RU2195238C2 - Method for treating glaucoma in children - Google Patents

Abstract

FIELD: medicine, ophthalmosurgery. SUBSTANCE: conjunctival and surface scleral fragments are formed, deep scleral fragment is separated from underlying vascular membrane and resected together with a strip of trabecular area, a surface scleral fragment is put to its place to fix it to adjacent sclera with interrupted sutures. Moreover, before wound sealing a Tennon's membrane is punctured with a needle in a direction parallel to the surface of underlying sclera by placing a needle's opening towards a Tennon's membrane. Then, by separate uninterrupted sutures one should suture a Tennon's and a conjunctival membranes, a syringe is put onto a needle's coupling being filled with perfluorocyclobutane at 1:1 ratio together with sterile air. This mixture is introduced under a Tennon's membrane at 0.2 ml amount by forming a subconjunctival cavity above operation area. EFFECT: more stable hypotensive action.

Description

 The invention relates to medicine, and specifically to ophthalmology, and can be used to treat various etiological forms of glaucoma in children.

 Children's glaucoma is characterized by the difficulty of achieving stable compensation for intraocular pressure (IOP). The main reason for the instability of the hypotensive effect in anti-glaucomatous surgery in children is the tendency of pediatric patients to develop plastic processes and rapidly overgrow out outflow pathways formed by the surgical method (Br. J. Ophthalmol 1991; N 75: 584-590). Due to adhesive inflammation in the surgical area, especially in the first days after the operation, the formation of a filtration cushion (AF), which is an indicator of the stability of IOP compensation, is not so characteristic for pediatric patients as it is for the adult patient population.

 Another problem in the early postoperative period after antiglaucomatous surgery is the pressure drop arising in the first days after surgery from hypertension to hypotension, which, being undoubted stress for the pathologically altered vascular system of the glaucoma eye, leads to undesirable reactions from the choroid and, as a result, the development of edema and detachment of the choroid (CCA). Filtration along the newly created outflow paths ceases due to the occurrence of pathological filtration of the fluid under the choroid.

 A known method for the treatment of glaucoma of various etiologies, including in children, is deep sclerectomy (GSE) (Clinical aspects of the pathogenesis and treatment of glaucoma: Sat scientific articles. - M., 1984, p. 64-67), including the formation of superficial conjunctival, superficial scleral and deep scleral flaps. The superficial scleral quadrangular flap is separated from the underlying sclera by 2/3 of its depth, with the base to the limb. A deep scleral flap of a triangular shape with the base to the limb is separated from the underlying choroid and excised at the base with the trabecular zone of this segment. The superficial scleral flap is returned into place, fixing it to the adjacent sclera with interrupted sutures. Seal the wound by applying a continuous suture to the conjunctival flap.

 However, the drop in the IOP that occurs during this method of surgical intervention has an undesirable effect on the vessels of the eyeball that are pathologically altered by the glaucomatous process, which is manifested in a variety of surgical and postoperative complications of the vascular system of the eye.

 The objective of the invention is to develop an effective method for the treatment of glaucoma in children, which makes it possible to mitigate the postoperative drop in IOP and at the same time stabilizes the hypotensive effect of the operation due to the intraoperative formation of a filtering pad (AF).

 The technical result is a stable normalization of IOP, a decrease in the number and intensity of complications from the choroid in the postoperative period, and, as a result, a reduction in the length of the patient’s hospital stay.

 The technical result is achieved by the fact that in the treatment method according to the invention, after performing the main steps of the surgical procedure, before suturing the tenon sheath, she is pierced with an injection needle, shearing the needle parallel to the surface of the underlying sclera, and the needle opening is directed to the tenon sheath, then the tenon sheath and conjunctiva are sutured with separate continuous sutures. A 1.0 ml syringe filled with perfluorocyclobutane related to heavy gases in proportion to sterile air 1: 1 is put on a needle sleeve and injected under a tenon sheath in an amount of 0.2 ml.

 The technical result is achieved by filling the cavity of the future AF with heavy gas, forming a cavity of the desired size, not allowing adhesive inflammation to occur and keeping the AF cavity intact for 9-10 days, necessary for gas resorption. This time is enough to stop the early postoperative inflammatory reaction against the background of ongoing anti-inflammatory treatment. Considering the property of perfluorocyclobutane to expand after administration, no more than 0.2 ml of gas is sufficient to enter under the tenon shell, which then, expanding, will occupy a volume of about 0.4 ml.

 Heavy gas, located directly above the surgical area, presses the superficial scleral flap to the underlying choroid, restricting the free exit of intraocular fluid (IHL) from the eye cavity and playing the role of a kind of "gas" valve. Thus, there is a reduction in the early filtration of HPW. The postoperative pressure drop decreases, the postoperative pathological vascular reactions soften - the number, intensity and duration of edema and choroid detachment (CCA) are reduced. As the gas is resorbed, the outflow of the HPW gradually increases, reaching a constant value by 9-10 days after the operation, when the gas is completely absorbed and the FP cavity fills directly into the HPW.

 The method is as follows. After standard processing of the surgical field, a conjunctival flap 6.0 mm high is removed in the desired segment along with the underlying tennon membrane. From the surface layers of the sclera, at 2/3 of its depths, a quadrangular flap 4 x 5 mm, with the base to the limbus, is cut out and it is separated from the underlying sclera. From the deep layers of the sclera, a triangular-shaped flap is cut out, with a base to the limb, smaller than the superficial scleral flap, it is separated from the underlying choroid and excised at the base with a strip of the trabecular zone and the schlemm canal. If necessary, a basal iridectomy is performed. The superficial scleral flap is returned into place, fixing it to the adjacent sclera with 2-3 interrupted sutures. 2 mm from the limb, closer to the lateral edge of the conjunctival flap, puncture the conjunctiva and tennon membrane with a needle with a diameter of 0.6 mm, a length of 30 mm, directing the movement of the needle parallel to the sclera surface. The hole of the needle is oriented toward the tenon sheath, positioning the hole of the needle at the projection site of the middle of the length of the conjunctival flap 2 mm from the limbus. Then, the tenon and conjunctival membranes are sutured with separate continuous sutures, and a syringe filled with heavy gas perfluorocyclobutane in the ratio of sterile air 1: 1 is put on the needle sleeve and injected under the tenn sheath in an amount of 0.2 ml. Immediately after the introduction of gas under the tennon shell, a slight elevation of the conjunctival flap is formed in this zone in the form of a cavity filled with gas distributed there. Already 2-3 days after surgery, the volume of the cavity under the conjunctival flap begins to increase due to the tendency of the injected gas to expand. The optimal volume of the cavity is maintained up to 5-6 days after the operation, after which the gas begins to dissolve gradually, the IHL begins to flow into the cavity, filling in the AF formed in the early stages.

 The invention is illustrated by the following example.

 Example 1. Patient B., 8 years old, was admitted for treatment to the children's department of the MNTK "MG" with a diagnosis of the right eye: developed, operated, uncompensated secondary glaucoma. Traumatic cataract. Left eye: healthy. 2 years ago, in October 1998, the boy suffered a penetrating wound to his right eye with a knife. The primary surgical treatment and leaching of swelling lens masses was performed on the day of injury at the place of residence. 2 months after the grass at the place of residence, IOP decompensation was detected and a diagnosis of secondary glaucoma was made. The appointment of a regime of antihypertensive instillations had no effect, and in March 1999 a filter-type anti-glaucomatous operation was performed at the child’s place of residence. Compensation of IOP after surgery persisted for 4 months, after which IOP again increased to 28-30 mm RT. Art. Conservative treatment had no effect and the child was sent to the MNTK "MG".

 When examining the right eye - penetrating the central scar of the cornea 23.5 mm, fused with the iris. The front camera is 3.2 mm. The iris is subatrophic. The pupil is slightly decentered towards the scar, 2 x 3 mm. Semi-absorbed traumatic cataract. Underlying environments are not visible. The visual acuity of the right eye is right. light projection. Due to low functions, the field of view was not reliably determined. IOP - 32 mmHg Topographic indicators showed a significant increase in Po - up to 33.3 mm Hg, a decrease in outflow - up to 0.03, with a moderate compensatory decrease in HPV production - up to 1.67, the Becker coefficient significantly increased, amounting to 235. According to the ultrasound data, the length 24.6 mm corresponded to the right eye, which is 1.9 mm more than the length of a healthy eye.

 In December 1999, the child underwent a deep sclerectomy with intraoperative AF formation according to the invention. In the first days after surgery, the IOP was at the level of 19-20 mm Hg. In the AF region, a heavy gas bubble of about 0.4 mm in volume remained for 9 days. Gradually, the volume of the gas bubble began to decrease; in part, it was replaced by the HPW. By day 10 after surgery, the AF cavity was filled with fluid. The digital values of IOP decreased to 16 mm Hg. During a hospital stay, the child was repeatedly examined for the condition of the posterior segment of the eyeball using the B-scan method. Mild swelling of the choroid, which occurred immediately after the operation, disappeared by 3 days after the operation.

 When viewed 6 months after repeated antiglaucomatous intervention, negative dynamics were not observed in the state of the organ of vision. The IOP remained stable and its digital values corresponded to 18-19 mm Hg. Art. Data from tonographic studies demonstrated the normalization of hydrodynamics - the outflow of HPW increased to 2.2, the production coefficient was 2.6, the Becker coefficient decreased to 89. The length of the eyeball during the observation did not change in both the operated and healthy eyes. During biomicroscopy in the surgical area, a flat, non-vascular AF of 6 x 8 mm was clearly differentiated, otherwise the state of the eyeball corresponded to the initial treatment.

 The invention is distinguished by the simplicity of technology, the absence of the need for expensive operating equipment, the execution of the method does not require special surgical skills. The application of the method provides a calmer, without complications from the posterior segment of the eyeball postoperative period and, as a result of this, a reduction in the length of the patient’s hospital stay. The obtained antihypertensive effect is stable due to the long life and effective functioning of AF.

Claims (1)

 A method for treating glaucoma in children, including the formation of a conjunctival and superficial scleral flap, cutting, separation from the underlying choroid and excision of the deep scleral flap along with the strip of the trabecular zone, returning the superficial scleral flap to its place and fixing it to the adjacent sclera with interrupted sutures, sealing the wound characterized in that before sealing the wound, the tennon membrane is pierced with a needle in a direction parallel to the surface of the underlying sclera, with the hole of the needle to the tenon sheath, then the tenon and conjunctival sheaths are sutured with separate continuous sutures, a syringe filled with perfluorocyclobutane in a 1: 1 ratio with sterile air is put on the needle sleeve, and this mixture is injected under the tenon sheath in an amount of 0.2 ml, thus forming subconjunctival cavity above the area of operation, and then remove the needle.