RU2327438C1 - Method of combinated surgery treatment of open-angle glaucoma and cataract associated with intraocular lens implantation and application of hydroacoustic trabecula activation - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: anterior circular capsulorexis is performed through valve self-sealing sclera incision. Conjunctiva is dissected along limb of length 3 mm and shifted upwards. Sclera is dissected for 3 mm by 1/3 of its thickness to limb forming semi-oval sclera apron of length 2.5 mm and height 2.0 mm. Then incision is laminated along the full length to transparent layers of cornea. Deep layers of sclera are removed correspondingly to sizes of external apron to inner wall of venous sinus with adjacent juxte-canalicular part of trabecula and uncovering of Descemet's membrane. After penetration to anterior chamber phakoemulsification is combined with IOL implantation. After that phako-needle is covered with branch pipe of diameter 2.5 mm, beyond needle hoop for 1.0 mm, and within 10-30 sec uncovered trabecula and Descemet's membrane is exposed with water jet at pressure 0.05-0.1 atm, ultrasonic activated aw frequency 28.5 kHz and power up to 30 ml W. Then trabecula is actively washed with water supplied through paracentesis to anterior chamber at power 0.05 atm. Intraocular fluid is aspirated from exterior surface of trabecula combined with evacuation of pigment and fine-dispersed material from intertrabecular sheets of filtration areas with vacuum to 10 mm of mercury column by means of aspiration-irrigation system of phakoemulsification using standard steel cannula as aspiration tip with aperture at the bottom. Surgery zone is covered with shifted intact conjunctiva with applied buried purse-string conjunctival suture by limb.

EFFECT: reduced complication number; more rapid recovery process and reduced rehabilitation time.

1 ex, 4 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 HV, Meyer D .: "Small incision trabeculotomy combined with phacoemulsification and intraocular lens implantation" J. Cataract Refract. Surgery - 1995 - Vol.21, No. 6 - 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 implemented in 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, - p.52-55), which allows 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 3.0 mm from the limbus by 2/3 of its thickness with an opening the walls of the Schlemm canal and exposure of the descemet shell.

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

- the implementation of the anterior circular capsulorhexis after HSE is difficult due to the inability to create optimal intraocular pressure (IOP) in the anterior chamber,

- removal of a deep scleral flap, the external wall of the Schlemm canal and exposure of the descemet sheath on the lower lip of the corneoscleral incision when the anterior chamber is opened is technically difficult without emptying it, which provokes constant IOP fluctuations and can lead to operational complications (loss of the iris, hyphema, etc. .),

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

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.

According to the literature, after microinvasive non-penetrating deep sclerectomy in the long-term postoperative period, up to 73.52% of patients need additional laser descemetogoniopuncture - (Kh.P. Takhchidi, D.I. Ivanov, D. B. Bardasov “Long-term results of microinvasive non-penetrating deep sclerectomy ophthalmosurgery No. 3. - 2003). Therefore, the issue of increasing permeability (improving drainage function) of trabeculae remains relevant.

According to the literature (B.N. Alekseev, Yussef Naim Yussef, A.S. Vvedensky, N.V. Mutonen, T.V.Sharnina "Study of the effect of ultrasonic phacoemulsification on eye hydrodynamics" Actual problems in ophthalmology. Abstracts. Moscow, 26 -27 September 2003. - p. -189-191) and based on our own research (M.Frankovska-Gerlak, N.P. Yanovskaya, E.Z. Mukhametshina "Retrospective analysis of the clinical and functional results of surgical treatment of age-related cataract by phacoemulsification and mechanical tunnel phacofragmentation with sclero-limbal dos mention "Actual problems of ophthalmology. All-Russian Conference of Young Scientists. Moscow - 2006. - pp. 176-179) we believe that the reliability of IOP reduction after performing FEC is due to the effect of ultrasonic waves on trabecular plates, which lead to their vibration, which helps to cleanse and leaching of pigment and other deposits, as well as the expansion of inter-trabecular fissures and improved filtration ability of the trabeculae.

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 with the aim of obtaining a more stable and lasting hypotensive effect.

The technical result achieved by using the invention is to reduce surgical and postoperative complications (hemorrhagic, inflammatory, hypertensive), accelerate healing processes, shorten rehabilitation time, obtain high, stable visual functions and a more stable hypotensive effect in the long-term postoperative period due to hydroacoustic activation of the trabecula .

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 incision of the sclera with the opening of the outer wall of the Schlemmis canal and initial exposure perform anterior circular capsulorexis, then produce a conjunctival incision along the limb 3 mm long with its displacement upwards and a 3.0 mm section of the sclera is made 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” of 0.5 length mm and its subsequent extension 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 external visor to the inner wall of the Schlemm canal with the adjacent juxta-canalicular part of the trabecula and exposure of the descemet shell. Then, after penetration into the anterior chamber, phacoemulsification is carried out with IOL implantation and before suturing the conjunctiva, a nozzle in the form of a silicone tube 2.5 mm in diameter and protruding 1.0 mm relative to the end of the needle is put on the phaco needle, a jet is exposed to the trabecula and descemet sheath water under pressure from 0.05 atm to 0.1 atm, activated by ultrasound with a frequency of 28.5 kHz and power up to 30 mW for 10-30 seconds, then the trabecula is washed by supplying water to the front chamber under a pressure of 0.05 atmosphere through parace synthesis and using a phacoemulsifier aspiration-irrigation system using a standard, steel cannula in the form of an aspiration tip with a bottom hole, vacuum, up to 10 mm Hg, is aspirated, intraocular fluid is aspirated from the outer surface of the trabecula with the evacuation of pigment and finely dispersed material from the intertrabular fissures of the zone the filtration and the surgical area are covered with a displaced intact conjunctiva with an immersed, purse-string conjunctival suture 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 3 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 3-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.

The removal of the deep scleral layers according to the dimensions of the external visor to the inner wall of the Schlemm canal with the adjacent juxta-canalicular 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 intraocular fluid filtration.

It is known that one of the main links in the pathogenesis of the development of open-angle glaucoma is a violation of the hydrodynamics of the eyes. The deterioration of the outflow of chamber moisture in open-angle glaucoma is mainly due to a violation of the permeability of the trabeculae as a result of dystrophic changes (destruction of fibrous structures, thickening of the trabecular plates, accumulation of organic deposits and pigment in the interstitial crevices and in the juxta-canalicular layer), which can ultimately lead to ocular occlusion cracks and violation of the filtration function of the endothelium of the walls of the Schlemm canal. (J. A. Mc Alister and R. P. Wilson: Alterations in the outlow system in chronic simple glaucoma. Glaucoma. London. 1986. p. 7-12). It is known that the narrowing or partial closure of the intertrabular gaps leads to a decrease in the ability of the trabecular filter to self-clean.

As a result of the action of ultrasound, the trabecula structures (plates) oscillate, which leads to the movement (trembling of cells) of the pigment, pseudoexfoliation material and other deposits in the anterior chamber corner, leaching and evacuation of finely dispersed material from the inter-trabecular slots of the filtration zone, which improves the outflow of aqueous humor through the drainage paths created during the operation, increases the hypotensive effect and lead to stable stabilization of intraocular pressure in the postoperative period. The impact of a jet of water under pressure from 0.05 atm to 0.1 atm, activated by ultrasound with a frequency of 28.5 kHz and a power of up to 30 mW, for 10-30 seconds on the exposed trabecula and descemet shell, followed by washing the trabecula with water under pressure 0 , 05 atm and vacuum, up to 10 mm Hg, its aspiration is sufficient to achieve a technical result.

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 region of possible excessive scarring, which subsequently also provides a persistent hypotensive effect in the long-term postoperative period.

The method is illustrated in figures 1-4.

Figure 1 schematically shows the anterior segment of the eyeball with a semi-oval-shaped incision located in the surgical area, figure 2 schematically shows the sagittal section of the combined surgical area with the location of the phaco-needle placed in the silicone tube during sonar activation of the trabecula, in figure 1 .3 schematically shows a sagittal section of the combined surgical area during vacuum aspiration using a phacoemulsion aspiration-irrigation system fikatora using standard, steel cannula into a suction nozzle with a hole bottom, Figure 4 schematically depicts a silicone tube of 2.5 mm diameter, 12.0 mm in length.

Position 1 denotes the cornea, 2 - the sclera, 3 - the pupil, 4 - incision of the sclera, 5 - semi-oval visor, 6 - “step”, 7 - tunnel, 8 - limb, and - visor length, c - visor height, 9 - trabeculae 10 - phaco-needle, 11 - silicone nozzle with a diameter of 2.5 mm, length 12.0 mm, 12 - irrigation tip, 13 - suction tip, 14 - steel cannula with an opening from the bottom.

The method is as follows:

The operation is performed under local anesthesia. Corneal paracentesis is performed in the meridian of 10 and 2 hours. Through one of the paracentesis, the mydriatic (for example, a 0.1% solution of mesatone) and viscoelastic (for example, viscomed) are introduced into the anterior chamber of the eye. Through paracentesis, the anterior lens capsule is opened by the method of circular capsulorexis. A conjunctiva incision 3.0 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 / place is determined outside the zone of location of the graduate vessels), a limb is made of a three-millimeter incision of the sclera 4 by 1/3 of its thickness with the formation of a semi-oval scleral visor 5, length a - 2.5 mm, height - 2.0 mm with a “step” 6 0.5 mm long. The next stage is the formation of a tunnel, penetrating 1.0-1.5 mm into the transparent layers of the cornea with a knife with a delaminator, 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 juxta-canalicular 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. Before suturing the conjunctiva, the phaco-needle 10 is put on a silicone pipe 11 and the exposed trabecula and descemet sheath are exposed to a jet of water under pressure from 0.05 atm to 0.1 atm, activated by ultrasound with a frequency of 28.5 kHz and a power of up to 30 ml W within 10-30 sec. Then trabecula 9 is actively washed by supplying water to the anterior chamber under a pressure of 0.05 atm through paracentesis and using a phacoemulsifier 12 using an aspiration-irrigation system using a standard steel cannula 14 with an aspiration tip 13 with an opening from below, produce vacuum, up to 10 mmHg. Art., aspiration of intraocular fluid from the outer surface of the trabecula with the evacuation of pigment and finely dispersed material from the intertrabular fissures of the filtration zone and the surgical area cover the displaced intact conjunctiva with the imposition of the limbus submersible, purse-string conjunctival suture.

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 area of the subsequent formation of the filter pad. The operation ends with the introduction of a subconjunctival antibiotic solution.

Example. Patient X. 66 years old.

Diagnosis OD - Open-angle glaucoma II - in stage, mature complicated cataract.

Visual acuity before surgery: 0.08 s - 3.0 Dsph = 0.1

Ophthalmometry: 5 degrees. 44.75 diopters., 95 degrees., 45.75 diopters.

Topography: P = 28.0; C = 0.12; F = 1.32; P / C = 233.

Field of view: narrowing by 25 degrees. from the nasal side, multiple absolute and relative scotomas from above and from the nasal side.

The angle of the anterior chamber is open, 35 degrees., Pigmentation 3 degrees, mixed, more pronounced in the lower segment of the eye.

Eye length: 23.34 mm.

The patient was performed simultaneously, 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 incision 3.0 mm long was performed on the limbus. The next stage at the limb was a tunnel valve section of the sclera into 1/3 of its thickness, 3.0 mm long, with the formation of a semi-oval scleral visor measuring 2.5 × 2.0 mm with a “step” 0.5 mm long and 1 penetration, 0-1.5 mm in the transparent layers of the cornea, along the length of the entire incision. Then, a deep layer of scleral tissue was removed with a given size of the superficial scleral flap, the outer wall of the Schlemm canal and the adjacent juxta-canalicular part of the trabecula, exposing 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. A posterior chamber elastic IOL of the Acrysof Naturale model with an optical power of + 20.0 diopters was implanted in the capsule bag. The next step exposed the trabecula and descemet shell with a stream of water under pressure from 0.05 atm to 0.1 atm, activated by ultrasound at a frequency of 28.5 kHz and a power of up to 30 mW using a phaco needle with a diameter of 2.5 mm, placed in a silicone tube protruding 1.0 mm relative to the end of the needle with a minimum vacuum (aspiration) of 5.0 mm Hg for 10 seconds, then trabecula was actively washed by supplying water to the anterior chamber under a pressure of 0.05 atm through paracentesis and from the outside the trabecula was vacuum, up to 1 0 mmHg, aspirating fluid using a phacoemulsifier aspiration-irrigation system using a standard, steel cannula in the form of an aspiration tip with an opening at the bottom. 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 an 8/0 submersible, 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: 110 degrees. 45.00 diopters 20 deg. 44.00 diopters

Topography: P = 14.2; C = 0.39; F = 1.57; P / C = 36.4.

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

The angle of the anterior chamber is open, 35 degrees., Pigmentation 3 degrees, mixed, more pronounced in the lower segment of the eye. In the upper segment, a surgical area with pigmentation of 1 degree is clearly visible.

Clinical and functional results remain stable over the entire follow-up period - 1 year.

The patient is satisfied with the result of the surgical treatment.

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,

- increase the antihypertensive effect of the intervention and lead to stable stabilization of intraocular pressure in the long-term postoperative period by washing and evacuating the pigment and finely dispersed material from the inter-trabecular slots of the filtration zone, which improves the outflow of aqueous humor through the drainage paths created during the operation,

- 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, 17 patients were operated on. All patients were characterized by an uncomplicated course of the operation with a quick restoration of visual functions, 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 the external wall of the Schlemm canal and exposing the descemetic casing, first performing an anterior incision, wherein conjunctiva along the limb 3 mm long with its displacement up and produce three millimeter the scleral incision is 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” 0.5 mm long and the subsequent continuation of the incision into transparent layers of the cornea along its entire length, after which the deep scleral layers are removed according to the dimensions of the external visor to the inner wall of the Schlemm canal with the adjacent juxta-canalicular part of the trabecula and exposure of the descemet sheath, then after penetration into the anterior chamber phacoemulsification with IOL implantation is performed and Before suturing the conjunctiva, a phaco-needle is put on a nozzle in the form of a silicone tube 2.5 mm in diameter and protruding 1.0 mm from the end of the needle, the exposed trabecula and descemet sheath are exposed to a stream of water under pressure from 0.05 to 0.1 atm. activated by ultrasound with a frequency of 28.5 kHz and a power of up to 30 mW for 10-30 s, then the trabecula is washed by supplying water to the anterior chamber under a pressure of 0.05 atmospheres through paracentesis and using a phacoemulsifier aspiration-irrigation system using a standard A steel cannula in the form of an aspiration tip with an opening from below produces a vacuum, up to 10 mm Hg, aspiration of the intraocular fluid from the outer surface of the trabecula with the evacuation of pigment and finely divided material from the inter-trabecular fissures of the filtration zone and the surgical area are covered with a displaced intact conjunctiva with limb of an immersive purse-string conjunctival suture.

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