RU2297816C1 - Surgical method for treating refractory glaucoma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves introducing 1 ml of 2% lidocaine solution into subtenon space. Conjunctival flap is formed near limb. Superficial tetragonal scleral flap being 1/3 times as thick as sclera layer and 5х5 mm as wide and turned with its base towards the limb. Triangular flap turned towards the limb is formed in deep sclera layers taking 1/3 of its thickness. It is separated to Schlemm's canal and removed together with external wall of Schlemm's canal and adjacent corneal tissue to descemet membrane. Endothelial lining of the Schlemm's canal is removed and deep flap is cut out as 4x1.5 mm large strip turned with its greater side towards the Schlemm's canal up to ciliary body. Spatula is applied for entering into the anterior chamber under this deep flap, and it is deleted and intervascular iridectomy is carried out. Collagenous porous biological drainage is implanted with one of its ends entering into the anterior chamber, and other end being placed on adjacent ciliary body strip and attached to deep sclera layers. The drainage is manufactured as 0.8 mm thick and 1.5 mm wide and 4.0 mm long strip from material containing bone collagen extracted from spongy bone of agricultural animals and saturated with sulfated bone glycosamines. Superficial scleral flap is laid on its place and fixed with two sutures.

EFFECT: enhanced effectiveness of treatment; activated primary and uveoscleral passages of intraocular liquid discharge for long time; prevented discharge passage cicatrisation and hemorrhages into anterior chamber; reduced risk of traumatic complications.

7 dwg

Description

The invention relates to ophthalmic surgery and can be used for surgical treatment of refractory glaucoma, such as secondary glaucoma with a closed angle of the anterior chamber, uveal, neovascular, pigmented, youthful, repeatedly operated primary glaucoma.

Etiopathogenesis of refractory glaucoma is complex and individual in each case. However, the main reason for the development of this disease is the pronounced anatomical changes in the drainage system of the eye, which greatly complicate, and sometimes make the outflow of intraocular fluid impossible. These include: grade II-III goniodysgenesis, coarse pigment dispersion on the structures of the anterior chamber angle in combination with goniodysgenesis, newly formed vessels of the iris root, gross goniosynechia, fusion of the iris root with the anterior wall of the anterior chamber angle (closed-angle “creeping” glaucoma). The gross anatomical changes in the drainage system of the eye are an organic blockade of the trabecula and Schlemm's canal, so the intraocular pressure (IOP) rises to very high numbers. Significant disturbances in the hydrodynamics of the eye lead to a rapid loss of visual functions and the development of terminal painful glaucoma as a result.

Cyclodestructive interventions are used as methods of surgical treatment of refractory glaucoma. The use of drainage in the operation area is currently considered as the most promising area of surgical treatment of refractory glaucoma.

Known drainage used in the surgical treatment of refractory glaucoma, one end of which is inserted into the anterior chamber of the made microtubules located in the shell of the hydrogel. However, since this allodrainage is made of synthetic material, it does not have sufficient biological inertness and does not have an anti-inflammatory effect, which does not imply its long-term presence in the eye cavity (A. M. Bessmertny, O. V. Robustova. Clinical evaluation of the effectiveness of the combined treatment method Neovascular Glaucoma. Collection of scientific articles. Glaucoma: problems and solutions. M., 2004, pp. 273-275).

The closest to the technical solution of the problem is a method of surgical treatment of refractory glaucoma, including the formation of a conjunctival flap and a superficial scleral flap, penetration into the anterior chamber in the projection area of the schlemm canal, implantation of anti-glaucomatous allodrainage, one end of which is inserted into the anterior chamber, and laying the superficial scleral flap on place with its subsequent fixation. In this case, the drainage is made of the amniotic membrane of a person, which gradually dissolves (RU 2240086 C2, published on November 20, 2004).

However, this method has significant disadvantages:

1. With this method of surgical treatment, an exact anatomical exit to the Schlemm canal is impossible (penetration into the anterior chamber is carried out “in the projection zone of the Schlemm canal”).

2. there is no stage of IOP reduction before opening the anterior chamber, which can cause serious complications as a result of a sharp drop in IOP after opening the anterior chamber (bleeding into the anterior chamber, expulsive hemorrhage);

3. allodrainage is made of the absorbable amniotic membrane of a person, which implies its long-term presence in the eye cavity, therefore there is a threat of repeated operations for this pathology.

An object of the invention is the creation of an effective method for the surgical treatment of refractory glaucoma with the goal of long-term stabilization of IOP by activating 2 outflow paths: uveoscleral and under the conjunctiva, using a new porous biological collagen drainage made in the form of a strip 0.8 mm thick, 1 wide , 5 mm, 4.0 mm long from a material containing bone collagen isolated from the trabecular bone of farm animals and saturated with bone sulfated glycosamine glycans, and the exception These serious complications such as bleeding in the anterior chamber and expulsive hemorrhage.

The specified technical task according to the invention is achieved by the fact that in the method of surgical treatment of refractory glaucoma, including local anesthesia by introducing 1.0 ml of a 2% lidocaine solution into the subtenon space, the conjunctival flap is separated directly from the limb, a 1/3 thickness superficial scleral flap is formed sclera of a quadrangular shape 5.0 × 5.0 mm with the base to the limb, then in the deep layers of the sclera 1/3 of its thickness cut out a 3-coal flap with the base also to the limb, it is separated to the helmets ova of the canal and removed together with the outer wall of the Schlemm canal and the adjacent corneal tissue to the descemet membrane, then remove the endothelial lining of the Schlemm canal and cut a deep flap in the form of a strip 4.0 × 1.5 mm with the greater side to the Schlemm canal to the ciliary body; in the anterior chamber under this deep flap, consisting of a strip of sclera, the inner wall of the Schlemm canal and the descemetic membrane, they are removed, an intervascular iridotomy is performed, a collagen porous biological drainage is implanted, one the end of which is inserted into the anterior chamber, and the other end is placed on the adjacent strip of the ciliary body and fixed to the deep layers of the sclera, then the superficial scleral flap is laid in place and fixed with two sutures, while the porous drainage is made in the form of a strip 0.8 mm thick, width 1.5 mm, 4.0 mm long from a material containing bone collagen isolated from the spongy bone of farm animals and saturated with bone sulfated glycosamine glycans.

According to the invention, during the surgical treatment of refractory glaucoma by performing a stage of non-penetrating deep sclerlimbectomy with exposure of the Schlemm canal and the limbal edge of the descemet membrane before opening the anterior chamber, a sharp drop in IOP is possible, which can lead to complications such as bleeding into the anterior chamber and expulsive bleeding, and sparing intervascular iridotomy reduces the trauma of the uveal tract and the risk of intraoperative hemorrhagic complications.

The use of a new biodegradation-resistant porous biological drainage (xenotissue) saturated with sulfated glycosaminoglycans helps prevent scarring of the outflow pathways created during the operation. Bone collagen isolated from the trabecular bone of farm animals is known to have a porous structure, and in combination with sulfated glycosamine glycans, has a sufficiently low solubility and high long-term filtering ability, since sulfated glycosamine glycans (keratan sulfate, chondroitin sulfate, heparin) are included the composition of the connective tissue and regulate the salt-water balance in it, the drainage pores remain open for a long time, sulfated glycosamine glycans increase biocompatibility Axle material for ophthalmology and reduce its antigenicity. These features increase the safety of drainage during prolonged stay in the eye, which, in combination with surgery, according to the invention, and provides long-term stable stabilization of IOP in severe forms of glaucoma. The porous structure of the drainage allows the flow of intraocular fluid throughout the drainage with its active transfer to the filtration zone. Drainage in the area of operation is placed at one end in the anterior chamber, and the other end is located on the adjacent strip of the ciliary body and is fixed with a suture 10.0 to the deep layers of the sclera. The elasticity and porous structure of the drainage allow plastic surgery of the anterior chamber angle profile, as well as the outflow of intraocular fluid into the suprachoroidal space and under the conjunctiva.

The proposed method is as follows. Local anesthesia is performed by introducing 1.0 ml of a 2% lidocaine solution into the subtenon space. The conjunctival flap is separated directly from the limbus. A superficial scleral flap is formed to 1/3 of the thickness of the sclera of a quadrangular shape with a 5.0 × 5.0 mm base to the limb, then in the deep layers of the sclera 1/3 of its thickness a 3-sided flap is cut out with the base also to the limb, and it is separated to the Schlemm's canal and removed together with the outer wall of the Schlemm's canal and the adjacent corneal tissue to the descemet membrane. The endothelial lining of the Schlemm canal is removed. Next, they cut a deep flap in the form of a strip 4.0 × 1.5 mm with the greater side to the Schlemm canal to the ciliary body, with a spatula enter the front chamber under this deep flap, consisting of the sclera strip, the inner wall of the Schlemm channel and the Descemet membrane, and remove it. An intervascular iridotomy is performed. A collagen porous biological drainage is implanted, one end of which is inserted into the anterior chamber, and the other end is placed on an adjacent strip of the ciliary body and fixed to the deep layers of the sclera. Then the superficial scleral flap is put into place and fixed with two sutures, while the porous drainage is made in the form of a strip 0.8 mm thick, 1.5 mm wide, 4.0 mm long from a material containing bone collagen isolated from the trabecular bone of farm animals and saturated with bone sulfated glycosaminoglycans. The operation ends with subconjunctival administration of 0.2 ml of a solution of Gentamicin and 0.2 ml of a solution of Dexamethasone.

The operation diagram is shown in figures 1, 2, 3, 4, 5, 6, 7.

A method for surgical treatment of refractory glaucoma is illustrated by clinical examples.

Example No. 1. Patient K., 55 years old. Diagnosis: OS - Operated closed-angle “creeping” III “c” glaucoma. Initial complicated cataract. Preproliferative diabetic retinopathy (condition after PPLK).

OD - Narrow-angle II "a" glaucoma. Initial complicated cataract. Preproliferative diabetic retinopathy (condition after PPLK). Before the operation. Visual acuity OD = 0.2 n / k; OS = 0.2 n / k. Po OD = 21.0 mm Hg on medication, treatment; Po OS = 35.5 mm Hg at maximum drug regimen.

The patient underwent antiglaucomatous surgery on his left eye according to the method according to the invention, while collagen porous biological drainage was implanted with a thickness of 0.8 mm, a width of 1.5 mm, and a length of 4.0 mm. The operation and the postoperative period were uneventful. Po during dynamic observation after a month, 2, 3, 4 months was equal, respectively: 10.0; 12.0; 12.5; 12.5 mmHg without topical use of medicines.

Visual acuity at the OS at the last examination 4 months after the operation was 0.2 n / k.

Example No. 2. Patient M., 60 years old. Diagnosis: OD - initial cataract. OS - Operated neovascular III "c" glaucoma. Initial complicated cataract. Postthrombotic retinopathy. Before the operation. Visual acuity OD = 0.7 n / k, OS = 0.06 n / k. Po OD = 15.0 mm Hg without drug treatment, Po OS = 35.5 mm Hg at the maximum regimen of local drug treatment.

The patient underwent antiglaucomatous operation of the left eye according to the method according to the invention, with collagen porous biological drainage 0.8 mm thick, 1.5 mm wide, 4.0 mm long implanted. The operation and the postoperative period without complications. Po OS during the entire observation period after 1 month, 2, 3, 4, 5 months was 12.0; 12.0; 15.0; 15.5; 18.0 mmHg accordingly, without local drug treatment.

Visual acuity at the last examination on OS = 0.06 n / a.

Example No. 3. Patient L., 70 years old. Diagnosis: OD - twice operated pigment III "c" glaucoma. Initial complicated cataract. OS - operated pigment II "a" glaucoma. Initial complicated cataract.

Before surgery: Visual acuity OD = 0.5 n / k, OS = 0.7 n / k. Po OD = 35.5 mm Hg at maximum drug regimen. Po OS = 15 mmHg on drug treatment.

The patient underwent an anti-glaucomatous operation on his right eye according to the method according to the invention, wherein a collagen porous biological drainage of 0.8 mm thick, 1.5 mm wide, 4.0 mm long was implanted. The operation and the postoperative period without complications.

During the entire observation period: after a month, 2, 5, 8, 12, 16 months, the Rho OD was equal to 8.0, respectively; 10.0; 12.0; 12.5; 12.5; 12.5 mmHg accordingly, without local drug treatment. The visual acuity of OD at the last examination was 0.5 n / a.

Claims (1)

A method for surgical treatment of refractory glaucoma, including the formation of a conjunctival flap, a superficial scleral flap, penetration into the anterior chamber in the projection area of the Schlemm canal and implantation of anti-glaucomatous allodrainage, one end of which is inserted into the anterior chamber and the superficial scleral flap is inserted into place with its subsequent fixation, characterized in that 1.0 ml of a 2% solution of lidocaine is introduced into the subtenon space, the conjunctival flap is separated directly from the limbus, f the surface scleral flap is rounded to 1/3 of the scleral thickness of the quadrangular shape with a 5.0 × 5.0 mm base to the limb, then in the deep layers of the sclera 1/3 of its thickness a 3-gonal flap is cut out with the base to the limb, and it is separated to the Schlemm canal and remove together with the outer wall of the Schlemm canal and the adjacent corneal tissue to the descemet membrane, then remove the endothelial lining of the Schlemm canal and cut a deep flap in the form of a 4.0 × 1.5 mm strip with the greater side to the Schlemm canal to the ciliary body, with a spatula enter the front to Amer under this deep flap, consisting of a strip of sclera, the inner wall of the Schlemm's canal and descemet membrane, remove a deep flap in the form of a strip, perform an intervascular iridotomy, implant a porous biological collagen drainage, one end of which is inserted into the anterior chamber, and the other end is placed on the adjacent strip of the ciliary body and fix to the deep layers of the sclera, then the superficial scleral flap is laid in place and fixed with two sutures, while the porous drainage is made in the form of a strip of thickness 0.8 mm, 1.5 mm wide, 4.0 mm long from a material containing bone collagen isolated from the trabecular bone of farm animals and saturated with bone sulfated glycosamine glycans.

Images