RU2238707C1 - Surgical method for treating the cases of open angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves dilating Schlemm's canal with viscoelastic material introduced by means of device having ring-shaped protrusion preventing from spilling the introduced solution. First, the device is introduced into the Schlemm's canal by one-third of its length and the zone is filled with 1% solution of hyaluronic acid. The device is introduced one more one-third of its length into the Schlemm's canal and it is filled with the same quantity of 1% solution of hyaluronic acid. Then, the device is introduced into the last one-third of its length into the Schlemm's canal and it is filled with the same quantity of hyaluronic acid solution. Thereafter, filtration cushion is formed and arranged under vascular tunic of eye by means of biologically inert material drainage one end of which is fixed in filtration area and the second one is placed under vascular tunic of eye.

EFFECT: stable intraocular pressure reduction; reduced risk of postoperative complications and disease recurrence.

Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of open-angle glaucoma.

A known method for the surgical treatment of open-angle glaucoma, including cutting out a superficial scleral rectangular flap to transparent layers of the cornea, forming a triangular flap from the middle layers of the sclera inside the bed, excising the corneoscleral strip, including the outer wall of the Schlemm canal and peripheral layers of the corneal stroma, exposing the limb membrane of the desna without opening the front camera (AS 1565484, USSR).

The disadvantage of this method is the small and short in some cases hypotensive effect of the operation.

A known method of surgical treatment of open-angle glaucoma (RF Patent No. 2143873, MKI ⁷ A 61 F 9/007). The method is as follows.

A conjunctival flap and a superficial scleral flap are formed, a corneoscleral strip including the outer wall of the Schlemm canal and peripheral layers of the corneal stroma are removed. The edge of the descemet membrane is exposed without opening the anterior chamber. The cushion of their superficial scleral flap is formed, which is prominently above the sclera surface. Rigidly fix the free edge of the surface of the scleral flap with sutures to his bed. Additionally, the side walls of the bed of the superficial scleral flap at the limb can be partially excised.

However, this method has a significant drawback: it does not allow to obtain a stable decrease in intraocular pressure of IOP and to reduce postoperative complications in the form of choroid detachments, hephemes, etc.

The technical problem solved by the invention: a persistent decrease in IOP, reduction of postoperative complications: detachment of the choroid, hephema and relapse of IOP.

The specified technical problem is solved by the fact that in the method of surgical treatment of open-angle glaucoma, including the formation of a conjunctival flap and superficial scleral flap, non-penetrating deep sclerectomy, the Schlemm canal is expanded by introducing viscoelastic by means of a device containing a body and a working part equipped with a sealing ring-shaped protrusion, with this the working part of the device is introduced one third into the Shlemmov channel to the sealing ring-shaped protrusion on one side of the Schlemm canal, and then this zone is filled with a 1% solution of hyaluronic acid with a volume of 0.01-0.033 milliliters, then the device is introduced one third further into the Schlemm canal to the sealing ring-shaped protrusion, the formed zone is filled with 1% solution of glururonic acid with with the same volume, then the device is introduced into the last remaining third of the length of the Schlemm canal to the sealing ring-shaped protrusion and is also filled with the same volume of glururonic acid, then all of the above is carried out similarly These operations to expand the Shlemm canal on the other side of the Shlemm canal, then form a filter cushion under the choroid by drainage from a biologically inert material, one end of which is fixed in the filtration area, and the other end is placed under the choroid by 3-4 mm.

The method is as follows.

A L-shaped incision of the conjunctiva is made with the base to the limb, a portion of the sclera 5 × 5 mm in size is isolated.

Diathermocoagulation of the sclera is performed in the formed area.

A scleral flap is cut in size 4.5 by 4.5 mm per ^1/2 _{of the} thickness of the base and limbus with an exit to the layers of the cornea by 1-1.5 mm.

Next, a non-penetrating deep sclerectomy is performed. Next, the Schlemmm channel is expanded by the introduction of viscoelastic through the device.

The device comprises a housing and a distal working part, the working part is equipped with a sealing ring-shaped protrusion located perpendicularly at a distance of 3.5 mm from the end surface of the working part, and the end part of the working part is curved.

Initially, the working part of the device is introduced one third into the Schlemm canal and then this zone is filled with a 1% solution of hyaluronic acid with a volume of 0.01-0.033 mm ³ .

In this case, the annular protrusion of the device prevents the spreading of the introduced solution. Next, the device is introduced one third more into the Schlemm's canal to the sealing ring-shaped protrusion and the formed zone is filled with a 1% solution of hyaluronic acid of the same volume. Next, the device is introduced into the last remaining three parts of the length of the Shlemmov channel to the sealing ring-shaped protrusion and is also filled with the same volume of hyaluronic acid. Then similarly carry out all the above operations to expand the Shlemmov channel on the other side of the Shlemmov channel.

The proposed method allows you to form a new way for the outflow of intraocular moisture through the expansion of the Schlemm canal and the additional expansion of the viscoelastic trabecular pores. Moreover, previously used channels through the Decemet membrane and the exposed part of the Shlemmov channel are also used in this method.

Next, a filtration cushion is formed under the choroid via drainage from a biologically inert material, one end of which is fixed in the filtration region. The second end is placed under the choroid 3-4 mm. The formation of a filter pad under the choroid helps to improve the outflow of intraocular fluid.

The method is characterized by the following clinical examples.

Example 1

Patient Soloviev V.A. 77 years old, and / b 3740 was admitted to TsOMHG on October 14, 2002 with a diagnosis of OD o / y II b glaucoma, artifakia.

In 1986, he underwent surgery on his right eye for immature age-related cataracts at the Institute. Helmholtz. The patient underwent an operation - extracapsular cataract extraction with implantation of a posterior chamber lens from polymethylmethacrylate. Visual acuity after surgery was 5-6 lines with sphere-prismatic correction.

Over the past 6 years, the patient was observed in clinic No. 1 of the Federal University “Medbioextrem”. The visual functions of the right eye were stable until 2000. In 2000, the patient began to notice some visual impairment in the distance, a decrease in twilight vision. An outpatient examination of the patient revealed an increase in IOP up to 29 mm Hg. Field of view unchanged. The patient was recommended to receive a 0.25% solution of “Arutimol” and dynamic observation.

During the year, the patient instilled “Arutimol”, the pressure on the right eye did not exceed 24-25 mm Hg. An ophthalmological examination on November 11, 2001 revealed a narrowing of the visual field: from the nose by 10 °, from the temporal by 5 °. The patient was recommended a new drug, “Betoptic,” which the patient instilled 2 drops 2 times a day.

For three months at Betoptika, the pressure did not rise above 25-26 mm Hg, however, in the subsequent follow-up hours, the clinic doctor began to notice an increase in IOP to 30 mm Hg. The patient was recommended antihypertensive drops “Xalatan”: 1 drop in the morning and 2 drops of a 1% solution of “Pilocarpine” at night. In this miotic regimen, the patient was observed until October 2002. The IOP of the right eye in combination therapy with “Xalatan” and “Pilocarpine” was 27 mm Hg. in the morning, visual acuity is 0.3-0.4 with maximum correction, the field of view was narrowed from the temporal side by 20 °, from the nasal side by 10 °, the patient was recommended hospitalization at the Central Medical and Surgical Center for the surgical treatment of glaucoma.

10.16.02 the patient underwent surgery according to the method described above. The operation went without complications.

The patient's condition on the next day after surgery was satisfactory. The patient did not complain of pain in the operated eye. Objectively: OD is calm, a small swelling in the place of the postoperative incision at 12 o’clock, the edges of the conjunctival incision are adapted, the anterior chamber is 2.5 mm, moisture is transparent, drug mydriasis is 5 mm, optical media are transparent, ophthalmotonus palpation-moderate hypotension. 3 days after surgery, the patient was discharged for outpatient observation. Visual acuity in the operated eye was 0.5 with correction, IOP - 16 mm Hg. The patient was observed on an outpatient basis for 1.5 months, during this time the IOP remained stable and did not exceed 18 mm Hg, visual functions remained unchanged. Eye condition was calm.

Example 2

Patient Timofeeva Evgenia Semenovna, 67 years old, and / b 376, was admitted to TsOMHG 12.02.02. The patient was observed for o / y glaucoma of the left eye in clinic No. 1 of MSCh-12 for 5 months, ambulatory card number 1836. For the first time, increased IOP of the left eye was noted during a physical examination. IOP was 23 mmHg on the right eye and 27 mmHg on the left. Upon re-examination, the IOP of the right eye was 22 mm Hg, the left eye was 26 mm Hg. The optic disc of both eyes was pale pink, the boundaries were clear, glaucomatous excavation was not observed. When determining the fields of vision, pathology was not detected. The patient was recommended to instill a 0.25% solution of “Timolol” in the left eye for a month.

A month after the cancellation of “Timolol”, the IOP of the left eye was 28 mm Hg, the ophthalmotonus in the right eye remained normal. The patient was recommended to continue instillation of “Timolol”, which reduced IOP to 23 mm Hg.

01.16.02 Survey data: Visa OU = 1.0, IOP - OV-24 mm Hg, OS-29 mm Hg (with a twofold instillation of 0.25 solution of “Timolol”). The field of view of the right eye is unchanged. The field of view of the left eye is concentrically narrowed from the temporal side by 15 °, from the nasal side by 10 °. With ophthalmoscopy, the optic disc of the right eye without glaucomatous changes, the optic disc of the left eye is gray, initial glaucomatous excavation. The patient was recommended to replace the solution “Timolol” with “Betoptik”. Surgery on the left eye is proposed.

02/03/02 the patient underwent surgery according to the method described above, the operation went without complications.

OS state on the first day after surgery: the eye is calm, the cornea is transparent, the anterior chamber is deep, 3.0 mm, the pupil is round, 3.0 mm in diameter. The crystalline lens is transparent, the optical medium is unchanged, a small swelling of the conjunctiva at 12 hours at the site of the operation. The nodal conjunctival suture is calm, the edges of the conjunctival incision are adapted, the deep flap is fixed with 2 sutures. Visual acuity was 0.9-1.0.

Data of the left eye at discharge 12.02.02: visual acuity of the left eye - 1.0, IOP - 16 mm Hg The eye is calm, the conjunctival edema at 12 hours has significantly decreased, the nodal conjunctival suture has been removed.

After the operation, the patient was observed in the clinic №1 MSC-12 at the doctor T. Khlopkina for 10 months. During outpatient observation, the visual functions of the left eye remained stable. The field of view during the entire observation period did not change, the IOP did not exceed 22 mm Hg. Visual acuity decreased to 0.6 with a slight plus correction due to the progression of age-related cataracts.

Example 3

Patient Sharyvzyanov Georgy Nikolaevich, 65 years old, and / b 582, was admitted to TsOMHG 03.03.02 with a diagnosis of o / II in glaucoma of the left eye. The patient turned to a consultative appointment with the doctor Gusev Yu.A. 03/14/02 with complaints of deterioration in the vision of the left eye, pain in the left temporal region, the periodic appearance of rainbow circles when viewed with the left eye. Previously, the patient did not contact the ophthalmologist. Of the common diseases noted: hypertension II degree, a history of concussion in 1989. During an ophthalmological examination: OD visus - 1.0, OS - 0.5-0.6, the field of view of the left eye and nose is narrowed by 30 °, from the temporal - by 15 °. IOP OD - 23 mmHg OS - 34 mmHg With ophthalmoscopy: the anterior chamber is of medium depth, the pupil is 2.5 mm, along the pupil edge is pseudoexflation. In the lens, clouding in the nuclear and cortical layers, the vitreous body is transparent, the optic nerve disc is gray, glaucomatous excavation with a shift in the vascular bundle, the phenomenon of hypertensive angiopathy. With gonioscopy: the anterior chamber angle is open, the trabecula is significantly pigmented. Recommended to the patient: “Xalatan” in the left eye once at night, operation on the OS in the near future.

03/28/02 the patient underwent surgery according to the method described above. The operation went without complications.

Examination data of the operated eye on the first day: ophthalmoscopy - the eye is moderately irritated, a small conjunctival edema, the conjunctival incision is fully adapted at 12 hours and on the temporal side, the conjunctival suture is 8.0, clean, the anterior chamber is moderately small 2.0 mm in the center in moisture, the anterior chamber is a small suspension of the shaped elements in the lower sections, the pupil is 3.5 mm, the lens and optical media are unchanged.

Data of an ophthalmological examination: OS vise - 0.3-0.4 with a spherical correction of + 2.0 D, ophthalmotonus palpation-moderate hypotension. The patient was recommended: “Maxitrol” 2 drops 4 times a day, “Midriacil” 2 drops 4 times a day, an injection of “Dexozone” 0.5 under the conjunctiva.

Examination data on the second day after the operation: the eye is almost calm, the conjunctival edema is significantly reduced, the edges of the conjunctival incision are adapted, there is no external filtration. Visus with spherical correction +1.0 D = 0.5-0.6, IOP palpation-moderate hypotension, anterior chamber 2.5-3.0 mm, moisture transparent, optical media unchanged. The patient was prescribed: “Tobrex” 2 drops 3 times a day.

The patient was discharged on the fifth day after surgery. Vision at discharge was 0.5-0.6, IOP at discharge was 16 mm Hg. Clinically, the condition of the eye was almost calm.

In the postoperative period, the patient was observed in the clinic №1 MSCH-12 for 7 months. During this time of postoperative observation, the ophthalmotonus of the left eye remained stable and did not exceed 20 mmHg. Some progression of opacities in the lens in the nuclear and cortical layers was noted, visual acuity due to the progression of cataracts decreased to 0.3. The field of view of the left eye is unchanged.

Claims (1)

A method of surgical treatment of open-angle glaucoma, including the formation of a conjunctival flap and superficial scleral flap, non-penetrating deep sclerotomy, characterized in that the Schlemm canal is expanded by introducing viscoelastic by means of a device containing a sealing ring-shaped protrusion, made with the ability to prevent the spreading of the injected solution, while initially introducing the working solution, part of the device one third inward of the Shlemmov Canal, fill this zone with 1% a solution of hyaluronic acid with a volume of 0.01-0.033 ml, then the device is introduced one third more into the Schlemm channel, the formed zone is filled with a 1% solution of hyaluronic acid of the same volume, the device is then introduced into the last remaining third and also filled with the same volume of hyaluronic acid, then similarly carry out all the above operations to expand the Schlemm canal on its other side, then form a filter cushion under the choroid via drainage from a biologically inert mother la, one end of which is fixed in the filtration region and a second end is placed under the choroid of 3-4 mm.