RU2223075C2 - Method for treating the cases of glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting-out superficial scleral rectangular flap of 1/3 of sclera depth turned with its base to limb. Deep scleral rectangular flap of 1/2-1/3 of sclera depth turned with its base to limb is formed with vascular tunic and ciliary body being exposed. Deep flap is truncated. Sinus trabeculectomy and basal iridectomy are carried out in the anterior chamber angle area. The truncated deep flap is introduced into the anterior chamber with tube preliminarily built on flap fold. EFFECT: reduced risk of inflation and post-surgical cicatrisation of anterior chamber angle area; improved intraocular fluid filtration and discharge conditions. 6 dwg _

Description

 The present invention relates to medicine, namely to ophthalmology, and can be used in the treatment of various forms of glaucoma, including angle-closure, open-angle and mixed.

 The term "glaucoma" combines a large group of diseases with a predominantly chronic course and a serious prognosis. Suffice it to say that the frequency of blindness from glaucoma here and abroad is steadily kept at 14-15% of the total number of all blind.

 Antiglaucomatous operations of all main types are performed in the region of the anterior chamber angle, less often in the area of the ciliary body. So, fistulizing operations have been proposed. Persistent normalization of ophthalmotonus after surgery is observed in 70-90% of cases. In the textbook "Glaucoma". / Edited by A.P. Nesterov. - M .: Medicine, 1995. - P.216 proposed a method for the surgical treatment of glaucoma, called "trabeculectomy." This operation begins with the preparation of a conjunctival flap. To do this, make an arcuate incision of the conjunctiva and tenon capsule 7-8 mm from the limb 8 mm long.

 The next stage of the operation is the preparation of a superficial scleral flap with the base to the limb. The size of the flap varies from 3 to 5 mm, the thickness is from 1/3 to 1/2 the thickness of the sclera, the shape can be triangular, square or trapezoid. The scleral flap is separated from the deep scleral plate until transparent corneal tissue appears. Next, a section of a deep corneoscleral plate is excised with a blade. The incision runs parallel to the limb across the entire width of the scleral pocket. The second same incision is made 1-1.5 mm in front of the first in the corneal part of the subscleral pocket. Then, the section of deep corneoscleral tissue between the two described incisions is excised with the same blade.

 Through the resulting defect, peripheral iridectomy is performed. Then the scleral flap is placed in place and, depending on its shape, 1 or 2 preparation sutures are placed on the edges of the flap. The next step is a continuous suture on the conjunctiva.

 The disadvantages of this method are the rapid scarring of the excised area, an insufficiently expressed hypotensive effect, limited use, as a rule, only with the open-angle form of glaucoma.

 Widely known methods for the treatment of glaucoma, in which implants are used. It can be both autoimplants and implants made of silicone or metal with shape memory.

 Also known is the method of treating glaucoma, which we adopted as a prototype (Guide to Eye Surgery. / Ed. By Prof. ML Krasnov. - M .: Medicine, 1988. - S. 239). The method involves the formation of a scleral autoimplant through the deep layers of the scleral bed by two longitudinal sections (4 mm long, as with standard trabeculectomy); The strip thus delimited in this way at both ends remains connected with the short sides of the trabeculectomy “window”. After crossing the strip in the center, two scleral legs are formed, the ends of which are tucked into the anterior chamber.

 The disadvantages of this method include high invasiveness; more often, hyphema and ciliochoroidal detachment are observed.

 Alloimplants are inserted into the anterior chamber through the formed sinastrabecular fissure after a sinus strabeculectomy. This method provides a longer hypotensive effect, because prevents the scarring of the formed “gap”, but it is more laborious, technically difficult, more often causes postoperative iridocyclitis (tissue reaction to an allograft) and increases the cost of the operation.

 The objectives of the proposed method include providing highly efficient drainage, reducing the risk of postoperative complications, reducing trauma, reducing surgery time and economic costs.

 The essence of this invention is auto-drainage by additionally cutting a squared flap with the base to the limb under the superficial scleral flap, truncating part of the flap and bringing the truncated part of the flap into the anterior chamber of the eye with the formation of a tubular flap on the fold.

 For a better understanding of the operation, FIG. 1-6, in which: 1 - the separated conjunctiva; 2 - a pupil; 3 - iris; 4 - superficial scleral flap; 5 - deep scleral flap; 6 - a bed of deep scleral flap; 7 - a bed of superficial scleral flap; 8 - angle of the anterior chamber (trabeculectomy window); 9 - peripheral coloboma; 10 - sutures on the superficial scleral flap; 11 - conjunctival suture (continuous).

 The operation is as follows. Retrobulbar anesthesia and akinesia are produced in the traditional way. On the patient’s eye (Fig. 1, pupil 2, iris 3 is schematically shown), an arcuate incision of the conjunctiva 1 is made. Then, from the upper layers of the sclera, 1 / 3-1 / 2 of its thickness is cut into a rectangular flap 4 (Fig. 1) with the base to the limbus until translucent layers of the cornea and turn up.

 From the deep layers of the sclera 7 (Fig. 1), a rectangular flap 5 (Fig. 2) is cut out on the remaining 1 / 2-1 / 3 of the sclera thickness with the base to the limb. It is located under the superficial scleral flap 4 (Fig. 2). In this case, the choroid and ciliary body 6 are exposed (Fig. 2), then a deep scleral flap 5 is truncated (Fig. 2). Next, in the area of the angle of the anterior chamber, a sinustrabekulectomy is performed, forming a “window” 8 (Fig. 5), basal iridectomy 9 (Fig. 6) is performed according to the standard method. Using a spatula, the resulting truncated flap 5 (Fig. 3) is inserted into the anterior chamber of the eye so that part of the flap (after bending) is “twisted” before being inserted into the anterior chamber, giving the shape of a tube (Fig. 4), thereby forming a flap on the fold scleral pocket and auto-drainage 5 (Fig. 5). Next, the superficial scleral flap 4 (Fig. 5) is placed in place 7 (Fig. 5). Then the laid surface scleral flap 4 (Fig. 6) is fixed from the sides and along the edges 4 by interrupted sutures 10 (Fig. 6). The operation is completed by imposing a continuous suture 11 on the conjunctiva (Fig.6).

 The method from 1999 to 2001 tested on 18 patients. At the same time, 10 people were operated on with open-angle (o / y) glaucoma, for 8 of them this operation proceeded as a reoperation, because previously they were operated on for o / u glaucoma and he underwent trabeculectomy; 5 people were operated in this way for mixed glaucoma and 3 people with closed-angle (s / y) form of glaucoma.

 Example: patient Osipov N.I. 76 years old entered the department with D.S. operated on / at II "C" glaucoma OD. Operated o / y II "A" OS glaucoma. Partial complicated cataract OU. On admission: vis OD = 0.4 n / a, intraocular pressure (IOP) = 34 mm Hg three times instillation of a 1% solution of pilocarpine. Vis OS = 0.7 n / a, IOP OS = 22 mmHg, OD and OS were previously operated on for glaucoma. It was decided to do an anti-glaucomatous surgery on OD, because there was a narrowing of the visual fields by 5-7% of the previous perimetry, which was done 6 months ago in the clinic at the place of residence. IOP OD by additional administration of β-blockers (timolol) and carbonic anhydrase inhibitors (diacarb) could not be reduced to normal, because it was kept within 27-28 mm Hg. The patient underwent surgery for glaucoma. A superficial scleral flap was cut out with the base to the limb, then under it a deep scleral rag was cut out with the rectangular base with the base to the limbus. Deep scleral flap truncated. Sinustabeculectomy, basal iridectomy was done. The truncated part of the flap is brought into the anterior chamber of the eye with the formation of a tubule flap on the fold. Superficial scleral flap laid in place, fixed with sutures. The surgical and postoperative period was uneventful. IOP OD at discharge 20-21 mm Hg and vis OD = 0.4 n / k. The patient was discharged under the supervision of an oculist at the place of residence. When re-examined after 6 months, IOP OD = 20 mm Hg, vis OD = 0.5 n / a, IOP OS = 23 mm Hg, vis OS = 0.7 mm Hg

The essence of this invention is the auto-drainage, which is formed from a deep scleral flap with the base to the limb, summing up the truncated part of the flap in the anterior chamber of the eye with the formation of a tube on the fold, which performs the functions of:
1. Prevents subsidence and rapid scarring of the excised area of the anterior chamber angle (sinus-extrabular zone).

 2. It acts as a spacer, thereby preventing the corner of the anterior chamber from falling off in both mixed and angle-closure forms of glaucoma.

 3. The bend, which is obtained due to the institution of the formed auto-drainage, is an additional pocket through which the intraocular fluid (IHF) is filtered from the angle of the anterior chamber (CCP) under the superficial scleral flap.

 4. The exposed zone of the choroid and ciliary body makes the hypotensive effect more pronounced and stable, because IHC flows in both the subconjunctival and supraciliary spaces.

 5. The morbidity of the operation is reduced.

 6. The risk of scarring of scleral tissue is reduced.

 7. The cost of the operation.

 8. The operation time is reduced by 20-25%.

Claims (1)

A method for treating glaucoma, including cutting a superficial sclera flap, sinus strabeculoectomy, peripheral iridectomy and suturing of the sclera, characterized in that they create auto-drainage by cutting a squared flap with the base to the limb under the superficial scleral flap, trimming the flap and bringing the truncated part of the eye to the trimming chamber. on the fold of the duct flap.

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