RU2795723C1 - Method for enhancing the hypotensive effect of selective laser trabeculoplasty - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: invention can be used to enhance the hypotensive effect of selective laser trabeculoplasty in combination with selective laser trabeculoplasty and cataract phacoemulsification with intraocular lens implantation. At the first stage, selective laser trabeculoplasty is performed at 360° at a power of 1.0 mJ, applying 100–110 pulses to the trabecular area. Then, no later than 1 hour later, cataract phacoemulsification is performed with intraocular lens implantation.

EFFECT: invention enhances the hypotensive effect of selective laser trabeculoplasty, which improves the outflow of intraocular fluid, significantly reduces intraocular pressure in patients with primary open-angle glaucoma, and also reduces the intensity of the antihypertensive drug regimen or avoids extensive surgical interventions for glaucoma.

1 cl, 3 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used to enhance the hypotensive effect of selective laser trabeculoplasty in patients with primary open-angle glaucoma due to its combination with cataract phacoemulsification.

Glaucoma is a progressive optic neuropathy that leads to irreversible blindness and disability throughout the world, despite advances in the treatment of this disease. The only modifiable risk factor for the development of glaucoma is intraocular pressure, the reduction of which can slow down the progression of the pathological process and is the goal of treatment today.

Along with glaucoma, cataract is also one of the leading causes of a significant reduction in visual acuity and blindness worldwide, but due to the wide spread and availability of surgical treatment, including phacoemulsification with intraocular lens implantation, this disease does not lead to permanent loss of vision.

Cataracts and glaucoma often coexist in the same eye of a patient and, in some cases, may influence each other. Since cataracts and glaucoma are the two most common causes of vision loss, cataract treatment by surgical removal in combination with one of the glaucoma treatments provides an advantageous opportunity to treat both diseases at the same time.

When analyzing the literature data, we did not find a way to achieve a hypotensive effect using a combination of cataract phacoemulsification with intraocular lens implantation with selective laser trabeculoplasty. However, the following methods can be used for this purpose.

Phacoemulsification of cataract is the most common operation worldwide. The execution technique was proposed back in 1967 by Charles Kelman [Kelman C.D. Phaco-Emulsification and Aspiration: A new technique of cataract removal: A preliminary report // American Journal of Ophthalmology. - 1967. - Vol. 64(1). - P. 23-35]. Today, the operation is performed under local anesthesia. A cut is made at 12 o'clock of the conditional dial on the limb. Viscoelastic is injected into the anterior chamber and capsulorhexis is performed. A phaco-needle is inserted through the incision, which uses ultrasonic energy to crush the lens. Crushed pieces of the lens are removed through the aspiration hole located in the phaco-needle. Instead of a lens, a folded intraocular lens is inserted into the eye through an injector, which expands inside the eye. At the end of the operation, the viscoelastic is removed from the anterior chamber. Due to its small size, the incision on the limbus does not require sutures and closes hermetically. Cataract phacoemulsification surgery may have a hypotensive effect on its own. So according to Poles et al. [Poley BJ. Intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship between the natural lens and open-angle glaucoma. / Poley BJ, Lindstrom RL, Samuelson TW, Schulze R // J Cataract Refract Surg. - 2009. Vol. 35(11). P. 1946-1955.] in 55% of patients, postoperative pressure became lower, in 30% of patients there was an increase in pressure, and in 15% of patients there was no change in pre- and postoperative intraocular pressure. They also established a pattern that the higher the level of intraocular pressure was before the operation, the more it decreased after it. However, often the next day after the operation, there is an increase in IOP due to the presence of viscoelastic residues in the anterior chamber, which can adversely affect the glaucomatous process in the patient. Also, the hypotensive effect of the operation is variable and has been accurately proven only for patients with an initially shallow anterior chamber, since the operation leads to an increase in its depth, opening of the angle of the anterior chamber and facilitating the outflow of moisture from the anterior chamber.

To achieve a hypotensive effect in patients with open-angle glaucoma and ophthalmohypertension, selective laser trabeculoplasty, proposed by Latina and Park in 1995, is also used [Latina MA. Selective targeting of trabecular meshwork cells: In vitro studies of pulsed and CW laser interactions. / Latina MA, Park C // Exp Eye Res. - 1995 Apr. Vol. 60(4). P. 359-371], the action of which is the pulsed laser action on the pigment cells of the trabecular meshwork, which leads to the release of pigmented particles [Kulikov AN. Anterior chamber particles are associated with reduction of intraocular pressure after selective laser trabeculoplasty. / Kulikov AN, Maltsev DS, Kazak AA, Burnasheva MA. // BrJ Ophthalmol. 2020. - Vol. 104(11). P. 1508-1511] and cellular detritus into the moisture of the anterior chamber, expansion of intertrabecular spaces and improvement of the outflow of intraocular fluid into the Schlemm canal. However, these pigmented particles tend to cause re-blocking of the anterior chamber fluid outflow pathways, which is reflected in a transient rise in intraocular pressure a few days after the procedure. McAlinden studied the efficacy of selective laser trabeculoplasty at 180° and 360° anterior chamber angle circumferences and found that the procedure was as effective as drug therapy and reduced intraocular pressure by an average of 20% of baseline [McAlinden C. Selective laser trabeculoplasty (SLT) vs other treatment modalities for glaucoma: a systematic review. / McAlinden C // Nature Research. eye. - 2014 Mar. Vol. 28(3). P. 249-58].

It is known that the hypotensive effect of selective laser trabeculoplasty lasts from six months to a year, but the procedure may be ineffective in about 25%.

The closest method for lowering the level of intraocular pressure is a combined method for the treatment of anterior open-angle glaucoma against the background of pseudoexfoliative syndrome in combination with cataracts (see RU 2555128, A61F 9/008, A61K 31/165, A61K 31/4439, A61P 27/02, publ. from 10.07.2015). The technique was chosen as a prototype and combines a combination of sequential performance of selective laser trabeculoplasty and cataract phacoemulsification in patients with primary open-angle glaucoma and pseudoexfoliation syndrome. Selective laser trabeculoplasty is performed, and the next day after laser exposure, cataract phacoemulsification is performed with intraocular lens implantation. During cataract phacoemulsification, pseudoexfoliative particles and pigment granules are washed out from the anterior chamber of the eye. However, this invention is applicable only to patients with pseudoexfoliative syndrome. Also Maltsev D.S. with co-authors (Maltsev D.S. Anterior chamber particles are associated with reduction of intraocular pressure after selective laser trabecularplasty. / A.N. Kulikov, D.S. Maltsev, A.A. Kazak, M.A. Burnasheva // Br J Ophtalmol. - 2019 Feb. P. 1-4) in their The work showed that the next day after selective laser trabeculoplasty, pigmented granules in the anterior chamber of the eye are single or completely absent, in accordance with which it can be concluded that cataract phacoemulsification is performed the next day after selective laser trabeculoplasty to wash out any contents of the anterior chamber not advisable.

The invention is based on the task of creating a method for enhancing the hypotensive effect of selective laser trabeculoplasty, which improves the outflow of intraocular fluid, significantly reduces intraocular pressure in patients with primary open-angle glaucoma, and also reduces the intensity of the antihypertensive drug regimen or avoids extensive surgical interventions for glaucoma.

The solution of the problem is provided by the fact that in the method of enhancing the hypotensive effect of selective laser trabeculoplasty, including the use of selective laser trabeculoplasty and subsequent cataract phacoemulsification with intraocular lens implantation, after selective laser trabeculoplasty by 360 ° at a power of 1.0 mJ, applying 100 -110 pulses, no later than 1 hour later, cataract phacoemulsification is performed with intraocular lens implantation.

The specified result of the method for achieving a hypotensive effect in primary open-angle glaucoma is achieved by enhancing the hypotensive effect of selective laser trabeculoplasty in sequentially performing selective laser trabeculoplasty and cataract phacoemulsification on the same day. The enhancement of the effect is achieved due to the washing out of floating pigmented particles during cataract phacoemulsification, which are formed after selective laser trabeculoplasty. Thus, a reduction in the risk of re-blocking the trabecular meshwork after selective laser trabeculoplasty is achieved.

The way to achieve a hypotensive effect in primary open-angle glaucoma is implemented as follows. After selective laser trabeculoplasty at 360 ° at a power of 1.0 mJ, applying 100-110 pulses to the trabecula zone, no later than 1 hour later, cataract phacoemulsification is performed with implantation of an intraocular lens. When performing selective laser trabeculoplasty, it is important to treat the maximum accessible area of the trabecula with a laser, not less than 180 °, since in his work McAlinden (McAlinden C. Selective laser trabeculoplasty (SLT) vs other treatment modalities for glaucoma: systematic review. // Nature Research Eye. - 2014 Mar; 28(3):249-58.) showed that the treatment of the trabecular meshwork at 90° is less effective, and the effectiveness at 180° and 360° corresponds to the effectiveness of drug therapy and reduces IOP by 20-30 % of baseline. First describing Latina and Park selective laser trabeculoplasty in 1995 (Latina MA. Selective targeting of trabecular meshwork cells: In vitro studies of pulsed and CW laser interactions. / Latina MA, Park C. // Exp Eye Res. - 1995 Apr; 60 (4):359-371), suggested a sufficiently large power range of 0.2-2.0 mJ for use in work, however, recent SooHoo studies (SooHoo JR. Ultrastructural changes in human trabecular meshwork tissue after laser trabeculoplasty. / SooHoo JR, Seibold LK, Ammar DA, et al. // J Ophthalmol. - 2015) using scanning electron microscopy showed that when high laser power (over 2.0 mJ) is used on the trabecular meshwork, pronounced tissue damage is formed. The number of pulses in the amount of 100-110 applied to the entire area of the trabecular meshwork was selected according to observational data and in the course of practical work. This break, no later than 1 hour, is necessary, firstly, due to the fact that the patient needs special preoperative preparation before performing fcoemulsification, and secondly, because, as shown by Liu et al. (Dan Liu. Outcome of Selective Laser Trabeculoplasty in Young Patients with Primary Open-Angle Glaucoma and Ocular Hypertension / Dan Liu, Di Chen, Qian Tan, l Xiaobo Xia, Haibo Jiang, and Jian Jiang // Hindai Journal of Ophthalmology. - 2020 June.) an hour after the procedure, the decrease in intraocular pressure begins.

The essence of the invention is illustrated by the following examples. The study included 3 groups of patients. The first group included 20 patients (21 eyes) with primary open-angle glaucoma stage 1a to 2b, who underwent a combination of selective laser trabeculoplasty and cataract phacoemulsification. Regression of intraocular pressure 3 months after the procedure was 27.4±23.0% with the abolition of at least one antihypertensive drug. The second group included 26 patients (26 eyes) with stage 1a to 3b primary open-angle glaucoma, who underwent only SLT. Regression of intraocular pressure 3 months after the procedure was 12.4±19.6% without discontinuation of concomitant antihypertensive therapy. The third group included 20 patients (20 eyes) without glaucoma with normal IOP, who underwent cataract phacoemulsification. Regression of intraocular pressure 3 months after the procedure was 2.3±28.3% without discontinuation of concomitant antihypertensive therapy. This example shows that the hypotensive effect of the combination of selective laser trabeculoplasty and cataract phacoemulsification in patients with primary open-angle glaucoma is more pronounced in comparison with the isolated hypotensive effect of each of them separately. Such a combined approach also makes it possible to reduce drug antihypertensive therapy without worsening the structural and functional parameters of the glaucomatous process.

Since 2016, patient N has been diagnosed with glaucoma in both eyes. At the time of contacting the ophthalmology clinic of the Military Medical Academy for cataracts, stage 2 glaucoma of both eyes was diagnosed. The patient received istillation antihypertensive therapy in the amount of a combined preparation, including taflupros with thymol and dorzolamide in both eyes. Upon admission, the pressure according to Goldman was 15.3 and 20.7 mm Hg in the right and left eyes, respectively. Selective laser trabeculoplasty was performed followed by cataract phacoemulsification in the left eye to reduce intraocular pressure and stabilize the glaucoma process. After 3 months, phacoemulsification of the cataract of the right eye was performed under the same hypotensive regimen. At the follow-up examination, the pressure was 9.9 and 7.5 mm Hg according to Goldman in the right and left eyes, respectively, in connection with which the hypotensive regimen was weakened and the patient was recommended to instill only dorzolamide in both eyes. At the control examination a month later, the pressure was 11.7 and 10.7 mm Hg according to Goldman in the right and left eyes, respectively, in connection with which it was decided to cancel the remaining hypotensive regimen. At the last control examination (2 months after the abolition of local installation antihypertensive therapy), intraocular pressure was 14.0 and 12.5 mm Hg according to Goldman in the right and left eyes, respectively. Thus, during treatment on the eye, where combined treatment with selective laser trabeculoplasty and cataract phacoemulsification was performed and local antihypertensive therapy was canceled, intraocular pressure decreased by 40% from the initial one at admission, and on the eye without selective laser trabeculoplasty, but also with the abolition of local antihypertensive therapy, by 9% of the original.

Patient M has been diagnosed with glaucoma in the left eye since 2019. At the time of contacting the clinic of ophthalmology of the Military Medical Academy for cataracts, stage 2 glaucoma was diagnosed in the left eye and ophthalmohypertension in the right eye, the patient was instilled with dorzolamide and a combination drug, including latanoprost with timolol, in both eyes. Upon admission, the intraocular pressure according to Goldman was 22.6 and 22.0 mm Hg in the right and left eyes, respectively; a combination of selective laser trabeculoplasty and subsequent cataract phacoemulsification in the left eye was performed to reduce intraocular pressure and stabilize the glaucoma process. At the control examination after 2 months, the intraocular pressure according to Goldman was 20.1 and 11.4 mm Hg in the right and left eyes, respectively. Due to increased intraocular pressure in the right eye, selective laser trabeculoplasty was performed. At the control examination after 1 month, intraocular pressure according to Goldman was 15.8 and 12.6 mm Hg in the right and left eyes, respectively, it was decided to weaken antihypertensive therapy and cancel timolol. At the control examination after another 4 months, the intraocular pressure according to Goldman was 18.1 and 14.4 mm Hg in the right and left eyes, respectively. Thus, in the course of treatment in the eye, where combined treatment was performed with selective laser trabeculoplasty and cataract phacoemulsification and the weakening of local antihypertensive therapy, intraocular pressure decreased by 42% from the initial on admission, and in the eye, where only selective laser trabeculoplasty was later performed, but, also with the weakening of local antihypertensive therapy, by 10% of the original.

Since 2012, patient T has been diagnosed with glaucoma in both eyes. At the time of contacting the ophthalmology clinic of the Military Medical Academy for cataracts, stage 1 glaucoma was diagnosed. The patient received istillation antihypertensive therapy in the amount of a combination drug, including dorzolamide with thymol and latanoprost in both eyes. Upon admission, the pressure according to Goldman was 23.2 and 20.7 mm Hg in the right and left eyes, respectively. Selective laser trabeculoplasty was performed followed by cataract phacoemulsification in the right eye to reduce intraocular pressure and stabilize the glaucoma process. At the control examination after 2 months, the pressure was 12.0 and 12.2 mm Hg according to Goldman in the right and left eyes, respectively, in connection with which the hypotensive regimen was weakened and the patient was recommended to instill only dorzolamide and latanoprost in both eyes. At the control examination after 2 months, the pressure was 8.7 and 12.0 mm Hg according to Goldman in the right and left eyes, respectively, and therefore it was recommended to weaken the hypotensive regimen in the right eye and instill only latanoprost into it. At the control examination after 3 months, intraocular pressure was 15.9 and 14.7 mm Hg according to Goldman in the right and left eyes, respectively. Thus, during treatment on the eye, where combined treatment was performed with selective laser trabeculoplasty and cataract phacoemulsification and local antihypertensive therapy was weakened, intraocular pressure decreased by 31.5% of the initial one at admission.

Claims (1)

A method for enhancing the hypotensive effect of selective laser trabeculoplasty, including the use of selective laser trabeculoplasty and subsequent cataract phacoemulsification with implantation of an intraocular lens, characterized in that after selective laser trabeculoplasty at 360 ° at a power of 1.0 mJ, 100-110 pulses are applied to the trabecula zone, no later than 1 hour later, cataract phacoemulsification is performed with intraocular lens implantation.