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COMPARATIVE EVALUATION OF COMBINED TRABECULOTOMY-TRABECULECTOMY WITH SUBCONJUNCTIVAL IMPLANTATION OF COLLAGEN MATRIX FOR PRIMARY
CONGENITAL GLAUCOMA
In study, we wanted to see whether combined trabeculotomy-trabeculectomy with subconjuntival implantation of collagen matrix implant lead to further lowering of IOP and improve success rate as compared to combined trabeculotomy-trabeculectomy alone in eyes with primary congenital glaucoma. It was a prospective randomized control study. The sample was 20 eyes and out of them 4 of them were bilateral and 12 were unilateral cases. The study was done from September 2012 to June 2013. Combined trabeculotomy-trabeculectomy was performed in 10 eyes (Group 1) and combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implant implantation in 10 eyes (Group 2). Examination was done under general anesthesia at 15 days, 3 month and 6 months intervals.
The change of IOP was significant when the preoperative IOP was compared with postoperative IOP in both the groups and the trend of IOP was comparable in both the groups. In combined trabeculotomy-trabeculectomy group (Group 1) success was seen in 80% (n=8 ) of the patients among them 60% (n=6) showed IOP control without any medication and 20% (n=2) showed IOP control with one medication and 20% (n=2) had more than the IOP that is required for success. In combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implantation group (Group 2), 90% (n=9) showed success. Among them 80% (n=8) showed control of IOP without any medication and 10% (n=1) showed control of IOP with one medication and 10% (n=1) had more than the IOP that is required for success.
Small sample, limited period of follow-up (6 months) makes it difficult to deduce firm conclusions. The results of both the groups were comparable and both the procedures can be taken up as primary procedures in case of congenital glaucoma. Larger studies with long-term follow-up are required to deduce firm conclusions.
Key words: primary congenital glaucoma, combined trabeculotomy-trabeculectomy, collagen matrix.
Primary congenital glaucoma is hereditary childhood glaucoma secondary to abnormal development of the filtration angle, which occurs unassociated with any systemic abnormalities. Primary congenital glaucoma is the most common type of pediatric glaucomas and is accounting for 55% of them [7]. Its overall occurrence is about 1 in 10.000 live births; affect less than 0.05% of ophthalmic patients [4].
Combined trabeculotomy-trabeculectomy is the standard procedure that is practiced; combined trabeculotomy-trabeculectomy with subconjuntival implantation of collagen matrix implant is another alternative procedure. In our study, we wanted to see whether combined trabeculotomy-trabeculectomy with subconjuntival implantation of collagen matrix implant lead to further lowering of IOP and improve success rate as compared to combined trabeculotomy-trabeculectomy alone in eyes with primary congenital glaucoma.
Materials and methods: All the cases that attended the Pediatric Department of Zarifa Aliyeva National Eye Centre, Baku were included in the study (bilateral and unilateral). It was a prospective randomized control study. The sample was 20 eyes and out of them 4 of them were bilateral and 12 were unilateral cases. The study was done from September 2012 to June 2013. Inclusion criteria. 1. Primary infantile congenital glaucoma. 2. Age< 2 years. Exclusion criteria. 1. Secondary glaucoma. 2. Glaucoma associated with other ocular anomalies. 3. Glaucoma associated with systemic anomalies. 4. Dense corneal opacity not allowing view of anterior chamber for trabeculotomy.
A detailed history of the patient regarding the illness was taken, its duration, prior EUA, treatment. Any significant history associated with birth of the child was taken along with the family history. Office examination of the patient was conducted in which the corneal diameters were measured and looked for gross features like corneal edema and Haab's striae. informed consent from the parents was taken before EUA along with the consent for the surgery if required.
A definite protocol for evaluation and management was followed for all patients. Examination was performed under general anesthesia in which induction was done with thiopentone sodium 5 mg/kg, fentanyl 2mg/kg and after intubation maintained on sevoflurane 0.4-0.6%. IOP was evaluated with Tonopen tonometer 2 minutes after the induction and detailed examination of the eye including corneal diameters, Haab's striae, density of corneal edema, any opacity, anterior chamber depth, angle structures were visualized with Jacob's- Swan lens, status of the crystalline lens, examination of the fundus, cup
disk ratio and examination of retina is done with indirect ophthalmoscope. In case the surgery was required, child was maintained in general anesthesia.
Combined trabeculotomy-trabeculectomy was performed in 10 eyes (Group 1) and combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implant (Ologen, Biogen Idec) implantation in 10 eyes (Group 2). The operation is performed under general anesthesia using an operating microscope with 10* to 40* magnification. Limbal based peritomy is made. The rectangular flap containing trabecular meshwork and canal of Schlemm as mapped out earlier is excised by making a radial incision on either side of radial incision. The Schlemm's canal lies just anterior to the sclera spur. A superficial radial incision starting from the blue zone and extending toward the white zone is made. The incision is very carefully deepened until the aqueous oozes from the cut ends. Small horizontal incisions are made on either side of this and the right-sided Harm's trabeculotome is inserted till the heel of the trabeculotome lies in the radial incision. Then the trabeculotome is rotated into the anterior chamber. The same procedure was done with the left-sided Harm's trabeculotome. The rectangular flap containing trabecular meshwork and canal of Schlemm as mapped out earlier is excised by making a radial incision on either side of radial incision made for trabeculotomy and excising the sclera block with Vannas scissors. A peripheral iridectomy is performed. The scleral flap is reposited and sutured at each corner of the flap posteriorly. The conjunctival flap is reposited in place and sutured with 8-0 Vicryl. Antibiotic injection is done and the eye is bandaged.
Combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implantation. The operation is performed under general anesthesia using an operating microscope with 10* to 40* magnification. Surgery was done as described above. After closing scleral flap with sutures, collagen matrix implant was placed on the top of the scleral flap under the conjunctiva (Fig 1). Then conjunctiva is sutured with 8-0 Vicryl. Antibiotic injection is done and the eye is bandaged.
Postoperative regimen. All the patients bandange was opened next morning and were started on topical antibiotic of flouroquinolones (ofloxacin, moxifloxacin 0.5%) and prednisolone acetate 1% drops. 2 hourly for the first wek followed by six times for next 3 weeks and later on the drug was tapered every week. Along with drops antibiotic steroid combination consisting of tobramycin and dexamethasone at night was given for 3 weeks.
Follow-up. A definite protocol was followed for all the patients postoperatively. Visual acuity was assessed with Teller acuity chart for children less than 1.5 year and with Cardiff acuity in children between 1.5 and 2 years. Those children who could not perform these two tests were assessed for their perception of light. Examination was done under general anesthesia at 15 days, 3 month and 6 months intervals. At each visit patients were examined and corneal diameters, edema, anterior chamber depth, IOP, axial lenghth, central corneal thickness (CCT), bleb appearance (Fig 2), fundus examination were noted. Refraction was done at 3 months and 6 months. Only in one cooperative child we could do Anterior Segment OCT 6 month after surgery and bleb height measurement with A-B scan (Fig 3,4).
Figure 1. Subconjunctival Figure 2. Bleb appearance 6 Fig 3. Anterior segment OCT 6 Figure 4. Bleb height measurement 6 kollagen matrix implantation. month after surgery. month after surgery. month after surgery.
Surgical success and failure were defined in the protocol and success criteria were judged and analyzed by the following criteria: 1. If the final IOP was less than or equal to 18 mm Hg without any medication it was considered 'complete success'. 2. If the final IOP was less than or equal to 18 mm Hg with one medication it was considered 'qualified success'.
Results and discussion. The change of IOP was significant when the preoperative IOP was compared with postoperative IOP in both the groups and the trend of IOP was comparable in both the groups. The horizontal corneal diameters in both the groups were comparable throughout the study.
Success of surgery was defined as complete success when IOP <18 mm Hg under general anesthesia without any medication and qualified success as IOP < 18 mm Hg with one medication under general anesthesia. In combined trabeculotomy-trabeculectomy group (Group 1) success was seen in 80% (n=8 ) of the patients among them 60% (n=6) showed IOP control without any medication and 20% (n=2)
showed IOP control with one medication and 20% (n=2) had more than the IOP that is required for success (Fig 5).
Table 1
Intervals Mean IOP 1 Mean IOP 2
Preoperative 41.0 ± 8.68 40.4 ± 6.87
15 days 12.7 ±1.34 10.9± 1.20
3 months 13.9± 1.60 12.2± 1.55
6 months 16.3 ± 1.89 13.6 ± 2.01
Table Comparison of horizontal corneal diameters in both the groups
Intervals Mean corneal diameter 1 Mean corneal diameter 2
Preoperative 13.85± 0.75mm 13.75± 0.76mm
15 days 13.85± 0.75mm 13.75± 0.76mm
3 months 13.75± 0.64mm 13.6± 0.57mm
6 months 13.75± 0.64mm 13.6± 0.57mm
In combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implantation group (Group 2), 90% (n=9) showed success. Among them 80% (n=8) showed control of IOP without any medication and 10% (n=1) showed control of IOP with one medication and 10% (n=1) had more than
the
OP that is required for success (Fig 6).
Group 1
IOP> 18 mm Hg
IOP< 18 mm Hg w/o med
IOP< 18 mm Hg w med
Figure 5. Success of surgery in Group 1.
Group 2
■ iop> 18 mm Hg
■ iop< 18 Tim Hg w/o med
m iop< 18 mm Hg w med
- io% 90% 80% io%
Figure 6. Success of surgery in Group 2.
There was no sight threatening intraoperative and postoperative complications. Complications were seen in 25% of cases. Two eyes (10%) had shallow anterior chamber which later fared well without any surgery. Three eyes (15%) had hyphema, which resolved after 2 days. No anesthetic complications were noted.
Primary congenital glaucoma is the most common type of pediatric glaucomas and accounting for 55% of them [7]. Its overall occurrence is about 1 in 10.000 live births; affect less than 0.05% of ophthalmic patients [4, 9, 16].
Children or young adults undergoing filtering surgery do not enjoy the same success as do those of older age group. The barriers to success of filtering surgery in children include thick tenons capsule, rapid wound healing response, lower sclera rigidity and a large buphtalmic eye with thin sclera. The prognosis of the primary congenital glaucoma is affected by various factors, such as time of presentation, severity and the time of surgery. The earlier in life the disease occurs, the worse the prognosis and the more severe the case, the higher is the failure rate. While the medical treatment of primary congenital glaucoma is useful as a temporary measure or as an adjunctive therapy, surgery is always necessary [5].
The conventional operative procedures described for congenital glaucoma were goniotomy, goniopuncture, goniotomy combined with goniopuncture. These procedures can be carried in cases with clear cornea to allow visualization of angle structures at the time of operation. Further these procedures are preferable in cases having maximal corneal diameter up to 14 mm [8]. Although classic operation for developmental glaucoma has been goniotomy, introduced by Barkan in 1938, it has been tempered by poor success rate in patients with primary congenital glaucoma. Schaffer followed 287 eyes long enough to be quiet certain of success or failure of goniotomy. The glaucoma was considered cured, if the IOP remained 20 mm Hg without any antiglaucoma medication for at least 6 months and the cupping of the optic nerve remained the same or improved. Overall, the success rate was 76.7% [14]. However, when the signs and symptoms of glaucoma were present at birth or over the age of 24 months (congenital or juvenile type), the success rate was close to 30%. In contrast, one or two goniotomies cured 90% of the cases diagnosed between the ages of 1 and 24 months. Broughton and Parks published the results of their
20 years experience with goniotomy to treat congenital glaucoma [2]. The results of normalizing the IOP with goniotomy were practically identical.
Beck and Lynch described a technique performing 360° trabeculotomy in a single procedure using a 6-0 propylene suture fragment and reported an 87% success rate after one procedure, which is equal to standard trabeculotomy techniques [3].
Filtration surgery creates an opening in the sclera over the anterior chamber, which allows the aqueous humor to drain under the conjunctiva, thus converting the potential subconjunctival space into a real space, the filtering bleb. The increased drainage of the aqueous fluid lowers the IOP. Failure occurs when the drainage is adequate to lower the IOP [5]. Natural wound healing process tend to shift the balance between overfiltration and underfiltration toward failure by causing subconjunctival fibrosis, bleb encapsulation, or closure of the sclerectomy.
Trabeculectomy is a procedure which is familiar to most of the ophthalmologists, whereas trabeculotomy requires an entirely separate approach and expertise and larger learning curve. Trabeculectomy is the most commonly performed antiglaucoma procedure, and most ophthalmologists are conversant with the procedure. Trabeculotomy is enjoying resurgence now in congenital glaucoma. Trabeculotomy has an advantage in that, compared with goniotomy, it does not require clear cornea. Since most of the patients in Azerbaijan present late and with opaque corneas, goniotomy is difficult. So combined trabeculotomy-trabeculectomy is one of the options in Azerbaijanian scenario. But trabeculotomy in itself is difficult procedure which needs a larger learning curve and expertise for which Schlemm's is identified to rotate the trabeculotome. So a procedure which most of the persons are wellversed with, is easier to perform than a complicated procedure lie trabeculotomy-trabeculectomy. Elder compared primary trabeculectomy with combined trabeculotomy-trabeculectomy and found the combined procedure to be superior. [6] Mullaney et al. [10] and Al-Hazmi et al. [1] used mitomycin-C in primary combined trabeculotomy-trabeculectomy and reported a higher success rate. Mandal et al., [11] from India, reported similar success rates but did not use mitomycin-C in primary surgery. Mandal et al. [12] also reported long-term outcome of 299 eyes of 157 patients who underwent the combined surgery; the success rate of 63.1% was maintained until 8 years of follow-up. Combined trabeculotomy-trabeculectomy is safe and effective in advanced primary congenital glaucoma with corneal diameter 14 mm or more. [13].
In our study we wanted to see whether combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implantation lead to further lowering of IOP and improve success rate as compared to combined surgery alone in eyes with primary congenital glaucoma. We found that the mean preoperative IOP in Group 1 decreased from 41.0 ± 8.68 to 12.7±1.34 mm Hg and was 16.3 ± 1.89 mm Hg at the end of 6 month and in Group 2 mean preoperative IOP decreased from 40.4 ± 6.87 to 10.9±1.20 mm Hg and was 13.6 ± 2.01 mm Hg at 6 months (P<0.001). There was no statistical difference in the comparative IOP in both the groups. Our study showed almost equitable results in both the groups but the follow-up here was only for 6 months which is too short to give any stern conclusions. We need to further follow-up the patients for a longer period to deduce firm conclusions. We had complications in 25% of the patients. Two eyes (10%) had shallow anterior chamber which later fared well without any surgery. Three eyes (15%) had hyphema, which resolved after 2 days. We had no episode of endophthalmitis. No anesthetic complications were noted.
Both combined trabeculotomy-trabeculectomy with subconjunctival collagen matrix implantation and combined trabeculotomy-trabeculectomy can be practiced as surgeries for congenital glaucoma. Collagen matrix implantation acts as spacer and after it is gone, it leaves a porous skeleton of connective tissue. It offers an opportunity for wound modulation while avoiding the most dreaded late complications we see with MMC [15]. This study had a short follow-up time. For a child with primary congenital glaucoma, 6 months are not enough as though to say which is best, so longer follow-up is required.
Small sample, limited period of follow-up (6 months) makes it difficult to deduce firm conclusions. The results of both the groups were comparable and both the procedures can be taken up as primary procedures in case of congenital glaucoma. Larger studies with long-term follow-up are required to deduce firm conclusions.
1. Al-Hazmi A. Effectiveness and complications of mitomycin-C use during pediatric glaucoma surgery / A. Al-Hazmi, J. Zwaan, A. Awad // - Ophthalmology - 1998, Vol.105, P. 1915-1920.
2. Broughton W.L. An analysis of treatment of congenital glaucoma by goniotomy / W.L. Broughton, M.M. Parks // Am J Ophthalmol - 1981, Vol.91, P. 566-572.
3. Beck A.D. Lynch MG. 360° trabeculotomy for primary congenital glaucoma / A.D. Beck // Arch Ophthalmol - 1995,Vol.113, P.1200-1202.
4. Christofer J. Epidemiology and pathophysiology of congenital glaucoma / J. Christofer, H. Dickens, D. Hoskins // The Glaucomas - 1996, Vol.;2, P.729-738.
5. Dietlein T.S. Prognosis of ab externo surgery for primary congenital glaucoma / T.S. Dietlein, P.C. Jacobi, G.K. Krieglstein // Br J Ophthalmol - 1999, Vol.83, P. 317-322.
6. Elder M. J. Combined trabeculotomy-trabeculectomy compared with primary trabeculectomy for congenital glaucoma / M. J. Elder // Br J Ophthalmol - 1994, Vol.78, P.745-748.
7. Ho C.L. Primary Congenital Glaucoma: 2004 update / C.L. Ho, D.S. Walton // J Paediatric Ophthalmol Strabismus - 2004, Vol.41, P.271-288.
8. Kwitko M. L. Glaucoma in infants and children (1st ed) / M. L. Kwitko // Appleton-Century Croffs, New York - 1973, 500p.
9. Kolker A. E. Congenital glaucoma. In: Becker-Schafer's diagnosis and therapy of the glaucomas (5th ed) / A. E. Kolker, T. J. Hethering // St Louis's: Mosby -1983, P.317-369.
10. Mullaney P.B. Combined trabeculotomy and trabeculectomy as initial procedure in uncomplicated congenital glaucoma / P.B. Mullaney, C. Selleck, A. Al-Awad [et al.] // Arch Ophthalmol - 1999, Vol.117, P. 457-460.
11. Mandal A.K. Safety and efficacy of simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma in India / A.K. Mandal, P.G. Bhatia, V.K. Gothwal [et al.] // - I ndian J Ophthalmol - 2002,Vol.50, P.13-19.
12. Mandal A. K. Long-term surgical and visual outcomes in Indian children with developmental glaucoma operated on within 6 months of birth / A.K. Mandal, P.G. Bhatia, A. Bhaskar [et al.] // Ophthalmology - 2004, Vol.111, P. 283-290.
13. Mandal A. K. Combined trabeculotomy and trabeculectomy in advanced primary developmental glaucoma with corneal diameter of 14mm or more / A.K. Mandal, J. Bhende, R. Nutheti [et al.] // - Eye - 2006, Vol. 20, P. 135-143.
14. Schaffer R. N. Prognosis of goniotomy in primary infantile glaucoma (trabeculodysgenesis) / R. N. Schaffer // - Trans Am Opthalmol Soc - 1982, Vol.80, P. 321-325.
15. Steven R. Sarkisian. Recent advances in glaucoma surgery- Clinical experiences of Ologen collagen matrix in over 1000 ocular surgeries / Steven R. Sarkisian. // WOC - 2012, Abu-Dhabi.
16. Walton D. S. Newborn primary congenital glaucoma: 2005 Update / D. S. Walton G. F. Katsavoundiou // MS J Paediatric Ophthalmol Strabismus - 2005, Nov-Dec, Vol.42(6), 332 p.
СРАВНИТЕЛЬНАЯ ОЦЕНКА КОМБИНИРОВАННОЙ ТРАБЕКУЛОТОМИИ-ТРАБЕКУЛЭКТОМИИ С СУБКОНЪЮНКТИВАЛЬНОЙ ИМПЛАНТАЦИЕЙ КОЛЛАГЕНОВОГО МАТРИКСА ПРИ ПЕРВИЧНОЙ ВРОЖДЕННОЙ ГЛАУКОМЕ Гасанова Н. А., Касимов Е.М.
В исследовании, мы хотели бы выяснить насколько комбинированная трабекулотомия-трабекулэктомия (КТТ) с субконьюнктивальной имплантацией коллагенового матрикс импланта приводит к дальнейшему снижению внутриглазного давления (ВГД) и улучшает показатель успеха по сравнению с комбинированной трабекулотомией-трабекулэктомией при первичной врожденной глаукоме (ПВГ). Это было проспективное рандомизирванное контрольное исследование. Были включены 20 глаз, из них 4 пациента страдало двусторонней и 12 односторонней патологией. Исследование проводилось с сентября 2012 по июнь 2013 года. КТТ была выполнена на 10 глазах (Группа 1) и КТТ с субконьюнктивальной имплантацией коллагенового матрикс импланта на 10 глазах (Группа 2). Обследование под анестезией было проведено через 15 дней, 3 месяца и 6 месяцев после операции. Результаты. При сравнении предоперационного ВГД с послеоперационными показателями в двух группах изменение ВГД было значительным и результаты были сопоставимы в обоих группах. В группе КТТ (Группа 1) успех был замечен у 80% (п = 8) пациентов среди них 60% (п = 6) показали контроль ВГД без каких-либо лекарственных препаратов, 20% (п = 2) показали контроль ВГД с одним лекарством и у 20% (п = 2) ВГД было больше, чем требуется для достижения успеха. В группе КТТ с субконъюнктивальной имплантацией коллагенового матрикс импланта (Группа 2), 90% (п = 9) показали успех. Среди них у 80% (п = 8) контроль ВГД был без каких-либо лекарств и 10% (п = 1) показали контроль ВГД с одним лекарством и у 10% (п = 1) ВГД было больше, чем требуется для достижения результата^ Заключение. Малое количество пациентов, ограниченный период наблюдения (6 месяцев) затрудняет вывод окончательных заключений. Результаты обоих групп были сопоставимы и
ПОР1ВНЯЛЬНА ОЦ1НКА КОМБ1НОВАНО1 ТРАБЕКУЛОТОМП-ТРАБЕКУЛЕКТОМП З СУБКОН'ЮНКТИВАЛЬН1Й ШПЛАНТАЦ1СЮ КОЛАГЕНОВОГО МАТРИКСУ ПРИ ПЕРВИНН1Й ВРОДЖЕН1Й ГЛАУКОМ1 Гасанова Н. А., Касимов Е. М.
У дослщженш, ми хотши б з'ясувати насюльки комбшована трабекулотомiя-трабекулектомiя (КТТ) з Субкон'юнктивальш iмплантацieю генового матрикс iмпланта призводить до подальшого зниження внутршньоочного тиску (ВОТ) i покращуе показник устху в порiвняннi з комбшованою трабекулотомiя-трабекулектомiя при первиннш вродженш глаую^ (ПВГ). Це було проспективне рандомiзiрванное контрольне дослщження. Були включен 20 очей, з них 4 пащенти страждало двостороннш i 12 односторонньо! патолопею. Дослщження проводилося з вересня 2012 по червень 2013 року. КТТ була виконана на 10 очах (Група 1) i КТТ з Субкон'юнктивальш iмплантацiею генового матрикс iмпланта на 10 очах (Група 2). Обстеження тд анестезiею було проведено через 15 дшв, 3 мюящ i 6 мюящв тсля операцп. Результата. При порiвняннi передоперацшного ВГД з тсляоперацшними показниками в двох групах змта ВГД було значним i результата були порiвняннi в обох групах. У грут КТТ (Група 1) устх був помiчений у 80% (п = 8) пащенив серед них 60% (п = 6) показали контроль ВГД без будь-яких лжарських препараив, 20% (п = 2) показали контроль ВГД з одним лжами i у 20% (п = 2) ВГД було бшьше, шж потрiбно для досягнення устху. У грут КТТ з субкон'юнктивальному iмплантацiею генового матрикс iмпланта (Група 2), 90% (п = 9) показали устх. Серед них у 80% (п = 8) контроль ВГД був без будь-яких лшв i 10% (п = 1) показали контроль ВГД з одним лжами i у 10% (п = 1) ВГД було бшьше, шж потрiбно для досягнення результату N Висновок. Мала кшьюсть пащенив, обмежений перюд спостереження (6 мюящв) ускладнюе висновок остаточних висновюв. Результати обох груп були порiвняннi i обидвi щ процедури можуть
обе эти процедуры могут быть приняты в качестве основных процедур в случае врожденной глаукомы. Требуется большее исследование с продолжительным сроком наблюдения для однозначных выводов.
Ключевые слова: первичная врожденная глаукома, комбинированная трабекулотомия-трабекулэктомия,
коллагеновый матрикс.
Стаття надшшла 3.03.2015 р.
бути приМнят в якост основних процедур у разi вроджено! глаукоми. Потрiбна бшьша дослщження з тривалим термшом спостереження для однозначних висновюв.
Ключовi слова: первинна вроджена глаукома, комбшована трабекулотомiя-трабекулектомiя,
колагеновий матрикс.
Рецензент Безкоровайна 1.М.
УДК 616.314.2
ОСОБЛИВОСТ1 ПЕРЕБ1ГУ ПРОЦЕСУ ДИФЕРЕНЦ1АЦП ЯСЕННОГО ЕП1ТЕЛ1Ю В
ДИНАМ1Ц1 МЕНСТРУАЛЬНОГО ЦИКЛУ
В статп приведенi результати комплексного цитолопчиого дослiдження перебiгу процесу дифереищаци ясенного епiтелiю жiнок молодого вку, в динамiцi менструального циклу. Отримаш данi дають можливiсть стверджувати про наявшсть циклiчного взаемозв'язку процесу диференщацп ясенного епiтелiю iз фазою менструального циклу. Про це свщчать стереотипний кйтинний склад цитограм пiхви та ясен у вщповщш фази та юльюсш змiни у пiзню фолжулшову фазу, якi вiдображають максимальний рiвень естрогеново! насиченостi органiзму.
Ключов! слова: ештелш, юптинний склад, ядро, цитоплазма.
Робота е фрагментом НДР «Роль запальних захворювань зубо-щелепного апарату в розвитку хвороб, пов 'язаних iз системным запаленням», номер державноI реестраци №0112и0011538.
Результаты клшчних спостережень останшх роюв дають можливють стверджувати про наявшсть цикшчного взаемозв'язку м1ж гормональною перебудовою жшочого оргашзму та диференщащею ештел1ю слизово! оболонки порожнини рота [2]. Власними напрацюваннями показано взаемозв'язок змш слизово! !з деякими динам1чними гормональними станами, зокрема таким як ваптшсть [8]. Результати дослщжень попередниюв показують, що актив1защя запального процесу в яснах вщзначаеться за 2-3 дш перед кожною менструащею в шзнш лютешовш фаз1. Спад його спостер1гаеться на 6-9-й день менструацй, у середнш лютешовш фаз1, що вщображае специфшу естроген-прогестрероново! взаемодй [3]. Проте вщсутшсть нормативних кшьюсних показниюв, характерних для кожно! фази в динамщ менструального циклу е суттевою перешкодою на еташ д1агностичного процесу [5].
Метою роботи було визначення особливостей морфолопчно! перебудови ясенного ештелда, в динамщ менструального циклу.
Матер1ал та методи дослщження. В робот керувалися правовими законодавчими та етичними нормами и вимогами при виконанш наукових та морфолопчних дослщжень [4, 6]. Матер1алом для дослщження слугував ясенний ештелш, забраний шляхом зшкряб1в у жшок молодого вшу у вщповщносп до фази менструального циклу. Ештелш забирали шпателем та переносили на предметне скло, висушували при вщкритому доступ пов1тря протягом 3-5 хвилин. Забарвлювали матер1ал за Пмзою-Романовським, з подальшим мшроскошчним та морфолопчним анатзом в п'яти полях зору, з урахуванням вщсоткового сшввщношення р1зних форм ештелюципв в нормь Статистичну обробку отриманих результат1в проведено у вщдш статистичних дослщжень ДВНЗ «Тернопшьський державний медичний ушверситет ¡меш I. Я. Горбачевського МОЗ Укра!ни». Параметричш методи застосовували для показниюв, розподш яких вщповщав вимогам нормальность Для оцшки характеру розподшу визначалися коефщент асиметрп та ексцес. Перев1рку нормальносп проводили за тестами асиметрп, проводили за тестом Шатро-У!лка. В1ропднють вщмшностей отриманих результапв для р1зних груп визначалася за допомогою 1>критер!ю Стьюдента. Вщмшносп вважали в1ропдними при загальноприйнятш у медико-бюлопчних дослщженнях !мов1рносп помилки р<0,05. 1мов1ршсть помилки оцшювали за таблицями Стьюдента з урахуванням розм1ру експериментальних груп. У випадках коли закон розподшу статистично-достов1рно вщр1знявся вщ нормального розраховували непараметричний критерш (и)Манна-У!тш як непараметричний аналог 1>критер!ю Стьюдента [5].
Результати дослщження та 1х обговорення. Кттинний склад цитограм ясен у менструальнш (1-3 доба) та раннш фолшулшовш фазах (4-7 доба) характеризуеться наявнютю
