RU2427355C1 - Method of surgical treatment of refractory glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology and can be used in treatment of refractory glaucoma. Superficial flap is separated. In deep layers of sclera bed is formed by partial dissection of scleral tissue. Intrasclerally explantodrainage is fixed under condition of scleral bridge preservation. In drainage zone by means of high-frequency probe made is a hole with 0.7 mm diameter. Operation zone is covered with superficial flap, scleral pedicles are freely brought into subchoroidal space.

EFFECT: method makes it possible to increase efficiency of surgical treatment of refractory glaucoma by formation bed for explantodrainage and its sutureless fixation in deep layers of sclera, which prevents drainage displacement, its obliteration, contributes to formation of intrascleral depot, resorbing watery moisture and preventing fusion of scleral flap with scleral bed.

2 ex

Description

The present invention relates to medicine, namely to ophthalmology, and can be used in the treatment of refractory glaucoma.

Glaucoma is one of the most severe eye diseases that occurs chronically and leads to a significant decrease in visual function up to blindness, despite appropriate treatment. The special form of glaucoma “refractory” (difficult to cure) combines a wide variety of clinical types, including pseudophakic, aphakic, and also repeatedly and unsuccessfully operated primary glaucoma. These forms of glaucoma have risk factors for excessive scarring in the area of surgical intervention. It is generally recognized that the surgical treatment plays a leading role among all treatments for refractory glaucoma. The main reason for reducing the effect of filtering operations is excessive, unregulated scarring in the area of newly created outflow pathways of intraocular fluid, which leads to relapse. In order to correct reparative processes in the area of surgical intervention, various types of drains are used to preserve the formed cavity.

An analogue is the method for treating glaucoma with implantation of Ex-PRESS R50 under a scleral flap. Ex-PRESS R50 is a 3 mm stainless steel shunt with an outer diameter of 400 microns and an inner diameter of 50 microns. The implantation technique includes an incision along the limb, separation of the scleral flap 3 × 3 mm into a part of the sclera thickness. The bed is treated with mitomycin C. Paracentesis is performed in a temporal square. Viscoelastic is introduced through it. With a 27 gauge needle, a limb is perforated under the scleral flap and drainage is introduced into the anterior chamber through the created channel. The outwardly protruding part is covered with a scleral flap, which is sutured to the sclera with two nodal nylon sutures 10.0, the conjunctiva is sutured to the limb with nodular vicryl sutures 10.0. (Nyska A., Glovinsky Y, Belkin M, Epstein Y. Biocompatibility of the Ex-PRESS miniature glaucoma drainage implant, J. Glaucoma 2003., Jun 12 (3): 275-80).

The disadvantages of this method of surgery is that metal-based drains are often encapsulated, complicated by conjunctival erosion, and drainage rejection.

Of the long-term complications, 7.7% observed drainage displacement, 11% conjunctival erosion, and insufficient drainage due to fibrosis. In addition, a significant drawback is the lack of outflow formation under the tenon capsule into the orbit due to suture fixation of the scleral flap, which reduces the effectiveness of the intervention in 38% of patients, which required additional intervention or the appointment of antihypertensive therapy.

Over the past 2 years, domestic ophthalmologists have used leukosapphire explant drainage.

Leucosapphire is a material with unique physico-chemical properties: preservation of mechanical properties, chemical inertness, biocompatibility, lack of adhesion. Explant drainage is a tube with an outer diameter of 700 microns, a hole diameter of 300 microns, a length of 2.6 mm.

For the prototype, we adopted the technique of Takhchidi H.P., Balashevich L.I., Naumenko V.V., Kachurin A.E. The use of leucosapphire explant drainage in the surgical treatment of patients with refractory forms of glaucoma. (Teaching aid, St. Petersburg, 2007, p. 12).

A 4 × 4 mm rectangular scleral flap with a base to the limb with a thickness of at least 1/3 of the sclera was marked with a microsurgical knife with a dosed blade feed or with a general surgical knife. Corneal paracentesis was performed and the anterior chamber was filled with a solution of viscoelastic to mild hypertension. The formation of the flap was carried out with a knife-delaminator approximately to the level of trabeculae. Penetration into the anterior chamber was performed with a needle with a diameter of about 0.3 mm. The direction of the needle was parallel to the plane of the bottom of the scleral flap. Leucosapphire explant drainage was installed in the puncture using tweezers. Additional fixation was usually not required. The scleral flap was put in place, nodal sutures were placed on the corners. The tenon capsule and conjunctiva (microsurgical silk or vicryl 8-0) were sutured separately. An antibiotic with a corticosteroid was administered subconjunctively.

The most significant drawback of suture fixation of the scleral flap is the outflow block under the tenon capsule, which leads to insufficient resorption of aqueous humor and fusion of the scleral flap with the scleral bed. If the suture fixation of the scleral flap to the scleral bed is free, then explant drainage, which is 4 times larger than the sclera thickness, can be displaced under the tenon capsule, the outflow from the anterior chamber worsens and conjunctival erosion forms, which can lead to drainage explantation , loss of filtering effect of surgical intervention.

The objective of the invention was to increase the effectiveness of surgical treatment of refractory glaucoma of the aphakic or artifact eyes, and to reduce the risk of complications. The inventive method of treating refractory glaucoma, including the separation of the surface flap, its fixation, implantation of implant drainage from leukosapphire into the anterior chamber, characterized in that in the deep layers of the sclera form a bed by partial excision of the scleral tissue, intrasclerally fix the explant drainage with the condition of preservation of the implant drainage under conditions of preservation a hole with a diameter of 0.7 mm is made in the drainage zone with a high-frequency probe, cover the operation zone with a surface flap, while the scleral legs freely lead into the subchoroid space.

The technical result of the proposal is to increase the efficiency of surgical treatment of refractory glaucoma by forming an explant drainage bed and seamless fixation in the deep layers of the sclera prevents drainage displacement and obliteration, and seamless fixation of the surface flap promotes the formation of an intrascleral depot resorbing aqueous humor and preventing the scleral flap from merging from the scleral flap .

The method is as follows:

1. The incision of the conjunctiva and tenon capsule in the upper or upper outer sector 1 mm from the limb with a length of 10-11 mm and 4 mm radially on one side towards the posterior pole of the eyeball with exposure of the sclera.

2. A T-shaped scleral flap is cut out from the surface layers 1/3 sclera thick. The dimensions of the T-shaped scleral flap: the maximum width of 10 mm, then two legs of 1.5-2 mm on the sides and the next step forms a base 6-7 mm wide.

Using a knife-delaminator, they finish forming a scleral flap with a base to the limb more than 0.2 mm thick, stratifying to transparent layers of the cornea.

3. In the area of the scleral bed in the middle layers of the sclera at a distance of 1 mm from the circular ligament, a scleral bridge is formed parallel to the limb, perpendicular to the limb 2 incisions are made with a depth of 5 mm, 5 mm long at a distance of 2 mm from each other, the middle layers of the sclera are excised and formed scleral canal, like a bed for drainage, but the anterior chamber does not open. The outer wall of the Schlemm canal is removed while maintaining the trabecular diaphragm and part of the corneal tissue, anterior to the Schwalbe border ring with exposure of the posterior border plate of the cornea.

4. Paracentesis is performed, viscoelastic is introduced into the anterior chamber.

5. In the projection of the formed scleral canal with a high-frequency probe, a hole with a diameter of 0.7 mm with coagulated edges is made in the trabecular diaphragm.

6. Explant drainage with tweezers is placed in the scleral canal under the scleral bridge and the beveled edge through the formed hole is inserted into the anterior chamber by 0.5-0.6 mm.

In this way, the fixation of the explant drainage and its correct position are achieved when the outlet opens into the scleral canal and there is no obstacle to the outflow from the anterior chamber under the tenon capsule.

Explant drainage receives double fixation: first under the scleral bridge, and then in a round hole in the trabecular diaphragm. The use of a high-frequency probe is important, since a puncture of the trabecular diaphragm with a needle gives sharp sharp edges that are easy to break and do not fix the drainage, while coagulated edges encircle the drainage and fix it in the anterior chamber.

7. Fixation of the superficial T-shaped scleral flap is done without suturing: in the zone of formation of the legs, a through sclera is cut through 2-2.5 mm and the legs of the T-shaped scleral flap are fixed subsclerally in the through sections of the sclera. Thus, a double seamless fixation of the drainage is achieved, while there is no constricting and pressing effect, and there is no obstacle to the intracanal location of the explant drainage. According to its physical properties, explant drainage cannot be located congruently in the scleral layers; therefore, the distal intrascleral section will be at an angle to the scleral membrane and free fixation of the surface flap does not deform its position and does not impede the flow of aqueous humor. A continuous suture (polypropylene 10/0) is applied to the conjunctiva and tenon capsule. In the lower-outer quadrant, posterior sclerectomy is performed to prevent ciliochoroidal detachments. The operation ends with a subconjunctival injection of a corticosteroid with an antibiotic.

EXAMPLE. Patient S., born in 1937, from 1.02.09 to 8.02.09 was treated at the Department of Eye Microsurgery No. 2 of the CVHB with a diagnosis of secondary uncompensated glaucoma, artifact of the right eye. Narrow-angle IIA glaucoma, initial cataract of the left eye. In 2005, glaucoma and initial cataract of the right eye were diagnosed, surgical treatment was carried out: non-penetrating deep sclerectomy in combination with laser iridectomy, compensation lasted for 6 months, then the appointment of carbonic anhydrase inhibitors was required. Compensation of intraocular pressure was unstable, peripheral vision loss progressed, cataract phacoemulsification with IOL implantation was performed in 2006, laser dyscisia of the posterior capsule was performed 3 months later, and penetrating deep sclerectomy was performed in 2008. IOP decompensation was detected in the last 4 months, antihypertensive therapy is ineffective. The patient is directed to surgical treatment.

Upon enrolment:

VIS OD = 0.3 s sph + 2.0D = 0.5,

IOP OD = 32 mm RT. Art.

According to the data of automatic static perimetry on the perimeter of “Perikom” according to the “glaucoma” program of 132 presented objects:

28 is the norm

24 - relative scotomas of the 1st level,

35 - relative scotomas of the 2nd level,

45 - absolute scotomas.

According to confocal laser retinotomography:

The volume of excavation of optic discs is 0.738 mm,

The volume of the neuroretinal rim is 0.054 mm,

The ratio of the area of excavation to the area of the welfare is 0.821,

The ratio of the average diameters of excavation and wound disks is 0.906,

The average thickness of the retinal nerve fibers is 0.239 mm,

The ratio of the area of the neuroretinal rim and the optic disc is 0.179.

The right eye is calm, scarring of the conjunctiva and sclera with thinning areas are determined on the upper limb, the cornea is transparent, the scar along the meridian is 11 hours after the corneal tunnel incision, the anterior chamber is deeper than average, the moisture is clear, the iris is subatrophic, the pupil is 3 mm in diameter, on the light does not respond, it does not respond to mydriatics, at 12 o’clock a basal coloboma, in the pupil’s lumen IOL, the lens in the correct position, destructive changes in the vitreous. On the fundus: optic nerve discs are pale gray, the boundaries are clear, E / D = 0.7, the shift of the vascular bundle nasally, the retina in the posterior region and on the periphery without pathology.

Gonioscopy - the angle of the anterior chamber is closed throughout.

On 2.02.09, a leucosapphire explant drainage was implanted into the anterior chamber with the formation of a bed and intrascleral fixation. Intervention was carried out along the meridian of 10-11 hours, aside from gross cicatricial changes and the site of thinning of the sclera.

The conjunctiva and tenon capsule were cut in the upper external sector 1 mm from the limb with a length of 10-11 mm and 4 mm radially from one side towards the posterior pole of the eyeball with exposure of the sclera. A T-shaped scleral flap was cut out from the surface layers 1/3 sclera thick. The dimensions of the T-shaped scleral flap: the maximum width of 10 mm, then two legs of 1.5-2 mm on the sides and the next step forms a base 6-7 mm wide. A scleral flap was formed with the help of a delaminating knife with the base to the limb more than 0.2 mm thick, with delamination to transparent layers of the cornea. In the area of the scleral bed in the middle layers of the sclera at a distance of 1 mm from the circular ligament, a scleral bridge is formed parallel to the limb, perpendicular to the limb 2 incisions are made 0.2 mm deep, 5 mm long, 2 mm apart, the middle layers of the sclera are excised and formed scleral canal as a bed for drainage. The outer wall of the Schlemm's canal was removed, while maintaining the trabecular diaphragm and part of the corneal tissue, anterior to the Schwalbe border ring with exposure of the posterior border plate of the cornea. Through paracentesis, viscoelastic is introduced into the anterior chamber. In the projection of the formed scleral canal with a high-frequency probe above the trabecular diaphragm, a hole with a diameter of 0.7 mm with coagulated edges is made. Explant drainage with tweezers is placed in the scleral canal under the scleral bridge and the beveled edge through the formed hole is introduced into the anterior chamber by 0.5-0.6 mm. A through incision of the sclera was made at 2-2.5 mm and the legs of the T-shaped scleral flap were fixed subsclerally in the through incisions of the sclera. A continuous suture (polypropylene 10/0) was placed on the conjunctiva and tenon capsule. In the lower outer quadrant, posterior sclerectomy was performed to prevent ciliochoroidal detachments. Subconjunctival injection of a corticosteroid with an antibiotic.

At discharge:

VIS OD = 0.3 s sph + 1.0D = 0.4,

IOP OD = 12 mm RT. Art.

According to the data of automatic static perimetry on the perimeter of “Perikom” according to the “glaucoma” program of 132 presented objects:

38 is the norm

34 - relative scotomas level 1,

25 - relative scotomas of the 2nd level,

- absolute scotomas.

The right eye is almost calm, the filter pad is moderately expressed, the seam is clean, scarring of the conjunctiva and sclera is determined on the upper limb, the cornea is transparent, the scar along the corneal meridian is 11 hours after the corneal tunnel incision, the anterior chamber is deeper than average, the moisture is clear, the iris is subatrophic, the pupil 3 mm in diameter, sluggishly reacts to light, at 12 o’clock a basal coloboma, in the lumen of the pupil of the IOL, the lens is in the correct position, the beveled edge of the explant drainage is determined at 11, the position is correct, contact with the cornea no, the clearance is free. On the fundus: optic nerve discs are pale gray, the boundaries are clear, E / D = 0.7, the shift of the vascular bundle nasally, the retina in the posterior region and on the periphery without pathology.

When viewed after 30 days:

VIS OD = 0.4 s sph + 1.0D = 0.5-0.6,

IOP OD = 16 mm RT. Art.

According to the data of automatic static perimetry on the perimeter of “Perikom” according to the “glaucoma” program out of 132 presented objects:

34 is the norm

24 relative scotomas of the 1st level,

29 relative scotomas of the 2nd level,

45 absolute scotomas.

Confocal laser retinotomography data without significant changes.

The right eye is almost calm, the filter pad is moderate, scarring of the conjunctiva and sclera is determined on the upper limb, the cornea is transparent, the scar on the meridian is 11 hours after the corneal tunnel incision, the anterior chamber is deeper than average, the moisture is clear, the iris is subatrophic, and the pupil has a diameter of 3 mm, sluggishly reacts to light, at 12 o’clock a basal coloboma, in the pupil’s lumen IOL, the lens is in the correct position, the beveled edge of the explant drainage is determined at 11, the position is correct, there is no contact with the cornea, t is free. On the fundus: optic nerve discs are pale gray, the boundaries are clear, E / D = 0.7, the shift of the vascular bundle nasally, the retina in the posterior region and on the periphery without pathology.

Gonioscopy - the angle of the anterior chamber is closed, along the meridian for 11 hours there is an explodation fixed above the trabecular diaphragm.

Example 2. Patient K-da Yu.T., born in 1941, from 02/08/09 to 02/15/09 was treated at the Department of Eye Microsurgery No. 2 of the CVHV with a diagnosis of secondary uncompensated glaucoma, artifact of the right eye. Initial cataract of the left eye.

A decrease in vision was noted in 2007, surgical treatment of cataracts - extracapsular extraction with IOL implantation in 2007, a year later in 2008 - non-penetrating deep sclerectomy in the right eye. Recently, IOP decompensation has been identified, antihypertensive treatment does not tolerate well. Received for surgical treatment.

VIS OD = 0.3 is not corrected,

VIS OS = 0.3 s core sphere + 1.0 diopters = 0.6,

IOP of the right eye 28 mm RT. Art. on antihypertensive mode,

IOP of the left eye 19 mm RT. Art.

OD - the eye is calm, the filtration pad is not detected, in the upper part of the conjunctiva in cicatricial changes, the postoperative corneal scar is determined from the upper limb from 11 hours to 1 hour, the anterior chamber is deep moisture clean, the iris is subatrophic, the basal coloboma is at 9 hours, the pupil is exposed to light does not respond, in the lumen of the pupil of the IOL, a pink reflex from the fundus, the optic disc is pale, the borders are clear, glaucomatous excavation is up to 0.6, the shift of the vascular bundle is nasal.

Automatic static perimetric data for the Glaucoma program on the Pericom apparatus. The number of objects is 132, the norm is 50, the scotoma of the 1st level - 18, the scotoma of the 2nd level 16, the absolute scotoma - 48.

Data of confocal laser retinotomography of the right eye:

DZN excavation volume - 0.293 mm,

The volume of the neuroretinal rim is 0.170 mm,

The ratio of the area of excavation to the area of the welfare is 0.550,

The ratio of the average diameters of excavation and wound disks is 0.742,

The average thickness of the retinal nerve fibers is 0.177 mm,

The ratio of the area of the neuroretinal rim and the optic disc is 0.450.

Gonioscopy: the anterior chamber angle is closed in two quadrants - the nasal and temporal, in two quadrants the angle is open, pigmentation is weak.

02.10.09 leukosapphire explant drainage was implanted into the anterior chamber with the formation of a bed and intrascleral fixation.

The conjunctiva and tenon capsule were cut in the upper external sector 1 mm from the limb with a length of 10-11 mm and 4 mm radially from one side towards the posterior pole of the eyeball with exposure of the sclera. A T-shaped scleral flap was cut out from the surface layers 1/3 sclera thick. The dimensions of the T-shaped scleral flap: the maximum width of 10 mm, then two legs of 1.5-2 mm on the sides and the next step forms a base 6-7 mm wide. A scleral flap was formed with the help of a delaminating knife with the base to the limb more than 0.2 mm thick, with delamination to transparent layers of the cornea. In the area of the scleral bed in the middle layers of the sclera at a distance of 1 mm from the circular ligament, a scleral bridge is formed parallel to the limb, perpendicular to the limb 2 incisions are made 0.2 mm deep, 5 mm long, 2 mm apart, the middle layers of the sclera are excised and formed scleral canal as a bed for drainage. The outer wall of the Schlemm's canal was removed while maintaining the trabecular diaphragm and part of the corneal tissue anterior to the Schwalbe border ring with exposure of the posterior border plate of the cornea. Through paracentesis, viscoelastic is introduced into the anterior chamber. In the projection of the formed scleral canal with a high-frequency probe, a hole with a diameter of 0.7 mm with coagulated edges is made in the projection of the trabecular diaphragm. Explant drainage with tweezers is placed in the scleral canal under the scleral bridge and the beveled edge through the formed hole is introduced into the anterior chamber by 0.5-0.6 mm. A through incision of the sclera was made at 2-2.5 mm and the legs of the T-shaped scleral flap were fixed subsclerally in the through incisions of the sclera. A continuous suture (polypropylene 10/0) was placed on the conjunctiva and tenon capsule. In the lower outer quadrant, posterior sclerectomy was performed to prevent ciliochoroidal detachments. Subconjunctival injection of corticosteroid with antibiotic.

At discharge:

VIS OD = 0.3 is not corrected,

VIS OS = 0.3 s core sphere + 1.0 diopters = 0.6,

IOP of the right eye 14 mm RT. Art.

IOP of the left eye 17 mm RT. Art.

The right eye is almost calm. The filter pad is well expressed, the seam is clean. The cornea is transparent, the anterior chamber is deeper than average, moisture is transparent. The iris is almost calm, the pupil is round, artifact. There is a pink reflex from the fundus, the optic disc is pale, the borders are clear, glaucomatous excavation is up to 0.6, the shift of the vascular bundle is nasal.

Gonioscopy - the anterior chamber angle is closed in two quadrants; an explant fixed in a trabecular diaphragm is located along the meridian for 12 hours.

Claims (1)

A method for the treatment of refractory glaucoma, including the separation of the surface flap, its fixation, implantation of explant drainage from leukosapphire into the anterior chamber, characterized in that the sclera are formed in the deep layers of the bed by partial excision of the scleral tissue, intrascleral fixation of explant drainage with the condition of preservation of high-scleral drainage with the scleral drainage with a probe, a hole with a diameter of 0.7 mm is made, the operation area is covered with a surface flap, while the scleral legs are freely inserted into the sub orioidalnoe space.