RU2701693C1 - Method for surgical management of primary open-angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. In surgical treatment of primary open-angle glaucoma, a conjunctival, rectangular surface scleral flap is formed with a base to a limb, trabeculectomy, iridectomy is performed. Superficial scleral flap is dissected longitudinally in the middle to a trabeculectomy to form two flaps. Flaps are transposed to opposite sections of the scleral bed with mutual crossing. Distal ends are fixed with sutures to edges of scleral bed.

EFFECT: method provides creation of additional ways of outflow of intraocular fluid, reduced risk of cicatrisation in a zone of cross-over of two flaps and, accordingly, achievement of stable hypotensive effect with reduction of 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 primary open-angle glaucoma (POAG).

With the progression of the glaucoma process, the most reliable way to achieve stable normalization of intraocular pressure (IOP) is surgical treatment, the success of which is determined by the duration of the hypotensive effect.

A known method for the surgical treatment of glaucoma (patent RU 2126671, 02.27.1999), including cutting a conjunctival flap with the base to the limb, forming a rectangular sclera flap half its thickness with a size of 4 × 4 mm with the base to the limb and 2 mm above it, excision through the entire thickness of the strip in a limb with a size of 4 × 1 mm, iridectomy. Next, the scleral flap is folded back to the cornea and fixed with two sutures in such a way as to cover the formed fistula. 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.

The basis of all surgical methods for treating glaucoma today remains trabeculectomy, proposed by Cairns in 1968. The operation is performed as follows. At 8 mm from the limb, a conjunctival flap 6 mm long is detached in the upper quadrant. A square flap of sclera with a side of 5 mm is outlined. The flap, about 2/3 thick of the sclera, is separated to the limbus. At the base of the flap, a sclera with trabecular tissue and a schlemm canal 4 × 1 mm in size is cut out and dissected. The sclera flap is fixed with 2-4 sutures in place. Suture the conjunctival flap. The effect of this operation may decrease over time due to scarring in the area of the fistulizing opening.

The closest analogue of the proposed method is a method of surgical treatment of POAG (patent RU 2232564, July 20, 2004), in which a conjunctival incision is made, a superficial scleral flap is formed in a rectangular shape with the base of the limb 1/3 of the thickness of the sclera. Two U-shaped flaps are formed in the form of flaps with the base outwards and the U-shaped flaps are wrapped outwards by folding them in half. The deep scleral flap of rectangular shape is formed with the base to the limb 1/3 of the sclera thickness, the anterior chamber is opened, and basal iridectomy is performed. Lay the superficial scleral flap with the free side into the incision of the angle of the anterior chamber, and the deep scleral flap over the superficial. The method allows to increase the effectiveness of the treatment of glaucoma due to the creation of additional pathways for the outflow of intraocular fluid (HPW). The disadvantage of this method, as well as the previous one, is a relapse of intraocular pressure increase on average in 35.5% of patients.

The task of the invention is to increase the effectiveness of surgical treatment of primary open-angle glaucoma.

The technical result of the proposed method is to create reliable ways of the outflow of intraocular fluid (IH) while reducing the risk of scarring under the scleral flap, between the scleral flap and conjunctiva, and, accordingly, obtaining a stable normalization of intraocular pressure with a decrease in the number of repeated operations.

The technical result is achieved by dissecting in the middle of the superficial scleral flap with the formation of two flaps, followed by their transposition to opposite sections of the scleral bed with mutual crossing.

Due to the formation of two flaps of the sclera surface sheet and their transposition, there is no contact between the external flap and the underlying sclera, as well as between the internal flap and the conjunctiva during the period of active tissue proliferation in the postoperative period. This ensures the formation of gaps in the area of intersection of the flaps. At the same time, on the one hand, the risk of scarring is significantly reduced, and on the other hand, the possibility of a stable outflow of HPW and, accordingly, the possibility of obtaining a prolonged effect are provided.

In FIG. 1 is a diagram of the operation, where 1 is a rectangular superficial scleral flap, divided in the middle, 2 - trabeculectomy, 3 - basal iridectomy, 4 - cornea.

In FIG. 2 is a diagram of the operation, where 1 is mutually crossed scleral flaps, 2 is trabeculectomy, 3 is basal iridectomy, 4 is the cornea.

The method is as follows.

A conjunctival, rectangular superficial scleral flap is formed with the base to the limb. Perform trabeculectomy, iridectomy. A superficial scleral flap is formed 6 mm long, cut in the middle longitudinally to the trabeculectomy zone with the formation of two flaps. The flaps are transposed with mutual crossing, after which their distal ends are fixed to the edges of the scleral bed.

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

Clinical example 1.

Patient N., age 68 years. Diagnosis: right eye - open-angle II “a” glaucoma, complicated initial cataract. The left eye is open-angle II "c" glaucoma, complicated initial cataract. Examination data: glaucoma for 8 years. Upon receipt, the visual acuity of the left eye of 0.4 with correction, intraocular pressure (IOP) 39 mm Hg at maximum antihypertensive mode. Peripheral field vision of the left eye from the nasal side to 40 °, from the temporal side to 65 °.

The patient underwent surgical treatment according to the proposed method. After processing the surgical field in the upper quadrant of the limbus at 12 hours, a conjunctiva was cut 7 mm long, the conjunctiva was separated, hemostasis was performed. A surface rectangular flap of the sclera was cut out to 2/3 of its thickness with the base to the limb and dimensions 5 × 6 mm. A strip of trabecular tissue 3 × 1 mm in size was excised at the base of the flap, and peripheral iridectomy was performed. After this, the superficial scleral flap is longitudinally dissected in the middle to the trabeculectomy zone with the formation of two flaps. Then, the flaps were transposed to opposite sections of the scleral bed with mutual crossing, with each of them fixed with two interrupted sutures to the edges of the scleral bed (thread 8-0). Conjunctival flap was repositioned with 2 interrupted sutures.

At discharge: IOP of the left eye 15 mm Hg Visual acuity of 0.4 with correction. Objectively: the filter cushion over the upper limb is 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 is determined at the site of the intervention, without excessive proliferation. 6 months after the operation, all indicators remained. This confirms a decrease in the risk of hypotension in the early postoperative period as a result of using the proposed method, as well as a decrease in the risk of scarring and the provision of a stable hypotensive effect in the late postoperative period.

Clinical example 2.

Patient A., age 72 years. Diagnosis: right eye - open-angle III "c" glaucoma, complicated initial cataract. The left eye is the initial cataract.

Examination data: upon receipt, visual acuity of the right eye 0.2 with correction, intraocular pressure - 34 mm Hg at maximum antihypertensive mode. The peripheral field of vision of the right eye is narrowed from the nasal side to 20 °, from the temporal to 30 °.

The patient underwent surgical treatment according to the proposed method. After processing the surgical field in the upper quadrant of the limbus at 12 hours, a conjunctiva was cut 7 mm long, the conjunctiva was separated, hemostasis was performed. A surface rectangular flap of the sclera was cut out to 2/3 of its thickness with the base to the limb and dimensions 5 × 6 mm. A strip of trabecular tissue 3 × 1 mm in size was excised at the base of the flap, and peripheral iridectomy was performed. After this, the superficial scleral flap is longitudinally dissected in the middle to the trabeculectomy zone with the formation of two flaps. Then, the flaps were transposed to opposite sections of the scleral bed with mutual crossing, with each of them fixed with two interrupted sutures to the edges of the scleral bed (thread 8-0). Conjunctival flap was repositioned with 2 interrupted sutures.

When extracting IOP of the right eye - 13 mm Hg The field of vision from the bow is expanded to 25 °. Visual acuity - 0.2 with correction. Objectively: the filter cushion over the upper limb is spilled. Gonioscopically the fistula at 12 o’clock is free. After 1.5-2 months, according to the UBM, a functionally active cavity is determined at the site of the intervention, without excessive proliferation, which indicates the functionality of the formed pathways of the outflow of HPW. 6 months after the operation, all indicators remained.

This operation was performed in 10 patients (10 eyes) of POAG II-III stages. The results were obtained: in the early postoperative period in 95% of cases of IOP was in the range of 13-15 mm Hg; after 6-8 months - 16-18 mm Hg (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 (OCT-POG). In the late - using UBM.

Thus, the use of this method allows to obtain a persistent antihypertensive effect in the long-term postoperative period.

Claims (1)

A method of surgical treatment of primary open-angle glaucoma, including the formation of a conjunctival, rectangular superficial scleral flap with the base to the limb, trabeculectomy, iridectomy, characterized in that the superficial scleral flap is formed 6 mm long, cut in the middle longitudinally to the trabeculectomy zone with the formation of two flap grafts, carried out with mutual crossing, after which their distal ends are fixed to the edges of the scleral bed.

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