RU2557705C1 - Method for surgical goniopuncture following non-penetrating deep sclerectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for performing a goniopuncture of trabeculo-Descemet's membrane following a non-penetrating deep sclerectomy (NPDS) if observing disturbed transparency of a cornea or fluid flow of an anterior chamber. The trabeculo-Descemet's membrane is micro-perforated from an angle of the anterior chamber within a projection of a postoperative intrascleral cavity by means of a non-traumatic boomerang needle 10-0, needle bend 3/8. The needle is pricked into the cornea at 3-3.5 mm from a limb with its distal end delivered towards an opened portion of the Descemet's membrane. A needle tip is brought through the cornea and further and advanced along a trajectory aligned with its flexion; the needle tip perforates the trabeculo-Descemet's membrane.

EFFECT: method enables achieving the stable normalisation of intraocular pressure following a minimum surgical intervention.

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Description

The invention relates to medicine, namely to ophthalmic surgery, and can be used in the surgical treatment of open-angle glaucoma.

A known method of surgical treatment of open-angle glaucoma using non-penetrating deep sclerectomy (NGSE). The mechanism of action of such an intervention is based on the principle of the operation of deep sclerectomy, which results in the outflow of anterior chamber moisture, bypassing the drainage zone through the walls of the ciliary body capillaries into the circulatory system, partly into the suprachoroidal space and, in some cases, under the conjunctiva. But at the same time, the anterior chamber does not open, and moisture from the anterior chamber passes through a stored trabecular apparatus, the permeability of which increases by removing the outer wall of the Schlemm's canal and exposing the descemet membrane (Fedorov S.N., Kozlov V.I., Timoshkina N.T. Non-penetrating deep sclerectomy with open-angle glaucoma // J. Ophthalmosurgery, - 1989, - No. 3-4, - p. 52-54.). Thus, during the operation of NSHE, the trabeculodescemet membrane separates the anterior chamber from the surgically formed outflow path. The practical use of this technology, at first, inspired confidence that an effective and reliable method for surgical treatment of open-angle glaucoma was found. However, quickly enough, the disadvantages of this technique began to appear. Approximately 2/3 of the patients treated with NSAID soon showed decompensation of intraocular pressure (IOP) due to excessive scarring of the operation area (Ivanova E.I., Zuev V.K. Non-penetrating deep sclerectomy with mitomycin-C // Ophthalmosurgery, - 1998, - No. 3, - p. 34-40).

To eliminate the IOP decompensation after the operation, the NSES began to successfully use laser goniopuncture. Its essence is to create microperforations in the corner of the anterior chamber, which would connect the anterior chamber of the eye with the new way of outflow of aqueous humidity created by NHSE (L.I. Balashevich, M.V. Gatsu, A.S. Izmailov, Laser treatment of glaucoma // Textbook, - SPbMAPO, - 2004, - pp. 42-43. - PROTOTYPE). In this case, the localization of the intervention zone and the guidance of the YAG laser beam are carried out using a Goldman lens. In the area corresponding to the site of the previous operation of NSHE, from the angle of the anterior chamber, respectively, of the projection of the postoperative intrascleral cavity, 2-3 to 10-15 laser pulses are applied anterior to the trabeculae and the anterior Schwalbe border ring until microdefects appear in the trabeculodescemetic membrane, through which steady outflow of aqueous humor.

The disadvantages of laser goniopuncture: the method is highly effective and widely used in surgical treatment today, however, in cases of violation of the transparency of the cornea and (or) moisture of the anterior chamber (old clouding of the cornea, edema of the corneal epithelium, postoperative descemetitis, suspension of shaped elements in the anterior chamber, etc. .) the implementation of laser goniopuncture is extremely difficult, since there are no conditions for the precise guidance and focusing of the laser beam. It should also be noted that the energy of the laser beam when passing through opaque media is dissipated and the desired result can not be achieved for this reason either.

The objective of the invention is to develop a method of surgical goniopuncture of the trabeculodedescemetic membrane after the operation of non-GSE in a situation of violation of the transparency of the cornea and (or) moisture of the anterior chamber.

EFFECT: stable normalization of intraocular pressure after minimal surgical intervention.

The specified technical result can be obtained if, in the method for performing goniopuncture after the operation of non-penetrating deep sclerectomy, including microperforation of the trabeculodescemetic membrane from the angle of the anterior chamber in the projection area of the postoperative intrascleral cavity, according to the invention, microperforation is performed using an atraumatic curved needle, namely, thread 10- 0, the bend of the 3/8 needle, which is injected into the cornea 3-3.5 mm from the limb, directing the distal end towards the exposed area of the descemet mete membranes, lead the end of the needle through the cornea and then, advancing the needle along a path corresponding to its curvature, perforate the trabeculodescemet membrane with the tip of the needle.

Among the essential features, the distinguishing features are:

- microperforation is performed using an atraumatic curved needle,

- characteristics of the needle: thread 10-0, bending of the needle 3/8,

- a needle is injected into the cornea 3-3.5 mm from the limb, directing the distal end towards the exposed portion of the descemet membrane (the exposed portion of the descemet membrane was formed during the operation of NSES),

- spend the end of the needle through the cornea and then, advancing the needle along the path corresponding to its curvature, the tip of the needle perforate the trabeculodedesmetic membrane.

Between the totality of the essential features and the claimed technical result, there is a causal relationship.

Injecting an atraumatic curved needle into the cornea at a distance of 3-3.5 mm from the limb is a safe procedure for the cornea, but allows you to approach the membrane that you want to perforate from the angle of the anterior chamber, that is, by the shortest path. Based on practical experience, we determined that if a 10-0 bent needle is used for this, and a 3/8 bend corresponds to it, then the needle is punctured into the cornea at a distance of 3-3.5 mm from the limb, while guiding the distal end towards the exposed portion of the descemet membrane, and further advancing the needle along the path corresponding to its curvature, as a result of these actions, the tip of the needle will be buried precisely in the trabeculodecemet membrane, which should then be perforated.

The method is as follows.

Epibulbar local anesthesia is performed.

An injection into the cornea is performed by a 10-0 atraumatic curved needle (3/8 curvature bend) in the projection area of the postoperative intrascleral cavity, at a distance of 3-3.5 mm from the limb. During the injection, the distal end of the needle is directed towards the exposed portion of the descemet membrane. Then, the end of the needle is passed through the cornea and then, advancing the needle along a trajectory corresponding to its curvature, the trabeculodedesmetic membrane is perforated with the tip of the needle. The fact that the perforation has successfully taken place is evidenced by the filling of the conjunctival filtration pad with intraocular fluid, which is observed by the surgeon.

Example. Patient V., 58 years old, entered our Center in February 2014.

From the anamnesis: 3 months ago, a non-GSE operation was performed on this patient in our Center, the operation went without any special features.

The patient was diagnosed with combined far-reaching uncompensated (operated + laser) glaucoma of the left eye.

VOS = 0.25

P ₀ OS = 54.0

The field of view is narrowed to 2-3 ° from the nasal side and to 0 ° from the upper nasal side.

Status: flat filter pad at 12 o’clock, swollen cornea, peripheral iris coloboma at 10 o’clock. Subatrophy of the stroma and pigment border of the iris. Rigid pupil. The crystalline lens is transparent.

Optic nerve disc (optic nerve disc) with clear contours. Excavation to DZH 1.0. The angle of the front camera is open.

After examination, the patient was sent to the laser department for laser descemetogoniopuncture. However, due to corneal edema, laser goniopuncture failed.

On the same day, the patient in the left eye was performed surgical goniopuncture according to the invention.

An hour after the goniopuncture of IOP (OS) = 14 mm Hg. Art.

VOS = 0.5

After 3 months, the filter pad is spilled. IOP (OS) = 20 mmHg. Art.

VOS = 0.7

After 6 months, the filter pad is spilled. IOP (OS) = 21 mmHg. Art.

VOS = 0.7

In our Center, using the claimed technology, 11 people were successfully operated on, all patients managed to lower the pressure during the operation, which later remained stable. The technique is simple, short in time and gives the desired effect.

Claims (1)

A method of performing goniopuncture after an operation of non-penetrating deep sclerectomy, including microperforation of the trabeculodescemetic membrane from the side of the anterior chamber angle in the projection area of the postoperative intrascleral cavity, characterized in that microperforation is performed using an atraumatic curved needle, namely, a thread 10-0, a needle bend 3/8, which is injected into the cornea 3-3.5 mm from the limb, directing the distal end towards the exposed portion of the descemet membrane, lead the end of the needle through the cornea and further, promoting the needle along the trajectory corresponding to its curvature, the tip of the needle is perforated trabeculodescemet membrane.