RU2776767C1 - Method for reconstructing the area of non-penetrating deep sclerectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical ophthalmology. Mitomycin C is used, while under operating conditions under a microscope, a conjunctival incision 2 mm long is made above the zone of non-penetrating deep sclerectomy (NPDS). The superficial scleral flap (SSL), formed during the previous operation, is separated, and the trabeculo-Descemet membrane is exposed. Next, the tupfer moistened with a solution of mitomycin C 0.04% is immersed under the conjunctiva and under the SSL for one minute. After that, the NPDS zone is washed with saline. Then, 0.2 ml of the Healaflow drainage implant is injected under the SSL and under the conjunctiva, the conjunctiva is fixed with interrupted sutures. In a particular case, when the anterior chamber collapses after separation of the SSL, the anterior chamber is filled with viscoelastic to normotonus, and the SSL is sutured with interrupted sutures.

EFFECT: method makes it possible to improve visualization of the NPDS zone, reduce trauma, reduce re-scarring, and reduce the likelihood of choroidal detachment.

2 cl, 2 ex

Description

The invention relates to the field of medicine, namely to surgical ophthalmology, and can be used in the preoperative period and after filter-type antiglaucoma surgeries.

Non-penetrating deep sclerectomy (NPDS) is a filter-type operation used to treat primary open-angle glaucoma (POAG). During the operation, the anterior chamber is not opened, and the intraocular fluid flows through the formed trabeculo-descemet membrane (TDM) and enters the circulatory system of the choroid, into the suprachoroidal space and under the conjunctiva. Due to this mechanism, a controlled, gradual decrease in intraocular pressure (IOP) occurs.

One of the problems that surgeons face after NGSE is scarring of the surgical site. To date, to increase the effectiveness of NGSE and prevent excessive scarring, a number of its modifications have been developed using various types of intrascleral drainages, cytostatics (mitomycin) and antimetabolites (fluorouracil).

The closest analogue is the method of revision of the zone of antiglaucoma surgery (AGO) after NGSE [Koukkoulli A, Musa F, Anand N. Long-term outcomes of needle revision of failing deep sclerectomy blebs. Graefes Arch Clin Exp Ophthalmol. Jan 2015; 253(1):99-106. doi: 10.1007/s00417-014-2810-4. Epub 2014 Oct 11. PMID: 25303883]. The method consists in introducing a solution of mitomycin C 0.01 mg or 0.02 mg with 0.05 ml of 2% lidocaine into the subconjunctival space using a 29 G needle. The injection was carried out 10 mm from the limbus. After 10-15 minutes, an audit of the AGO zone was carried out with a 25 G needle at 10 mm from the limbus between 10 and 2 hours. With translational movements, the needle was passed to the AGO zone, separating the conjunctival adhesions and further under the scleral flap. In some cases, a 12 G needle or a 1.5 mm double beveled paracentesis knife was used.

However, this method has some disadvantages: revision of the AGO area under a slit lamp does not provide the necessary visualization of the operation area, which increases the risk of the needle entering the anterior chamber and can lead to pronounced fluid filtration from the anterior chamber with a sharp decrease in IOP, which can cause complications such as detachment of the choroid and the occurrence of a block of outflow tracts by the root of the iris.

The objective of the invention is to create a method for reconstructing the NGSE zone, which makes it possible to increase the efficiency of the operation, create optimal conditions for the formation of outflow tracts of intraocular fluid (IHF) and prolong the effect of the previously performed surgical intervention.

The technical result of the proposed method is to improve visualization of the NGSE zone, reduce trauma, reduce re-scarring, reduce the likelihood of choroidal detachment, the occurrence of a block of outflow tracts by the root of the iris.

The specified technical result is achieved by the fact that the method of reconstructing the NGSE zone is performed under operating conditions under a microscope, a conjunctival incision is made parallel to the limbus 2 mm long above the operation zone, and the NGSE zone is opened. The superficial scleral flap (SSL), formed during the previous operation, is separated, the TDM is exposed, the tupfer moistened with a solution of mitomycin C 0.04% is immersed under the conjunctiva and under the superficial scleral flap for 1 minute, then the area is washed with saline, then under 0.2 ml of the Healaflow drainage implant is injected under the conjunctiva, and the conjunctiva is fixed with interrupted sutures with 8-0 silk thread. If, after separating the PSL, the anterior chamber collapsed, during the operation it is filled with viscoelastic to normotonus, and the PSL is sutured with interrupted sutures with 8-0 silk thread.

In the proposed method, the reconstruction of the NGSE area is performed under operating conditions under a microscope, which increases the visualization of the operation area, the accuracy of the manipulations and reduces the trauma. The use of the Healaflow drainage implant provides additional prevention of scarring in the area of the revision, reduces the risk of scar tissue. HealaFlow consists of a non-animal linked reticular sodium hyaluronate, which, being in the subconjunctival space, resolves within 3-6 months, which is an additional prevention of late scarring.

If the anterior chamber collapsed after separation of the PSL, a viscoelastic agent can be immediately introduced into the anterior chamber during the operation, which will reduce the likelihood of the following complications: detachment of the choroid, blockade of the surgical area with the root of the iris.

The method is characterized by the following clinical examples.

Example 1

Patient A., 67 years old. In the anamnesis: in 2019, during the medical examination, an increase in IOP in both eyes was revealed. Assigned to the maximum antihypertensive therapy, the target IOP in the left eye is not achieved. Sent to IRTC MG, Moscow, consulted in the department of glaucoma, an operation was performed on the left eye: NGSE. After 6 months, laser surgery was performed on the left eye: descemetogoniopuncture. The patient was followed up at the place of residence, re-sent to the MNTK MG in Moscow in 2021 due to IOP decompensation in the left eye on maximum antihypertensive therapy.

Examination of the left eye: Visus 0.3 does not correct (n/c). Pneumotonometry: IOP=29 mm Hg. Perimetry: corresponds to the advanced stage of glaucoma. Biomicroscopy: the eye is calm, the adnexa of the eye without features, the filtration cushion is flat for 12 hours, the cornea is transparent, the anterior chamber is of medium depth, the moisture is transparent, the iris is subatrophic, the lens is clouded in the cortical layers and the nucleus. Ophthalmoscopy: optic disc pale, clear boundaries, E/D=0.9, macular area behind the veil, on the periphery without features. Gonioscopy: the angle of the anterior chamber (AAC) is open, for 12 hours the NGSE zone is visualized. Diagnosed with: OS Primary open-angle glaucoma 3B operated, complicated cataract; OD Primary open-angle glaucoma 2A, complicated by cataract. Surgical treatment was carried out according to the proposed method: OS reconstruction of the NGSE zone.

In the early postoperative period without features. At discharge: no complaints; Visus OS 0.3 n/a; pneumotonometry: IOP OS=15 mm Hg. without antihypertensive therapy. According to the ultrasound B-scan OS - membranes are adjacent. At the control examination after 1 month, no negative dynamics were noted during the examination. IOP OS=14 mmHg (pneumotonometry) without antihypertensive therapy. As a result of treatment, the patient achieves a stable hypotensive effect and preserves visual functions.

Example 2

Patient V., 74 years old. History: primary open-angle glaucoma was diagnosed in both eyes in 2015 at the place of residence. In 2020, IOP decompensation in the left eye was referred to the Moscow Scientific and Technical Technical Complex, Moscow, consulted in the glaucoma department, an operation was performed on the left eye: NGSE. After 4 months, descemetogoniopuncture was performed on the left eye. The patient was followed up at the place of residence, re-sent to the MNTK MG in Moscow in 2021 due to IOP decompensation in the left eye on antihypertensive therapy. When examining the left eye: Visus 0.8 n/a. Pneumotonometry: IOP=26 mm Hg. Perimetry: corresponds to the advanced stage of glaucoma. Biomicroscopy: the eye is calm, the adnexa of the eye without features, the filtration cushion is flat at 11 o'clock, the cornea is transparent, the anterior chamber is of medium depth, the moisture is transparent, the iris is subatrophic, the initial clouding of the lens. Ophthalmoscopy: optic disc pale, clear boundaries, E/D=0.7, macular zone without pathology, without features on the periphery. Gonioscopy: APC is open, at 11 o'clock the NGSE zone is visualized. Diagnosed with: OS Primary open-angle glaucoma 2 B operated, initial cataract; OD Primary open-angle glaucoma 1 A, initial cataract. Surgical treatment was carried out according to the proposed method: OS reconstruction of the NGSE zone. During the operation, a collapse of the anterior chamber was revealed, and 0.2 ml of viscoelastic was introduced into the anterior chamber through corneal paracentesis.

In the early postoperative period without features. At discharge: no complaints; Visus OS 0.8 n/a; pneumotonometry: IOP OS=17 mm Hg. without antihypertensive therapy. According to the ultrasound B-scan OS - membranes are adjacent. At the control examination after 3 weeks, no negative dynamics were noted during the examination. IOP OS=11 mmHg (pneumotonometry) without antihypertensive therapy. As a result of treatment, the patient achieves a stable hypotensive effect and preserves visual functions.

Claims (2)

1. A method for reconstructing a zone of non-penetrating deep sclerectomy (NPDS), including the use of mitomycin C, characterized in that, under operating conditions, under a microscope, a conjunctival incision is made 2 mm long above the zone of NPDS, the superficial scleral flap (SSL), formed during the previous operation, is separated , expose the trabeculo-descemet membrane, then the tupfer moistened with a solution of mitomycin C 0.04% is immersed under the conjunctiva and under the PSL for one minute, after that the NGSE zone is washed with saline, after which 0.2 ml of drainage is injected under the PSL and under the conjunctiva implant Healaflow, the conjunctiva is fixed with interrupted sutures. 2. The method according to claim 1, characterized in that when the anterior chamber collapses after separation of the PSL, the anterior chamber is filled with viscoelastic to normotonus and the PSL is sutured with interrupted sutures.