RU2295939C1 - Method for carrying out combined surgical open angle glaucoma and cataract treatment with intraocular lens being implanted - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves first carrying out frontal circular capsulorhexis through corneal paracentesis. Then, 4 mm long conjunctival incision is carried out along limb moving upwards. 4 mm long sclera cut is done by 1/3 of its thickness near limb. 2,5 mm long and 2.0 mm high scleral screen of semi-oval shape is formed with 1,5 mm long step. The incision is continued into transparent layers of cornea over the whole its length. Deep scleral layers are further removed corresponding to the external screen size up to internal Schlemm's canal wall. The removal is done with adjacent juxta-canal trabecule portion and Descemet membrane being exposed. The anterior chamber is opened and phacoemulsification with intraocular lens implantation is carried out. After having laid superficial scleral flap on its original place, surgical intervention zone is covered with displaced intact conjunctiva. Buried purse-string suture is placed near the limb.

EFFECT: reduced risk of complications; accelerated healing processes; recovered stable visual function; prevented scleroconjunctival adhesion.

1 dwg

Description

The invention relates to medicine, namely to ophthalmology, and can be used for simultaneous surgical treatment of cataracts and glaucoma.

A known method of combining antiglaucomatous surgery with cataract phacoemulsification (Gimbel H.V, Meyer D .: "Small incision trabeculotomy combined with phacoemulsification and intraocular lens implantation" J. Cataract Refract. Surgery - 1995 - Vol. 21, N6 - P. 653-660).

The disadvantage of the existing technique is that as an anti-glaucomatous component of the operation, sinus-strabulectomy with iridectomy is used, therefore a relatively high percentage of complications is noted in the postoperative period: small anterior chamber, hyphema, choroid detachment, etc.

At the same time, the operation of non-penetrating deep sclerectomy is widely introduced into clinical practice (S.N. Fedorov, V.I. Kozlov, N.T. Timoshkina et al .: // Non-penetrating deep sclerectomy in open-angle glaucoma // Ophthalmosurgery - 1989. - No. 3-4. - S.52-55), allowing to achieve high clinical results with significantly fewer complications.

The closest analogue is the method of surgical treatment of open-angle glaucoma and cataract with implantation of an intraocular lens (RF patent No. 2155566 from 09.10.2000, Bull. No. 25). This method of surgical treatment of open-angle glaucoma and cataract with implantation of an intraocular lens includes simultaneous consecutive cataract phacoemulsification (FEC) and non-penetrating deep sclerectomy (NGSE) through a valve self-sealing sclera incision 3.0 mm from the limbus to 2/3 of its thickness with an opening Helm canal and exposure of the Descemet shell.

The disadvantages of the sequence of stages of the existing method of combined operations are:

- opening the anterior chamber on the eye with high intraocular pressure can lead to operational complications (rupture of the posterior capsule, damage to portions of the zinned ligament, iris, detachment of the choroid, hemorrhagic complications, cystic edema of the macula, etc.),

- removal of a deep scleral flap and the external wall of the Schlemm canal on the lower lip of the corneoscleral section after FEC with the anterior chamber opened, makes it difficult to carry out the above stage of NSH without emptying the anterior chamber, which provokes constant fluctuations in intraocular pressure (IOP) and can lead to operational complications (loss of the iris, hypheme, etc.),

- assessment of the level of filtration (filtration sample) may be unreliable due to the front chamber opened during the FEK,

- removal of a deep scleral flap, the external wall of the Schlemm canal and exposure of the descemet sheath in the area of the corneal incision when the anterior chamber is opened is technically difficult.

The disadvantages of the performed surgical approach include:

1) a relatively large area of surgical intervention, therefore, a large invasiveness of tissues, as well as the possibility of the formation of sclero-scleral adhesions in the incision zone, which may prevent the outflow of intraocular fluid;

2) the formation of the outer sclera flap at 2/3 of its thickness does not allow to obtain the optimal depth of the decompression chamber, because excised deep flap less than 1/3 of the sclera thickness. It also increases the likelihood of scleroscleral fusion of the bed of the operating area and can cause retention of intraocular fluid;

3) a conjunctival incision is projected over the surgical area, which can increase the likelihood of sclero-conjunctival adhesions and reduce the hypotensive effect of the operation.

The objective of the invention is to develop a safe and highly effective method for the combined surgical treatment of open-angle glaucoma and cataracts.

The technical result achieved by using the invention is to reduce operational and postoperative complications (hemorrhagic, inflammatory, hypertensive), accelerate healing processes, shorten rehabilitation periods and obtain high, stable visual functions in combination with a persistent hypotensive effect in the long-term postoperative period.

The technical result is achieved by the fact that during the combined surgical treatment of open-angle glaucoma and cataract with implantation of an intraocular lens, including simultaneous cataract phacoemulsification and non-penetrating deep sclerectomy through a single valve self-sealing sclera incision with opening of the external wall of the Schlemm canal, the invention is exposed and exposed anterior circular capsulorexis, then a conjunctival incision is made along the limb 4 mm long with its displacement up and perform a 4-mm incision of the sclera by 1/3 of its thickness near the limb with the formation of a scleral visor with a semi-oval shape 2.5 mm long and 2.0 mm high with a "step" 1.5 mm long and then continuing it into the transparent layers of the cornea along the entire length of the sclera incision, after which the deep sclera layers are removed according to the dimensions of the outer visor to the inner wall of the Schlemm canal with the adjacent juxtacanalicular part of the trabecula and exposure of the descemet shell. Then, after penetration into the anterior chamber, phacoemulsification is performed with IOL implantation and a surgical intervention area, covered with a displaced intact conjunctiva and an immersed purse string conjunctival suture is placed at the limb.

The modern development of simultaneous combined surgery for glaucoma and cataracts places high demands on tissue incisions and the implementation of all stages of the intervention to ensure maximum patient safety. From this perspective, the advantage of the proposed method for surgical treatment of open-angle glaucoma and cataract with implantation of an intraocular lens is that according to the invention, anterior circular capsulorexis is initially performed, since to conduct it qualitatively and to avoid operational complications, it is necessary to create the necessary level of intraocular pressure.

A conjunctival incision along the limb with a length of 4 mm with the preservation of an almost intact conjunctiva and tenon membrane allows to reduce surgical trauma, the volume of coagulation of the episcleral vessels and, therefore, to reduce the level of excessive scarring and the formation of conjunctival adhesions in the long-term postoperative period.

Performing a 4-mm section of the sclera by 1/3 of its thickness near the limb with the formation of a semi-oval scleral visor with a length of 2.5 mm and a height of 2.0 mm allows creating optimal conditions for the formation of a deep decompression chamber, preventing the formation of sclero-scleral fusions and ensuring a constant the outflow of intraocular fluid, which guarantees a persistent hypotensive effect in the long-term postoperative period.

Removing the deep layers of the sclera according to the size of the outer visor to the inner wall of the Schlemm canal with the adjacent juxtacanalicular part of the trabecula and exposing the descemet sheath is performed before opening the anterior chamber, which allows them to be performed at the initial level of ophthalmotonus and to obtain an adequate assessment of the filtration of intraocular fluid.

Covering the displaced intact conjunctival area of the surgical intervention promotes the development of a spilled, stable filtration pad around the scleral flap and eliminates excessive reparative processes, which allows a stable outflow of intraocular fluid and a persistent hypotensive effect in the postoperative period.

The location of the submersible purse-string conjunctival suture near the limb, outside the scleral visor area prevents external filtration, promotes the formation of a filter cushion in the outer area of possible excessive scarring, which subsequently also provides a persistent hypotensive effect in the long-term postoperative period.

The method is illustrated in the drawing, which schematically depicts the anterior segment of the eyeball with a semi-sectional incision located in the surgical intervention area, where:

1 - cornea, 2 - sclera, 3 - pupil, 4 - incision of the sclera, 5 - semi-oval visor, 6 - “step”, 7 - tunnel, 8 - limb, and - visor length, b - visor height.

The method is as follows:

Under local anesthesia, an eyelid expander is applied, the upper rectus muscle is taken on the stitch-holder. Corneal paracentesis is performed in the meridian of 10 and 2 hours, midriatic (for example, 0.1% mesatone solution) and viscoelastic (for example, viscomede) are introduced into the anterior chamber of the eye. Through paracentesis, the anterior lens capsule is opened by the method of circular capsulorexis. A section of the conjunctiva 4.0 mm long is carried out along the limb, concentrically to it with its displacement up. In the upper half of the eyeball (the meridian is 12 hours, the place is determined outside the zone of location of the graduate vessels), a four-millimeter incision of the sclera 4 by 1/3 of its thickness is made at the limbus with the formation of a semi-oval scleral visor 5, length a - 2.5 mm, height b - 2.0 mm with a “step” 6 1.5 mm long. The next step is the formation of a tunnel 7 with a knife with a fiber sealer, penetrating 1.0-1.5 mm into the transparent layers of the cornea along the entire length of the incision. Then, the deep layers of scleral tissue with a given size of the superficial scleral flap, the outer wall of the Schlemm canal with the adjacent juxtancanalicular part of the trabeculae and exposing the descemet sheath to obtain visible filtration of the intraocular fluid are removed. Penetration into the anterior chamber of the eye is carried out under the external scleral flap above the area of the exposed descemet sheath using a spear-shaped knife. Hydrodissection and hydrodelineation of the lens is carried out, followed by its removal using a phacoemulsifier. The remains of the lens masses are removed using an irrigation-aspiration system. An IOL is implanted in the capsule bag. The superficial flap of the scleral tunnel fits into place. The intact conjunctiva moves to the surgical area with the imposition of an immersive purse-string conjunctival suture near the limb outside the zone of the subsequent formation of the filtering pad. The operation ends with the introduction of a subconjunctival antibiotic solution.

Example

Patient: P. 62 years.

Diagnosis OD - Open-angle glaucoma of the 1st stage, immature complicated cataract.

Visual acuity before surgery: 0.2 s - 1.0 cyl ax 165 = 0.4.

Ophthalmometry: 169 degrees. 46.50 diopters, 79 degrees 47.50 diopters

Topography: P = 25.3, C = 0.09, F = 1.51, P / C = 111.

Field of view: narrowing by 10 degrees. from the nasal side, single absolute and relative scotomas from above and from the nasal side.

The anterior chamber angle is open, narrow, 20 deg., Pigmentation of 1-2 degrees of the posterior part of the trabecular zone is more pronounced in the lower segment of the eye.

Eye length: 21.71 mm.

The patient was performed simultaneous combined operation of the proposed method.

After local anesthesia and akinesia of the eyeball with a 2% lidocaine solution, a vector dilator was applied.

Initially, corneal paracentesis was performed in the meridian for 2 hours, midriatic (0.1% mesatone solution) and viscoelastic (viscomed) were introduced into the anterior chamber of the eye. Through paracentesis with an injection needle, anterior circular capsulorexis was performed.

A conjunctiva 4.0 mm long was performed on the limbus. The next stage at the limb was a tunnel valve section of the sclera 1/3 of its thickness 4.0 mm long with the formation of a semi-oval scleral visor measuring 2.5 × 2.0 mm with a “step” 1.5 mm long and a penetration of 1.0- 1.5 mm into the transparent layers of the cornea, along the length of the entire incision. Then, a deep layer of scleral tissue was removed by the specified size of the superficial scleral flap, the outer wall of the Schlemm canal and the adjacent juxtacanalicular part of the trabecula with exposure of the descemet sheath to obtain visible filtration of the intraocular fluid.

Penetration into the anterior chamber of the eye was carried out under an external scleral flap above the area of the exposed descemet sheath using a spear-shaped knife. Hydrodissection and hydrodelineation of the lens was carried out, followed by its removal using a phacoemulsifier. Hanita model posterior chamber elastic IOL was implanted into the capsule bag with an optical power of +21.0 diopters. The superficial flap of the scleral tunnel fit into place. Then, at the final stage, the intact conjunctiva was moved to the surgical area with the 8/0 immersive purse-string conjunctival suture at the limb, outside the scleral visor zone. The operation ended with the introduction of a solution of gentamicin and dexazone subconjunctival.

Visual acuity without correction 3 months after the operation was 0.9 n / k.

Ophthalmometry: 135 degrees 46.00 diopters, 45 degrees 47.00 diopters Topography: P = 15.90; C = 0.38; F = 2.23; P / C = 42.

Field of view: single relative scotomas from above and from the nose are preserved.

The anterior chamber angle is open, of an average width of 30 degrees, pigmentation of 1-2 degrees of the posterior part of the trabecular zone is more pronounced in the lower segment of the eye. In the upper segment, the surgical area is clearly visible.

The results obtained allow us to conclude that the method is effective and safe.

Using the proposed method allows you to:

- reduce the morbidity of surgical intervention,

- reduce the number of intra- and postoperative complications (hemorrhagic, inflammatory, hypertensive),

- significantly expand the indications for simultaneous intervention due to intraoperative compensation for IOP,

- increase the efficiency of the operation by accelerating the healing process,

- to obtain a persistent antihypertensive effect and high stable visual functions in the long-term postoperative period,

- accelerate the process of social and visual rehabilitation of patients.

According to the proposed method, 25 patients were operated on. All patients were characterized by an uncomplicated course of the operation with a quick restoration of visual function, compensation of intraocular pressure without anti-glaucomatous drugs, and the preservation of visual fields in the postoperative period.

Claims (1)

A method for the combined surgical treatment of open-angle glaucoma and cataract with implantation of an intraocular lens, including simultaneous cataract phacoemulsification and non-penetrating deep sclerectomy through a valve, self-sealing sclera incision with opening of the external wall of the Schlemm canal and exposure of the descemet capsule, which first comprises a front circle, wherein a conjunctiva incision along a limb 4 mm long with its displacement up and produce four millimeters throat section of the sclera by 1/3 of its thickness near the limb with the formation of a semi-oval scleral visor 2.5 mm long and 2.0 mm high with a "step" 1.5 mm long and the subsequent continuation of the section into transparent layers of the cornea along its entire length, then remove the deep layers of the sclera according to the size of the outer visor to the inner wall of the Schlemm canal with the adjacent juxtacanalicular part of the trabecula and exposing the descemet sheath, then after penetrating the anterior chamber, phacoemulsification with implantation of And A zone and surgical cover shifted intact conjunctiva at the limbus with the imposition of a submersible conjunctival purse-string suture.