RU2604403C2 - Method of normalization of intraocular pressure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and is intended for normalization of intraocular pressure. Conjunctiva is incised in 5 millimeters from following stages of sclera surgery with length of 3-3.5 mm. Scleral incision is performed in 4 mm from limb in parallel with length of 3.5 mm, at the depth of 300 mcm, then viscoelastic is introduced in intrascleral channel. Additionally one interrupted suture is applied on upper part projecting from intrascleral channel, conjunctiva incision is sealed by diathermy and by applying one interrupted suture. After formation of intrascleral channel introduction into it of various structures is also possible.

EFFECT: method provides stable normalization of intraocular pressure, while reducing risk of operative and postoperative complications.

1 cl, 2 ex

Description

The invention relates to medicine and is intended to normalize intraocular pressure.

High intraocular pressure leads to the development of optic atrophy. This group of diseases is called glaucoma. The main treatment for glaucoma is surgical, aimed at reducing intraocular pressure.

A known method of trabeculectomy, in which form a conjunctival flap with the base to the limb. After careful hemostasis from the outer layers of the sclera, a quadrangular flap is formed with the base to the limb, and then a scleral strip is cut out and excised in the filtration zone along with the trabecula and scleral sinus. Produce basal iridectomy. A superficial scleral flap is placed in its bed and fixed with two or more interrupted sutures. After this, a continuous suture is applied to the conjunctiva (M. M. Krasnov, “Glaucoma Microsurgery”, 1980, M., Medicine, p. 247). This most common operation has several disadvantages: trauma to eye tissues, the risk of bleeding from the vascular plexuses of the limb, poor dosage of the hypotensive effect (the occurrence of persistent hypotension with excessive filtration, or vice versa hypertension with excessive scarring). Various modifications of the operation have been developed aimed at eliminating the existing complications. Patent number: 2157678, A61F 9/007 publication date 10/20/2000. Makashova N.V. Formula of the invention: A method for the surgical treatment of glaucoma, including goniocycloretraction and trabeculectomy, characterized in that three longitudinal strips are cut from a deep rectangular flap, the middle one is tucked into the corner of the anterior chamber, and the two side ones are placed into the suprachoroidal space and additionally placed on top of the last two biodegradable allograft exceeding them in length, made of hygroscopic material and saturated with drugs. 2. The method according to p. 1, characterized in that diplen is used as an allograft.

Patent number: 2172157, A61F 9/007, Date of publication: 08.20.2001. Formula of the invention: Drainage for the treatment of glaucoma, made of a polymer compound based on a hydrogel, characterized in that it has a large-pore structure with a fixed water content in the polymer (60-85 wt.%), While the drainage is made in the form of a cylinder with a cross-section diameter in dry form 0.3-1.5 mm, length 3-20 mm.

As a prototype patent is considered: 2071749, A61F 9/007. from 07.28.1993 Authors: Yerichev VP; Alekseev I.B. The aim of the invention is to achieve a persistent antihypertensive effect by preventing excessive scarring in the surgical area. This goal is achieved by the fact that in the method of anti-glaucomatous surgery, which involves cutting a surface scleral flap to the filtration zone, a distinctive feature is that in the filtration zone two through parallel limb incisions are made, the formed scleral block is scattered in the center with the formation of two valves, and the angles of the surface the scleral flap is fixed with two sutures to the middle of the scleral bed.

It should be noted that the above modifications of the operation are aimed at increasing the outflow of intraocular fluid flowing from the eye cavity, which, in turn, increases the risk of complications associated with excessive filtration, namely: development of macular edema, choroid detachment, progression of opacities in the lens. The aim of this invention is to provide a method for normalizing intraocular pressure, which increases efficiency, provides a stable normalization of intraocular pressure while reducing the risk of surgical and postoperative complications.

This goal is achieved by changing the technique of operation at each stage. The first stage “conjunctival incision” is performed 5 millimeters from the subsequent stages of the operation on the sclera. Conjunctival displacement is possible due to the fact that it is easily displaced relative to the sclera. The length of the cut is 3-3.5 mm, significantly less than when performing the operation in the prototype. The advantages of this stage of the operation are less trauma and prevention of the possibility of excessive filtering through the conjunctival incision in the postoperative period. The next stage, “scleral incision”, is performed 4 mm from the limb parallel to it with a length of 3.5 mm, superficially by one third of the sclera thickness, which corresponds to 300 microns. Further, the sclera is cut with a tunnel knife at a specified depth until the tip of the knife appears in the anterior chamber of the eye. A significant difference from the prototype is the absence of lateral incisions and the exclusion of the separation of the scleral flap, which significantly reduces trauma to the sclera and the associated complications in the form of bleeding, the formation of gross postoperative adhesions. Significantly reduced the area of the operation, since in the prototype a flap of rectangular shape with a side of 5 mm is detached. Also a significant difference is the depth of the cut (in the prototype it is half the thickness of the sclera in the proposed method, one third). The choice of such a depth of cut is due to the anatomical features of the corneoscleral zone, it is at a depth of one third of the sclera (300 μm) that the risk of bleeding is minimal. With a deeper arrangement of incisions, the risk of damage to the deep intrascleral vascular plexus increases. This depth of cut excludes the possibility of trauma to the deeper ciliary body, which is a serious complication leading to the appearance of a pronounced inflammatory reaction.

A significant difference is the use at the subsequent stage of viscoelastics, which are introduced using a cannula into the intrascleral space of the incision. This provides several new qualities that are missing from the prototype. Viscoelastics have a hemostatic effect, which eliminates the possibility of hemorrhagic complications. They provide for the plugging of the formed intracellular canal and prevent a sharp drop in intraocular pressure during perforation of the anterior chamber of the eye. It is this factor of a sharp decrease in intraocular pressure during antiglaucomatous surgery that is the most significant factor in the development of such a frequent and severe complication as choroid detachment. This complication negatively affects the effectiveness of antiglaucomatous operations. It requires repeated surgical intervention, posterior trepanation of the sclera, in addition, the introduction of hormonal anti-inflammatory drugs is necessary. The detachment of the choroid changes the hydro- and hemodynamics of the eye so much that it can lead to the progression of dystrophic changes in the intraocular structures, especially the onset of cataracts.

In the proposed method, there is no stage of a sharp drop in intraocular pressure and, accordingly, the risk of this type of complications, in particular choroid detachment, is reduced. The introduction of viscoelastics into the intrascleral space provides several more advantages, namely:

- prevention of postoperative scarring of the formed outflow paths.

- the possibility of less traumatic implantation into the intrascleral pathways of various types of drainage,

- the formation of a stable intrascleral pathway of the outflow of intraocular fluid.

The prevention of intrascleral scarring is ensured by the fact that the presence of viscoelastic forms a space in which the walls of the created channel of the outflow of fluid do not close. The most important for the formation of the scarring process are the first day after the operation, when fibrin is released and primary adhesions are formed, which later turn into a scar. Since there is viscoelastic in the intrascleral canal, the biochemical process of formation of the fibrin matrix is disturbed and primary scarring does not occur. The introduction of viscoelastic into the intrascleral space does not lead to side effects, since in the future it is washed out for 1-3 days by an intraocular fluid, which also has a fibrinolytic effect.

Sealing the conjunctiva incision with diathermy and applying 1 nodal suture. Hormonal anti-inflammatory therapy in the postoperative period, unlike the prototype, is not used.

As follows from the description, each stage of the operation is less traumatic, providing new qualities, optimizing the parameters of fluid outflow as a result of creating an intrascleral channel and preventing excessive scarring. Of particular note is the prevention factor for hemorrhagic complications due to the use of viscoelastics and the choice of thickness of the scleral incision. Also, a significant advantage is the operation without trauma to the natural drainage paths - the area of operation outside the main elements of the eye drainage system - trabeculae, Schlemm's canal. Excludes trauma to the ciliary body during the stages of the operation and, accordingly, ensures the absence of an inflammatory reaction. The regulation of the rate of outflow of intraocular fluid is made by choosing the geometric parameters of intrascleral implants.

Thus, the proposed method for normalizing intraocular pressure realizes the goal of increasing the efficiency of the operation, ensuring stable normalization of intraocular pressure, reducing the risk of surgical and postoperative complications as a result of creating an operation technique that has significant differences from the prototype.

Examples of clinical use.

Patient N. 48 years old. Diagnosis: open-angle 2 s (uncompensated) glaucoma of the right eye. The preoperative level of intraocular pressure is 32 mm RT. Art. The operation was performed under local anesthesia, Lidocaine 2.5% 0.5 ml was injected under the conjunctiva, the conjunctiva was cut in the upper inner quadrant 3-3.5 mm long, then the sclera was cut 4 mm from the limb parallel to it 3.5 mm long. Tunnel knife at a depth of 300 microns. A scleral incision was made and an intrascleral tunnel was formed until the tip of the knife appeared in the anterior chamber of the eye. Using a cannula, viscoelastic is introduced into the intrascleral canal. Intrascleral space introduced drainage. 1 nodal suture of silk 9-00 was applied to the conjunctiva. There were no complications in the postoperative period. Intraocular pressure after surgery 18 mm RT. Art. The term of postoperative observation is 14 months.

Patient N., 68 years old. Diagnosis: open-angle 1 in (uncompensated) glaucoma of the left eye. The preoperative level of intraocular pressure is 28 mm Hg. Art. The operation was performed under local anesthesia, Lidocaine 2.5% 0.5 ml was injected under the conjunctiva, the conjunctiva was cut in the upper inner quadrant 3-3.5 mm long, then the sclera was cut 4 mm from the limb parallel to it 3.5 mm long. Tunnel knife at a depth of 300 microns. A scleral incision was made and an intrascleral tunnel was formed until the tip of the knife appeared in the anterior chamber of the eye. Using a cannula, viscoelastic is introduced into the intrascleral canal. 1 nodal suture of silk 9-00 was applied to the conjunctiva. There were no complications during the operation. Intraocular pressure after surgery 20 mm RT. Art. Postoperative follow-up is 19 months.

Claims (1)

A method for normalizing intraocular pressure, including a conjunctiva and sclera incision, characterized in that the conjunctiva incision is performed 5 millimeters from the sclera incision 3-3.5 mm long, the sclera incision is made 4 mm from the limbus parallel to it 3.5 mm long to a depth of 300 μm, the incision is continued, forming the intrascleral canal, until the tip of the knife appears in the anterior chamber of the eye, then viscoelastic and drainage of a suitable design are introduced into the intrascleral canal, the conjunctival incision is sealed with diathermy and the application of one node of the seam.