RU2565332C1 - Method for reducing intraocular pressure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: cut-out deep intrascleral flap is separated at 2.0-2.5 mm into corneal tissue up to Descemet's membrane. The flap is incised along a corneal edge. A through incision 2.0-3.0 mm wide is made in the Descemet's membrane at 1.5-2.0 mm from the limb. The incision in the Descemet's membrane does not involve trabecule and ciliary canal.

EFFECT: method enables avoiding haemorrhagic complications, as well as outflow block with silicone, exudate or blood; and keeping an anterior chamber deep enough.

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Description

The invention relates to medicine, in particular to ophthalmology, and can be used to reduce intraocular pressure.

To reduce intraocular pressure by surgery, all previously proposed methods include the formation of a filtering hole - filtering operations, or filtering membranes - non-penetrating operations - in the projection of the eye drainage system, represented by the trabecula and schlemm's canal. In this regard, in the presence of newly formed vessels in the trabecula tissue, surgeons face the problem of a high probability of hemorrhagic complications. If the periphery of the anterior chamber angle is closed with blood emulsified with silicone or fibrin — a pre-trabecular block — creating a filtration hole in the structures of the anterior chamber angle does not produce a hypotensive effect. To avoid complications or insufficient hypotensive effect in glaucoma surgery, localization of the filtering area of the operation outside the projection of the trabecula and the inner wall of the Schlemm canal would allow, but such options for intervention are not currently presented in the literature.

There is a method of antihypertensive treatment of glaucoma, which consists in cutting out conjunctival and superficial scleral flaps, removing a portion of the middle layers of the sclera and forming a filter membrane from the inner layers of the corneoscleral part of the trabecula and the limbal edge of the descemet sheath, fixing the superficial scleral flap to the sclera with one or two nodal sutural closure suturing, suturing continuous seam (1).

The disadvantage of this method is that in the presence of silicone, newly formed vessels in the structures of the anterior chamber angle, the filter membrane becomes impermeable to intraocular fluid, which does not allow to obtain a hypotensive effect or leads to hemorrhagic complications.

A classic method for the surgical treatment of glaucoma is known, during which, after the formation of a conjunctival and superficial scleral flap, a section of deep corneoscleral tissue is excised with the base to the limb, including the trabecula and Schlemm's canal - a filtering hole. 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 (2).

The disadvantage of this method is the localization of sections in the area of the drainage system, where newly formed vessels or an additional substance that prevents the outflow of intraocular fluid can be concentrated. This method is taken as a prototype.

The purpose of the invention is to develop a microsurgical operation that can effectively reduce intraocular pressure with a pre-trabecular obstruction of the outflow of intraocular fluid, while avoiding hemorrhagic complications.

This goal is achieved by the fact that when forming a deep scleral flap, it is separated from the circular ligament together with the outer wall of the Schlemm canal and a strip of corneoscleral tissue and extended into the cornea by 2.0-2.5 mm to the descemet membrane, the flap is excised along the corneal edge and made a through incision in a descemetic membrane 2.0-3.0 mm wide at a distance of 1.5-2.0 mm from the scleral edge until intraocular fluid is filtered from the anterior chamber, thus creating a pathway for the outflow of intraocular fluid to bypass the trabeculae s and Schlemm's canal. This allows intraocular fluid to actively flow out of the eye, even if there is a pre-trabecular block in the corner of the anterior chamber with silicone, exudate or blood, and to avoid hemorrhagic complications during neovascularization of the trabecula, since the Descemet membrane is an avascular formation.

The method is implemented as follows.

After the conjunctival flap is formed with the base to the limb and the surface scleral flap is square 5 × 5 mm in size and half the thickness of the sclera, a deep scleral flap of rectangular shape is cut out with the base to the limb, it is separated from the circular ligament along with the outer wall of the Schlemm canal and the strip of corneoscleral tissue by 2 , 0-2.5 mm into the corneal tissue to the descemet membrane and a flap is excised along the corneal edge. In the descemetic membrane at a distance of 1.5-2.0 mm from the scleral edge, a through incision is made with a width of 2.0-3.0 mm, without affecting the trabecula and Schlemm's canal, until intraocular fluid is filtered from the anterior chamber. The superficial scleral flap is fixed to the sclera with one or two interrupted sutures, a continuous suture is applied to the conjunctiva. Peripheral iridectomy is not required, since the anterior chamber in this zone is quite deep. Descemet's membrane does not regenerate, which eliminates the problem of scarring of the internal fistula.

The technical result of the invention is to create a filtration zone of intraocular fluid from the anterior chamber of the eye into the subconjunctival space through an opening in the descemetic membrane of the cornea that does not affect the trabecula and Schlemm's canal.

A method for reducing intraocular pressure is illustrated by a clinical example:

CLINICAL EXAMPLE

Patient W., born in 1964.

Diagnosis: Secondary neovascular II "c" operated glaucoma of the left eye. Secondary neovascular terminal glaucoma of the right eye. Proliferative diabetic retinopathy in both eyes.

There was antihypertensive surgery in the left eye in March 2013. Against the background of instillation of the maximum regimen of antihypertensive drops: latanoprost, dorzolamide and timolol, the eye pressure in both eyes remained elevated.

Visual acuity of the right eye = 0 zero.

Visual acuity of the left eye = 0.1 M 1.25D = 0.2.

Intraocular pressure of the right eye - 53 mm Hg

The intraocular pressure of the left eye is 52 mm Hg.

The field of view of the left eye is narrowed to 20 degrees. from the fixation point in the upper nasal part.

Gonioscopy of the left eye - the anterior chamber angle is open, a trabecula with many newly formed vessels, in the area of the previous operation - anterior synechia, neovascularization.

The patient underwent surgery according to the proposed technique. After retrobulbar anesthesia and akinesia, a conjunctival flap was formed with the base to the limb and a superficial scleral flap measuring 5 × 5 mm in half the thickness of the sclera to transparent layers of the cornea. A deep scleral flap was cut out, it was separated from the circular ligament together with the outer wall of the Schlemm's canal and a strip of corneoscleral tissue 2.0-2.5 mm into the corneal tissue. A deep scleral flap was excised, an incision was made in the descemet corneal membrane at a distance of 1.5-2.0 mm from the scleral edge 2.0-3.0 mm wide. The superficial scleral flap was fixed with two interrupted sutures. The conjunctiva had a continuous suture.

The postoperative period was uneventful; the patient underwent anti-inflammatory, antibacterial treatment. The intraocular pressure of the left eye decreased to 12 mm Hg, visual acuity did not change.

The intraocular pressure of the operated eye is kept at normal numbers for 1 year after surgery.

Information sources

1. S.N. Fedorov and others. The journal "Ophthalmosurgery", No. 3-4, 1989, p. 52-55.

2. "Glaucoma." A.P. Nesterov, 2nd edition, revised; Moscow, 2008

Claims (1)

A method for reducing intraocular pressure, including the formation of superficial and deep scleral flaps, separation of a deep scleral flap from a circular ligament together with the outer wall of the Schlemm canal and a strip of corneoscleral tissue, characterized in that the deep scleral flap is separated by 2.0-2.5 mm into the tissue cornea to the descemet membrane, excised flap along the corneal edge; in the descemetic membrane of the cornea at a distance of 1.5-2.0 mm from the scleral edge, without affecting the trabecula and Schlemm's canal, make a through incision 2.0-3.0 mm wide until filtration of intraocular fluid from the anterior chamber; the inner filtration zone of intraocular fluid from the anterior chamber of the eye under the conjunctiva does not pass through the drainage system of the eye, but through the Descemet's membrane of the cornea, which avoids hemorrhagic complications during neovascularization of the trabeculae and provides sufficient filtration for the inner block of the trabecula with the contents of the anterior chamber angle — silicone, fibrin, blood.