RU2712640C1 - Method for activating the uveoscleral pathway of outflow of intraocular liquid - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. Following stages are carried out to activate the uveoscleral pathway of outflow of intraocular fluid in glaucoma of various aetiology: performing paracentesis, introduction into anterior chamber of carbachol solution 0.1 % 0.2 ml and solution of hyaluronic acid 1.4 % 0.2–0.3 ml, conjunctiva section at limb, separation of conjunctiva and tenon shell from sclera, cutting a surface scleral flap with a base to a limb, through incisions of deep scleral layers, performing cyclodialysis ab externo with a spatula, introducing non-absorbable collagen drainage into a cyclodialysis tunnel, sealing incisions of deep layers of sclera with interrupted sutures, closing surface scleral flap of sclera and conjunctiva with interrupted sutures. On the remaining deep layers of the sclera after cutting the superficial scleral flap, 2.0 mm from the posterior border of the surgical limb and parallel the limb, a horizontal through incision is made to the ciliary body. Further, along the horizontal incision edges, two through vertical incisions of the sclera are perpendicular to the limb in the sclera front part with size of 1.0 mm, thereby creating a valve, 0.1–0.2 ml of 1.4 % hyaluronic acid is introduced into the cycloidal tunnel previously formed by the spatula, and then the non-absorbable collagen drain tube.

EFFECT: method enables activating the uveascleral pathway of the outflow of the IOF for a long period of time, achieving a stable hypotensive effect, reducing the number of hypotensive agents, reducing the number of intra- and postoperative complications, and reducing the length of the patient's stay in the hospital.

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), they produce cyclodialysis to communicate the anterior chamber of the eye with supracilira and suprachoroid spaces. 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. Cyclodialysis, according to many ophthalmic surgeons, has a short-term hypotensive effect due to obliteration of the cyclodialysis gap [Mamikonyan VR, Petrov S.Yu., Karlova EV Safonova D.M., Cyclodialysis in the treatment of glaucoma. History and modernity. National Journal of Glaucoma. 2015; 14 (1): 76-83.]. In order to prevent blockade of the created cyclodialysis slit, various types of drainages are used [Kammer JA, Mundy KM. Suprachoroidal Devices in Glaucoma Surgery. Middle East Afr J Ophthalmol. 2015; 22 (1): 45-52.]. Recently, many authors as an anti-glaucoma component suggest the use of cyclodialysis and its modifications [Frolov MA Combined methods of treatment with a combination of cataracts and glaucoma. Bulletin of Ophthalmology. 2017; 133 (4): 42-46., Karlova E.V. Surgical activation of uveoscleral outflow in glaucoma. National Journal of Glaucoma. 2014; 3: 77-87]. One of the prerequisites for this was the lack of functioning of the anterior outflow of HPV in patients arriving at the late stages of the glaucoma process [T. Stavitskaya Uveoscleral outflow and its role in the regulation of ophthalmotonus. Clinical Ophthalmology. 2000; 1: 19-21].

Known Method for the treatment of glaucoma [RU No. 94030051, publ. 10.20.1996], which consists in the formation of conjunctival and superficial scleral flaps, the removal of the deep scleral layers in the form of a triangle, the implantation of drainage, one end of which is placed in the anterior chamber, and the other is laid on the ciliary body at the site of excision of the deep layers of the sclera, the tops of the dissected deep layers of the sclera of cyclodialysis, in the space of which the ends of the drainage are placed, and fixing the superficial scleral flap laid in place, characterized in that they use an additional nazh which is laid on the first perpendicular thereto at the top layers of the sclera excised, and placed in the space cyclodialysis free ends of the additional drainage, and the fixing surface the scleral flap is carried by at least four points.

This method of surgical treatment of glaucoma has several disadvantages: the complexity of the implementation, requires the use of two drains and the development of postoperative hypotension.

A known method of surgical treatment of congenital glaucoma [RU No. 2555398, publ. 07/10/2015], which consists in the fact that a conjunctival flap is sequentially formed by a cut along the limb, then a superficial scleral flap is formed on 1 / 2-1 / 3 of the sclera thickness 5 × 5 mm, with the base to the limb, then a triangular flap is formed under it, the base to the limb, 4 × 5 mm in size, on its top, all layers of the sclera are removed until the ciliary body is exposed - a trepanation hole. Next, 2 scleral channels are formed on each side of the triangular flap, perpendicular to them, so that their outer end extends beyond the bed of the superficial scleral flap. When separating a deep flap in the limb zone, a surface incision is made in the middle of the base of the triangular flap to detect the scleral spur and the Shlemmov canal (CC). The goal is to remove a deep scleral flap, posterior wall of HSC or tissue of the limbus and cornea without opening the eyeball. For this, it is possible to stratify the limbal zone with a spatula. After that, two collagenic drains with a thickness of 0.8-1.2 mm, a width of 1.0-1.5 mm, a length of 4.0-5.0 mm, respectively, model the bed of the superficial scleral flap so that its corneal end is as narrow as possible and the scleral is rounded at the end. The length of the drainage should not exceed the length of the scleral flap, and when hemming the scleral flap, the drainage should not protrude from under it. Both drains are placed along the outer edges of the scleral bed and are fixed to the underlying sclera layers with one suture nylon 10-0. After that, the anterior chamber of the eye is opened with a cut along the limb, iridectomy is performed, the anterior chamber is completely filled with viscoelastic and the ends of two drains are inserted into the anterior chamber so that a window forms in the trabeculo-descemet membrane and the ends of the drains are not blocked by the root of the iris. In cases of grade III-IV hydrophthalmus, it is possible to supplement the operation with partial cyclodialysis by introducing a small amount of viscoelastic, mainly 0.1-0.2 ml, into the trepanation hole at the apex of the triangular scleral flap. The superficial scleral flap is put in place and fixed with 4 sutures: two at the ends of the flap and two at the limb, while the drains are completely submerged under the flap. The conjunctival flap is fixed with 2-4 sutures at the limb.

The aforementioned method of surgical treatment has several disadvantages: complexity of execution, trauma, iridectomy, carries the risk of developing postoperative complications: hyphema; hypotension; cyclochoroidal detachment, filtration into the subconjunctival space, which is not physiological.

A known method of surgical treatment of primary glaucoma [RU No. 2456970, publ. 07/27/2012]. Technique of operation: form a conjunctival flap with the base to the arch. Separate the superficial scleral flap 1/2 of the sclera thickness to the corneal part of the limb by 1.0 mm in the transparent layers of the cornea with the base to the limb. Separate a deep scleral flap of a triangular shape together with the outer wall of the barcode and excise it. Further, in the scleral bed, on the side facing the arch, a through section of the sclera is made and cyclodialysis is performed through it. Paracentesis is performed in the anterior chamber. Produce basal iridectomy. An hourglass drain is prepared from a polymer plate. Drainage is implanted in such a way that the peripheral end is inserted through paracentesis into the anterior chamber, and the central end into the cyclodialysis slit. The method is completed, as is customary, by fixing the superficial scleral flap to the edges of the bed with two interrupted sutures and by applying a continuous conjunctival suture.

The aforementioned method of surgical treatment has several disadvantages: it requires certain surgical forever, the need for iridectomy, the development of postoperative complications: hyphema, hypotension.

The closest analogue is the method of surgical treatment of refractory glaucoma [RU No. 2297815, publ. April 27, 2007]. The method is as follows: local anesthesia is carried out by introducing 1 ml of a 2% lidocaine solution into the subthenon space. The conjunctival flap and superficial scleral flap are separated by 1/3 of the scleral thickness of a quadrangular shape of 4 × 4 mm with the base to the limb. At the top of the scleral flap, cyclodialysis is formed to the ciliary body. In the deep layers, the sclera is cut out and a triangular flap is removed to 1/3 of its thickness with the base to the limb together with the outer wall of the SC and the adjacent corneal tissue to the descemet membrane. Remove the endothelial lining of HQ. A collagen porous biological drainage is implanted into the formed bed with one end to the barcode, with its other end protruding 1 mm from the surface scleral flap. Additionally, on one or the other side of the superficial scleral flap, a narrow strip of sclera is cut out to 1/2 of its thickness 2 × 4 mm with the smaller side facing the limb. A deep scleral flap of 2 × 2 mm is removed in the projection zone of the HSC. An intervascular iridotomy is performed. A second collagenous porous biological drainage is implanted, one end of which is inserted into the anterior chamber, and the other end is fixed to the deep layers of the sclera. A narrow strip of sclera is laid in place and fixed with a seam. The superficial scleral flap is returned to its place and fixed with two sutures. Both drains are made of material containing bone collagen isolated from the spongy bone of farm animals and saturated with bone sulfated glycosamine glycans, in the form of plates 0.8 mm thick, 1.5 mm wide and 4.0 mm long.

The aforementioned method of surgical treatment has several disadvantages: complexity of execution, trauma, a large volume of surgery, the need for iridectomy, two drains are used, filtration into the subconjunctival space, which is not physiological.

The technical results of the invention are the activation of the uveoscleral pathway of the outflow of the HPW for a long time, the achievement of a stable hypotensive effect, a decrease in the number of antihypertensive drugs, a decrease in the number of intra- and postoperative complications, and a reduction in the patient's hospital stay.

The technical result is achieved by the fact that the method of activation of the uveoscleral pathway of the outflow of the hepatitis C in case of glaucoma of various etiologies includes the following steps: performing paracentesis, introducing a 0.1% - 0.2 ml carbachol solution and a 1.4% - 0 hyaluronic acid solution into the anterior chamber , 2-0.3 ml, incision of the conjunctiva at the limb, separation of the conjunctiva and tenon membrane from the sclera, cutting out the superficial scleral flap with the base to the limbus, through sections of the deep layers of the sclera, conducting ab externo cyclodialysis using a spatula, introducing ner absorbable collagen drainage into the cyclodialysis tunnel, sealing the sections of the deep scleral layers with interrupted sutures, suturing the scleral surface sclera flap and conjunctiva with interrupted sutures, characterized in that on the remaining deep scleral layers after cutting the superficial scleral flap 2.0 mm from the posterior border of the surgical limb and parallel to the limb, a horizontal through cut is made to the ciliary body, then 2 through vertical cuts are made along the edges of the horizontal cut CLAIR perpendicularly to the limb in the anterior part of the sclera 1.0 mm, creating in this way the valve, the introduction of non-absorbable collagen drainage tunnel tsiklodializny previously formed by shpatlya.

The technique of the operation is as follows: after traditional anesthesia and akinesia are performed, a 7-0 polypropylene holder is sutured through the upper limb for 12 hours. Paracentesis is performed at 7-8 hours or 4-5 hours, depending on the operated eye (right or left, respectively). A 0.2 ml carbachol solution (pupil drug narrowing) and a 1.4% hyaluronic acid solution of 0.2-0.3 ml (maintaining the depth of the anterior chamber of the eye, prevention of postoperative hypotension and hyphema) are injected into the anterior chamber. A conjunctival incision is made along the limb from 10 to 1 h. A conjunctival flap 5 mm in size is separated, with the base to the arch of the eyeball and the tenon membrane is separated from the sclera. If necessary, economical diathermocoagulation of the superficial vessels of the sclera is performed. Using a knife, a surface rectangular scleral flap is cut into 1/3 of the sclera thickness, with a base to the limb, 3 × 3 mm in size. Then, on the remaining deep layer of the sclera, 2.0 mm departing from the posterior border of the surgical limb and parallel to the limb, a horizontal through section is made to the ciliary body, then along the edges of the horizontal section, 2 through vertical sections of the sclera are made perpendicular to the limb in front of the sclera 1.0 mm in size , also up to the ciliary body, creating a valve in this way. Cyclodialysis ab externo using a spatula. The dimensions of the created cyclodialysis tunnel: width - 3 mm, length - 2 mm, these tunnel sizes provide direct and reliable communication between the anterior chamber of the eye and the supraciliary space, which leads to the activation of the natural (uveoscleral) pathway of the outflow of the intraocular fluid. 0.1-0.2 ml of 1.4% hyaluronic acid is injected into the created tunnel (to facilitate drainage implantation and reduce trauma). Then, with the help of tweezers, non-absorbable collagen drainage is introduced into the cyclodialysis tunnel so that the front end of the drainage enters the anterior chamber of the eye and does not overlap with the root of the iris. The posterior end of the collagen drainage is placed under the posterior lip of the horizontal scleral incision, the drainage is made of material containing bone collagen isolated from the spongy bone of farm animals and saturated with bone sulfated glycosamine glycans, in the form of plates 0.8 mm thick, 1.5 mm wide and 4 long , 0 mm. Next, the scleral incision is sealed with two or three nodal joints 10-0 nylon. The superficial flap is laid in place and fixed with interrupted sutures. The conjunctival flap is sutured to the limbus. The operation is completed by the introduction of a dexamethasone solution under the conjunctiva and a monocular dressing is applied.

Currently, we have operated on 30 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 1. Patient A., 78 years old, was admitted to the hospital with a diagnosis of primary operated open-angle glaucoma glaucoma IIIc and complicated cataract of the right eye; primary open-angle IIa and immature cataract of the left eye. The patient was at the maximum antihypertensive regimen, including B-blockers insolation, carbonic anhydrase inhibitor and prostaglandin analogues. Visual acuity before surgery of the right eye 0.1-0.2; does not correct, left eye 0.5; does not correct. The field of view of the right eye is narrowed concentrically, the left - narrowed from the nasal side by 5 °. Daily tonometry data: right eye - 33-35 mm Hg (according to Maklakov); the left eye - 19-20 mm RT.article. The patient underwent surgery by the proposed method on the right eye. The operation and the postoperative period proceeded without complications. With gonioscopy, the cyclodialysis slit is well visualized, collagen drainage is in place. The patient was discharged two days after the operation. 3 months after the intervention, gonioscopy determines collagen drainage in the cyclodialysis fissure, intraocular pressure of 18 mm Hg. without antihypertensive regimen. Visual acuity is 0.4-0.5. The field of view remains the same. The eye is calm, the patient does not show 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)

The activation method of the uveoscleral pathway of the outflow of intraocular fluid in glaucoma of various etiologies includes the following steps: performing paracentesis, introducing a 0.1% 0.2 ml carbachol solution and a 1.4% 0.2-0.3 ml hyaluronic acid solution into the anterior chamber , incision of the conjunctiva at the limb, separation of the conjunctiva and tenon membrane from the sclera, cutting out the superficial scleral flap with the base to the limb, through cuts of the deep layers of the sclera, cyclic dialysis ab externo with a spatula, the introduction of non-absorbable collagen drainage into the cyclodialysis tunnel, sealing sections of the deep layers of the sclera with interrupted sutures, suturing of the scleral surface sclera and conjunctiva with interrupted sutures, characterized in that on the remaining deep layers of the sclera after cutting the superficial scleral flap 2.0 mm from the posterior border of the surgical limb and parallel the limbus make a horizontal through incision to the ciliary body, then along the edges of the horizontal incision make 2 through vertical incisions of the sclera perpendicular to imbu in front of the sclera 1.0 mm, creating in this way a valve in tsiklodializny tunnel previously formed with a spatula, administered 0.1-0.2 ml 1.4% hyaluronic acid, and then non-absorbable collagen drainage.