RU2220691C1 - Method for carrying out laser treatment of infantine terminal glaucoma aggravated with congenital aniridia and buphthalmia - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves determining ciliary body projection on sclera. Controlled power supply mode is differentially selected to apply diode laser treatment corresponding to sclera thickness with adjacent envelopes in future treatment zone. Transscleral diode laser cyclocoagulation is carried out by covering the whole ciliary body projection zone with the exception of staphyloma zones previous surgical intervention zones. EFFECT: retained bad prognosis eye; improved cosmetic effect. 1 tbl

Description

 The invention relates to pediatric ophthalmology and is intended for non-invasive antihypertensive treatment of terminal glaucoma with organ preservation in children with congenital aniridia and buftalm.

 Congenital glaucoma is relatively rare (1 case per 5000-20000 newborns), however. this disease progresses rapidly, then with late, untimely treatment, it often leads to irreversible changes in the neuroreceptor apparatus - therefore, the relative density of congenital glaucoma is among the causes of blindness in children (2.5-7.0%) (Avetisov E. S. et al. Guidelines for Pediatric Ophthalmology. - M.: Medicine, 1987. - p. 148; Sidorov EG et al. Congenital Glaucoma and its treatment. - M.: Medicine, 1991, - p.3.).

 A characteristic feature of the terminal forms of congenital glaucoma in children is the fast, progressive stretching of the eyeball (buphthalmus), which is especially pronounced with concomitant aniridia - the length of the sagittal axis of the eye increases to 35 mm or more, the sclera becomes thinner, the choroid appears, the anterior intercalary staphylomas appear, right down to before rupture of sclera.

 In the late stages of glaucoma, especially in repeatedly operated patients, it is not possible to restore the natural outflow pathways due to pronounced secondary changes that occur due to eye enlargement and stretching of the membranes (Avetisov E.S. et al. Guidelines for Pediatric Ophthalmology. - M.: Medicine, 1987, p. 167), therefore, operations of both reconstructive and fistulizing type are usually futile, fraught with a high risk of eye death on the operating table. For organ-preserving purposes, surgical interventions can be used to reduce the production of intraocular fluid (intraocular fluid) - cyclodiothermocoagulation or cyclocryoapplication of the sclera, but the hypotensive effect is usually small and often unstable (ibid. P. 168).

 Such eyes, which underwent usually repeated microsurgical antiglaucomatous operations, often not only become blind and lose their visual functions, but also disfigure the child due to the large increase and / or deformation of the blind eye, often accompanied by the formation of a thorn and / or corneal staphyloma. Unlike adult glaucoma, in children, especially young children, congenital glaucoma is rarely accompanied by pain, therefore, despite the mutilating baby's buphthalmus, parents rarely agree to early enucleation of the eye. But not only parents, but also surgeons do not decide on repeated anti-glaucomatous surgical interventions. Moreover, for any surgical operation, the child needs another anesthesia, which is not always possible (congenital glaucoma is rarely an isolated disease: up to 75% of cases, congenital glaucoma is accompanied by concomitant pathology not only of the eye, but also of the body as a whole).

 T. about. it is obvious that children need a non-invasive hypotensive organ-preserving method of treating the terminal stages of congenital glaucoma. In this situation, diodlaser transscleral cyclocoagulation seems to us to be a very attractive alternative to surgical treatment with the aim of preserving the eye, (usually blind) at least as an organ: the procedure is performed without opening the eye, without the need for general anesthesia, designed to reduce intraocular fluid production by cyclocoagulation, which means - to reduce intraocular pressure (IOP) and preservation of the eye.

 There is no information on the use of an organ-preserving diode laser in the terminal stages of congenital glaucoma in children.

 At the same time, with far-reaching stages of primary open-angle glaucoma in adults, the possibility of the effective use of diode laser transscleral cyclocoagulation (DLTC) is described, which is indicated when it is impossible to perform fistulizing surgery due to the risk of loss of residual vision or due to the general severe somatic condition of patients ( Mazunin I.Yu. Diode laser in the treatment of patients with primary open-angle glaucoma. Abstract of thesis ... Ph.D., M., 2001, - 24 pp.).

 There is a known method of diode laser transscleral cyclocoagulation (DLTC), in which the tip of the diode laser (model of the ophthalmic laser "Vizulas - diode II", wavelength 790-830 nm, maximum power up to 3 W) is applied to the sclera in the projection area of the ciliary body - 1.5-2 mm from the limb (in adult patients!), and around the entire circumference - 360 degrees. The number of laser applications is 24-30, the exposure is 0.5-1 sec, the power is 1.5-2 watts. (Mazunin I.Yu. Diode laser in the treatment of patients with primary open-angle glaucoma. Abstract of thesis ... Ph.D., M., 2001. - 24 p.).

 However, the simple use in children with congenital glaucoma of the DLTC method proposed for primary open-angle glaucoma in adults is impossible in our experience, given the above features of the terminal forms of congenital glaucoma in children (fast, progressive stretching of the eyeball - butphthalmos, especially pronounced with concomitant aniridia; multiple spontaneous or postoperative staphylomas and thinning of the sclera), as

- recommended in adults, circular cyclocoagulation performed on a pathologically altered eye of a child, in our own experience, can lead to irreversible subatrophy of the eye;
- the place of projection of the ciliary body on the sclera (necessary for applying diode laser coagulates in the ciliary body) in the eyes of adult patients with primary open-angle glaucoma is usually determined simply by measuring the standard distance - "1.5 mm from the limbus."

 Less commonly, and only during surgical antiglaucomatous operations in adults, the position of the angle of the anterior chamber during surgery is determined visually: “the position of the scleral spur is marked by the transition from the transparent layers of the limb to opaque - the venous sinus of the sclera is located a little posterior to it” (Manual on Eye Surgery, Edited by M.L. Krasnov, V.S. Belyaev.M .: Medicine, 1988, p. 236) - i.e. posterior to it is the desired projection area of the ciliary body on the sclera.

 Such methods for determining the projection of the ciliary body on the sclera are unacceptable in children, because pathological eye strain, thinning, staphyloma of sclera in children with terminal stages of congenital glaucoma, change the anatomomorphological relationships and the position of the ciliary body cannot remain “standard”. In such eyes, cyclocoagulation 1.5 mm from the limb will be projected onto the area of the stretched, staphylomatically changed cornea, and not onto the desired area of the ciliary body. This is especially important in the eyes with aniridia and butphthalmos, when external examination of the eye does not allow to evaluate the boundaries of the altered cornea, limbus, sclera, and even more so to assess the position of the ciliary body.

 1) The energy parameters recommended for the diode laser cyclocoagulation of the standard sclera of an adult patient are not suitable for the thinned stretched sclera of the eyes of children with congenital glaucoma, aniridia and buphthalmos - can lead to staphylomas and even perforation of the sclera.

 The technical result of the invention is organ-preserving non-invasive antihypertensive laser treatment, with the exception of the need for a surgical operation with the opening of the eyeball, fraught with the risk of intraoperative death of the eye as an organ.

 The technical result is achieved through: the use of a diode laser transscleral effect on the ciliary body in combination with the mandatory use of the method for determining the projection of the ciliary body on the sclera by the method of precise diaphanoscopy, a partial (non-circular) method of applying applications and a differentiated choice of the energy regime, depending on the thickness of the sclera, determined by clinical criteria (biomicroscopy) and ultrasound (US) measurement of the thickness of the sclera with adjacent membranes in the intervent firs.

The proposed method is characterized by features:
1) The projection of the process region of the ciliary body on the sclera (i.e., the site of the planned application of transsclerical diolaser coagulates) is determined using the transscleral refinement diaphanoscopy method. The method of “clarifying diaphanoscopy” is used in a number of surgical antiglaucomatous operations to determine the projection of the angle of the anterior chamber (CPC) on the sclera. It is carried out as follows: after three instillations of a 0.25% solution of dicaine with an interval of 1 minute, the "beak" of the diaphanoscope is placed on the anesthetized cornea in the region of the anterior pole of the eye, and a line of clearly visible transition from the luminous region (anterior chamber) to darkening is marked on the sclera ( ciliary body). The mark corresponds to the location of the CPC. As a diaphanoscope, a domestic traditional transilluminator is used - a nozzle based on a manual electric ophthalmoscope EO - 61 (Volkov V.V., Gorban A.I., Dzhaliashvili O.A. Clinical eye examination with instruments, ed. Medicine, Leningrad Department, 1971 p. 103-121).

 2) Diode laser coagulates are not applied to the sclera along the entire circumference, but only on 1 / 2-2 / 3 of its circumference, excluding the area of pathologically altered sclera (areas of postoperative or spontaneous staphylae - usually in the upper part of the eye). Partial, rather than circular, coagulation does not cause a sharp, catastrophic for the children's eye, decrease in the production of HPW, which prevents collapse and wrinkling of the eye (which we personally observed in children's eyes after circular cyclocoagulation). Non-application of laser coagulates to the area of spontaneous intercalary and / or postoperative staphylae prevents scleral perforation in its weakened areas.

 3) The energy regime of diode laser coagulation is non-standard, it is determined individually, depending on the thickness of the sclera of the child. Energy modes of diode laser coagulation in various types of sclera in children with congenital glaucoma (see table).

 Ultrasonic measurement of the thickness of the sclera with adjacent membranes was more accurate compared to biomicroscopic assessment. There were cases of inaccurate sclera assessment by the biomicroscopic method: B. B., 1.5 years, and / b 1243/01, a / c 22738/00); when, due to the presence of sclera staphyloma, which was biomicroscopically assessed as thinned (type 1), it turned out to be very thick during ultrasound measurement in areas outside the staphyloma (planned for laser irradiation) - up to 2 mm. Therefore, the minimum energy regime (1 W-1 sec - 10), calculated by us as for type 1 sclera, was not enough and the child later needed to conduct an additional laser coagulation diode session to obtain a hypotensive effect.

 The method of dosed diode laser transscleral cyclocoagulation - (DDLTC) is carried out in the following way: use, for example, the domestic diode laser device ALOD - 01, "Alcom" (St. Petersburg). The wavelength of 0.81 microns, maximum power - up to 3 watts.

 Stage 1. Local anesthesia. Double instillation of a solution of dicaine 0.5% in the eye of a child. Only in some children with inappropriate behavior (13%) had to resort to anesthesia.

 2 stage. Biomicroscopic assessment of sclera. On a slit lamp (domestic SchL-56 or Karl Zeiss, etc.), through a transparent conjunctiva, sclera produce traditional scleral biomicroscopy under diffuse, direct and indirect focal illumination (Shulpina NB Biomicroscopy of the eye. - M.: Medicine. - 1974, p. 26-29). By the color of the sclera, the relief of its surface, the presence of thinning, staphylae or thickenings, the optical degree of density of the sclera, roughly determine the type of sclera (see table).

 3 stage. Transscleral specifying diaphanoscopy determination of the projection area of the ciliary body on the sclera

 A diaphanoscope tip is placed on the center of the child’s cornea (a domestic traditional transilluminator is a nozzle based on a manual domestic electric ophthalmoscope EO-61).

On the sclera, a tap marks the line of a clearly visible transition from the luminous region (anterior chamber) to darkening (ciliary body). The mark corresponds to the location of the angle of the anterior chamber - a projection of the ciliary body is located posterior to it. Mark with a tap the annular zone of the sclera subject to laser coagulation, excluding all sections of staphylum and thinning of the sclera (!). Moreover, the projection zone of the ciliary body on the sclera is not always in the form of a ring of regular shape!
4th stage. Ultrasonic measurement of the thickness of the sclera with adjacent membranes in the area of the planned laser operation - clarification of the type of sclera (determined approximately by biomicroscopy) - to select the optimal differentially dosed energy regime. It is determined for different areas of the sclera: in 2-3 quadrants of the annular zone of the sclera, selected for laser coagulation (outside the staphylum and previous operations).

 It is produced on the Oftaskan - B ultrasonic diagnostic apparatus, of the Alkon company through a contact medium (water).

 Depending on the type of sclera, determined approximately biomicroscopically and refined by ultrasound examination, the optimal energy regime for all sections of the zone of future laser exposure is selected according to the table (see the appendix).

 5 stage. Metered diode laser transscleral cyclocoagulation (DDLTC).

 In the area of the found and refined projection of the ciliary body, scrubs are applied to the sclera with the tip of a diode laser device, and not around the entire circumference, but only on 1 / 2-2 / 3 of its circumference - excluding areas of the pathologically altered sclera (areas of postoperative or spontaneous intercalary scleral staphyloma - usually in the upper part of the eye).

 Optimum energy regime (see table). The laser operation is completed by the installation of disinfecting eye drops (vitabact or albucid, etc.). In the morning, an hour before the intervention and an hour after it, "afterburner" is performed (intensive instillation - 6 times per hour) of a 0.1% naklof solution.

 The laser method we offer usually does not require anesthesia in contact children (more than 86%), while the previously used surgical method was necessarily performed for all children under anesthesia.

 Example. Patient M., 3 years old, and.b. 1245/01, a / c 12286/98.

 Diagnosis: congenital absolute uncompensated double-operated glaucoma, buphthalmos, corneal sore throat, aniridia, aphakia, vitreous fibrosis, retinal detachment of the right eye. Visual acuity - 0. Palpation IOP +2 (Maklakov measurement is unreliable due to deformation of the eye and cornea). The eye does not hurt, but is unpromising in vision and cosmetically very disfigures the child. Optical reconstructive interventions are futile, associated with the risk of death of the eye as an organ. Given the refusal of the parents of the child from enucleation, in order to try to save the eye as an organ, DDTLC was performed according to our method (see above), and under local anesthesia, without anesthesia. Biomicroscopically, the sclera was assigned to us approximately to type 1 (the sclera is thin, bluish in color, of uneven thickness, from 10 to 2 hours behind the limb 2 extensive adjacent staphylomas of the sclera were revealed in the area of previous operations (i.e., it is planned to carry out transscleral diode laser coagulation of the ciliary body along the circumference : from 3 to 9 hours, bypassing the area with scaphleral staphylum.) The method of specifying diaphanoscopy determined the zone of projection of the ciliary body on the sclera in the zone of the forthcoming exposure: from 3 to 7 hours - 2 mm from the limbus, and from 7 to 9 hours - 4 m from the limb (!). The tap indicates the annular zone of the upcoming laser exposure (unevenly distant from the limb in different segments!). According to the ultrasound data, the thickness of the sclera with adjacent membranes was determined. It turned out to be different: in the staphylum, from 10 to 2 hours = 0 , 8-0.9 mm, at 3 and at 9 o’clock = 1.5 mm, at 6 o’clock = 2 mm, therefore, a differentially dosed energy regime was chosen: diode laser applicates were applied in the annular zone of the projection of the ciliary body in a circle from 3 to 9 hours (bypassing the area with staph ery); and at 3-4 and at 8-9 hours, pulse energy = 1 W with a pulse duration of 0.5-1 sec was used, and from 5 to 7 hours at the same pulse energy, its duration was increased to 1.9 seconds. Experience has shown that an increase in the power of laser exposure should first be done by lengthening the pulse duration, and only then, with insufficient efficiency, should the pulse energy be added (see table). Only 14 coagulates were applied. The postoperative period was reactive, without complications. 10 months after the laser operation, the stability of the achieved organ-preserving and hypotensive effect was noted: the eye was calm, decreased in size (PZO by ultrasound decreased from 29 mm to 20 mm), intraocular pressure was palpation-normal (applanation tonometry according to Maklakov remains unreliable due to the uneven surface cornea), sclera staphylomas are flattened, deformation of the eyeball is reduced and the selection of a cosmetic contact lens is possible, parents are happy with preserving the eye (without surgery and without drug a) and cosmetic effect obtained.

 Thus, the proposed method is a highly effective hypotensive method for the noninvasive treatment of terminal inoperable stages of congenital glaucoma, especially with congenital aniridia and buphthalmus, which allows preserving unpromising, inoperable eyes, with good cosmetic effect, and in 87% of cases without anesthesia.

Claims (1)

A method for treating terminal congenital glaucoma in the presence of aniridia and butphthalmus, characterized in that the projection of the ciliary body onto the sclera is preliminarily determined, a differentially dosed energy regimen is selected for the diode laser exposure in accordance with the thickness of the sclera with adjacent membranes in the zone of future exposure, and the trans-scleral cyclo-coagulation diode laser is performed by applying applications along the entire projection of the ciliary body, excluding the staphilus zones and previous operations.

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