RU2213547C2 - Method for preventing postoperative complications due to antiglaucoma operations done - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves placing transplant from biologically inert resolvable material over exposed vascular tunic after performing posterior sclera trepanation. The transplant has two protrusions of opposite direction branching from its upper and bottom surfaces. The lower transplant protrusion is implanted into subchoroid space distally relative to limb for allowing discharge to subchoroid fluid. The upper one is attached to adjacent sclera proximally relative to limb. The transplant is impregnated with diuretic agent solutions mixture for reducing vascular wall permeability. EFFECT: reduced risk of postoperative hemorrhagic complications and amotio retinae. 6 cl

Description

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

 One of the common complications associated with antiglaucomatous operations is postoperative choroid detachment (CCA), which, according to various authors, occurs with a frequency of 1.8-97%. The frequency and severity of the clinical course of CCA increases with surgery of advanced forms of glaucoma, and especially with surgical interventions in patients with various forms of secondary glaucoma. An increased risk of developing OSO in the postoperative period is associated with a gross pathology of the vascular system of the eyeball, affected by a long-existing glaucomatous process, and concomitant secondary glaucoma pathology (uveitis, post-traumatic disorders, etc.). The problem of postoperative CCA is even more acute in pediatric patients, who are characterized by extremely rapid stretching of the eyeball in the absence of compensation for intraocular pressure (IOP), accompanied by gross changes in the vascular wall and, as a result, an increased risk of both surgical and postoperative complications - high , often hemorrhagic nature of the CCA, a variety of hemorrhagic complications.

 One of the starting points for the occurrence of TOC is a sharp drop in IOP during the operation, which causes a vascular response in the form of transudation of fluid and blood through a pathologically dilated vascular wall (Eremina A.I. Postoperative detachment of the choroid: Abstract of diss. ... cand. Medical Sciences. - M., 1971. - 19 p.).

 The development of CCA in the early postoperative period reduces the hypotensive effect of surgical intervention, directing the outflow of intraocular fluid into the subchoroid space and, thereby, restricting filtration along the surgically formed outflow paths, inhibiting the formation of a filtering pad. Developed CCA requires active conservative treatment associated with frequent and difficult to tolerate patients, especially children, retrobulbar injections for the necessary drug to reach its destination - the choroid.

 A known method for the prevention of CCA by means of posterior trepanation of the sclera (Eremin A.I. Postoperative detachment of the choroid of the eye. Abstract. Thesis... Candidate of Medical Sciences. - M., 1971. - 19 C.), including the formation of a through scleral hole . The posterior trepanation of the sclera is 8-9 mm from the limb, in the zone of the most frequent formation of CCA blisters - the lower outer or lower inner segment. After the formation of the hole and exposure of the choroid, the triangular scleral flap is excised. This procedure is able to reduce intraocular pressure by 2-6 mm Hg, to somewhat soften the intraoperative drop in IOP. After the completion of the posterior trepanation, the sclera proceeds to the planned antiglaucomatous surgical intervention.

 However, the posterior trepanation of the sclera does not fully meet the requirements for the prevention of complications. Judging by the timing of the occurrence of CCA (2-5 days after a fistulizing operation), the reason for the low efficiency of the posterior trepanation of the sclera is the rapid obstruction of the opening of the adjacent choroid and the absence of a prolonged outflow of fluid from the subchoroid space.

 The objective of the invention was to develop an effective way to prevent the development of CCA, hemorrhagic and other complications after antiglaucomatous operations, which allows for a prolonged delivery of the necessary drugs directly to the destination - the choroid and suppress due to the appropriate selection of drugs the transudative vascular reaction, as well as, if necessary to create a stable outflow of fluid from the subchoroid space in the postoperative period va, providing thus reliable prevention CCA and other hemorrhagic complications posterior segment of the eye.

 The technical result is to reduce the risk of developing postoperative CCA and hemorrhagic complications after antiglaucomatous operations and, as a result, reducing the length of the patient’s hospital stay, as well as stable compensation for IOP.

 The technical result is achieved by the fact that in the method for the prevention of complications according to the invention, after conjunctival incision, posterior trepanation of the sclera is performed in the lower external or lower inner segment of the eyeball 8-10 mm from the limbus, and after cutting the scleral flap cut off, a graft smaller than trepanation hole, size. The transplant is equipped with two protrusions extending from its lower and upper surface and directed in opposite directions. The lower protrusion of the graft distal to the limb is implanted in the subchoroid space, and the upper protrusion proximal to the limb is sutured to the sclera adjacent to the trepanation opening, thus protecting the transplant from possible displacement. The size of the graft should not exceed 2.0-2.5 mm, the thickness of the graft is 0.4-0.6 mm. The graft protrusions have a length of 2.5-3.0 mm, a width of 1.5 mm, the thickness of the protrusions is 0.2-0.3 mm.

 The graft is made of a biologically inert absorbable material (e.g., collagen). Pre-transplant is impregnated with a mixture of antihypertensive drugs and agents that reduce the permeability of the vascular wall, taken in the following ratio: antihypertensive drugs - 30-90%, drugs that reduce the permeability of the vascular wall - 10-70%.

 If the inflammatory factor is included in the pathogenetic chain of the glaucomatous process, the graft is additionally impregnated with steroid preparations.

 With an increased risk of postoperative infectious process, the transplant is additionally saturated with antibiotics. With advanced glaucoma, complicated by significant trophic disorders of the organ of vision, the graft is additionally impregnated with antioxidants. In the presence of severe desensitization of both local and general nature, the transplant is additionally impregnated with desensitizing drugs.

 In the presence of vascular pathology, the graft is additionally impregnated with antispasmodic agents that improve microcirculation.

 After implantation and fixation of the graft, a nodal immersion suture is placed on the conjunctival incision and proceeds to the planned antiglaucomatous intervention.

 The technical result is achieved due to the following.

 1. The lower protrusion of the graft implanted into the subchoroid space serves as a drainage and, being made, for example, of a collagen copolymer, drains the transudative fluid when it accumulates under the choroid in the postoperative period. Due to its small thickness, subchoroidal drainage does not pose a threat of additional expansion of the subchoroidal space.

 2. Placing the graft directly on the choroid provides a smooth and time-stretched (for 1-1.5 months) flow of drugs directly to the destination (choroid). Resorption of the graft within 4-6 months eliminates the need to remove it after performing its intended function.

3. An adequate selection of drugs allows you to influence the various links of the pathogenetic chain of the development of CCA and hemorrhagic complications in the early stages of their occurrence and, when complications occur, softens their clinical course. For this purpose, it is advisable to use the following groups of drugs:
1) Diuretic drugs (lasix, uregitis, mannitol), which have decongestants. The antihypertensive effect of the action of Lasix and uregitis, related to saluretics, is mainly associated with inhibition of reabsorption of Na and C1 ions and, to varying degrees, inhibition of carbonic anhydrase of the ciliary body. The antihypertensive and decongestant effect of mannitol related to osmotic diuretics is due to an increase in the osmotic pressure of the plasma and a decrease in water reabsorption.

 2) Means that reduce the permeability of the vascular wall (dicinone, emoxipin, vikasol), belong to various pharmacological groups. Dicinon, which belongs to the group of angioprotectors, improves blood microcirculation and metabolic processes, normalizes the permeability of the vascular wall and has a hemostatic effect in connection with an activating effect on the formation of thromboplastin. Vikasol, being a synthetic analogue of vitamin K, takes part in the formation of prothrombin and helps to normalize blood coagulation. Emoxipin, belonging to the group of retinoprotectors, has antioxidant properties, promotes resorption of intraocular hemorrhages and reduces capillary permeability.

 3) Steroid preparations (prednisone, dexazone, betamethasone) have anti-inflammatory, desensitizing, antitoxic and immunosuppressive effects.

 4) Antibiotics (gentamicin, netromycin, rocefin) have an antibacterial effect.

 5) Desensitizing drugs (suprastin, tavegil, pipolfen), acting on peripheral mediator processes, have an antihistamine effect.

 6) Antioxidants (mexidol, cytochrome, emoxipin) affect tissue metabolism, activate the processes of tissue respiration, accelerate the course of oxidative reactions.

 7) Antispasmodics (trental, cavinton, compliance) increase the supply of oxygen to tissues, stimulate blood flow and have an antispasmodic effect.

 The method is as follows. After standard processing of the surgical field, in the lower inner or lower outer segment, a conjunctiva is cut 8-10 mm from the limbus. Coagulate the surface of the sclera to prevent bleeding. A sclera of a triangular shape is made through a blade and a scleral flap is formed, separating two faces of the triangle from the underlying choroid, after exposure of the choroid, the third side of the scleral flap is cut off from the adjacent sclera, ending with the formation of a trepanation hole. A collagen graft is impregnated onto the choroid, saturated with a set of medications that is appropriate to the etiology of the glaucomatous process and the ophthalmostatus. The lower protrusion of the graft is implanted into the subchoroid space to a depth of 1 mm, and the upper protrusion is placed on the sclera adjacent to the trepanation hole and is sutured to it with one interrupted suture. An immersive conjunctival suture is applied to the conjunctival incision and proceeds to the planned antiglaucomatous intervention.

 The invention is illustrated by the following examples.

 Example 1. Patient T., 13 years old. He entered the children's department of MNTK MG with a diagnosis of OD: secondary (post-traumatic) uncompensated glaucoma. Traumatic cataract. OS: healthy. 7 months ago, he suffered a penetrating wound in his right eye. 2 months ago, secondary glaucoma was detected in the right eye. On examination of the right eye - a paraceigral traumatic scar of the cornea, fused with the iris. The posterior synechia along the pupil edge. Traumatic half-absorbed cataract.

 Vis OD = right light projection; OS = 1.0; IOP 0D = 30 mm Hg; OS = 21 mmHg The length of the anteroposterior axis of the right eye was 23.8 mm (on the left eye, the length of the anteroposterior axis corresponded to 23.4 mm).

A non-penetrating sclerectomy with the prevention of postoperative complications by the proposed method was performed on a child in the right eye. Given the stage of development of the glaucomatous process, the transplant was saturated with lasix and dicinone in the following ratio of components, vol.%:
Lasix - 70
Dicinon - 30
The operation and the postoperative period were uncomplicated. Dynamic ultrasound scanning did not reveal a postoperative pathology of the choroid during the entire observation period. The child was discharged from the hospital on the 11th day after the operation. IOP on the right eye at discharge amounted to 16 mm Hg

 Example 2. Patient S., 8 years old. Received treatment with a diagnosis of OD: secondary uveal uncompensated almost absolute glaucoma. OS: healthy. He was operated on for glaucoma three times, with a short-term hypotensive effect.

 When examining the right eye - marginal tape-like dystrophy of the cornea. The front camera has a depth of 2.5 mm, uniform. Mesodermal dystrophy of the iris. A pupil with a diameter of about 2 mm. Secclusio pupil, pupil film. In a crystalline lens inhomogeneous opacities. Underlying environments are not visible.

Visual acuity of the right eye is the correct light projection. IOP - 32 mmHg. Art. The length of the anteroposterior axis of the eye is increased to 29.4 mm. Given the etiology of glaucoma and the stage of development of the disease, a deep sclerectomy was performed on the child’s right eye with prophylaxis of complications according to the proposed method, while the transplant was impregnated with a mixture of the following composition, vol.%:
Mannitol - 30
Vikasol - 25
Betamethasone - 25
Cytochrome C - 20
The operation and the postoperative period proceeded without complications. In the early stages (on the 3rd day after the operation), according to the data of ultrasound scanning, the child was diagnosed with peripheral CCA with a maximum height of 1.5 mm. The CCA disappeared by day 8 after surgery without additional therapy. The child was discharged from the hospital on the 12th day after the operation. The IOP of the operative eye at discharge was 17 mm Hg.

 Example 3. Patient A., 16 years old, was admitted for treatment to the children's department of the MNTK MG with a diagnosis of the right eye - secondary operated uncompensated glaucoma. The left eye is healthy. Sturge-Weber Syndrome. He had a history of surgery for secondary glaucoma with a short-term hypotensive effect. In 2000, IOP decompensation was detected (up to 32 mmHg). The appointment of a regime of antihypertensive instillations did not give effect and the patient was sent to the ISTC MG.

When viewed from the right eye, the cornea is transparent. A pupil with a diameter of about 3.5 mm, the reaction to light is preserved. The lens is transparent. In the vitreous body, isolated semi-fixed opacities. With ophthalmoscopy, the optic disc is pale, monotonous, with a displacement of the vascular bundle to the nose and a marked expansion of physiological excavation. The central zone and periphery of the retina without focal pathology. With gonioscopy in the lower segment, a conglomerate of newly formed vessels located in the corner of the anterior chamber from 17 to 18 hours is determined. The visual acuity of the right eye is -0.06 with sph-3,0D = 1,0. The field of view is narrowed from the bow by 10 ^o IOP - 34 mm Hg

In February 2000, the patient underwent a deep sclerectomy with explant drainage according to the proposed method with implantation in the area of posterior trepanation of the sclera graft soaked in a mixture of drugs of the following composition, vol.%:
Lasix - 30
Dicinon - 20
Gentamicin - 20
Trental - 20
Suprastin - 10
In the first days after surgery, the depth of the anterior chamber was 2.5 mm. IOP was in the range of 14-15 mm Hg. A control ultrasound examination conducted on the 2nd, 4th and 7th days after surgery revealed a slight swelling of the choroid, not exceeding 1.0 mm in the periphery and the absence of TOC. The edema of the choroid is completely stopped, according to ultrasound, by the 7th day after the operation. The postoperative period was characterized by a smooth course, not differing in specific features and complications. The patient was discharged from the hospital on the 8th day after the operation. Vision at discharge 0.06 with sph-3,0D = 0.1. IOP - 17 mm. Hg. Art. Recommendations on postoperative neurotrophic treatment and IOP monitoring at the place of residence are given.

 The invention provides an effective way to combat the occurrence of postoperative hemorrhagic and inflammatory complications, as well as CCA during surgery for severe forms of glaucoma. Using the method according to the described method accelerates the rehabilitation of the patient and, due to the reduction of postoperative complications, stabilizes the hypotensive effect of surgical intervention. The method is technically simple and affordable, does not require additional surgical skills and expensive equipment.

Claims (5)

1. A method for the prevention of postoperative complications of antiglaucomatous operations, including posterior trepanation of the sclera, characterized in that after posterior trepanation of the sclera, a graft of biologically inert absorbable material with two protrusions extending from its upper and lower surfaces and directed in opposite directions is placed on the exposed choroid at the same time, the lower protrusion of the graft is implanted distally in relation to the limb into the subchoroidal space to ensure the outflow of subchor ioid fluid, and the upper one is fixed proximal to the adjacent sclera with respect to the limbus, and the graft itself is impregnated with a mixture of drugs taken in the following ratio, vol.%:
Antihypertensive drugs with decongestant action - 30-90
Means that reduce the permeability of the vascular wall - 10-70
2. The method according to claim 1, characterized in that the transplant is additionally impregnated with steroid preparations, which use dexazone, or prednisolone, or betamethasone.  3. The method according to claims 1 and 2, characterized in that the transplant is additionally impregnated with antibiotics, which are used as gentamicin, or rocefin, or netromycin.  4. The method according to claims 1 to 3, characterized in that the transplant is additionally impregnated with antioxidants, which use mexidol, and / or cytochrome, and / or emoxipine.  5. The method according to claims 1 to 4, characterized in that the transplant is additionally impregnated with desensitizing preparations, which are used as suprastin, or tavegil, or pipolfen.  6. The method according to claims 1-5, characterized in that the graft is additionally impregnated with antispasmodic agents that improve microcirculation, which are used as trental, and / or cavinton, and / or compliant.