RU2797882C1 - Method of surgical correction of intraocular pressure increase after ex-press shunt implantation - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: surgical correction of increased intraocular pressure after implantation of the Ex-press shunt is performed. A YAG laser with a wavelength of 1,064 nm is used with pulses applied to the holes of the Ex-press shunt. Pulses are applied in the amount of 6, 3 to each hole of the Ex-press shunt located in the anterior chamber, with a laser power of 2.0 mJ. After applying the pulses, an audit of the area of antiglaucoma surgery (AGO) is carried out in the following way: a conjunctival incision 3 mm long is performed along one of the lateral edges of the previously formed superficial scleral flap (SSL). It is separated until the distal opening of the Ex-press shunt located on the outer plate. Then, retreating from the outer plate 1 mm distally, a section of the sclera 1 mm wide and 2 mm long is excised until the ciliary body is exposed, going beyond the borders of the PSL. Next, 0.1 ml of the HealaFlow drainage implant is injected under the PSL, completing the operation by placing two interrupted sutures on the conjunctiva.

EFFECT: method makes it possible to eliminate the obstruction of the Ex-Press shunt, restore the previously created aqueous humor outflow tract (IHF), create an additional intraocular fluid outflow tract, normalize intraocular pressure (IOP) and stop the progression of loss of visual functions.

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Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used to treat an increase in intraocular pressure (IOP) in the late postoperative period after a filter-type antiglaucoma operation (AGO) with implantation of an Ex-Press metal shunt.

Glaucoma is a progressive disease that is the leading cause of blindness in the world. Despite the fact that ophthalmologists have a large number of antihypertensive drugs in their arsenal, surgical intervention in the treatment of glaucoma, including the use of drains, is a more effective method to achieve a stable reduction in IOP. One of the drainage devices implanted during surgery is the Ex-press shunt.

Despite the effectiveness of its use, this type of surgical intervention has its own postoperative complications. According to various authors, there are a number of complications that accompany the implantation of the Ex-Press antiglaucoma metal shunt, including its obturation. The cause of obstruction of the shunt and, as a result, an increase in IOP can be blood, a fibrin clot, pseudoexfoliative material, the vitreous body, or mild chronic inflammation.

Also, the reason for the decrease in the hypotensive effect after the implantation of the Ex-press shunt is the scarring of the filtration cushion zone, especially during repeated interventions.

The foregoing determines the relevance of correcting the increase in IOP after implantation of the Ex-Press antiglaucoma shunt in order to prolong the effect of AGO.

The closest analogue is a method for treating increased IOP after implantation of an antiglaucoma Ex-Press shunt (Mustafa, M., Shoham-Hazon, N., Reiss, G. R., Samuelson, T. W., Condon, G., & Ahmed, I. Neodymium Laser Treatment of IOP Rise Following Ex-press Glaucoma Device Implantation // Journal of Glaucoma. - 2019. Vol.29, No. 2. - P. 92-96.), which includes the use of a YAG laser with a wavelength of 1064 nm with the production of shots (pulses) according to holes of the Ex-Press shunt with a power of 0.8 to 3.2 mJ in an amount of 5 to 19.

The disadvantages of this method include the lack of impact on such a complication of the postoperative period as scarring of the filtration cushion, which also leads to an increase in IOP. In this regard, the effectiveness of treatment after YAG laser exposure of the shunt only from the anterior chamber cannot be guaranteed. The median time between Ex-Press implantation and IOP elevation requiring intervention with a YAG laser was 34.2 months in this study, suggesting the presence of scarring in the filtration zone.

Also, the disadvantage is a large range of laser energy power, which makes it impossible to predict the effectiveness of the operation.

The objective of the invention is to develop a safe and effective method for correcting an increase in IOP in the postoperative period after implantation of an anti-glaucoma Ex-Press metal shunt.

The technical result of the proposed method is to eliminate the obstruction of the Ex-Press shunt, restore the previously created intraocular fluid outflow tract (IOL), normalize IOP and stop the progression of loss of visual functions.

The technical result is achieved by the fact that in the method for correcting an increase in IOP after implantation of the Ex-Press shunt, which includes the use of a YAG laser with aiming it at the holes of the Ex-Press shunt and the product of pulses from them with a laser with a wavelength of 1064 nm, a power of 2.0 mJ, in the amount of 3 pulses in each hole (total - 6), according to the invention, the next step is to revise the AGO zone, while making a conjunctival incision 3 mm long along one of the lateral edges of the previously formed superficial scleral flap (SSL), separate the SSL to expose the distal holes of the Ex-press shunt located on its outer plate, then, retreating from the outer plate by 1 mm distally, a section of the sclera 1 mm wide and 2 mm long is excised until the ciliary body is exposed, going beyond the borders of the PSL, then 0.1 ml of HealaFlow drainage implant, completing the operation with 2 interrupted sutures on the conjunctiva.

The invention is illustrated by a figure showing a view of the method of operation: position 1 indicates the conjunctival incision, 2 - limbus, 3 - PSL, 4 - external plate of the Ex-press shunt with a distal opening located on it, 5 - exposed area of the ciliary body, 6 - drainage HealaFlow implant, 7 - interrupted sutures.

The method is carried out as follows.

First, under operating conditions under local instillation anesthesia with a solution of proxymethacaine 0.5% (Alkain), a YAG laser with a power of 2.0 mJ, a wavelength of 1064 nm is used to produce 6 pulses (3 pulses in each hole) with the laser pointing at shunt holes Ex-Press.

Then, an audit of the AGO zone is carried out in the operating room. A 3 mm long conjunctival incision is made along one of the lateral edges of the previously formed PSL. Next, the PSL is separated until the distal opening of the Ex-press shunt located on its outer plate is exposed. Then, retreating from the outer plate by 1 mm distally, a section of the sclera 1 mm wide and 2 mm long is excised until the ciliary body is exposed, going beyond the borders of the PSL. Next, 0.1 ml of the HealaFlow drainage implant is injected under the PSL. The operation is completed by placing two interrupted sutures on the conjunctiva.

The implementation of laser exposure to the openings of the Ex-Press shunt in the anterior chamber makes it possible to eliminate its blockage by particles of various etiologies and restore the previously created path of outflow of the intraocular fluid.

Revision of the AGO zone allows destroying cicatricial adhesions in the AF zone and restoring the outflow of intraocular fluid, thereby prolonging the hypotensive effect after the AGO, which will avoid repeated AGO. Exposure of the ciliary body creates an additional uveoscleral outflow pathway for intraocular fluid, which increases the hypotensive effect. The introduction of the drainage implant Healaflow allows to reduce scarring in the area of the formed outflow tracts of the intraocular fluid.

The method is confirmed by the following example.

Patient M., 67 years old. History: In March 2016, he applied to the clinic at the place of residence with complaints of decreased vision, fog OU. An increase in IOP on OS was detected, OS was diagnosed Primary open-angle glaucoma 2c, OU Complicated cataract, an antihypertensive regimen was prescribed - 1 drug. In May 2016, there was an increase in pressure on the OS, the antihypertensive regimen was increased to 2 drugs. Against the background of a repeated increase in IOP on OS, he was referred to the MRTC MG, Moscow, consulted in the department of glaucoma surgery, the diagnosis was confirmed, surgical treatment was performed OS Cataract phacoemulsification with intraocular lens implantation + Non-penetrating deep sclerectomy. IOP was compensated, the hypotensive regimen was cancelled. From June 2016 to August 2021, an increase in IOP on OS was recorded three times at the polyclinic at the place of residence, 1 antihypertensive drug was added at each appointment. In September 2021, an increase in IOP on OS was again recorded, the patient was referred to the MNTK MG, Moscow, consulted in the department of glaucoma surgery, the diagnosis was OS Primary open-angle glaucoma 2c, operated, Artifakia. When contacting VIS OS=0.55, IOP=29 mm Hg. Art., the number of antihypertensive drops - 3 drugs. At gonioscopy: Anterior chamber angle (ACA) is open, medium wide, the AGO zone is sclerotic at 12 o'clock, single goniosynechia, pigmentation of the 2nd degree. Surgical treatment was performed - OS Implantation of an antiglaucoma metal shunt Ex-press. IOP OS compensated, hypotensive regimen cancelled. In February 2022, against the background of an increase in IOP on OS, he was re-sent to MNTK MG, Moscow, consulted in the department of glaucoma surgery, diagnosed with OS Primary open-angle glaucoma 2c, operated, Artifakia. When contacting VIS OS=0.5, IOP=26 mm Hg. Art., does not install antihypertensive drops. OS biomicroscopy: the eye is calm, the filtration cushion is sclerotic at 12 o’clock, the AF is flat at 13 o’clock, the cornea and anterior chamber moisture are transparent, at 13 o’clock the metal shunt is visualized in the APC in the correct position, the anterior chamber is of medium depth, the iris is subatrophic, the pupil is round, intraocular lens in a capsular bag. With ophthalmoscopy: the optic disc (ON) is pale, the boundaries are clear, E/D=0.7, the macular area is without features. At gonioscopy: the APC is open, medium wide, the AGO zone is sclerotic at 12 o'clock, free at 13 o'clock, single goniosynechia, pigmentation of the 2nd degree.

In March 2022, the treatment according to the invention was carried out. At the first stage, the patient underwent laser surgery using a YAG laser: 6 pulses were produced (3 pulses in each hole) with the laser pointing at the holes of the Ex-Press shunt. The second stage, according to the invention, was an audit of the AGO zone.

No complications were observed in the postoperative period.

On the 1st day of treatment VIS OS 0.5, IOP=14 mm Hg. Art., without antihypertensive drugs.

At discharge on day 3: VIS OS 0.5, IOP=12 mm Hg. Art., without antihypertensive drugs. At gonioscopy: the APC is open, medium wide, the AGO zone is sclerotic at 12 o'clock, free at 13 o'clock, isolated goniosynechia, pigmentation of the 2nd degree. OS biomicroscopy: the eye is calm, the filtration cushion is sclerotic at 12 o’clock, the filtration cushion is pronounced at 13 o’clock, the cornea and moisture of the anterior chamber are transparent, at 13 o’clock the metal shunt is visualized in the APC in the correct position, the anterior chamber is medium wide, the iris is subatrophic, the pupil is round, intraocular lens in a capsular bag. Ophthalmoscopy: the optic disc (ON) is pale, the boundaries are clear, E/D=0.7, the macular area is without features.

In the future, no negative dynamics were noted during observation up to 3 months. VIS OS 0.5, IOP=15 mmHg Art., without hypotensive drops.

As a result of combined treatment, the patient was able to eliminate the obstruction of the Ex-Press shunt, restore the previously created ways of outflow of intraocular fluid, compensate for IOP, and stop the progression of visual function loss.

Claims (1)

A method for surgical correction of an increase in intraocular pressure after implantation of an Ex-press shunt, including the use of a YAG laser with a wavelength of 1064 nm with applying pulses to the holes of the Ex-press shunt, characterized in that the pulses are applied in the amount of 6, 3 to each hole of the Ex-shunt -press, located in the anterior chamber, with a laser power of 2.0 mJ; after applying the pulses, the area of antiglaucoma surgery (AGO) is revised, for this, a conjunctival incision 3 mm long is made along one of the lateral edges of the previously formed superficial scleral flap (SSL), it is separated until the distal opening of the Ex-press shunt located on the outer plate is exposed, then, retreating from the outer plate 1 mm distally, a section of the sclera 1 mm wide and 2 mm long is excised until the ciliary body is exposed, going beyond the boundaries of the PSL, then 0.1 ml of the HealaFlow drainage implant is injected under the PSL, completing the operation by applying two interrupted sutures to conjunctiva.

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