RU2763875C1 - Method for surgical treatment of glaucoma using microinvasive trabeculectomy with fixed iridencleisisand autovalve drainage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. After the formation of a superficial rectangular scleral flap with the base to the limbus, cut out a triangular scleral flap with the base to the limbus, above the Schlemm's canal zone. Under the triangular flap, an area of

the Schlemm's canal 3 mm long and 0.5 mm wide is cut out with penetration into the anterior chamber. A basal iridotomy and its cut-off part connected to the iris by a leg are performed, brought out between the lower and middle triangular scleral flap and sutured to the lower scleral flap, forming a fixed iridencleisis. After that, departing 0.5 mm from iridencleisis, a horizontal incision of the sclera with a length of 3 mm is performed to the choroid and a triangular flap is inserted between the choroid and the inner layer of the sclera. Two interrupted sutures are applied to the superficial scleral flap, a viscoelastic is introduced into the anterior chamber, and the Tenon's sheath is sutured separately, with a continuous suture, and then the conjunctiva.

EFFECT: method allows achieving a stable and long-term hypotensive effect, as well as to reduce the risk of intra- and postoperative complications.

1 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of various types of glaucoma: primary open-angle and closed-angle, mixed, glaucoma in the eyes with aphakia and pseudophakia, some types of secondary glaucoma - uveal, post-traumatic, previously operated primary glaucoma.

In the surgical treatment of glaucoma over the past decades, almost all operations and their modifications have been aimed at making a filtering hole in the trabecular area or forming additional outflow tracts, which facilitates the flow of aqueous humor out of the anterior chamber into the subconjunctival space.

For more than 50 years, the “gold standard” among fistulizing operations has been sinustrabeculectomy (Cairns J.) due to a fairly high effect and simple technique (Shaarawy, T. Glaucoma therapy - current issues and controversies. - trabeculotomy - the golden standard / T. Shaarawy, J.Flammer - London: CRC Press, 2004. - P.249; Petrov S.Yu. Sinustrabeculectomy: history, terminology, technique / S.Yu. Petrov, A.V.Volzhanin // National Journal of Glaucoma. - 2017. - T. 16, No. 2. - S. 82-91). At the same time, in the postoperative period, the risk of developing the following complications is high (Batmanov, Yu.E. Problems of modern glaucoma surgery / Yu.E. Batmanov, V.Yu. Evgrafov, F.V. Guliyev / / Bulletin of Ophthalmology. - 2008. - No. 4. - S. 53-55):

- decrease in the normal level of intraocular pressure (IOP) as a result of excessive filtration through the area of the scleral flap with its insufficient adaptation; also, hypotension may indicate the occurrence of such a formidable complication as cilichoroidal detachment (CHO);

- shallow anterior chamber syndrome as a result of hyperfiltration;

- increased IOP as a result of insufficient filtration (extrascleral, subconjunctival fibrosis, blockade of the fistula by excessive tension of the scleral flap);

- progression of cataract;

- development of hyphema;

- endophthalmitis.

Despite the developed a large number of modifications of sinustrabeculectomy aimed at improving the surgical technique, preventing complications and stabilizing the hypotensive effect, work continues to optimize the technique of surgical intervention.

A few years ago, a new method for the treatment of glaucoma was developed, which has a dual mechanism for activating the outflow of intraocular fluid - subconjunctival and uveal, without the use of artificial drains, shunts and valves, using draining autovalvular limbosclerectomy (patent RU No. 2610003), which consists in the formation of a conjunctival and superficial U-shaped of the scleral flap with its base to the limbus, excision of the distal part of the deep scleral flap to the supraciliary space, formation of a limbectomy hole under the base of the scleral flap and iridectomy, insertion of a superficial scleral flap through it into the supraciliary space and application of three parallel vertical incisions of the deep layers of the sclera in the proximal part of the bottom of the scleral bed from the limbectomy opening, prototype. The method created autovalve regulation of IOP. The scleral flap performs the role of a "live" autodrainage into the supraciliary space, and also redistributes chamber moisture into the filtration pad.

However, when using the proposed technique for conducting and fixing the scleral flap, there is a risk of damage to the choroid and bleeding. In addition, as a result of using the method, forced filtration of chamber moisture is possible, threatening the risk of developing serious complications (CHO, hyphemas, infectious complications, and the syndrome of a shallow anterior chamber can lead to the development of endothelial-epithelial corneal dystrophy, synechia and result in an increase in IOP) .

The present invention solves the problem of developing a new effective method for the treatment of glaucoma with autovalvular drainage of the supraciliary space.

The essence of the invention is as follows.

A superficial rectangular 4x5 mm scleral flap is cut out with its base to the limbus with a thickness of 1/3 of the sclera up to the limbus area. A triangular flap of the sclera is cut out with its base to the limbus, 1/3 of the sclera thick, above the area of the Schlemm's canal. Under the triangular flap, a Schlemm canal zone 3 mm long and 0.5 mm wide is cut out with penetration into the anterior chamber. A basal iridotomy 1 mm long is performed and its cut-off part, connected to the iris pedicle, is removed between the lower and middle triangular scleral flap and sutured to the lower scleral flap 0.5-1 mm from the basal iridectomy with a 10.0 suture, forming a fixed iridencleisis. Departing 0.5 mm from the iridencleisis, a horizontal incision of the sclera 3 mm long is performed to the choroid and a triangular flap is tucked between the choroid and the inner sclera. 2 interrupted sutures 10.0 are placed on the superficial scleral flap, a viscoelastic is introduced into the anterior chamber to deepen it and create mild hypotension. Separately, Tenon's membrane is sutured with a continuous 10.0 suture, and then the conjunctiva.

The technical result from the implementation of the method is to achieve a stable and long-term hypotensive effect and reduce the risk of intra- and postoperative complications.

Performing a fixed iridencleisis prevents displacement and blockade of the peripheral iridectomy by the iris tissue and disruption of the formed fluid flow from the anterior and posterior chambers of the eye (prevents blocking of the coloboma zone), and filling the triangular flap between the choroid and the inner sclera and applying two interrupted sutures to the superficial scleral flap creates the possibility of dosed outflow in different sections of artificially created outflow tracts (under the choroid and under the conjunctiva).

The invention is carried out as follows.

At 4-5 mm from the limbus, an incision of the conjunctiva and Tenon's membrane 5 mm long is performed with its separation to the limbus. A superficial rectangular 4x5 mm scleral flap is formed with its base to the limbus, 1/3 of the sclera thick to the limbus region. A triangular flap of the sclera is cut out with its base to the limbus, 1/3 of the sclera thick, above the area of the Schlemm's canal. Under the triangular flap, a Schlemm canal zone 3 mm long and 0.5 mm wide is cut out with penetration into the anterior chamber. A basal iridotomy 1 mm long is performed and its cut-off part, connected to the iris pedicle, is brought out between the lower and middle triangular scleral flap and sutured to the lower scleral flap 0.5-1 mm from the basal iridectomy with a 10.0 suture, forming a fixed iridencleisis. Departing 0.5 mm from the iridencleisis, a horizontal incision of the sclera 3 mm long is performed to the choroid and a triangular flap is tucked between the choroid and the inner sclera. 2 interrupted sutures 10.0 are placed on the superficial scleral flap, a viscoelastic is introduced into the anterior chamber to deepen it and create mild hypotension. Separately, Tenon's membrane is sutured with a continuous 10.0 suture, and then the conjunctiva.

The invention is illustrated by the following clinical examples.

Example 1. Patient D., born in 1952, was admitted to the Tambov branch of the FGAU "NMIC" IRTC "Eye Microsurgery" named after. S.N. Fedorova with a diagnosis:

Primary open-angle III "C" glaucoma OD, suspected glaucoma OS, degeneration of the iris and ciliary body, degeneration of the macula and posterior pole, complicated cataract OU.

On admission:

Vis OD = 0.05 n.c.

Vis OS = 0.5 sph + 1.75 cyl-2.75 ax 80° = 0.7

IOP OD P ₀ = 33.1 mm Hg

IOP OS P ₀ = 15.8 mm Hg

The field of view is narrowed from the inside to 10° fixation point

MDOS-(-1.9dB)

Biomicroscopy data: OD - The cornea is transparent, the anterior chamber is of medium depth, the pupil is round, its position is central, iris stroma degeneration, pseudoexfoliation along the edge of the pupil, the pigment border is atrophic, there are single opacities in the lens. The optic disc (OND) is pale, glaucoma excavation, macular area without focal pathology.

The patient underwent antiglaucomatous surgery according to the proposed method.

At 12 o'clock, 4 mm from the limbus, a 5 mm incision was made in the conjunctiva and Tenon's membrane with its separation to the limbus. A superficial rectangular flap of the sclera 4×5 mm was cut out with its base to the limbus, 1/3 of the sclera to the limbus region thick. A triangular flap of the sclera was cut out with its base to the limbus, 1/3 of the sclera thick, above the area of the Schlemm's canal. Under the triangular flap, an area of the Schlemm canal 3 mm long and 0.5 mm wide was cut out with penetration into the anterior chamber. A basal iridotomy 1 mm long was performed and its cut-off part, connected to the iris pedicle, was removed between the lower and middle triangular scleral flap and sutured to the lower scleral flap 1 mm from the basal iridectomy with a 10.0 suture, forming a fixed iridencleisis. Departing 0.5 mm from the iridencleisis, a horizontal incision of the sclera 3 mm long was made to the choroid and a triangular flap was tucked between the choroid and the inner layer of the sclera. Two interrupted 10.0 sutures were placed on the superficial scleral flap, and viscoelastic was introduced into the anterior chamber to deepen it and create mild hypotension. Separately, Tenon's membrane was sutured with a continuous 10.0 suture, and then the conjunctiva.

On discharge:

Vis OD = 0.3 sph + 1.75 cyl-2.75 ax 80° = 0.7

Vis OS = 1.0

IOP OD P ₀ = 8.1 mm Hg.

IOP OS P ₀ = 8.l mm Hg

The field of view is narrowed from the inside to 10° fixation point

MD OS-(-1.9dB)

OD - The filtration cushion is pronounced, the cornea is transparent, the anterior chamber is of medium depth, the pupil is round, its position is central, stromal dystrophy of the iris, pseudoexfoliation along the edge of the pupil, the pigment border is atrophic, there are single opacities in the lens. The optic disc is pale, glaucoma excavation, the membranes are adjacent, the macular zone is without focal pathology.

Example 2. Patient M., born in 1957, was admitted to the Tambov branch of the FGAU "NMIC" IRTC "Eye Microsurgery" named after. S.N. Fedorov with a diagnosis of primary open-angle III "B" glaucoma OS, operated open-angle III "A" glaucoma OD, macular and posterior pole degeneration, complicated cataract OU.

On admission:

Vis OD = 0.1 sph + 2.0 cyl-0.5 ax 75° = 0.2

Vis OS = 0.1 sph + 1.75 = 0.3

IOP OD P ₀ = 15.6 mm Hg

IOP OS P ₀ = 20.2 mm Hg

MD OD - (- 29.82 dB)

MD OS - (- 28.04 dB)

Biomicroscopy data: OS - Transparent cornea, anterior chamber of medium depth, round pupil, central position, iris stroma degeneration, pseudoexfoliation along the edge of the pupil, atrophic pigment border, single opacities in the lens. ONH is pale, glaucomatous excavation, drusen in the macular zone, small atrophic foci.

The patient underwent antiglaucomatous surgery according to the proposed method.

On discharge:

Vis OD = 0.1 sph + 2.0 cyl-0.5 ax 75° = 0.2

Vis OS = 0.2

IOP OD P ₀ = 15.6 mm Hg

IOP OS P ₀ = 20.2 mm Hg

MD OD - (- 29.82 dB)

MD OS - (- 28.04 dB)

OS - The filtration cushion is pronounced, the cornea is transparent, the anterior chamber is of medium depth, the pupil is round, its position is central, iris stroma degeneration, pseudoexfoliation along the edge of the pupil, the pigment border is atrophic, there are single opacities in the lens. ONH is pale, glaucomatous excavation, membranes are adjacent, drusen in the macular zone, small atrophic foci.

Claims (1)

A method of surgical treatment of glaucoma, including performing trabeculectomy and forming autovalvular drainage of the supraciliary space, characterized in that after the formation of a superficial rectangular scleral flap with its base to the limbus, a triangular scleral flap is cut out with its base to the limbus, above the Schlemm's canal zone, under the triangular flap, a Schlemm's canal zone of length 3 is cut out mm and a width of 0.5 mm with penetration into the anterior chamber, a basal iridotomy is performed and its cut-off part, connected to the iris by the pedicle, is removed between the lower and middle triangular scleral flap and sutured to the lower scleral flap, forming a fixed iridencleisis, after which, retreating 0 .5 mm from iridencleisis, a horizontal incision of the sclera 3 mm long is performed to the choroid and a triangular flap is tucked between the choroid and the inner sclera; two interrupted sutures are placed on the superficial scleral flap, a viscoelastic is introduced into the anterior chamber, and the Tenon's membrane, and then the conjunctiva, are sutured separately with a continuous suture.