RU2805396C1 - Method of combined laser treatment of primary open-angle glaucoma with any degree of trabecular pigmentation - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: transscleral cyclophotocoagulation (mCPC) is carried out contact-transsclerally using a diode laser in a micropulse mode with a wavelength of 810 nm and an exposure of 80 s, with an energy of 1,200 mJ, with a duty cycle of 31.3%, a pulse duration of 0.5 ms, a period of 1.1 ms. The mCFC is carried out along the arc of a circle 160°, concentric to the limbus, in the upper hemisphere of the eyeball, and one hour before the mCFC, a YAG laser activation of the trabecula is performed, for which a Selecta Trio Nd-YAG laser is used with the following parameters: wavelength — 1,064 nm, spot diameter — 10 microns, exposure — 3 ns, energy — 0.8–1.2 mJ. The exposure is performed in single applications in the amount of 55–70, with a length of 160°, concentric to the limbus, in the lower hemisphere of the eyeball, at an equal distance from each other, so that a bubble forms at each focus point.

EFFECT: method allows preserving visual functions, obtaining activation of uveoscleral and trabecular outflow tracts of intraocular fluid regardless of the degree of trabecular pigmentation, achieving a hypotensive effect, as well as reducing the number of groups of antihypertensive drugs or canceling their use.

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Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used for the treatment of primary open-angle glaucoma of the initial and advanced stages, in the absence of normalization of intraocular pressure (IOP) against the background of the installation of 2-3 groups of antihypertensive drugs.

One of the major challenges in the field of ophthalmology continues to be the provision of effective treatment for glaucoma. In Russia, a significant increase in the level of primary disability due to primary open-angle glaucoma has been registered [Libman E.S., Shakhova E.V., Chumaeva E.A. and others. Disability due to glaucoma in Russia // Mat. All-Russian scientific-practical conference "Glaucoma: problems and solutions." - Moscow, 2004. - P. 429-432]. Many factors contribute to the development of glaucoma; at the moment, the only pathogenetically substantiated treatment method is to reduce IOP. In recent years, laser treatment methods have become widespread, which are aimed at improving the outflow of intraocular fluid, due to their high safety and low risk of complications. These operations have a minimal impact on trabecular tissue and at the same time enhance the drainage path of outflow of intraocular fluid (IOH), having a pathogenetic orientation [Sokolovskaya T.V., Doga A.V., Magaramov D.A., Kochetkova Yu.A. Laser activation of trabecula in the treatment of primary open-angle glaucoma // Ophthalmosurgery. - 2015. - No. 1. - P. 27-31].

Micropulse transscleral cyclophotocoagulation (mCPC) is one of the latest promising developments in the field of laser treatment of glaucoma. It has a proven hypotensive effect, which is achieved by enhancing the outflow of intrauterine fluid through the implanted and uveoscleral pathways.

Data can be found in the literature indicating that the use of mCPA as the only treatment method does not always achieve the desired hypotensive effect. [Khodzhaev N.S., Sidorova A.V., Starostina A.V., Eliseeva M.A. Micropulse transscleral cyclophotocoagulation in the treatment of glaucoma. Russian ophthalmological journal. 2020; 13(2): 105-111. https://doi.org/10.21516/2072-0076-2020-13-2-105-111]. Consequently, currently an urgent problem in the field of ophthalmology is the development of new methods of laser treatment and combination treatment technologies.

The closest analogue is a method of combined surgical treatment of primary open-angle glaucoma (RF patent for invention No. 2688974), including the formation of a conjunctival incision, a superficial scleral flap (PSL) with the base to the limbus, and before the formation of the conjunctival incision, transscleral cyclophotocoagulation (mCPC) is performed contact-transscleral with using a diode laser in micropulse mode with a wavelength of 810 nm and an exposure of 80 sec, along a circular arc of 90 degrees in length in the lower hemisphere of the eyeball, 3-4 mm from the limbus, with an energy of 1200 mJ, with a duty cycle of 31.3%, pulse duration 0.5 ms, with a period of 1.1 ms, after the formation of the PSL, a deep scleral flap is formed, which is excised together with the outer wall of Schlemm’s canal and a strip of corneoscleral tissue, exposing Descemet’s membrane 0.5-0.8 mm wide, Healoflow drainage is introduced, put the PSL in place and complete the operation by applying a conjunctival suture.

The disadvantages of the closest analogue are high invasiveness, since it involves the formation of a conjunctival incision, as well as superficial and deep scleral flaps, which increases the likelihood of complications both in the intraoperative and postoperative periods.

The objective of the invention is to develop a method for treating the initial and advanced stages of primary open-angle glaucoma in patients who have uncompensated or subcompensated IOP while using 2-3 groups of antihypertensive drugs, regardless of the degree of trabecular pigmentation.

The technical result of the proposed method is the preservation of visual functions, activation of the uveoscleral and trabecular outflow pathways of the intraocular fluid, regardless of the degree of trabecular pigmentation, and the achievement of a hypotensive effect, which makes it possible to reduce the number of groups of antihypertensive drugs or eliminate their use.

The technical result is achieved by the fact that in the method of surgical treatment of primary subcompensated or uncompensated open-angle glaucoma, YAG laser activation of the trabecula (YAG-LAT) is performed 1 hour before mCPK. To perform YAG-LAT after instillation anesthesia, a Goldmann contact lens for gonioscopy was installed on the patient’s eye, through the side mirrors of which the laser beam was focused, using the Nd-YAG laser “Selecta Trio” from Lumenis Ltd. (Israel) with the following parameters: wavelength - 1064 nm, spot diameter - 10 microns, exposure - 3 ns, energy - 0.8-1.2 mJ. The surface of the trabecula in the projection of Schlemm's canal was sequentially subjected to laser action with single applications in the amount of 55-70, with an extension of 160 degrees, concentrically to the limbus, in the lower hemisphere of the eyeball, at an equal distance from each other, so that a small bubble was formed at each focusing point.

Next, according to the invention, mCFC is carried out, the second stage of combined treatment using a diode laser in a micropulse mode with a wavelength of 810 nm and an exposure of 80 s, along a circular arc of 160 degrees in length in the upper hemisphere of the eyeball, concentric to the limbus, using a MicroPulse P3 tip, with laser energy 1200 mJ, duty cycle 31.3%, pulse duration 0.5 ms, period 1.1 ms.

In the claimed method, performing mCFC along a 160-degree arc of a circle in the upper hemisphere of the eyeball reduces the likelihood of developing inflammatory complications after surgery and has a beneficial effect on patient tolerance to this procedure.

There is a cause-and-effect relationship between the set of essential features and the achieved technical result. Performing YAG-LAT causes a dosed reduction in IOP; laser exposure on the surface of the trabecula causes a shock wave, which moves the moisture of the anterior chamber and deposits on the surface of the trabecula, improving the trabecular outflow of IOP, which does not depend on the degree of pigmentation of the trabecula. On the other hand, mCPA enhances the extratrabecular outflow of intraocular fluid through activation of the uveoscleral pathway, which leads to a joint hypotensive effect of non-invasive methods acting in different directions.

The method is confirmed by the following examples.

Example 1. Patient D., 53 years old, was diagnosed at his place of residence in 2021 with primary open-angle glaucoma of the right eye. Pigmentation of the drainage zone I-II degree. A maximum antihypertensive regimen was prescribed: he was on three groups of antihypertensive drugs, IOP was compensated.

After 3 months, at an appointment at the place of residence, subcompensation of IOP was revealed, and therefore he was referred to the MNTK "Eye Microsurgery" in Moscow. Upon treatment VIS OD 0.6 sph 1.0 cyl 1.0 D=0.8, IOP 27 mm Hg. on antihypertensive drops.

In June 2021, the patient underwent a combined operation on the right eye using the claimed method: YAG-LAT, then mCPC using a diode laser in micropulse mode.

YAG-LAT was performed under installation anesthesia using a gonioscopic lens with the following parameters: wavelength - 1064 nm, spot diameter - 10 µm, exposure - 3 ns, energy - 0.8 mJ with 55 applications.

For transscleral CFC in micropulse mode, Cyclo G6 Glaucoma laser cyctem (IRIDEX, USA), wavelength 810 nm with an exposure of 80 sec, along a circular arc of 160 degrees in length in the upper hemisphere of the eyeball, 4 mm from the limbus, with an energy of 1200 mJ, was used. duty cycle 31.3%, pulse duration 0.5 ms, period 1.1 ms.

There were no complications observed in the postoperative period.

Upon discharge on the 2nd day: no complaints, OD IOP 22 mm Hg. VIS OD 0.6 sph 1.0 cyl 1.0 D=0.8.

In the postoperative period, cancellation of 2 groups of antihypertensive therapy. When monitored after 1 week, IOP was compensated.

At control after 1 month, the patient remained on one type of antihypertensive drugs, IOP was compensated. As a result of the operation, the patient had preservation of visual functions, a hypotensive effect was achieved, and a decrease in the hypotensive regime was achieved.

Example 2. Patient V., 66 years old, was diagnosed at his place of residence in 2020 with primary open-angle glaucoma of the left eye. Pigmentation of the drainage zone 0-1 degree. At the place of residence, a maximum antihypertensive regimen was prescribed: he was on three types of antihypertensive drugs, and there was no compensation for IOP.

The patient came for an appointment at MNTK MG in May 2020, with a diagnosis of VIS OS 0.4 shp 2.0 cyl 0.75 ax 70 D=0.5, IOP=26 mmHg, combined laser treatment was recommended.

In June 2020, a combination laser treatment was performed according to the invention: YAG-LAT, then mCPK using a diode laser in micropulse mode.

YAG-LAT was performed under installation anesthesia using a gonioscopic lens with the following parameters: wavelength - 1064 nm, spot diameter - 10 µm, exposure - 3 ns, energy - 1.0 mJ with 64 applications.

For transscleral CFC in micropulse mode, Cyclo G6 Glaucoma laser cyctem (IRIDEX, USA), wavelength 810 nm with an exposure of 80 sec, along a circular arc of 160 degrees in length in the upper hemisphere of the eyeball, 4 mm from the limbus, with an energy of 1200 mJ, was used. duty cycle 31.3%, pulse duration 0.5 ms, period 1.1 ms.

There were no complications observed in the postoperative period.

Upon discharge on the 2nd day: no complaints, OS IOP 22 mm Hg.VIS OS 0.4 shp 2.0 cyl 0.75 ax 70 D=0.5

In the postoperative period, cancellation of 2 groups of antihypertensive therapy. When monitored after 1 week, IOP was compensated.

When monitored after 1 month, no negative dynamics were noted; the patient remained on 2 types of antihypertensive drugs, IOP was compensated. As a result of the operation, the patient had preservation of visual functions, a hypotensive effect was achieved, and a decrease in the hypotensive regime was achieved.

Example 3. Patient T., 40 years old, was diagnosed at his place of residence in 2022 with primary open-angle glaucoma of the right eye. Pigmentation of the drainage zone of the III-IV degree. An antihypertensive regimen was prescribed at the place of residence: he was on two types of antihypertensive drugs, IOP remained at the upper limit of normal.

The patient came for an appointment at MNTK MG in August 2022, with a diagnosis of VIS OD 0.6 shp 1.0 cyl 0.75 ax 110 D=0.8, IOP=25 mm Hg, combined laser treatment was recommended.

In September 2022, a combination laser treatment was performed according to the invention: YAG-LAT, then mCPK using a diode laser in micropulse mode.

YAG-LAT was performed under installation anesthesia using a gonioscopic lens with the following parameters: wavelength - 1064 nm, spot diameter - 10 µm, exposure - 3 ns, energy - 1.2 mJ in 70 applications.

For transscleral CFC in micropulse mode, Cyclo G6 Glaucoma laser cyctem (IRIDEX, USA), wavelength 810 nm with an exposure of 80 sec, along a circular arc of 160 degrees in length in the upper hemisphere of the eyeball, 4 mm from the limbus, with an energy of 1200 mJ, was used. duty cycle 31.3%, pulse duration 0.5 ms, period 1.1 ms.

There were no complications observed in the postoperative period.

Upon discharge on the 2nd day: no complaints, IOP OD 20 mm Hg.VIS OD 0.6 shp 1.0 cyl 0.75 ax 110 D=0.8.

In the postoperative period, discontinuation of antihypertensive therapy. When monitored after 1 week, IOP was compensated.

When monitored after 1 month, no negative dynamics were noted, the patient was without antihypertensive therapy, IOP was compensated.

As a result of the operation, the patient's visual functions were preserved, a hypotensive effect was achieved, and the hypotensive drip regimen was discontinued.

Claims (1)

A method of combined laser treatment of primary open-angle glaucoma, including transscleral cyclophotocoagulation (mCPC) contact-transscleral using a diode laser in a micropulse mode with a wavelength of 810 nm and an exposure of 80 s, with an energy of 1200 mJ, with a duty cycle of 31.3%, pulse duration 0 .5 ms, with a period of 1.1 ms, characterized in that mCFC is carried out along a 160° arc of a circle, concentric to the limbus, in the upper hemisphere of the eyeball, and one hour before mCFC, YAG laser activation of the trabecula is performed, for which Nd is used -YAG laser “Selecta Trio” with the following parameters: wavelength - 1064 nm, spot diameter - 10 microns, exposure - 3 ns, energy - 0.8-1.2 mJ, exposure is carried out in single applications in the amount of 55-70, extending 160°, concentric to the limbus, in the lower hemisphere of the eyeball, at an equal distance from each other, so that a bubble is formed at each focusing point.