RU2454978C1 - Method of surgical treatment of glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology and is intended for surgical treatment of open-angled glaucoma to ensure stable process of intraocular pressure reduction for long period after operation. Conjunctive cut is performed, surface flap is cut out and formed, turned in sideward of limb, external wall of ciliary canal and strips of cornea-scleral tissue with deep layers of sclera are removed until descemet membrane. From middle layers of sclera U-shaped flap is cut out and formed with base to lateral wall of sclera bed, where pocket is formed, into which top of middle sclera turned inside flap is tucked in. Surface flap is shortened by 1/3 of length and laid into sclera bed without suturing. Uninterrupted suture is applied on conjunctiva.

EFFECT: method makes it possible to increase efficiency of operation on open-angled glaucoma by ensuring stability of hypotensive process in post-operative period due to formation of additional ways of intraocular liquid outflow in deep layers of sclera, considerable reduction of risk of their obliteration caused by shortening of surface scleral flap and absence of sutures that fix it.

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Description

The proposed method relates to medicine, namely to ophthalmology, and is intended for the surgical treatment of open-angle glaucoma.

Among the numerous surgical methods for the treatment of glaucoma, methods have been disseminated that use the autoplasty method, which consists in using the own tissues of the eyeball to form additional pathways for the outflow of intraocular fluid and to provide a hypotensive process.

A known method for the surgical treatment of open-angle glaucoma (RF Patent No. 2308917 C1, A61F 9/007, 10.27.2007), which consists in the fact that after the conjunctiva is cut, a T-shaped scleral flap is formed with the base to the limb, is diverted to the limb, in the distal part of the scleral the bed is made through two incisions, at the base of the scleral flap, a strip of trabecular tissue is excised, cyclodialysis is performed through the through incisions in the sclera with a spatula, and the contours of the T-shaped flap are filled into the subchoroid space, after which fits a continuous seam on the conjunctiva.

The disadvantage of this method is excessive scarring between the conjunctiva and the episclera, as well as in the area of dissection of the trabecular tissue, especially observed in patients under the age of 50 years.

The closest set of essential features to the proposed method is a method for the surgical treatment of glaucoma (RF Patent No. 2228657, A61F 9/007, 06/10/2004, Bull. No. 16).

The essence of this method consists in the fact that after the cannunctival incision in the lumen of the wound of the conjunctiva, a surface flap 5 × 5 mm in size is cut out and formed at 1/3 of the sclera depth, detached deep into the transparent layers of the cornea and 1 mm turns away towards the limb.

The outer wall of the Schlemm's canal is removed to the width of the bed of the superficial scleral flap and a strip of corneoscleral tissue with deep layers of the sclera.

After that, from the middle layers of the sclera, 2 U-shaped flaps are cut out with their bases to the sides of the scleral bed, fold outward at the edges, fit into the scleral bed, and are covered with a surface flap.

The superficial flap is fixed on the sclera with knotted sutures: two at the base and two at the apex with "grabbing" the edges of the flap from the middle layer of the sclera. Then impose a continuous conjunctival suture.

This method is not effective enough in that, due to the fixation of the superficial flap and parts of the middle flap to the sclera, the superficial flap is incremented to the sclera, and the subscleral tunnel formed between the superficial and deep scleral layers overlaps, which reduces the effect of the antihypertensive process.

The problem to be solved and the expected technical result of the proposed method is to increase the effectiveness of anti-glaucomatous operations by reducing their invasiveness, reducing the causes of excessive scarring and overgrowth of additional outflow pathways of intraocular fluid.

The problem is solved by the proposed method for the surgical treatment of glaucoma, including performing a conjunctival incision, cutting and forming the superficial and middle scleral flap, removing the outer wall of the schlemm canal, a strip of corneoscleral tissue with deep layers of sclera, strips of corneal tissue, cutting and laying the mid-scleral flap with filling of its apex in a pocket formed under its base at the side of the scleral bed, shortening and folding superficially th scleral flap, the application of a conjunctival suture, characterized in that the sutures on the superficial flap are not superimposed.

The proposed method is carried out by the following sequence of operations depicted in the functional drawings (Fig.1-7).

1. The treatment of the surgical field, anesthesia and acenesis of the eyeball, the application of an eyelid extender.

2. At a distance of 1 mm from the limb, a cut is made concentrically on the conjunctiva 3 mm long.

3. In the lumen of the wound of the conjunctiva, a U-shaped incision is made on the sclera at 1/3 of its depth and a flap 3 × 3 mm in size is formed with the base to the limb (Figure 1).

4. Hemostasis is performed, the superficial flap (1) is separated to the transparent layers of the cornea 1 mm in depth and is turned towards the limb (Figure 2).

5. The outer walls of the Schlemm's canal (2) are removed to the width of the scleral bed of the superficial flap, strips of corneoscleral tissue with deep layers of the sclera, strips of corneal tissue, and the size of the corneal part of the removed stripe is 0.5-1.0 mm (Figure 3).

6. From the middle layers of the sclera, a U-shaped flap (3) is cut out with the base to the lateral side of the scleral bed, it is separated and turned upward towards the base (Figure 4).

7. Under the base of the middle scleral flap, a pocket is formed, the flap is tucked in and tucked into the pocket (Figure 5).

8. The surface flap from the top is truncated 1/3 of the length and fits into the scleral bed without fixation with a seam (Fig.6-7).

9. A continuous suture is applied to the conjunctiva.

A positive aspect of the proposed method is an increase in the volume of the filtration zone due to the formation of additional space between the superficial scleral flap and deep scleral layers in the area of the lateral side of the scleral bed at the base of the middle scleral flap, the space between the conjunctiva and deep scleral layers in the area of truncation of the superficial flap, and the formation of as a result of this, additional pathways of the outflow of water-repellent, a decrease in the likelihood of overgrowing of these paths due to the absence of a seam fixing superficial scleral flap.

This is confirmed by clinical examples from the practice of applying the proposed method.

Example 1. Patient I., 67 years old, card number 131940.

Diagnosis: right eye open-angle, 1 and operated uncompensated glaucoma, complicated cataract. Upon receipt of IOP - 20 mm Hg on antihypertensive drugs. The operation was performed by the proposed method. After a 3 mm long conjunctival incision was made in the lumen of the conjunctival wound, a superficial scleral flap 3 × 3 mm in size was formed to the transparent layers of the cornea, 1 mm deep and the outer wall of the Schlemm canal was removed to the width of the scleral bed of the superficial flap and a strip of corneoscleral tissue with deep layers of sclera and a strip of corneal tissue. From the middle layers, the sclera cut a U-shaped flap with the base to the side of the scleral bed, formed a pocket under the base of the flap, into which the top of the middle flap folded inward was tucked into.

They truncated the superficial flap 1/3 of the length from the apex, laid them in the scleral bed over the middle flap, and made a conjunctival suture.

The conjunctival suture was removed on the 5th day. At discharge, IOP was 16 mm Hg, after a month - 17 mm Hg, after 3 months - 19 mm Hg, after 6 months - 19 mm Hg with stable visual load. Complaints about poor eyesight and the uncomfortable state of the body were not reported.

Example 2. Patient U., 80 years old, card number 172237.

Diagnosis: the right eye is open-angle III in glaucoma, complicated cataract, the left eye is open-angle III a glaucoma, complicated cataract.

IOP: right eye - 29 mm Hg, left eye - 25 mm Hg on antihypertensive drugs.

An operation was performed on the right eye with the proposed method. The conjunctival suture was removed on the 5th day. At discharge IOP was 15 mm Hg, after 10 days - 16 mm Hg, after 1 month - 18 mm Hg, after 3 months - 18 mm Hg. Complaints about poor eyesight and the uncomfortable state of the body were not reported.

Control examinations in both cases were carried out respectively 1, 2, 3, 4, 5 years after the operation.

Claims (1)

A method for the surgical treatment of glaucoma, including performing a conjunctival incision, forming and cutting a U-shaped surface scleral flap with the base to the limb, removing the outer wall of the Schlemm canal, strips of corneoscleral tissue with deep layers of sclera and strips of corneal tissue, cutting out the middle layers of the sclera of the U-shaped flap according to the size of the scleral bed with the base to its lateral side, the formation of a pocket under the base of the middle scleral flap, tucking of the middle scleral flap, laying the superficial scleral flap, suturing the conjunctiva, while the top of the middle scleral flap after tucking is tucked into the pocket formed under its base, the superficial scleral flap is truncated 1/3 of the length and fits into the scleral bed without being fixed with a suture.

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