Method for determining differentiated treatment indications for early hypertension patients after having antiglaucoma operations of filtering type

FIELD: medicine.

SUBSTANCE: method involves carrying out tonometry, patient examination in slit lamp light, determining filtration cushion size and relief, carrying out test with sterile air introduced under conjunctiva in operation zone in combination with glycocorticosteroid preparation. Filtration cushion height increasing and air entering the anterior chamber, diuretic drugs are prescribed and preparations inhibiting intraocular fluid secretion. Filtration cushion becoming flat, glycocorticosteroid preparations, enzyme preparations are introduced and antimetabolite is introduced under conjunctiva outside of operation field. Filtration cushion relief being variable and air passes into the anterior chamber, anti-inflammatory therapy, anti-proliferative treatment course, glycocorticosteroid and enzyme preparations are prescribed. Filtration cushion becoming flat, and air does not enter the anterior chamber, gonioscopy is carried out and surgical intervention zones are revised in the cases of open internal fistula and antibiotic of cytostatic activity is to be prescribed. Internal fistula being blocked, laser surgical intervention is carried out. Hypertension being persistent, anti-glaucoma intervention is carried out in another eyeball segment with antibiotic of cytostatic activity being applied.

EFFECT: enhanced effectiveness of treatment selection.

 

The invention relates to medicine, namely to ophthalmology, and can be used to determine the indications for differentiated treatment of patients with early hypertension in the postoperative period antiglaucomatous operations (AGO) filter type.

At the present stage AGO filter type is the most common surgical intervention, performed in patients with glaucoma of various etiologies. Regardless of the AGA filter type standard point of view that reduce their efficiency occurs, as a rule, in the early postoperative period and are caused by excessive regeneration in the area of surgical intervention (Joseph J.P., R.A. Hitchings, et al. Chemotactic activity of activity of aqueous humor a cause of failure of trabeculectomies // Arch. Ophthalmol. - 1989. - Vol.107. - P.69-74). If the cause of hypertension is associated with the formation of interstitial growths in the area of operation, when the timely adoption of appropriate measures, this process may be suspended in the early stages of its development. However, in some cases leading role in the development of early postoperative hypertension plays hyperproductive intraocular fluid (VGG) of the ciliary body as a form of his response to the operating injury. Traditional research methods to conduct differential diagnostics of the reasons of early postoperative hypertension is difficult, at the same time emendatione diagnosis allows the surgeon to make the right choice of tactics of the further treatment of the patient.

There is a method of determining indications for surgical intervention in the insolvency of the preceding operations, the main criterion of which is the conduct of tonometry and topography in the dynamics (Nesterov A.P. Glaucoma. M.: Medicine, 1995, p.4-9).

This method has some significant drawbacks is determined by only the indications for surgical intervention, however, they can be installed only in the late postoperative period. This method does not provide a differentiated and individual approach to treatment in different clinical cases and does not create the possibility of normalization of intraocular pressure (IOP) is a non-surgical method. It should be noted that the holding of the topography with a considerable increase in IOP often not be technically possible in the absence of outflow UGG. In addition, this method does not allow you to install partial obstruction surgically formed by way of the outflow (HSPA), as is often the case in the early stages of the formation of interstitial growths.

The objective of the invention is to develop indications for differentiated treatment of patients with early hypertension AGO after filtration type that will allow you to make the right choice of tactics of conducting the patient and in some cases to normalize IOP, misoperate the authorized way, while identifying obstruction of HSPA to determine the optimal method of corrective intervention.

The technical result is to improve the quality of treatment of patients with early hypertension AGO after filtration type due to the normalization in some cases, IOP non-surgical method of reducing the length of patient stay in hospital and improve the accuracy of selecting the correct course of treatment.

The technical result is achieved in that in the method of determining indications for differentiated treatment of patients with early hypertension AGO after filtration of the type initially examined the patient in the light of the slit lamp. Then according to the invention additionally examine the condition of the filtration bags (AF) - define its size and topography, and register these settings, conducting the survey in the dynamics and comparing the results of the survey with those of the previous inspection. After that with the purpose of the study the patency of HSPA test is done with sterile air. To do this, under the conjunctiva and tenon shell in the zone of operations introducing sterile air in the mixture with glucocorticosteroid drug (for example, dexason), with glucocorticosteroid drug use for additional anti-inflammatory effect and facilitate the penetration of air ceresco. The injection is performed with the needle (with an inner diameter of 0.4 mm, 12 mm in length) on the insulin syringe. The needle is inserted through the conjunctiva and tenon shell, some distance of 1-2 mm from the border zone of operations, and deliver it to the sclera in the area of AF. For an unrestricted air entrance in front of the camera have needle tangentially to the surface of the eyeball, gradually promote it to the border of the superficial scleral flap (STGS) and stop her, not reaching 0.5-0.7 mm from the edge of the PDP. Throughout the manipulation continue to put pressure on the plunger of the syringe.

When patency (even partial) HSPO the air together with steroid medication passes under pressure under PSL and entered via the internal fistula in front of the camera, clearly defined therein in the form of one or more bubbles (positive test results).

When obstruction of HSPO the air together with the medicinal product is not able to get in front of the camera and is distributed in the zone of injection (between the conjunctiva, tenon's capsule and the sclera), causing a temporary elevation of the conjunctiva in extraocular the area of operation (negative test result).

When developing the indications for treatment of patients with early hypertension AGO after the filter type, the authors were guided by the following:

1. The increase in speaker is height or size of AF, as well as positive test results with sterile air indicate functional competence (patency) HSPA, and hypertension in this case is associated with hyperproduction of reactive UGG ciliary body.

in these cases within 3-5 days prescribed diuretics (for example, diacarb)and instillation of drugs that reduce the secretion of UGG (for example, trusopta). After flattening the OP for preventing the formation of interstitial growths are activating HSPA, which consists in the introduction under the conjunctiva in the area of operation of solutions of steroids and enzymes, as well as in the introduction under the conjunctiva out-of-area operations solution antimetabolite (for example, 5-fluorouracil).

Suppression products UGG naturally leads to reduction of its outflow, HSPA, indirect causes flattening of the OP, which creates favorable conditions for the development of interstitial growths. It is in this regard, the use of instillation, reduce the secretion of UGG, is an indication for the prevention of the formation of interstitial growths.

2. Flattening the OP or change its relief (the appearance of zones of "impressions" in the OP) indicates the formation of interstitial growths, but in combination with positive test results with sterile air shows partial (but not sufficient for the protection of normotone) patency of the path of the outflow, and hypertension in this case related to a partial functional failure of HSPA.

in these cases within 2-3 weeks conducting anti-inflammatory therapy in combination with a course of anti-proliferative assignments (e.g., electrophoresis with lidsay and the rate of beta applications), as well as to inject the activation of HSPA with solutions of glucocorticosteroids and enzyme preparations.

The relief OP reflects the activity of formation of interstitial growths in extraocular the area of operations and change in dynamics correlates with the intensity of the hyperplastic process.

3. The pronounced flattening or disappearance of AF in combination with negative test results with sterile air shows ileus HSPA, which in this case is a cause of hypertension.

- in these cases are gonioscopy and

- open the internal fistula produce a revision of the entire outer region of the ways outflow (subconjunctival and subscleral zones) AGO split formed of interstitial growths and additional intraoperative subconjunctival application of antibiotic and cytotoxic activities (e.g., mitomycin C [MMC]).

- in the presence of blockade of the inner zone fistula performed laser surgery to restore patency inside the division drainage path (for example, laser goniopuncture in the area of surgical intervention). With the normalization of IOP additional activities not conducted.

- when saving hypertension after the laser treatment is repeated antiglaucoma intervention in another segment of the eyeball with additional intraoperative subconjunctival and intrasternally applique antibiotic cytotoxic action, ensuring a pronounced antiproliferative effect (e.g., MMS).

The method is as follows. A patient with early hypertension AGO after filtration the type of conduct tonometry (IOP control) and if it is impossible to study the hydrodynamics of the eye method monografii examine the condition of AF in the light of the slit lamp. Determine the size and topography of the OP and register these settings in dynamics, comparing the survey results with similar results from the previous inspection. After this test is done with sterile air under the conjunctiva and tenon shell in the zone of operations introducing sterile air in the mixture with glucocorticosteroid drug (for example, dexason). The injection is performed with the needle (with an inner diameter of 0.4 mm, 12 mm in length) on the insulin syringe. The needle is injected tangentially to the surface of the eyeball in the place of injection, so as to increase the angle of the needle in the relationship is to the sclera causes tension and conjunctival Ternovoi shells, expands the input of the injection hole and leads to the release of air and expired drug. The air is mixed with the drug is injected slowly, allowing you to feel resistance in the presence of interstitial growths. For an unrestricted air entrance in front of the camera the needle gradually advance to the border of the superficial scleral flap and stop her, not reaching 0.5-0.7 mm from the edge of the superficial scleral flap. Throughout the manipulation continue to put pressure on the plunger of the syringe. When patency (even partial) surgically formed the way the air together with the medicinal product is held under pressure under the scleral flap and went in front of the camera, clearly defined therein in the form of one or more bubbles. When obstruction surgically formed by way of the outflow of the air together with the medicinal product is not able to get in front of the camera and is distributed in the zone of injection (between the conjunctiva, tenon's capsule and the sclera), causing a temporary elevation of the conjunctiva in extraocular the area of operations.

Analyze the results and choose pathogenetically reasonable tactics of conducting the patient.

The invention is illustrated by the following examples.

Example 1. Patient B., age 12. Diagnosis: Secondary posttrauma the ical glaucoma of the right eye. On the 9th day after surgery (deep sclerectomy - GSS), the patient is marked hypertension. Digital values of IOP according to tonometry - 44 mm Hg Tonography for technical reasons could not be realized. Examination of the patient in the light of the slit lamp showed an increase in the height of AF in comparison with earlier examinations. According to the invention carried out the test with sterile air. Positive test results (the emergence of several air bubbles in the anterior chamber) explained the appropriate tactics. The patient had been prescribed medications General and local actions that inhibit the production UGG - oral diakarba (1/2 tablet in the morning for three days) and instillation of 2% solution - trusopta, 2 drops in the operated eye 2 times a day - 4 days. On the 2nd day after starting treatment IOP was normalized, amounting to 20 mm Hg, FP, apostilas. With the aim of preventing the development of interstitial growths patient within 5 days after the start of treatment was performed subconjunctival injections dexasone under the conjunctiva in the area of AF. Consistently been cancelled diacarb and instillation trusopta, after which a slight increase in the height and size of AF. IOP remained stable and was in the range of 17-18 mm Hg Factor ease of movement according to monografii corresponded to 0.33 mm3/min/mm Hg For the next observation in dynamics demonstrated the stability of normotone, monograficheskih indicators and the state of AF.

Example 2. Patient K., 19 years. Diagnosis: Secondary aphakic glaucoma of the right eye. Patients received GSS. On the 5th day after surgery IOP of the right eye was 17 mm Hg, the ratio ease of movement - 0.30 mm3/min/mm Hg On day 12 after surgery, the patient had elevated IOP up to 32 mm Hg the Tonography showed a decrease of the coefficient of ease of movement, which amounted to 0.14 mm3/min/mm Hg patient Survey in light of the slit lamp revealed flattening of the OP and the emergence of zones of "impressions" in the OP, missing in the previous examinations. According to the invention carried out the test with sterile air. The emergence of several air bubbles in the anterior chamber, showing positive test results, combined with the flattening of the OP allowed to conclude insufficient to maintain normotone patency of the path of the outflow and outlined the subsequent management of the patient. The patient underwent a course of anti-inflammatory (instillation of naclof 1 drop 5 times a day and dexamethasone 1 drop 4 times a day) and antiproliferative (5 subconjunctival injections of 5-fluorouracil in another segment of the eyeball and the rate of beta applications within 10 days of therapy. Simultaneously made of injection activation of HSPA (five subconjunctival injection what s dexasone and seven subconjunctival injection of chymotrypsin). 10 days after the start of treatment OP bought bottled character, local areas presses disappeared, IOP decreased to 19 mm Hg, the Tonography evidence demonstrated facilitating ease of movement - coefficient increased to 0.28 mm3/min/mm Hg Monitoring over the next 6 months confirmed the stability of the normalization of IOP and monograficheskih indicators.

Example 3. Patient U., 31. Diagnosis: congenital repeatedly operated glaucoma of the right eye on the background of the syndrome Sterg-Weber. Condition after GSS. Postoperative IOP in the right eye was in the range of 19-20 mm Hg, the ratio ease of movement corresponded to 0.30 mm3/min/mm Hg At discharge in the area of operations differentiated plaskolite OP. 19 days after surgery, residence in a patient with elevated IOP up to 27 mm Hg, a reduction factor ease of movement to 0.12 mm3/min/mm Hg Inspection Advisory reception in MNTK "MG" revealed a sharp flattening of the OP. According to the invention carried out the test with sterile air, which gave negative results. Gonioscopy showed an open area of the internal fistula. The current clinical situation was indicative of a high probability of obstruction extraocular and intrasternally areas HSPA. In accordance with the obtained data the mi patient was the audit of the entire outer region of the ways outflow (subconjunctival and subscleral zones) AGO split formed of interstitial growths. Addition was performed intraoperative subconjunctival application of cytostatic MMS, at a dose of 0.4 mg/ml at the time of application of 5 minutes. After surgical revision IOP was normalized to 20 mm Hg, the ratio ease of movement increased to 0.32. Done within 8 months of the study demonstrated the stability of the results obtained - steady normotone (19-20 mm Hg) and stability of the topographic indices.

Example 4. Patient W., 27 years. Diagnosis: secondary posttraumatic glaucoma of the left eye V degree; condition after GSS. At discharge from hospital IOP - 19 mm Hg, the ratio ease of movement - 0.28 mm3/min/mm Hg In the zone of operations at biomicroscopy was determined spilled OP. 16 days after surgery the patient is reiterated in MNTK "MG" in connection with the deterioration of the operated eye. When examination revealed increased IOP of 30 mm Hg, a reduction factor ease of movement to 0.08 mm3/min/mm Hg patient Survey in light of the slit lamp revealed the disappearance of AF. According to the invention carried out the test with sterile air, which gave negative results. The clinical situation was indicative of obstruction surgically formed by way of the outflow. In order to restore patency of intraocular fistula patient who performed laser goniopuncture in the area of surgical intervention. Repeating the test with sterile air gave positive results. IOP was normalized and amounted to 17 mm Hg Factor ease of movement increased to 0.31 mm3/min/mm Hg In the next 12 months held in the dynamics research (tonometry, topography and gonioscopy) demonstrated the stability of the obtained results: stable normotone, normalization monograficheskih performance, stability gonioscopic picture.

Example 5. Patient A., aged 14. Diagnosis: secondary (uveal) glaucoma of the left eye. Condition after GSS. In the area of operations was formed plaskolite OP. Postoperative IOP in the left eye - 15 mm Hg, the ratio ease of movement 0,29 mm3/min/mm Hg After 3 weeks after surgery, to check in MNTK "MG" elevated IOP to 34 mm Hg, a reduction factor ease of movement to 0.09 mm3/min/mm Hg patient Survey in light of the slit lamp revealed the complete disappearance of AF. According to the invention carried out the test with sterile air, which gave negative results. Gonioscopy inner area of surgical intervention showed interstitial growths in the field of internal fistula. Try laser time georegistration in the area of effect is not given. The clinical situation was indicative of complete obstruction of HSPA. Sick stitches is repeated AGO in another segment of the eyeball with additional intraoperative subconjunctival and intrasternally applique MMS, at a dose of 0.5 mg/ml when the exposure time is 5 minutes. The postoperative course was uncomplicated, IOP operated eye was in the range of 17-19 mm Hg, the ratio ease of movement - 0.29 to 0.31 in mm3/min/mm Hg Monitoring over the next 12 months showed the stability of the obtained results: stable normotone, normalization monograficheskih indicators.

Using the proposed method provides a lifetime obtaining information about the state of the zone previously performed surgery to determine the localization of the hydrodynamic unit. The proposed method makes it possible to individualize the tactics of conducting the patient with timely use of to interrupt the pathogenic chain of development of hypertension and to avoid surgical intervention, if necessary, re-surgery - to reduce its volume and invasiveness, allowing you to maintain functional performance in this difficult group of patients. The method is technically simple and accessible, does not require additional equipment and special surgical skills.

Under the proposed method defined indications for differentiated treatment and carried out corrective measures in 16 patients with early hypertension in paleoptera the ion period AGO filter type. In all cases achieved persistent normalization of IOP (17-21 mm Hg).

The method of determining indications for differentiated treatment of patients with early hypertension after antiglaucomatous operations of filter types, including tonometry and examination of a patient in the light of the slit lamp, characterized in that it further examine the condition of the filtration bags (AF) - define its size and topography, and register these settings, conducting the survey in the dynamics and comparing the results of the survey with those of the previous inspection, after this test is done with sterile air, which consists in the introduction under the conjunctiva in the area of operation of sterile air in the mixture with glucocorticosteroid drug, the injection is carried out, departing at 1-2 mm from the border zone operations, and advance the needle to the border of the superficial scleral flap (PSL), stopping it, not reaching 0.5-0.7 mm from the edge of the PDP and, if the dynamics is determined by increasing the height of AF, and the air together with the drug passes in front of the camera, shown by appointment diuretic funds and instillation of drugs that reduce the secretion of intraocular fluid, and after flattening the OP shows the activation of the surgically formed by way of the outflow (HSPA) solutions of glucocorticosteroids and EN zymes the different drugs and the introduction under the conjunctiva out-of-area operations solution antimetabolite, if the dynamics is determined by the flattening or change the relief of the Fi and air passes in front of the camera, is shown holding anti-inflammatory therapy in combination with a course of anti-proliferative assignments and injection activation of HSPA solutions glucocorticosteroids and enzyme preparations, if the dynamics is determined by the flattening or disappearance of AF, and the air does not pass in front of the camera, then spend gonioscopy and open when the internal fistula produce a revision of subconjunctival and subscleral zones surgical intervention division formed of interstitial growths and additional intraoperative subconjunctival application of antibiotic cytotoxic action, when there is a blockade internal fistula performed laser surgery in the area of operation and the normalization of IOP additional activities not carried out, while maintaining hypertension after the laser treatment is repeated antiglaucoma intervention in another segment of the eyeball with additional intraoperative subconjunctival and intrasternally applique antibiotic cytotoxic action.



 

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EFFECT: improved vision functions; improved connective tissue trophism.

FIELD: medicine.

SUBSTANCE: method involves moving working end piece over pathological focus in continuous passage several times within 3-5 min on each jaw. Pauses are reduced to minimum of 1-2 s in frenulum and fibrous tissue bands vicinity. Vacuum treatment degree is maximally reduced to tissue stimulation degree not exceeding 35 mm of mercury column. Combined action of vacuum tension is provided in values range of 10-35 mm of mercury column in pulsating mode and laser radiation in red bandwidth with power density of 0.3-0.8 mW/cm2 in continuous mode. The combined treatment course is 5-10 sessions long depending on necessity. Vacuum rarefaction of 20-80 mm of mercury column is applied to places of cleaning pathological zones in treating periodontium diseases accompanied with profuse pus discharge from pouches. Then, combined treatment is continued after having changed the end piece member and having done antiseptic treatment of the oral cavity.

EFFECT: enhanced effectiveness of treatment.

3 cl

FIELD: medicine.

SUBSTANCE: method involves applying multiple irradiation in infrared wavelength bandwidth with irradiation energy density equal to 15-40 J/cm2 to spongious bones projection.

EFFECT: provided effective stem cells concentration within prolonged time interval.

4 cl

FIELD: medicine, surgery.

SUBSTANCE: on the 1st d after operation a patient should be injected with mexidol intravenously by drops at the dosage of 300 mg, during the next 2 d mexidol should be injected intramuscularly twice daily at the dosage of 200 mg. Moreover, during 10 d after operation a patient should be perorally introduced with ADP-37 preparation a the dosage of 6 capsules daily and during 5 d one should affect the wound with impulse magnetic field at about 0.5-1.0 Tl intensity through Dalcex-trypsin filter cloth impregnated with 0.01%-serotonin solution, once daily. The innovation enables to accelerate the terms of wound healing up to 6-7 d and avoid therapy-induced complications.

EFFECT: higher efficiency of therapy.

1 ex

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