RU2530756C1 - Method for minimally invasive nonpenetrating deep sclerectomy in open-angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: 2 mm conjunctival incision is performed at a limb at 2 mm therefrom. A superficial scleral flap is cut out. A deep trapezoid flap is formed and removed together with peripheral layers of the cornea and an outer wall of the Schlemm's canal until the trabecular area and the Descemet's membrane are exposed. Strips 0.5 mm wide are cut off from lateral sides of the superficial scleral flap and its apex. A strip 1x2 mm is removed from a bed of the above flap towards an equator of the eye by the scleral thickness S. A collagen sponge is laid on the prepared scleral bed and exposed for 4 minutes. The sponge is pre-wetted in 5-fluorouracil of the concentration 0.5 mg/m. The collagen sponge is removed. The incisional space is excessively washed with physiologic saline. The superficial scleral flap is laid without suturing.

EFFECT: prolonged postoperative hypotensive effect ensured by creating intrascleral paths of the intraocular liquid outflow and forming a diffuse conjunctival filtration pad.

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Description

The invention relates to medicine, namely to the field of ophthalmology, and can be used to increase the effectiveness of surgical treatment of open-angle glaucoma.

The closest analogue is a method for the surgical treatment of glaucoma, including anesthetic support, the formation of a conjunctival flap in the upper segment of the eyeball with separation of 1-2 mm from the limbus, the formation of a superficial scleral flap with 1-2 mm entry into the transparent layers of the cornea, the formation of a deep rectangular, triangular or trapezoidal scleral flap and subsequent removal of a deep scleral flap, complete excision of the sclera at the top of the deep flap to the surface of the cyl body, removal of the outer wall of the Schlemm's canal and corneoscleral tissue to a depth until the trabecula and descemetic membrane are exposed, laying the superficial scleral flap with its fixation to the sclera with 1-2 interrupted sutures, applying one nodal suture to the conjunctiva with injection under the dexazone conjunctiva with antibiotic and then the application of a monocular dressing (Method for the surgical treatment of primary open angle glaucoma using microinvasive non-penetrating deep sclerectomy (RF patent No. 2405512)).

However, the effect of the above method is limited by the fact that in some cases a cicatricial restriction of the filtering bag is formed directly around the superficial scleral flap with the development of intraocular fluid retention under the conjunctiva and, as a result, increased intraocular pressure (IOP) after surgical treatment of open-angle glaucoma in the postoperative period.

The objective of the invention is to provide a microinvasive method for the treatment of non-penetrating deep sclerectomy in open-angle glaucoma.

The technical result of the invention is to achieve a prolonged hypotensive effect in the postoperative period due to the formation of intrascleral pathways of the outflow of intraocular fluid under the conjunctiva and its partial passage through an additional scleral canal towards the equator of the eye with the formation of a more diffuse filter pad.

The technical result is achieved by the fact that in the microinvasive method of surgical treatment of open-angle glaucoma, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a spilled filtration conjunctival pillow, conducting a conjunctival incision at the limb at a distance of 2 mm from it, 2 mm long, cutting out a superficial scleral flap, the formation and removal of a deep trapezoidal flap along with the peripheral layers of the cornea and the outer wall of the Schlemm's canal up to pressing areas of the trabeculae and descemetic membrane, according to the invention, cut strips of sclera 0.5 mm wide from the sides of the surface scleral flap and its apex, and remove strips from the surface layers of the sclera in ½ of its thickness, size 1, from the top of its bed towards the equator of the eye × 2 mm, after which a collagen sponge moistened with a solution of 5-fluorouracil with a concentration of 0.5 mg / m, size 3 × 4 mm, is placed on the prepared scleral bed with an exposure of 4 minutes, followed by removal of the collagen sponge and plentiful washing the operating zone with physiological saline, after which the surface scleral flap is laid without suturing.

A distinctive feature of the method from the closest analogue is that when conducting a microinvasive non-penetrating deep sclerectomy, the surface scleral flap is truncated from the sides and its apex by 0.5 mm and the sclera strip is removed from the surface layers of the sclera by 1/2 of its thickness from the top of the surface bed scleral flap towards the equator of the eye with a length of 2 mm and a width of 1 mm, lay the collagen sponge 3 × 4 mm in size on the prepared scleral bed moistened with a solution of 5-fluorouracil, concentration of 0.5 mg / m, exposure for 4 minutes, followed by removal of the collagen sponge and abundant washing of the operating area with physiological saline, after which the surface scleral flap is laid without suturing.

The positive aspect of the proposed method is that after the operation, due to the excision of the lateral edges and the top of the surface flap, the intraocular fluid after passing through the trabecular tissue and descemetic membrane freely passes in all directions from the surface scleral flap, which creates less favorable conditions for the formation of sclero-scleral and sclero -conjunctival adhesions directly around the superficial scleral flap. In addition, the removal of the surface layers of the sclera from the top of the bed of the superficial scleral flap towards the equator of the eye in the form of a rectangular strip of the sclera 1/2 of its thickness 1 mm wide, 2 mm long towards the equator contributes to the formation of an additional drainage channel for the outflow of intraocular fluid towards the equator eyes with the formation of a spilled filter pad, which subsequently leads to a prolongation of the hypotensive effect in the postoperative period.

The method is illustrated in Fig. 1-6, which depicts the stages of the operation, where:

1 - Superficial scleral flap

2 - Deep scleral flap

3 - Bed of superficial scleral flap

4 - Shlemmov channel

5 - Corneoscleral trabecula

6 - Descemet's shell

7 - Rectangular strip of sclera

8 - Excised surface flap

The proposed method is carried out by the following sequence of steps.

1. The processing of the surgical field, anesthesia, akinesia of the eyeball, and the application of an eyelid extender are performed.

2. A conjunctival incision 2 mm long is made in the upper segment concentrically to the limb at a distance of 2 mm.

3. A superficial scleral flap 1 is cut out by a surface incision of ½ thickness of the sclera, entering the surface layers of the cornea with a base of 2 mm and a height of 2 mm.

4. Then, a deep trapezoidal scleral flap 2 is cut out and 1/3 of the sclera thickness 2 mm high, 2 mm base at the limb and 1 mm apex together with the outer wall of the schlemm's canal 4 and the site of corneoscleral tissue anterior to the schlemm's canal with exposure of the corneoscleral trabecula 5 and the periphery of the descemetic membrane 6 to obtain a pronounced filtration of intraocular fluid.

5. From the top of the bed 3 of the surface scleral flap 1, the surface layers of the sclera are removed by 2/3 of its thickness towards the equator of the eye in the form of a rectangular strip 8 with a length of 2 mm and a width of 1 mm.

7. Removing the sclera from the sides of the surface flap 1 and its apex at a distance of 0.5 mm.

8. Place a 3 × 4 mm collagen sponge on the prepared scleral bed moistened with a solution of 5-fluorouracil, a concentration of 0.5 mg / m, exposure for 4 minutes, then remove the collagen sponge and rinse the operating area with saline.

9. Place the excised superficial scleral flap 8 into the scleral bed without suture fixation.

A continuous suture is applied to the conjunctiva.

Confirmation of this are clinical examples from the application of the proposed method.

Example 1. Patient C, 68 years old, was admitted to the Eye Microsurgery FGBI MNTK with a diagnosis of Primary open-angle operated glaucoma, advanced stage (III), with moderately elevated IOP (B) of the left eye. Visual acuity of the left eye = 0.45; intraocular pressure 26 mm RT. Art. The coefficient of ease of outflow of 0.04. During biomicroscopy: the cornea is transparent, the anterior chamber is of medium depth, opacities in the cortical layers of the lens. Fundus: optic disc gray, excavation 0.8 disc diameter (DD).

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method. After pre-treatment of the surgical field, anesthesia, akinesia of the eyeball, the application of an eyelid expander.

A conjunctival incision 2 mm long was made concentrically in the upper segment of the limbus at a distance of 2 mm. A superficial scleral rag, the base of which is 2 mm, and a height of 2 mm with access to the surface layers of the cornea, is cut by a surface cut ½ of the sclera thickness. Then, a trapezoidal deep scleral flap was excised and removed, 2 mm high, 2 mm base at the limb, 1 mm apex, together with the outer wall of the Schlemm canal and a section of the corneoscleral tissue anterior to the Schlemm canal, exposing the corneoscleral trabecula and the periphery of the descemetic membrane to obtain pronounced intraocular filtration liquids. From the top of the bed of the superficial scleral flap, scleral surface layers were removed by 2/3 of its thickness towards the equator of the eye in the form of a rectangular strip 2 mm long and 1 mm wide, the sclera was removed from the sides of the superficial flap and its vertex by a distance of 0.5 mm, laying a 3 × 4 mm collagen sponge on a prepared scleral bed moistened with a solution of 5-fluorouracil, a concentration of 0.5 mg / ml, exposure for 4 minutes, followed by removal of the collagen sponge and copious washing of the operating area with physiological m solution stacking surface scleral flap in scleral bed without suture fixation. A continuous suture on the conjunctiva.

In the control study 1 day after surgery, the visual acuity of the left eye = 0.5, intraocular pressure of 6 mm RT. Art. Biomicroscopic: the cornea is transparent, the anterior chamber is of medium depth, the filter pad is spilled, pronounced.

In the control study 7 days after the operation, visual acuity of the left eye = 0.45, intraocular pressure of 10 mm RT. Art., filter cushion spilled, expressed.

In the control study 1 month after the operation, visual acuity of the left eye = 0.45, intraocular pressure 12 mm RT. Art., a filter pad spilled.

In the control study 1 month after the operation, visual acuity of the left eye = 0.45, intraocular pressure of 14 mm RT. Art., a filter pad spilled.

Example 2

Patient N., 75 years old, was admitted to the Eye Microsurgery FGBI MNTK with a diagnosis of Primary open-angle operated glaucoma, advanced stage (II), with moderate elevated IOP (B) of the right eye. Visual acuity of the left eye = 0.6; intraocular pressure 29 mm RT. Art. The coefficient of ease of outflow of 0.06. During biomicroscopy: the cornea is transparent, the anterior chamber is of medium depth, opacities in the cortical layers of the lens. Fundus: optic nerve disc gray, excavation 0.9 disc diameter (DD).

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method. After pre-treatment of the surgical field, anesthesia, akinesia of the eyeball, the application of an eyelid expander.

A conjunctival incision 2 mm long was made concentrically in the upper segment of the limbus at a distance of 2 mm. A superficial scleral rag, the base of which is 2 mm, and a height of 2 mm with access to the surface layers of the cornea, is cut by a surface cut ½ of the sclera thickness. Then, a trapezoidal deep scleral flap was excised and removed, 2 mm high, 2 mm base at the limb, 1 mm apex, together with the outer wall of the Schlemm canal and a section of the corneoscleral tissue anterior to the Schlemm canal, exposing the corneoscleral trabecula and the periphery of the descemetic membrane to obtain pronounced intraocular filtration liquids. From the top of the bed of the superficial scleral flap, scleral surface layers were removed by 2/3 of its thickness towards the equator of the eye in the form of a rectangular strip 2 mm long and 1 mm wide, the sclera was removed from the sides of the superficial flap and its vertex by a distance of 0.5 mm, laying a 3 × 4 mm collagen sponge on a prepared scleral bed moistened with a solution of 5-fluorouracil, a concentration of 0.5 mg / ml, exposure for 4 minutes, followed by removal of the collagen sponge and copious washing of the operating area with physiological m solution stacking surface scleral flap in scleral bed without suture fixation. A continuous suture on the conjunctiva.

In the control study 1 day after the operation, visual acuity of the right eye = 0.65, intraocular pressure of 8 mm RT. Art. Biomicroscopic: the cornea is transparent, the anterior chamber is of medium depth, the filter pad is spilled, pronounced. In the control study 7 days after the operation, visual acuity of the right eye = 0.65, intraocular pressure of 10 mm RT. Art., filter cushion spilled, expressed.

In the control study 1 month after the operation, visual acuity of the right eye = 0.65, intraocular pressure of 11 mm RT. Art., a filter pad spilled.

In the control study 3 months after the operation, visual acuity of the right eye = 0.65, intraocular pressure 12 mm RT. Art., a filter pad spilled.

Claims (1)

A microinvasive method for surgical treatment of open-angle glaucoma, which consists in creating intrascleral pathways of the outflow of intraocular fluid with the formation of a spilled filtration conjunctival pillow, conducting a conjunctival incision at the limbus at a distance of 2 mm from it, 2 mm long, cutting out a superficial scleral flap, forming and removing deep trapezoid with the peripheral layers of the cornea and the outer wall of the Schlemm's canal until the trabeculae and descemetic membrane are exposed characterized in that scleral strips 0.5 mm wide are cut from the sides of the superficial scleral flap and its apex, and strips from the superficial layers of the sclera are removed from the top of its bed towards the equator of the eye in ½ of its thickness, 1 × 2 mm in size, after that, a collagen sponge moistened with a solution of 5-fluorouracil with a concentration of 0.5 mg / m, size 3 × 4 mm, is placed on the prepared scleral bed with an exposure of 4 minutes, followed by removal of the collagen sponge and abundant washing of the operating area with physiological saline rum, whereupon scleral flap folding surface without suture.

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