RU2790760C1 - Method for treatment of congenital glaucoma - Google Patents

Abstract

FIELD: ophthalmology.

SUBSTANCE: method includes cutting out a conjunctival and superficial scleral flap with its base towards the limbus and a thickness of 2/3 of the sclera thickness. At the 2 clock position, a triangular superficial scleral flap is cut out via the limbal zone. 5-fluorouracil is applied in the subconjunctival zone and under the superficial scleral flap. The top of the scleral flap is fixed to the sclera with an interrupted suture, Provisc is introduced under the superficial scleral flap. Then, at the 9 clock position, paracentesis is performed, a viscoelastic is introduced into the anterior chamber, and perforative coagulates are formed ab interno using high-frequency diathermy in the projection of the base of the scleral flap in the corner of the anterior chamber until filtration of the intraocular fluid appears. At the same time an application of 5-fluorouracil is carried out for 4 minutes.

EFFECT: method reduces the risk of small anterior chamber syndrome, ciliochoroidal detachment, hyphema against the background of preventing the cicatricial processes in the intervention area due to a combination of two approaches to the trabecular zone.

3 cl, 2 dwg

Description

The invention relates to medicine, namely to ophthalmology, and is intended for the treatment of congenital glaucoma.

Congenital pathology of the eyes is the main cause of blindness and low vision in childhood. Congenital glaucoma in children occurs with a frequency of one child per 10,000-20,000 newborns, in the structure of eye pathology its share reaches 0.1%, its share in the structure of causes of childhood blindness is large - up to 9% (Actual problems of pediatric ophthalmology Text. / A V. Khvatova, L. N. Zubareva, E. I. Sidorenko, V. V. Mishutin // VII Congress of Russian ophthalmologists: abstracts. M, 2000). More than 75% of patients with glaucoma are bilateral. In 60% of children, clinical signs of congenital glaucoma appear in the first 6 months of life, in 80% - in the first year of life. Congenital glaucoma leads to persistent irreversible changes in the structures of the organ of vision. The treatment of congenital glaucoma is exclusively surgical, while in children, penetrating operations are predominantly performed in the form of various modifications of sinustrabeculoectomy (Khvatova A.V., Arestova N.N. Twenty years of experience in the treatment of congenital glaucoma in children // Topical issues of pediatric ophthalmology: Scientific materials .-practical conf. - M., 1997.). However, the search for an effective method of treating congenital glaucoma remains an urgent problem in pediatric ophthalmology due to the wide variety of early and late complications after existing methods of surgical treatment of congenital glaucoma.

The main intraoperative features of glaucoma surgery are a sharp drop in IOP and hemorrhagic complications of varying intensity, which are caused by manipulations on the APC structures, which in children is covered by mesodermal vascularized tissue. Among the early postoperative complications, the main ones are: hypotension, small anterior chamber syndrome, ciliochoroidal detachment.

In the late postoperative period, the reason for the lack of a persistent hypotensive effect is cicatricial obliteration of the created pathways for the outflow of intraocular fluid (Sidorov E.G., Mirzayants M.G. Congenital glaucoma and its treatment, 1991). To suppress excessive scarring, antimetabolites, drains, various auto-, allo- and xenografts are used, the properties of dispersion viscoelastic are also used (N.F. Bobrova, N.B. Trofimova et al., Filtration surgery for congenital glaucoma in children - viscosinustrabeculotomy, Ophthalmosurgery - 2013. - No. 2 - S. 62-67.). Among cytostatics, preference is given to mitomycin C and, above all, 5-fluorouracil, which reduce the proliferation of episcleral fibroblasts by toxic effects, reducing scarring in the area of the filtration cushion (N.F. Bobrova, N.B. Trofimova et al., Odessa, Filtration surgery for congenital glaucoma in children - viscosinustrabeculotomy, Ophthalmosurgery - 2013 - No. 2).

A known method for the treatment of congenital glaucoma, in which a penetrating sinus trabeculectomy is performed, while the superficial scleral flap is cut out and separated using an ultrasound scalpel and an ultrasound round knife with a gradual increase in amplitude sufficient to obtain the necessary cutting and coagulating effect, after separation of the flap, the inner surface is leveled additional ultrasound effect. A strip of deep layers of the sclera and corneoscleral trabeculae is excised with a blade. When suturing the conjunctiva, additional interrupted sutures are applied to the subconjunctiva and Tenon's capsule (RU 2199295, 27.02.2003). This method of treatment of congenital glaucoma does not exclude the occurrence of such complications as a sharp drop in IOP intraoperatively, shallow anterior chamber syndrome and the occurrence of ciliochoroidal detachment in the early postoperative period, as well as scarring in the subconjunctival space in the postoperative period. A known method for the treatment of glaucoma in children, in which, when forming a subscleral outflow tract of intraocular fluid, a conjunctival incision is performed within the planned scleral flap with a laxative notch 1.5-2 mm long perpendicular to the limbus. The conjunctiva is separated from the subconjunctival layer and resected within the superficial scleral flap. Next, a superficial scleral flap is cut out, and a narrow triangular flap is cut out from the deep layers of the sclera with the base to the limbus, exposing a portion of the ciliary body. Perpendicular to the sides of the bed of the triangular flap, 2-3 canals are marked and cut out on each side so that their outer end extends beyond the bed of the superficial scleral flap. The triangular flap is removed. The posterior wall of Schlemm's canal is removed. The superficial scleral flap is put in place and fixed with an interrupted suture, the conjunctival flap is fixed to the limbus with two interrupted sutures along the edges of the scleral flap (RU 3313317, 27.12.2007). The disadvantages of this method include: a high probability of the appearance of staphylomas of the sclera in the area of the surgical intervention, since the deep scleral flap is removed completely, and the extensibility of the tissues of the child's body is high; a sharp drop in IOP during surgery, the occurrence of a syndrome of a shallow anterior chamber and ciliochoroidal detachment in the early postoperative period are not excluded.

The closest analogue of the proposed method is a method for the treatment of congenital glaucoma, in which a conjunctival, superficial scleral and deep triangular flap is formed with the base to the limbus with exposure of the ciliary body, 2 scleral canals are formed on each side of the triangular flap perpendicular to them, the outer end of the scleral canal should go beyond superficial scleral flap bed, two collagen drains are sutured to the formed scleral bed, the length of which should not exceed the length of the scleral flap, opening the anterior chamber of the eye with an incision along the limbus, iridectomy, introducing the ends of two drains into the anterior chamber, forming a window in the trabeculo-descemet membrane (RU 2555398, 07/10/15). However, this method requires additional stages of surgical treatment, which increases the time of the operation, while maintaining the risks of excessive proliferation and scarring in the postoperative period.

The objective of the invention is to create a combined method for the treatment of congenital glaucoma.

The technical result of the proposed method is to reduce the risk of small anterior chamber syndrome, ciliochoroidal detachment, hyphema while preventing scarring in the intervention area.

The technical result is achieved by combining two approaches to the trabecular zone - from the side of the scleral flap and ab interno - to ensure the filtration of intraocular fluid through perforated coagulates in the projection of the base of the scleral flap in the angle of the anterior chamber against the background of the use of viscoelastic and the application of 5-fluorouracil.

Due to the introduction of viscoelastic material into the anterior chamber and the creation of an internal fistula ab interno after fixing the top of the scleral flap and inserting viscoelastic material under the superficial scleral flap, it is possible to exclude an intraoperative sharp drop in IOP.

Ab interno access to obtain perforated coagulates in the projection of the base of the scleral flap in the angle of the anterior chamber before the appearance of intraocular fluid filtration reduces the risk of postoperative complications in the form of a small anterior chamber syndrome, CHO and hyphema.

A combination of techniques in the form of application of 5-fluorouracil and the use of the properties of high-frequency diathermy ensures the absence of both cicatricial obliteration of the internal fistula and scarring in the subconjunctival and intrascleral spaces in the long term.

The method was implemented in 8 patients with congenital glaucoma. In all patients in the group, intraocular pressure returned to normal on the first day after surgery; there were no postoperative complications in the early postoperative period. All children were examined 3 months after surgery; intraocular pressure parameters remained stable.

The method is carried out as follows.

Cut out the conjunctival and superficial scleral flap of triangular shape with the base to the limbal zone and a thickness of 2/3 of the thickness of the sclera. Spend the application of 5-fluorouracil in the subconjunctival zone and under the superficial scleral flap. The top of the scleral flap is fixed to the sclera with an interrupted suture, a viscoelastic is introduced under the superficial scleral flap. In the opposite quadrant, paracentesis is performed, viscoelastic is introduced into the anterior chamber, and perforative coagulates are formed ab interno using high-frequency diathermy in the projection of the base of the scleral flap in the angle of the anterior chamber until filtration of the intraocular fluid appears.

The application of 5-fluorouracil is carried out mainly for 4 minutes. As a viscoelastic, viscose is preferably used. Perforative coagulates are formed, in particular, using a tip included in the Oertli OS4 ophthalmic surgical system (https://nevacert.ru/reestry/med-reestr/rzn-2018-7067-24832).

The method is illustrated by the following clinical examples.

Example 1. Patient. A. Diagnosis: OD Uncompensated congenital glaucoma. At the age of three months, lacrimation appeared from the right eye, photophobia. On examination: OD cornea: enlarged in diameter up to 13.5 mm, diffuse edema, posterior embryotoxon, anterior chamber deepened, iris hypoplastic, round pupil, reaction to light weakened. Examination of the fundus is difficult due to corneal edema. OS optical media are transparent, the fundus is without pathology. PZO OD 22.95 mm OS 20.35 mm.

An intervention was carried out according to the proposed method. Under the control of an operating stereomicroscope, a fixation suture was placed on the superior rectus muscle. At 4 mm from the limbus at 14 o'clock, microsurgical scissors made a conjunctival incision 5-6 mm long, the conjunctival flap was bluntly separated to the limbus zone. After preliminary hemostasis, a triangular flap 3.5 × 3.5 mm in size was cut out from the surface layers of the sclera with its base to the limbus 2/3 of the sclera thick and separated from the underlying sclera with entry into the limbal zone. Performed subconjunctival and under the superficial scleral flap application of 5-fluorouracil for 4 minutes on the media - hemostatic sponge. Abundantly washed the area of surgical intervention with 40 ml of BSS. The scleral flap was fixed at apex 1 with an 8-0 standard interrupted suture to the adjacent sclera. Under the scleral flap, a viscus was introduced. The conjunctival incision was sealed, as is customary, with interrupted 7-0 vicryl sutures.

At 9 o'clock, paracentesis of the cornea was performed, the viscoelastic material Provisk was introduced. Through paracentesis, a tip was inserted into the anterior chamber to conduct high-frequency diathermy in the projection of the base of the scleral flap at 14 o'clock in the corner of the anterior chamber under the control of the goniolens and perforated coagulates were performed until filtration of the intraocular fluid appeared, the filtration cushion increased in volume. The viscoelastic material was partially removed from the anterior chamber. Corneal paracentesis was sealed with a hydraulic lock.

On the first day after surgical treatment, intraocular pressure was within the normal range, no lacrimation was noted during examination of the OD, the cornea was transparent. B-scan: OD- The vitreous body is acoustically transparent, the shells are slightly thickened (up to 2 mm), adjacent, excavation of the ONH is not visualized. Early postoperative period without complications. 4 months after surgical treatment Tonometry according to Maklakov 10 g: OD 22mmHg OS 21mmHg; PZO OD 23.32 mm, OS 20.71 mm. After 6 months - OD 21mmHg, OS 22mmHg; PZO OD 23.43 mm, OS 21.38 mm, adhesion of the filtration cushion is not observed, the internal fistula is well-founded.

Example. 2. OU Uncompensated congenital glaucoma OD advanced OS initial. At 5 months of life, the child developed lacrimation, clouding of the cornea of the right eye. On examination: OU on the skin of the eyelids, vascular malformation, cornea: the limbus zone is stretched, OD is diffuse corneal edema, OS is a transparent shiny cornea; the anterior chamber is deepened, the iris is hypoplastic, the pupil is round, the reaction to light is weakened. OD Examination of the fundus is difficult due to corneal edema. OS fundus without pathology. Tonometry according to Maklakov 10 g: OD 27mmHg OS 25mmHg; PZO OD 22.50 mm OS 20.96 mm.

An intervention was performed on the right eye according to the proposed method. Under the control of an operating stereomicroscope, a fixation suture was placed on the superior rectus muscle. At 4 mm from the limbus at 14 o'clock, microsurgical scissors made a conjunctival incision 5-6 mm long, the conjunctival flap was bluntly separated to the limbus zone. After preliminary hemostasis, a triangular flap 3.5 × 3.5 mm in size was cut out from the surface layers of the sclera with its base to the limbus 2/3 of the sclera thick and separated from the underlying sclera with entry into the limbal zone. Performed subconjunctival and under the superficial scleral flap application of 5-fluorouracil for 4 minutes on the media - hemostatic sponge. Abundantly washed the area of surgical intervention with 40 ml of BSS. The scleral flap was fixed at apex 1 with an 8-0 standard interrupted suture to the adjacent sclera. Under the scleral flap, a viscus was introduced. The conjunctival incision was sealed with 7-0 interrupted vicryl sutures, as is customary.

At 9 o'clock, paracentesis of the cornea was performed, the viscoelastic material Provisk was introduced. Through paracentesis, a tip was inserted into the anterior chamber to conduct high-frequency diathermy in the projection of the base of the scleral flap at 14 o'clock in the corner of the anterior chamber under the control of the goniolens and perforated coagulates were performed until filtration of the intraocular fluid appeared, the filtration cushion increased in volume. The viscoelastic material was partially removed from the anterior chamber. Corneal paracentesis was sealed with a hydraulic lock.

On the first day after surgical treatment, intraocular pressure was within the normal range, no lacrimation was noted during examination of the OD, the cornea was transparent. B-scan: OD vitreous body is acoustically transparent, shells are thickened up to 1.92 mm, adjacent, OD excavation is not determined

Early postoperative period without complications.

Maklakov Tonometry 10 g: OD 22mmHg; PZO OD 21.74 mm; adhesion of the filtration cushion is not observed, the internal fistula is wealthy.

After 4 months - OD 21mmHg; PZO: OD 22.19 mm, adhesion of the filtration pad is not observed, the internal fistula is well-founded.

Thus, the proposed method for the treatment of congenital glaucoma reduces the risk of small anterior chamber syndrome, ciliochoroidal detachment, hyphema while preventing scarring in the intervention area.

Claims (2)

1. A method for the treatment of congenital glaucoma, including cutting out the conjunctival and superficial scleral flap with the base to the limbus and a thickness of 2/3 of the thickness of the sclera, characterized in that at 14 hours a triangular superficial scleral flap is cut out with entry into the limbal zone, 5-fluorouracil is applied in the subconjunctival zone and under the superficial scleral flap, the top of the scleral flap is fixed to the sclera with an interrupted suture, a proviscus is inserted under the superficial scleral flap, then paracentesis is performed at 9 o’clock, viscoelastic is injected into the anterior chamber and perforative coagulates are formed using high-frequency diathermy in the projection of the base ab interno scleral flap in the anterior chamber angle until intraocular fluid filtration occurs. 2. The method according to p. 1, characterized in that the application of 5-fluorouracil is carried out for 4 minutes.