RU2828734C1 - Method for laser suture lysis using glass blade l 85 - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: invention can be used for laser suture lysis after fistulizing surgical antiglaucoma operations. Method of laser suture lysis for restoration of outflow of intraocular fluid along newly created outflow pathways at level of scleral sutures consists in application of glass blade L 85, flat part of which provides visualization and simultaneously a flat conjunctiva of a filtration pad.

EFFECT: use of the invention provides improved results of trabeculectomy.

1 cl, 4 dwg

Description

The proposed invention relates to medicine, namely to ophthalmology, and can be used to perform laser suturolysis after fistulizing surgical antiglaucoma operations.

Laser suturolysis is a relatively simple but effective procedure that allows for the transection of scleral flap sutures after penetrating or non-penetrating sclerectomy using 532 nm diode lasers. This procedure allows for a dosed increase in aqueous humor outflow in the early or late postoperative period after fistulizing glaucoma surgeries.

One of the most common filtering surgical operations is trabeculectomy, proposed in 1968 by J.E. Cairns and aimed at reducing the level of IOP by creating artificial pathways for the outflow of aqueous humor from the anterior chamber under the conjunctiva through a scleral flap under the upper eyelid. The conjunctival flap is separated in the upper quadrant of the eyeball with the base facing the limbus. A superficial flap of the sclera is formed at half its thickness, measuring 4x4 mm, with the base facing the limbus. At the base of the flap, a strip is excised in the drainage zone of 3x1 mm. Basal iridectomy is performed. The scleral flap is repositioned and fixed with interrupted sutures.

A fundamentally important point is the use of the technique of “tight” fixation of the scleral flap in the scleral bed using a tension immersion suture and a black nylon 10.0 thread, which allows reducing the resistance of the intraocular fluid through the edge of the flap so that the postoperative pressure is neither too high nor too low, which ensures stability of the anterior chamber, slow and unforced outflow of intraocular fluid along the formed path, as well as a “controlled” decrease in IOP.

Scarring of the outflow tract, both in the early and late postoperative period, is the main disadvantage of this type of surgery. Active introduction of antimetabolites (mitomycin C and 5-fluorouracil), which suppress the natural healing reaction, increases the likelihood of success of trabeculectomy. However, the use of these drugs has led to an increase in the number of postoperative complications in the form of prolonged hypotension, maculopathy, induction of cataractogenesis, failure and purulent inflammation of the filtration cushion, death of the corneal endothelium, uveitis and endophthalmitis.

In this regard, there was a need for further search for adjuvants aimed at modulating the healing process. Morphogenesis of newly created outflow pathways is determined by technical intraoperative nuances and individual features of the course of the regenerative-reparative process, the main ones being disruption of the formation of outflow pathways (35.3%), various blockades at the level of the intrascleral canal and filtration cushion, both isolated and combined (18-57%). In the early postoperative period, this is associated with hyperfiltration and the development of ciliochoroidal detachment due to inadequate positioning of the scleral flap in the scleral bed. In more remote periods - with its obliteration and a decrease in the hypotensive effect of the operation. Surgical intersection of sutures often provokes the development of an inflammatory reaction and increased scarring processes, there is a risk of infection (Siberian Scientific Medical Journal, Vol. 39, No. 3, 2019. "Laser suturolysis instead of trabeculectomy: indications, technique, effectiveness" Volkova N.V., Yuryeva T.N. et al.).

The simplest, most accessible, safe and effective method of influencing the state of intrascleral outflow tracts both in the early and late periods with increased IOP is laser intersection of scleral sutures using a diode laser with a wavelength of 532 nm.

An increase in the IOP level in the postoperative period in combination with a flat or cystic filtration cushion indicates ineffective outflow of intraocular fluid through the scleral flap. Bulbar massage of the eyeball, under visual control using a slit lamp, shows the state of the outflow pathways. An increase in the height or area of the filtration cushion, as well as a decrease in the IOP level, indicate the viability of the scleral outflow pathways. In such conditions, laser suturolysis is performed to maintain or improve the outflow of intraocular fluid.

Initially, a Zeiss four-mirror gonioscopic lens, slightly seated on a ledge, was used to perform the procedure. Currently, several special lenses are used, such as Hoskins, Blumenthal, Mandelkorn or Ritch, Layden lenses. They not only help to keep the patient's eye open, but also, by applying gentle pressure of the lens, compress the tissues and vessels of the conjunctiva, and also have a magnification that allows better visualization of the sutures. The Blumenthal lens has the highest magnification (2-3 times).

The operation is performed under local instillation anesthesia using a diode laser with a wavelength of 532-577 nm. The power is 300 mW, the exposure is 0.2 sec, the spot diameter is 50 μm. On average, one or two laser pulses are enough to cross the ligature, and as a result of tension, the suture diverges.

However, in clinical practice, the above-mentioned specialized lenses, which are considered expensive medical equipment, are not always available.

The objective of the proposed invention is to present a new method for performing laser suturolysis after fistulizing surgical antiglaucoma operations.

The proposed method of laser suturolysis differs in that during the operation a glass spatula L 85 is used (Fig. 1).

The technical result of the invention is the restoration of the outflow of intraocular fluid along newly created outflow paths at the level of the scleral sutures.

The technical result is achieved by using the L 85 glass spatula, the flat part of which allows visualization and simultaneously flattening of the conjunctiva of the filtration cushion. The operation is performed under local instillation anesthesia and the parameters of the effect are the same as when using special lenses (Fig. 2).

The method is confirmed by the following clinical examples.

Example #1

Patient V., 71 years old. Surgery for angle-closure glaucoma II "a" of the left eye was performed at the Irkutsk branch of the Federal State Autonomous Institution "National Medical Research Center "MNTK" Eye Microsurgery", modified sinus trabeculectomy and posterior trepanation of the sclera were performed. Before the operation, the IOP level was 24 mm Hg, at discharge IOP (P) was 12 mm Hg, the patient was discharged for outpatient follow-up care with a control visit to monitor IOP and remove conjunctival sutures after 14 days. At the control visit, the IOP level was 20 mm Hg, the filtration bleb was poorly defined, according to UBM - a narrow intrascleral canal, which indicates a violation of the outflow of intraocular fluid along the newly created outflow pathways at the level of the scleral sutures. A follow-up visit for laser suturolysis was scheduled in 2 weeks. At the follow-up visit, the IOP level was 24 mm Hg, laser suturolysis of two ligatures of the scleral flap was performed using a 532 nm diode laser and an L 85 glass spatula, which was used to compress the filtration pad with visualization of the scleral flap sutures. Spot diameter: 50 μm, energy level: 300 mW, exposure: 0.2 sec (Figs. 3, 4). There were no complications during the surgery. The IOP (P) level after the laser surgery was 12 mm Hg. The patient was discharged for outpatient observation at the place of residence.

Example #2

Patient S., 62 years old. She underwent surgery for open-angle glaucoma II "a" of the left eye at the Irkutsk branch of the Federal State Autonomous Institution "NMITs "MNTK" Eye Microsurgery", where non-penetrating deep sclerectomy was performed. Before the surgery, the IOP level was 26 mm Hg, at discharge IOP (P) 8 mm Hg, discharged for outpatient follow-up treatment with a control visit in 1 month for laser goniodescemetopuncture. Upon arrival for laser treatment, the IOP level was 20 mm Hg, the filtration pad was flat, limited. According to UBM, the intrascleral canal is narrow, there is a violation of the outflow of intraocular fluid along the newly created outflow pathways at the level of the scleral sutures. Laser goniodescemetopuncture was performed. In the postoperative period, the IOP level was 20 mm Hg. After 2 weeks, the IOP level was 21 mm Hg, laser suturolysis was performed according to the proposed technique (compression of the filtration cushion with the flat part of a glass spatula with visualization of the scleral flap sutures), suturolysis of four ligatures of the scleral flap was performed with a spot diameter of 50 μm, energy level: 300 mW, exposure: 0.2 sec. There were no complications during the surgery. The IOP (P) level after the laser surgery was 17 mm Hg. The patient was discharged for outpatient observation at the place of residence.

As can be seen from the presented examples, the use of this method of laser suturolysis using the L 85 glass blade allows for a significant expansion of the use of this method in ophthalmological practice and is an effective and minimally invasive method for improving filtration and modulation of IOP in order to improve the results of trabeculectomy.

Claims (1)

A method for performing laser suturolysis to restore the outflow of intraocular fluid along newly created outflow pathways at the level of the scleral sutures, which consists of using a glass spatula L 85, the flat part of which provides visualization and simultaneously a flat conjunctiva of the filtration pad.