RU2675967C1 - Method of surgical treatment of glaucama developed against the background of iridocorial endothelial syndrome - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to ophthalmology. For treating glaucoma that has developed on the background of iridocorneal endothelial syndrome, a conjunctival flap is formed, with the base to the limb, a superficial scleral flap (PSL) is cut out, size 4×4 mm, base to limb, and separation of that is carrying out from underlying sclera to the corneal part of the limbus, entering 1 mm in transparent layers of the cornea. 3–5 minute application of mitomycin C (MMS) is carried out; as a delivery vehicle of which, a hemostatic sponge is used, cutting it out for scleral application according to the size of the scleral bed, for subconjunctival application – 1–1.5 mm larger than its size. After removing hemostatic sponge, area of application is abundantly washed with saline. Cut out deep scleral flap (GSL) of triangular shape, with base to the limb and separating it from underlying choroid at half its height, starting from the apex, and when separating remaining half of GSL, thin network of scleral fibers is left on the choroid, upon reaching limbal zone, strip of trabeculo-Descemet's membrane (TDM) is exposed. GSL is excised at the bottom, leaving nude TDM intact. From the side edges of the PSL with the help of Vanass scissors form strips – scleral autodrainage 0.7–0.8 mm wide, keeping their connection with the PSL at the base. PSL is laid in place and hemmed to the adjacent sclera with two interrupted sutures in distal corners, a cohesive viscoprotector is inserted under it. Thin spatula is placed under PSL, parallel to plane of iris and normal to limbus, propel it through a layer of cohesive viscoprotector towards the base of the PSL. Passing with spatula into front chamber (PC) and shift it in a horizontal direction, destroying the TDM. Spatula is removed from under the PSL. Scleral autodrainage through viscoprotector layer is charged into anterior chamber.EFFECT: method provides prolongation of hypotensive effect of surgical intervention due to absence of interstitial adhesions not only in the extrascleral and intrascleral areas of the operation, but also of the intraocular part of the fistula free of adhesions.1 cl, 1 ex

Description

The invention relates to medicine, and more specifically to ophthalmology, and can be used to treat glaucoma, which developed against the background of iridocorneal endothelial syndrome. Iridocorneal endothelial syndrome includes three forms of pathology - Chandler syndrome, Cogan-Reese syndrome and progressive essential mesoderm atrophy of the iris. The common manifestation of these diseases is excessive proliferation of the corneal endothelium with the formation of peripheral anterior synechia and the development of secondary angle-closure glaucoma. Based on the foregoing, glaucoma with iridocorneal endothelial syndrome refers to such forms of the disease in which the anterior chamber angle is the primary site of manifestation of the pathological process.

Glaucoma, concomitant with iridocorneal endothelial syndrome, is characterized by a severe course and a refractory nature, often leading to progressive glaucoma atrophy of the optic nerve and irreversible loss of function.

The closest analogue is a method of treating angle-closure glaucoma that developed against the background of iridocorneal endothelial syndrome, fistulizing antiglaucoma operations with antimetabolite - a cytostatic chemotherapeutic drug, usually mitomycin C (M. Lanzl, RP Wilson, D. Dudley, JJ Augsburger, IM Aslan Spaeth, "Outcome of trabeculectomy with mitomycin-C in the iridocorneal endothelial syndrome," Ophthalmology, vol. 107, no. 2, pp. 295-297, 2000). The technique of the operation was standardized and in all cases included cutting out the conjunctival flap with the base to the limb, hemostasis and cleaning the episclera in the area of the upcoming surgical intervention. To achieve an antiproliferative effect, the authors performed a subconjunctival application of cytostatic at a dilution of 0.4 mg / ml, choosing a surgical sponge as a delivery vehicle. The duration of the application ranged from 1 to 4 minutes, averaging 1.9 minutes. After thoroughly washing the area of operation to completely remove the remnants of the MMC cytostatic, the operation was continued as usual trabeculectomy. A superficial scleral flap was formed with the base to the limb and a deep scleral flap 1 × 2 mm in size was dissected. An iridectomy was performed, after which the superficial scleral flap was fixed with interrupted sutures to the adjacent sclera, and the operation was completed by separate suturing of the tenon membrane and conjunctiva.

However, a significant drawback of these interventions is the rapid depletion of the hypotensive effect of the operation (E.A. Doe, DL Budenz, SJ Gedde, and NR Imami, "Long-term surgical outcomes of patients with glaucoma secondary to the iridocorneal endothelial syndrome," Ophthalmology, vol. 108, no. 10, pp. 1789-1795, 2001.). To a large extent, this is due to the generally accepted localization of the intraoperative application of the mitomycin C antimetabolite (MMS) in the subconjunctival and, often, intrascleral areas of the operation, which limits the effect of the drug on these areas. Moreover, in cases of iridocorneal endothelial syndrome, initially the hydrodynamic block develops precisely at the level of the internal fistula. The failure of fistulizing antiglaucoma surgery is caused by an internal fistula contraction caused by excessive proliferation of the corneal endothelium with the formation of peripheral anterior synechia (Poltanova T.I., Bessonova L.A. Case of essential-mesodermal dystrophy of the iris (clinical observation) // Ophthalmosurgery - 2012. 3 - S. 85).

The objective of the invention is to develop an effective method for the surgical treatment of angle-closure glaucoma, which developed against the background of iridocorneal endothelial syndrome, by suppressing excessive scarring in the area of the operation, including the inside of the fistula, providing an unhindered outflow of intraocular fluid and prolonging the hypotensive effect of the operation.

The technical result is the prolongation of the hypotensive effect of surgical intervention due to the absence of interstitial adhesions, not only in the extrascleral and intrascleral areas of the operation, but also free of adhesions, which is passable for intraocular fluid, the intraocular part of the fistula.

The technical result is achieved by the fact that in the method of surgical treatment of glaucoma, which developed against the background of the iridocorneal endothelial syndrome, including the formation of a conjunctival flap, with a base to the limb, cutting out a superficial scleral flap (PSL), 4 × 4 mm in size, with the base to the limb and its separation from the subject sclera to the corneal part of the limb, going into the transparent layers of the cornea by 1 mm; application of mitomycin C (MMS), the haemostatic sponge is used as a delivery vehicle, cutting it out for scleral application according to the size of the scleral bed, for subconjunctival application - 1-1.5 mm larger than its size, the cut out sponge is impregnated with a solution of MMS in a concentration of 5 mg / ml and placed for 3-5 minutes under the conjunctival and superficial scleral flaps, avoiding contact with the edges of the tenon membrane and conjunctiva, after removing the hemostatic sponge, the application area is rinsed abundantly by physiologists With a saline solution, a deep scleral flap (GSL) of a triangular shape is cut out, with a base to the limb, and it is separated from the underlying choroid half its height, starting from the top, and when separating the remaining half of the HSL, a thin network of scleral fibers is left on the choroid, when limbal the zones expose the strip of the trabeculo-descemetic membrane (TDM), according to the invention, excise GSL at the base, leaving the exposed TDM intact, from the side edges of the PSL using Vanass scissors form strips - the clerical autodrainages 0.7-0.8 mm wide, while maintaining their connection with the PSL at the base, the PSL is put in place and hemmed to the adjacent sclera with two interrupted sutures in the distal corners, a cohesive viscoprotector is inserted under it, a thin spatula is placed under the PSL, in parallel the iris plane and normal to the limb, push it through the cohesive viscoprotective layer towards the base of the PSL, pass with a spatula to the front chamber (PC) and displace it horizontally, destroying the TDM, remove the spatula from under the PSL, scleral autodrainage through a layer of viscoprotective tuck into the front camera.

The technical result is achieved due to:

1. Cutting out scleral autodrainages from PSL, pre-treated with a solution of MMS antimetabolite, which ensures the prevention of the formation of interstitial adhesions, both autodrainages and the edges of the internal fistula. Thorough washing of all tissues in contact with MMS, ensures the absence of its negative effect on all structures in the area of the operation, including PC eyes.

2. Improvements in the outflow of intraocular fluid by expanding the angle of the PC and the area of the inner fistula with scleral autodrainage treated with MMC antimetabolite.

3. The introduction of a cohesive viscoprotector under the PSL, which supports the volume of the intrascleral cavity, levels the intraoperative IOP drop, prevents the flow of intraocular fluid, stabilizes the iris during subsequent surgical procedures. In addition, enveloping the surface of the auto-drainage with a viscoprotector ensures its subsequent sliding, facilitates the conduct of auto-drainage through the edges of the internal fistula and its filling into the PC of the eye.

The method is as follows. Conduct standard processing of the surgical field in the desired segment, form a conjunctival flap 1 mm high, 4.5 mm long with the base to the limb. Then, a surface scleral flap (PSL), 4 × 4 mm in size, is cut out with a base to the limb and it is separated from the underlying sclera to the corneal part of the limb, going into the transparent layers of the cornea by 1 mm. For subconjunctival and intrascleral application of MMC antimetabolite, a hemostatic sponge is used as a delivery vehicle, cutting it out for scleral application according to the size of the scleral bed, for subconjunctival application it is 1-1.5 mm larger than its size. The cut out sponge is impregnated with a solution of MMS in a concentration of 5 mg / ml and placed for 3-5 minutes under conjunctival and superficial scleral flaps, avoiding contact with the edges of the tenon membrane and conjunctiva. After removal of the hemostatic sponge, the application area is washed abundantly with saline in an amount of 50-60 ml.

GSL is cut out of a triangular shape, smaller in size, with the base to the limb and it is separated from the underlying choroid by half the height of the triangular flap, starting from the top of the triangle, and when separating the remaining half of the triangular flap, a thin network of scleral fibers is left on the choroid. Upon reaching the limbal zone, a strip of TDM with a height of 1.0 mm is exposed. A deep scleral flap is excised at the base, leaving an intact strip of open TDM. With the help of Vanass scissors, narrow strips are formed from the lateral edges of the PSL — scleral autodrainages (about 0.7-0.8 mm wide), maintaining their connection with the PSL at the base. PSL is laid in place and sutured to the adjacent sclera with two interrupted sutures (for example, vicryl 8-0) in the distal corners of the quadrangle. A cohesive viscoprotector (e.g., Healon) is administered under PSL.

A thin spatula is placed under the PSL, strictly parallel to the plane of the iris and perpendicular to the limb. The putty knife is advanced through the cohesive viscoprotective layer towards the base of the PSL and destroy the TDM. They pass with a spatula into the anterior chamber and displace it in the horizontal direction, making sure that the TDM is destroyed throughout the inner fistula. Remove the spatula from under the PSL. Scleral autodrainages are threaded through the viscoprotector layer into the anterior chamber using tweezers and a spatula. If necessary, PSL is fixed to the adjacent sclera with an additional nodal suture (for example, Vicryl 8-0) for the side face closer to the base of the PSL.

The operation is completed by sealing the conjunctival incision with a continuous immersion suture (for example, Vicryl 8-0). The suture consistency is checked by administering a steroidal anti-inflammatory drug (for example, dexazone in a volume of 0.2-0.3 ml on a 25G needle) under the conjunctiva in this area.

Example. Patient M., 12 years old, was admitted for treatment to the Department of Eye Microsurgery of the Morozov Children's Children's Clinical Hospital DZM with a diagnosis of operated secondary developed angle-angle developed decompensated glaucoma of the right eye. Iridocorneal endothelial syndrome (essential mesodermal atrophy of the iris). From the anamnesis it is known that about 3 years ago (at the age of 6 years) the girl’s parents noted the expansion of the pupil in her right eye. About a year and a half ago, the eye was operated on for secondary angle-closure glaucoma. However, after 6 months, after prolonged insolation during the summer rest, the pupil of the right eye acquired an irregular shape, expanded to 6-7 mm, and the pupil shifted upward. IOP increased again, and it was not possible to normalize it with the help of antihypertensive instillations. The child was sent for reoperation for the decompensated operated secondary angle-closure glaucoma in the right eye.

Upon receipt, the right eye is calm. At 12 o’clock in the area of the previous operation, there is no filtration cushion (AF); conjunctival relief impressions are visualized, indicating the formation of conjunctival scleral fusion. The cornea is transparent, shiny. The anterior chamber is of medium depth, uniform. The pupil is dilated to 6 × 7 mm, deformed and displaced by 12 hours; the reaction of the pupil to light is practically absent. Inversion of the pigment border around the entire circumference of the pupil. The iris pattern is distorted (the radial orientation of the crypts is lost), single crater-shaped gaps with the thinning of the mesodermal leaf of the iris at 12, 5 and 8 hours. The lens and vitreous are transparent. When examining the fundus - the optic nerve disk (optic nerve disc) is pale, monotonous, the boundaries are clear, the pigment border around the entire circumference; subtotal glaucoma excavation of optic disc with the inflection of the vascular bundle and its displacement to the nasal side. Arteries in caliber are not changed, veins are moderately full-blooded. The macular zone and the visible periphery of the retina without pathology.

Vis OD = 0.2 sph-2.0D = 1.0

OS = 1.0

IOP OD - 32 mm Hg

OS - 16 mmHg

PZR OD - 24.4 mm

OS - 22.6 mm

Gonioscopy OD: the anterior chamber angle is sharply narrowed, closed in some places due to the formation of goniosynechies and anterior synechia in the basal zone of the iris. The most pronounced changes were found at 12 o’clock in the area of the previous operation - the inner zone of the operation is completely blocked by the newly formed gonosynechias.

The patient in the right eye underwent an anti-glaucoma operation according to the invention.

After processing the surgical field, a conjunctival flap 1 mm high, 4.5 mm long was formed in the upper-inner quadrant. It is cut and separated from the underlying sclera PSL, size 4 × 4 mm. Subconjunctival and intrascleral applications of MMS antimetabolite on a hemostatic sponge were performed at a concentration of MMS of 5 mg / ml with an application duration of 5 minutes. The application area is washed extensively with saline (60 ml). Cut out and separated from the underlying choroid of the GSL of a triangular shape, smaller; when separating the proximal half of the flap on the choroid, a thin network of scleral fibers is preserved. Stripes, scleral auto-drains (0.7 mm wide), were formed from the PSL lateral edges using Vanass scissors. PSL is hemmed to the adjacent sclera by 2 interrupted sutures (Vicryl 8-0) in the distal corners of the quadrangle. Healon is introduced under PSL.

A thin spatula was drawn under the PSL through a layer of viscoprotector to the entrance to the anterior chamber. The TDM was destroyed with a spatula and the intraocular part of the fistula was formed. Scleral autodrainage is also conducted through the viscoprotector layer and tucked into the anterior chamber. PSL is fixed to the adjacent sclera with an additional nodal suture behind the lateral face. The conjunctival incision is sealed by a continuous submersible suture.

The early postoperative period against the background of standard anti-inflammatory therapy was characterized by a calm course. Ultrasound examination showed the absence of a pronounced reaction from the posterior segment of the eye - slight swelling of the choroid (the height of the edema did not exceed 1.5 mm). The edema of the choroid disappeared, according to the control ultrasound examination, by the 4th day after the operation. The patient was discharged from the hospital on the 6th day after surgery. IOP at discharge was 16 mm Hg. The vision of the right eye corresponded to preoperative values.

In the long term (2 years after the operation), IOP stability was observed, not exceeding 18-19 mm Hg. An avascular diffuse AF without signs of thinning is located in the upper-inner quadrant. Scleral autodrainages are well visualized in the anterior chamber. With gonioscopy, the inner area of the fistula is open. Myopization of the eye ceased, high visual acuity remains (Vis OD = sph-2,0D = 1,0; OS = 1,0).

The invention provides an effective way to combat the development of insolvency of antiglaucomatous surgery associated with the closure of the internal fistula in iridocorneal endothelial syndrome.

The method is not associated with severe surgical and postoperative complications. Using the method accelerates the rehabilitation of patients with secondary angle-closure glaucoma, which developed against the background of iridocorneal endothelial syndrome, and helps to stabilize the hypotensive effect of the operation. The method does not require additional surgical equipment, technically simple and affordable.

Claims (1)

A method for the surgical treatment of glaucoma that developed against the background of iridocorneal endothelial syndrome, including the formation of a conjunctival flap with a base to the limb, cutting out a surface scleral flap (PSL), 4 × 4 mm in size, with the base to the limb, and separating it from the underlying sclera to the corneal part of the limb, going into the transparent layers of the cornea by 1 mm; application of mitomycin C (MMS), the haemostatic sponge is used as a delivery vehicle, cutting it out for scleral application according to the size of the scleral bed, for subconjunctival application - 1-1.5 mm larger than its size, the cut out sponge is impregnated with a solution of MMS in a concentration of 5 mg / ml and placed for 3-5 minutes under the conjunctival and superficial scleral flaps, avoiding contact with the edges of the tenon membrane and conjunctiva, after removing the hemostatic sponge, the application area is copiously washed physiologically a deep scleral flap (GSL) of triangular shape, the base to the limb, is cut out and separated from the underlying choroid half its height, starting from the top, and when separating the remaining half of the HSL, a thin network of scleral fibers is left on the choroid, upon reaching of the limbal zone expose the strip of the trabeculo-descemetic membrane (TDM), characterized in that the GSL is excised at the base, leaving the exposed TDM intact, from the lateral edges of the PSL using Vanass scissors form strips - sk Oral auto-drains 0.7-0.8 mm wide, keeping their connection with PSL at the base, PSL is put in place and hemmed to the adjacent sclera with two interrupted sutures at distal angles, a cohesive viscoprotector is inserted under it, a thin spatula is placed under the PSL, in parallel the iris plane and normal to the limb, push it through the cohesive viscoprotective layer towards the base of the PSL, pass the spatula into the front chamber and displace it horizontally, destroying the TDM, remove the spatula from under the PSL, scleral autodrain through the viscoprotective layer is tucked into the front chamber.