RU2613439C1 - Nethod of low-invasive non-penetrating deep sclerectomy in case of open-angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to field of ophthalmology, and can be used for increasing efficiency of surgery of open-angle glaucoma. Superficial scleral flap is cut to 1/3 of sclera depth in form of trapezium with larger base 3 mm near limbus and smaller base 2 mm from the side of eye equator, 4 mm high. In the process of cutting out deep scleral flap in the middle of bed of superficial scleral flap, 3.5 mm long and 1 mm wide strip from middle layers of sclera, located perpendicular to limbus, remains non-separated. Lateral edges of superficial scleral flap are excised throughout the length with 0.3 mm width. Superficial scleral flap is placed on the previous place without suture fixation to sclera.

EFFECT: method makes it possible to achieve prolonged hypotensive effect in postoperative period.

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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 of microinvasive non-penetrating deep sclerectomy with open-angle glaucoma, including the formation of a conjunctival flap in the upper segment of the eyeball with separation 1-2 mm from the limbus, the formation of a superficial scleral flap with 1-2 mm entering the transparent layers of the cornea, the formation of a deep rectangular , triangular or trapezoidal scleral flap with its subsequent removal together with the outer wall of the Schlemm's canal and the peripheral layers of the cornea to the obn zheniya trabeculae and Descemet's membrane, the complete excision of the deep scleral flap at the top of the surface of the ciliary body, the scleral flap stacking surface with its fixation to the sclera with interrupted sutures of 1-2, overlaying a single continuous seam on the conjunctiva (RF Patent №2405512).

However, the effect of the above method is limited by the fact that in some cases scleral-scleral scar adhesions are formed between the superficial scleral flap and the remaining scleral layers 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 postoperative period.

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

The technical result of the invention is to reduce the formation of sclero-scleral cicatricial fusion in the area of antiglaucomatous surgery with prolongation of the hypotensive effect in the postoperative period due to the formation of a cavity above the trabeculodescemetic membrane and the creation of a shorter route for the outflow of intraocular fluid under the conjunctiva.

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 a distance of 2 mm from the limbus, 2 mm long, cutting out a superficial scleral flap, removing a deep scleral flap together with the peripheral layers of the cornea and the outer wall of the Schlemm's canal until the trabecula zone is exposed descemet shell according to the invention, the superficial scleral flap is cut into 1/3 of the sclera thickness in the form of a trapezoid with a large base of 3 mm at the limb and a smaller base of 2 mm from the equator of the eye, 4 mm high, when cutting a deep scleral flap in the middle of the bed of the superficial scleral flap is left an unseparated strip of the middle layers of the sclera located perpendicular to the limb, 3.5 mm long and 1 mm wide, parallel to the lateral sides of the superficial scleral flap excised along the entire length 0.3 mm wide, then the superficial scleral flap is laid in its original place without suture fixation to the sclera.

A distinctive feature of the method from the closest analogue is that when performing a microinvasive non-penetrating deep sclerectomy when cutting a deep scleral flap, an unseparated strip of middle scleral layers is left in the middle of the bed of the surface scleral flap, perpendicular to the limbus, and the surface scleral marginal truncation is truncated, the flap is laid in its original place without suturing.

Between the set of essential features and the achieved technical result there is a causal relationship:

1. The left strip from the middle layers of the sclera in the middle of the bed of the superficial scleral flap makes it possible to raise the superficial scleral flap above the trabeculodescemetic membrane when it is put back in place and create a cavity for the outflow of intraocular fluid, thereby preventing the formation of cicatricial fusion between the superficial scleral flap and trabeculum.

2. Truncation of the superficial scleral flap along the lateral edges creates a shorter outflow of intraocular fluid from the trabeculodescemet membrane immediately below the conjunctiva in the area of the larger base of the superficial scleral flap and towards the equator of the eye along the newly formed channels along the edges of the bed of the superficial scleral flap.

All this allows for free outflow of intraocular fluid immediately under the conjunctiva along the newly formed shorter paths, to reduce the risk of sclero-scleral scar adhesions in the area of anti-glaucomatous surgery, and thereby prolong the hypotensive effect in the postoperative period.

The method is illustrated in FIG. 1-6, where the steps of the operation are depicted, 1 denotes a superficial scleral flap, 2 - a bed of a superficial scleral flap, 3 - incisions when cutting a scleral strip from the middle scleral layers in the middle of the bed of the superficial scleral flap, 4 - a strip of middle scleral layers, 5 - corneoscleral trabecula, 6 - Schlemm's canal, 7 - Descemet's membrane, 8 - excised lateral edges of the superficial scleral flap, 9 - truncated superficial scleral flap.

The proposed method is as follows.

The processing of the surgical field, anesthesia, akinesia of the eyeball, and the application of an eyelid extender are performed. A conjunctival incision 2 mm long is made concentrically in the upper segment at a distance of 2 mm from the limbus, the conjunctiva is separated to the limbus, then the tenon membrane is dissected in the upper-outer direction with a size of 2 × 3 mm, after which the diathermocoagulation of the vessels is performed.

A trapezoidal superficial scleral flap 1 is cut with a 1/3 thickness of the sclera by cutting into the surface layers of the cornea with a large base of 3 mm near the limb, with a smaller base of 2 mm from the equator of the eye, 4 mm high. When cutting a deep scleral flap, a strip of 4 from the middle layers of the sclera is left in the middle of the bed 2 of the superficial scleral flap 1 perpendicular to the limb, not separated, 3.5 mm long and 1 mm wide. The peripheral layers of the cornea with the outer wall of the Schlemm's canal 6 are removed until the trabecula 5 and descemet sheath 7 are exposed.

Parallel to the lateral sides of the superficial scleral flap along the entire length, the edges 8 are cut out with a width of 0.3 mm, after which the flap 9 is laid in its original place without suture fixation to the sclera. Impose a continuous seam on the conjunctiva. Subconjunctival injection of dexazone 0.3 ml and gentamicin 0.2 ml is performed.

The method is illustrated by the following examples.

Example 1

Patient L., 70 years old, was admitted to the Eye Microsurgery FGBI MNTK with a diagnosis of Primary open-angle glaucoma, advanced stage (II), with moderately increased intraocular pressure (B) of the left eye. Visual acuity of the left eye = 0.4; intraocular pressure = 26 mmHg Outflow ease factor = 0.07. During biomicroscopy: the cornea is transparent, the anterior chamber is smaller than the average (≈2.7 mm), turbidity in the cortical layers of the lens. The fundus of the eye: the optic disc is pale, excavation 0.7 of the diameter of the disk (DD). Field of view: narrowing of the field of vision of the left eye from the upper nasal side to 40 °.

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method. After performing akinesia and preliminary processing of the surgical field, anesthesia of the eyeball and application of an eyelid expander were performed. A conjunctival incision 2 mm long was made in the upper segment concentrically to the limb at a distance of 2 mm from it. The tenon shell was dissected in the upper-outer direction with a size of 2 × 3 mm, after which vascular diathermocoagulation was performed.

A trapezoidal superficial scleral flap was cut with a 1/3 thickness of the sclera by cutting into the surface layers of the cornea with a large base of 3 mm near the limb, with a smaller base of 2 mm from the equator of the eye, 4 mm high.

When cutting out a deep scleral flap, a strip of middle scleral layers was left in the middle of the bed of the superficial scleral flap perpendicular to the limb with an unseparated length of 3.5 mm and a width of 1 mm. The peripheral layers of the cornea with the outer wall of the Schlemm canal were removed until the trabecula and descemetic sheath were exposed.

Parallel to the lateral sides of the superficial scleral flap along the entire length, 0.3 mm wide edges were dissected, after which the flap was placed in its original place without suture fixation to the sclera. A continuous suture was applied to the conjunctiva and a subconjunctival injection of 0.3 ml of dexazone and 0.2 ml of gentamicin was given.

In the control study 1 day after surgery, the visual acuity of the left eye = 0.4, intraocular pressure = 9 mm Hg Biomicroscopically: the cornea is transparent, the anterior chamber is smaller than the average (≈2.8 mm), the filter pad is pronounced, spilled, ≈0.8 mm high. Narrowing of the field of vision of the left eye from the upper nasal side to 40 °.

In the control study 7 days after surgery, the visual acuity of the left eye = 0.4; intraocular pressure = 10 mm Hg, filtration pad spilled, height = 1.1 mm. Narrowing of the field of vision of the left eye from the upper nasal side to 40 °.

In the control study, 1 month after the operation, visual acuity of the left eye = 0.4, intraocular pressure = 12 mm Hg, filter cushion spilled, height = 1.0 mm. Narrowing of the field of vision of the left eye from the upper nasal side to 40 °.

Example 2

Patient K., 69 years old, was admitted to the Eye Microsurgery FGBI MNTK with a diagnosis of Primary open-angle glaucoma, advanced stage (III), with moderately increased intraocular pressure (B) of the left eye. Visual acuity of the left eye = 0.3; intraocular pressure = 28 mmHg Outflow ease factor = 0.08. During biomicroscopy: the cornea is transparent, the anterior chamber is smaller than the average (≈2.8 mm), opacities in the cortical layers of the lens. Fundus: optic nerve disc gray, excavation 0.8 DD. Field of view: narrowing of the field of view of the left eye from the upper nasal and upper sides to 15 °.

The operation was performed: microinvasive non-penetrating deep sclerectomy according to the proposed method. After performing akinesia and preliminary processing of the surgical field, anesthesia of the eyeball and application of an eyelid expander were performed. A conjunctival incision 2 mm long was made in the upper segment concentrically to the limb at a distance of 2 mm from it. The tenon shell was dissected in the upper-outer direction with a size of 2 × 3 mm, after which vascular diathermocoagulation was performed.

A trapezoidal superficial scleral flap was cut with a 1/3 thickness of the sclera by cutting into the surface layers of the cornea with a large base of 3 mm near the limb, with a smaller base of 2 mm from the equator of the eye, 4 mm high. When cutting out a deep scleral flap, a strip of middle scleral layers was left in the middle of the bed of the superficial scleral flap perpendicular to the limb with an unseparated length of 3.5 mm and a width of 1 mm. The peripheral layers of the cornea with the outer wall of the Schlemm canal were removed until the trabecula and descemetic sheath were exposed.

Parallel to the lateral sides of the superficial scleral flap along the entire length, 0.3 mm wide edges were dissected, after which the flap was placed in its original place without suture fixation to the sclera. A continuous suture was applied to the conjunctiva and a subconjunctival injection of 0.3 ml of dexazone and 0.2 ml of gentamicin was given.

In the control study 1 day after the operation, visual acuity of the left eye = 0.3, intraocular pressure = 10 mm Hg Biomicroscopically: the cornea is transparent, the anterior chamber is smaller than the average (≈2.8 mm), the filter pad is pronounced, spilled, ≈ 1.25 mm high. Narrowing the field of view of the left eye from the upper nasal and upper sides to 15 °.

In the control study, 7 days after the operation, visual acuity of the left eye = 0.3, intraocular pressure = 11 mm Hg, filter cushion spilled, height ≈ 1.2 mm. Narrowing the field of view of the left eye from the upper nasal and upper sides to 15 °.

In the control study, 1 month after the operation, visual acuity of the left eye = 0.3, intraocular pressure = 13 mm Hg, filter cushion spilled, height ≈ 1.2 mm. Field of view: narrowing of the field of view of the left eye from the upper nasal and upper sides to 15 °.

Claims (1)

A microinvasive method for surgical treatment of open-angle glaucoma, including conducting a conjunctival incision in the limbus, cutting out a superficial scleral flap, removing a deep scleral flap along with the peripheral layers of the cornea and the outer wall of the schlemm canal until the trabecula and descemetic sheath are exposed, characterized by the fact that the superficial sclera 1/3 of the sclera thickness in the form of a trapezoid with a large base of 3 mm at the limb and a smaller base of 2 mm from the equator of the eye, in 4 mm high, when cutting a deep scleral flap in the middle of the bed of the superficial scleral flap, an unseparated stripe from the middle layers of the sclera is located, perpendicular to the limb, 3.5 mm long and 1 mm wide, truncate the lateral edges of the superficial scleral flap along its entire length with a width of 0, 3 mm, then the superficial scleral flap is laid in its original place without suture fixation to the sclera.

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