RU2676967C2 - Method of glaucoma surgical treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely to ophthalmology, and is intended for the surgical treatment of glaucoma. Reverse cyclodialysis is carried out to a depth of 5–6 mm for 4–5 hours with a length of 11–12° of the radius of the corneal angle. Before cyclodialysis, after the medical constriction of the pupil, anterior chamber is filled with a 1.4 % hyaluronic acid solution, which is then removed. Restore the anterior chamber with a balanced salt solution. Cuts are sealed with corneal stroma hydration and the operation is completed by administering dexamethasone solution under the conjunctiva.

EFFECT: method provides a reduction in the number of complications and a reduction in the patient's stay in the hospital due to the achievement of a persistent hypotensive effect.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology, and is intended for the surgical treatment of glaucoma of various origins.

Known surgical methods for the treatment of glaucoma, in which, in order to activate the uveoscleral pathway of the outflow of intraocular fluid (IVC), cyclodialysis is performed to communicate the anterior chamber of the eye with the suprachoroid space. This operation has found its place in improving the outflow of HPW both with the open angle of the anterior chamber and with its narrow profile. It is used both in primary glaucoma and in its many refractory forms: both as a monooperation and in combination with other interventions. Recently, many authors have proposed using cyclodialysis and its modifications as an anti-glaucoma component. One of the prerequisites for this was the lack of functioning of the anterior outflow pathway in patients entering the late stages of the glaucoma process.

A known method of surgical treatment of severe glaucoma, in which perform cyclocryocoagulation in two rows on one third of the projection of the ciliary body. Additionally, cyclodialysis is carried out in the same zone through the scleral incision between the rows of coagulates and 1 ml of viscoelastic is introduced into the cyclodialysis slit. (RF patent No. 2393827, IPC A61F 9/007, publ. 07/10/2010).

This method of surgical treatment of glaucoma has several disadvantages: the technical complexity of the implementation, a laser installation is required. The application of cyclocryocoagulants injures the ciliary body, which leads to a decrease in the production of HPV, which is not physiological.

A known method for the surgical treatment of glaucoma is a combined operation, which is performed as follows: a superficial scleral flap is cut with a base to the limbus, sinusotrabeculectomy and cyclodialysis are performed. Then, in the projection of the superficial scleral flap in the cyclodialysis zone, a deep scleral flap of the inverse profile is cut out layer by layer. A sleeve of biodegradable material is put on it and fixed in the same place. (RF patent No. 2535510, IPC A61F 9/007, publ. 10.12.2014)

The disadvantages of this method of treatment are: the technical complexity of the implementation, the invasiveness. In addition, filtering into the subconjunctival space is not excluded, which is not physiological.

A known method for the combined surgical treatment of complicated cataracts in patients with glaucoma. The operation is performed as follows: initially, cyclodialysis is performed in one sector for 6 hours with a length of 15 ° to a depth of 2-3 mm, then at least two coagulates are applied to the ends of the formed cyclodialysis with an Nd: YAG laser with a wavelength of 1.44 μm, pulse energy 10-20 mJ, pulse duration 250 μs, or tip for diathermocoagulation phacoemulsifier. Next, cataract removal is performed by laser cataract extraction or phacoemulsification with implantation of an intraocular lens into a capsule bag (RF patent No. 2395256, IPC A61F 9/007, published on July 27, 2010).

The above-mentioned method of surgical treatment has several disadvantages: a laser installation is required, cyclodialysis is performed to a depth of 2-3 mm, which is insufficient to achieve a suprachoroidal space. The application of coagulates to the ciliary body increases the invasiveness of the operation, there is a risk of an excessive decrease in the production of HPV.

There is a method of combined surgical treatment of glaucoma and cataract - the essence of the operation is to perform cataract extraction using a tunnel type incision. Next, the anti-glaucoma component of the intervention is produced: through the corneal paracentesis in the upper outer and upper inner quadrants, using the spatula, reverse cyclodialysis is performed in two doses of 30 ° -40 ° of the circle of the iris-corneal angle to each side and to a depth of 5-6 mm (RF patent No. 2342918, IPC A61F 9/007, publ. 1.01.2009).

This method of surgical treatment has several disadvantages: the technical complexity of performing reverse cyclodialysis through paracentesis and in two doses, which leads to an increase in the duration of the operation. Reverse cyclodialysis is performed along the 30 ° -40 ° circle of the iris-corneal angle in each direction, that is, the ciliary body is exfoliated by 60-80 degrees. This in turn increases the risk of developing postoperative complications: hyphema, hypotension, and cyclochoroidal detachment (CCO).

The closest analogue is the method of combined surgical treatment of glaucoma and cataract. The operation is performed as follows: cataract is removed by means of a tunnel-type operation. Through corneal paracentesis used in cataract extraction, a metered reverse cyclodialysis is performed along a circle of 70 ° -80 ° of the circle of the iris-corneal angle to a depth of 5-6 mm (RF patent for the invention No. 2326635, publ. June 20, 2008).

This method of surgical treatment has several disadvantages: detachment of the ciliary body at 70 ° -80 ° of the circumference of the iris-corneal angle increases the risk of postoperative complications, such as hyphema, hypotension, CHO, weakening of the ligamentous apparatus of the lens and iridodonez.

The technical result of the invention is to reduce the number of complications and reduce the time spent by the patient in the hospital, to achieve a stable hypotensive effect.

The technical result is achieved by the fact that the method of surgical treatment of glaucoma involves conducting reverse meridial cyclodialysis to a depth of 5-6 mm for 4-5 hours with a length of 11-12 ° of the circumference of the iris-corneal angle, while before the cyclodialiasis, after the pupil is narrowed, its anterior chamber is filled a viscoprotector - 0.3 mm with a 1.4% solution of hyaluronic acid.

The technique of the operation is as follows: after traditional anesthesia and akinesia, a 2.4-2.75 mm corneal incision is made or an incision made for cataract phacoemulsification is used. The pupil is narrowed medically. A carbachol solution of 0.1% -0.2 ml is introduced into the anterior chamber. Further, after narrowing the pupil to maintain the anterior chamber, it is filled with a viscoprotector (hyaluronic acid solution - 1.4% - 0.3 ml). At 4-5 hours, using a special spatula, reverse cyclodialysis is carried out with a length of 11-12 degrees of the circumference of the iris-corneal angle and to a depth of 5-6 mm. This depth provides a direct communication between the anterior chamber of the eye and the suprachoroidal space, which leads to the activation of the natural (uveoscleral) pathway of the outflow of the HPW. A length of 11-12 degrees is sufficient to ensure a persistent hypotensive effect and can reduce the number of surgical and postoperative complications. Then the viscoprotector is removed, the anterior chamber is restored with balanced saline. The sections are sealed with hydration of the corneal stroma. The operation is completed by the introduction of a dexamethasone solution under the conjunctiva.

Currently, we have operated on 20 patients with glaucoma of various origins. In all patients, the use of this operation allowed to achieve a good positive effect and reduce the number of surgical and postoperative complications.

EXAMPLE OF PRACTICAL APPLICATION OF THE METHOD.

Patient A., 78 years old, (and / b 617/2016) was admitted to the hospital with a diagnosis of terminal pain operated open-angle glaucoma and complicated cataract of the right eye; open-angle and immature cataract of the left eye. The patient was at the maximum antihypertensive regimen. Instilled B-blockers and prostaglandin analogues. On examination, the visual acuity of the right eye 0 (zero), left eye 0.5, does not correct. The field of view of the right eye is not determined, the left - narrowed from the nasal side by 5 °. Daily tonometry data: right eye - 47-49 mm Hg (according to Maklakov); left eye - 19-20 mm Hg The patient underwent surgery by the proposed method on the right eye. The operation and the postoperative period was uneventful. With gonioscopy, the cyclodialysis slit is well visualized. The patient was discharged on the third day after surgery. 3 months after the intervention, gonioscopy determines a wide cyclodialysis fissure, intraocular pressure of 18 mm Hg. The eye is calm, the patient has no complaints of pain.

This operation is indicated for all types and stages of glaucoma, and can be used as a separate operation, or in combination with cataract surgery.

Claims (1)

A method for the surgical treatment of glaucoma, including reverse cyclodialysis to a depth of 5-6 mm, characterized in that the reverse cyclodialysis is carried out for 4-5 hours with a length of 11-12 ° of the circumference of the iris-corneal angle, while the anterior, before the cyclodialiasis, after drug narrowing of the pupil the chamber is filled with a 1.4% solution of hyaluronic acid, which is then removed, the anterior chamber is restored with balanced saline, the sections are sealed with hydration of the corneal stroma, and era tio introduction subconjunctival dexamethasone solution.