = 0.5 s corr.

P ₀ = 34.5 mm RT. Art. C = 0.02 F = 0.46 P ₀ / C = 1725.

 The boundaries of the visual fields are narrowed to 10-15 degrees at all points. The eye is calm. Filtration cushion flat, sclero-conjunctival adhesions in the projection of the operation area. The anterior chamber angle is open at III, the degree of pigmentation is 2, at 12 o’clock - postoperative goniosynechia. Eye length 23.59 mm, anterior chamber depth 2.78 mm.

After carrying out the main stages of NSES and fixing the superficial scleral flap, 0.1 ml of the pharmaceutical composition was introduced under the last flap in the following ratio of components, wt.%:
Bleomycin - 1
Visited - Else
The postoperative period was uneventful. 3 months after surgery: IOP = 16 mm Hg Visual acuity = 0.6 s corr. P ₀ = 12 C = 0.28 F 0.95 P ₀ / C = 42.9 Fields of view expanded 10 degrees from the bow.

 Example 2

 A 54-year-old patient S. with a diagnosis of primary open-angle GL operated glaucoma of the left eye. Received complaints of decreased visual acuity in the left eye. Installs 2 times fotil in the left eye. It is known that 1 year ago an antiglaucomatous operation was performed on the left eye. An increase in ophthalmotonus up to 34 mm Hg. Art. - 3 months after surgery.

 Left eye. IOP = 29.5 mm Hg. Art. Visual acuity = 0.1 s corr.

P ₀ = 29.5 mm RT. Art. C = 0.04 F = 2.4 P ₀ / C = 737.

 The boundaries of the visual fields are narrowed to 10 degrees from the fixation point. The eye is calm. Filtration cushion pillow. The anterior chamber angle is open at II, the degree of pigmentation is 3, at 12 o’clock - postoperative iris coloboma. Eye length 22.88 mm, anterior chamber depth 2.35 mm.

After the main stages of NSES and fixation of the superficial scleral flap, 0.1 ml of the pharmaceutical composition was administered under the last. After suturing the conjunctiva with a continuous suture, 0.2 ml of the pharmaceutical composition was additionally introduced subconjunctively into the projection of the surgical area in the following ratio of components, wt.%:
5-Fluorucil - 1.25
Visited - Else
The postoperative period was uneventful. 3 months after surgery: IOP = 18 mm Hg Visual acuity = 0.1 s corr. P ₀ = 18 C = 0.25 F 1.65 P ₀ / C = 72. Fields of view expanded by 5 degrees from the bow.

 Indications for the method is glaucoma of various etiologies, especially cases with an increased risk of developing intra- and postoperative complications and excessive reparative processes in the postoperative period.

 Example 3

 Patient D. 69 years old with a diagnosis of primary open-angle operated IIIC glaucoma of the right eye. Received complaints of decreased visual acuity in the left eye. Installs 4 times pilocarpine in the left eye. From the anamnesis: six months ago, an anti-glaucomatous operation was performed on the right eye. Ophthalmotonus increase up to 32 mm Hg - 4 months after surgery.

 Left eye. IOP = 29.5 mm Hg. Art. Visual acuity = 0.3 s corr.

P ₀ = 43.6 mm RT. Art. C = 0.05 F = 1.57 P ₀ / C = 872.

 The boundaries of the visual fields are narrowed to 10 degrees from the fixation point on the nasal side. The eye is calm. The filtration cushion does not differentiate, but the conjunctival scar is visible in the area of operation. The anterior chamber angle is open at II, the degree of pigmentation is 3, at 12 o’clock - postoperative iris coloboma. Eye length 23.26 mm, anterior chamber depth 2.87 mm.

After carrying out the main stages of NSES and fixing the superficial scleral flap, 0.1 ml of the pharmaceutical composition was introduced under the last flap in the following ratio of components, wt.%:
Mitomycin-C - 0.005
Visited - Else
Intra- and postoperative periods were uneventful. 6 months after surgery: IOP = 18.9 mm Hg P ₀ = 18.9 C = 0.29 F = 2.57 P ₀ / C = 65. Visual acuity and field of vision have not changed.

 Indications for the method is glaucoma of various etiologies, especially cases with an increased risk of developing intra- and postoperative complications and excessive reparative processes in the postoperative period.

Claims (1)

A method of surgical treatment of open-angle glaucoma, which consists in conducting non-penetrating deep sclerectomy, characterized in that an additional pharmaceutical composition containing cytostatics and viscoelastic is additionally administered under the superficial scleral flap and on the scleral surface in the area of antiglaucomatous surgery with the following content of these components, wt. %:
Cytostatics - 0.001-2.5
Viscoelastic - Else