RU2829426C1 - Method for non-penetrating antiglaucoma surgery using spongy allotransplant drainage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmosurgery, and can be used for surgical treatment of open-angle glaucoma. That is ensured by an incision of the conjunctiva. Surface scleral flap of rectangular shape 5 mm long, 4 mm wide to a limb is cut out with entering the deep layers of the sclera, as well as surface layers of the cornea with excision of the trabecular zone and exposing the Descemet's membrane. At the bottom of scleral bed 3 mm from the cornea, a through linear incision of deep layers of the sclera is made to the suprauveal space. Spongy allograft rectangular drainage of 3×5 mm is placed into the scleral bed with one end close to Descemet's membrane. Other end is inserted through a through linear incision of the deep layers of the sclera into the suprauveal space. Superficial flap is laid on top of the drainage and fixed at the angles to the sclera with two interrupted sutures, and one continuous suture is applied on the conjunctiva.

EFFECT: invention provides simplifying the operation, reducing the number of postoperative complications by preventing sclero-scleral and sclero-conjunctival adhesions and achieving a long-term hypotensive effect.

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Description

The invention relates to medicine, namely to ophthalmic surgery, and is aimed at effective surgical treatment of open-angle glaucoma.

Glaucoma remains one of the leading causes of blindness in ophthalmology today. Surgical intervention is the key method of its treatment.

Various surgical techniques are offered to effectively reduce intraocular pressure, while minimizing trauma and reducing the likelihood of complications during surgery and in the postoperative period.

One of the factors leading to the leveling of the hypotensive effect after surgical interventions is excessive scarring of the wound in the area of newly formed drainage pathways. Implantation of drainage is considered as a prevention of scleroscleral and sclero-conjunctival adhesions to maintain long-term normalization of intraocular pressure.

The closest analogue of the invention is a method of surgical treatment of open-angle glaucoma, which consists in separation of the conjunctival flap, separation of the superficial scleral flap (SSF), removal of the middle layers of the sclera until the internal layers of the corneoscleral part of the trabecula and the limbal edge of Descemet's membrane are exposed, implantation of the Glautex drainage, and reposition of the SSF. For this purpose, a rectangular SSF is cut out with an entry into the superficial layers of the cornea with a base of 3.5 mm at the limbus and a height of 4 mm. Removal of the middle layers of the sclera is performed along the edges of the SSF bed corresponding to its height, preserving the middle layers of the sclera in the middle of the bed in the form of a strip 1 mm wide. Then, a Glautex drainage measuring 2.5 x 5.2 mm is implanted under the SSF with a smaller base towards the limbus, in front of the Schlemm canal. From the lateral sides of the PSL, 0.5 mm wide strips of sclera are cut along the entire length and after repositioning the PSL, a continuous suture is applied to the conjunctiva above it and fixed to the PSL [Patent of the Russian Federation for Invention No. 2662904, 2018]. However, the effect of this method is limited by the fact that in some cases, after the resorption of the bioresorbable drainage, the formation of scleroscleral adhesion between the scleral flaps continues by forming scar tissue and obstructing the outflow of intraocular fluid and, as a consequence, an increase in intraocular pressure, leading to the need for additional surgical interventions.

The objective of the invention is to develop a method for non-penetrating surgical treatment of open-angle glaucoma using non-biodestructive allograft drainage.

The technical result of using the invention is a simplification of the operation, a reduction in the number of postoperative complications due to the prevention of scleroscleral and scleroconjunctival adhesions and the achievement of a long-term hypotensive effect.

The invention is illustrated by the following figures: Fig. 1 schematically shows the cutting of a rectangular superficial scleral flap, 5 mm long and 4 mm wide, where: 1 is a superficial scleral flap; Fig. 2 is the separation of the superficial scleral flap with an extension into the deep layers of the sclera, as well as the superficial layers of the cornea with excision of the trabecular zone and exposure of Descemet's membrane, where: 2 is the outer wall of Schlemm's canal, 3 is Descemet's membrane; Fig. 3 is a through linear incision of the deep layers of the sclera to the suprauveal space, where: 4 is a through incision of the deep layers of the sclera; Fig. 4 is the placement of a rectangular spongy allograft drainage system measuring 3x5 mm, where: 5 is a spongy allograft drainage system; Fig. 5 - fixation of the superficial scleral flap over the drainage to the sclera with two interrupted sutures.

The proposed method of non-penetrating antiglaucoma surgery is performed as follows. A 7 mm long conjunctival incision is made, a rectangular superficial scleral flap is cut out, 5 mm long, 4 mm wide to the limbus (Fig. 1) with entry into the deep layers of the sclera, as well as the superficial layers of the cornea with excision of the trabecula zone and exposure of the Descemet membrane (Fig. 2). At the bottom of the scleral bed, 3 mm from the cornea, a through linear incision is made in the deep layers of the sclera to the suprauveal space (Fig. 3). A rectangular spongy allograft drainage Alloplant [Allografts for surgery "Alloplant"® according to TU 9398-001-04537642-2011] of 3x5 mm in size is placed in the scleral bed with one end close to the Descemet membrane, creating an active path for the outflow of intraocular fluid through the drainage. The other end is inserted through a through linear incision of the deep layers of the sclera into the suprauveal space (Fig. 4). The superficial flap is placed over the drainage and fixed at the corners to the sclera with two interrupted sutures (Fig. 5) and 1 continuous suture is applied to the conjunctiva.

The distinctive features of the proposed method from the prototype, providing simplification of non-penetrating antiglaucoma surgery and reduction of the number of postoperative complications are: separation of only one superficial flap of the sclera is performed, which reduces the trauma and duration of intervention in the eye structures. Then a through incision is made in the deep layers of the sclera parallel to the limbus up to the suprauveal space in order to create a path for the outflow of intraocular fluid from the anterior chamber of the eye into the suprauveal space along and through the drainage, to reduce the frequency of postoperative complications and long-term normalization of intraocular pressure. Instead of the bioresorbable drainage "Glautex", a non-biodestructive spongy allotransplant drainage Alloplant is placed, which has a porous structure that helps create a depot of intraocular fluid in the interscleral space, eliminating the possibility of fusion of the scleral flap with the underlying tissue, creating a constant flow of intraocular fluid along and through the spongy allotransplant drainage from the anterior chamber to the suprauveal space.

The essence of the invention is illustrated by the following clinical examples.

Example 1. Patient A., 58 years old, diagnosed with stage 2 open-angle glaucoma, suffered from decreased visual acuity and visual fields over the past two years. Visual acuity in the right eye is 0.9, in the left eye 0.3. Visual fields in both eyes correspond to stage 2 glaucoma. Intraocular pressure in the right eye was 24 mm Hg while taking dorzolamide 2% twice daily, in the left eye the intraocular pressure reached 31 mm Hg while taking dorzolamide 2% twice daily in combination with latanoprost 0.005% once daily.

The left eye was operated by the proposed method of non-penetrating antiglaucoma surgery using spongy allotransplant drainage. The conjunctiva was opened 4 mm from the limbus, 7 mm long, in the lower outer sector. Hemostasis of the episcleral vessels.

A superficial scleral flap is cut out to 2/3 of its thickness, measuring 5x4 mm to the limbus with an entry into the deep layers of the sclera, as well as the superficial layers of the cornea with excision of the trabecula zone and exposure of the Descemet membrane. At the bottom of the scleral bed, 3 mm from the cornea, a through linear incision is made in the deep layers of the sclera to the suprauveal space. A rectangular Alloplant spongy allotransplant drainage measuring 3x5 mm is placed in the scleral bed, with one end close to the Descemet membrane, creating an active path for the outflow of intraocular fluid through the drainage. The other end is inserted through a through linear incision in the deep layers of the sclera into the suprauveal space. The superficial flap is placed over the drainage and fixed at the corners to the sclera with two interrupted sutures and the conjunctiva is strengthened with one continuous suture. The postoperative course is uneventful. The patient was examined after 12 months. The eye is calm. Intraocular pressure stabilized at 19 mm Hg without the use of antiglaucoma drops.

Example 2. Patient B., 65 years old, diagnosed with stage 3 primary open-angle glaucoma five years ago, experienced progressive deterioration of vision and intraocular pressure variations from 22 to 30 mmHg. The patient uses local drug antiglaucoma therapy. Visual acuity in the right eye is 0.5, in the left eye 0.1. The visual fields in both eyes correspond to stage 3 glaucoma. Intraocular pressure in the right eye was 22 mmHg while taking brinzolamide 1% twice daily in combination with timolol 1% twice daily, in the left eye the intraocular pressure reached 31 mmHg while taking brinzolamide 1% twice daily in combination with timolol 1% twice daily.

The left eye was operated on using non-penetrating antiglaucoma surgery with sponge allograft drainage. The conjunctiva was opened 4 mm from the limbus, 7 mm long, in the lower outer sector. Hemostasis of the episcleral vessels.

A superficial scleral flap is cut out to 2/3 of its thickness, measuring 5x4 mm to the limbus, entering the deep layers of the sclera, as well as the superficial layers of the cornea with excision of the trabecula zone and exposure of the Descemet membrane. At the bottom of the scleral bed, 3 mm from the cornea, a through linear incision is made in the deep layers of the sclera to the suprauveal space. A rectangular spongy allotransplant drainage Alloplant measuring 3x5 mm is placed in the scleral bed, with one end close to the Descemet membrane, creating an active path for the outflow of intraocular fluid through the drainage. The other end is inserted through the through linear incision in the deep layers of the sclera into the suprauveal space. The superficial flap is placed over the drainage and fixed at the corners to the sclera with two interrupted sutures and the conjunctiva is strengthened with one continuous suture.

The postoperative course is smooth. The patient was examined after 12 months. The eye is calm. Intraocular pressure stabilized at 17 mm Hg without the use of antiglaucoma drops.

Thus, the given examples demonstrate the effectiveness and safety of the proposed method, as well as its advantages compared to other known methods of treating glaucoma.

The proposed method was used to operate on 20 patients. Of these, 14 were diagnosed with primary open-angle glaucoma of the 2nd degree, and 6 patients with primary open-angle glaucoma of the 3rd degree. All patients showed a positive result of the operation in the form of normalization of intraocular pressure. The use of the invention ensures a stable and long-term reduction in intraocular pressure, prevents postoperative complications and improves the quality of life of patients.

Claims (1)

A method of surgical treatment of open-angle glaucoma, including cutting out a rectangular superficial scleral flap (SSF) with a base at the limbus, forming a scleral bed and implanting a rectangular drainage, applying one continuous suture to the conjunctiva, characterized in that a SSF 5 mm long, 4 mm wide to the limbus with an entry into the deep layers of the sclera, as well as the superficial layers of the cornea with excision of the trabecular zone and exposure of the Descemet membrane, at the bottom of the scleral bed 3 mm from the cornea, a through linear incision of the deep layers of the sclera to the suprauveal space is made, a spongy allotransplant drainage Alloplant measuring 3 × 5 mm is placed in the scleral bed with one end close to the Descemet membrane, the other end is inserted through a through linear incision of the deep layers of the sclera into suprauveal space, after which the PSL is placed over the drainage and fixed at the corners to the sclera with two interrupted sutures.