RU2830376C1 - Method of treating open-angle glaucoma - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: surface flap is cut out, deep layers of sclera are divided into 3 parts, deep layers are removed with excision of external wall of Schlemm's canal (SC) in front part. Collagen drainage is implanted into a suprachoroidal space (SCS), and a posterior one-third of the sclera is removed. During the first stage, a surface rectangular scleral flap is cut out for 1/3 of the scleral thickness, with its base to the limb, measuring 4×4 mm. Deep scleral layers are divided into 3 parts by two incisions to the ciliary body at distance of 2 mm and 3 mm from the limb and parallel to it. In the anterior part, all deep layers of the sclera are removed together with the outer wall of the SC, leaving 0.5 mm of the sclera on the ciliary body, inner wall of the SC is thinned with removal of the endothelial lining. 2 pieces of blue polypropylene thread 0.5 mm long are implanted into the lumen of the opened SC on both sides, limiting the surgical intervention area, in the middle part with deep layers of the sclera—a scleral bridge, with a spatula, cyclodialysis is performed, entering the suprachoroidal space and the SCS. Then the collagen drainage is implanted so that its front end is at 0.5 mm from the inner wall of the SC, and the other end is in the SCS. Third part of the sclera is completely removed, exposing the ciliary body and choroid, the superficial scleral flap is placed in place and closed, at the second stage of operation, laser trabeculotomy is performed. One hole is created in the trabecular apparatus between two polypropylene blue threads by means of a YAG laser and a single-mirror gonioscopy lens.

EFFECT: method enables simultaneous activation of the trabecular and uveoscleral outflow tracts of the intraocular fluid and perform the second stage of the operation exactly in the surgical intervention area using less used laser energy inside the eye and laser pulses.

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Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used to treat open-angle glaucoma. During the first stage, after cutting out a 4×4 superficial scleral flap, the deep scleral layers are divided into 3 parts by 2 vertical incisions to the ciliary body at a distance of 2 and 3 mm from the limbus and parallel to it, then all deep layers of the sclera in the anterior part are removed together with the outer wall of the Schlemm's canal (SC), leaving 0.5 mm of sclera on the ciliary body, 2 pieces of blue polypropylene thread (5-0 or 4-0) 0.5 mm long, which are clearly visible gonioscopically, are implanted at both ends of the opened SC, then a collagen drain is implanted under the middle part (scleral bridge) in the suprachoroidal space (SCS) and the posterior third is removed, exposing the ciliary body and choroid. During the second stage of the operation, laser trabeculotomy is performed in the area of surgical intervention between the two threads. The method allows for simultaneous activation of the trabecular and uveoscleral outflow pathways of the intraocular fluid, and performing the second stage of the operation precisely in the surgical intervention area using a smaller amount of laser energy used inside the eye and laser pulses.

A method for treating open-angle glaucoma is known (Baranov I.Ya., Mitrofanov N.V., Chizh L.V. Method for treating open-angle glaucoma, Patent No. 2520820 published on 27.04.2013). The known method for treating open-angle glaucoma includes subscleral excision of the outer wall of the glaucoma at the first stage and laser goniopuncture in the area of the operation at the second stage. During the first stage, the surgical intervention area is reduced: a superficial scleral flap is cut out measuring 2x2 mm with the base toward the limbus, the SC is excised using the probe we proposed for dissecting the SC (Baranov I.Ya., Dyatlov V.N. Probe for dissecting the Schlemm's canal. // Patent No. 104063 published on 10.05.2011) with subsequent removal of its outer wall in the surgical area. The scleral flap is sutured to the sclera with one interrupted suture (dark-colored suture material, such as nylon) and the nodule is pulled through the superficial scleral flap so that the nodule is between the scleral surfaces and is subsequently clearly visible gonioscopically. The second stage - laser goniopuncture - is performed precisely in the surgical intervention area, which is easily determined by the suture material shining through the trabecula. In this method, the operation is performed without opening the eyeball, the size of the surgical intervention zone on the cervical canal is reduced, the number of laser pulses at the second stage of the operation is reduced to the required minimum, precise gonioscopic localization of the intervention zone is ensured, trauma and the number of intra- and postoperative complications are reduced.

The above mentioned method is technically difficult to perform, requires certain surgical skills and requires the application of a black nylon suture (10-0), which biodegrades over time and can lead to endophthalmitis.

A method for treating open-angle glaucoma is known, which consists of excising the outer wall of the SC under the scleral flap and draining the intraocular fluid into the SCS at the first stage and performing laser trabeculotomy in the area of the previously excised outer wall of the SC at the second stage (this method is adopted by the authors as a prototype), which allows performing the operation without opening the eyeball, simultaneously activating the trabecular and uveoscleral pathways of the outflow of intraocular fluid for a long period, achieving a stable hypotensive effect, reducing the number of hypotensive drugs used, reducing the number of intra- and postoperative complications, and shortening the patient's stay in the hospital. (Kumar V., Frolov M.A., Shradka A.S., Abu Zaalan K.A., Dushina G.N., Bezbezabotnov A.I. Surgical method for one-stage activation of intraocular fluid outflow pathways in glaucoma.// Patent No. 2782126 dated 10.21.2022).

This method has a disadvantage: in the postoperative period, the boundaries of the operation zone are not visible gonioscopically, which leads to the need to perform laser trabeculotomy over a much larger area, an increase in the number of laser pulses and an extension of the procedure time. When performing the second stage, hemorrhagic complications are possible.

The purpose of the invention is to preserve the advantages of the prototype, the main one of which is to perform the operation without opening the eyeball and eliminate its shortcomings, reduce the number of laser pulses at the second stage of the operation to the required minimum, ensure precise gonioscopic localization of the intervention zone, reduce trauma, reduce laser energy when performing the second stage and the number of intra- and postoperative complications.

The set goal is achieved in the known method of treatment of open-angle glaucoma, including subscleral excision of the outer wall of the SC and implantation of collagen drainage in the SCS at the first stage and laser trabeculotomy in the area of operation at the second stage, during the first stage the superficial scleral flap is cut out measuring 4x4 mm with the base to the limbus, the deep layers of the sclera are divided into 3 parts, in the anterior part all layers of the sclera are removed together with the outer wall of the SC in the area of operation, leaving 0.5 mm on the ciliary body, 2 polypropylene threads (5-0 or 4-0) 0.5 mm long are implanted at both ends of the SC, collagen drainage is implanted in the SCS. Later the threads in the lumen of the SC are clearly visible gonioscopically, between them there is an area of intervention. The scleral flap is sutured to the sclera with two interrupted sutures. The second stage - laser trabeculotomy, is performed precisely in the area of surgical intervention, which is located between two threads shining through the trabecula.

The technical results of the invention are the achievement of a stable hypotensive effect, a reduction in the number of hypotensive agents used, a reduction in intra- and postoperative complications, a reduction in the time of patients' stay in hospital due to the simultaneous activation of the trabecular and uveoscleral outflow pathways of the intraocular fluid and the possibility of performing YAG laser trabeculotomy precisely in the area of surgical intervention.

The surgical technique is as follows: after traditional anesthesia and akinesia, a 7-0 polypropylene stay suture is applied through the upper/lower limbus at 12 or 6 o'clock. A conjunctival incision is made along the limbus from 10 to 1 o'clock. A 7 mm conjunctival flap is cut out with the base towards the fornix of the eyeball. If necessary, economical bipolar diathermocoagulation of the superficial vessels of the sclera is performed. Using a blade, a superficial rectangular scleral flap is cut out by 1/3 of the sclera thickness, with the base towards the limbus, measuring 4×4 mm. Then the deep scleral layers are divided into 3 parts by 2 vertical incisions to the ciliary body at a distance of 2 and 3 mm from the limbus and parallel to it. In the anterior part, all deep layers of the sclera are removed together with the outer wall of the CC, leaving 0.5 mm of sclera on the ciliary body. Next, using tweezers to perform a capsulorhexis, the inner wall of the CC is thinned, removing the endothelial lining. Both ends of the opened CC are expanded using special bougies and 2 pieces of blue polypropylene thread (5-0 or 4-0) 0.5 mm long are implanted into the lumen of the CC. Next, cyclodialysis is performed under the remaining scleral flaps using a spatula, entering the supraciliary space and the SCS. A collagen drain is implanted in the SCS so that its anterior end is 0.5 mm from the inner wall of the CC, and the other end is in the SCS. The third part of the sclera is completely removed, exposing the ciliary body and choroid. The superficial scleral flap is put in place and sutured with 10-0 nylon interrupted sutures, the conjunctiva is sutured with interrupted sutures to the cornea. The operation is completed by introducing a dexamethasone solution under the conjunctiva and applying a monocular bandage. In the postoperative period, if the IOP is elevated, the second stage of the operation (YAG laser trabeculotomy) is performed, but not earlier than 7-10 days after the operation, as follows: using a YAG laser and a single-mirror goniolens, one or more holes are created in the trabecular apparatus in the area of the primary surgical intervention (the first stage of the operation), which is clearly visible between the two blue polypropylene threads. In Fig. 1, a gonioscopic view of the anterior chamber angle in the postoperative period is visually visible, a piece of polypropylene thread is clearly visualized in the lumen of the Schlemm's canal (white arrow) and in the area of surgical intervention (black arrow), the second piece of thread is not in the field of view. Implanted threads are visible in the lumen of the Schlemm's canal during the first stage of the operation, this method promotes the resistance-free outflow of intraocular fluid from the anterior chamber of the eye into the supraciliary and suprachoroidal spaces. The course of the operation is schematically shown in Fig. 2, where a is the superficial scleral flap, b is the residual layers of the sclera on the ciliary body in the anterior part of the bed, c is the exposed part of the ciliary body and choroid, g is the middle part of the deep layers of the sclera (scleral bridge), d is the anterior end of the collagen drainage is 0.5 mm from the inner wall of the Schlemm's canal (g), e is the posterior end of the collagen drainage is in the suprachoroidal space, h is pieces of polypropylene thread in the lumen of the Schlemm's canal on both sides, limiting the area of surgical intervention, f is the inner wall of the Schlemm's canal and is the proposed location for YAG laser trabeculotomy in the future.

The method allows for simultaneous activation of the trabecular and uveoscleral pathways of intraocular fluid outflow for a long period, achieving a stable hypotensive effect, reducing the amount of hypotensive drugs used, reducing the number of intra- and postoperative complications, and shortening the patient's stay in hospital. The advantage of this method is that it is possible to repeatedly perform YAG laser trabeculotomy with increased intraocular pressure with precision in the area of surgical intervention.

The achievement of the set goal was confirmed during 35 operations on patients at different stages of glaucoma. At present, this method is planned for wide application in the Clinic "Pro zrenie", Khimki.

Clinical examples

Example 1.

Patient A., 80 years old, was admitted to hospital with a diagnosis of refractory open-angle glaucoma IIIc and complicated cataract in the right eye; operated open-angle IIa and pseudophakia in the left eye. The patient was on the maximally tolerated hypotensive regimen, including beta-blockers, a carbonic anhydrase inhibitor, and a prostaglandin analogue. Preoperative visual acuity was 0.02 in the right eye, uncorrected, and 0.9 in the left eye. Daily tonometry data: right eye - 32 mmHg (Icare); left eye - 14 mmHg (according to Icare). The patient underwent a combined operation to remove cataracts using phacoemulsification with implantation of an intraocular lens into the capsular bag and antiglaucoma surgery on the right eye using the proposed method. The operation was uneventful. In the postoperative period, increased IOP was noted in the operated eye to 23-24 mm Hg (Icare) in the hypotensive mode. Two weeks after the surgery, the patient underwent YAG laser trabeculotomy in the area of the surgical intervention. Three holes were formed using three pulses with an energy of 6 mJ for each (Appa YAG laser, Appasamy Associates, India). Biomicroscopy revealed the appearance of a flat filtration cushion with a decrease in IOP. The patient canceled the instillation of hypotensive drops and was prescribed instillation of non-steroidal anti-inflammatory drugs drops (Indocollyre) for 10 days. Seven days after the YAG laser procedure, the eye is calm, the patient has no complaints, the absence of a filtration cushion was revealed, the IOP decreased to 14 mm Hg (Icare), which remained at this level until the last examination. Optical coherence tomography revealed activation of the outflow of OGJ through the lymphatic vessels of the conjunctiva. Visual acuity increased to 0.6. The patient noted an improvement in the quality of life.

Example 2.

Patient A., 84 years old, was admitted to hospital with a diagnosis of refractory open-angle glaucoma IIIc and complicated cataract in the right eye; operated open-angle IIa and pseudophakia in the left eye. The patient was on the maximally tolerated hypotensive regimen, including beta-blockers, a carbonic anhydrase inhibitor, and a prostaglandin analogue. Preoperative visual acuity was 0.02 in the left eye, uncorrected, and 0.9 in the left eye. Daily tonometry data: right eye - 32 mm Hg (Icare); left eye - 14 mm Hg (according to Icare). The patient underwent a combined operation to remove cataracts using phacoemulsification with implantation of an intraocular lens into the capsular bag and antiglaucoma surgery on the right eye using the proposed method. The operation was uneventful. In the postoperative period, increased IOP was noted in the operated eye up to 24-25 mmHg (Icare) in the hypotensive mode. Two weeks after the surgery, the patient underwent YAG laser trabeculotomy in the area of the surgical intervention. Three holes were formed using three pulses with an energy of 6 mJ for each (Appa YAG laser, Appasamy Associates, India). Biomicroscopy revealed the appearance of a flat filtration cushion with a decrease in IOP. The patient canceled the instillation of hypotensive drops and was prescribed instillation of non-steroidal anti-inflammatory drugs drops (Indocollyre) for 10 days. Seven days after the YAG laser procedure, the eye is calm, the patient has no complaints, the absence of a filtration cushion was revealed, the IOP decreased to 14 mmHg (Icare), which remained at this level until the last examination. Optical coherence tomography revealed activation of the outflow of OGJ through the lymphatic vessels of the conjunctiva. Visual acuity increased to 0.6. The patient noted an improvement in the quality of life.

The use of this method of surgical treatment of glaucoma made it possible to achieve a stable and long-lasting hypotensive effect, as well as to reduce the number of intra- and postoperative complications and the number of hypotensive drugs used.

Claims (1)

A method for treating open-angle glaucoma, including cutting out a superficial flap, dividing the deep layers of the sclera into 3 parts, removing the deep layers with excision of the outer wall of the Schlemm's canal (SC) in the anterior part, implanting a collagen drain into the suprachoroidal space (SCS), removing the posterior third of the sclera, characterized in that during the first stage a superficial rectangular scleral flap is cut out by 1/3 of the thickness of the sclera, with the base towards the limbus, measuring 4x4 mm, the deep scleral layers are divided into 3 parts by two incisions to the ciliary body at a distance of 2 mm and 3 mm from the limbus and parallel to it, in the anterior part all the deep layers of the sclera are removed together with the outer wall of the SC, leaving 0.5 mm of sclera on the ciliary body, the inner wall of the SC is thinned with removal of the endothelial lining, into the lumen of the opened SC on both sides implant 2 pieces of blue polypropylene thread 5-0, 0.5 mm long, limiting the area of surgical intervention, in the middle part with deep layers of the sclera - a scleral bridge, perform cyclodialysis with a spatula, entering the supraciliary space and SCS, then implant collagen drainage so that its front end is 0.5 mm from the inner wall of the sclera, and the other end in the SCS, the third part of the sclera is completely removed, exposing the ciliary body and choroid, the superficial scleral flap is put in place and sutured, at the second stage of the operation, laser trabeculotomy is performed, while using a YAG laser and a single-mirror goniolens, one hole is created in the trabecular apparatus between two blue polypropylene threads.