RU2317047C1 - Surgical method for treating open angle glaucoma cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves cutting out superficial scleral flap, cutting out and removing deep scleral flap with internal wall of Schlemm's canal being exposed. Schlemm's canal bougienage is carried out. Corneoscleral tissue is cut in operation zone above the Descemet membrane near lateral deep scleral flap bed wall in perpendicular to limb. The first 0.1-1 mm wide strip is cut out from corneoscleral tissue along the whole exposed Schlemm's canal area having its base near the lateral deep scleral flap wall. Incision is made in perpendicular to the limb near the strip base. The second strip of the same width is formed along the whole exposed Schlemm's canal area having its base near the opposite lateral deep scleral flap wall. The second strip base is notched by 1/3-3/4 of its width in perpendicular to the limb from superficial scleral flap base towards the Schlemm's canal. The second strip is rotated by 180° about the base. Then, the strips are implanted between the Descemet membrane and corneal stroma immediately in front of dilated Schlemm's canal towards both sides from non-penetrating deep sclerectomy.

EFFECT: prolonged hypotensive effect; widening Schlemm's canal lumen; facilitated intraocular fluid discharge.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of patients with glaucoma.

A known method of surgical treatment of open-angle glaucoma, including cutting a superficial scleral flap, cutting and removing a deep scleral flap with exposure of the inner wall of the schlemm canal, bougie of the schlemm canal, dissection of the corneoscleral tissue above the descemet membrane in the middle perpendicular to the limb, and forming two strips from it at the outer edge of the bed of the superficial scleral flap, the invagination of these strips and their location between the stroma of the horn ovum and descemet membrane directly in front of the schlemm canal on both sides of the operation area (Bochkarev M.V., Yakub A., Uzunyan D.G., Shatskikh A.V. Canalodilation of the venous sinus of the sclera // Conference articles for doctors of central hospitals, diagnostic centers and military clinics, - Glaucoma: theories, trends, technologies, HRT club of Russia, - Moscow, - 2005, - p.60-64).

The disadvantage of this method is in some cases, insufficient and short-term effect of the operation.

The objective of the method is to enhance and prolong the hypotensive effect of antiglaucomatous surgery.

The technical result achieved by using the invention is to more efficiently restore the outflow of intraocular fluid through natural ways, to widen the lumen of the Schlemm canal, reduce the likelihood of developing functional blockade of the Schlemm canal, to facilitate the outflow of intraocular fluid from the venous sinus of the sclera into the zone of non-penetrating deep sclerectomy, and to reduce the effect of reparative processes on the hypotensive effect of the operation.

The technical result is achieved by the fact that in the method of surgical treatment of open-angle glaucoma, including cutting a superficial scleral flap, cutting out and removing a deep scleral flap with exposure of the inner wall of the schlemm canal, bougie of the schlemm canal, dissection in the area of the corneoscleral tissue operation above the descemetic membrane perpendicular to the limb, formation from two strips with a base at the outer edge of the bed of the superficial scleral flap, the invagination of these strips and them between the stroma of the cornea and the descemet membrane directly in front of the schlemm canal on both sides of the operation area, according to the invention, dissection of the root scleral tissue over the descemet membrane is carried out at the side wall of the bed of the deep scleral flap in the direction perpendicular to the limbus, then one strip of corneoscleral tissue is cut at the beginning along the root the entire area of the exposed Schlemm's canal 0.1-1 mm wide, with the base at the side wall of the deep scleral flap, then at the base of this strip in perpendicular to the limb, an incision of the corneoscleral tissue is made and a second strip is also formed from it along the entire section of the exposed Schlemm canal with a width of 0.1-1 mm, with a base at the opposite side wall of the deep scleral flap, the base of the second strip is cut at 1 / 3-3 / 4 its width in the direction perpendicular to the limb, from the center of the cornea to the periphery, then rotate the second strip around the base by 180 °, then cut strips of corneoscleral tissue are implanted between the descemet membrane and the stroma cornea immediately before the advanced Schlemm's canal in both sides of the zone of non-penetrating deep sclerectomy.

The method allows to enhance the hypotensive effect of non-penetrating deep sclerectomy due to the partial restoration of the outflow of intraocular fluid through natural drainage paths. In this case, the implantation of strips of corneoscleral tissue between the stroma of the cornea and the descemet membrane directly in front of the schlemm canal allows to significantly expand the lumen of the venous sinus of the sclera. At the same time, the probability of a functional blockade of the Schlemm canal sharply decreases. In addition, a free, wide communication is created between the zone of non-penetrating deep sclerectomy and the lumen of the Schlemm's canal on both sides of the operation zone. This facilitates the outflow of intraocular fluid from the lumen of the Schlemm canal along the newly created pathways for the outflow of intraocular fluid. Unlike the known method for the surgical treatment of glaucoma, strips of corneoscleral tissue are cut two times longer, and therefore, the lumen of the Schlemm's canal expands at a much greater distance from the NSES zone. This helps to strengthen and prolong the action of the proposed operation.

It should be noted that this technique can dramatically reduce the area of the zone of non-penetrating deep sclerectomy, and therefore, minimize the effect of excessive reparative processes on the hypotensive effect of the operation.

The invention is illustrated by drawings, which depict:

Figure 1 - cutting a superficial scleral flap, cutting and removal of a deep scleral flap;

Figure 2 - cutting strips of autologous tissue stroma of the cornea;

Figure 3 - rotation of the second strip;

Figure 4 - implantation zone of the formed strips of corneal autotissue.

The method is as follows.

Under local anesthesia, a conjunctiva and tenon capsule is incised 2 mm from the limbus. A superficial scleral flap is cut out (1) with a base at the limb at 1 / 3-2 / 3 of the sclera thickness with entry into the transparent layers of the cornea. Under it, a triangular deep scleral flap (2) is marked and cut out with the base facing the limb, until the surface of the ciliary body is partially exposed. They open the Schlemm's canal, exposing the trabecula (3) along the entire base of the deep scleral flap. The deep scleral flap (2), including the outer wall of the Schlemm's canal, is removed. At the same time, a strip of corneoscleral tissue remains over the area of the descemetic membrane adjacent to the trabecula (4). The front camera remains unopened (Figure 1). After that, a microsurgical instrument is inserted into the schlemm canal at a distance of 3 mm on each side of the zone of non-penetrating deep sclerectomy and the front wall of the schlemm canal is destroyed with the descemet membrane stratified from the corneal stroma at a distance of 0.1 to 2 mm from the schlemm canal (5) without opening the anterior chamber of the eye. Microsurgical instrument is removed. This strip of corneoscleral tissue rises with tweezers and is dissected at one of the lateral walls of the deep scleral flap perpendicular to the limb by 0.1-1 mm. Then, a strip of corneoscleral tissue is cut parallel to the limb to the opposite side wall of the deep scleral flap. After that, at the base of the cut out corneoscleral strip (6), the corneoscleral tissue is cut perpendicular to the limb by 0.1-1 mm. Then an incision is made of a strip of corneoscleral tissue parallel to the limb at the base of the superficial scleral flap to the opposite lateral wall of the deep scleral flap (7) (Figure 2). The base of the second cut corneoscleral strip (7) is incised from the base of the superficial scleral flap in the direction of the Schlemm's canal. The second strip (7) rotate around its base by 180 ° (Figure 3). Then, cut strips of corneoscleral tissue (6, 7) are implanted between the descemet membrane and the stroma of the cornea directly in front of the schlemm canal (5) on both sides of the operation area (Figure 4). Next, a continuous suture is applied to the mucous membrane of the eye.

Example 1. Patient K., 69 years old, was admitted with complaints of a narrowing of the visual fields and a decrease in visual acuity of the right eye; Diagnosis: primary open-angle glaucoma III from the right eye. Instills a 2-fold solution of fotil in the right eye.

Right eye. IOP = 32 mmHg Visual acuity = 0.7 s corr.

P ₀ = 35.8 mm Hg, C = 0.04, F = 0.38, P ₀ / C = 895.

The boundaries of the visual fields are concentrically narrowed to 10 degrees from the fixation point. The eye is calm. The angle of the anterior chamber is open at III, the degree of pigmentation 2. The length of the eye is 23.78 mm, the depth of the anterior chamber is 2.83 mm.

After a non-penetrating deep sclerectomy, implantation of strips of corneoscleral tissue in front of the enlarged schlemm's canal was performed on both sides of the operation area using the described technology.

The postoperative period was uneventful. 3 months after surgery: IOP = 15 mm Hg Visual acuity = 0.8 s corr. P ₀ = 12.1, C = 0.28, F = 0.95, P ₀ / C = 43. The field of view expanded by 5-10 degrees from the fixation point.

Example 2. Patient U. 76 years old was admitted with a diagnosis of primary open-angle glaucoma IIc, complicated cataract of the left eye. Complaints of decreased visual acuity of the left eye. Instills a 2-fold azopt solution in the left eye.

Left eye. IOP = 37 mmHg Visual acuity = 0.5 s corr.

P ₀ = 41.6 mm Hg, C = 0.04, F = 1.23, P ₀ / C = 1040.

The boundaries of the visual fields are narrowed by 30 degrees from the bow. The eye is calm. The anterior chamber angle is open at IV, the degree of pigmentation is 1-2. Eye length 25.36 mm, anterior chamber depth 3.28 mm.

An operation was performed according to the described technology.

The postoperative period was uneventful.

3 months after surgery: IOP = 14 mm Hg Visual acuity = 0.4-0.5 with corr., P ₀ = 11.8, C = 0.30, F = 0.26, P ₀ / C = 39. The field of view has not changed.

Claims (1)

A method of surgical treatment of open-angle glaucoma, which consists in cutting out a superficial scleral flap, cutting out and removing a deep scleral flap with exposure of the inner wall of the schlemm canal, bougie of the schlemm canal, dissection of the corneocleral tissue above the descemet membrane in the area of the operation, perpendicular to the limb, forming two strips with a base from it the outer edge of the bed of the superficial scleral flap, the invagination of these strips and their location between the stroma of the cornea and descemet membrane directly in front of the schlemm canal on both sides of the operation zone, characterized in that the scleral tissue is dissected above the descemet membrane at the lateral wall of the bed of the deep scleral flap in the direction perpendicular to the limb, then first one strip of corneoscleral tissue is cut along the entire section of the exposed schelmetal canal 0.1-1 mm wide, with the base at the side wall of the deep scleral flap, then at the base of this strip in the direction perpendicular to the limb, the wire The incision of the corneoscleral tissue is formed and a second strip is formed from it along the entire section of the exposed Schlemm's canal with a width of 0.1-1 mm, with a base at the opposite side wall of the deep scleral flap, the base of the second strip is cut into 1 / 3-3 / 4 of its width in the direction perpendicular to the limb, from the base of the superficial scleral flap towards the Schlemm canal, then rotate the second strip around the base by 180 °, then cut out strips of corneoscleral tissue are implanted between the descemet membrane and the stromal cornea immediately in front of the enlarged schlemm canal on both sides of the zone of non-penetrating deep sclerectomy.

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