RU2132178C1 - Method for treating the cases of secondary glaucoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making sinusotrabeculotomy, after uncovering a fragment of ciliary body by cutting out U-shaped flap from deep layers of sclera with base facing equator. Sinusotrabeculotomy is made by applying ultrasonic treatment. Ciliary body is exposed to ultrasound of 7-8 mcm amplitude and 44 kHz frequency. The sclera flap is to be returned to its initial position. The deep sclera flap is not fixed. Sclera flaps are cut out by means of ultrasonic instruments. EFFECT: enhanced effectiveness of treatment course.

Description

 The invention relates to the field of medicine - ophthalmology and is intended for the treatment of patients with secondary glaucoma.

 Glaucoma is one of the most serious ophthalmic diseases, occupying one of the leading places in the nosological structure of primary disability due to eye diseases - 21.6% (Travkin A.G., Kiseleva O.A., Petrova T.Kh. et al. - Results a static analysis of the causes of primary visual disability in the RSFSR. // Abstracts of scientific and practical conf .: Diagnosis and microsurgery of shrapnel eye wounds today and tomorrow. - M., 1991. - P. 9-10).

 Of particular difficulty is the treatment of secondary glaucoma, which, in contrast to primary glaucoma, is the result of a previous illness or injury to the eyeball. This is due to the presence of various anatomical disorders that impede the outflow of intraocular fluid, and the development of organic changes in the natural ways of its outflow. The variety of combinations of various hydrostatic blocks that arise during this, the early obliteration of the Schlemm canal determines the frequent inefficiency of conservative treatment and conventional fistulizing and draining operations. The severity of scarring processes and the invasiveness of reconstructive operations that contribute to the restoration of natural hydrostatic ratios inside the eyeball interferes with the radical treatment of secondary glaucoma and often dramatically reduces the effectiveness of the operations performed, in particular, one of the most common operations for the treatment of open-angle secondary glaucoma - sinusotrabeculetomy (Krasnov M. M - Glaucoma Microsurgery. - M .: 1980, p. 146-154), selected by us for the closest analogue.

 At the same time, there are known methods of surgical treatment of primary glaucoma using an ultrasound instrument, the action of which is based on slowing down the processes of regeneration and scarring, which leads to the formation in the area of the operation of a gentle, filtering scar that has numerous cavities lined with endothelial cells. In this case, regenerative processes in the tissues are suppressed and permanent microfistulas are formed (O.G. Kretova - Use of low-frequency ultrasound in the surgical treatment of patients with open-angle glaucoma. // Abstract of thesis ... Candidate of Medical Sciences. - M., 1978, 16s .; Kretova OG, Kodzov MB, Method for the treatment of glaucoma. // USSR copyright certificate for the invention N 6956667: Bulletin N 417 - publication date 11/05/79).

 The technical result of the present invention is to enhance the filtration of intraocular fluid due to the combined effect of activation of the outflow from the anterior chamber through the fistula in the area of the scral sinus and the outflow from the posterior chamber and vitreous body through multiple microchannels formed in the ciliary body using ultrasound under the conjunctiva.

 The technical result is achieved by the fact that after cutting out a standard U-shaped sclera flap, the base facing the limb, before performing sinusotrabeclectomy, a fragment of the ciliary body is exposed by cutting a U-shaped flap from the deep layers of the sclera with the base facing the equator, then sinusotrabeclectomy is performed using ultrasound then they act on the ciliary body with ultrasound with an amplitude of 7-8 μm and a frequency of 44 kHz and return the sclera flaps to their original position without fixing it, except for t second, shearing scleral flaps produced by an ultrasonic tool.

 The method is as follows.

 After local anesthesia, the conjunctiva is cut and separated from the limb. Then, according to a well-known technique, for example, an U-shaped sclera is cut into a U-shaped sclera by 1/2 of its thickness, with the base to the limb, measuring 4x3 mm.

 Under the scleral flap, 0.5 mm from the limb, a U-shaped section of the deep layers of the sclera is made with the base facing the equator to the ciliary body with the same instrument. Then a sinusotrabeculectomy is performed with an ultrasonic scalpel in the same mode, followed by basal iridectomy with microsurgical scissors. A sclera deep flap is turned posteriorly, exposing a fragment of the ciliary body. An exposed ciliary body is affected by an ultrasonic applicator in the following mode: amplitude - 7-8 microns, frequency 44 kHz.

 During the operation, the front chamber is filled with the resulting gas bubbles, which eliminates the need for additional air at the end of the operation.

 A deep scleral flap is laid in its original place without fixation. On top of it, a superficial scleral flap is laid in place and fixed with two microsurgical sutures (8-00 silk) at the corners to the superficial layers of the adjacent sclera. A continuous shock is applied to the conjunctival wound.

 Specific examples of the method.

 1. Patient Ms, 4 months ago received a blunt injury to his right eye (punch). After 1 week, an increase in IOP was detected.

On admission:
Visus OD = 0.02 s -6.0 D = 0.08
Visus OS = 0.04 s -7.0 D = 0.9
Right eye with congestive conjunctiva and sclera injection. The cornea is dull, swollen. The front camera is of medium depth - in the center up to 3 mm. Mydriasis 5 mm. The lens is transparent. In the vitreous, filamentous destruction. On the fundus, myopic staphilloma of the optic disc. With gonioscopy, a circular recession of the iridoroganic angle was revealed.

 Upon receipt of IOP of the right eye = 27-28 mm Hg

 Tonography.

OD: Po = 25.06; C = 0.06; F = 0.90; KB = 418
OS: Po = 12.62; C = 0.14; F = 0.37; KB = 90
Sonography OD: retinal detachment is not detected, in the vitreous body floating opacities.

 EFI.

OD: 90 μA threshold, 39 Hz lability
OS: threshold 40 μA, lability 38 Hz
Perimetry: narrowing of the visual field in the upper nasal quadrant by 10-15 ^o .

 Diagnosis: OD - contusion secondary glaucoma II B, circular recession of the iris cornea, high complicated myopia, OS - high complicated myopia.

 The OD operation was performed using an ultrasonic instrument according to the method described above. During the operation, sharp hyperemia of the ciliary body was revealed. In the postoperative period, there was a small swelling of the conjunctiva from below, which persisted until discharge.

 IOP at discharge = 16 mmHg

 Tonography 1 month after surgery.

OD: Po = 14.37; C = 0.17; F = 0.76; KB = 65
OS: Po = 15.76; C = 0.16; F = 0.42; KB = 98
Normalization of IOP is maintained for 1 year. At the same time, corneal enlightenment and an increase in visual acuity to 0.6 (with correction of -63.0 D) were noted.

 2. Patient A-ko. Three years ago, he received a penetrating wound to his left eye in an explosion in a fire (domestic injury). The next day, the primary surgical treatment of sclera wounds was made. After 5 days - extraction of swelling traumatic cataract. After 1 year, secondary OS glaucoma was detected. Received conservative treatment without effect. In connection with the negative dynamics sent to the Institute.

On admission:
Visus OD = 1.0
Visus OS = 0.01 s +12.0 D
The left eye is enlarged, stagnant injection of conjunctiva and sclera. The penetrating scar of the conjunctiva and sclera in the lower half of the eyeball. The cornea is transparent. The anterior chamber is deep (in the center up to 4 mm). Aphakia. Destructive changes in the vitreous body. Fundus: optic nerve disc gray, with severe glaucomatous excavation.

 IOP OD = 31 mm Hg; OS = 16 mmHg

 Tonography.

OD: Po = 13.81; C = 0.25; F = 0.84; KB = 53
OS: Po = 31.82; C = 0.04; F = 0.87; KB = 795
Perimetry: a portion of the field of view is maintained in the lower-outer quadrant.

 EFI.

OD:
threshold 30 μA; lability 34 Hz
OS: threshold 40 μA; lability 36 Hz
Ultrasound biometry: front-rear axle OS = 22.5 mm: OS = 25.1 mm.

 Diagnosis: OD - healthy; OS - post-traumatic glaucoma III B, penetrating scar of the sclera, aphakia, butphthalmos.

 An OS operation was performed using an ultrasonic instrument according to the method described above. During the operation and in the postoperative period, no complications were noted.

 IOP at discharge = 15 mmHg

 Tonography 1 month after surgery.

OD: Po = 14.46; C = 0.18; F = 0.54; KB = 80
OS: Po = 18.26; C = 0.15; F = 0.76; KB = 122
Additionally, an instillation of a 0.25% solution of arutimol in the left eye is prescribed once a day. This contributes to the normalization of tonographic indicators:
OD: Po = 15.06; C = 0.19; F = 0.42; KB = 79
OS: Po = 16.52; C = 0.17; F = 0.34; KB = 97
Normalization of IOP in this mode is maintained for 10 months. At the same time, a slight increase in visual acuity to 0.02 with correction was noted.

 In total, the proposed method operated on 11 patients. In all cases, a stable normalization of IOP was obtained, and in 7 patients without the use of additional instillation therapy (myotics or timolol maleate).

 The main advantage of the proposed method over existing ones is the increased outflow of intraocular fluid, due to the simultaneous effect on the filtration zone of the angle - sinusotrabeculectomy and the effect on the ciliary body, creating conditions for drainage of intraocular fluid entering the vitreous body, as well as slowing down the regeneration processes when using ultrasonic surgical instruments.

Claims (2)

 1. A method of treating secondary glaucoma, including sinusotrabeculectomy, characterized in that prior to sinusotrabeculectomy, a fragment of the ciliary body is exposed by cutting a U-shaped flap from the deep layers of the sclera with the base facing the equator, then a sinusotrabeculectomy is performed using ultrasound, followed by ultrasound, and then body with ultrasound with an amplitude of 7-8 microns and a frequency of 44 kHz and return the scleral flap to its original position without fixing it.  2. The method according to p. 1, characterized in that the sclera flaps are cut using an ultrasound instrument.