The way to prevent postoperative complications antiglaucomatous surgery

 

(57) Abstract:

The invention relates to medicine, namely to ophthalmology, and for the prevention of postoperative complications antiglaucomatous surgery. To do this, after the rear trephination of the sclera on Nude vascular sheath is placed transplant from biologically inert biodegradable material with two projections extending from its upper and lower surfaces and pointing in opposite directions, the lower ledge of the graft is implanted in spheriodal space distal of the limb to ensure outflow subhorizontally fluid, and the top is fixed to the adjacent sclera proximally relative to the limb, and the graft is impregnated with a mixture of solutions of diuretics and means for reducing the permeability of the vascular wall. The method allows to reduce the risk of postoperative retinal choroid and hemorrhagic complications. 5 C.p. f-crystals.

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

One of the most common complications associated antiglaucomatous authors, with a frequency of 1.8 to 97%. The frequency and severity of the clinical course of CCA increase with surgery advanced forms of glaucoma, especially in surgical interventions in patients with different forms of secondary glaucoma. The increased risk of CCA in the postoperative period is associated with the gross pathology of the vascular system of the eyeball affected long-existing glaucoma process, and related secondary glaucoma pathology (uveitis, PTSD, and so on). An even greater problem of postoperative CCA acquires pediatric patients, which is characterized by extremely rapid elongation of the eyeball in the absence of compensation intraocular pressure (IOP), accompanied by gross changes of the vascular wall and, consequently, increasing the risk of both operating and postoperative complications is high, often hemorrhagic nature of the CCA, a variety of hemorrhagic complications.

One of the starting points of occurrence of CCA is a sharp drop in IOP during the operation, causing a response of the vascular response in the form of extravasation of fluid and blood through pathologically stretched the vascular wall (Eremina ptx2">

The development of CCA in the early postoperative period reduces hypotensive effect of surgical intervention, directing the outflow of intraocular fluid spheriodal space and, thereby limiting the filtering surgically formed paths outflow, slowing the formation of filter bags. Developed CCA requires active conservative treatment, paired with frequent and hard to bear with patients, especially children, retro-bulbar injection required for admission to a medicinal product to the destination - choroid.

The known method of prevention CCA through the rear trephination of the sclera (Eremin A. I. Postoperative detachment of the choroid. Abstract. dis. . . . Kida. the honey. Sciences. - M., 1971. - 19 S.), including the formation of the through scleral buckling holes. Rear trepanning sclera produce 8-9 mm from the limbus, in the area of the most frequent bubbles CCA - ninananajna or niininen segment. After forming the holes and outcrops of the choroid triangular scleral flap is excised. This procedure can reduce the intraocular pressure of 2-6 mm RT.art., to soften intraoperation surgery.

However, the rear trepanation sclera does not fully meet the requirements of the prevention of complications. Judging by the timing of the CCA (2-5 day after fistulipora operations), the reason of low efficiency of the rear trephination of the sclera is quick obturation of holes adjacent the choroid and the absence of prolonged outflow of fluid from spheriodal space.

The objective of the invention was to develop an effective method of preventing the development of CCS and other hemorrhagic complications after conducting antiglaucomatous operations, allowing to provide prolonged delivery of essential drugs directly to the destination - choroid and suppress through adequate selection of drugs transudative vascular reaction and, if necessary, to create in the postoperative period of a steady outflow of fluid from spheriodal space, ensuring in this way, reliable prevention of CCA, and other hemorrhagic complications of posterior eye segment.

The technical result is to reduce the risk of postoperative CCA and hemorrhagic complications after glaucoma IOP compensation.

The technical result is achieved in that in the method of the prevention of complications according to the invention after incision of the conjunctiva produce back trepanation of the sclera in ninananajna or niininen segment of the eyeball in 8-10 mm from the limbus, and after the cut-off cut scleral flap on Nude vascular sheath is placed transplant, less than trepanation hole size. The graft is provided with two protrusions extending from its upper and lower surface and pointing in opposite directions. The bottom ledge of the graft, distal with respect to limb, implanted in spheriodal space, and the upper ledge, proximal with respect to limb, is stitched to adjacent to trepanations the hole in the sclera, thus preventing the graft from potential bias. The size of the graft should not exceed 2.0 to 2.5 mm, the thickness of the graft is 0.4-0.6 mm Lugs transplant have a length of 2.5-3.0 mm, width of 1.5 mm, the thickness of the projections is 0.2-0.3 mm

The graft is made of a biologically inert biodegradable material (e.g. collagen). Pre-transplant impregnated with a mixture of anti-hypertensive drug is rata - 30 to 90%, drugs, reducing the permeability of the vascular wall is 10-70%.

In the case of inclusion in the pathogenetic chain of glaucoma inflammatory factor graft is additionally impregnated with steroid drugs.

When you increase the risk of postoperative infectious process, the graft is additionally impregnated with antibiotics. In advanced glaucoma, complicated by significant trophic disorders of the visual organ, the transplant is additionally impregnated with antioxidants. In the presence of severe desensitization of both local and General, the graft is additionally impregnated with desensibilisation drugs.

In the presence of vascular pathology transplant additionally impregnated with antispasmodic means, improves microcirculation.

After implantation and fixation of the graft to the incision of the conjunctiva impose nodal submersible seam and move to the planned antiglaucoma intervention.

The technical result is achieved due to the following.

1. Implanted in spheriodal space the lower ledge of the graft performs the function of drainage is the situation under the choroid in the postoperative period. Due to the small thickness subhorizontally drainage does not create threats additional extensions spheriodal space.

2. Placement of the graft directly on the vascular sheath provides a smooth and stretched in time (within 1-1 .5 months) receipt of drugs directly to the destination (choroid). Resorption of the graft within 4-6 months eliminates the necessity of its removal after performing its intended function.

3. Adequate selection of the drugs can affect different parts of the pathogenetic chain of development of the CCA and hemorrhagic complications in the early stages of their occurrence and the appearance of complications, softens their clinical course. With this aim it is advisable to use the following groups of drugs:

1) Diuretics (lasix, origit, mannitol), which has anti-edema effect. Hypotensive effect of lazica and Brigita related to saluretics, mainly associated with the inhibition of the reabsorption of Na and C1 and, in varying degrees, inhibition of carbonic anhydrase ciliary body. Anti-hypertensive and anti-edematous effect of mannitol related to Omote is 2">

2) Means of reducing the permeability of the vascular wall (dicine, emoxipin, menadione), belong to different pharmacological groups. Dicine belonging to the group of angioprotectors, improves blood circulation and metabolic processes, normalizes vascular permeability and has a hemostatic effect in connection with an activating action on the formation of thromboplastin. Menadione, being a synthetic analogue of vitamin K is involved in the formation of prothrombin and helps normalize blood clotting. The emoxipin, belonging to the group of renoprotection, has antioxidant properties, promotes the resorption of intraocular hemorrhages and decreases capillary permeability.

3) Steroid drugs (prednisone, dexasone, betamethasone) have anti-inflammatory, desensibilizing, toxic and immunosuppressive effect.

4) Antibiotics (gentamicin, netromycin, rocephin) have antibacterial effect.

5) Antisense drugs (suprastin, tavegil, pipolphen), acting on peripheral mediator, have anti-histamine effect.

6) Antioxidants is, accelerate oxidation reactions.

7) Antispasmodic (trental, Cavinton, complain) increase the supply of oxygen to tissues, stimulate blood flow and has antispasmodic effects.

The method is as follows. After standard processing operating margins, niininen or ninananajna segment, 8-10 mm from the limbus an incision of the conjunctiva. Coagulated surface of the sclera for the prevention of bleeding. The blade is produced through an incision in the sclera is triangular in shape and form a scleral flap, tsepilova two faces of the triangle from the underlying choroid, after exposure of the choroid third cut face of the scleral flap from the adjacent sclera, to the formation of trepanation holes. On the vascular membrane stack collagen graft impregnated relevant etiology of glaucoma process and ophthalmotonus set of drugs. The bottom ledge of the graft is implanted in spheriodal space to a depth of 1 mm, and the upper protrusion placed on adjacent to trepanations the hole in the sclera and is stitched to her one anchor suture. Conjunctival tonnage intervention.

The invention is illustrated in the following examples.

Example 1. Patient T. , aged 13. Enrolled in the children's branch of IRTC MG diagnosed with OD: secondary (post-traumatic) uncompensated glaucoma. Traumatic cataract. OS: healthy. 7 months ago suffered a penetrating wound of the right eye. 2 months ago in my right eye revealed secondary glaucoma. When viewed from the right eye - preceisely traumatic scar the cornea, associated with the iris. Posterior synechia in pupillary edge. Traumatic polyresistant cataract.

Vis OD=right. svetoproekt; OS=1,0; IOP 0D=30 mm RT.article; OS=21 mm RT.article The length of the anteroposterior axis of the right eye was 23.8 mm (left eye length anteroposterior axis corresponded to 23.4 mm).

The child on his right eye produced non-penetrating sclerectomy with prevention of postoperative complications on the proposed method. Given the stage of development of glaucomatous process, the graft was soaked lasix and dicynodon in the following ratio of components,%:

Lasix - 70

Dicine - 30

Operation and postoperative period was uncomplicated. Held in the dynamics of the ultrasound scan revealed no postoperative ptoperly. IOP in the right eye when the extract was 16 mm RT.article.

Example 2. Patient S., aged 8. Was admitted for treatment with a diagnosis of OD: secondary uveal uncompensated almost absolute glaucoma. OS: healthy. History of surgery for glaucoma three times, with short-term hypotensive effect.

When viewed from the right eye - edge ribbon-like dystrophy of the cornea. The front camera has a depth of 2.5 mm, a uniform. Mesoderm degeneration of the iris. The pupil diameter of about 2 mm Selusio pupil, pupillary film. In the inhomogeneous lens opacities. More deep superficial environment is not visible.

Visual acuity of the right eye - right svetoproekt. IOP - 32 mm RT. Art. the length of the anteroposterior axis of the eye is increased to 29.4 mm Considering the etiology of glaucoma and stage of development of the disease, the child on his right eye made deep sclerectomy with prevention of complications on the proposed method, the graft was soaked in a mixture of the following composition,%:

Mannitol - 30

Menadione - 25

Betamethasone - 25

Cytochrome C - 20

The operation and the postoperative period was uneventful. In the early stages (on the 3rd day after the operation) according to the ultrasonic scan of the child's balachine additional therapy. The child was discharged from the hospital on the 12th day after surgery. IOP surgical eye at discharge was 17 mm RT.article.

Example 3. Patient A., age 16, was admitted for treatment at the children's branch of IRTC MG diagnosis: right eye - operated non-compensated secondary glaucoma. The left eye is healthy. The Syndrome Sterg-Weber. In history operated on for secondary glaucoma with short-term hypotensive effect. In 2000 revealed decompensation IOP (up to 32 mm RT.cent.). The purpose of the mode hypotensive instillation of effect has not given and the patient was sent to the IRTC MG.

When viewed from the right eye - the cornea transparent. The pupil diameter of about 3.5 mm, reaction to light saved. The lens is transparent. In the vitreous body unit polupolirovannye opacities. If Ophthalmoscope - optic disc pale, monotonous, offset vascular bundle to the nose and a pronounced expansion of physiological excavation. The Central area and the periphery of the retina without focal pathology. If gonioscopy in the lower segment is defined by a conglomerate of newly formed vessels, located in the anterior chamber angle with 17 to 18 hours. Visual acuity of the right eye -0,06 with sph-3.0 D=1.0 in. Field of vision narrowed to the nasal side is irectory with explantation under the proposed method with implantation in the region of the rear trephination of the sclera graft, impregnated with a mixture of medicines the following composition,%:

Lasix - 30

Dicine - 20

Gentamicin - 20

Trental - 20

Suprastin - 10

In the first days after surgery, the anterior chamber depth was 2.5 mm IOP was within 14-15 mm RT.article Control ultrasound examination held in the 2nd, 4th and 7th days after surgery, showed a slight swelling of the choroid, not exceeding 1.0 mm in the periphery and the absence of CCA. Swelling of the choroid fully docked, by ultrasound, to 7 days after surgery. The postoperative period was characterized by a smooth flow, not differing specific features and complications. The patient was discharged from the hospital on the 8th day after the operation. The vision statement 0,06 with sph-3.0 D=0,1. IOP - 17 mm RT. Art. recommendations on conducting post-operative neurotrophic treatment and control IOP at the place of residence.

The invention provides an effective way of dealing with the occurrence of postoperative hemorrhagic and inflammatory complications, and CCA with surgical intervention concerning severe forms of glaucoma. The use of the method according to opican the t hypotensive effect of surgical intervention. The method is technically simple and accessible, does not require additional surgical skills and expensive equipment.

1. The way to prevent postoperative complications antiglaucomatous operations, including the rear trepanation of the sclera, characterized in that after the rear trephination of the sclera on Nude vascular sheath is placed transplant from biologically inert biodegradable material with two projections extending from its upper and lower surfaces and pointing in opposite directions, the lower ledge of the graft is implanted in spheriodal space distal of the limb to ensure outflow subhorizontally fluid, and the top is fixed to the adjacent sclera proximally relative to the limb, and the graft is impregnated with a mixture of medicines taken in the following ratio.%:

Anti-hypertensive drugs with anti-inflammatory effect - 30-90

Means of reducing vascular permeability - 10-70

2. The method according to p. 1, characterized in that the graft is additionally impregnated with steroid drugs, which are used dexason, or prednisolone or betamethasone.

< is using gentamicin, or rocephin, or netromycin.

4. The method according to PP.1-3, characterized in that the graft is additionally impregnated with antioxidants, which are used Mexidol, and/or cytochrome, and/or emoxipin.

5. The method according to PP.1-4, characterized in that the graft is additionally impregnated with desensibilisation drugs, which are used suprastin, or tavegil, or pipolphen.

6. The method according to PP.1-5, characterized in that the graft is additionally impregnated with antispasmodic means, improves microcirculation, which use trental and/or reverse and/or complain.

 

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