RU2530647C1 - Method for preparation of patient for glaucoma surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: 1-1.5 hours before the surgery, the selective β-adrenergic blocker Betaloc is injected in an amount of 0.3-0.5 ml subconjunctivally in an upper semi-circle of the eyeball in accordance with 10 to 2 o'clock of a clock face. Then, 30-40 minutes before the surgery, 50% analgin 2.0 ml, 1% dimedrol 1.0 ml, seduxen 2.0 ml are injected intramuscularly. The surgery is immediately preceded by a subtenon block with 2% naropin 1.5 ml.

EFFECT: method enables providing the more effective pre-surgical preparation by reducing an intraocular pressure in a combination with preventing systemic complications and postoperative inflammations.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used in the preoperative preparation of patients for antiglaucomatous surgery.

Treatment of patients with glaucoma is an urgent task of modern ophthalmology, since glaucoma is a leading cause of low vision, blindness and visual impairment in many countries of the world, including Russia (Volkov V.V. Glaucoma is open-angle .- M .; Medical Informational LLC agency ", 2008. - 352 pp .; Yerichev VP, Tumanov VP, Panyushkina LA Glaucoma and neurodegenerative diseases. Glaucoma. Journal of the Research Institute of RAMS 2012; No. 1, pp. 45-49).

According to many authors, surgical treatment of glaucoma is currently the most effective way to permanently reduce intraocular pressure (IOP), and therefore more often leads to stabilization of visual functions in patients with glaucoma. However, the risk of developing intra- and postoperative complications (hyphema, hemophthalmus, ciliochoroid detachment, etc.) associated with a significant drop in IOP during the operation leads to the fact that operations are often performed by patients in advanced or advanced stages of glaucoma. To reduce the risks of developing intra- and postoperative complications, surgeons use some techniques and / or medications to reduce high IOP before surgery. This is a finger massage of the eyeball directly in the operating room until the main stages of the operation are performed (A.P. Nesterov. Primary glaucoma. - M .: Medicine, 1982. - p.227).

The disadvantage of this method is that finger massage of the eyeball leads to a short-term decrease in IOP, and then after a few minutes ophthalmic hypertension develops, which is dangerous when a penetrating type of glaucomatous surgery is performed.

The administration of 0.25-0.5 g diacarb in the evening before the operation and the next day in the morning, one hour before the operation, the patient takes glycerin at the rate of 1.5 g / kg weight to reduce IOP and blood pressure (A.P. Nesterov. Primary glaucoma. - M.: Medicine, 1982, p.227.).

The disadvantage of using diacarb and glycerin before surgery is frequent systemic complications - arterial hypotension, hypokalemia, cardiac arrhythmias, i.e. complications that are potentially life-threatening to the patient. In addition, systemic use of the diacarb carbonic anhydrase inhibitor and glycerol osmodiuretic do not always effectively reduce IOP.

It is known that tamponade of the anterior chamber of the eye with a viscoelastic preparation Visiton during anti-glaucoma surgery is an effective way to prevent intra- and postoperative complications (A. Onishchenko. The use of Visiton viscoelastic in surgery for primary and secondary glaucoma. Bulletin of the East Siberian Scientific Center SB RAMS , 2004, Volume 3, No. 1. - P.46).

The disadvantages of this method are as follows. Firstly, there is a difficulty in dosing the required amount of viscoelastic preparation for administration into the anterior chamber, since the volume of the anterior chamber of the eye depends on the refraction of the eye, the presence or absence of its own crystalline lens (aphakia), or an artificial crystalline lens in the eye cavity (artifact), therefore hypoeffect is possible surgery, or the development of ophthalmic hypertension with excessive administration of a large volume of viscoelastic drug. Secondly, in some cases, with the introduction of a viscoelastic drug into the anterior chamber of the eye, the development of an exudative reaction in the eye cavity in the postoperative period is possible.

Closest to the claimed is a method of preoperative preparation, including installations in the conjunctival cavity of the drug Betoptik and Arutimol (RF Patent 2314069, IPC A61F 9/00. Method of preoperative preparation of patients for the surgical treatment of cataracts complicated by glaucoma / H.P. Tahchidi, E.M. Mironova, NP Yanovskaya, M. Frankivsk-Gerlak; Federal State Institution Scientific and Technological Center Eye Microsurgery named after Academician SN Fedorov of Roszdrav. - No. 2006117873, declared May 25, 2006, published January 10, 2008, Bull. No. 1). The prototype authors proposed the use of installations in the conjunctival cavity of 0.5% Betoptic solution or 0.5% Arutimol 2 times a day and / or Azopt 2 times a day before surgery.

The disadvantage of this method is that the drug, which was installed in the conjunctival cavity, penetrates the eye cavity transcornally by diffusion and osmosis. But with high IOP (more than 35 mm Hg), which often happens in patients before surgery, the mechanisms of diffusion of the drug through the cornea do not work for physical reasons. In these cases, it is necessary to administer the drug parenterally. Secondly, timolol is a non-selective β-blocker, therefore, after the use of timolol, the development of arterial hypotension, bradycardia is possible, which provokes a decrease in pulse blood flow and perfusion pressure in the ophthalmic artery and central retinal artery against the background of high IOP.

The objective of the invention is to increase the efficiency of preoperative preparation of the patient to perform anti-glaucomatous surgery by reducing intraocular pressure.

The problem is achieved by the method of preoperative preparation of the patient for antiglaucomatous surgery, including the use of β-blocker. 1-1.5 hours before antiglaucomatous surgery, a selective β-adrenoblocker, the antihypertensive drug Betalok, is administered as an injection of 0.3-0.5 ml under the conjunctiva in the upper semicircle of the eyeball as a β-blocker, according to the hour dial from 10 to 2 hours. 30-40 minutes before surgery, intramuscularly injected with a 50% solution of dipyrone 2.0 ml, 1% solution of diphenhydramine 1.0 ml, sibazon 2.0 ml. Immediately before the operation, subtenone blockade is performed with a 2% solution of napropin 1.5 ml.

The novelty of the invention lies in the use of subconjunctival injection of the antihypertensive drug Betalok and subtenon blockade with napropine.

The set of essential features of the invention allows to obtain a new technical result: to increase the effectiveness of preoperative preparation by reducing IOP while preventing the occurrence of systemic complications, preventing postoperative inflammation.

The introduction of Betaloc under the conjunctiva provides a neuroprotective effect, since the drug effectively reduces IOP, and with preserved values of systemic blood pressure, this causes an improvement in hemomicrocirculation in the optic nerve head, as the retinal nutrition balance increases.

The effectiveness of the method is explained by the fact that the Betalok drug from the subconjunctival "depot" quickly penetrates the eye cavity through the emissaries and perineural gaps in the sclera and blocks the β-adrenergic receptors of the ciliary body and the iris, reducing intraocular pressure. Another part of the Betalok preparation during the blinking movements of the eyelids from the subconjunctival “depot” enters the conjunctival cavity and, through diffusion, penetrates transcornally into chamber moisture. Betaloc is a selective β-adrenoblocker metoprolol, therefore, patients do not develop systemic complications - arterial hypotension, bradycardia, an attack of bronchial asthma. In addition, with the introduction of Betalock, which has a membrane-stabilizing effect, a calm course of the postoperative period is observed, since the drug prevents postoperative inflammation.

The long-term maintenance of the therapeutic concentration of Betaloc in the chamber moisture is explained by the constant peculiar massage of the “depot” - conjunctival pads with blinking movements of the eyelids, movements of the eyeball.

The method is simple, does not require complex technical means. The technique of periocular injection is owned by all ophthalmologists.

The effectiveness of the method is proven in the experiment and the clinic. Clinical observations consisted of 10 patients - 10 eyes with primary open-angle stage III glaucoma with high IOP at the age of 67 to 85 years. Of these, 6 women and 4 men. In the main group of 5 patients - 5 eyes, 1 hour before surgery, patients were injected under the conjunctiva in the upper semicircle of the eyeball in accordance with the hour dial from 10 to 2 hours, 0.3-0.5 ml of the anti-hypertensive drug Betalok once and for 30 For 40 min, premedication was performed - intramuscularly 50% dipyrone solution 2.0 ml, 1% diphenhydramine solution 1.0 ml and 2.0 ml sibazon. Anti-glaucomatous surgery was performed after subtenon blockade with a 2% solution of napropin 1.5 ml. A control group of patients 5 people - 5 eyes underwent antiglaucomatous surgery after similar premedication intramuscularly with 50% dipyrone solution of 2.0 ml, 1% diphenhydramine solution of 1.0 ml and 2.0 ml of sibazon and subtenon blockade with 2% napropin solution of 1.5 ml. The initial level of IOP of the eyes before surgery in the main and control groups was comparable to 31.2 mm Hg. and 32.2 mmHg respectively. Compared with the control in the main group, patients did not complain of pain during antiglaucomatous surgery and in the postoperative period. In patients of the main group, antiglaucomatous operation proceeded without complications, the postoperative period also proceeded smoothly, without complications. Patients in the control group during the operation in 2 cases had severe bleeding of their iris vessels. In the postoperative period on 3 eyes hyphema with a level of more than 2 mm. In one eye, the postoperative period was complicated by cyclitis. In the postoperative period, IOP in the main group was 16.4 mm Hg, in the control group - 21.2 mm Hg.

The method is as follows. 1-1.5 hours before antiglaucomatous surgery, a selective β-adrenoblocker, the antihypertensive drug Betalok, is administered as an injection of 0.3-0.5 ml under the conjunctiva in the upper semicircle of the eyeball as a β-blocker, according to the hour dial from 10 to 2 hours. 30-40 minutes before surgery, intramuscularly injected with a 50% solution of dipyrone 2.0 ml, 1% solution of diphenhydramine 1.0 ml, sibazon 2.0 ml. Immediately before the operation, subtenone blockade is performed with a 2% solution of napropin 1.5 ml.

Clinical example 1.

Patient D., 72 years old, with a diagnosis of Primary open-angle glaucoma in both eyes. III with OD; I a OS. Upon receipt of a complaint of blurred vision on the right. OD - Visual acuity of 0.4 n / a; intraocular pressure - 38 mm Hg Edema of the corneal epithelium. Front camera of medium depth. Subatrophy of the anterior leaf of the iris, pseudoexfoliation along the edge of the pupil. Wedge-shaped opacities of the lens cortex. On the fundus of the marginal glaucomatous excavation of the optic nerve disc, a shift of vessels in the nasal side.

OS - Visual acuity -1.0 intraocular pressure = 26 mm Hg

Biomicroscopy revealed a slight subatrophy of the iris, the lens is transparent. Ophthalmoscopically revealed an expansion of excavation to 0.6-0.7 DZN.

Against the background of conservative treatment, IOP OD decreased to 31 mm Hg, and IOP OS decreased to 18 mm Hg. The patient is scheduled for surgical treatment of glaucoma OD. 1 hour before the operation, the patient was injected under the conjunctiva in the upper semicircle of the eyeball in accordance with the hour dial from 10 to 2 hours, 0.3 ml of the anti-hypertensive drug Betalok was administered once and 40 minutes before the medication was performed - intramuscularly 50% analgin solution 2.0 ml , 1% solution of diphenhydramine 1.0 ml and 2.0 ml sibazon. In the operating room, after subtenon blockade with a 2% solution of 1.5 ml of napropin, an antiglaucomatous operation was performed. Operation progress: conjunctival incision 7 mm from the limbus 6-8 mm long. A triangular flap is formed from the surface layers of the sclera with a base to the limb of 5 mm and a height of 5 mm. From the deep layers of the sclera, a strip of 5-1 mm in size is cut out in the projection of the Schlemm's canal. Performed basal iridectomy. A nodal suture was applied to the scleral flap. A continuous suture was placed on the conjunctival incision. Under the conjunctiva, an injection of dexon 0.3 ml and gentamicin 10 mg was performed. The course of the operation is “smooth”, without complications. The postoperative period was uneventful. The patient was discharged on the 9th day after the operation with visual acuity OD = 0.6, IOP = 16 mm. Hg

Clinical example 2.

Patient K., 69 years old, with a diagnosis of Primary open-angle glaucoma in both eyes. III with OD; II a OS. Immature cataracts of both eyes. Upon receipt of a complaint about blurred vision on the right, decreased vision in both eyes. OD-Visual Acuity 0.2 n / a; intraocular pressure - 39 mm Hg Edema of the corneal epithelium. Front camera of medium depth. Subatrophy of the iris, pseudoexfoliation along the edge of the pupil. Clouding of the cortex and nucleus of the lens. On the fundus of the marginal glaucomatous excavation of the optic nerve disc, a shift of vessels in the nasal side.

OS - Visual acuity - 0.5, intraocular pressure - 25 mm Hg

Biomicroscopy revealed slight subatrophy of the iris, clouding of the cortex and nucleus of the lens. Ophthalmoscopically revealed an expansion of excavation to 0.7 DZN. Narrowing the nasal border of the visual field to 40 degrees.

Against the background of conservative treatment, IOP OD decreased to 32 mm Hg, and IOP OS decreased to 20 mm Hg. The patient is scheduled for surgical treatment of glaucoma OD. 1.5 hours before surgery, the patient was injected under the conjunctiva in the upper semicircle of the eyeball in accordance with the hour dial from 10 to 2 hours, 0.5 ml of Betalok antihypertensive drug was administered once and 30 minutes before surgery, the patient was premedicated - intramuscularly 50% solution Analginum 2.0 ml, 1% diphenhydramine solution 1.0 ml and 2.0 ml sibazon. In the operating room, after subtenon blockade with a 2% solution of 1.5 ml of napropin, an antiglaucomatous operation was performed. Operation progress: conjunctival incision 7 mm from the limbus 6-8 mm long. A triangular flap is formed from the surface layers of the sclera with a base to the limb of 5 mm and a height of 5 mm. From the deep layers of the sclera, a strip of 5-1 mm in size is cut out in the projection of the Schlemm's canal. Performed basal iridectomy. A nodal suture was applied to the scleral flap. A continuous suture was placed on the conjunctival incision. Under the conjunctiva, an injection of dexon 0.3 ml and gentamicin 10 mg was performed. The course of the operation is “smooth”, without complications. The postoperative period was uneventful. The patient was discharged on the 9th day after the operation with visual acuity OD = 0.3, IOP = 17 mm Hg.

Thus, the proposed method allows to obtain the hypotensive effect of the injection under the conjunctiva of the antihypertensive drug Betalok, as well as the prophylactic effect of the drug before penetrating type anti-glaucomatous surgery.

Claims (1)

A method for preoperative preparation of a patient for anti-glaucomatous surgery, including the use of a β-blocker, characterized in that 1-1.5 hours before anti-glaucomatous surgery, a selective β-blocker antihypertensive drug Betalok is administered as an injection of 0.3-0, as an β-blocker, 5 ml under the conjunctiva in the upper semicircle of the eyeball, in accordance with the hour dial from 10 to 2 hours, 30-40 minutes before surgery, intramuscularly injected 50% analgin solution 2.0 ml, 1% diphenhydramine solution 1.0 ml, sibazon 2, 0 ml and before opera iey operate subtenonovuyu blockade Naropin 2% solution of 1.5 ml.