RU2743491C1 - Method for surgical treatment of primary open-angle glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to ophthalmology. Formation of a conjunctival, superficial rectangular scleral flap with the base to the limb, trabeculectomy, iridectomy is performed. In this case, at the base of the superficial scleral flap, transverse incisions are made with a length of 1.5 mm and strips with a width of 1 mm are excised along the sides of the flap. From the remaining part of the scleral flap, a tube is formed in the transverse direction with the inner surface inside and its edges are fixed on both sides with sutures to the scleral bed.

EFFECT: method makes it possible to create reliable pathways for intraocular fluid (IOF) outflow while reducing the risk of scarring in the area of the formed scleral tube, between the scleral flap and the conjunctiva, and, accordingly, obtaining stable normalization of with a decrease in the number of re-operations.

1 cl, 2 ex, 2 dwg

Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the surgical treatment of primary open-angle glaucoma.

To achieve stable normalization of intraocular pressure (IOP) during the progression of the glaucomatous process, the most reliable way is surgical treatment.

The most common operation for glaucoma today is trabeculectomy, proposed by Cairns in 1968. The operation is performed as follows. In 8 mm from the limbus in the upper quadrant, a conjunctival flap 6 mm long is separated. A square scleral flap with a side of 5 mm is marked. The flap, approximately 2/3 of the sclera thick, is separated to the limbus. At the base of the flap, a scleral strip with trabecular tissue and a Schlemm canal measuring 4 × 1 mm is cut out and excised. The scleral flap is fixed with 2-4 sutures in place. Sutures are applied to the conjunctival flap. The effect of this operation may decrease over time due to scarring in the area of the fistulizing opening.

A known method for the surgical treatment of glaucoma (patent RU 2126671, 02/27/1999), including cutting out the conjunctival flap with the base to the limbus, the formation of a rectangular scleral flap of half its thickness measuring 4 × 4 mm with the base to the limbus and 2 mm above it, excision through the entire thickness of the strip at the limbus measuring 4 × 1 mm, carrying out iridectomy. Next, the scleral flap is folded back to the cornea and fixed with two sutures so as to cover the formed fistula. The conjunctival flap is repositioned with a continuous suture. However, this method in the early postoperative period is often complicated by uncontrolled hypotension.

A known method of surgical treatment of POAG (patent RU 2232564, 20.07.2004), in which a conjunctival incision is performed, a superficial scleral flap of rectangular shape is formed with a base at the limbus by 1/3 of the thickness of the sclera. Two U-shaped flaps are formed in the form of valves with the base outward and the U-shaped flaps are wrapped outward by folding them in half. A deep scleral flap of rectangular shape is formed with the base to the limbus by 1/3 of the scleral thickness, the anterior chamber is opened, and basal iridectomy is performed. A superficial scleral flap is placed with its free side in the incision of the anterior chamber angle, and a deep scleral flap is placed over the surface. The method makes it possible to increase the efficiency of glaucoma treatment by creating additional pathways for the outflow of intraocular fluid (IVF). The disadvantage of this method is the recurrence of increased intraocular pressure on average in 35.5% of patients.

The closest analogue of the proposed method is a method of surgical treatment of POAG (patent RU 2135132, 27.08.1999). After the formation of the conjunctival and superficial rectangular flaps on the lateral sides of the scleral bed, rectangular pedicle flaps are formed. Before repositioning the main flap, the distal ends of the additional flaps are sutured. The method is aimed at preventing fusion of the scleral flap with the scleral bed.

The objective of the present invention is to improve the efficiency of surgical treatment of primary open-angle glaucoma.

The technical result of the proposed method is the creation of reliable pathways for the outflow of intraocular fluid (IVF) while reducing the risk of scarring in the area of the formed scleral tube, between the scleral flap and the 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 forming a transverse tube from a laterally reduced surface scleral flap and fixing its edges to the scleral bed.

As a result of the formation of the tubule, the wound surface is inside the tubule, due to this, the risk of scarring of the sclero-scleral and sclero-conjunctival flaps during the period of active tissue proliferation in the postoperative period is reduced. This ensures the possibility of a stable outflow of IHF on the sides of the flap between the superficial and deep flap of the sclera and through the scleral tube and, accordingly, the possibility of obtaining a prolonged effect.

FIG. 1 is a diagram of the operation, where 1 - laterally reduced rectangular superficial scleral flap, 2 - transverse incisions, 3 - trabeculectomy, 4 - basal iridectomy, 5 - cornea.

FIG. 2 shows a diagram of the operation, where 2 - transverse incisions, 3 - trabeculectomy, 4 - basal iridectomy, 5 - cornea, 6 - scleral tube.

The method is carried out as follows.

A conjunctival, rectangular superficial scleral flap is formed with the base to the limbus. Trabeculectomy and iridectomy are performed. At the base of the superficial scleral flap, transverse incisions are made 1.5 mm long and strips 1 mm wide are excised along the lateral sides of the flap. From the rest of the scleral flap, a tube is formed in the transverse direction with its inner surface inward. The edges of the tube are fixed with sutures on both sides to the scleral bed.

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

Clinical example 1.

Patient Z., age 59. Diagnosis: right eye - open-angle II "a" glaucoma, complicated initial cataract. Left eye - open-angle II "c" glaucoma, complicated initial cataract. Survey data: glaucoma within 12 years. On admission, visual acuity of the left eye was 0.4 with correction, intraocular pressure (IOP) was 35 mm Hg. Art. at the maximum hypotensive mode. Peripheral field of vision of the left eye from the nasal side up to 40 °, from the temporal side up to 65 °.

The patient underwent surgical treatment according to the proposed method. After processing the operating field in the upper quadrant at the limbus at 12 o'clock, a 7 mm long incision of the conjunctiva was made, the conjunctiva was separated, and hemostasis was performed. A superficial rectangular scleral flap was cut out 2/3 of its thickness with the base to the limbus and measuring 5 × 7 mm. At the base of the superficial scleral flap, transverse incisions were made 1.5 mm long and strips 1 mm wide were excised along the lateral sides of the flap. Next, a 3 × 1 mm strip of trabecular tissue was excised, and peripheral iridectomy was performed. After that, a tube was formed from the remaining part of the scleral flap in the transverse direction with its inner surface inward. Then the edges of the tube were fixed with two interrupted sutures on both sides to the scleral bed (thread 8-0). The conjunctival flap was repositioned with a continuous suture.

At discharge: IOP of the left eye 16 mm Hg. Art. Visual acuity 0.4 with correction. Objectively: the filtration cushion above the upper limb is spilled. Gonioscopically, the fistula is free at 12 o'clock. After 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 were preserved. 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 persistent hypotensive effect in the late postoperative period. Clinical example 2.

Patient L., age 73. Diagnosis: right eye - open-angle III "c" glaucoma, complicated initial cataract. Left eye - open-angle II "a" glaucoma, initial cataract.

Survey data: on admission, the visual acuity of the right eye was 0.2 with correction, intraocular pressure was 34 mm Hg. Art. at the maximum hypotensive 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 operating field in the upper quadrant at the limbus at 12 o'clock, a 7 mm long incision of the conjunctiva was made, the conjunctiva was separated, and hemostasis was performed. A superficial rectangular scleral flap was cut out 2/3 of its thickness with the base to the limbus and measuring 5 × 7 mm. At the base of the superficial scleral flap, transverse incisions were made 1.5 mm long and strips 1 mm wide were excised along the lateral sides of the flap. Next, a 3 × 1 mm strip of trabecular tissue was excised, and peripheral iridectomy was performed. After that, a tube was formed from the remaining part of the scleral flap in the transverse direction with its inner surface inward. Then the edges of the tube were fixed with two interrupted sutures on both sides to the scleral bed (thread 8-0). The conjunctival flap was repositioned with a continuous suture.

At discharge, the IOP of the right eye was 13 mm Hg. Art. The field of vision from the nasal side is expanded to 25 °. Visual acuity - 0.2 with correction. Objectively: the filtration cushion above the upper limb is spilled. Gonioscopically, the fistula is free at 12 o'clock. After 1.5-2 months, according to UBM data, a functionally active cavity is determined at the site of the intervention, without excessive proliferation, which indicates the functionality of the formed IHF outflow pathways. 6 months after the operation, all indicators were preserved.

In this way, the operation was performed in 13 patients (13 eyes) POAG stages II-III. The results were obtained: in the early postoperative period, in 95% of cases, IOP was within 13-15 mm Hg. Art .; after 6-8 months - 16-18 mm Hg. Art. (according to Maklakov). The effectiveness of the operation in the early postoperative period was confirmed using optical coherence tomography of the anterior segment of the eye (OCT-POG). Late - with the help of UBM.

Thus, the use of this method allows you to obtain a persistent hypotensive 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, superficial rectangular scleral flap with the base to the limbus, trabeculectomy, iridectomy, characterized in that at the base of the superficial scleral flap, transverse incisions are made 1.5 mm long and strips 1 mm wide are excised along the lateral sides of the flap, from the remaining part of the scleral flap, a tube is formed in the transverse direction with the inner surface inward and its edges are fixed on both sides with sutures to the scleral bed.

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