Expulsive hemorrhage is a dangerous operation and one of the most severe postoperative complications. Its frequency ranges from 0.028% to 0.4%. Expulsive bleeding (EC) was first described by Wenzel in 1799, the term was proposed by Therson in 1894.

With expulsive hemorrhage, bleeding from the posterior ciliary arteries is observed, filling the suprachoroidal space with blood with a sharp increase in intraocular pressure and displacement of the contents eyeball through the operating wound.

Of all massive suprachoroidal hemorrhages (MSH, acute hemorrhagic detachment choroid) 35% refer to trauma and its surgery, 30% - to cataract surgery, 17.5% - to glaucoma surgery, 6.5% - to a through corneal transplant, 3% - to vitrectomy through pars plana, 3.5% - to secondary implantation of intraocular lenses (IOL), 4.5% - to other pathology. Large suprachoroidal hemorrhages, when blood occupies more than 50% of the vitreous cavity, occur in 1.9% of all intraocular operations.

Due to the improvement of microsurgical techniques during ophthalmic operations, the frequency of EC has decreased. For example, this complication occurs in 1.2% (taking into account cases of limited suprachoroidal bleeding) with extracapsular cataract extraction (EEC) and up to 0.4% with phacoemulsification (FEC).

Classification

• full - the contents of the eye are completely pushed out of the wound by blood, there is a complete loss of vision.
• partial (incomplete) - the membranes of the eye are only pushed back from the sclera, but do not fall out; visual function is partially preserved.

As a rule, expulsive hemorrhage occurs during the intervention, when the surgical wound is open. However, cases have been described even several hours or even days after the operation.

The reasons:

• rupture of the posterior ciliary arteries;
• choroidal (uveal) effusion - a quick discharge of clear fluid into the suprachoroidal space for unknown reasons, which causes the same consequences as choroidal hemorrhage;

in both cases, fluid or blood quickly accumulates in the suprachoroidal space, increasing intraocular pressure.

Risk factors:

• high myopia with an axial axis of more than 25 mm. Reduced rigidity of the sclera, increased fragility of the choroidal vessels. Of all patients with massive suprachoroidal bleeding, 52% have myopia;
• arterial hypertension;
• atherosclerosis;
• blood diseases;
• diabetes;
• glaucoma and ocular hypertension;
• heart rhythm disturbances;
• prolapse of the vitreous during surgery;
• sudden ocular decompression;
• A history of EC in the paired eye;
• prolonged hypotension of the eye;
• inadequate anesthesia;
• expanded use of cryotherapy and photocoagulation by the transscleral method.

Pathogenesis

Choroidal bleeding usually begins from the short posterior ciliary arteries where they pass through the sclera, surrounding the optic nerve. Choroidal vessels contain a large number of hyaline dilations (like the vessels of the spleen), often with sclerosis of the middle layer of the vascular wall, even in the absence of general vascular pathology.

Unlike other blood vessels, intraocular choroidal and retinal vessels are affected by intraocular pressure and can undergo vascular collapse, especially at the level of arterioles, where intravascular pressure drops significantly. The result is a slowdown in circulation at this vascular level, which reduces the blood supply to the vascular wall. All this leads to a malnutrition of the vessels themselves, sclerosis and subsequent necrotic changes in the vascular wall, which may not withstand the pressure drop during the operation.

Histopathological studies have shown that in many cases rupture of the necrotic part of the arterial wall occurs.

One of the features of the microcirculation of the eye is that a relatively high intravascular (intravasal) pressure (approximately 25–30 mm Hg) acts on the walls of intraocular capillaries from the inside, and intraocular (extravasal) pressure, which is significant compared to other organs, outside ( normally 16–20 mm Hg). The pressure difference on both sides of the vessel wall is called transmural pressure. Inside the eye, oppositely directed forces act on the capillary wall: blood pressure stretches it (expands the lumen), and the pressure of the surrounding tissues and the contents of the eyeball (extravasal pressure) affects the opposite way.

When the nucleus is removed during EEC or cataract cryoextraction, the anterior and posterior chambers are fragmented with a loss of lens volume, which leads to the forward displacement of the iridocular lens and a sharp decrease in IOP. Due to the loss of the anterior chamber and removal of the nucleus, a certain free volume is formed in the anterior part of the eye, the frame function of the iridocular diaphragm is sharply reduced, which leads to a forward displacement of the vitreous body and a decrease in IOP in the posterior part of the eye. This can cause effusion of transudate into the suprachoroidal space, displacement of the vitreous body forward, which during cataract cryoextraction can lead to an increase in IOP in the posterior part of the eye and rupture of the hyaloid membrane, prolapse of the vitreous body and an even greater decrease in pressure in the suprachoroidal space and the posterior part of the eye.

With EEC, the forward displacement of the vitreous body due to the emptying of the anterior and posterior chambers and the removal of the nucleus causes the maximum deflection of the posterior capsule forward, which increases the volume of the posterior part of the eye and decreases the IOP. This increases the transmural pressure in the vessels and can lead to their rupture. An increase in total blood pressure with the onset of pain after poor-quality or rapidly passing anesthesia with an increase in the time of surgical intervention due to additional manipulations leads to an even greater increase in transmural pressure in the vessels of the eyeball.

With FEC, a decrease in IOP in the posterior part of the eye occurs after the removal of the nucleus at the time the tip is removed from the incision, displacing the irido-lenticular diaphragm forward. With an increase in blood pressure at this moment, the transmural pressure in the vessels of the eye rises sharply, this can lead to rupture of the vascular wall and expulsive hemorrhage.

In operations for glaucoma, the presence of a fistula with filtration of intraocular fluid through artificial outflow pathways leads to a decrease in the volume of the anterior chamber and a decrease in IOP. This is especially pronounced in aphakia or pseudophakia.

An increase in blood pressure against the background of a decrease in IOP in the operated eye gives an increased load on the vessel wall, the elastic properties of which are reduced due to necrosis of the middle layer of the wall of the short ciliary arteries.

Surgery for patients at increased risk of expulsive hemorrhage requires:

• general anesthesia with controlled hypotension for complete relief of pain syndrome, maximum reduction
• BP and IOP (anesthesia lowers IOP by about 3 mm Hg);
• maximum antihypertensive therapy before surgery (preferably within several days);
• the fastest possible sealing of the wound with an increase in intraocular pressure;
• monitoring the state of the suprachoroidal space through a previously made sclerotomy opening. With pronounced effusion, the partial release of the suprachoroidal fluid temporarily reduces the IOP and makes it possible to deepen the anterior chamber, suture and thereby increase the IOP, restoring the correct anatomical ratios of the eyeball.

In the postoperative period, constant monitoring of blood pressure with its maximum decrease (taking into account atmospheric pressure and the general condition of the patient) is necessary. Particular attention should be paid to relieving the pain syndrome using pain medications, and the patient's psycho-emotional state, reducing his anxiety and fears with sedatives.

Clinical picture

With the development of expulsive hemorrhage, the patient complains of a sharp pain in the eye, which becomes hard, the anterior chamber is crushed, the pink reflex from the fundus may disappear (or change), and the iris prolapse into the surgical wound. If by this moment the lens has not yet been removed (with EEC), then it spontaneously comes out, as a rule, it is followed by vitreous, shell and blood. All this can happen very quickly and at different stages of the operation.

Treatment tactics

During the intervention, the fastest and most complete sealing of the surgical wound is required.

In the case of FEC, it is sometimes enough to remove the tip of the phacoemulsifier from the anterior chamber - and under the influence of increased IOP, the lower lip of the incision tightly and reliably seals the surgical wound (the increasing pressure plugs the bleeding and prevents it from developing into a massive one with the ejection of membranes).

If possible (with FEC), fill the anterior chamber with high molecular weight viscoelastic and press down on the eye with the index finger to further increase the pressure.

With EEC, there is no doubt about the performance of posterior trepanation of the sclera, since this allows at least for some time to reduce the IOP and, if possible, to correct the fallen iris or other membranes and seal the wound with minimal losses.

With FEC, posterior trepanation of the sclera can be performed in a delayed period, since a decrease in IOP can stimulate continuation of bleeding or rupture of another vessel. In addition, manipulations with the choroid (with posterior trepanation) can cause ruptures of other vessels and additional bleeding, which, with high IOP, can lead to retinal infringement at the site of sclerotomy.

If the bleeding has stopped and there is a large amount of lens masses, the operation can be completed in 2–3 hours. When the core and most of the lens masses are removed, it is advisable to complete the intervention if possible. If in doubt about the completion of the operation, it is necessary to conduct a course of conservative therapy and only then decide whether to remove the remnants of the lens, implant an IOL, and posterior trepanation of the sclera.

Conservative therapy consists in the use of local and general antihypertensive drugs, vasoconstrictor drugs, steroid anti-inflammatory therapy.

After 3-4 days, resorption therapy can be started until complete resorption of the clot in the suprachoroidal space.

Patients need long-term postoperative follow-up (a year or more) together with a vitreoretinal surgeon to timely address the need for vitrectomy in order to prevent retinal detachment, proliferative vitreoretinopathy, neovascular glaucoma, and eyeball subatrophy.

Practical cases

Patient K., 74 years old. Was admitted to the Department of Eye Microsurgery for a planned FEC on the only sighted left eye. Diagnosis: immature complicated cataract OU. Open-angle IV B glaucoma OD, II A glaucoma OS. Uveopathy, pseudoexfoliative syndrome, grade 3 both eyes. Concomitant pathology: ischemic heart disease, vascular atherosclerosis, AH II risk IV.

On admission, visual acuity OD \u003d hand movement in the face, OS \u003d 0.02 n / a. IOP OD \u003d 28 mm Hg. Art., OS \u003d 15 mm Hg. Art.

During FEC, at the stage of removing the last fragments of the nucleus, the patient developed pain in the eye, increased IOP, and the anterior chamber was crushed. It was decided to suspend the operation, and stitches were put on the incisions. ZSE was performed in the inferior-outer segment, fresh blood was evacuated. Hypotensive, angioprotective and osmotherapy were performed. The next day, echoscopic examination of the left eye revealed a detachment of the choroid with intrathecal contents (blood) of 7.27 mm in height.

7 days later, ZSE was performed in the inferior-outer segment, anterior vitrectomy with removal of the remaining fragments of the nucleus.

The patient continued to receive anti-inflammatory, antihypertensive and angioprotective therapy. Discharged on the 10th day.

Visual acuity on OS with correction was +10.0 D \u003d 0.3–0.4. After 2 months, control echoscopy: there was an expansion of the intershell space in the left eye up to 1.5 mm. After 4 months, the secondary implantation of the T-19 IOL was performed. The operation took place without complications, visual acuity at discharge was 0.3, IOP OS \u003d 11 mm Hg. Art.

Patient G., 73 years old. He was admitted to the Department of Eye Microsurgery for planned surgical treatment of glaucoma in the right eye. Diagnosis: open-angle III – IV C glaucoma OD, open-angle III B glaucoma OS, immature complicated cataract OU, pseudoexfoliative syndrome OU, hyperopia weak degree OU. Concomitant pathology: ischemic heart disease, atherosclerotic cardiosclerosis, permanent form of atrial fibrillation. Atherosclerosis of the aorta, coronary arteries, H1, AH II risk IV.

Upon admission, visual acuity OD \u003d 0.2 s / cor spr +1.5 \u003d 0.3; OS \u003d 06 s / cor sfr +1.0 \u003d 0.7; IOP OD \u003d 29 mm Hg. Art., OS \u003d 21 mm Hg. Art.

During the antiglaucoma operation (sinustrabeculectomy) at the final stage of restoring the volume of the anterior chamber with sterile air, the patient developed pain in the eye, increased IOP, and the anterior chamber was shredded.

The volume of the anterior chamber was restored, and an interrupted suture was placed on the paracentesis. The next day, echoscopic examination of the right eye revealed a detachment of the choroid with intrathecal contents (blood) with a height of 6.2 mm. After 5 days, ZSE was performed in the inferior-outer segment, blood was evacuated from the intrathecal space, and the lens began to cloud intensively during the hospital stay.

The patient continued to receive anti-inflammatory, antihypertensive and angioprotective therapy. Discharged on the 10th day. Visual acuity was at OD \u003d 0.01. After 1 month, a control echoscopy was performed, a course of anti-inflammatory and angioprotective therapy was performed. After 2 months, FEC was performed with implantation of the T-26 IOL. The surgery went without complications.

Visual acuity at discharge OD \u003d 0.2–0.3, IOP OD \u003d 14 mm Hg. Art.

conclusions

1. Based on the analysis, a combination of those risk factors that can cause the development of expulsive hemorrhage have been confirmed.

2. The fundamental mechanism of the pathogenesis of the development of suprachoroidal bleeding has been determined - a sharp decrease in IOP due to an increase in volume in the anterior part of the eyeball when removing the lens and emptying the anterior chamber, with a decrease in pressure in the vitreous body and suprachoroidal space and with an increase in blood pressure.

3. The technique of small incisions for phacoemulsification of complicated cataracts allows minimizing possible surgical complications and successfully coping with expulsive hemorrhage.

4. Performing posterior sclerectomy (PES) in case of expulsive hemorrhage during surgery, and in the cases shown, repeated after the intervention allows restoring the normal anatomy of the eyeball, predicting further tactics and a good functional result.

5. Surgical treatment of cataracts in combination with glaucoma, uveopathy in elderly patients with severe cardiovascular pathology requires careful preoperative preparation in order to reduce the risk possible complications.

Surgical treatment of glaucoma

NATIONAL GLAUCOM GUIDE
Edited by E.A. Egorova Yu.S. Astakhova A.G. Shchuko
Authors and table of contents
Moscow. 2008

General principles

Different types of antiglaucomatous operations have their own indications depending on the form of glaucoma. So, in the case of angle-closure glaucoma, peripheral iridectomy and iridocycloretraction are used, with congenital - goniotomy or variants of sinustrabeculectomy, with open-angle glaucoma, numerous modifications of penetrating and non-penetrating surgical interventions. With repeated surgical interventions using drains and antimetabolites. At the terminal stages, various types of cyclodestructive operations.

The choice of intervention is related to a number of factors:

1. Ineffectiveness of other treatments.

2. Inability to implement other methods of treatment (including non-compliance with medical recommendations, expressed side effects) or the unavailability of appropriate drug therapy.

3. Impossibility of achieving the required individual "target" IOP with local antihypertensive drugs or laser therapy.

4. The presence of a high level of IOP, which is unlikely to be normalized by any other method of treatment other than surgery.

5. The level of risk in carrying out a particular operation.

6. Individual preferences of the surgeon.

Indications and timing of surgical treatment

Surgical treatment of glaucoma is carried out if it is impossible to achieve the level of individual "target" pressure due to ineffectiveness conservative treatment or the impossibility of laser treatment.

The timing of operations should be determined based on the data clinical research (IOP dynamics, perimetry, assessment of the optic nerve head). When deciding on an operation, many factors must be taken into account, including whether the patient will follow the doctor's prescriptions, the stage of the glaucomatous process, etc.

Surgical treatment is also the method of choice in cases when pressure control by other methods is not possible or when the IOP level is initially high in the early stages of the disease.

Preoperative preparation.

During the preoperative examination, the place and nature of the retention is determined. The leading place in determining the place of retention is taken by gonioscopy. Depending on the state of the anterior chamber angle, a conclusion is made about the form of glaucoma, which is the basis for choosing a method of surgery.

The principles of preparing patients for antiglaucomatous operations, in general, do not differ from the usual ones used in operations with opening the eyeball.

The examination includes traditional analyzes, therapeutic control to exclude general contraindications, sanitation of the oral cavity and other possible foci of focal infection.

The goal of general medical therapy in preparation for an intervention is primarily to reduce the neuropsychic stress associated with the operation. It is important to get good sleep before surgery, if necessary with sleeping pills.

In cases of chronic inflammatory diseases eyelids and conjunctiva on the eve of the operation should be prescribed instillation of broad-spectrum antibiotics. In the absence of any special indications, antibiotics are not prescribed either on the eve of the operation, or on the day it is performed.

Antihypertensive therapy: the use of previous local and general antihypertensive therapy before the day of surgery.

It is important on the eve of the operation, in order to prevent intraoperative complications (expulsive hemorrhage, ciliochoroidal detachment, etc.), especially when performing surgical interventions with opening the eye, to achieve the maximum reduction in intraocular pressure. It is advisable to take inside glycerin (at the rate of 1.5 g per 1 kg of weight), diluted with an equal amount of fruit juice or diacarb 250 mg in the evening, on the eve of the operation.

Surgery

The most common filtering (penetrating and non-penetrating) surgeries such as trabeculectomy, sinusotomy, which create new or stimulate existing outflow tracts.

Since various ophthalmic surgeons use numerous modifications of antiglaucoma interventions, only classical methods of surgery will be presented, detailed description the technique of operations is not the purpose of this manual.

Of course, the absence of the need for drug therapy after an operation is an important indicator of its effectiveness.

In practice, if surgically it was not possible to achieve the individual “target” pressure, it is necessary to prescribe local antihypertensive therapy, as a rule, the number of drugs in this case is much less than before the operation. But the main criterion in subsequent treatment should be the achievement of the target pressure.

Antiglaucomatous fistulizing surgery

Trabeculectomy

Today, the operation of choice for POAG is trabeculectomy with the formation of a fistula under the scleral flap.

The advent of modern operating microscopes, microsurgical instrumentation and suture materials contributed to the development of numerous improvements in surgical techniques. They include modifications to the size, shape and thickness of the scleral flap, features of the conjunctival flap (base to the limbus and base to the fornix of the conjunctiva), combination with cyclodialysis, the type of scleral sutures, introduction of viscoelastic drugs into the anterior chamber and under the scleral flap, as well as the use of antimetabolites and others. drugs that reduce scarring.

According to expert estimates, the effectiveness of the first fistulizing surgery performed on a previously unoperated eye (without or with additional antihypertensive therapy) is up to 85% in terms of up to 2 years; however, the criteria for the success of the interventions in these assessments are very diverse.

If the effectiveness of the surgical intervention in combination with drug therapy is insufficient, one should resort to repeated surgical intervention.

Trabeculectomy surgery technique

usually a wide (7 - 8 mm) conjunctival flap is formed with a base at the limbus. Tenon's capsule is separated from the sclera to the limbus. Produce hemostasis. Non-through incisions (1 / 3-1 / 2 of the scleral thickness) outline a triangular (square or trapezoidal) zone with a base (5 mm wide, 4 mm high) at the limbus; accordingly, lamellar dissection of the sclera is produced. At the bottom of the stratified zone, the position of the scleral spur is usually clearly visible (along the transition from the transparent layers of the limbus to the opaque ones); slightly posterior to it is the venous sinus of the sclera. According to the position of the sinus, a strip of deep scleral layers (1.5 mm wide, 4 mm long) is cut concentrically to the limbus. Usually, the deep layers of the sclera are excised with a diamond knife or a disposable blade. At the same time, at the beginning, the boundaries of the excised strip are outlined, and then a strip of deep layers of the sclera is removed with the tip of the knife together with the trabecula. In this case, the iris falls into the wound. Basal iridectomy is performed.

The superficial scleral flap is placed in place and sutured back to the bed with 1-3 sutures. The conjunctival suture (usually virgin silk) must be applied very carefully; full adaptation of the incision edges contributes to better formation of the filter cushion and prevents external filtration.

Postoperative management.

In the postoperative period, antibacterial drops are instilled, usually 4 times a day, mydriatics (atropine 1%, cyclomed 1%) 1-2 times a day, with the help of which a moderately dilated pupil is maintained. Corticosteroids are prescribed until postoperative iritis is relieved. In cases where the filtration cushion is not very pronounced and there is a tendency to an increase in intraocular pressure, massage of the eyeball is useful for better formation of the filtering pathways.

Complications of STE

Complications of the early postoperative period (up to 1 month).

1. Hyphema.
2. Ciliochoroidal detachment (CCO).
3. External filtration of VHF (hypotension).
4. Hypertension.
5. Inflammation.
6. Pupillary block.

Complications of the late postoperative period (up to 6 months)

1. Accelerated progression of cataracts.
2. Filter bag infection.
3. Hypotension.
4. Hypertension.
5. Excessive scarring.
6. Ciliochoroidal detachment.
7. Recurrent hyphema.

Long-term complications (more than 6 months)

1. Cystic changes in the filter cushion.
2. Cataract progression

Treatment of postoperative complications

Hyphema usually resolves on its own and special treatment does not require. With prolonged existence of hyphema or its recurrence, it is recommended: topically - instillation of 2% or 3% calcium chloride solution, parabulbar injections of dicinone, intravenously - 20 ml of 40% glucose solution and 10 ml of 10% calcium chloride solution, inside - 0.25 diacarb, 100 -200 ml of 30% glycerin solution.

Ciliochoroidal detachment. Signs of CCO are shallow anterior chamber syndrome, hypotension, and a decrease or absence of a filtration cushion.

If the anterior chamber is preserved, conservative treatment of CCO is carried out. For this purpose, caffeine is prescribed 0.5 ml of a 5% solution, mydriatics (atropine 1%). In most cases, this leads to restoration of the anterior chamber and filtration under the conjunctiva. In the absence of the anterior chamber or persistence of signs of CCO, the operation of posterior trepanation of the sclera is performed within 3 days.

In case of hypotension associated with the presence of external filtration (diagnostics is carried out using a test with fluorescein 0.5%), it is necessary to seal the wound edges. In some cases, the effect of applying a pressure bandage to the filtration area.

In cases of postoperative hypertension and the absence of a filtration cushion, an eyeball massage can be effective. If there is no effect, the area of \u200b\u200bsurgery is revised to determine the causes of moisture retention.

To relieve postoperative inflammation, instillations of mydriatics and corticosteroids are prescribed, dexazone 0.5 ml is injected under the conjunctiva until signs of inflammation are relieved.

In the long term after trabeculectomy (as well as after many other antiglaucomatous operations), there is an accelerated progression of cataract changes in the lens; in some cases, the patient should be notified of the possibility of this in advance.

In case of an increase in IOP in the late postoperative period, the following measures can be performed:

• In the presence of a cystic pillow, a subepithelial opening (needling).
• In case of blockade of intrascleral tracts - closed revision with a spatula-knife.
• In case of violation of the outflow in the area of \u200b\u200bthe internal opening of the fistula - revision of the internal fistula "ab interno".
• With complete obliteration, repeated antiglaucomatous surgery in another sector of the eyeball.

Non-invasive interventions for glaucoma

I. Non-penetrating deep sclerectomy.

• Viscocanalostomy.

Collectively, these techniques differ in the size and depth of the incision and resection of the second flap in the sclera. However, since the principle of operations is similar, the complications and tactics of patient management do not differ significantly.

Indications:

Primary open-angle glaucoma in patients with a target pressure of ≥20 mm Hg, which cannot be achieved with medication.

Benefits:

• lower, relative to trabeculectomy, the level of intra- and postoperative complications;
• the possibility of restoring the outflow of intraocular fluid in natural ways with viscocanalostomy.

Disadvantages:

• the hypotensive effect is inferior to that of trabeculectomy (on average by 2-4 mm Hg);
• technical complexity, requiring a higher qualification of the surgeon;
• the possibility of developing episcleral fibrosis, leading to an unsatisfactory effect.

Preoperative preparation:

• anti-inflammatory therapy: instillation of antibacterial and non-steroidal or steroidal anti-inflammatory drugs for 3 days before surgery;
• hemostatic therapy: oral intake drugs (askorutin, dicinone) within 7 days before surgery;
• antihypertensive therapy: the use of previous local and general antihypertensive therapy before the day of surgery;
• correction of concomitant pathology;
• during the operation, standard techniques of local anesthesia are used with or without potentiation.

Deep sclerectomy

During the operation, a deep layer of corneoscleral tissues and the outer wall of the Schlemm's canal are removed under the superficial scleral flap.

The epithelial layer of the inner wall of the Schlemm's canal and the anterior sections of the Descemet's membrane are also removed.

Filtration is carried out through the pores of the remaining trabecular meshwork and Descemet's membrane.

After repositioning the superficial flap, a "scleral lake" is formed under the episcleral flap.

Variants of the operation can be the use of drains with their placement under the scleral flap.

Complications:

• intraoperative: hyphema (? 1% of cases), trabecular microperforation with or without iris insertion;
• postoperative: detachment of the choroid (? 2% of cases), episcleral / conjunctival fibrosis (to prevent the development of this complication, options for operations using various drains or cytostatic drugs can be used);
• repeated increase in IOP or insufficient hypotensive effect.

Postoperative management:

In uncomplicated cases:

• anti-inflammatory therapy: instillation of antibacterial and steroid anti-inflammatory drugs for 7 days after surgery, followed by a switch to non-steroidal anti-inflammatory drugs for 2 weeks;
• postoperative examinations on days 1, 3 and 7, control instrumental studies 1 and 6 months after the operation.

In complicated cases:

• hyphema: topically - instillation of 2% or 3% calcium chloride solution, parabulbar injections of dicinone, intravenously - 20 ml of 40% glucose solution and 10 ml of 10% calcium chloride solution, inside - 0.25 g of diacarb, 100-200 ml of 30% glycerin solution.
• detachment of the choroid: a complex of traditional therapeutic and prophylactic measures, including subconjunctival administration of dexamethasone, caffeine, mezaton, emoxipin, as well as methyluracil, ascorutin, indomethacin in tablets per os. In the absence of effect - posterior trepanation of the sclera (posterior sclerectomy);
• with insufficient hypotensive effect, operations can be used:
• Nd: YAG laser goniopuncture;
• drug antihypertensive therapy.

SURGICAL TREATMENT OF PRIMARY CLOSED-ANGLE GLAUCOMA.

INDICATIONS for surgical treatment:

• uncompensated intraocular pressure in an acute attack of angle-closure glaucoma;
• chronic angle-closure glaucoma in the interictal period;
• crushing of the anterior chamber in creeping angle-closure glaucoma;
• vitreo-lens unit.

AND. IRIDECTOMY.

Training. Anesthesia.

At night before the operation, anxiolytics (phenazepam 0.5 mg) and antihistamines (diphenhydramine 0.05) are administered orally.

In the morning before the operation, patients do not eat breakfast and do not take oral medications. For 30-45 minutes, patients undergo premedication, including anxiolytics (diazepam 5 mg - 2.0 ml). Ataralgesia is supported by fractional administration of opioid analgesics (fentamine 0.05-0.1 mg).

For local anesthesia, the introduction of 2% lidocaine solution 1-2 ml into the subtenon space is used.

The surgical field is processed 1% alcohol solution chlorhexidine - double skin treatment. The conjunctival cavity is washed with 0.9% sodium chloride solution, 2 drops of antibiotic are instilled.

Operation technique. Subscleral iridectomy ab externo is currently used. The conjunctiva is dissected along the limbus in the meridian for 10-2 hours, separated from the limbus by 5 mm, a superficial scleral flap of a triangular shape is cut out with a base to the limbus with a height of 4 mm, a base of 4 mm. A scleral flap at the apex? thickness, to the limbus deepens to the basement membrane. Before entering the anterior chamber, it is advisable to conduct a final hemostasis. A preliminary 8-0 silk suture is applied to the apex of the scleral flap. The anterior chamber is opened with a metal or diamond blade (incision length 3 mm, incision area 12-2 hours for the right eye, 10-12 hours for the left eye). The fallen root of the iris is captured with tweezers and cut off with scleral scissors closer to the scleral lip (branches parallel to the limbus). If the iris does not fall out, then you can provoke this by lightly pressing the scleral lip of the wound. To refuel the iris into the anterior chamber, if it has not refueled itself, light pressure on the scleral lip produces a slight emptying of the anterior chamber, after which the iris is adjusted by itself or as a result of careful stroking on the cornea. A preliminary seam is tied on the sclera. The conjunctiva at the limbus is pulled and fixed with 8-0 interrupted silk sutures or a thermocoupler. 0.5 ml of antibiotic and 2 mg of dexazone are injected under the conjunctiva.

Fig. Ab externo incision for iridectomy with a metal blade.

Complications.

1. An incision through the ciliary body can cause hemophthalmos, iritis, and retinal detachment.
2. A corneal incision can make it difficult for the iris to prolapse.
3. Bleeding from the iris after iridectomy requires mechanical hemostasis (by pressing on the bleeding site with a cotton swab), pharmacological (topically: aminocaproic acid, chilled saline, intravenous ethamsylate). Apply pressure to the eye for at least one minute.
4. Persistent hypertension after iridectomy with a shallow anterior chamber may indicate a cyclo-lens block. One should start with conservative therapy: atropine 1% solution topically, glycerin, urea inside (1.5 g per kg of patient's body weight). In case of ineffectiveness of conservative treatment, one should proceed to surgical treatment - closed vitrectomy.
5. Subarachnoid hemorrhage (incomplete expulsive hemorrhage) can give similar symptomatic hypertension. Release of subarachnoid blood is required through the trepanation opening in the sclera 6-8 mm from the limbus. In some of these cases, severe choroidal edema develops, the so-called massive choroidal ephrusion, which is diagnosed using two-dimensional echography. As treatment measures diuretics are used (acetazolamide up to 1 g per day) and corticosteroids parabulbar and intravenous (dexamethasone 4 mg and 12 mg, respectively).

Postoperative management.

Inflammatory (especially infectious) complications after iridectomy are rare. Eye irritation is usually mild and easily amenable to traditional therapy: topical corticosteroids (dexazone drops) and prostaglandin synthesis inhibitors (diclofenac 0.1% solution or indomethacin 0.1% solution). In order to prevent the development of posterior synechiae (especially after prolonged use of miotics), it is recommended to “massage” the pupil by prescribing short-term mydriatics and miotics alternately during the first 5-7 days.

In the case of poorly absorbable hyphema, especially if it reaches the pupil area, corneal paracentesis is performed. It is not recommended to strive to completely evacuate all blood due to the intensifying hemolysis processes after paracentesis.

B. IRIDOCYCLORETRACTION

Indications.

In the case of adhesions in the corner of the anterior chamber, which prevent the outflow of intraocular fluid, basal iridectomy will not normalize intraocular pressure. In addition, the forward displacement of the irido-lenticular diaphragm is also due to morphological factors: the anterior position of the diaphragm and the large size of the lens. In the cases described, the introduction of "spacers" is required, separating the root of the iris from the angle of the anterior chamber. The predominant significance of the synechial nature of the blockade of the anterior chamber angle is revealed by the chronic course of angle-closure glaucoma with a constant rise in intraocular pressure during the interictal period. On the contrary, in angle-closure glaucoma with pupillary block in the interictal period, an increase in IOP is not detected.

Preparation for surgery and anesthesia do not differ from those with iridectomy.

Operation technique.

The conjunctiva is dissected concentrically to the limbus at 7-8 mm from it in the meridian from 11 to 1 hour, separated to the limbus. The superior rectus muscle can be grasped with a Pean forceps to reduce blood flow to the eyeball through the muscle arteries. On both sides of the muscle, close to its edges, U-shaped flaps with a crossbar towards the equator are outlined in the sclera with blind cuts. The distance between the longitudinal cuts is 2 mm, the length is 3.5-4 mm, the distance of the ends of the cuts from the limb is 3-4 mm, the thickness of the cut out flaps is 2/3 of the thickness (Fig. 4-a). On the anterior border of the stratification (at the base of the "tongues"), through incisions (b) are made through the remaining layers of the sclera (3-4 mm from the limbus, parallel to it). Thorough hemostasis with a diathermocoagulant or using a solution of aminocaproic acid (1 g in 50 ml) drip into the wound.

Through through scleral incisions with a spatula, a canal is formed in the supraciliary space until the end of the instrument enters the anterior chamber. The spatula should be pressed against the sclera from the inside. Upon reaching the scleral spur area, there is a noticeable obstruction to detachment. This obstacle should be overcome with caution with swaying movements. After the introduction of the spatula into the anterior chamber, the ciliary body should be detached between the "tongues" by movements from the pupil from both incisions. In order to prevent bleeding into the anterior chamber after detachment of the ciliary body, pressure should be applied to the eyeball with a cotton swab for a minute. When hyphema occurs, sterile air must be introduced into the anterior chamber. The formed "tongues" are filled into the anterior chamber with a thin spatula (c). Their ends should protrude beyond the root of the iris (practically reach the limbus). After that, the clamp is removed from the superior rectus muscle.

Finally, the front chamber is filled with air. The conjunctival incision is sutured with a continuous silk suture (8-0). 0.5 ml of antibiotic and 2 mg of dexazone are injected under the conjunctiva. A monocular bandage is applied.

Complications are almost the same as with iridectomy. Some of them (detachment of the iris root, perforation of the ciliary body, detachment of the Descemet's membrane) are the result of a gross violation of the surgical technique. This determines the prevention of these complications.

Iridocyclitis can last at the subclinical level for quite a long time (months), which requires long-term monitoring of patients. Biomicroscopic control is necessary for early detection of posterior synechiae and timely treatment when they occur. Mydriatics use short-acting to quickly restore normal pupil width and prevent re-closure of the anterior chamber angle.

Fig. Iridocycloretraction technique.

You should also carefully combat the hyphema to prevent the formation of goniosynechiae and posterior synechiae.

Postoperative management. Given the tendency to develop hyphema, patients after iridocycloretraction observe a gentle regimen and receive antihemorrhagic therapy (calcium chloride, dicinone, vicasol, vitamin C and etc.). The suture from the conjunctiva is removed for 7-10 days. When hyphema appears, active resorption therapy is indicated (enzymes inside and under the conjunctiva, phonophoresis with lidase in the absence of contraindications, autohemotherapy); with large hyphemas and the absence of positive dynamics - evacuation of blood through the corneal paracentesis approximately 7 days after the operation.

To stop the inflammatory reaction, corticosteroid and non-steroidal anti-inflammatory drugs are prescribed topically. It is necessary to remember about the possibility of increasing intraocular pressure with prolonged local application corticosteroids, which normalize after their withdrawal.

Congenital Glaucoma Surgery

Indications: congenital glaucoma in the first year of a child's life in order to avoid excessive stretching of the eyeball, irreversible changes in the outflow pathways of the intraocular fluid, secondary damage to the cornea and glaucomatous optic nerve atrophy.

GONIOTOMY.

Indicated in the presence of residual tissue in the corner of the anterior chamber.

Training. Anesthesia. Preference is given to mask and nasopharyngeal anesthesia with spontaneous breathing. These methods differ little from those adopted in general surgical practice. Preparing children for surgical treatment is also common.

Operation technique. The upper and lower rectus muscles are fixed with interrupted sutures or fixation forceps with a lock (in the latter case, it is more convenient to operate without an eyelid dilator). The patient's head is turned at an angle of 45? from a surgeon whose left hand holds the lens in contact with the eyeball. The goniolin is shifted somewhat eccentrically to make room for the goniotome.

The focusing of the operating microscope is performed on the trabecular zone, the place where the knife is inserted is not in focus. The injection has to be done under direct control of the corneal 1-2 mm from the limbus.

The assistant holds the eye so that the plane of the iris is strictly parallel to the direction of the knife in the anterior chamber. The blade is held over the pupil as quickly as possible so that the conical part of the knife tampers the injection site and does not allow the moisture of the anterior chamber to escape.

To maintain a normal anterior chamber depth, a cannulated goniotome or a saline cannula (0.9% sodium chloride solution or BSS) additionally inserted through corneal paracentesis can be used.

The tip of the knife should enter the trabecular zone immediately behind the Schwalbe line. Shouldn't the incision be too deep, at least? the blades of the goniotome must remain clear for observation (an important landmark). Sometimes it is required to rotate the knife along the axis to determine the depth of its immersion.

With an arcuate movement of the knife, the filtering zone is dissected by about 60?. Then the blade is unfolded and cut in the opposite direction for the same length.

The knife must be removed quickly to avoid damage to the lens, the back of the blade is oriented to the cornea to maintain the size of the wound channel.

We fill the anterior chamber with sterile air at?. in order not to cause blockage of the pupil, fill the rest with a balanced mixture of BSS.

Complications. Most often, bleeding into the anterior chamber is noted, the blood must be washed to avoid the formation of clots. Can be used to flush with prourokinase and fill the anterior chamber with air to help squeeze out blood, especially from the pupil area.

Perforation of the eye wall is usually the result of a violation of surgical technique. This does not require any special measures, but it is necessary to monitor the final restoration of the anterior chamber upon completion of the operation.

Sometimes there is a tendency to the formation of anterior or goniosinechia. In order to prevent this complication, the surgical wound should be carefully cleaned and the anterior chamber should be fully restored by the end of the operation. Especially carefully it is necessary to treat the endothelium of the cornea.

Postoperative management.

A guard mode is required until air is absorbed in the anterior chamber. The head should be in such a position that the air in the anterior chamber is located in the area of \u200b\u200bthe goniotomy. Miosis must be maintained for at least the first 4-5 days. In the future, mydriasis is also undesirable. Instillation steroids are indicated for several days.

SINUSOTRABECULECTOMY

The indications for this surgical intervention in congenital glaucoma are significant changes in the structure of the anterior chamber angle or lack of effect after goniotomy.

Preparation and anesthesia are similar to those for goniotomy.

Operation technique. The processing of the operating field is standard. A fairly wide conjunctival flap (5-6 mm) parallel to the limbus, 6 mm from it. A lamillary scleral flap is formed with a base at the limbus (base length 5 mm, height up to the limbus 4 mm). At the bottom of the separated zone, the helmet canal is localized and its outer and inner walls are removed in the meridians from 10 h 30 min to 1 h 30 min in one block together with the remaining scleral strip above it 1 mm wide (from the posterior limbus border and 1 mm posteriorly) (see. fig. 6). From one end of the strip, its resection begins.

The fallen root of the iris is resected with scleral scissors parallel to the limbus. The anterior chamber is reconstituted with a stabilized BSS solution or 0.9% sodium chloride solution during emptying. The scleral lamellar flap is repositioned and fixed to the bed with 1-3 silk sutures 8-0. A continuous 8-0 silk suture is applied to the conjunctiva. A solution of an antibiotic and a corticosteroid is injected under the conjunctiva.

Complications and postoperative management does not differ from other fistulizing operations for glaucoma.

ANTIGLAUCOMATOUS OPERATIONS USING DIFFERENT TYPES OF DRAINAGE

Indications.

Indications for the use of various antiglaucomatous drainages in order to improve the outflow of intraocular fluid can be secondary and refractory glaucoma that cannot be treated by traditional methods, as well as so-called "complex cases" such as secondary glaucoma in uveitis and rubeosis, diabetic secondary glaucoma, congenital glaucoma.

The basic operation is cyclodialysis plus various drains are implanted.

Antiglaucomatous drains can be:

From auto tissue.

Autosclera flaps to widen the angle of the anterior chamber and ciliary space.

Disadvantage: drainage from autotissue is quickly exposed to organization, scarring, and further outflow pathways formed by the operation are gradually blocked.

Explant drains are synthetic, made of polymeric materials: the most common and often used is silicone drainage.

According to most researchers, the main reason for the recurrence of increased intraocular pressure when using silicone drains is the formation of a connective tissue capsule around the outer end of the drain.

Complications:

• prolonged postoperative hypotension;
• shallow front camera;
• macular edema;
• uveitis;
• corneal edema;
• rejection of the implant;
• formation connective tissue around the capsule, blockage of the tube.

Currently, explant drainage is widely used - the Ahmed valve; the mechanism of its action consists (according to the author) of a built-in unidirectional self-regulating valve for pressure regulation.

Advantage: there is no pronounced hypotension.

Allodrainages

The most common is the use of collagen and hydrogels as drains produced by MNTK Eye Microsurgery, as well as spongy allogenic biomaterial created using the Alloplant transplant technology (produced in the tissue transplant laboratory of the Federal State Institution All-Russian Center for Eye and Plastic Surgery of Roszdrav). Spongy allodrainage implanted into the anterior chamber allows, due to its porous structure, to dosed reduce intraocular pressure by improving the outflow of intraocular fluid from the anterior chamber into the suprauveal space or intrascleral.

The antiglaucomatous drains suggested by Molteno, Krupin, Baerveldt4, Ahmed, and Sbocket are usually used in patients who are likely to undergo trabeculectomy with antimetabolic therapy.

These are patients with previous fistulizing interventions with the use of cytostatics, excessive scarring of the conjunctiva due to previous surgery, severe conjunctival pathology, active neovascularization, aphakia, as well as in cases of technical difficulties in performing fistulizing interventions.

A number of other drains designed to replace conventional fistulizing interventions in primary open-angle glaucoma are in various stages of development.

Antiglaucomatous operations in combination with neuroprotective surgical stimulation

The normalization of intraocular pressure does not always ensure the stabilization of the glaucomatous process, and often visual functions in these patients continue to decline against the background of a successfully performed antiglaucomatous operation and an effective drug reduction in intraocular pressure.

In the modern concept of the pathogenesis of primary glaucoma, the development of glaucomatous optic neuropathy (GON) is one of the main factors of the glaucomatous process. Based on this, the application of various methods of neuroprotection in patients with normalized blood pressure is relevant. This section discusses the methods of surgical treatment, which can be divided into the following groups:

1) vasoreconstructive operations, methods of redistributing blood flow in the eye blood supply system by increasing the blood flow of the ophthalmic artery - in clinical practice, ligation of the branches of the temporal artery was more often used;

2) extrascleral operations - introduction into the sub-Tenon space for the purpose of stimulation metabolic processes in the posterior part of the eyeball of various allotissues: sclera, dura mater, amnion, allocartilage, etc.; most often and successfully used is the powder form of the biomaterial "Alloplant", which is inserted using a blunt-pointed needle-cannula specially bent in the shape of the eyeball in the form of a gel (powder + saline solution + 0.5ml of dexamethasone) retrobulbar, into the sub-Tenon space; the advantage of the Alloplant biomaterial is the ability to carry out this operation repeatedly every 6-12 months, thereby preventing the progression of GON, stabilizing visual functions;

3) decompression operations - aimed at reducing venous stasis in the vessels of the retina and optic nerve by dissecting the scleral ring, this helps to improve the conditions for the functioning of the optic nerve fibers, reduces the bend of the vascular bundle over the edge of the scleral ring in the formed glaucomatous excavation; the operation allows to stabilize visual functions;

4) revascularizing operations - aimed at improving the blood supply to the choroid by implanting various tissues (fibers of the eye muscles, tenon membrane, vascular episcleral flap, etc.) into the suprachoroidal space, quite common and used in many clinics is the method of revascularization of the choroid and optic nerve by implantation into the suprachoroidal space of an allograft processed using the Alloplant technology, the replacement process of which is accompanied by various biological effects that improve blood supply and metabolism in the choroid, retina and optic nerve;

5) surgery for subtenon implantation of a collagen infusion system (SICIS), trophic sclerectomy, which combine the advantages of extrascleral, revascularizing operations and targeted delivery of neuroprotective drugs to the retina and optic nerve.

According to most researchers, the most effective is surgical neuroprotective treatment in patients with glaucomatous optic nerve atrophy with normalized ophthalmotonus, or a combined intervention is possible: antiglaucomatous surgery in combination with one of the above methods of surgical neuroprotection of the optic nerve.

Methods for preventing scarring of the filter cushion

Antimetabolites (5-fluorouracid, mitomycin C).

Purpose: Prevention of postoperative scarring of the conjunctiva and sclera; achieving a low target IOP level.

5-Fluorouracil:

Dose: 5 mg. Available in concentrations of 25 and 50 mg / ml. The most commonly used dilution is 50 mg / ml. Applied during and after surgery.

Intraoperative use:

Apply an undiluted solution of 25 or 50 mg / ml on a piece of filter paper or a sponge. The exposure time is usually 5 minutes (less time reduces the effectiveness of 5-FU). Subsequent washing with 20 ml of BSS or saline.

Postoperative use of 5-fluorouracil

A relative contraindication for use is the presence of epitheliopathy.

For 1 injection, 0.1 ml of a 50 mg / ml solution (without dilution) is injected with a thin needle (30 gauge needle, on an insulin syringe). The solution is introduced into the area adjacent to the filtration pad, but not into the pad itself (pH 9).

Mitomycin C

Dose: 0.1-0.5 mg / ml. Available in various dilutions; should be used in dilution to the prescribed concentration. Used intra- and postoperatively.

Intraoperative use:

Concentration: 0.1-0.5 mg / ml. Application during surgery on a piece of filter paper or a sponge for 1-5 minutes.

Contact with the edge of the conjunctival incision should be avoided.

After application, rinse with 20 ml of BSS or saline.

Postoperative use:

Concentration: 0.02 mg / ml. For 1 injection, 0.002 mg is injected with a thin needle (30 gauge needle, on an insulin syringe).

1. The solution is injected into the area adjacent to the filtration pad, but not into the pad itself.
2. It is possible to carry out a series of injections, since, according to some reports, performing less than 3 procedures has only a minimal anti-scar effect.

General principles of antimetabolite use

Application cytotoxic drugs increases the requirements for accuracy when performing an intervention. The lack of sufficient control over the level of outflow of intraocular fluid can provoke persistent hypotension. Outflow restriction techniques include a smaller scleral foramen, a large scleral flap, and the use of absorbable scleral sutures or sutures with adjustable tension.

Do not allow the cytotoxic drug to enter the eye.

pH 5-FU corresponds to 9.0. One drop (0.05 ml) of MMS can cause irreversible damage to the endothelium.

You should carefully read the precautions for the use of cytotoxic drugs and disposal of contaminated waste and monitor their observance.

Complications:

• corneal epitheliopathy (5-FU);
• external filtration through the conjunctival incision or the wall of the filter cushion;
• hypotension;
• inflammatory process in the filter cushion;
• endophthalmitis.

Surgical treatment of children with congenital glaucoma is at the center of the therapeutic measures carried out by such patients. There are two target areas of surgical interventions for congenital glaucoma. The first provides for the restoration of the outflow of aqueous humor, either by removing an obstacle in its natural path, or by forming a new path of moisture outflow (fistula) bypassing natural drainage paths. Another area of \u200b\u200bsurgical treatment of children with congenital glaucoma is represented by interventions aimed at reducing the production of aqueous humor by the ciliary body. We will begin our consideration of the methods of surgical treatment of children with congenital glaucoma with interventions aimed at restoring the outflow of aqueous humor.

Surgical methods for restoring the outflow of aqueous humor should be divided into two groups:

Operations aimed at removing organic obstacles (mainly mesodermal tissue) on the path of aqueous humor to the trabecula;

Fistulizing interventions involving the formation of a new canal from the anterior chamber of the eye outward into the intrascleral space.

The most common among the operations of the first group has been a goniotomy for many years (M. DeVincentis, 1892). It provides for the dissection with a knife - a goniotome of the mesodermal tissue covering the trabecula, which opens the access of aqueous humor to the drainage pathways (Fig. 3).

The operation is performed with the use of a goniolens to control the movements of the goniotome in the eye. Usually, a goniotome is injected at the external limbus (preferably from under the conjunctiva), introduced into the anterior chamber and advanced to the iridescent-corneal angle of the nasal side. To avoid damage to the iris and lens, an injection needle can be used instead of a goniotome and a viscoelastic can be inserted through it into the anterior chamber during the intervention. The dissection of the mesodermal tissue is performed at 1/3 of the circumference of the iris-corneal angle.

Of course, goniotomy is only effective when unaltered drainage pathways are present under the mesodermal tissue. If the child has concomitant iris-corneal angle dysgenesis, then the effect of this operation is naturally reduced. In this regard, various modifications of the goniotomy have been proposed.

In particular, goniopuncture (H. Sheie, 1950) provides for a puncture of the limbus (either instead of a goniotomy, or upon its completion: the so-called goniotomy with goniopuncture) from the side of the anterior chamber with the same goniotome, which is brought out from the opposite side under the conjunctiva (Fig. 4).

In general, the effectiveness of goniotomy and goniopuncture ranges from 60-85% and depends on the pathogenetic characteristics of glaucoma in each individual patient [Sidorov EG, Mirzayants MG, 1991].

Among the fistulizing surgical interventions specially proposed for the treatment of children with congenital glaucoma, modifications of goniopuncture and goniotomy operations, however, performed ab externo should be noted. These include diathermogoniopuncture and microdivermogoniopuncture operations, as well as trabeculotomy surgery. ab externo.

Diathermogonyopuncture (T.I. Eroshevsky, 1962) consists in the formation of a fistula through the limbal zone from the corner of the anterior chamber into the subconjunctival space. In this case, the fistula is created from under the conjunctiva on the side of the sclera using a wide spatula-like electrode. The operation is complemented by basal iridectomy in the intervention area.

In order to reduce tissue trauma and reduce the drop in ophthalmotonus during the operation, E.G. Sidorov and M.G. Mirzayants (1983) modified the considered operation by forming several point diathermogonyopunctures and eliminating manipulations with the iris (Fig. 5). The authors called this operation microdathermogonyopuncture. According to the results of their long-term observations, the effect of the intervention was 44.4% [Sidorov EG, Mirzayants MG, 1991].

Ab externo trabeculotomy (H. Burian, 1960) provides for the creation of a direct communication between the anterior chamber and the venous sinus of the sclera. In this case, the surgical access to the sinus is performed from the outside.

The operation is started as with a sinustrabeculectomy. After localization of the venous sinus of the sclera, the sinus is opened from under the scleral flap with a blade. Its outer (scleral) wall is excised with microscissors for 2-3 mm and the working part of the trabeculotome is inserted into the lumen of the sinus to one side by 7-10 mm. Then it is turned towards the anterior chamber, tearing the trabecula, and at the same time it is removed from the sinus with a trabeculot: “when leaving, destroy” (Fig. 6). A similar manipulation is performed on the other side of the venous sinus of the sclera.

According to various authors, after a single trabeculotomy, stable normalization of ophthalmotonus occurs in approximately every second child with congenital glaucoma. The effectiveness of the operation is inversely proportional to the degree of goniodysgenesis, as well as the frequency of previous surgical interventions [Sidorov E.G., Mirzayants M.G., 1991].

In the clinic of ophthalmology of the St. Petersburg State Pediatric Medical Academy in the treatment of children with congenital glaucoma, a combined operation of sinustrabeculectomy with basal valvular iridenkleisis has proven itself well. The operation involves a combination of known interventions: sinustrabeculectomy, basal valvular iridencleisis, deep sclerectomy and posterior trepanation of the sclera under its external flap in the intervention area.

The sinustrabeculectomy stage aims to form a fistula from the anterior chamber of the eye into the intrascleral space (the volume of which is expanded by deep sclerectomy). Basal valvular iridencleisis prevents blocking of the fistula by the iris, improves the drainage of moisture from the posterior chamber and, finally, forms a natural drainage of the fistula from the root zone of the iris. Posterior trepanation of the sclera is intended for the prevention of ciliochoroidal detachment in the postoperative period.

The technique of intervention is as follows (Fig. 7). After incision and separation of the conjunctiva in the upper part of the eyeball, a quadrangular scleral flap is cut out with the base to the limbus? its thickness is 5x5mm. Separation of the flap is continued for 0.5 mm into the transparent layers of the cornea. Further, under the scleral flap, cut out a triangular flap with the base to the limbus, thickness? the remaining depth of the sclera and excised. In the projection of the venous sinus of the sclera, a strip of "deep" sclera with sinus and trabecula 0.3 mm high and 2-3 mm long is excised. They grasp the iris with tweezers and cut out its full-thickness valve with the base to the limbus with scissors. The top of the valve is brought out through a formed hole in the drainage paths. After restoring the correct shape of the pupil (achieved by laxative incisions at the base of the iris valve), a 3x2x2mm through hole is formed with a blade in the thinned sclera at the apex of its excised triangular flap. The superficial scleral flap is sutured to its original place with two interrupted sutures, the conjunctiva is sutured.

The efficiency of the considered operation is 62.8% and consists in stabilizing the ophthalmotonus within normal limits, as well as in stopping the glaucoma process [Nikitina TN, 2005].

To date, the practicing physician has been provided with a fairly wide choice of methods for surgical restoration of the outflow of aqueous humor in congenital glaucoma. The most common ones have already been discussed above. At the same time, some other technologies of surgical interventions deserve attention.

In particular, the operation of goniodialysis with trabeculotomy ab externo (Fig. 8: Sidorov E.G., Mirzoyants M.G., 1991) was effective in 2/3 of cases of congenital glaucoma.

The operation of internal drainage of the anterior chamber of the eye is also very effective (E.E. Somov, 1995). It is carried out by the formation of a wide passage into the suprachoroidal space with the simultaneous invagination of the ciliary body with a microexplant (Fig. 9).

Great prospects for surgical restoration of the outflow of aqueous humor in congenital glaucoma are associated with the introduction into clinical practice of "children's" valve drains of the Ahmed type (Fig. 10). The implantation of such a drain allows for a long-term maintenance of the ophthalmotonus within the normal range, without sharp fluctuations in the early postoperative period.

It should be noted that among the surgical methods for restoring the outflow of aqueous humor in children with congenital glaucoma, laser methods are also used, in particular, laser trabeculopuncture. It is performed with a Nd: YAG laser using a goniolens. Multiple laser applications on the trabecula zone open the access of aqueous humor to the venous sinus of the sclera.

The above and many other methods of surgical treatment are aimed at restoring the obstructed outflow of aqueous humor in children with congenital glaucoma. In general, these operations have not only a convincing pathophysiological rationale, but also sufficient efficiency. However, in some cases, their effect turns out to be insufficient. An alternative to surgical methods of restoring the outflow of aqueous humor are operations aimed at reducing its secretion.

Surgical methods for reducing the secretion of aqueous humor.

The considered direction of surgery for congenital glaucoma is based on the effect (usually temperature), either directly on the ciliary processes, or on the posterior long ciliary arteries feeding them.

Among the operations of the first group, two are most widespread: laser cyclophotocoagulation and cyclokryopexy in various modifications.

Laser cyclophotocoagulation is performed either with a Nd: YAG laser or with a diode laser.

The operation is carried out transscleral, through the conjunctiva. In total, 15-20 applications are carried out 1.5 mm from the limbus using a laser probe, which is placed perpendicular to the sclera with slight compression. Power and exposure for a diode laser are 0.5-1.0W and 0.5-2.0s, and for a Nd: YAG laser - 4.0-6.0W and 1.0-5.0s, respectively.

Cyclocryopexy is also performed transscleral. However, unlike laser cyclophotocoagulation, the cold effect on the ciliary processes can be carried out both through the conjunctiva and through the open or thinned sclera. There are also methods of contact (so-called open) cyclocryopexy, when a cooled probe is applied directly to the open ciliary body.

In the treatment of children with congenital glaucoma, the transscleral method of cryopexy of the ciliary body has been the most widely used. Cold exposure is carried out both with the help of special devices (Cryotherm, Crio-super-deluxe, etc.), and probes cooled in liquid nitrogen or carbon dioxide.

During the operation, the working platform of the probe is tightly pressed against the sclera in its various parts "step by step", concentrically to the limbus around a 360 ° circumference, 3-4 mm from the limbus. Exposure time - 1 min.

Diathermocoagulation of the posterior long ciliary arteries is an alternative to surgical methods involving direct thermal action on the ciliary body.

The method is based on a violation of the blood supply to the ciliary body, induced by hyperthermia of the posterior long ciliary arteries feeding it.

During the operation, scleral flaps are formed in the projection of the posterior long ciliary arteries (under the external and internal rectus muscles), maximally thinning the sclera. Then, the thinned sclera is coagulated with the diathermocoagulator tip (with a wide working platform).

After completing the considered operations of the "cyclodestructive" plan, the child is prescribed acetazolamide (diacarb) for 2-3 days in an age-specific dosage, thus combining surgical and drug effects on the ciliary body.

The operations of the considered plan, despite their "non-physiological nature" (in congenital glaucoma, the outflow of aqueous humor suffers), serve as a reliable alternative traditional methods surgical treatment and are the operations of choice in children with terminal glaucoma.

In general, the considered methods of surgical treatment of children with congenital glaucoma are still far from perfect, which requires further research in this area.

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• Algorithms for examining patients with suspected glaucoma and glaucoma
• Principles of neuroprotective therapy for glaucomatous optic neuropathy

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Relevance

Non-penetrating deep sclerectomy (NGSE) was developed by academician S.N. Fedorov and co-authors, and is currently one of the most common operations for primary open-angle glaucoma (POAG). This intervention is performed without opening the anterior chamber, which makes it possible to reduce the number and severity of intraoperative and postoperative complications.

Non-penetrating surgery provides an opportunity to avoid a sharp surgical decompression of the eye with the emptying of the anterior chamber during the operation, which leads to a violation of the hydrodynamics of the eye and detachment of the choroid (CCA). However, operations of the non-penetrating type, like classical penetrating operations, in some cases are accompanied by a significant decrease in intraocular pressure (IOP) with subsequent postoperative hypotension and the development of changes in blood circulation in the vessels of the uveal tract, which is clinically manifested by hemorrhages and CCA (7.5-21.5% ).

CCA is a fairly common complication of hypotensive operations, including those of the non-penetrating type. CCA leads to prolonged hypotension, which negatively affects the state of visual functions.

To prevent CCA, many ophthalmic surgeons use posterior scleral trepanation (PTS), which is performed during antihypertensive intervention. ZTS is a rather traumatic and risky intervention with exposure of the choroid.

With the modern approach to glaucoma surgery, implying minimization of intervention, we have a question about the advisability of performing intraoperative ZTS.

purpose

To evaluate the effectiveness of intraoperative ZTS in the prevention of CCA.

Material and methods

The study carried out a retrospective analysis of case histories of 201 patients (201 eyes), 70 men and 131 women, who were in our clinic in 2013-2015. performed "non-penetrating deep sclerectomy" according to Fedorov-Kozlov (NGSE) and "subscleral removal of the outer wall of the Schlemm's canal" according to I.Ya. Baranov (SUSS). The average age of patients is 65 years (55 to 78 years). The stage of glaucoma is developed (68%) and far advanced (32%) according to the results of kinetic perimetry and assessment of the excavation of the optic nerve head by indirect ophthalmoscopy. The initial IOP level averaged 35.2 mm Hg. (from 25 to 40 mm Hg) according to Maklakov. In the preoperative period, all patients underwent antihypertensive therapy at the maximum mode, including the appointment of a drug from the group of beta-blockers, a local and systemic carbonic anhydrase inhibitor, A2-adrenomimetic. The operations were performed by two doctors of the 1st ophthalmological department of the St. Petersburg branch of the MNTK. The operations were performed according to the methods proposed by academician S.N. Fedorov and Professor V.I. Kozlov - "non-penetrating deep sclerectomy" (NGSE) and Ph.D. AND I. Baranov - "subscleral removal of the outer wall of the Schlemm's canal" (SUSS). The patients were divided into two groups. Group I: 105 patients who underwent NHSE or SUSS without ZTS, Group II: 96 patients with ZTS. To diagnose postoperative CCA, B-scan and optical coherence tomography were used, which were performed in all patients with postoperative hypotension (Maklakov's IOP is below 14 mm Hg).

results

In group I, AOM was diagnosed in 10 cases (10.5%). In group II - in 12 eyes (12.5%) (Table 1).

In the first group, AOM was diagnosed on the first day in 30% of cases, on days 2-4 postoperatively - in 50%, on days 5-8 - in 20%. In the second group, 41.6% of NDEs were diagnosed on the first postoperative day, from 2 to 4 days - 25%, on 6-8 days - 16.6%. In the long-term postoperative period, CCA in 16.6% of cases occurred on the 15th and 19th days (Table 2).

In 82% (18 eyes) of cases, the CCA was characterized by a subclinical picture: flat CCA with the preservation of normal PC depth and moderate hypotension. In this group of patients, NDE regressed on days 1-3 of conservative treatment. In 18% of cases (4 eyes), CCA proceeded with the formation of “bubbles” and required additional interventions (revision of the existing trepanation hole or ZTS).

Discussion

With the advent of non-penetrating glaucoma surgery, there was a tendency to a significant decrease in the incidence of complications both during the operation and in the postoperative period. In the course of non-penetrating hypotensive surgery, there is no sharp decompression of the eye with emptying of the anterior chamber and a sharp decrease in intraocular pressure, but this does not guarantee that in the postoperative period there will be no hypotension with impaired hydrodynamics of the eye and, as a complication, detachment of the choroid.

To prevent CCA, many surgeons perform posterior trepanation of the sclera. ZTS is a penetrating intervention with exposure of the choroid.

With the introduction of non-penetrating glaucoma surgery, which implies minimizing intervention, the question arises about the advisability of performing intraoperative ZTS.

The data obtained indicate that the implementation of ZTS does not lead to a decrease in the incidence of CCA. However, ZTS as a method of prevention is still used by ophthalmic surgeons.

conclusions

1. Non-penetrating hypotensive surgery is effective in achieving normal IOP in patients with decompensated POAG.

2. The best diagnostic methods for choroidal detachment are B-scan and optical coherence tomography.

3. ZTS as a method of preventing choroid detachment cannot exclude the development of this complication, and its implementation as an additional surgical manipulation remains the surgeon's choice in each individual case.

Is a surgical intervention that provides decompression of the eyeball and normalization of ophthalmotonus. The surgical technique is used for glaucoma, expulsive hemorrhage, ciliochoroidal and hemorrhagic detachment of the choroid. To perform trepanation, an open surgical approach and a special microsurgical technique are required. During the operation, two flaps of different shapes and sizes are formed in the thickness of the sclera. After excision of the connective tissue sheath, a trepanation hole is formed in the upper part of the triangular flap. The operation is completed with layer-by-layer suturing of the surgical wound.

Indications

Surgical tactics helps to stabilize intraocular pressure with subsequent restoration of visual functions. The operation is used in isolation or after performing the classical, modified sinustrabeculectomy, allodrainage of the suprachoroidal space in order to arrest the hyphema or drain the hemorrhagic detachment of the choroid. In some cases, surgery is preceded by cataract extirpation. The main indications for posterior trepanation of the sclera are:

• Congenital and decompression glaucoma... Surgical intervention is carried out in order to normalize ophthalmotonus and prevent detachment of the choroid in patients with a congenital form of the disease or in the event of decompression glaucoma against the background of a lens block. With the development of the clinic of ciliochoroidal detachment, scleral trepanation is repeated.
• Expulsive hemorrhage. With this pathology, surgical intervention makes it possible to remove the accumulation of blood in the suprachoroidal space and prevent a secondary increase in intraocular pressure. Fistulizing surgery allows you to eliminate bleeding by mechanical removal of blood or coagulation of blood vessels, which in turn relieves the underlying disease and normalizes ophthalmotonus again.

Contraindications

Microsurgical treatment tactics lead to the formation of through trepanation holes in the posterior part of the outer connective tissue membrane of the eye. Due to the high likelihood of postoperative complications, a careful selection of patients for scleral trepanation is carried out. Absolute contraindications include:

• Malignant intraocular neoplasms... Surgical intervention in patients with ocular melanoma or retinoblastoma contributes to the hematogenous pathway of the spread of the tumor process, the formation of primary multiple tumors or metastasis. Also, the implementation of trepanation is impractical due to the fact that a volumetric formation in the cavity of the orbit can lead to ophthalmic hypertension or hemorrhage.
• Anterior eye infections... The formation of through holes in the sclera in patients with infectious conjunctivitis or keratitis is contraindicated due to the high risk of developing pan- or endophthalmitis.

Surgery is limited in case of violation of vascular-platelet or coagulation hemostasis. Surgical treatment is started only after compensation for the pathology of the blood coagulation system.

Preparing for surgery

In the preoperative period, a thorough examination and drug preparation of the patient is carried out. The purpose of this stage is the timely identification of contraindications to scleral trepanation and identification of possible complications. A special set of examinations includes:

• Non-contact tonometry... It is used to measure intraocular pressure. If there are objective signs of ophthalmic hypertension during the preoperative period, antihypertensive therapy is recommended.
• Biomicroscopy of the eye... Allows you to diagnose pathological conditions of the anterior part of the eyeball.
• Direct ophthalmoscopy - a mandatory research method in the preoperative period, which makes it possible to study the state of the optic nerve head and retina.
• Ultrasound of the eye in B-scan mode... It is carried out to examine the structures of the eyeball. In case of clouding of the optical media of the eye, optical coherence tomography is used before trepanation.
• Visiometry and perimetry - standard studies to measure visual acuity and study the characteristics of the patient's visual fields.

At the stage of preparation for surgery, a standard examination is performed, which additionally includes a study of the state of the blood coagulation system using a coagulogram. In order to prevent infectious and inflammatory complications in the preoperative period, antibacterial drugs and non-steroidal anti-inflammatory drugs are prescribed. Glucocorticosteroids are used only for individual indications. To exclude individual intolerance to drugs for anesthesia at the stage of preparation for surgery, an allergological test with an anesthetic (prick test) is recommended.

Methodology

Posterior trepanation of the sclera is performed under retrobulbar anesthesia using local anesthetics. The main stages of surgical intervention:

1. Formation surgical access and isolation of scleral flaps... After processing the operating field, an incision is made, the conjunctiva in the upper part of the eyeball is separated. The formed flap of the connective membrane should have a quadrangular shape with the base facing the junction of the cornea and sclera. The separation of the superficial ball is extended into the transparent layer of the cornea. A second flap is formed under the formed flap, which occupies the remaining half of the depth of the sclera.
2. Trepanning hole formation... The connective tissue plate is excised in the projection area of \u200b\u200bthe venous sinus. The iris is fixed with tweezers and, with the help of scissors, a valve is formed from all layers, the base turned to the limbus. The top of the iris valve is withdrawn through the formed opening in the drainage system. With the help of small incisions at the base of the valve, the correct shape of the pupil is restored. A trepanation hole is formed with a scalpel in the upper posterior part of the triangular flap.
3. The final stage of trepanation... The flap formed from the superficial part of the sclera is sutured with two interrupted sutures in its original place. Next, the conjunctival incision is sutured. An aseptic dressing is applied to the operating wound.

After trepanation of the sclera

During the early postoperative period, the dressing is changed daily. During the dressing, the wound surface is washed with antiseptic solutions that do not contain alcohol. Shown are instillations of broad-spectrum antibacterial agents and non-steroidal anti-inflammatory drugs in a short course. The stitches are removed 4-5 days after the operation. The timing of the patient's complete recovery depends on the indications for surgical intervention and the characteristics of the course of the intra- and postoperative period. For 7-10 days, intraocular pressure is measured daily in a non-contact manner. Restriction of physical activity is recommended during the entire rehabilitation period.

Complications

Normally, during the first 3-5 days of the operation, patients complain of soreness, excessive lacrimation, and discomfort. After surgery, it is possible to develop transient ophthalmic hypertension, which is stopped with the help of antihypertensive drugs. In the postoperative period, there is a risk of the following complications:

• Hyphema and hemophthalmos... Hemorrhage in the anterior chamber of the eye or the vitreous develops when the vessels of the choroid or the central retinal vein are damaged.
• Allergic reactions... Quincke's edema or urticaria may occur due to individual intolerance to the drugs used during the operation.
• Infectious and inflammatory complications of the anterior part of the eyes (conjunctivitis, keratitis) or eyelids, as a rule, develop if the doctor's recommendations are not followed in the pre- and postoperative period regarding the regimen of taking antibacterial agents.

The cost of posterior scleral trepanation in Moscow

The operation is carried out in specialized medical institutions of the capital, equipped with modern equipment and staffed with qualified ophthalmologist surgeons. The price of posterior scleral trepanation in Moscow varies depending on several factors, the main of which are the form of ownership, the reputation and location of the clinic, the amount of preoperative preparation (including diagnostic tests and prescribed medications), and the presence of complications in the postoperative period. With simultaneous scleral trepanation and other interventions, the total cost of the operation increases.

Surgery

The most common filtering (penetrating and non-penetrating)

operations such as trabeculectomy, sinusotomy, which create new or stimulate existing outflow tracts.

Since various ophthalmic surgeons use numerous modifications of antiglaucoma interventions, only

classical methods of surgery, a detailed description of the technique of operations is not the purpose of this manual.

Of course, the absence of the need for drug therapy after an operation is an important indicator of its effectiveness.

In practice, if it was not possible to achieve an individual

"Target" pressure, it is necessary to prescribe local antihypertensive therapy,

as a rule, the number of drugs in this case is much less than before

operations. But the main criterion in subsequent treatment should be the achievement of the target pressure.

Antiglaucomatous fistulizing surgery

Trabeculectomy

Today, the operation of choice for POAG is trabeculectomy with the formation of a fistula under the scleral flap.

The advent of modern operating microscopes, microsurgical instrumentation and suture materials contributed to the development of numerous improvements in surgical techniques. These include size modifications,

shape and thickness of the scleral flap, features of the conjunctival flap

(base to the limbus and base to the fornix of the conjunctiva), combination with cyclodialysis, type of scleral sutures, introduction of viscoelastic drugs into the anterior chamber and under the scleral flap, as well as the use of antimetabolites and other drugs that reduce scarring.

According to expert estimates, the effectiveness of the first fistulizing operation performed on a previously unoperated eye (without or with additional antihypertensive therapy) is up to 85% in the period before

2 years old; however, the criteria for success of interventions in these evaluations are very

varied.

If the effectiveness of the surgical intervention in combination with drug therapy is insufficient, one should resort to repeated

surgical intervention.

Trabeculectomy surgery technique

Usually a wide (7-8 mm) conjunctival flap is formed with

base at the limb. Tenon's capsule is separated from the sclera to the limbus.

Produce hemostasis. Non-penetrating incisions (1/3 - 1/2 of the scleral thickness)

outline a triangular (square or trapezoidal) zone with a base (5

mm wide, 4 mm high) at the limb; accordingly produce

lamellar dissection of the sclera. At the bottom of the stratified zone, the position of the scleral spur is usually clearly visible (along the transition from the transparent layers of the limbus

to opaque); slightly posterior to it is the venous sinus of the sclera.

According to the position of the sinus, a strip of deep scleral layers (1.5 mm wide, 4 mm long) is cut concentrically to the limbus. Usually, the deep layers of the sclera are excised with a diamond knife or a disposable blade. At the same time, at the beginning, the boundaries of the excised strip are outlined, and then a strip of deep layers of the sclera, together with the trabecula, is removed with the tip of the knife. In this case, the iris falls into the wound. Basal iridectomy is performed.

The superficial scleral flap is placed in place and sutured back to the bed with 1-3 sutures. Suture on the conjunctiva (usually virgin silk)

must be applied very carefully; full adaptation of the incision edges contributes to better formation of the filter cushion and prevents external filtration.

Fig. 1. Sinustrabeculectomy

Postoperative management.

In the postoperative period, instillation of antibacterial

drops, usually 4 times a day, mydriatic (atropine 1%, cyclomed 1%) 1-2 times a

day, with the help of which a moderately dilated pupil is maintained.

Corticosteroids are prescribed until postoperative iritis is relieved. In cases where the filtration cushion is not very pronounced and there is a tendency to an increase in intraocular pressure, massage of the eyeball is useful for better formation of the filtering pathways.

Complications of STE

Complications of the early postoperative period (up to 1 month).

1. Hyphema.

2. Ciliochoroidal detachment (CCO).

3. External filtration of VHF (hypotension).

4. Hypertension.

5. Inflammation.

6. Pupillary block.

Complications of the late postoperative period (up to 6 months)

1. Accelerated progression of cataracts.

2. Filter bag infection.

3. Hypotension.

4. Hypertension.

5. Excessive scarring.

6. Ciliochoroidal detachment.

7. Recurrent hyphema.

Long-term complications (more than 6 months)

Cystic changes in the filter cushion.

Cataract progression

Treatment of postoperative complications

Hyphema usually resolves on its own and does not require special treatment. With long-term existence of hyphema or its recurrence, it is recommended: topically - instillation of 2% or 3% calcium chloride solution,

parabulbar injections of dicinone, intravenously - 20 ml of 40% glucose solution and 10 ml of 10% calcium chloride solution, inside - 0.25 diacarb, 100-200 ml of 30%

glycerin solution.

Ciliochoroidal detachment. Signs of CCO are shallow anterior chamber syndrome, hypotension, and a decrease or absence of a filtration cushion.

If the anterior chamber is preserved, conservative treatment of CCO is carried out. For this purpose, caffeine is prescribed 0.5 ml of a 5% solution, mydriatics

(atropine 1%). In most cases, this leads to restoration of the anterior chamber and filtration under the conjunctiva. In the absence of the anterior chamber or persistence of signs of CCO, the operation of posterior trepanation of the sclera is performed within 3 days.

In case of hypotension associated with the presence of external filtration (diagnostics is carried out using a test with fluorescein 0.5%), it is necessary to seal the wound edges. In some cases, the effect of applying a pressure bandage to the filtration area.

In cases of postoperative hypertension and the absence of filtration

pillows can be effective massage the eyeball. Without

effect, a revision of the surgical intervention area is performed to determine the causes of moisture retention.

For relief of postoperative inflammation,

instillation of mydriatics and corticosteroids, dexazone 0.5 ml is injected under the conjunctiva until signs of inflammation are relieved.

In the long term after trabeculectomy (as well as after many other antiglaucomatous operations), accelerated progression is noted

cataract changes in the lens; about the possibility of this, the patient should be

in in some cases notified in advance.

IN in case of an increase in IOP in the late postoperative period, the following measures can be performed:

In the presence of a cystic pillow, a subepithelial opening (needling).

With blockade of the intrascleral tract - closed revision with a spatula

In case of violation of the outflow in the area of \u200b\u200bthe internal opening of the fistula - revision of the internal fistula "ab interno".

With complete obliteration, repeated antiglaucomatous surgery in another sector of the eyeball.

Non-invasive interventions for glaucoma

I. Non-penetrating deep sclerectomy.

II. Viscocanalostomy.

Collectively, these techniques differ in the size and depth of the incision and resection of the second flap in the sclera.

However, since the principle of operations is similar, the complications and tactics of patient management do not differ significantly.

Indications:

Primary open-angle glaucoma in patients with target pressure ≤20

mm Hg, which cannot be achieved with medication.

Benefits:

lower, relative to trabeculectomy, the level of intra- and

postoperative complications;

the possibility of restoring the outflow of intraocular fluid in natural ways with viscocanalostomy.

Disadvantages:

the hypotensive effect is inferior to that of trabeculectomy (on average by 2-4 mm Hg);

technical complexity, requiring a higher qualification of the surgeon;

the possibility of developing episcleral fibrosis, leading to an unsatisfactory effect.

Preoperative preparation:

anti-inflammatory therapy: instillation of antibacterial and non-steroidal or steroidal anti-inflammatory drugs for 3 days before surgery;

hemostatic therapy: oral administration of drugs (askorutin,

dicinone) within 7 days before surgery;

antihypertensive therapy: the use of previous local and general antihypertensive therapy before the day of surgery;

correction of concomitant pathology;

during the operation, standard techniques of local anesthesia are used with or without potentiation.

Deep sclerectomyDuring the operation, a deep layer of corneoscleral tissues and the outer wall of the Schlemm's canal are removed under the superficial scleral flap.

The epithelial layer of the inner wall of the Schlemm's canal and the anterior sections of the Descemet's membrane are also removed.

Filtration is carried out through the pores of the remaining trabecular meshwork and Descemet's membrane.

After repositioning the superficial flap under the episcleral flap

a "scleral lake" is formed.

Variants of the operation can be the use of drains with their placement under the scleral flap.

Fig. 2. Non-penetrating deep sclerectomy

Complications:

intraoperative: hyphema (≈1% of cases), trabecular microperforation

with or without iris insertion;

postoperative: detachment of the choroid (≈2% of cases),

episcleral / conjunctival fibrosis (to prevent the development of

of this complication, options for operations with

the use of various drains or cytostatic drugs);

repeated increase in IOP or insufficient hypotensive effect.

Postoperative management:

IN uncomplicated cases:

anti-inflammatory therapy: instillation of antibacterial and steroid anti-inflammatory drugs within 7 days after surgery, followed by switching to non-steroidal

anti-inflammatory for a period of 2 weeks;

postoperative examinations on days 1, 3 and 7, control instrumental studies 1 and 6 months after the operation.

IN complicated cases:

hyphema: topically - instillation of 2% or 3% calcium chloride solution,

parabulbar injection of dicinone, intravenously - 20 ml of 40% solution

glucose and 10 ml of 10% calcium chloride solution, inside - 0.25 g of diacarb,

100-200 ml of 30% glycerin solution.

detachment of the choroid: a complex of traditional medical

preventive measures, including subconjunctival administration of dexamethasone, caffeine, mezaton, emoxipin, and

methyluracil, askorutin, indomethacin tablets per os. In the absence of effect - posterior trepanation of the sclera (posterior sclerectomy);

with insufficient hypotensive effect, operations can be used:

o Nd: YAG laser goniopuncture;

o drug antihypertensive therapy.

SURGICAL TREATMENT OF PRIMARY CLOSED-ANGLE GLAUCOMA.

INDICATIONS for surgical treatment:

- uncompensated intraocular pressure in an acute attack of angle-closure glaucoma;

- chronic angle-closure glaucoma in the interictal period;

- crushing of the anterior chamber in creeping angle-closure glaucoma;

- vitreo-crystalline block.

A. IRIDECTOMY.

Training. Anesthesia.

At night before surgery, anxiolytics (phenazepam 0.5 mg) and

antihistamines (diphenhydramine 0.05).

In the morning before the operation, patients do not eat breakfast and oral medications are not

accept. For 30-45 minutes, patients undergo premedication, including anxiolytics (diazepam 5 mg - 2.0 ml). Ataralgesia is supported by fractional administration of opioid analgesics (fentamine 0.05-0.1 mg).

For local anesthesia, injection into the sub-Tenon space is used

2% lidocaine solution 1-2 ml.

The treatment of the operating field is carried out with 1% alcohol solution

chlorhexidine - double skin treatment. The conjunctival cavity is washed with a 0.9% sodium chloride solution, 2 drops are instilled

iridectomy ab externo. The conjunctiva is dissected along the limbus in the meridian 10-2

hours, it is separated from the limbus by 5 mm, a superficial scleral flap of a triangular shape is cut out with the base to the limbus 4 mm high,

base 4 mm. The scleral flap is ½ thick at the apex, deepens towards the limbus to the basement membrane. Before entering the anterior chamber, it is advisable to

carry out the final hemostasis. A preliminary 8-0 silk suture is applied to the apex of the scleral flap. The anterior chamber is opened with a metal or diamond blade (incision length 3 mm,

incision area 12-2 hours for the right eye, 10-12 hours for the left eye).

The dropped root of the iris is grasped with tweezers and cut off

scleral scissors closer to the scleral lip (branches parallel to the limbus). If the iris does not fall out, then it can be provoked

light pressure on the scleral lip of the wound. To refuel the iris into the anterior chamber, if it has not refueled itself, light pressure on the scleral lip produces a slight emptying of the anterior chamber,

after which the iris is adjusted by itself or as a result of careful stroking on the cornea. A preliminary seam is tied on the sclera.

The conjunctiva at the limbus is pulled and fixed with 8-0 interrupted silk sutures or a thermocouter. 0.5 ml of antibiotic and 2 mg of dexazone are injected under the conjunctiva.

Fig. 3. Incision ab externo with iridectomy with a metal blade.

Complications.

1) An incision through the ciliary body can cause hemophthalmos, iritis, and retinal detachment.

2) A corneal incision can make it difficult for the iris to prolapse.

3) Iris bleeding after iridectomy requires mechanical hemostasis

(by pressing on the bleeding site with a cotton swab), pharmacological

(topically: aminocaproic acid, refrigerated saline,

etamsylate intravenously). Pressure on the eye is carried out at least one

4) Persistent hypertension after iridectomy with a shallow anterior chamber may indicate a cyclo-lens block. You should start with

conservative therapy: atropine 1% solution topically, glycerin, urea inside

(1.5 g per kg of patient's body weight). In case of ineffectiveness of conservative treatment, one should proceed to surgical treatment - closed vitrectomy.

5) Subarachnoid hemorrhage (incomplete expulsive hemorrhage) can give similar symptomatic hypertension. Requires release of subarachnoid blood through the burr hole in the sclera into

6-8 mm from the limb. In some of these cases, a sharp edema of the choroid develops,

the so-called massive choroidal ephrusion, which is diagnosed using two-dimensional echography. Diuretics (acetazolamide up to 1 g per day) and parabulbar and intravenous corticosteroids (dexamethasone 4 mg and 12 mg, respectively) are used as therapeutic measures.

Postoperative management... Inflammatory (especially infectious)

complications after iridectomy are rare. Eye irritation is usually mild and easily amenable to traditional therapy: topical corticosteroids (dexazone drops) and prostaglandin synthesis inhibitors (diclofenac 0.1% solution or indomethacin 0.1% solution). In order to prevent the development of posterior synechia

(especially after prolonged use of miotics) it is recommended that

"Massage" the pupil by prescribing short-term mydriatics and miotics alternately during the first 5-7 days.

In the case of poorly absorbable hyphema, especially if it reaches