RU2429809C1 - Surgical procedure for combination treatment of glaucoma and cataract - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: there is created a scleral bed of a drain canal by separating a scleral flap of a thickness not exceeding a half of its thickness with its base facing a limb, and a flap projection is pre-fixed with respect to the sclera with at least one unknotted suture. The scleral strips are cut partially within a ciliary canal. A tunnel paracentesis and a incision are made in a cornea. Further, a capsulorexis 3 to 5 mm in diameter is made. A removed anterior portion of the capsule is preserved. It is followed by phacoemulsification and removal of crystalline lens, implantation of an IOL, closure of the corneal tunnels, final removal of the scleral strip within the ciliary canal. The drain canal is formed by autoimplantation of a portion of the capsule of lens in the scleral bed with setting one end of the canal in an anterior chamber. The scleral flap is fixed by tightening and knotting a suture with an incisional wound closed in a conjunctiva.

EFFECT: procedure substantially reduces a risk of drain canal block and postoperative glaucoma progression.

3 cl, 1 tbl, 12 dwg, 5 ex

Description

Technical field

The invention relates to the combined surgical treatment of glaucoma and cataracts. In most cases, such treatment can be outpatient, followed by monitoring the patient’s condition, medication anti-inflammatory prophylaxis, and removal of the surgical suture after healing of the surgical wound in the conjunctiva.

State of the art

The simultaneous disease of glaucoma and cataract is quite common. Different authors estimate the frequency of such cases in the range from 17% to almost 39% of the total number of patients with eye diseases.

The standard approach provides for a time-independent surgical treatment of glaucoma and cataract in an order that depends on the course and stage of development of each of these diseases in specific patients and the recommendations of individual scientific schools.

Usually, glaucoma is surgically treated with trabeculoectomy and the formation of a drainage canal with the introduction of one end of this canal into the anterior chamber of the eye and the second end under the tenon sheath almost to the equator of the eye, and cataract surgery is mainly based on phacoemulsification of the affected crystalline lens with suction of the resulting suspension and implantation into the capsular bag of the intraocular lenses (hereinafter IOL) of a flexible biocompatible polymer.

In this case, the basis of the drainage channel is a heteroimplant in the form of a thin tube made of biologically inert polymer material (see, for example: A.D. Chuprov, V.V. Podyninogina, I. A. Gavrilova “Results of surgical treatment of advanced and terminal glaucoma using silicone drainage ”// GLAUKOM, 3/2006, p.26-28).

However, regardless of the order of execution, any two-time surgical intervention mentally traumatizes patients, is expensive and significantly increases the risk of postoperative complications and the duration of visual and social rehabilitation. Moreover, the use of heteroimplants very often leads in the postoperative period to at least partial blockage of the drainage channel and the progression of glaucoma.

Therefore, it is now preferable to a single combined surgical treatment of both of these diseases (see, for example: 1. Alekseev B.I., Ermolaev A.L. Trabeculotomy ad interno in combination with simultaneous cataract extraction // Herald of Ophthalmology. - 2003 No. 4, p. 7-10; 2. Dolzhich G.Yu., Lakhdar Atef, Clinical and functional justification of a simultaneous visor synustrabekuloectomy with cataract extraction and IOL implantation // Glaucoma at the turn of the millennium: Results and prospects: All-Russian scientific-practical conference: Materials. - M., 1999, p. 276-278; and many others). The main options for a single treatment were examined in detail by A.V. Bakharev (see the Abstract of the dissertation "A new approach to the surgical treatment of cataracts in combination with glaucoma" for the degree of candidate of medical sciences M., 2008).

The same author proposed “A method for the surgical treatment of cataracts in combination with glaucoma and an instrument for performing the method” (RU 2313315), which preferably includes traditional preparation of the surgical field, separation of the conjunctiva, formation of scleral tunnel access to the anterior chamber of the eye, lens removal by capsulorexis and phacoemulsification, the implantation of a suitable IOL into the capsular bag and the creation of a drainage canal by biting the Schlemm canal region together with the trabecular apparatus ohm while maintaining the integrity of the walls of the scleral tunnel, for which a gonioscope and instrument are used in accordance with the above RU 2313315.

In patients with previously operated on glaucoma, cyclodialysis is achieved using a hydrogel heteroimplant as drainage. The operation is completed by sealing the surgical wound in the conjunctiva with atraumatic thread.

Complete biting of the Schlemm's canal area together with the trabecular apparatus positively affects the stabilization of glaucoma in the postoperative period, but this effect is achieved by excessive trauma to the eye. Therefore, there is reason to believe that at least a partial filling of the formed cavity with a hydrogel or other heteroimplant will be necessary not only in cases of previously operated glaucoma. Accordingly, there is a risk of glaucoma progression as a result of blocking such a heteroimplant.

The closest in technical essence the combined method of surgical treatment of glaucoma and cataract is known from RU 2371149. It provides:

separation of the conjunctiva in the upper quadrant with the base to the limb,

the formation of a superficial rectangular sclera flap with the base to the limb,

the formation of a deep triangular sclera flap with the base to the limb,

a through incision at the base of a deep triangular sclera flap,

additional corneal paracentesis,

phacoemulsification of the lens through the specified paracentesis and through incision,

implantation of a flexible IOL with removal of the anterior part of the lens capsule,

a through incision in the scleral bed parallel to the limbus and cyclodialysis with a spatula,

folding of the removed anterior lens capsule into the tube and introducing one of its ends into the anterior chamber, and the second end through the cyclodialysis fissure into the suprachoroid space,

fixing the superficial rectangular sclera flap with two interrupted sutures with a slight displacement towards the limb and

standard conjunctival fixation with a continuous suture.

Using the front of the lens capsule as an autograft reduces the risk of blocking the drainage channel formed from it and the progression of glaucoma in the postoperative period.

However, the formation of a deep triangular sclera flap (instead of cutting a narrow strip of sclera) and a through incision at the base of the specified flap, complete removal of the anterior part of the lens capsule and the formation of a cyclodialysis bed with a spatula before laying the folded into the tube anterior wall of the lens capsule significantly injure the patient's eye and can cause postoperative complications .

SUMMARY OF THE INVENTION

The basis of the invention is the task, by improving the procedure for performing surgical techniques using the patient’s own biomaterial to form a drainage channel, to create a less traumatic surgical method for the combined treatment of glaucoma and cataracts.

The problem is solved in that the surgical method for the combined treatment of glaucoma and cataract according to the invention includes:

preparation of the surgical field,

separation of the conjunctiva in the upper quadrant of the limb with hemostasis,

the formation of the scleral bed of the future drainage canal by partial separation of the scleral rag facing the base to the limb with a thickness of not more than half its thickness and preliminary fixation of the protrusion of this rag relative to the sclera of at least one loose atraumatic thread,

partial cutting of the sclera strip in the area of the Schlemm's canal,

the implementation in the cornea of tunnel paracentesis and a tunnel incision with the concomitant administration of an anesthetic drug and a drug to dilate the pupil into the anterior chamber of the eye,

tinting the front of the lens capsule with a biocompatible dye,

filling the anterior chamber of the lens capsule with a biocompatible viscoelastic,

capsulorexis with a diameter of 3 to 5 mm and removing the cut out front of the capsule for temporary storage in a sterile container in an antibiotic solution,

ultrasonic destruction of the lens and aspiration of the resulting mass,

implantation of the IOL into the capsular bag,

leaching of viscoelastic residues from the capsular bag,

sealing the tunnels in the cornea,

final cutting and removal of the sclera strip in the area of the Schlemm's canal with entry into the anterior chamber of the eye,

the formation of a drainage channel by autoimplantation of the excised front part of the lens capsule into a previously formed scleral bed with the introduction of one end of the specified channel into the anterior chamber of the eye and the final fixation of the specified scleral flap by tightening and tying at least one atraumatic thread and

sealing the surgical wound in the conjunctiva with atraumatic thread.

This method is significantly less traumatic in comparison with the prototype, because it eliminates excessive trauma to the sclera in the zone of formation of the drainage channel. This further reduces the risk of blocking the progression of glaucoma in the postoperative period.

The first additional difference is that capsulorexis is performed with a double-curved insulin needle. The use of commonly available disposable insulin needles allows the ophthalmic surgeon to easily adjust the size of the cut out parts of the lens capsules and further reduce the cost of surgical intervention.

The second additional difference is that for the convenience of manipulating the instruments inside the eye during cataract removal, tunnel paracentesis is performed at approximately the 2nd hour of the limb, and the tunnel incision is approximately at the 10th hour of the limb, both tunnels being almost the same length (as a rule, no more than 2 mm).

Brief Description of the Drawings

Further, the invention is illustrated by a detailed description of the proposed method, examples and results of its application and drawings, which depict:

figure 1 - diagram of a section of the conjunctiva (conditional side view);

figure 2 - arrangement of a cut rectangular patch of sclera relative to the limb (conditional side view);

figure 3 is a diagram of the preliminary fixation of the protrusion of the sclera flap according to figure 2 mainly with two loose threads (conditional side view);

figure 4 - diagram of a partial trimming of the strip of the sclera in the area of Schlemm's canal (conditional side view);

figure 5 - arrangement of microsurgical instruments in the surgical field at the beginning of the removal of the lens (conditional side view);

6 is a conditional view of the eye from above to capsulorexis;

Fig.7 is a conditional top view of the eye after capsulorexis;

Fig - primary form of the cut out front of the lens capsule;

Fig.9 is a conditional top view of the eye after implantation of the IOL;

figure 10 is a conditional side view of the eye after removing the strip of sclera with trabeculae and laying in the scleral bed of the previously removed anterior part of the lens capsule:

11 is a diagram of the final fixation of the scleral flap around the drainage channel on the basis of the autoimplanted front of the lens capsule with two tightened and tied threads (conventional side view);

Fig - arrangement of the seam for sealing the conjunctiva (conditional side view).

In the drawings: eyeball 1, iris (iris) 2, limb 3, conjunctiva 4, sclera 5 sclera, threads 6, scleral bed 7 of the drainage channel, phacoemulsification instrument 8, tip 9 of the irrigation and aspiration system, temporarily removed front part 10 lens capsules, an intraocular lens 11 and a drainage channel 12 formed from an autoimplanted anterior 10 of the lens capsule. These positions are shown only for a better understanding of the drawings and are not mentioned hereinafter.

BEST EMBODIMENTS

Before deciding on a combined surgical intervention, patients with glaucoma and cataract are examined with a mandatory measurement of intraocular pressure (hereinafter IOP) and at least the magnitude of the field of view as a percentage of normal (hereinafter referred to as PP). IOP values were measured according to Maklakov standard tonometer model TGD-01, and to study the field of view used the well-known analyzer "PERITEST-300", which is also suitable for determining the sensitivity to light inside the field of view in daylight, twilight and night vision.

The application of the proposed method is indicated for arbitrary combinations of glaucoma and cataract. Contraindication is the presence of a pacemaker. Temporary obstacles are infectious diseases that must be treated with appropriate drugs while waiting for surgery.

The proposed method is performed in three stages.

The first preparatory stage aims to create the prerequisites for the combined surgical treatment of glaucoma and cataracts. It includes:

preparing the surgical field by disinfecting at least the upper part of the patient’s face, for which it is enough to double-treat it with a 0.5% chlorhexidine solution or other suitable disinfectant,

epibulbar anesthesia (usually 1.0% alkaine solution),

isolation of the intermarginal edges of the eyelids with a soft sterile material and the application of a standard eyelid extender,

incision and separation of the conjunctiva in the upper quadrant, that is, about 12 hours from the limbus, as shown in figure 1, with concomitant hemostasis (usually by thermo- or electrocoagulation of damaged blood vessels),

the formation of a scleral bed with a micro-blade of the future drainage canal by partial cutting and separation of the at least triangular (and mostly rectangular, as shown in Fig. 2) scraper flap facing the base to the limb, approximately one third but not more than half its thickness,

preliminary fixation of the protrusion of this patch relative to the sclera of at least one untrained almost atraumatic thread 10-00 thick (if the patch is triangular), or mainly by two such threads, as shown in figure 3 for a rectangular patch, and

partial trimming of the sclera strip in the area of the Schlemm's canal (see Fig. 4).

The second, intermediate stage aims to treat cataracts and includes:

the execution in the cornea at about the 2nd hour of the limb of tunnel paracentesis from 1.8 to 2.0 mm long and at about the 10th hour of the limb also the tunnel section from 1.8 to 2.0 mm long with the accompanying introduction into the anterior chamber of the eye an anesthetic drug, in particular a 0.5% solution of lidocaine, and a drug for dilating the pupil, for example 1% solution of mesatone (see figure 5),

tinting the front of the lens capsule with a biocompatible dye (in particular methylene blue) to increase the contrast of the surgical field,

filling the front chamber of the lens capsule with a biocompatible viscoelastic of type 1-3% sodium hyaluronate solution (in particular, the Amvisk brand from Bausch & Lomb, USA),

capsulorexis with a diameter of from 3 to 5 mm (and mainly from 3.5 to 4.0 mm) and removing the cut out front of the capsule for temporary storage in a sterile container in a solution of an antibiotic, for example, oftaxiquix (see, respectively, Figures 6, 7 and 8 , which shows the conditional view of the eye from above before and after capsulorexis and the anterior part of the lens capsule almost circular in plan),

phacoemulsification, that is, ultrasonic destruction of the lens, and aspiration of the resulting mass with a conventional irrigation-aspiration system,

implantation of the IOL into the capsular bag (see Fig. 9),

leaching viscoelastic residues from the capsular bag and

sealing tunnels in the cornea.

Capsulorexis is advisable to perform a double-curved insulin needle.

The third, final stage has the goal of treating glaucoma and includes:

Sinustrabeculoectomy by final cutting with a micro blade and removal of sclera strips in the area of the Schlemm canal with tweezers with penetration into the anterior chamber of the eye (see Fig. 10),

microdraining of the anterior chamber of the eye, i.e., the formation of a drainage canal by implantation of the cut out part of the lens capsule into a previously formed scleral bed with the exit of one end of the canal into the anterior chamber of the eye to a depth of about 1.0 mm and the final fixation of the scleral flap by tightening and tying the threads (Fig. 11 ) and

sealing the surgical wound in the conjunctiva with a thread of 8-00 thickness (Fig. 12).

In conclusion, for prophylaxis of inflammation, they are injected subconjunctively: about 0.3 ml of dexamethasone, oftaxwix is installed and a temporary monocular dressing is applied.

In the postoperative period, patients are repeatedly examined with the measurement of IOP and an assessment of the magnitude of the PZ in order to timely detect the possible progression of glaucoma.

Such examinations are carried out 3, 6 and 12 months after the operation, and then every 6 months.

The following are typical examples of the application of the method described above, in which, to avoid repetition, the main stages of the operations are indicated by generalized terms.

Example 1. Patient S. at the age of 82 years.

Diagnosis during hospitalization: Central cataract, open-angle II-B glaucoma of the left eye. Artifakia, open-angle II-B glaucoma of the right eye. IOP of the left eye before surgery 32 mm RT.article against the background of instillation of travan once a day

A combined operation was performed on the left eye, namely: cataract phacoemulsification with IOL implantation and sinistrabeculoelectomy with microdrainage of the anterior chamber of the eye with an autoimplant of the anterior part of the lens capsule 3.0 mm in diameter. The operation and the postoperative period were uneventful. At discharge IOP was 18 mm Hg. The same IOP values were determined during examinations after 6 and 12 months.

Example 2. Patient G. aged 61 years.

Diagnosis during hospitalization: Artifact, operated angle-closure glaucoma of the right eye. Complicated central cataract, closed-angle II-A glaucoma of the left eye. IOP of the left eye before surgery 25 mm RT.article against the background of instillations of 0.5% cousimalol twice and 1% pilocarpine also twice a day.

A combined operation was performed on the left eye, namely; phacoemulsification of cataracts with IOL implantation and sinuustrabeculoectomy with microdrainage of the anterior chamber of the eye with an autoimplant of the anterior part of the lens capsule with a diameter of 5.0 mm. The operation and the postoperative period were uneventful. IOP was at discharge 19 mm Hg, after 6 months 16 mm Hg and after 12 months, 17 mmHg

Example 3. Patient G. aged 73 years.

Diagnosis during hospitalization: Open-angle II-A glaucoma in both eyes. Phacosclerosis of the right eye. Complicated cataract of the left eye. IOP of the left eye before surgery 27 mm Hg against the background of instillations of 0.5% cousimalol twice and travatan once a day.

A combined operation was performed on the left eye, namely: cataract phacoemulsification with IOL implantation and sinistrabeculoectomy with microdrainage of the anterior chamber of the eye with an autoimplant of the anterior part of the lens capsule 4.0 mm in diameter. The operation and the postoperative period were uneventful. IOP was 18 mmHg at discharge, and after 6 and 12 months 16 mm Hg

Example 4. Patient I. at the age of 83 years.

Diagnosis during hospitalization: Open-angle III-A glaucoma, immature complicated cataract of the right eye. Open-angle II-A glaucoma, central complicated cataract of the left eye. Myopia of an average degree of both eyes. IOP of the right eye before surgery 27 mm Hg against the background of instillations of 0.5% cousimalol twice and 0.05% lanatan once a day.

A combined operation was performed on the right eye, namely: cataract phacoemulsification with IOL implantation and sinistrabeculoelectomy with microdrainage of the anterior chamber of the eye with an autoimplant of the anterior part of the lens capsule with a diameter of 3.5 mm. The operation and the postoperative period were uneventful. IOP was 20 mmHg. at discharge and 18 mm Hg after 6 and 12 months.

Example 5. Patient B. aged 78 years.

Diagnosis during hospitalization: Complicated cataract, Open-angle II-B glaucoma of the right eye. Operated III-A glaucoma, artifact of the left eye. IOP of the right eye before surgery 30 mm RT.article against the background of installations of 0.5% cousimalol twice and xalatan once a day.

A combined operation was performed on the right eye, namely, cataract phacoemulsification with IOL implantation and sinistrabeculoelectomy with microdrainage of the anterior chamber of the eye with an autoimplant of the anterior part of the lens capsule 4.0 mm in diameter. The operation and the postoperative period were uneventful. IOP was 19 mm Hg. at discharge and 17 mm Hg after 6 and 12 months.

A total of 94 patients were operated on. IOP and PZ were necessarily measured before surgery, at discharge, and after 1 month, 6 and 12 months after surgery.

42 patients were additionally examined after 18 months and after 24 months. None of them were diagnosed with glaucoma progression.

Averaged indicators of the condition of patients before and after surgery are given in the table.

RESULTS OF EXAMINATIONS OF OPERATED PATIENTS

Number of proopera
n Glaucoma stage The average IOP before surgery mm Hg Examination period and average values after surgery 1st month 6th month 12th month IOP mmHg PZ,% of normal IOP mmHg PZ,% of normal IOP mmHg PZ,% of normal 27 I 28 +/- 5 18 +/- 2 74 +/- 2 17 +/- 2 85 +/- 2 17 +/- 2 85 +/- 2 38 II 30 +/- 6 20 +/- 2 63 +/- 3 18 +/- 2 78 +/- 2 18 +/- 2 80 +/- 2 29th III 29 +/- 5 19 +/- 2 51 +/- 3 20 +/- 2 57 +/- 2 20 +/- 3 60 +/- 2

Industrial applicability

The method according to the invention can be carried out on an outpatient and clinical basis using available tools. As can be seen in the table, it significantly reduces the likelihood of glaucoma progression in the postoperative period. This accelerates the visual and social rehabilitation of patients.

Claims (3)

1. A surgical method for the combined treatment of glaucoma and cataracts, including: preparing the surgical field; separation of the conjunctiva in the upper quadrant of the limb with concomitant hemostasis; the formation of the scleral bed of the future drainage canal by partial separation of the scleral rag facing the base to the limb with a thickness of not more than half its thickness and preliminary fixation of the protrusion of this rag relative to the sclera of at least one loose atraumatic thread; partial cutting of the sclera strip in the area of the Schlemm canal; the implementation in the cornea of tunnel paracentesis and also a tunnel incision with the concomitant administration of an anesthetic drug and a drug to dilate the pupil into the anterior chamber of the eye; tinting the front of the lens capsule with a biocompatible dye; filling the anterior chamber of the lens capsule with a biocompatible viscoelastic; capsulorexis with a diameter of 3 to 5 mm and removal of the cut out front of the capsule for temporary storage in a sterile container in an antibiotic solution; ultrasonic destruction of the lens and aspiration of the resulting mass; implantation of an intraocular lens in a capsular bag; leaching of residues of viscoelastic from the capsular bag; sealing tunnels in the cornea; final cutting and removal of the sclera strip in the area of the Schlemm canal with penetration into the anterior chamber of the eye; the formation of a drainage channel by autoimplantation of the excised front part of the lens capsule into a previously formed scleral bed with the introduction of one end of the specified channel into the anterior chamber of the eye and the final fixation of the specified scleral flap by tightening and tying at least one atraumatic thread; and sealing the surgical wound in the conjunctiva with atraumatic thread. 2. The method according to claim 1, in which capsulorexis is performed by a double-curved insulin needle. 3. The method according to claim 1 or 2, in which tunnel paracentesis is performed at approximately the 2nd hour of the limb, and the tunnel incision is approximately at the 10th hour of the limb, both tunnels being almost the same length.

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