RU2782126C1 - Surgical method for simultaneous activation of aqueous humour outflow tracts in glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely, to ophthalmology. All aqueous humour (AH) outflow tracts in glaucoma are simultaneously activated. The conjunctiva is incised at the limbus, the conjunctiva and the Tenon's shell are separated from the sclera, bipolar diathermocoagulation of the superficial scleral vessels is performed. Then a superficial scleral flap is cut with the base by the limbus, 4×4 mm in size; a deep scleral flap 4×4 mm in size is cut and removed before dissecting the Schlemm's canal (SC), leaving the scleral tissue on top of the ciliary body. The endothelial lining of the SC is removed, 3-scleral strips 3×1 mm in size are formed perpendicular to the limbus. The two lateral scleral strips are removed, exposing the ciliary body; cyclodialysis is performed using a spatula. A collagen drainage is implanted over the central strip parallel to the limbus, the superficial scleral flap and conjunctiva are sutured with interrupted sutures. After the deep scleral flap and the endothelial lining of the SC are removed, four through incisions are made on the remaining deep scleral layers, retreating from the posterior border of the SC by 0.5 mm, perpendicular to the limbus, so as to create three scleral strips. The lateral strips are then removed, exposing the ciliary body, followed by performing cyclodialysis under the central strip and at the sides under the sclera at the edge of the scleral bed using a spatula. A collagen drainage is herein implanted parallel to the limbus so as to be located over the scleral strip, and so the ends thereof are located under the edges of the scleral bed; then, depending on the IOP level, but not earlier than 7 days after the operation, YAG laser trabeculotomy is performed using a YAG laser and a single-mirror gonio lens, and at least one hole is made in the trabecular apparatus in the area of the primary surgical intervention.

EFFECT: possibility of achieving a consistent hypotensive effect, reducing the number of hypotensive products used, reducing the amount of intra- and postoperative complications, and shorten the duration of hospital stay of the patients due to the simultaneous activation of the trabecular and uveoscleral AH outflow tracts, filtration of AH into the subconjunctival space, and possibility of delayed YAG laser trabeculopuncture.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology, and is intended for the surgical treatment of glaucoma.

Surgical methods for the treatment of glaucoma are known, in which, in order to activate the uveoscleral outflow tract of the intraocular fluid, cyclodialysis is performed to communicate the anterior chamber of the eye with the supraciliary and suprachoroidal spaces. This operation has found its place in improving the outflow of intraocular fluid both with an open angle of the anterior chamber and with its narrow profile. It is used both in primary glaucoma and in its numerous refractory forms: both as a mono-operation 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 V.R., Petrov S.Yu., Karlova E.V. 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 the blockade of the created cyclodialysis gap, various types of drainage are used (Kammer J.A., Mundy K.M. Suprachoroidal Devices in Glaucoma Surgery. Middle East Afr J Ophthalmol. 2015; 22(1): 45-52). Recently, many authors have proposed the use of cyclodialysis and its modifications as an antiglaucoma component (Frolov M.A. et al. Combined treatment methods for the combination of cataract and glaucoma. Bulletin of Ophthalmology. 2017; 133(4): 42-46, Karlova E. B. Surgical Uveoscleral Outflow Activation in Glaucoma National Journal of Glaucoma 2014;3:77-87. One of the prerequisites for this was the lack of functioning of the traditional way of outflow of intraocular fluid in patients admitted at the late stages of the glaucoma process (Stavitskaya T.V. Uveoscleral outflow and its role in the regulation of ophthalmotonus. Clinical ophthalmology. 2000; 1: 19-21).

A 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 deep layers of the sclera in the form of a triangle, the implantation of a drain, one end of which is placed in the anterior chamber, and the other is placed on ciliary body at the site of excision of the deep layers of the sclera, performing cyclodialysis at the top of the excised deep layers of the sclera, in the space of which the ends of the drainage are placed, and fixing the superficial scleral flap laid in place. This method differs in the use of additional drainage, which is placed on the first one perpendicular to it at the top of the excised sclera layers, and the free ends of the additional drainage are placed in the cyclodialysis space, while fixing the superficial scleral flap at least at four points.

This method of surgical treatment of glaucoma has a number of disadvantages: the complexity of implementation, the need to use 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 along the limbus, then a superficial scleral flap is formed for 1/2-1/3 of the thickness of the sclera with a size of 5 × 5 mm , with the base to the limbus, then a triangular flap is formed under it, with the base to the limbus, 4 × 5 mm in size, all layers of the sclera are removed at its top until the ciliary body is exposed - a burr hole. Next, 2 scleral canals 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 limbus zone, a superficial incision is made in the middle of the base of the triangular flap to detect the scleral spur and Schlemm's canal (SC). The goal is to remove a deep scleral flap, the posterior wall of the SC, or limbus and cornea tissue without opening the eyeball. To do this, it is possible to exfoliate the limbal zone with a spatula. After that, two collagen drains 0.8-1.2 mm thick, 1.0-1.5 mm wide, 4.0-5.0 mm long are modeled respectively on 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 drain should not exceed the length of the scleral flap, and when the scleral flap is sutured, the drain should not protrude from under it. Both drains are placed along the outer edges of the scleral bed and fixed to the underlying layers of the sclera with a single 10-0 nylon suture. After that, the anterior chamber of the eye is opened with an incision along the limbus, an iridectomy is performed, the anterior chamber is completely filled with viscoelastic, and the ends of two drains are inserted into the anterior chamber in such a way that a window is formed in the trabeculo-descemet membrane and the ends of the drains do not overlap with the root of the iris. In cases of grade III-IV hydrophthalmos, 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 burr hole at the top of the triangular scleral flap. The superficial scleral flap is placed in place and fixed with 4 sutures: two at the ends of the flap and two at the limbus, while the drains are completely immersed under the flap. The conjunctival flap is fixed with 2-4 sutures at the limbus.

The above method of surgical treatment has a number of disadvantages: the complexity of implementation, trauma, iridectomy increases the risk of postoperative complications: hyphema, hypotension, cyclochoroidal detachment.

A known method of surgical treatment of primary glaucoma (RU No. 2456970, publ. 27.07.2012). Operation technique: a conjunctival flap is formed with its base towards the fornix. The superficial scleral flap is separated by 1/2 of the thickness of the sclera to the corneal part of the limbus by 1.0 mm into the transparent layers of the cornea with the base towards the limbus. A deep triangular scleral flap is separated along with the outer wall of the SC and excised. Further, in the scleral bed, on the side facing the arch, a through incision of the sclera is made and cyclodialysis is performed through it. Perform paracentesis in the anterior chamber. Produce basal iridectomy. Drainage in the form of an hourglass is prepared from a polymer plate. Drainage is implanted in such a way that the peripheral end is inserted through the paracentesis into the anterior chamber, and the central end is inserted into the cyclodialysis slot. The method is completed, as is customary, by fixing the superficial scleral flap to the edges of the bed with two interrupted sutures and applying a continuous conjunctival suture.

The above method of surgical treatment has a number of disadvantages, the need for certain surgical skills, the need for iridectomy, the possibility of developing postoperative complications: hyphema, hypotension.

The closest analogue is the method of surgical treatment of refractory glaucoma (RU No. 2297815, publ. 27.04.2007). The method is carried out as follows: the conjunctival flap and the superficial scleral flap are separated by 1/3 of the thickness of the quadrangular sclera 4×4 mm with the base towards the limbus. At the top of the scleral flap form cyclodialysis to the ciliary body. In the deep layers of the sclera, a triangular flap is cut out and removed by 1/3 of its thickness with the base towards the limbus together with the outer wall of the SC and the adjacent corneal tissue up to the Descemet's membrane. The endothelial lining of the SC is removed.

A collagen porous biological drainage is implanted into the formed bed with one end to the SC, and its other end should protrude 1 mm from under the superficial scleral flap. Additionally, on one or the other side of the superficial scleral flap, a narrow strip of sclera is cut out for 1/2 of its thickness 2×4 mm with the smaller side towards the limbus. A deep scleral flap 2×2 mm is removed in the area of the SC projection. An intervascular iridotomy is performed. A second collagen 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 placed in place and fixed with a suture. The superficial scleral flap is returned to its place and fixed with two interrupted sutures. Both drains are made of a material containing bone collagen isolated from spongy bone of agricultural animals and saturated with bone sulfated glycosaminoglycans, in the form of plates 0.8 mm thick, 1.5 mm wide and 4.0 mm long.

The above method of surgical treatment has a number of disadvantages: complexity, trauma, large volume of surgery, the need for iridectomy, the use of two drains.

The technical results of the invention are the achievement of a stable hypotensive effect, a decrease in the number of antihypertensive drugs used, a decrease in intra- and postoperative complications and a reduction in the time of patient stay in the hospital due to the simultaneous activation of the trabecular and uveoscleral outflow tracts of the intraocular fluid, the filtration of intraocular fluid into the subconjunctival space and the possibility of conducting a delayed IAH- laser trabeculopuncture.

The technical result is achieved by the fact that the surgical method of activating all possible ways of outflow of intraocular fluid in glaucoma consists of an incision of the conjunctiva at the limbus, separation of the conjunctiva and Tenon's membrane from the sclera, bipolar diathermocoagulation of the superficial vessels of the sclera, then cut out the superficial scleral flap with the base to the limbus, 4×4 in size mm, a deep scleral flap 4×4 mm in size is cut out and removed until the SC is opened, leaving a minimum scleral tissue on top of the ciliary body, endothelial linings of the SC are removed, 3 scleral strips 3×1 mm in size are formed perpendicular to the limbus, two lateral scleral strips are removed, exposing ciliary body, cyclodialysis is performed with a spatula, collagen drainage is implanted above the central strip parallel to the limbus, the superficial scleral flap and conjunctiva are sutured with interrupted sutures, after removal of the deep scleral flap and endothelial lining of the SC, on the remaining deep layers of the sclera, retreating from the posterior borders s SC by 0.5 mm, four through incisions are made perpendicular to the limbus, creating three scleral strips, then the side strips are removed, exposing the ciliary body, then cyclodialysis is performed under the central strip and on the sides under the sclera at the edge of the scleral bed using a spatula, while collagen drainage is implanted parallel to the limbus so that the drainage is above the scleral strip, and its ends are under the edges of the scleral bed, then, depending on the level of IOP, but not earlier than 7 days after the operation, YAG-laser trabeculotomy is performed using YAG- laser and a single-mirror goniolens, create one or more holes in the trabecular apparatus in the area of the primary surgical intervention.

The choice of the size of the formed scleral bed 4×4 mm is justified by the fact that the point of attachment of the superior rectus muscle to the sclera is located at a distance of 8 mm from the limbus, thus eliminating the possibility of damage to the superior rectus muscle and the development of strabismus. These dimensions are optimal and allow you to freely perform surgical procedures. An indentation from the posterior border of the SC by 0.5 mm allows leaving free space in the SC externalization zone, through which the AHF flows freely from the anterior chamber into the scleral bed formed during the operation. At the same time, the choice of the size of 3×1 mm of the scleral strip is due to the size of the drainage and leads to a decrease in post-surgical complications.

The technique of the operation is as follows: after traditional anesthesia and akinesia, a 7-0 polypropylene holder is sutured through the upper / lower limbus at 12 or 6 hours. The conjunctiva is incised along the limbus from 10 to 1 hour. A conjunctival flap of 7 mm in size is separated, with the base to the fornix of the eyeball, and Tenon's membrane is separated from the sclera. If necessary, produce economical bipolar diathermocoagulation of the superficial vessels of the sclera. Using a blade, a superficial rectangular scleral flap is cut out for 1/3 of the thickness of the sclera, with the base to the limbus, 4 × 4 mm in size. Next, a deep scleral flap 4×4 mm is formed and removed until the SC is opened, leaving the minimum scleral tissue on top of the ciliary body. Next, the endothelial lining of the SC is removed. Then, on the remaining deep layers of the sclera, retreating 0.5 mm from the posterior border of the SC, perpendicular to the limbus, four vertical through incisions are made (departing from the lateral borders of the scleral bed by 1 mm on each side). Further, through the through incisions, cyclodialysis is performed under the strips, using a spatula, entering the supraciliary space. Next, the lateral scleral strips are removed, exposing the ciliary body, then collagen drainage is implanted parallel to the limbus so that the drainage is above the central strip, and its ends are in the supraciliary space under the edges of the scleral bed. The superficial scleral flap is laid in place and closed with 10-0 nylon interrupted sutures, the conjunctiva is closed with interrupted sutures to the cornea. The operation is completed with the introduction of a solution of dexamethasone under the conjunctiva and a monocular bandage is applied. In the postoperative period, the second stage of the operation (YAG laser trabeculotomy) is performed as follows: using a YAG laser and a single-mirror goniolens, one or more holes are created in the trabecular apparatus in the area of the first stage of this operation, which contributes to the unresisting outflow of intraocular fluid from the anterior chamber of the eye into supraciliary and further into the suprachoroidal space, as well as the filtration of the intraocular fluid into the subconjunctival space.

EFFECT: method allows simultaneous activation of trabecular and uveoscleral outflow tracts of intraocular fluid for a long period of time, achievement of a stable hypotensive effect, reduction of the amount of antihypertensive drugs used, reduction of the number of intra- and postoperative complications, reduction of the patient's stay in the hospital. This method, in addition to activating the aforementioned outflow pathways of the intraocular fluid, contributes to the filtration of intraocular fluid into the subconjunctival space, which makes it possible to achieve a stable and prolonged hypotensive effect. The advantage of this method is that it is possible to repeatedly carry out delayed YAG laser trabeculopuncture with an increase in IOP, since the formed scleral bed, together with drainage, is separated from the anterior chamber of the eye by only thin layers of the inner wall of the SC (remainder of the trabecular apparatus).

Example 1

Patient A., aged 78, was admitted to the hospital with a diagnosis of refractory open-angle glaucoma IIIc and complicated cataract of the right eye; operated open-angle IIa and pseudophakia of the left eye. Medically, the patient was on a maximally tolerated antihypertensive regimen, including beta-blockers, a carbonic anhydrase inhibitor, and a prostaglandin analogue. Visual acuity before the operation of the left eye 0.02, does not correct, the left eye 0.9. Daily tonometry data: left eye - right eye - 32 mm Hg. Art. (Icare); 14 mmHg Art. (according to Icare). The patient underwent a combined cataract surgery by phacoemulsification with intraocular lens implantation in the capsular bag and antiglaucoma surgery by the proposed method on the right eye. The operation proceeded without complications. In the postoperative period, there was an increased IOP in the operated eye up to 23-24 mm Hg. Art. (Icare) on a hypotensive regimen. 2 weeks after the operation, the patient underwent YAG laser trabeculotomy in the area of the surgical intervention. The 6th mode of laser energy was used (Anna YAG laser, Appasami Associate, India). One pulse was required to create one hole in the trabecular zone. Biomicroscopy revealed the appearance of a flat filtration cushion with a decrease in IOP. The patient was canceled instillation of antihypertensive drops and was prescribed instillation of non-steroidal anti-inflammatory drugs drops (Indocollir) for 10 days. 7 days after the YAG laser procedure, the eye is calm, the patient does not complain, the absence of a filtration cushion was revealed, IOP decreased to 14 mm Hg. Art. (Icare), which was kept at this level until the last examination. An optical coherence tomogram revealed activation of the outflow of intraocular fluid in the lymphatic vessels of the conjunctiva. Visual acuity increased to 0.6. The patient notes an improvement in the quality of life.

Currently, 15 patients with glaucoma have been operated on. The use of this method of surgical treatment of glaucoma made it possible to achieve a stable and prolonged hypotensive effect, as well as to reduce the number of intra- and postoperative complications and the number of antihypertensive drugs used.

This operation is indicated for all types and stages of development of glaucoma, and can be used as a separate operation or in combination with cataract surgery.

Claims (1)

Surgical method of simultaneous activation of all outflow tracts of intraocular fluid (IOL) in glaucoma, consisting of an incision of the conjunctiva at the limbus, separation of the conjunctiva and Tenon's membrane from the sclera, bipolar diathermocoagulation of the superficial vessels of the sclera, then cut out the superficial scleral flap with its base to the limbus, 4 × 4 mm in size , a deep scleral flap 4×4 mm in size is cut out and removed until the Schlemm canal (SC) is opened, leaving the scleral tissue on top of the ciliary body, the endothelial lining of the SC is removed, 3-scleral strips 3×1 mm in size are formed perpendicular to the limbus, two lateral scleral strips are removed , exposing the ciliary body, cyclodialysis is performed with a spatula, collagen drainage is implanted above the central strip parallel to the limbus, the superficial scleral flap and conjunctiva are sutured with interrupted sutures, after removal of the deep scleral flap and endothelial lining of the SC on the remaining deep layers of the sclera, retreating from the posterior border of the SC by 0.5 mm, four through incisions are made perpendicular to the limbus, creating three scleral strips, then the side strips are removed, exposing the ciliary body, then cyclodialysis is performed under the central strip and on the sides under the sclera at the edge of the scleral bed using a spatula, while collagen drainage is implanted parallel to the limbus so that the drainage is above the scleral strip, and its ends are under the edges of the scleral bed, then, depending on the level of IOP, but not earlier than 7 days after the operation, a YAG laser trabeculotomy is performed using a YAG laser and a single-mirror goniolens , create at least one hole in the trabecular apparatus in the area of the primary surgical intervention.