Method for surgical treatment of glaucoma

FIELD: medicine.

SUBSTANCE: superficial scleral flap is cut out with its base facing the limb. Sinus trabeculectomy and cyclodialysis are performed. A full deep inverted scleral flap is cut out within the cyclodialysis area in a projection of the superficial scleral flap. A cuff made of a biodegradable material is put on the flap and fixed in the previous place.

EFFECT: method provides stable intraocular pressure reduction by the formed intraocular fluid outflow tract.

1 ex

The present invention relates to ophthalmology and is intended for the surgical treatment of glaucoma.

In recent years, domestic and foreign researchers began to define a specific clinical form of glaucoma - refractory glaucoma (WG). The distinctive feature of this type of glaucoma is persistent, are not amenable to traditional methods of therapeutic and surgical treatment of increased intraocular pressure (IOP).

The basis of pathogenesis of WG are expressed changes in the drainage system of the eye, which greatly hinder or make impossible the outflow of intraocular fluid (UGG). In advanced and terminal stages of the disease with marked pain syndrome requires multiple re-operations, as in this case, it's almost impossible to get an adequate result in treatment with traditional medicines, laser techniques and surgical interventions. Conservative treatment of WG is characterized by low efficiency and plays only a supporting role. As for the surgical treatment of glaucoma, it used a huge number of different interventions. And now constantly offered new methods and their modifications.

The following types of surgical treatment of glaucoma:

1) the cycle is destructive interference;

2) reconstructive intervention;

3) standard filter interference with the use of cytostatics;

4) drainage ways (Bottom A. B. Explantation in the treatment of refractory posttraumatic glaucoma. Diss. ... K. M. N., M., 2011. - S. 23-24).

For the treatment of refractory glaucoma the most effective recognized as drainage ways. The use of drainage implants allows for the outflow UGG in conditions of severe fibroblastic activity of tissues. Among the drains can distinguish three main types: 1) translumbalna drains-setone; 2) the shunt tube; 3) shunt device.

The first works were completed in 1906 M. Rollett, and in 1912 A. Zorab, which are used for implantation silk thread and offered to introduce her sclerotomies hole to enable outflow UGG from the anterior chamber under the conjunctiva and to prevent overgrowth of scleral fistula. However, in the remote period formed the path of the outflow was healed. Among drainages of heterogeneous materials most widely glaucoma drainage of freeze-dried collagen porcine sclera. Such drainage is fully resorcinols for 6-9 months and replaced by newly formed by loose connective tissue, the sclera remains the tunnel, which carries out the I outflow UGG. (Kozlov Century. And. and other, non-Penetrating deep sclerectomy with collagenoplasty / Ophthalmosurgery. - 1990. No. 3. - S. 44-46). In the following was developed collagen drainage "Xenopus from purified collagen type 1 animal origin, rich sulfated by glycosaminoglycans. The structure of this porous material structure similar histological structure of trabecular tissue, therefore, its use helps to restore the outflow MIC (Anisimov, S. Y. and other Remote results of surgical treatment of WG using persistent to biodegradation of the collagen drainage//Glaucoma. - 2010. No. 2 - C. 28-33).

The closest analogue of the present invention is a method of surgical treatment of glaucoma, the technical essence of which is as follows: after the anesthesia produce separation conjunctival flap in any way: the basis of limb or limb, then markup and separation of the superficial scleral flap, having the form of a high-line. After the formation of the superficial scleral flap drainage put it on him (as a clutch), followed by the necessary operations depending on the types of antiglaucoma intervention (penetrating or non-penetrating). Fixation scleral flap with put on him drainage etc the lead 1-2 interrupted sutures. The seams on the conjunctiva impose regardless of version ofseparate to achieve a good adaptation (Long S. S. Prevention of excessive scarring when conducting antiglaucomatous surgery. Abstract. Diss. ... K. M. N., M., 2012. - S. 13 [S. 24]).

The disadvantages of this method are:

1. Use only one mechanism of activation of the outflow on the basis of the formation beneath the flap of sclera fistula in the area of trabeculae and schlemm's canal, providing drainage of intraocular fluid filtration pad conjunctiva.

2. Surface implantation of drainage Glautex over and under the superficial scleral flap to prevent scarring of the filtration pads. In the early postoperative period because of swelling drainage under the influence filtered from the anterior chamber intraocular fluid this leads to the displacement of the conjunctival flap and disruption of forming the filter pads.

3. In addition, the swelling drainage Glautex in the early postoperative period and the offset of the conjunctival flap is accompanied in some cases by dehiscence of the surgical incision of the conjunctiva.

The task of the invention is to develop a combined method of surgical treatment of glaucoma using biodegradable material.

T the economic results of the present invention is a persistent decrease in intraocular pressure in severely ill patients.

The technical result is achieved by forming simultaneously two ways of outflow of intraocular fluid expansion uweoscleeralny tract using biodegradable drainage and an additional outflow of intraocular fluid from the drainage zone of the anterior chamber angle in the generated filter pad conjunctiva using microvasculature operations.

Developed a combined intervention, providing, along with microvasculature mechanism sinusotrabeculactomy (traction), additional activation uweoscleeralny outflow of intraocular fluid, is provided by implantation of biodegradable drainage simultaneously in suprachoroidal space and between the layers of the sclera to form a new path of flow of liquid, in this case, in addition, it eliminates the offset of the conjunctival flap in the postoperative period due to the deep implantation of drainage. The essence of the techniques of the method is that after cutting out the superficial scleral flap and sinusotrabeculactomy spend cyclodienes, then cut out in the area of cyclodialysis in the projection of the superficial scleral flap, a full-layer deep scleral flap reverse profile, put on his sleeve from biodegradable material and fixed in the same place. Thus, the basis is the use of a deep scleral flap is opposite from the Foundation of the superficial scleral flap position, it has the opposite profile, and provides two ways of intraocular fluid.

The method is as follows.

The patient in the preoperative period, as is generally accepted, conduct a comprehensive ophthalmic examination, including visiometry, pneumotonometry, biomicroscopy, ophthalmoscopy, ultrasonic a - and b-scan, ultrasound biomicroscopy, optical coherence tomography of the anterior segment of the eye.

Preoperative preparation and anesthesia are common. Put the bridle suture on the upper straight muscle. If you have previous interventions an incision of the conjunctiva in quadrant, undamaged previous operations, length of 10-12 mm Bare sclera, starting from the limbus and to zone 6 mm from it. Form a U-shaped flap of sclera size 5×6 mm base to limb 1/2 of its thickness. Spend sinusotrabeculactomy and cyclodienes. In the area of cyclodialysis in the projection of the superficial scleral flap cut out a full-layer deep scleral flap reverse profile, put on his sleeve from biodegradable material and fixed in the same place. The superficial flap of sclera put in place and fixed with interrupted sutures. Impose a continuous seam on the conjunctiva. In front of the camera injected with saline and asdoh. The surgery is completed subconjunctival the introduction of a solution of dexamethasone 0,4% 0,3 mg and gentamicin 0,3 mg Impose aseptic monocular bandage.

Clinical example.

Patient S., 58 years. Hospitalized with a diagnosis of OS - posttraumatic glaucoma III-IV with penetrating corneoscleral scar the cornea, artificial erythrostoma aperture (IHD). At the time of admission: Vis OS = hand movement of the person Vis OD=0.8 n/K. IOP OS=34 mm RT.article OD=14 mm RT.article The socket without pathological changes. The eye position is correct, the motion in full. The cornea is edematous, in the Central zone Bulla, penetrating corneoscleral scar, front camera is of medium depth. END displaced medially. The fundus of the eye behind the veil. The length of the axis of the eyeball according to ultrasound biometry: OD - 22.5 mm, OS - 23,6 mm On the results of a comprehensive study, including USBM and OCT - thickness corneal 0.66 mm (center). END garantirovanno shifted to the inner corner of the eye. In 3 quadrants (upper, inner and partially bottom) the angle of the anterior chamber obturated by fusion of the cornea with the remnants of the iris.

Conducted preoperative sedation, including diphenhydramine 0.1 mg/kg, Relanium 0.15-0.2 mg/kg, seduxen 0.2 mg/kg of the Operation carried out under local anesthesia. Conducted regular processing of the surgical field. Established blueparrott.After conducting the pterygopalatine-orbital anesthesia with 2% lidocaine solution and drip anesthesia solution of alcaine, put the bridle suture on the upper straight muscle. Made an incision of conjunctiva in pre-selected quadrant of the Meridian 6 hours. Made hemostasis. Made the U-shaped incision in the sclera 5∗6 mm base to limb and formed a superficial scleral flap at 1/2 the thickness of the sclera within this section. Under his basis isikli fragment trabeculae 1∗5 mm. Made spatula cyclodienes towards the equator within the Lodge scleral flap. On the couch scleral flap made 2 cross-section of the deep layers of the sclera, from zone trabeculectomy in the direction of the equator parallel to the edge of the bed. Formed U-shaped flap from the deep layers of the sclera size 4∗5 mm inverse, relative to the scleral surface of the flap profile. Removing deep flap, exposed the ciliary body. The deep flap wore drainage Glautex. Deep flap of sclera recorded two interrupted sutures to the deep layers of the sclera within the bed surface of the flap, preserving formed in the beginning of the operation window in the area of the trabeculae. The superficial flap of sclera put in place and fixed with interrupted sutures. Put a continuous bead on the conjunctiva. In front of the camera introduced saline and air. Under the conjunctiva was injected solution dexamethasone 0,4% 0,3 mg and gentamicin of 0.3 mg. Imposed ASEP is practical monocular bandage.

In the postoperative period any complications was not. At discharge after 5 days Vis OS=0,01 no Corr. At the bottom of the limb for 6 hours. formed filtration pad conjunctiva. The cornea is transparent. Front camera is of medium depth. END in the same position as before the operation. The fundus of the eye reflex pink, the details are not seen well. IOP OS=15 mm RT.article.

When viewed through 3 months formed expressed filtration pad conjunctiva. The cornea is transparent. Front camera is of medium depth. Position IHD has not changed. In the fundus severe glaucomatous excavation of the optic nerve. Vis OS=0,01 no Corr. IOP OS=17 mm RT.article You can establish a persistent decrease in IOP.

Thus, the proposed method provides long-lasting hypotensive effect due to the combined action involving along with microvasculature mechanism sinusotrabeculactomy (traction) additional activation uweoscleeralny outflow of intraocular fluid.

The method of surgical treatment of glaucoma, including cutting out the superficial scleral flap base to limb and holding sinusotrabeculactomy, characterized in that after sinusotrabeculactomy spend cyclodienes, cut out in the area of cyclodialysis in the projection of the superficial scleral flap, a full-layer deep scleral the second flap reverse profile put on it the clutch from a biodegradable material and fixed in the same place.