RU2296543C2 - Method for eliminating intraocular fluid retention in carrying out cataract extraction when treating patients for open angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves intraoperatively determining Schlemm's canal filling with blood after having accomplished cataract phacoemulsification. Schlemm's canal being not filled with blood, sinusotomy or sinusectomy is carried out. Schlemm's canal being filled, anterior chamber is intraoperatively filled with fluid and surgical intervention type is determined that is required for eliminating retention on blood presence or absence in Schlemm's canal after filling the anterior chamber.

EFFECT: simplified and reliable operation selection method; no negative pressure to be created; no anesthesia and additional equipment needed.

8 cl, 3 dwg, 8 tbl

Description

The invention relates to ophthalmology and is intended for intraoperative diagnosis and elimination of retention of intraocular fluid during cataract extraction by phacoemulsification in patients with open-angle glaucoma.

A known method of choosing a pathogenetically oriented treatment of glaucoma ("Guide to eye surgery", under the editorship of Krasnov ML, Belyaev B.C., M., 1988), where gonioscopy is used as a preoperative examination, which determines the nature of retention. In this case, the main diagnostic indicator is the angle of the anterior chamber. At an anterior chamber angle of medium width or wide, most surgeons prefer to perform trabeculectomy or sinusotrabeculotomy. However, it is recognized that preoperative gonioscopy is not sufficiently informative for the diagnosis of trabecular and intrascleral retention, as well as their combination. Accordingly, there are no any reliable gonioscopic criteria for determining the place of retention, which serve to select a pathogenetically oriented intervention.

A known method of gonioscopic examination of the Schlemm canal with a combination of cataract with open-angle glaucoma (RU 94028945, 08.27.1996). The known method includes a gonioscopic study of Schlemm's canal filling before and after cataract extraction surgery.

The diagnostic findings were as follows: the open angle of the anterior chamber, increased pigmentation, filling the Schlemm's canal with lumps of pigment. However, even in this method, the intraoperative determination of retrograde filling of the Schlemm's canal with blood was not carried out and the task was not to select a pathogenetically oriented operation that removes the obstacle to the circulation of intraocular fluid.

A known method of surgical treatment of patients with a combination of cataract and glaucoma (RU 2160573, 20.12.2000), in which cataract extraction is carried out under local anesthesia, after which local cyclodialysis is performed. For visual control of cyclodialysis, a gonioscope is used, the mirror plane of which is set at an angle that provides the best view of the angle of the anterior chamber. This method can be considered as the closest analogue. However, in this method, gonioscopic determination of retrograde blood filling of the Schlemm's canal is not performed, which does not allow for an accurate diagnosis of the pathogenesis of retention and to choose a pathogenetically oriented operation.

Thus, the analysis of the prior art revealed that none of the above methods, including the closest analogue, does not perform intraoperative determination of Schlemm's canal filling with blood during cataract phacoemulsification in patients with open-angle glaucoma. And moreover, there is no indication as to the possibility of judging by the level and nature of filling the Schlemm's canal about at what level of anatomical structures retention takes place. There is also no evidence that the level and nature of the Schlemm's canal filling can serve as a reliable criterion for choosing a pathogenetically oriented operation.

The technical result achieved by the invention consists in the simplicity and reliability of the choice of pathogenetically oriented surgery in patients with open-angle glaucoma with cataract phacoemulsification, the absence of the need to create negative pressure, the use of anesthesia and additional equipment.

The specified technical result is achieved by the fact that intraoperatively, after cataract phacoemulsification, the Schlemm canal is filled with blood, the pathogenesis of retention is determined by the level and nature of its filling and, depending on it, the indications for a pathogenetically oriented operation are determined. When the Schlemm canal is partially or completely filled with blood, intraoperative filling of the anterior chamber with liquid is performed, and in the absence of blood in the schlemm canal after filling the anterior chamber with liquid, the ultrasonic treatment is considered sufficient for phacoemulsification to eliminate retention, and if there is blood in the schlemm canal after filling the anterior chamber with liquid, produce trabeculotomy. In the event that the first intraoperative gonioscopic examination revealed a lack of blood filling the Schlemm's canal, a sinusotomy or sinusectomy is performed. After sinusotomy or sinusectomy, the trabeculae's ability to filter is determined by the presence of moisture on the outer wall of the trabeculae, and the operation is completed if there is moisture on the outer wall of the trabeculae, and sinuso-trabeculotomy or sinuso-trabeculoectomy is performed if there is no moisture on the outer wall of the trabecula.

The method is as follows. A patient with a combination of cataract and open-angle glaucoma undergoes cataract extraction by phacoemulsification. Intraoperatively, after cataract extraction, a Goldman or van Beuningen gonioscope is placed on the patient’s cornea under the control of an operating microscope, and the Schlemm canal filling with blood is determined gonioscopically intraoperatively. The pathogenesis of retention is determined by the level and nature of its filling, and depending on it, indications for a pathogenetically oriented operation are determined as follows. When the Schlemm canal is partially or completely filled with blood, intraoperative filling of the anterior chamber with liquid is performed, and in the absence of blood in the schlemm canal after filling the anterior chamber with liquid, the ultrasonic treatment is considered sufficient for phacoemulsification to eliminate retention, and if there is blood in the schlemm canal after filling the anterior chamber with liquid, produce trabeculotomy. In the event that the first intraoperative gonioscopic examination revealed a lack of blood filling the Schlemm's canal, a sinusotomy or sinusectomy is performed. After a sinusotomy or sinusectomy, the trabeculae's ability to filter is determined by the presence of moisture on the outer wall of the trabeculae, and if there is moisture on the outer wall of the trabeculae, the operation is completed. In the absence of moisture on the outer wall of the trabeculae, a sinuso-trabeculotomy or sinuso-trabeculoectomy is performed.

The inventive method is illustrated by drawings, which show a gonioscopic picture of the Schlemm canal, where in Fig. 1 is the absence of blood filling the Schlemm canal (1 is the cornea; 2 is the schlemm canal not filled with blood; 3 is the iris), Fig. 2 is the filling of Schlemm channel around the entire circumference in the form of a homogeneous line (1 - cornea; 2 - Schlemm canal evenly filled with blood; 3 - iris), Fig.3 - filling Schlemm's canal in the form of unevenly colored segments with a tendency to merge (1 - cornea; 2 - Schlemm's canal, partially filled with blood; 3 - iris).

The invention is illustrated by the following clinical examples.

1. Patient U., born in 1932 Diagnosis: OD - mature age-related cataract, open-angle II-III In glaucoma, OS - mature cataract, open-angle IV A glaucoma. Vis OD hand movement in the face n / a. Vis OS count of fingers in the face.

IOP (according to Maklakov) OD 31 mm Hg OS 28 mmHg

In electronic tonography

Table 1 OD OS true intraocular pressure (Po) 28.9 23.8 outflow ease factor (C) 0.05 0.04 minute volume of chamber moisture (F) 0.95 0.61 Becker coefficient 579 585

Produced cataract extraction by phacoemulsification on OD according to standard methods. During phacoemulsification, after cataract removal, against the background of surgical hypotension, before the stage of increasing intraocular pressure by introducing fluid into the anterior chamber of the eye, gonioscopically examined the angle of the anterior chamber of the eye in order to assess the blood filling of the Schlemm's canal. The complete filling of the Schlemm's canal with blood was revealed. Performed intraoperative fluid filling of the anterior chamber. After filling the anterior chamber with fluid, a lack of blood was detected in the schlemm's canal. Ultrasonic exposure during phacoemulsification was considered sufficient to eliminate retention and the intervention was completed.

Examination 1.5 months after surgery

Vis OD 0.9-1.0 sph + 0.5 = 1.0

Vis OS facial finger count

IOP (according to Maklakov) OD 20 mmHg OS 28 mmHg

In electronic tonography

Table 2 OD OS true intraocular pressure (Po) 14.5 23.8 outflow ease factor (C) 0.26 0.04 minute volume of chamber moisture (F) 1.19 0.61 Becker coefficient 56 585

2. Patient S., born in 1927 Diagnosis: OD - initial cataract, open-angle I-II B glaucoma. OS - initial cataract, open-angle IA Glaucoma.

Vis OD 0.06 sph-3.0 = 0.1.

Vis OS 0.2 sph-2.0 = 0.9.

IOP (according to Maklakov) OD 27 mm Hg OS 20 mmHg

In electronic tonography

Table 3 OD OS true intraocular pressure (Po) 22.2 15.8 outflow ease factor (C) 0.13 0.21 minute volume of chamber moisture (F) 1.61 1.23 Becker coefficient 172 76

Produced cataract extraction by phacoemulsification on OD according to standard methods. During the operation, after cataract removal, against the background of surgical hypotension, before the stage of increasing the level of intraocular pressure by introducing fluid into the anterior chamber of the eye, gonioscopically examined the angle of the anterior chamber of the eye in order to assess the blood filling of the Schlemm's canal. A partial filling of the Schlemm's canal with blood was revealed: in the nasal, lower and temporal sections it looks like a “bead” with a tendency to merge. In the upper section of Schlemm's canal there is no sign of blood filling. Performed intraoperative fluid filling of the anterior chamber. Having revealed the presence of blood in the schlemm canal after filling the anterior chamber with fluid, a trabeculotomy was performed.

Examination 1.5 months after surgery

Vis OD 0.5 sph-0.5 cyl-0.5 ax 40 = 0.8

Vis OS 0.2 sph-2.0 = 0.9

IOP (according to Maklakov) OD 22 mm Hg OS 20 mmHg

In electronic tonography

Table 4 OD OS true intraocular pressure (Po) 17.6 15.8 outflow ease factor (C) 0.22 0.21 minute volume of chamber moisture (F) 1.61 1.23 Becker coefficient 88 76

3. Patient B., born in 1939 Diagnosis: OI - initial cataract, open-angle I Glaucoma.

Vis OD 0.06 sph-5.0 = 0.1.

Vis OS 0.4 sph-2.0 = 0.8

IOP (according to Maklakov) OD 27 mm Hg - OS 21 mm Hg

In electronic tonography

Table 5 OD OS true intraocular pressure (Po) 20.6 16.3 outflow ease factor (C) 0.13 0.21 minute volume of chamber moisture (F) 1.37 1.23 Becker coefficient 158 76

Produced cataract extraction by phacoemulsification on OD according to standard methods. During phacoemulsification, after cataract removal, against the background of surgical hypotension, before the stage of increasing intraocular pressure by introducing fluid into the anterior chamber of the eye, gonioscopically examined the angle of the anterior chamber of the eye in order to assess the blood filling of the Schlemm's canal. Revealed the lack of filling Schlemm's canal with blood. They performed a sinusotomy. After sinusotomy, the trabeculae's ability to filter was determined by the presence of moisture on the outer wall of the trabeculae. Having revealed the presence of moisture on the outer wall of the trabeculae, the operation was completed.

Examination 1.5 months after surgery

Vis OD 0.7 cyl + 0.75 ax 140 = 0.9

Vis OS 0.4 sph-2.0 = 0.8

IOP (according to Maklakov) OD 23 mm Hg OS 21 mmHg

In electronic tonography

Table 6 OD OS true intraocular pressure (Po) 18.0 16.3 outflow ease factor (C) 0.16 0.21 minute volume of chamber moisture (F) 1.17 1.23 Becker coefficient 108 76

4. Patient A., born in 1929 Diagnosis: OD - initial cataract, open-angle I-II B glaucoma. OS - initial cataract, open-angle IA Glaucoma.

Vis OD 0.06 sph-3.0 = 0.1.

Vis OS 0.2 sph-2.0 = 0.9.

IOP (according to Maklakov) OD 27 mm Hg OS 20 mmHg

In electronic tonography

Table 7 OD OS true intraocular pressure (Po) 22.2 15.8 outflow ease factor (C) 0.13 0.21 minute volume of chamber moisture (F) 1.61 1.23 Becker coefficient 172 76

Produced cataract extraction by phacoemulsification on OD according to standard methods. During the operation, after cataract removal, against the background of surgical hypotension, before the stage of increasing the level of intraocular pressure by introducing fluid into the anterior chamber of the eye, a gonioscopic examination of the angle of the anterior chamber of the eye was performed to assess the filling of Schlemm's canal with blood. Revealed the lack of filling Schlemm's canal with blood. They performed a sinusectomy. After a sinusectomy, the trabeculae's ability to filter was determined by assessing the presence of moisture on the outer wall of the trabeculae. Having revealed the absence of moisture on the outer wall of the trabecula, they performed a sinusotrabeculoectomy.

Examination 1.5 months after surgery

Vis OD 0.5 sph-0.5 cyl-0.5 ax 40 = 0.8

Vis OS 0.2 sph-2.0 = 0.9

IOP (according to Maklakov) OD 22 mm Hg OS 20 mmHg

In electronic tonography

Table 8 OD OS true intraocular pressure (Po) 17.6 15.8 outflow ease factor (C) 0.22 0.21 minute volume of chamber moisture (F) 1.61 1.23 Becker coefficient 88 76

Thus, clinical studies have shown high efficiency, simplicity and safety of a method for eliminating retention of intraocular fluid during phacoemulsification of cataracts in patients with open-angle glaucoma.

Claims (8)

1. A method for eliminating retention of intraocular fluid during cataract phacoemulsification in patients with open-angle glaucoma is that after cataract phacoemulsification, the Schlemm canal is filled with blood intraoperatively, and if the Schlemm canal is not filled with blood, a sinusotomy or sinusectomy is performed, and if there is a Schlemm filling blood channel intraoperatively fill the anterior chamber with fluid and determine the type of surgical intervention necessary to eliminate retention the presence or absence of blood in Schlemm's canal after filling the anterior chamber. 2. The method according to claim 1, characterized in that in the absence of blood in the schlemm's canal after filling the anterior chamber with liquid to eliminate retention, ultrasonic exposure during phacoemulsification is considered sufficient. 3. The method according to claim 1, characterized in that in the presence of blood in the schlemm's canal after filling the anterior chamber with liquid to eliminate retention, trabeculotomy is performed. 4. The method according to claim 1, characterized in that after a sinusotomy, the ability of the trabeculae to be filtered is determined by the presence of moisture on the outer wall of the trabeculae, and if there is moisture on the outer wall of the trabeculae, the operation is completed. 5. The method according to claim 1, characterized in that after a sinusectomy, the ability of the trabeculae to be filtered is determined by the presence of moisture on the outer wall of the trabeculae, and if there is moisture on the outer wall of the trabeculae, the operation is completed. 6. The method according to claim 1, characterized in that after a sinusotomy, the trabeculae's ability to filter is determined by the presence of moisture on the outer wall of the trabeculae, and in the absence of moisture on the outer wall of the trabeculae, a sinusotrabeculotomy is performed. 7. The method according to claim 1, characterized in that after a sinusectomy, the trabeculae's ability to filter is determined by the presence of moisture on the outer wall of the trabeculae, and in the absence of moisture on the outer wall of the trabeculae, a sinusotrabeculotomy is performed. 8. The method according to claim 1, characterized in that after a sinusectomy, the trabeculae's ability to filter is determined by the presence of moisture on the outer wall of the trabeculae, and in the absence of moisture on the outer wall of the trabeculae, a sinusotrabeculectomy is performed.

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