RU2582047C1 - Method for surgical treatment of glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to ophthalmology, and can be used in surgical management of glaucoma. In the quadrant of eyeball, first, superficial rectangular sclera flap is exsected for 1/3 of its thickness with its base to limb with base of 5 mm and lateral side of 4 mm. Further, from deep laying scleral layers scleral flap is exsected of rectangular shape on 1/3 of its thickness to limb with base of 4 mm and lateral side of 3 mm. Then at base of deep flap strip of trabecular tissue is excised. Lateral edges of deep flap turned outside and made drainage is placed between them. One end of drain tube is placed in anterior chamber angle, and second is on base of deep flap. Edge of deep flap is fixed with one or two sutures to each other so that they do not come into contact with each other. Superficial flap is laid above closing edge deep flap to form between formed flaps tunnel rounded, while leaving gap between its walls and drainage. Edge surface flap is fixed on periphery to sclera.

EFFECT: method enables reducing risk of scarring in area of formed tunnel and provides obtaining reliable hypotensive effect with reducing number of repeated operations.

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Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the surgical treatment of glaucoma.

Currently, the most radical methods of treating glaucoma are surgical treatments. However, in severe forms of glaucoma, traditional surgical interventions do not allow to achieve a stable normalization of intraocular pressure (IOP). In this regard, interventions using drainage are becoming more common.

Known methods for the surgical treatment of glaucoma using various microdrainages: in the form of a plate made of a polymer material (patent RU No. 2212215, 09/20/2003), hydrogel microtubules (Patent RU 2192821, 11/20/2002), valve - type Ahmed (Colerman Αl., Hill R ., Wilson MR Initial clinical experience with Ahmed glaucoma valve implant. / Am. J. Ophtholmol., 1995, v. 120, 23-31). However, when using them, a number of complications can arise, such as displacement, exposure, rejection of the drainage, and scarring in the area of the newly created outflow paths, which ultimately leads to an unfavorable outcome of the surgical treatment of glaucoma and causes the development of ophthalmic hypertension in the postoperative period.

There is a method of surgical treatment of primary open-angle glaucoma (POAG), providing for subscleral implantation of carbon microdrainage (Stepanov A.V., Kolycheva S.Yu., Gomzaeva U.S. The first clinical results of a new method of microdrainage in the treatment of secondary glaucoma // VII ROOF: Collection scientific works. - M., 2014. - T. 1. - P. 360). Carbon material does not have a general toxic, irritating, sensitizing effect on the body and is sufficiently biocompatible with human tissues. The disadvantages of this method include the low sorption capacity of the carbon fiber, which does not provide the proper outflow of intraocular fluid (IHL) due to the fragility of the carbon fiber, therefore, the active use of this material as microdrainage is limited.

A known method for the surgical treatment of glaucoma using drainage "Xenoplast" (Anisimova S.Yu., Anisimov SI, Rogacheva IV Surgical treatment of refractory glaucoma using a new, biodegradable collagen drainage // National Journal of Glaucoma. - M ., 2006. - V. 5. - No. 2. - S. 51-56). The drainage collagen antiglaucoma "Xenoplast" consists of insoluble porous xenocollagen isolated from the bone tissue of farm animals, made in the form of a thin and narrow strip. Drainage is biologically inert, does not have allergen properties. However, if the drainage is improperly installed or if the size of the operating bed and the size of the drain do not match, blockage of the operation area with the occurrence of postoperative hypertension is possible. When used during anti-glaucoma operations, it does not exclude the occurrence of complications, such as postoperative inflammation, detachment of the choroid or retina, macular edema, complicated cataracts.

The closest analogue of the proposed method is a method of surgical treatment of POAG (Patent RU 2103964, 02/10/1998), including cutting a conjunctival flap with the base to the limb, forming a rectangular sclera flap at 2/3 of its thickness with the base to the limb, and holding a length notch at the base of the flap on both sides 1 mm, trabeculectomy, turning the lateral edges of the scleral flap inward and fixing with one suture in the middle of the formed tunnel so that the edges do not touch each other. Then the sclera superficial flap is put into place and fixed at the edges with two sutures to the sclera. A conjunctival flap is repositioned with a continuous suture applied to it. However, this operation in the early postoperative period is often complicated by uncontrolled hypotension, and in a later period by scarring of newly created outflow pathways.

The objective of the invention is to provide a method for the surgical treatment of glaucoma with a stable drainage system for the outflow of intraocular fluid.

The technical result of the proposed method is to reduce the risk of scarring in the area of the formed tunnel and, accordingly, to obtain a stable antihypertensive effect with a decrease in the number of repeated operations.

The proposed form of cellular drainage improves the outflow of water-repellent, and after some time, the drainage placed inside the formed tunnel undergoes resorption, while leaving a formed connective tissue capsule around the gap between the walls of the tunnel and the drainage, which prevents the scar from creating a scar and closure. during the operation, the tunnel for the outflow of water-borne fluids.

The invention consists in the following.

A method for the surgical treatment of glaucoma involves performing a trabeculectomy. New is that they prepare a drainage with a diameter of 1.5-2 mm and a length of 5 mm by knotless weaving of four polyglycolide threads. In the upper quadrant of the eyeball, a superficial rectangular scleral flap is cut out 1/3 of its thickness with the base to the limb with the base of 5 mm and the side of 4 mm. Next, from the deep-lying layers of the sclera, a deep sclera flap is cut into a rectangular shape 1/3 of its thickness with the base to the limb with the base of 4 mm and a side of 3 mm. Then, at the base of the deep flap, a strip of trabecular tissue is excised. The lateral edges of the deep flap are turned outward and the manufactured drainage is placed between them. One of the ends of the drainage is located in the corner of the anterior chamber, and the second - on the basis of a deep flap. The edges of the deep flap are fixed with one or two seams between each other so that they do not touch each other. The surface flap is laid on top, covering the edges of the deep flap with the formation of a round-shaped tunnel between the formed flaps, leaving a slit-like space between its walls and the drainage. The edges of the superficial flap are fixed along the edges to the sclera.

The method is as follows.

Drainage from a polyglycolide thread is preliminarily prepared: in the operating room, under sterile conditions, a polyglycolide thread is removed from a vacuum package.

Polyglycolide thread is a synthetic suture material consisting of woven monofilaments (RU 2207093, 06.27.2003). The thread coating is made of polycaprolactone and calcium stearate, while the thread itself consists of glycolic acid filaments. This type of surgical suture material is characterized by the fact that the substances contained in the thread are not collagen, do not cause an allergic reaction, do not have antigenic properties, are not toxic, and do not cause a pronounced acute inflammatory reaction. The thread undergoes resorption by hydrolysis, and complete absorption occurs within 60-90 days. Drainage is made manually for 3-4 minutes under sterile conditions before surgery. The threads are woven using knotless weaving of four threads. The manufacturing process is quite simple and does not require additional devices, except for the hands of the surgeon. As a result, the drainage takes the form of a cylinder of a cellular structure, has elasticity and the ability to model.

Drainage is intertwined in the form of a knotless weaving of four threads. It has a diameter of 1.5-2 mm and a length of 5 mm. In FIG. 1 shows a general view of the drainage.

Then surgery is performed: in the upper quadrant of the eyeball, a conjunctival flap is cut out with the base to the limb. Then form a surface rectangular flap of the sclera on 1/3 of its thickness with the base to the limb and with a size of 5 mm base and 4 mm lateral side. Next, from the underlying layers of the sclera, a deep squared flap is cut into 1/3 of the sclera thickness with the base to the limb and 4 mm in size, the base on the 3 mm lateral side. Then, at the base of the deep flap, a strip of trabecular tissue 3 × 2 mm in size is excised (trabeculectomy). The lateral edges of the deep scleral flap are turned outward, the manufactured drainage is placed between them so that one of its ends is placed in the corner of the anterior chamber, and the second is on the base of the deep flap. Then the edges of the deep flap are fixed with one or two seams, 8-00, between each other in the middle so that they do not touch each other.

In FIG. 2 is a diagram of the operation, where 1 is a superficial scleral flap, 2 is a deep scleral flap, 3 is a polyglycolide thread drainage.

After this, the surface flap is laid in place, covering the edges of the deep flap with the formation of a tunnel, and fixed along the edges with two sutures to the sclera.

Thus, a round-shaped tunnel is formed from the sclera with the drainage placed inside, leaving a slit-like space between the walls of the formed tunnel and the drainage.

A conjunctival flap is repositioned with a continuous suture applied to it.

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

Clinical example 1

Patient B., age 57 years. Diagnosis: right eye - open-angle III "c" glaucoma, complicated initial cataract. The left eye is open-angle II "c" glaucoma, complicated initial cataract. Examination data: glaucoma for 20 years, maximum antihypertensive regimen. On admission, visual acuity of the right eye of 0.8 with correction, intraocular pressure of 36 mm Hg at maximum antihypertensive mode. Peripheral field vision of the right eye from the nasal side to 30 °, from the temporal side to 60 °.

The patient underwent surgical treatment according to the proposed method. After making the drainage, they started surgical intervention. After processing the surgical field in the upper quadrant of the limb at 13 o'clock, the conjunctiva was cut 7 mm long, the conjunctiva was separated, hemostasis was performed. A surface rectangular flap of the sclera was cut to 1/3 of its thickness with the base to the limb and 5x4 mm in size. Then, a deep rectangular sclera flap was cut to 1/3 of its thickness with the base to the limb and 4 × 3 mm in size. At the base of the deep flap, a 3 × 2 mm strip of trabecular tissue was excised. The lateral edges of the deep scleral flap turned outward, the manufactured drainage was placed between them, one end of the drainage was placed in the corner of the anterior chamber. Then the edges of the deep flap are fixed with two sutures, 8-00, between each other in the middle so that they do not touch each other. After that, the superficial flap is put in place, covering the edges of the deep flap with the formation of a round tunnel, and is fixed at the edges with two sutures to the sclera. The conjunctival flap was repositioned with a continuous suture imposed on it.

At discharge: IOP of the right eye of 17 mmHg. The field of vision from the bow is expanded to 40 °. Visual acuity of 0.7 with correction and aperture. Objectively: the filter cushion above the upper limb is flat, spilled. Gonioscopically the fistula at 12 o’clock is free. After 1.5-2 months, according to the data of ultrasound biomicroscopy (UBM), a functionally active cavity in the intervention is determined, without excessive proliferation. 6 months after the operation, all indicators remained. This confirms the decrease in the risk of hypotension in the early postoperative period as a result of using the proposed method, as well as the reduction in the risk of scarring and the provision of a stable hypotensive effect in the late postoperative period due to resorption of the drainage and the formation of a connective tissue capsule inside the tunnel.

Clinical example 2

Patient R., age 67 years. Diagnosis: right eye - artifact. The left eye - secondary neovascular III "c" glaucoma, complicated initial cataract.

Examination data: upon receipt, visual acuity of the left eye of 0.3, does not correct. IOP of the left eye - 34 mm Hg at maximum antihypertensive mode. Gonioscopically, the angle of the anterior chamber (CCP) is closed, the newly formed vessels are determined. The peripheral field of vision of the left eye is narrowed from the nasal side to 15 °, from the temporal to 55 °, there is a paracentral annular scotoma.

The patient underwent surgery according to the proposed method. After making the drainage, they started surgical intervention. After processing the surgical field in the upper quadrant of the limb at 13 o'clock, the conjunctiva was cut 7 mm long, the conjunctiva was separated, hemostasis was performed. A surface rectangular flap of the sclera was cut to 1/3 of its thickness with the base to the limb and 5 × 4 mm in size. Then a deep rectangular sclera flap was cut out with dimensions of 4 × 3 mm. At the base of the deep flap, a 3 × 2 mm strip of trabecular tissue was excised, and a peripheral iridectomy was performed. Next, the lateral edges of the deep scleral flap are turned outward, the manufactured drainage is placed between them, the peripheral end of the drainage is placed in the corner of the anterior chamber. Then the edges of the deep flap are fixed with one suture, 8-00, between each other in the middle so that they do not touch each other. After that, the surface flap is put in place, covering the edges of the deep flap with the formation of a round tunnel. The superficial flap is fixed at the edges with two sutures to the sclera. The conjunctival flap was repositioned with a continuous suture imposed on it.

When extracting IOP of the left eye - 14 mm Hg. Visual acuity - 0.3, does not correct. Objectively: the filter cushion above the upper limb is flat, spilled. Gonioscopically the fistula at 12 o’clock is free. After 1.5-2 months, according to the UBM, a functionally active cavity in the intervention is determined without excessive proliferation, which indicates a formed connective tissue capsule inside the tunnel. 5 months after the operation, all indicators remained.

This operation was performed on 7 patients (7 eyes) of POAG II-III stages who did not have a history of eye surgery. The results were obtained: in the early postoperative period, in 95% of cases of IOP was within 13-15 mmHg; after 6-12 months - 16-18 mmHg (according to Maklakov). The effectiveness of the operation in the early postoperative period was confirmed using optical coherent tomography of the anterior segment of the eye (OST). In the late - using UBM.

Thus, the use of this operation allows you to get a more stable hypotensive effect in the long-term postoperative period and reduce the risk of hypotension in the early postoperative period.

Claims (1)

A method for the surgical treatment of glaucoma, including performing a trabeculectomy, characterized in that a drainage is prepared with a diameter of 1.5-2 mm and a length of 5 mm by knotless weaving of four polyglycolide threads; in the upper quadrant of the eyeball, the surface rectangular sclera flap is first cut to 1/3 of its thickness with the base to the limb with the base of 5 mm and the side of 4 mm, then from the underlying sclera layers the deep sclera flap is cut into the 1/4 of its thickness rectangular sclera with the base to the limb with a base of 4 mm and a lateral side of 3 mm, then at the base of a deep flap, a strip of trabecular tissue is excised; after which the lateral edges of the deep flap are turned outward and the manufactured drainage is placed between them, placing one of its ends in the corner of the anterior chamber and the second on the base of the deep flap, then the edges of the deep flap are fixed with one or two seams so that they do not touch each other with each other, the surface flap is laid on top, covering the edges of the deep flap with the formation of a rounded tunnel between the formed flaps, leaving a slit-like space between its walls and the drainage, the edges of the surface a flap is fixed along the edges to the sclera.

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