RU2328253C1 - Method of treatment of early postoperative hypertension caused by trabecular descemet's membrane prominence to intrasclera cavity following non-penetrating antiglaucomatous operations - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: invention is applied for treatment of early hypertension caused by thin trabecular Descemet's membrane (TDM) prominence to operation zone following non-penetrating filter antiglaucomatous operations. Conjunctiva is dissected for 1 mm within inferior-internal and inferior-external sclera graft (SG) angle bordering zone. Distal end of SG is raised with spatula. Syringe-installed cannula is inserted under graft and placed within SG plane, perpendicularly to its distal end and base, along SG center line. To avoid TDM traumatisation cannula is forwarded to SG base no more than 1/2 of its length. As cannula is forwarded, viscoelastic is inserted under SG. Under the influence of viscoelastic, TDM is separated from SG even in case of fresh adhesions. Procedure is completed, cannula is removed while viscoelastic is kept is ISC. Method provides reduction of early postoperative hypertension caused by intrasclera cavity blockage after non-penetrating filter antiglaucomatous operations and ISC recovery.

EFFECT: provided stable normalised ophthalmotonus within early postoperative period; prevention of indirectly developed tissue adhesion in operation zone and prolonged hypertensive effect of operation.

3 cl, 3 ex

Description

The invention relates to medicine, and more specifically to ophthalmology, and is intended for the treatment of early hypertension associated with the prominence of a thin trabeculo-descemet membrane in the surgical area after non-penetrating antiglaucomatous operations (NAGO).

One of the complications of the early postoperative period of NAGO filtering type is a relapse of increased intraocular pressure (IOP) associated with blockade of the intrascleral cavity (ICP) by the trabeculo-descemet membrane (TDM). Diagnosis of the position of TDM is carried out using ultrasound biomicroscopy (UBM). This technique allows us to evaluate not only the thickness and acoustic density of the membrane, but also the specifics of its position - UBM is able to establish any degree of TDM prominence in the ICP, from the light retraction of the membrane in the ICP to the complete blockade of the latter. Complete blockage of the intrascleral cavity of the TDM gradually leads to the development of adhesions of the TDM with the scleral flap (SL) and the disruption of the hypotensive effect of the operation. The lack of filtration from the anterior chamber causes the gradual desolation of the overlying sections of the outflow paths and the complete overgrowth of the surgically formed drainage channel. Irreversible changes in the surgical area become the reason for the need for repeated antiglaucomatous surgery.

There is a method of treating early postoperative hypertension due to the pathology of TDM after filtering type NAGO, which consists in conducting a laser intervention, known as descemetogoniopuncture (BPH) (L.I. Balashevich, M.V. Gatsu and others: Laser treatment of glaucoma. - St. Petersburg. - 2004. - P 41-43).

This method has a number of significant drawbacks. The position of the TDM is determined using gonioscopy. However, gonioscopy does not provide an objective assessment of the degree of contact of TDM with SL. The presence of full contact of TDM with SL makes it difficult to determine the area of operation by the gonioscopy method, and therefore the points of application of laser exposure are chosen tentatively. To clarify the location of the surgical area, often use the external landmarks of the area of operation. Accordingly, the total power of the laser radiation increases while there is no possibility to produce dosed BPH. All of the above increases the invasiveness of the laser procedure and reduces its practical value. In addition, not all medical institutions are equipped with expensive laser equipment necessary for this type of treatment.

The objective of the invention was the creation of an effective method for the treatment of early postoperative hypertension due to blockage of the intrascleral cavity of the trabeculo-descemetic membrane after NAGO, which allows to restore the topographic relationship between TDM and ICP, preserving the integrity of the TDM during the procedure, and subsequently, if necessary, allowing dosed BPH to be performed.

The technical result is the relief of early postoperative hypertension due to blockade of the intrascleral cavity of the TDM after the filter type HAP, restoration of the ICP, stable normalized ophthalmotonus in the early postoperative period and, as a result, the prevention of the mediated development of interstitial fusion in the zone of the NAGO, ensuring the prolongation of the hypotensive effect of the operation and a decrease in frequency repeated surgical interventions.

The technical result is achieved by the fact that in the method of treating early postoperative hypertension due to blockage of the intrascleral cavity by the trabeculo-descemetic membrane after the NAGO filter type, according to the invention, a conjunctiva is cut up to 1.0 mm in size in an area bordering the lower inner or lower outer angle SL. The distal edge of the trunk is raised with a spatula. A cannula is inserted under the flap on a syringe filled with viscoelastic (for example, a visitor), and a viscoelastic is inserted under the SL, placing the cannula in the SL plane along its midline perpendicular to the distal edge and the base of the SL. To avoid trauma, the TDM cannula is advanced towards the base of the SL by no more than 1/2 of its length, introducing viscoelastic under the SL as the cannula moves. Under the influence of viscoelastic, TDM is separated from the SL even in the presence of fresh adhesions. Finishing the procedure, remove the cannula, leaving the viscoelastic in the ICP.

In the case of sclero-scleral and / or sclero-conjunctival adhesions, through the previously made conjunctiva incision, interstitial adhesions are separated in the area of operation with a spatula and an additional viscoelastic is introduced into the cavity of the filter pad (AF). The intervention is completed by applying a nodal suture to the conjunctival incision. IOP is monitored and, in addition, the first days after surgery (on the 4th-7th day), UBM of the surgical intervention zone is performed, assessing the position of the TDM.

In the case of a subsequent increase in IOP after surgery, a dosed BPH is carried out, determining the localization of the intraocular zone of the operation using gonioscopy.

The technical result is achieved due to the fact that:

1. The perpendicular position of the cannula with respect to the base of the SL and adjacent TDM provides the introduction of viscoelastic at right angles to the TDM, which facilitates its squeezing from the SL under the pressure of the injected drug and eliminates the trigger factor for the development of early postoperative hypertension - the TDM prominence in the area of operation.

2. The absence of the need to open the cavity of the eye prevents the occurrence of complications associated with the drop in IOP - edema and detachment of the choroid.

3. The presence of viscoelastic in the ICP increases the pressure in it and thereby eliminates the sharp difference between the IOP and the pressure in the ICP, which prevents the relapse of TDM prominence into the operation area.

4. In the case of indications for subsequent BPH, the correct position of the TDM makes it possible to carry out laser intervention under visual control, which not only reduces the duration of the procedure, but also facilitates the dosing of laser exposure and partially preserves the TDM intact, which is the key to uniform filtration of intraocular fluid (MIC) along the outflow paths.

The method is as follows.

With an increase in IOP in the early stages after NAGO, a UBM is performed and, if the TDM prominence that causes ICP blockade is detected, surgical correction of the TDM position is performed. To do this, at the border of the lower inner or lower outer corner of the superficial scleral flap (SL), a small section of the conjunctiva is made with a length of not more than 1.0 mm. A distal edge of the SL is raised with a spatula, if necessary, simultaneously separating interstitial adhesions between the SL and the ICP bed. A cannula is placed under the flap on a syringe filled with viscoelastic (for example, a visitor). The cannula is placed strictly perpendicular to the distal edge (and base) of the SL along its midline. Gradually moving the cannula towards the base of the SL in the ICP (under the SL), a viscoelastic is introduced. To avoid trauma to TDM, cannula advancement is completed by passing no more than 1/2 of its length, introducing viscoelastic under the SL as the cannula advances. Under pressure, viscoelastic TDM is separated from the SL even in the presence of fresh adhesions. After filling the ICP with viscoelastic, the procedure is completed, leaving the viscoelastic in the ICP. If necessary, through the previously made incision of the conjunctiva, the sclero-conjunctival adhesions are separated with a spatula in the area of the operation, the cavity of the filter cushion (AF) is restored and an additional viscoelastic is introduced into the AF area. The intervention is completed by applying a nodal suture to the conjunctival incision. From the first days after surgery, IOP is measured and, in addition, on the 4th - 7th day, UBM of the surgical intervention zone is performed, assessing the position of the TDM.

Subsequently, with an increase in IOP, the localization of the intraocular zone of the operation is determined using gonioscopy and metered laser intervention (BPH) is performed.

The invention is illustrated by the following examples.

Example 1. Patient P, 54 years old. Diagnosis: right eye - operated primary open-angle glaucoma II c.

3 weeks ago, a patient at the place of residence (Kostroma) underwent non-penetrating deep sclerectomy (NSES). 2 weeks after surgery, there was a relapse in increasing IOP to 34 mm Hg. Attempts to conservatively normalize IOP did not give effect, and the patient was referred for consultation at the MNTK MG.

When examining the right eye in the upper segment of the eyeball (at 12 o’clock), the area of surgical intervention is clearly differentiated. AF is absent. The conjunctiva in the area of operation is slightly hyperemic. The cornea is transparent. The anterior chamber is 3.0 mm deep, uniform, its moisture is transparent. The pupil is round, 2.5 mm in diameter, the reaction to light is sluggish. The lens is transparent. With ophthalmoscopy, blanching of the temporal half of the optic nerve disc (optic nerve disc), shift of the vascular bundle to the nose, glaucomatous excavation is determined. When conducting gonioscopy, it was not possible to identify the area of operation from the angle of the anterior chamber.

UBM in radial sections revealed a complete blockade of the intrascleral cavity of TDM.

The patient was treated with early postoperative hypertension due to the prominence of the trabeculo-descemetic membrane after non-penetrating type anti-glaucomatous surgery according to the proposed method — TDM was squeezed from the SL by introducing viscoelastic under the SL (visited). In ICP left 0.1 ml visited. Normalization of IOP (17 mmHg) took place from the first days after the restoration of topographic relations between TDM and ICP. In the area of the operation, a spilled AF is clearly visible in the light of the slit lamp. With gonioscopy at 12 o’clock, the area of operation is clearly defined in the form of a translucent rectangular area. Conducting UBM in radial sections on the 7th day after the intervention confirmed the disappearance of the TDM prominence and the restoration of its direct profile, the appearance of COI. The acoustic density of the TDM membrane was in the range of 50-55%, and the minimum thickness values were 0.09 mm. Dynamic examinations of the patient at 3, 6, 12 and 18 months after surgery showed the stability of the state of the left eye. IOP - 18-19 mm Hg In the area of surgical intervention, diffuse AF is preserved.

Example 2. Patient T., 11 years old. Diagnosis: left eye - secondary post-traumatic glaucoma. Traumatic cataract. The right eye is healthy.

The girl suffered a left eye injury 7 months ago. Primary surgical treatment was performed on the day of injury at the place of residence. The diagnosis of secondary (post-traumatic) glaucoma was made 3 months ago. The appointment of antihypertensive instillations did not work.

When examining the left eye - corneoscleral traumatic scar at 11 o'clock, fused with the iris. Depth of anterior chamber 3.5. Moderate atrophy of the iris tissue, expressed by the smoothness of its structure. The pupil is 2.5 × 3.5 mm, in the form of an oblique oval with the direction of the long axis towards the scar. The reaction to light is uneven due to the presence of a single posterior synechia along the pupil edge. Complete traumatic cataract. Underlying environments are not visible. With gonioscopy, the open angle of the anterior chamber with single goniosynechias is determined.

Visual acuity of the left eye is the correct light projection. The length of the anteroposterior axis of the eyeball is increased to 24.1 mm. IOP - 27-28 mm Hg against the background of the maximum regime of antihypertensive instillations.

The patient was hospitalized in the children's department MNTK "MP" for surgical treatment. Given the initial stage of glaucoma, a non-penetrating trabeculectomy was performed on the left eye. 7 days after the operation, an increase in IOP to 29 mm Hg occurred. At the same time, a sharp flattening of AF was noted in the external area of the operation, and gonioscopy revealed the absence of topographic landmarks of the surgical intervention zone, which consists in the almost complete disappearance of the transparent area formed by the TDM. Conducting UBM in radial sections revealed an almost complete blockade of ICP TDM. Slit-like ICP could only be determined in some acoustic sections. The patient underwent surgical correction of the position of the TDM according to the proposed method — the TDM was squeezed from the SL by introducing viscoelastic (methyl cellulose) under the SL. In ICP left 0.1 ml visited. Additionally, the division of conjunctival scleral fusions that managed to form was made. Under the conjunctiva in the field of AF introduced visited. The postoperative period was uneventful. From the first days after the correction of the position of the TDM, the IOP decreased to 19-20 mmHg. An increase in the size of AF was noted. Conducting UBM in radial sections on the 5th day after the intervention showed the restoration of the direct TDM profile and the presence of ICP, the volume of which was 3.46 mm ³ . The AP TDM of the membrane was in the range of 45-55%, and the thickness did not exceed 0.08 mm. The child was discharged from the department on the 7th day after correction of the TDM position. Dynamic examinations of the patient in terms of 3, 6, 12 and 18 months after surgery showed the stability of the state of the left eye. IOP - 19-20 mm Hg, with no tendency to increase it. In the area of surgical intervention, diffuse, weakly vascularized AF is visualized. The dynamics in terms of the length of the anteroposterior axis of the eyeball was not detected.

Example 3

Patient L., 62 years old. Diagnosis: left eye - operated primary open-angle glaucoma III c. Right eye: operated primary open-angle glaucoma II a.

18 days ago, a patient at the ISTC "MG" underwent NGSE. When extracting IOP of the left eye - 22 mm Hg In the outer area of the operation, a flat-spaced AF was visualized. 18 days after surgery, an advisory appointment revealed an increase in IOP in the left eye to 36 mm Hg. Examination of the left eye revealed a flattening of AF, the conjunctiva in the area of operation is slightly hyperemic. Under the conjunctiva, the area of surgical intervention is clearly differentiated. The cornea is transparent. The anterior chamber is 3.0 mm deep, uniform, its moisture is transparent. The pupil is round, 2.5 mm in diameter, the reaction to light is sluggish. The lens is transparent. With ophthalmoscopy, blanching of the temporal half of the optic nerve disc (optic nerve disc), shift of the vascular bundle to the nose, glaucomatous excavation is determined. During gonioscopy, it was not possible to identify the area of operation from the angle of the anterior chamber.

The patient was recommended UBM study. Conducting UBM in radial sections revealed a complete blockade of ICP TDM.

The patient underwent surgical correction of the position of the TDM according to the proposed method - under the SL through the cannula worn on the syringe, a viscoelastic was introduced (visited); TDM is squeezed from the trunk. In ICP left 0.1 ml visited. Normalization of IOP (17 mmHg) took place from the first days after the restoration of topographic relations between TDM and ICP. The AF height increased; it began to be clearly visible in the light of a slit lamp. The gonioscopic picture returned to normal - at 12 o’clock the operation zone in the form of a translucent rectangular area became easily differentiated from the surrounding tissues. Conducting UBM in radial sections on the 5th day after the intervention confirmed the restoration of the direct TDM profile and the presence of COI. AP TDM membrane was in the range of 45-50%, and the thickness did not exceed 0.09 mm. Dynamic examinations of the patient in terms of 3, 6 months after surgery showed the stability of the state of the left eye. IOP - 19-21 mm Hg Spilled AF remained in the outer area of the surgical intervention.

However, 9 months after surgery, a follow-up advisory appointment revealed a repeated increase in IOP to 28 mm Hg. The appointment of antihypertensive instillations provided an insufficient reduction in IOP, which remained within 24-25 mm Hg. When viewed, flattening of the AF is noted. Gonioscopy showed the dustiness of the transparent rectangular portion of the inner area of the operation with pigment. Conducting UBM revealed an increase in AP TDM to 65-75% with a simultaneous increase in its thickness, the minimum values of which corresponded to 0.13 mm. The examination showed that the block of outflow of intraocular fluid is located at the level of TDM, and the patient was recommended laser descemetogoniopuncture (BPH). BHP was performed on a Visulos YAG II plus Zeiss ophthalmic unit with a wavelength of 1.064 μm and a power of 2.4-5.7 mJ. Laser intervention went without complications. IOP decreased to 17-18 mm Hg immediately after the procedure. The need for antihypertensive instillations has disappeared. Subsequent (within 1.5 years) observation of the patient showed stability of the achieved results, IOP was in the range of 19-20 mm Hg.

The invention is an effective method for the treatment of early postoperative hypertension due to blockage of the intrascleral cavity of the trabeculo-descemetic membrane after NAGO. The proposed method is atraumatic, provides reliable and persistent correction of the TDM position, as well as the normalization of IOP by restoring the correct topographic ratios of structures in the inner zone of the operation, the possibility of dosed laser BPH in the long term. Using the method according to the described method improves the quality of patient rehabilitation. The method is technically simple and affordable, does not require additional surgical skills and expensive equipment and is especially suitable in institutions that do not have laser equipment.

According to the proposed method, 10 interventions were performed that corrected the position of the TDM, there were no complications. In the early stages, a stable normalization of IOP was achieved (17-21 mm Hg). In 5 patients (5 eyes), in the period from 3 months to a year, BPH was performed, the indication of which was an increase in IOP. All laser procedures proceeded without complications.

Claims (3)

1. A method of treating early postoperative hypertension due to pathology of the trabeculo-descemetic membrane (TDM) after non-penetrating type anti-glaucomatous surgery, including position correction of the TDM, characterized in that a conjunctiva incision of up to 1 size is made at the border of the lower inner or lower scleral flap (SL), 0 mm, under the flap, a viscoelastic is inserted through the cannula put on the syringe through the cannula put on the syringe, placing the cannula along the midline of the SL perpendicular to its distal edge, cannula is advanced no more than 1/2 the length of the trunk and complete the process, leaving a viscoelastic in ICP. 2. The method according to claim 1, characterized in that in the presence of sclero-scleral adhesions they are separated before the introduction of viscoelastic into the ICP, and in the presence of conjunctival-scleral adhesions before completion of the procedure, they are separated with a spatula through a previously made conjunctival incision to restore the cavity of the filter pad ( AF) and viscoelastic is introduced into the AF zone. 3. The method according to claims 1 and 2, characterized in that, with a subsequent increase in intraocular pressure, descemetogoniopuncture is additionally carried out, while the localization of the intraocular zone of the operation is determined using gonioscopy.