RU2436551C1 - Method of preventing scarring after antiglaucoma operations with application of denervation principle - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be applied for surgical treatment of glaucoma. Conjunctiva is cut and separated from Tennon's capsule to limb. Flap of sclera is cut out. Episclera and Tennon's capsule are excised. Destruction of Axenfeld's loops is performed by thermocoagulation of sclera in area of exit from sclera from both sides from cut out sclera flap without damaging anterior ciliary artery and vein. ^ EFFECT: method makes it possible to normalise intraocular pressure for longer term without application of local hypotensive medications due to activation of intraocular fluid outflow, which leads to extension of peripheral boundaries of visual field, reduction of number of absolute and relative scotomas and preservation of sight acuity in patients with initial non-compensated glaucoma. ^ 1 tbl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and is used as a method of surgical treatment of glaucoma, with the aim of increasing the stability of the hypotensive effect and preserving visual functions.

A number of methods for the surgical treatment of glaucoma are known. Closest to the claimed is a method of damaging the nerve endings by cauterizing the rabbit cornea in an experiment (Belyaev B.C. Operations on the cornea and sclera - M., Medicine, 1984. P.3-26). However, this technique was studied only under experimental conditions (not on the glaucoma model) and no information was obtained on the reproducibility of experimental results in patients. The author did not conduct clinical studies and did not obtain the results of applying the principle of denervation in patients with various stages of glaucoma. The experiment was performed only on the cornea of animals. No data were obtained on the processes of connective tissue maturation in the corneoscleral region, which is very important for the subsequent prediction of the scarring of the filtration zone after antiglaucomatous operations.

Also close to our proposed method is the “Method for reducing the formation of scar tissue after non-penetrating deep sclerectomy” (Bakunina N.A., Fedorov A.A., Kolesnikova L.N., 2008). The authors performed a non-penetrating deep sclerectomy with excision of the episclera and subconjunctiva. The authors themselves note that the method consists in removing the subconjunctiva as a source of proliferating fibroblasts. However, given the segmental arrangement of nerve fibers, there is no certainty that in this case, when the subconjunctiva and episclera with the excised site are excised, the nerve fibers will be removed. In addition, this study was performed on a small amount of material (18 eyes), and the table presented by the authors shows that the outflow ease coefficient after 1.5 years approaches the maximum permissible value [0.3 mm ³ / min mm Hg] (Nesterov A.P. Hydrodynamics of the eye .-- M., Medicine, 1967. - P.75). These data indicate a decrease in the antihypertensive effect 1.5 years after the operation.

The technical result of the invention is the prevention of scarring, based on a violation of the maturation of collagen by denervation of the future filtration zone of surgical intervention.

The technical result is achieved as follows: the operation is performed under local anesthesia (Sol.Lidocaini 2% - 2 ml retrobulbar and Sol.Inocaini 0.4% epibulbar during the operation). A frenulal fixation suture is applied to the superior rectus muscle of the eye. The conjunctiva is cut in the meridian from 11 h to 1 h at 8 mm from the limb. The conjunctiva together with the subconjunctiva are separated from the tenon capsule to the limbus. After that, a flap of rectangular shape 6 × 6 mm in size 1/3 of the sclera thickness is cut out from the surface layers of the sclera. Tenon capsule and episclera are dissected above it and 3 mm from the edges of the cut flap, after which Aksenfeld loops are destroyed (by thermocoagulation of the sclera in the emissary area on both sides of the cut scleral flap without damaging the anterior ciliary artery and vein). Further, the surgical intervention is performed according to the standard technique for performing deep sclerectomy (GSE operation according to S.N. Fedorov, 1980) (Nesterov A.P. Primary glaucoma - M., Medicine, 1982. - P. 243-242). The scleral flap should be separated before the appearance of translucent limbal tissue. A triangular-shaped flap 4 × 4 mm in size, with a base to the limb, is excised from the deep layers. A peripheral iridectomy is performed in the iris for 12 hours. The superficial sclera flap is placed in its original place and fixed with two atraumatic sutures, the conjunctiva is sutured with a continuous atraumatic suture (8/0).

The operation is completed by subconjunctival administration of the solution.

Sol.Genthamycini - 0.2 ml and Sol.Dexametasoni - 0.2 ml.

For ever: Sol.Laevomycetini 0.25%, Sol.Taufoni 0.4%.

New according to the invention is: thermal degradation of Aksenfeld loops, thereby achieving denervation of not only superficial but also deep layers of the sclera, based on the peculiarities of innervation (Guide to Ocular Diseases: 5 vol. Medgiz, 1962. - V. 1. Book 1. - S. 144, 148).

Confirmation of the effectiveness of the proposed method are the following examples.

Example 1

An example is the patient’s medical history: M., born in 1938, medical history No. 88.

She was treated in the ophthalmic department from 01/14/2008 to 01/24/2008.

Patient's diagnosis: right eye (OD) - Open-angle glaucoma IIc, uncompensated. Initial cataract. Left Eye (OS) - Open angle glaucoma IIIa, operated on. Immature cataract.

Concomitant pathology: Coronary heart disease. Angina pectoris, functional class III. Hypertension II. Chronic heart failure II.

From the anamnesis: the patient has been suffering from glaucoma since August 2002 (first diagnosed).

The regimen of antihypertensive therapy was as follows: “Pilocarpine-1%” and “Okupres-0.25%” were instilled 2 times a day in both eyes. Intraocular pressure (IOP) in the left eye has not returned to normal.

In 2003, an anti-glaucomatous operation (AGO) was performed on the left eye (OS) by the method indicated by us.

Ophthalmic status (before and after surgery)

The examined eye:
Visus OD (right eye) OS (left eye) 0.9 n / box 0.4 n / box Gonioscopy CPC open, medium width. Moderately pronounced pigmentation of trabeculae and HQ. Sclerosis trabeculae. CPC open, medium width. Moderately pronounced pigmentation of trabeculae and HQ. Sclerosis trabeculae. Tonometry (according to Maklakov, gr 10 gr) 20 mmHg (in drug regimen)
19 mmHg (in drug regimen - at discharge) 32/35 mmHg (at maximum drug regimen)
16 mmHg (without drops - at discharge)

The operation and the postoperative period without complications. After the antiglaucomatous operation performed, the intraocular pressure in the left eye decreased to 16 mmHg, visual functions remained unchanged. With ophthalmoscopy: the optic nerve disc is grayish in color, with clear boundaries, glaucoma excavation, the vascular bundle is displaced to the nasal side. Arteries are sclerotic, convoluted, Salus I-II.

During the observation period from 2003 to 2009, the IOP in the operated eye ranged from 18 to 20 mmHg. without the use of local antihypertensive therapy. IOP in the right eye began to rise.

Since 2006, Xalatan (Sol.Latanoprosti 0.005%) was added to the non-operated eye 1 time (1 drop) overnight. Vision deteriorated, glaucomatous excavation progressed. The patient refused the operation due to the general state of health. After stabilizing the function of the cardiovascular system, the patient underwent antiglaucomatous surgery. The right eye was operated on in January 2008 according to our proposed technique.

Status ophthalmicus upon admission (01/14/2008):

The examined eye:
Visus OD (right eye) OS (left eye) 0.2 not cor. Hand movement in the face Tonometry (according to Maklakov, gr 10 gr) 01/15/2008 30 (at max drug regimen) 01/15/2008 20 01/16/2008 25 01/16/2008 22 01/17/2008 25 01/17/2008 20 01/24/2008 19 (at discharge) 01/24/2008 20 (at discharge)

With ophthalmoscopy: the optic nerve disc is grayish in color, with clear boundaries, glaucoma excavation, the vascular bundle is displaced to the nasal side. Arteries are sclerotic, convoluted, Salus I-II.

At discharge 01/24/2008:

visual acuity of the operated right eye increased by 0.2 (to 0.4). IOP decreased to 19 mm Hg Field of view: the peripheral borders on both eyes expanded by 5-10 °, and the number of absolute and relative cattle decreased within 30 ° (the number of absolute cattle decreased from 46 to 29, relative - from 24 to 6). Visual acuity in the left eye decreased as a result of cataract progression. By 2008, Vis on OS did not exceed 0.001 (hand movement in the face). IOP of both eyes is compensated without medication. The field of view is maintained within the previous values.

In 2009, the patient underwent cataract extraction with IOL implantation on the left eye.

Visual acuity of the left eye increased to 0.4.

Example 2

Patient M., born 1939 No. of medical history: 3648.

The patient was treated in the eye department of the 17th City Clinical Hospital of Voronezh from 11.30.2009 to 12.12.2009.

Diagnosis at admission: OD: Primary open-angle glaucoma IIa, compensated. Immature cataract. OS: Primary open-angle glaucoma IIIa, operated. Artifakia.

Concomitant pathology: Coronary heart disease. Hypertension II. Chronic heart failure II. Type II diabetes mellitus (since 2000). Chronic gastritis (remission stage).

From the anamnesis: the patient is registered in the clinic for glaucoma since 1996.

The patient was operated on in 2001 according to our proposed technique for performing filtering antiglaucomatous surgery. 05/20/2001, was hospitalized in an emergency room with a diagnosis of: OS - an acute attack of glaucoma. Immature cataract. OD - primary open-angle glaucoma IIa. Immature cataract.

Objective data before surgery:

Vis OS = 0.2 n / a. The total field of view in ° along the 8 meridians = 135 °. IOP = 38 mmHg

Due to edema of the cornea and lens, details of the fundus are not visualized with ophthalmoscopy.

The patient underwent antiglaucomatous surgery on the left eye according to the proposed method. The operation and the postoperative period without complications.

Data at discharge: (2.06.2001): Vis OS = 0.3 n / a. SGPZ ° at 8 meridians = 250 °. IOP = 18 mmHg

Ophthalmoscopy: grayish color optic nerve disc, with clear boundaries, glaucoma excavation, the vascular bundle is displaced to the nasal side. Arteries are sclerotic, convoluted, Salus I-II.

The regimen of antihypertensive therapy in the patient: in the right eye “Pilocarpine”, “Ocupres-0.25%” 2 times a day.

On the left eye, IOP is compensated (without the use of antihypertensive drops). The patient undergoes metabolic drug therapy (1-2 times a year). As a result of cataract progression, visual functions in the left eye were steadily declining, but the patient refused surgery (in October 2006 Vis OS = light sensation with the correct projection, visual field - residual from the temporal side -40 °). November 14, 2006, as planned, patient M. in the left eye (OS) underwent an EEC operation with IOL implantation. The operation and the postoperative period without complications.

Data at discharge: Vis OS = 0.3. CGP ° ° along 8 meridians = 365 °. IOP = 19 mmHg

Recommended: in OD - the regimen of local antihypertensive therapy is the same.

In OS - local anti-inflammatory and antibacterial therapy for 1 month.

For more than 9 years after the antiglaucomatous operation (on OS), the ophthalmotonus independently remains at a fixed level (up to 21 mm Hg) without the use of local antihypertensive therapy, which indicates the effectiveness of the filtering operation performed.

Status ophthalmicus at discharge (12/9/2009)

The examined eye:
Visus OD (right eye) OS (left eye) 0.9 no box 0.5 not box Gonioscopy CPC open, medium width. Moderately pronounced pigmentation of trabeculae and HQ. Sclerosis trabeculae. CPC open, medium width. Severe exogenous and endogenous with pigmentation of trabeculae and HQ. Sclerosis trabeculae. Tonometry (according to Maklakov, gr 10 gr) 11/30/2009 24 (on a medical regimen) 11/30/2009 19 (without local antihypertensive therapy) 12/05/2009 20 12/05/2009 18 12/9/2009 20 (at discharge) 12/9/2009 19 (at discharge)

Fundus condition:

OU: optic nerve disc grayish, with clear boundaries, glaucoma excavation (expressed on OS), the vascular bundle is displaced to the nasal side. Arteries are sclerotic, convoluted, Salus I-II.

Biomicroscopy (OS) data: anterior segment of the eye without pathology.

Optical media are transparent.

Recommended: in OD- “Xalatan” 1 time per night. Quinax 3 times a day. OS: without local antihypertensive therapy.

Long-Term Evaluation

The effectiveness of the proposed surgical treatment technique was evaluated in dynamics in 141 patients (142 eyes) with developed and advanced stages of uncompensated primary open-angle glaucoma for up to 5 years (of which 4 patients had up to 10 years).

The results of indicators that most fully reflect the stabilization of the glaucoma process, according to the authors of a similar method, are the field of view and the state of outflow of intraocular fluid (Bakunina N.A., Fedorov A.A., Kolesnikova L.N., 2008) are presented in table 1.

Since the authors do not have the results of the analysis of the visual field by stages, we also combined stages II and III for the convenience of comparison. Given that in the prototype these visual fields are given after 1 year, and tonographic indicators after 1.5 years, we also present the results in the same time frame.

Comparative results of the prototype (Bakunina N.A., Fedorov A.A., Kolesnikova L.N., 2008) and the proposed method of surgical treatment

Table 1 Indicators: The known method (prototype) The proposed method (denervation) Before surgery After surgery (at discharge) Before surgery After surgery (at discharge) Outflow ease state (C, mm ³ / min mm Hg) Stages of glaucoma II 0.11 ± 0.03 No data 0.13 ± 0.02 0.16 ± 0.02 III 0.08 ± 0.01 0.22 ± 0.04 0.19 ± 0.01 Line of sight (%) Improvement No data 98% No change 2% Worsening - Long-term results 1 year after antiglaucomatous surgery Line of sight (%) Stayed extended 66.7% 98% No change 33.3% - Worsening - 2% Long-term results 1.5 years after surgery Outflow ease state (C, mm ³ / min mm Hg) Stages of glaucoma II 0.18 ± 0.02 0.18 ± 0.02 III 0.24 ± 0.02 0.18 ± 0.02 Long-term results 5 years after surgery Outflow ease state (C, mm ³ / min mm Hg) Stages of glaucoma II No data 0.2 ± 0.03 III 0.19 ± 0.01 Line of sight (%) No change No data 85.5% Narrowing 14.5%

The above examples and comparative results confirm the fact that our proposed method for the surgical treatment of glaucoma, which consists in applying the principle of denervation of the future filtration zone, is a simple, affordable way to treat decompensated glaucoma, which does not require additional expensive equipment.

The proposed technique allows normalizing IOP for a longer time interval without the additional use of local antihypertensive therapy. This operation allows you to save visual functions and expand the peripheral boundaries of the field of view and reduce the number of absolute and relative cattle.

The indicated technique can be used when performing both penetrating and non-penetrating antiglaucomatous operations in patients with advanced and advanced stages of glaucoma.

Claims (1)

A method for the treatment of primary glaucoma, consisting in the excision of the tenon capsule and episclera, characterized in that the denervation of the filtration zone is achieved by thermal destruction of Axenfeld loops in the emissary.