RU2757320C1 - Method for surgical treatment of patients with organic blockage of anterior chamber angle - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely to ophthalmology. For surgical treatment of angle-closure glaucoma with organic blockage of the anterior chamber angle, conjunctival detachment, episcleral vessel coagulation, formation of a superficial scleral flap, excision of a deep scleral flap and formation of a drainage hole are performed using a diode laser with a wavelength of 810 nm. Before forming the drainage hole, the entire exposed surface of the ciliary body is evenly flattened using a diode laser installation with an output power of 0.3 W using an optical probe with an outer diameter of 2 mm and a working spot size of 1.5 mm. Then a drainage hole with a diameter of 2 mm is formed using an optical probe with an outer diameter of 0.9 mm and a working spot size of 0.5 mm, with an output power of 0.2 W of the above-mentioned diode laser. Next, the edges of the formed drainage hole are coagulated using an optical probe with the above parameters. Then a coloboma is formed between the inner surface of the sclera and the outer surface of the vascular membrane and a hydrogel drainage is installed with its fixation with two nodal sutures.

EFFECT: method ensures the achievement of a more stable hypotensive effect by reducing the total radiation power, a more directed exposure of laser radiation during the formation of a drainage channel and the creation of a consistent and stable path of the outflow of ocular fluid through the use of hydrogel drainage.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used for the surgical treatment of angle-closure glaucoma with organic blockade of the anterior chamber angle.

The goal of treatment of angle-closure glaucoma with organic blockade of the anterior chamber angle is to compensate for intraocular pressure (IOP), which is the main risk factor for disease progression. To reduce IOP, there are drug, laser and surgical methods of treatment. The creation of additional pathways for the outflow of intraocular fluid (IHF) during surgical methods of treatment is achieved by performing fistulizing operations, in which the formation of intrascleral outflow pathways of the IHF occurs with the formation of a conjunctival filtration cushion. Such operations include sinustrabeculectomy, deep sclerectomy, two-chamber drainage, and transciliary drainage of the posterior chamber.

The closest analogue is a method for treating glaucoma (RF patent for invention No. 2128490), in which, under local anesthesia, a conjunctival flap is cut out in the upper half of the eyeball with the base to the limbus, after which a superficial quadrangular sclera flap is formed in half its thickness, also with the base to the limbus. The flap is separated to the circular ligament, then a deep scleral flap is formed, which is excised as a result. Then, by means of a pulsed action of a VISULAS DIODE II diode laser from ZEISS with a wavelength of 810 nm (power from 1000 to 1600 mW), a drainage canal is formed in the projection zone of the ciliary sulcus into the posterior chamber. The pulsed action of laser radiation on the tissue of the ciliary body (CG) is carried out until the pigment layer is perforated and stable filtration of the intraocular fluid from the posterior chamber of the eye is achieved. Subsequently, the superficial scleral flap is placed in its place and fixed with two interrupted sutures, a continuous suture is applied to the conjunctiva.

This method has certain disadvantages - the development of reactive hypertension due to the maximum parameters of the laser radiation power, the formation of CT edema, which leads to scarring and, consequently, to a decrease in the hypotensive effect after surgery.

The objective of the invention is to improve the efficiency of surgical intervention to achieve a more stable hypotensive effect.

The technical result is to achieve a more stable hypotensive effect by reducing the total radiation power, a more directional exposure of laser radiation during the formation of a drainage channel and creating a consistent and stable pathway for the outflow of high-blood fluid due to the use of hydrogel drainage.

This technical result is achieved by the fact that in the method of surgical treatment of angle-closure glaucoma with organic blockade of the anterior chamber angle, including separation of the conjunctiva, coagulation of episcleral vessels, formation of a superficial scleral flap, excision of a deep scleral flap and formation of a drainage hole using a diode laser with a wavelength of 810 nm , according to the invention, before the formation of the drainage hole, the entire exposed surface of the ciliary body is uniformly flattened using a diode laser installation, with an output power of 0.3 W using an optical probe with an outer diameter of 2 mm and a working spot size of 1.5 mm, then a drainage hole with a diameter of 2 mm using an optical probe with an outer diameter of 0.9 mm and a working spot size of 0.5 mm, an output power of 0.2 W of the above diode laser, then the edges of the formed drainage hole are coagulated using an optical probe with the above With these parameters, then a coloboma is formed between the inner surface of the sclera and the outer surface of the choroid and a hydrogel drainage is installed with its fixation with two interrupted sutures.

Performing first flattening of the CG surface makes it possible to reduce the power of the laser action during the formation of the drainage hole at the next stage. The formation of a drainage hole at the second stage on the pre-flattened surface of the ciliary body makes it possible to create a hole with clear edges using the minimum laser energy, which reduces the risk of postoperative inflammatory and reactive processes leading to scarring and reducing the hypotensive effect of the operation. Coagulating the edges of the hole in the third step further reduces the risk of scarring. The installation of a hydrogel drainage at the fourth stage allows the formation of a more prosperous and stable drainage canal, less prone to scarring processes.

The method is carried out as follows:

1. A conjunctival incision is performed parallel to the limbus at a distance of 1 mm from the limbus, 2.0 mm long. The conjunctiva is separated.

2. Hemostasis of episcleral vessels is performed along the perimeter of the scleral flap planned for cutting out, using the MIRA4000 diathermocoagulator having an end working platform of 0.2 mm.

3. A superficial rectangular scleral flap of 3x3 mm is cut out at half the thickness of the sclera.

4. A rectangular deep scleral flap 3x3 mm in size is excised until the surface of the CT is exposed.

5. Uniform flattening of the entire exposed surface of the CT is carried out using an optical probe with an outer diameter of 2 mm and a working spot size of 1.5 mm, using an Alcom Medical diode laser device (Russia) with a wavelength of 810 nm, an output power of 0.3 W.

6. A drainage hole with a diameter of 2 mm is formed, in the zone of the flat part of the central heating, using an optical probe with an outer diameter of 0.9 mm and a working spot size of 0.5 mm, an output power of 0.2 W and until filtration of the high-pressure liquid from the rear chamber appears. eyes.

7. The edges of the formed drainage hole are coagulated using a laser using an optical probe with an outer diameter of 0.9 mm and a working spot size of 0.5 mm, an output power of 0.2 W.

8. Using a pointed blade 1.5 mm wide, a coloboma is formed to the choroid distal from the drainage hole between the inner surface of the sclera and the outer surface of the choroid.

9. The hydrogel drainage is inserted into the formed coloboma and fixed with two interrupted sutures to the sclera posterior to the excised deep scleral flap, thereby forming a drainage canal.

10. The superficial scleral flap is returned to its original place and is fixed with two interrupted sutures.

11. The conjunctival incision is closed with a continuous suture. This method is presented in the example described below.

Example # 1

Patient A. in 2018 was diagnosed with OU Primary narrow-angle glaucoma. Sol was prescribed. Timololi maleati 0.5% 1k 2 times a day, Sol. Dorzolamidi 2% 1K 2 times a day in both eyes. Hospitalized in 2020 at the MNTK "Eye Microsurgery" with a diagnosis: Main: OS Primary angle-closure glaucoma 2 V. Concomitant: OD Primary narrow-angle glaucoma 2A, operated on by OU Complicated cataract. The somatic status is complicated by stage 2 hypertension. The diagnosis was made on the basis of biomicroscopy OD (transparent cornea, anterior chamber shallow, iris subatrophy, opacity in the lens of the nucleus and cortical layers, the fundus of the eye is not ophthalmoscopic), OS (transparent cornea, anterior chamber shallow, iris subatrophy, opacity in the lens areas of the nucleus and cortical layers, the fundus is not ophthalmoscopic), additional examination methods (visual acuity upon admission OD 0.3 OS 0.2; IOP OD 19 mm Hg OS 31 mm Hg (according to pneumotonometer) ; gonioscopy - OS angle of the anterior chamber is closed along the entire perimeter to the Schwalbe line.

Surgical intervention was performed according to the proposed method. The postoperative period was uneventful, a spilled filtration cushion formed over the limbus at 12 o'clock. The anterior chamber deepened, the iris assumed a concave profile. IOP at discharge 13 mm. rt. Art. The control examination after 6 months showed a stable, compensated IOP of 14 mm. rt. Art. accordingly, without the additional use of antihypertensive drugs.

Claims (1)

A method of surgical treatment of angle-closure glaucoma with organic blockade of the anterior chamber angle, including separation of the conjunctiva, coagulation of episcleral vessels, formation of a superficial scleral flap, excision of a deep scleral flap and formation of a drainage channel using a diode laser with a wavelength of 810 nm, characterized in that before the formation of drainage holes evenly flatten the entire exposed surface of the ciliary body using an Alcom Medical diode laser system with an output power of 0.3 W using an optical probe with an outer diameter of 2 mm and a working spot size of 1.5 mm, then a drainage hole with a diameter of 2 mm is formed using an optical probe with an outer diameter of 0.9 mm and a working spot size of 0.5 mm, an output power of 0.2 W and a pulse duration of 3 seconds of the above diode laser, then the edges of the formed drainage hole are coagulated using an optical probe with the above PA After that, a coloboma is formed between the inner surface of the sclera and the outer surface of the choroid and a hydrogel drainage is installed with its fixation with two interrupted sutures, thereby creating a drainage channel.