CC BY
7
Bakhritdinova Fazilat Arifovna, doctor, of medicine, professor, Tashkent medical academy, department of ophthalmology
E-mail: [email protected] Bilalov Bakhodir Erkinovich, manager, of the department of ophthalmology Tashkent medical academy, department of ophthalmology
E-mail: [email protected]
PREVENTION OF EXCESSIVE SCARRING IN TERMINAL GLAUCOMA
Abstract: The results of present study of surgical treatment of terminal glaucoma by prevention of excessive scarring using the method of auto drainage of filtration zone are presented. Remote results of clinical studies have shown that the patients of the main group, the operation resulted in a significant decrease of intraocular pressure (IOP), after the subsequent observation period IOP gradually increased within normal variation (20-23 mm Hg), and it stabilized by 6 months after treatment and averaged 21.1 ± 1.3 mm Hg.
The decrease of the height of filtration cushion (FC) was not observed in 6 months period in the patients of the main group. The proposed operation of deep sclerectomy with auto drainage of the filtration zone, which contributed to a significant improvement in tonometric parameters that made it possible to increase the effectiveness of terminal glaucoma treatment.
Keywords: terminal glaucoma, intraocular pressure, ultrasonic biomicroscopy, filtration cushion, scleral flap, intrascleral cavity.
The topicality of the study. Glaucoma is one of the ment is ineffective in its development, and only treated
most common and severe eye diseases and occupies one surgically [2, 3, 4, 5].
of the main places in the structure of blindness and blur- At present the preservation of the organ is the main
ry vision. Despite the certain success achieved in the di- direction in the field of ophthalmology. In our country
agnosis and treatment of early stages of the disease, part and abroad the most common are two areas in the organ-
of the patients who have been complaining are already preserving surgical treatment of terminal glaucoma. First,
consulting in the terminal stage ofthe disease [9, 10, 13]. these are various modifications of fistulizing operations
The problem of treating terminal glaucoma in the [3, 7, 11]. Secondly, the thermal and laser operations [2,
world ophthalmology is still in the leading position. De- 4, 6, 8] effect on the ciliary body in order to lower the
spite the success in studying the normal physiology of in- secretion of watery moisture.
traocular pressure, in the medical treatment of glaucoma The unpredictability of the hypotensive effect and a
due to the appearance of new types of medicine, as well as number of serious complications, both in the early and
the constantly improving types of surgical and laser inter- late postoperative period after cyclodestructive interven-
ventions [1, 2, 3, 4, 5, 6, 7, 8, 12], the terminal glaucoma is tions, they limit their broad application in the treatment
still one of the main causes of irreversible blindness. of terminal glaucoma [6, 12].
Drug therapy in the terminal glaucoma is often inef- Another approach that has attracted ophthalmolo-
fective due to the expressed dystrophic changes in the gists for a long time was an attempt to create drainage
drainage system of the eye and ciliary body, iris rubeo- that provides a directed outflow of watery moisture un-
sis. Usually, such patients are treated conservatively be- der the conjunctivitis in order to reduce the ophthalmo-
fore the onset of pain syndrome, and since drug treat- tonus [1, 5, 7, 13, 14]. According to the literature, the
percentage of IOP normalization after drainage surgical interventions varies from 20 to 75%. Complication of drainage surgery includes hypotension leading to a cil-iochoroidal detachment, suprachoroidal hemorrhage, hypotonic maculopathy, corneal decompensation, as well as limiting the mobility of the eyeball and diplopia, endothelial-epithelial dystrophy [1, 3, 7].
Thus, in order to create an outflow from the anterior chamber, it is important not to have moves in the drainage, but to form slit-like spaces around it that are as close as possible to the physiological pathways of the outflow of the anterior chamber moisture.
The aim of study. To evaluate the effectiveness of surgical treatment of terminal glaucoma by preventing excessive scarring by autodraination method of the filtration zone.
Materials and methods of study. 60 patients were observed (60 eyes) with terminal glaucoma with high IOP, the distribution was as follows: 37 (61.7%) men, 23 (38.3%) women. The age ofpatients ranged from 40 to 70 years. The mean age of the patients was 55.7 ± 3.4 years.
Based on the anamnesis of patients, the following diseases were the causes of terminal glaucoma: primary glaucoma in 35 (58.3%) patients, of which closed-angle glaucoma in 21 (60%) and open-angle glaucoma in 14 (40%) patients, and secondary glaucoma of different
etiology in 25 (41.7%) patients. The causes of the secondary glaucoma were: thrombosis of the central vein of the retina (CVR) and its branches in 12 (48%), diabetes mellitus in 9 (36%) patients, who had uveitis in 2 (8%), and eye injury in 2 (8%). The first control group consisted of patients who underwent deep sclerectomy with preliminary posterior trepanation of the sclera - 30 patients (30 eyes). The second main group consisted of 30 (30 eyes) patients who underwent antiglaucomatous operation with autodraination of the filtration zone by V. P. Yerichev [7] in our modification (RUz., rationalization proposal No. 651 of 11.09.2013, «Modified surgical method for the treatment of refractory glaucoma». Bakhritdinova F. A., Bilalov E. N., Bilalov, B.E.).
The effectiveness of the treatment was determined by the data of biomicroscopy, the assessment of the condition of filtration cushion, pain relief, tonometry, tonography, ultrasound biometry and ultrasound bio-microscopy. The observation period made up 6 months.
Results and discussion. In all patients before the surgery, ophthalmotonus compensation for anti-hypertensive drugs was absent and averaged 47.1 ± 5.2 mm Hg. The visual functions in patients with terminal glaucoma of both groups were practically lost, in 45 (75%) cases the visual acuity was equal to zero; in 15 (25%) there was a light sense with an incorrect projection of the light.
Control aMain
Figure 1. Dynamics of intraocular pressure in different terms after the treatment (M ± m) Note: * - differences in comparison with initial values are statistically significant; (P <0.05); - differences in comparison with the values of control group after the treatment are statistically significant (P <0.05);
Significant positive dynamics was noted in the state of the iris and the angle of the anterior chamber under the of iris and the angle of the anterior chamber of an eye. Af- gonioscopic picture became noticeably disappeared. 3-6 ter the surgery in most patients, the newly formed vessels months after the operation the frequency of occurrence
of iris rubeosis was noted only in 1 (5%) patient in the main group. In the control group the frequency of occurrence of iris rubeosis was noted in 8 (40%) patients.
The hypotensive effect of surgical interventions in the early postoperative period (5-7 days after the surgery) and the long-term period (from 1 month to 6 months) is presented in pic. 1.
In early postoperative period in the main group the IOP level corresponded to a moderately expressed hypotension - 16-18 mm Hg, and in the control group -20-22 mm Hg.
A week after the operation, IOP decreased in 2, 3 times in patients in the main group relatively to the operating indices and averaged 20.3 ± 1.8 mm Hg, in patients in the control group this index decreased 1,8 times.
Long-term results of clinical studies showed that in patients in the main group the operation resulted in significant decrease of IOP, which in subsequent observation period gradually increased within the normal variation (20-23 mm Hg), it stabilized to 6 months after the treatment and averaged 21.1 ± 1.3 mm Hg, where as the mean IOP was 32.3 ± 1.5 in the control group.
In the first day after the operation, a filter cushion (FC) was visualized in patients of all clinical groups with biomicroscopy without signs of inflammation. The filter cushion was significantly marked in the patients in the main group and it was less marked and flatter in the control group.
According to the UBM data, in the early term after the operation (1 month later), in patients in the main group had a well- marked FC, the height of which varied in the range of 1.32 ± 0.04 mm. Its volume on average made up 55.3 ± 2.44 mm3 and the acoustic density of this structure was in the range of 40 ± 5%. The sclerotic flap (SF) with an average thickness of 0.38 ± 0.002 mm was clearly visualized. The acoustic density of SF on average made up 65 ± 10%. The height and volume of the intrasclerotic cavity (ISC) ranged within 0.65 ± 0.03 mm and 4.81 ± 0.35 mm3, respectively. The acoustic density was within 30 ± 5%. Already in the early stages hypoechogenic tunnels were marked in all eyes, resulting in from under the SL and connecting the ISP with OP.
1 month after the operation the changes were detected in all levels of the drainage system in the patients of the control group. FC was less marked, and its height on average made up 0.41 ± 0.03 mm and volume - 6.26 ±1 mm3.
The acoustic density of SF was in the range 63 ± 3% and was higher than in patients in the main group.
After 3 months FC was more marked in the main group (1.23 ± 0.03 mm) than in the control group (0.38 ± 0.02 mm) and differed in the decrease of the volume up to 36.45 ± 0.02 mm in the main group and up to 8.8 ± 0.4 mm in the control group.
Within 6 months a decrease in the height of the FC was not observed in the patients of the main group, it seems that it is apparently due to autodraination of the filtration zone.
Typical for a 6-month follow-up period after treatment of patients in the control group, a progressive decrease in the parameters of the drainage system examined for UBM was noted against the background of a progressive increase in the acoustic density of the structures.
During postoperative period the absence of FC was detected much more often in 51% of cases in the control group and the height averaged 0.35 ± 0.01 mm, volume -8.4 ± 0.3 mm3.
Although the SF thickness decreased slightly in the patients in the main group, compared with the previous terms and it made up 0.28 ± 0.002 mm, but the acoustic density of the structure remained in the range of 65 ± 5%. In patients of the control group the thickness and acoustic density of SF continued to increase and made up 0.38 ± 0.01 mm (90 ± 5%). Occurring visualized changes undoubtedly testify to the gradual development of sclero-conjunctival fusion, as well as the fibrosis of adjacent integumentary tissues.
The investigated average values of height and volume of intrascleral cavity (ISC) in patients in the main group were 0.40 ± 0.01 mm respectively, 1.65 ± 0.24 mm3. The acoustic density of the structure remained low, to 35 ± 5%. A hypoechoic slit connecting the ISP with FC and reflecting the intensity of outflow of intraocular moisture from under the conjunctiva was present in 80% of cases. In the control group, the dimensions of the ISC (height 0.28 ± 0.02 mm, volume 1.23 ± 0.08 mm3) were significantly reduced, in comparison with the previous studies.
Conclusion. 1. The proposed operation of deep sclerectomy with autodraination of the filtration zone, contributing to a significant improvement in tonomet-ric parameters, enabled to improve the effectiveness of terminal glaucoma treatment. Compensation of the oph-thalmotonus was noted in 83.3% of cases.
2. In terms of UBM indices in the long-term period, tioning of drainage system structures. In the traditional
after operation with autodraination of the filtration zone, antiglaucomatous operation of deep sclerectomy with
the parameters of FC and ISC with a reduced acoustic iridectomy, these parameters were respectively, 67.5%
density (56.6%) were retained, satisfactory visualization and 50.5%, which indicates more marked violations of
of tunnels (75%) was noted, which confirms the func- the drainage system of the eye.
References:
1. Анисимова С. Ю., Анисимов С. И., Рогачева И. В. Хирургическое лечение рефрактерной глаукомы с использованием нового, стойкого к биодеструкции коллагенового дренажа // Глаукома.- 2006. -№ 2.- С. 51-56.
2. Бачалдин И. Л., Егоров В. В., Марченко А. Н., Сорокин Е. Л. Транссклеральная диодлазерная циклокоагу-ляция в лечении терминальной болящей глаукомы // РМЖ - 2007.- Т. 8.- № 4.
3. Бикбов М. М., Суркова В. К., Хуснитдинов И. И., Чайка О. В., Оренбуркина О. И., Джамантаева Ш. Д. Результаты применения дренажа Ahmed при рефрактерной глаукоме // РМЖ. «Клиническая офтальмология».- Москва, - 2013. - № 3.- С. 98-101.
4. Бойко Э. В., Куликов А. Н., Скворцов В. Ю. «Лазерная циклодеструкция: термотерапия или коагуляция» // Сборник трудов 12-й всероссийской школы офтальмолога.- 2013.- Москва.- С. 45-55.
5. Вашкевич Г. В., Имшенецкая Т. А., Ситник Г. В. Отдаленные результаты синусотрабекулоэктомии с интра-склеральной и эписклеральной амниопластикой при глаукоме с различной степенью риска послеоперационного рубцевания // РМЖ. «Клиническая офтальмология».- Москва,- 2011.- № 4.- С. 142-144.
6. Гаврилова Т. В., Мухамадаева С. Н. Эффективность применения транссклеральной диодной циклофотоко-агуляции в лечении больных с терминальной болящей глаукомой. // Сборник статей 12-й всероссийской школы офтальмолога.- Москва.- 2012.- С. 59-61.
7. Еричев В. П., Бессмертный А. М., Робустова О. В. Хирургическая профилактика склеро-склеральных сращений у больных рефрактерной глаукомой // Актуальные проблемы офтальмологии: Сб. науч. тр.- М.,-2003.- С. 214-215.
8. Либман Е. С., Калеева Э. В., Рязанов Д. П. Комплексная характеристика инвалидности вследствие офталь-мопатологии в Российской Федерации. // Федоровские чтения - 2011: 9-я Всероссийская научно-практическая конференция с международным участием. Сб. тезисов.- М.,- 2011.- С. 57-82.
9. Мазунин И. Ю., Краева А. А., Кравецкая Е. И. Динамическая микроимпульсная диодлазерная транссклеральная циклокоагуляция (ДМИДТЦК) в лечении далекозашедших стадий глаукомы // Глаукома: теории, тенденции, технологии. HRT Клуб Россия - 2009: VII международная конференция: Материалы.- М.,-2008.- С. 357-360.
10. Нероев В. В. Основные пути развития офтальмологической службы Российской Федерации // Тез.докл. IX съезда офтальмологов России.- М.,- 2010.- С. 52-55.
11. Connor M., Knape R., Oltmanns M. Et al. Trainee glaucoma surgery: experience with trabeculectomy and glaucoma drainage devices // Ophthalmic Surg Lasers Imaging.-2010.- 41(5).- P. 523-31.
12. Neuburger M., Bringer D., Jordan J. F. Endocyclophotocoagulation for the treatment of glaucoma // Ophthal-mologe.- 2010.- Jan;107(1).- P. 68-74.
13. Patel S., Pasquale L. R. Glaucoma drainage devices: a review of the past, present, and future // Semin Ophthalmol.- 2010.- 25 (5-6).- P. 265-70.
14. Tzamalis A., Pham D. T., Wirbelauer C. Diode laser cyclophotocoagulation versus cyclocryotherapy in the treatment of refractory glaucoma // Eur J Ophthalmol.- 2011. Sep-Oct.- 21(5).- P. 589-596.
