RU2440075C1 - Method of surgical management of glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely ophthalmology, and may be used for surgical management of glaucoma. A trapeziform superficial scleral flap of Ѕ thickness is formed. In a limbal zone, a deep scleral strip with trabecular tissue is cut out and excised. Basal iridectomy is conducted. The scleral flap is repositioned and sutured at least once within a smaller base and at a greater base of the scleral flap. An absorbable suture surrounds the scleral flap to form spiral loops between the bases of the trapezoid. The loops are started from the greater or smaller base of the trapezoid to wind around the flap remained non-deformable. The suture ends are exteriorised and tightened together within one of the sides of the trapezoid. The conjunctival flap is repositioned, and an uninterrupted suture is used.

EFFECT: method provides a permanent and long-term hypotension effect and decreases possibility of repeated surgeries ensured by prevented fusions within a bed base, along a bed edge, and between the conjunctiva and the scleral flap.

4 cl, 1 ex

Description

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

Glaucoma is a large group of eye diseases with characteristic visual impairment. In many cases, the abandonment of the operation or its untimely execution leads to a progressive decline in visual functions and blindness. Fistulizing operations allow you to create new ways of outflow of aqueous humor from the eye. A traditional operation of choice in the surgical treatment of glaucoma is sinustrabekulectomy with basal iridectomy. During the operation, an arched incision of the conjunctiva and tenon capsule is made 7-8 mm from the limbus. The tenon capsule is separated from the sclera to the limbus. Cut out the superficial scleral flap with the base to the limb. The size of the flap varies from 3 to 5 mm, the thickness - from 1/3 to 1/2 the thickness of the sclera. The scleral flap is separated from the deep scleral plate until a transparent corneal tissue appears and, depending on its shape, 1 or 2 sutures are applied to the edges of the flap. A section of the deep corneoscleral plate is excised, the incision runs parallel to the limb across the entire width of the scleral pocket. The second same incision is made 1-1.5 mm anterior to the first in the corneal part of the subscleral pocket. Then, a section of deep corneoscleral tissue is excised between the two described incisions. Through the resulting defect, a peripheral iridectomy is performed. Nodal sutures are applied to the scleral flap. The operation ends with a thorough suturing of the wound of the conjunctiva (Glaucoma. AP Nesterov, 2nd edition, revised; Moscow 2008).

However, in some of the operated patients, at various times after the operation, cicatricial blockade occurs in the area of the scleral flap and filter pad, with a decrease in the hypotensive effect.

To reduce the likelihood of such a complication, a modification of trabeculectomy, taken as a prototype, was proposed - a method for the surgical treatment of glaucoma (patent RU No. 2181273, 04/20/2002). This operation is as follows. In the upper quadrant of the eyeball, the conjunctival flap is separated with the base to the limb. A superficial scleral flap is formed at ^1/2 _of its thickness, 4 mm by 4 mm in size with the base to the limb. The lateral edges of the scleral bed are stitched in a zigzag fashion. In the limbal zone, a strip of sclera with trabecular tissue is cut out. Perform a basal iridectomy. Reposition the scleral flap with the imposition of two nodal sutures and the conjunctival flap with the continuous suture.

The disadvantages of this method include the fact that in the early postoperative period, contact remains between the scleral flap and the conjunctiva, which leads to the formation of sclero-conjunctival fusion, as well as sclero-scleral fusion along the rib of the scleral flap, which reduces the effectiveness of the treatment.

The task: to develop a method for the treatment of glaucoma with the prevention of the formation of sclero-scleral and conjunctive-scleral adhesions.

The technical result achieved by the implementation of the proposed method is to prevent the formation of adhesions under the scleral bed, along the rib of the scleral flap, as well as between the scleral flap and the conjunctiva. As a result, there is a persistent normalization of intraocular pressure while maintaining the effect for a long time. The proposed method allows radical prevention of the formation of adhesions around the entire scleral flap with surrounding tissues on all its surfaces. Prevention of the formation of adhesions under the scleral bed, along the edge of the scleral flap, as well as between the scleral flap and the conjunctiva, occurs due to the lack of contact between the scleral flap and the underlying sclera, conjunctiva, during the period of active tissue proliferation.

The invention consists in the following.

In the surgical treatment of glaucoma, the following intervention is performed. Separate the conjunctival flap with the base to the limb. A scleral flap is formed with a base in the limb. Sinustrabekulectomy with basal iridectomy is performed. A slit-like space is formed between the scleral flap and the scleral bed. The scleral flap is repositioned with its fixation in the scleral bed area. In this case, a scleral flap is formed in the form of a trapezoid, placing a larger base of the trapezium in the limb area. After reposition, the scleral flap is fixed with at least one suture in the region of the smaller base. Then a resorbable suture is carried out around the scleral flap with the formation of turns between the bases of the trapezoid in a spiral, wrapping the flap without deforming it. Then the ends of the thread are connected to each other. Impose a continuous seam on the conjunctiva.

In this case, the ends of the thread can be brought out and connected to each other in the region of one of the sides of the trapezoid. The formation of turns begins from a larger or smaller base of the trapezoid.

The method is as follows.

Separate the conjunctival flap with the base to the limbus. A superficial scleral flap is formed in the form of a trapezoid with a large base in the limb region by ^1/2 _of its thickness, measuring from 3 to 6 mm in the region of the larger base and from 2 to 4 mm in the region of the smaller base of the trapezoid. Then, a deep strip of sclera with trabecular tissue is cut out and excised in the limbal zone. Perform basal iridectomy. The scleral flap is repositioned with one nodal suture in the region of the smaller base and two at the larger base of the scleral flap. An absorbable suture is carried out around the scleral flap, starting from the larger or smaller base of the scleral flap, with the formation of turns between the bases of the trapezoid in a spiral, without deformation of the scleral flap. The density of the turns can vary and is chosen by the surgeon during the operation. A high density of overlapping turns of the thread is possible, at which the distance between the turns is equal to one diameter of the thread. An average density is possible at which the distance between the turns is equal to two or three diameters of the thread. The ends of the thread are connected together, without deformation of the spiral turns. The scleral flap is wrapped with a self-absorbing thread, starting from the right or left side of the scleral flap. The ends of the thread are brought out and connected to each other in the region of one of the sides of the trapezoid. A conjunctival flap is repositioned with a continuous suture.

The absorption of the self-absorbable thread occurs over a period of 3 to 4 months, it depends on the type of self-absorbable thread chosen. Therefore, in the early postoperative period, which is characterized by active scarring, there is no direct contact between the superficial scleral flap and the bed, between the scleral flap and the conjunctiva, between the edge of the scleral flap rib and the base of the bed.

The proposed method is implemented in the presented clinical example.

Patient N., 70 years old I / B No. 10319, was admitted to the hospital with a diagnosis of OS — operated on III-IV B glaucoma, mature tremulating cataract, OD — operated on II-III B glaucoma, initial cataract. From the anamnesis in 2003, anti-glaucoma coma operation was performed on the OS. Upon admission to the hospital, the pressure on the left eye is 26 mm Hg. at the maximum anti-glaucomatous regime, gross cicatricial changes are observed in the area of the filtration pad. Given this clinical picture, it was decided to perform surgical treatment of glaucoma with the proposed method. Performed separation of the conjunctival flap with the base to the limb. Formed scleral flap surface in the form of a trapezoid with the larger base in the region of the limbus at _^half its thickness and a length of 5 mm length of the smaller base the trapezoid 3 mm, at 13 hours, considering rough cicatricial changes from the previously performed operation. A deep strip of sclera with trabecular tissue is cut and dissected in the limbal zone. Performed basal iridectomy. The scleral flap was repositioned with one nodal suture in the region of the smaller scleral flap and two at the larger base of the scleral flap. An absorbable suture was carried out around the scleral flap, starting from the larger base of the trapezium, on the right side of the scleral flap, with the formation of turns between the bases of the trapezoid in a spiral, without deformation of the scleral flap. The distance between the turns is equal to two diameters of the thread. The ends of the thread were tied together. Reposition of the conjunctival flap with a continuous suture. When discharged from the hospital, palpation pressure is normal, the filter pad is moderate, it functions well. When re-examined 1.5 months after the operation, the intraocular pressure of 19 mm Hg, the filter pad functions well, according to ultrasound biomicroscopy, the implanted material is preserved. When viewed after 4 months, a flat filter pad, intraocular pressure - 18 mm Hg According to ultrasound biomicroscopy, complete resorption of the thread was confirmed.

The method was tested in the Ophthalmic Clinical Hospital on 7 patients who were made the proposed method. In all cases, intraocular pressure is within normal limits, the absence of cicatricial changes in the area of the filter pad and scleral flap, the filter pad is flat, fully fulfilling its function. The average follow-up period is 7 months. Thus, as a result of the implementation of the proposed method, the desired result was achieved.

Thus, this type of operation allows you to get a more stable and lasting hypotensive effect than the prototype, and reduce the likelihood of repeated surgical interventions by preventing adhesions in the area of the base of the bed, along the edge of the scleral flap, and between the conjunctiva and scleral flap.

Claims (4)

1. A method for the surgical treatment of glaucoma, including the separation of the conjunctival flap with the base to the limb, the formation of a scleral flap with the base in the limb, a sinusustrabulectomy with basal iridectomy, the formation of a slit-like space between the scleral flap and the scleral bed, reposition of the scleral flap with its scleral fixation the application of a continuous suture on the conjunctiva, characterized in that they form a scleral flap in the form of a trapezoid, placing more bases in the limb area set, fixing is performed after reduction of the scleral flap at least one seam in the region of the smaller base, followed by resorbable thread around the scleral flap to form the turns between the bases of the trapezoid spirally wrapping flap without deformation with the subsequent binding yarn ends together. 2. The method according to claim 1, characterized in that the ends of the thread are removed and connected to each other in the region of one of the sides of the trapezoid. 3. The method according to any one of claims 1 or 2, characterized in that the formation of turns begins from a larger base of the trapezoid. 4. The method according to any one of claims 1 or 2, characterized in that the formation of turns begins from the smaller base of the trapezoid.