The stage of glaucoma can be determined by the condition of the optic nerve head and the degree of narrowing of the visual field. There are four stages of the disease: initial, advanced, advanced and terminal.
In the terminal stage of glaucoma, there is a loss of objective vision, that is, visual acuity decreases to light perception. Sometimes there is a complete loss of visual function, that is, blindness.
In nom the amplitude of oscillations inside eye pressure during the day does not exceed 5 mm Hg. in the case of glaucoma development, the amplitude increases significantly. The leading sign of glaucoma is the development of ophthalmotonus, in which intraocular pressure rises to 27 mm Hg. and more. In this case, fluctuations exceed 5 mm Hg. With the development of glaucoma, there is also a narrowing of the visual field, starting from the nasal areas, and a decrease in its acuity.
In the terminal stage of glaucoma, only light perception is present, the patient cannot distinguish objects, and often completely loses vision.
The dynamics of visual function should be determined by systematic and long-term (at least 6 months) observation of the visual field:
The cardinal manifestation of end-stage glaucoma is disc excavation optic nerve, it is accompanied by posterior protrusion and expansion of the cribriform plate under the influence high pressure inside the eye. Atrophy of glial tissue and nerve fibers also occurs.
With ophthalmoscopy in the terminal stage of glaucoma, it is possible to detect an inflection of the retinal vessels in the area where they pass through the edge of the optic nerve head. In some cases, these vessels completely disappear behind the edge of the disc during its excavation. Sometimes you have to carry out differential diagnosis between pronounced physiological excavation and changes associated with end-stage glaucoma.
Another sign of glaucoma is retinal swelling. To identify it, the size of the blind spot is determined, which gradually increases.
The social significance of glaucoma is that it is the leading cause of end-stage blindness. In most cases (about 80%), patients suffer from open-angle glaucoma, which leads to severe visual impairment. In the terminal stage of the disease, achieve stabilization pathological process almost impossible.
surgeries in terminal aching glaucoma
A.D. Chuprov, I.A. Gavrilova
Kirov Ophthalmologic Hospital, Kirov
Purpose: to compare results of various types of preserving surgery in terminal aching glaucoma.
Methods: analysis included indicators of visual acuity, tonometry (by Maklakov), before measured operation, in early postoperative period (5-7 days) and in 1-2 year after surgical antiglaucomatous treatment.
Results: Data of 72 patients with terminal aching glaucoma which underwent surgical treatment in the period of 2005-2010 was analyzed. Visual acuity varied from complete blindness to light sensitivity with incorrect projection. Average level of ophthalmotonus on the background of medicamental treatment was 41.6±0.91 mm Hg, and there was also pain syndrome in all patients. All patients were divided into 3 groups depending on the type of the surgery. First group included patients after filtering surgery (22 eyes), second (20 eyes) - after sclerectomy with cyclocryopexy, and third (30 eyes) - after diode laser transcyclocoagulation.
Stable normalization of IOP level was reached in 18 patients of the 1st group (81.8%), in 18 patients of the second group (90%) and in 26 patients of the 3rd group (86.7%). Pain syndrome was eliminated in all patients.
Conclusion: preserving surgery may be considered as efficient treatment of patients with terminal aching glaucoma.
Relevance
Glaucoma is one of the most common and serious illnesses eyes: the number of people blind due to glaucoma, according to various authors, varies from 5.2 to 9.1 million people. In Russia, glaucoma ranks first in the nosological structure of visual disability, its share increased from 14% in 1997 to 28% in 2005. In addition, when re-examining disabled people with group III a year after the initial diagnosis of disability, the relative stabilization of the disease stated only in 54.8% of cases; in 29% of disabled people due to progression, group II was established, and in 16.2% - group I [Libman E.S., 2000-2005]. Thus, the number of patients with end-stage glaucoma has not decreased over the years.
The goal of treatment for such patients is usually to eliminate pain. Drug therapy for terminal glaucoma is often ineffective due to pronounced degenerative changes drainage system eyes and ciliary body, rubeosis of the iris. At the same time surgical treatment is accompanied by a significant number of intra- and postoperative complications, so the choice of treatment method is often ambiguous. Currently applied various types organ-preserving operations, both fistulizing and cyclodestructive.
Purpose of the study: to compare the results of various organ-preserving operations for terminal painful glaucoma.
Materials and methods
We analyzed the results of surgical treatment of 72 patients with terminal painful glaucoma at the Kirov Clinical Ophthalmological Hospital for 2005-2010. The age of patients is 48-79 years; men made up 47.2% (34 people), women - 52.8% (38 people). Primary glaucoma was diagnosed in 40 patients, various shapes secondary glaucoma - in 32 patients. Visual acuity was zero in 47 people, light perception with incorrect light projection was in 25 people. The average level of ophthalmotonus according to Maklakov against the background of maximum drug therapy was 41.6 ± 0.91 mm Hg, all patients had pain syndrome varying degrees expressiveness.
Patients of the 1st group (22 eyes) underwent various fistulizing operations (deep sclerectomy with preliminary posterior trepanation of the sclera, deep sclerectomy with drainage, double-chamber drainage), patients of the 2nd group (20 eyes) underwent multiple sclerectomy with direct cyclocryopexy, patients 3 group 3 (30 eyes) - diode laser transscleral cyclophotocoagulation (TCPC). The period of observation of patients after surgery is from 1 to 2 years.
Results and discussion
Stable normalization of ophthalmotonus was achieved in 18 patients of group 1 (81.8%), 18 patients of group 2 (90%) and 26 patients of group 3 (86.7%). The pain syndrome was eliminated in all patients, which has great importance for patients with terminal painful glaucoma. The hypotensive effect of surgical interventions in the early postoperative period (5-7 days after surgery) and the long-term period (1-2 years) is presented in Table 1.
As follows from the presented data, in the early postoperative period decrease in IOP more pronounced in patients of group 1 (fistulizing operations). But in the long term, the pressure in this group increases again, while after cyclodestructive interventions there is a gradual, persistent decrease in ophthalmotonus.
The following intra- and postoperative complications(Table 2).
Noteworthy is the fact that the prevailing complications in group 1 and groups 2-3 are different. Ciliochoroidal detachment, the most common complication of fistulizing operations, often requiring posterior sclerotomy, practically does not occur with cyclodestructive interventions. A serious intraoperative complication - expulsive bleeding - was observed during 1 operation in the 1st group. At the same time, more than half of the patients in groups 2-3 postoperative period complicated by iridocyclitis of varying severity(often with fibrinous effusion into the anterior chamber), in many it was accompanied pain syndrome within 1-2 weeks. The incidence of hemorrhagic complications, corneal dystrophy, as well as postoperative hypotonia and subatrophy is comparable in all groups. Thus, the number of complications in group 1 is higher than in groups 2 and 3.
We noticed that hypotensive effect in the 2nd and 3rd groups differs slightly. Also, in these groups, almost the same number of complications is observed, with the exception of vitreous prolapse, which was recorded only with perforating interventions.
When choosing a surgical method for patients with terminal painful glaucoma, several points should be taken into account. Firstly, as shown above, the number of complications with non-perforating interventions is less than with perforating ones. Secondly, TCFC is a technically simple procedure and is accessible even to novice surgeons. Thirdly, elderly and elderly patients often have a “bouquet” concomitant diseases, therefore, the duration of the operation and anesthesia is important, which again is an argument in favor of transscleral laser cyclophotocoagulation.
Conclusions
1. Organ preservation operations are effective method treatment of patients with terminal painful glaucoma.
2. Transscleral laser operations are shorter lasting, technically simpler and safer than perforating interventions, which allows us to recommend them as the operations of choice for terminal painful glaucoma.
Literature
1. Bachaldin I.L., Egorov V.V., Marchenko A.N., Sorokin E.L. Transscleral diode laser cyclocoagulation in the treatment of terminal painful glaucoma // Breast cancer. 2007. T. 8. No. 4.
2. Bessmertny A.M., Robustova O.V. Combined treatment neovascular glaucoma in patients with objective vision // Glaucoma. 2004. No. 2. P. 34-37.
3. Dumnov E.V., Lebedev O.I. Using a combined method laser treatment with secondary neovascular glaucoma // Glaucoma. 2009. No. 1. P. 40-42.
4. Zhaboedov G.D., Kovalenko Yu.V. Comparative assessment effectiveness of diode laser transscleral cyclocoagulation methods in the complex treatment of patients with primary open-angle glaucoma // Ophthalmol. magazine. 2006. No. 3. P. 156-157.
5. Klyuev G.O. Laser transscleral contact-compression cyclocoagulation for age-related changes in eye structures // Glaucoma: theories, trends, technologies. HRT Club Russia - 2008: VI international conference: Materials. M., 2008. pp. 273-281.
6. Mazunin I.Yu., Kraeva A.A., Kravetskaya E.I. Dynamic micropulse diode laser transscleral cyclocoagulation (DMTCC) in the treatment of advanced stages of glaucoma // Glaucoma: theories, trends, technologies. HRT Club Russia - 2009: VII international conference: Materials. M., 2008. pp. 357-360.
7. Mikheeva E.G., Popova O.E., Yablonskaya L.Ya. Clinical effectiveness organ-preserving operations for terminal glaucoma // Glaucoma: theories, trends, technologies. HRT Club Russia - 2008: VI international conference: Materials. M., 2008. pp. 462-465.
8. Postupaev A.V., Netrebenko N.V. Optimization of cyclophotocoagulation in the treatment of secondary neovascular glaucoma // Glaucoma: theories, trends, technologies. HRT Club Russia - 2009: VII international conference: Materials. M., 2008. pp. 455-458.
9. Robustova O.V., Bessmertny A.M., Chervyakov A.Yu. Cyclodestructive interventions in the treatment of refractory glaucoma // Glaucoma. 2003. No. 1. P. 40-46.
Terminal (absolute) glaucoma – last stage such a common disease today as glaucoma, accompanied by irreversible consequences in all departments eyeball And complete atrophy optic nerve, leading to blindness.
The degree of the disease is determined by the condition of the anterior ciliary vessels and the level of intraocular pressure. When the disease just begins to develop, eye pressure readings usually do not exceed 28 mmHg. Pressure above this indicator leads to dilation of the blood vessels in the eye, swelling of the cornea and eye tissue. Constantly elevated pressure disrupts the normal functioning and metabolism of eye tissues, subsequently leading to irreversible changes visual function.
Absolute glaucoma is accompanied by severe pain, damage to the cornea, incorrect perception of light perception, internal ruptures, thinning and stretching of the posterior and anterior ocular sections, associated infectious diseases eye, and often has unfavorable outcome. If a perforation of the ocular cornea occurs, the posterior arteries are ruptured and the membranes of the eye are pushed out of the eyeball during high ocular pressure.
Absolute glaucoma has pronounced symptoms, including:
In absolute glaucoma, the blind eye may long time look like healthy eye and not cause discomfort to the patient.
Later, complications may arise, for example, glaucomatous cataracts that cannot be operated on, corneal ulcers, and dystrophic keratitis. Sometimes complications may not arise immediately, but slowly progress for some time, after which the eyes suddenly become red (as if bloodshot), severe pain occurs, and sharp deterioration patient's health.
There are cases when partial atrophy of the optic fibers occurs. In such cases, patients have a chance to successful treatment, which consists in partial restoration of vision.
Early diagnosis of the disease is very important, because in some cases, surgical intervention in advanced or advanced stages does not provide guarantees even for partial restoration vision.
Since absolute glaucoma develops unnoticed, often without noticeable severe symptoms, identifying it in a timely manner is very difficult even for experienced specialists. Therefore, the manifestation of even the most minor symptoms, such as discomfort, dryness, pain, eye pain, is a reason to consult a doctor for examination.
With strong eye pain accompanied by loss of vision are used following methods treatment:
With absolute glaucoma, vision is zero. The assessment of visual function is determined by the degree of compensation for the stage of the disease by the doctor while measuring the level of intraocular pressure and assessing the condition of the anterior ciliary vessels. The decompensated stage of the disease is one hundred percent absolute glaucoma.
After an unsuccessful conservative treatment The most effective method of getting rid of absolute glaucoma is considered to be an operation during which the severe pain resulting from degenerative changes nerve endings.
Basically, surgical treatment is aimed at reducing intraocular pressure, reducing pain threshold, preservation of the blind eye. In case of absolute glaucoma, which is constantly accompanied by severe inflammation and pain, surgery to remove the eyes is necessary. The prognosis in this case is unfavorable, because recovery visual functions is no longer possible.
It is very important that the operations of diathermocoagulation of the ciliary nerves and ciliarotomy in the treatment of absolute glaucoma take place without complications (there are cases of transection of the optic nerve during surgery), because this is most favorable for removing pain and restoration of the cornea of the eye. Both operations are technically difficult, but not dangerous. Postoperative recovery occurs very quickly.
When there is no way to save the eyes, surgery is performed to remove the eyeballs, after which for cosmetic purposes intraocular prosthetics is performed.
Professional ophthalmologists are increasingly talking about the ineffectiveness of conventional operations for patients with glaucoma, explaining this by various complications, among which are widespread:
Today, as many years of world practice show, the best option Opticociliary neurectomy is considered an ophthalmic surgery for terminal glaucoma. This is a technically simple operation that allows you to quickly eliminate pain, normalize intraocular pressure, and most importantly, preserve the eye as a cosmetic organ.
Undoubtedly, there are contraindications to picociliary neurectomy, which include:
Optociliary neurectomy should be used very carefully as a method surgical treatment with trophic changes in the cornea to avoid the risk of an unfavorable result.
Absolute glaucoma does not have a negative effect on the process of conception and gestation. According to the results of some studies conducted in Europe, in a certain percentage of women with the pathology of absolute glaucoma, on the contrary, pregnancy contributed to the normalization of eye pressure.
Mostly, negative influence The development of the fetus is affected by the medications that the woman takes during treatment. Some drug components end up in breast milk, harming the baby.
Every year, cases of diagnosing terminal glaucoma in children are becoming more frequent.
Absolute glaucoma in children occurs due to:
This disease is rare in infants. If it occurs, stopping the development process and promptly operating on a child is much easier than on an adult. Postoperative treatment in 94% of cases it gives the child a chance to see normally. In order not to miss the opportunity to restore the baby’s full vision, it is important to diagnose this disease in time.
It is very often possible to diagnose absolute glaucoma in infants based on certain symptoms, and in older children based on certain symptoms. behavioral signs, among which are:
Usually, in initial stage, the disease occurs without any symptoms, so parents, in order not to miss the onset of glaucoma development, are recommended to visit the pediatrician every month during the first year of the baby’s life.
Absolute glaucoma is most often diagnosed during a child’s examination by a pediatrician or ophthalmologist, less often by a geneticist. During the examination, the causes and stage of the disease are determined, and the most effective treatment options are selected. In the first stages of the disease, the symptoms of absolute glaucoma are similar to conjunctivitis, therefore, to clarify the diagnosis, it is necessary to measure intraocular pressure and carefully examine the cornea.
In the treatment of absolute glaucoma in children, both drug and surgical treatment are used.
Drug treatment consists of instillation eye drops newborns to normalize intraocular pressure. But it is not effective for recovery normal function vision, therefore, if there are no contraindications, it is necessary to perform an operation, the purpose of which is to reduce pressure by increasing the outflow of fluid from the eye. The effectiveness of the operation depends on the stage of the disease, the presence or absence of concomitant eye diseases and the age of the child.
Postoperative treatment includes additional drug therapy for a speedy recovery. If the first operation did not produce positive results, a second operation is necessary. It is important to carry it out as early as possible, since absolute glaucoma develops in childhood very quickly.
It is best to measure intraocular pressure in newborns during normal sleep using additionally sleeping pills or anesthesia.
Due to the rapid progression of the disease in infancy and in order to increase the child’s chances of maintaining normal vision in the future, any manifestations of glaucoma must be diagnosed as early as possible and their treatment must begin at the initial stage.
A diagnosis of absolute glaucoma in children is not a sentence to remain blind for life. Modern microsurgical ophthalmology makes it possible to stop the development of the disease, and if diagnosed in a timely manner, completely restore vision.
Characterized by significant dystrophic changes V anterior section eyeball (dystrophic changes in the cornea, rubeosis and dystrophic changes in the iris, clouding of the lens, etc.).
With a significant increase in intraocular pressure, unbearable pain appears in the eye, which radiates to the corresponding half of the head.
That's why terminal glaucoma is also called absolute painful glaucoma, which requires urgent treatment.
Symptoms. Patients with terminal glaucoma note excruciating pain in the eye, which radiates to the corresponding half of the head. Nausea and vomiting are also possible.
Objectively - moderate swelling of the eyelids, photophobia and lacrimation. Palpebral fissure narrowed. There is a pronounced stagnant injection on the eyeball. The cornea is edematous, dystrophically changed, there are vesicles of raised epithelium on its surface, eroded in places, and thickened.
The anterior chamber is shallow. The iris is dystrophically changed, rubeosis is noted, the pupil is dilated and does not respond to light. The lens may be cloudy.
Intraocular pressure is increased to 50-60 mm Hg.
Treatment of terminal (painful) glaucoma
Conservative treatment is aimed at normalizing ophthalmotonus, but is practically ineffective.
Surgical treatment aimed at improving the outflow of aqueous humor is also ineffective and is fraught with serious complications in a dystrophic eye. The question of removing the eye often arises, but this is a last resort measure in the treatment process.
IN lately Surgeries have been proposed aimed at reducing the production of aqueous humor, helping to reduce intraocular pressure and reduce pain. These are operations on the ciliary body - diathermocoagulation and cryopexy of the ciliary body.
A.I. Gorban proposed an operation - artificial retinal detachment as an antiglaucomatous operation in patients with terminal absolute painful glaucoma.
This surgical intervention opens back way outflow of aqueous humor from the eye through a retinal tear into the rich bloodstream of the choroid, which leads to a decrease in intraocular pressure and pain relief.
Operation technique
After epibulbar and retrobulbar anesthesia, a frenulum suture is placed on the superior rectus muscle. Then, in the upper outer corner of the eyeball, 6-7 mm from the limbus, an incision is made in the conjunctiva, separated from the sclera, in which a small through incision is made. An injection needle placed on a syringe is inserted into this incision to the center of the eyeball and 1 ml of its liquid part is sucked out of the vitreous body into the syringe.
Then the needle is inserted deeper until it stops into the membranes of the eye in the equator area and the syringe is tilted in different sides The sharp end of the needle ruptures the retina and choroid in an area of 10-15 mm. After this, the needle is removed to the central position of the vitreous and suctioned again vitreous with blood. The needle is removed and sutures are placed on the scleral and conjunctival wounds.
Instilled into the conjunctival sac antibacterial drops. Antibiotic and corticosteroids are administered parabulbarly. Apply an aseptic dressing.
Terminal glaucoma is usually called the final stage of the disease, upon the onset of which irreversible blindness develops (with possible preservation of light perception).
Ultimate terminal stage- this is a possible outcome of the disease if glaucoma is not treated. It is caused by a gradual increase in changes in the fundus of the eye: atrophy of the optic nerve, degenerative processes of the retina. In this case, there is a sharp decrease in visual acuity and peripheral vision almost completely disappears.
There is also the concept of “terminal painful glaucoma”. It is applicable when the disease is accompanied by severe pain. The pain is sharp, debilitating, and radiates to half of the head and face. In strength it can be compared with toothache and sensations characteristic of neuralgia trigeminal nerve. This kind of pain is difficult to treat medications. And only surgical intervention can normalize intraocular pressure and relieve pain.
To other symptoms this state can be attributed:
The described symptoms are the result of swelling of the cornea with irritation of its nerve endings. Corneal tissues become powerless to resist penetration infectious agents, therefore, the disease is often complicated by keratitis (inflammation of the cornea), iridocyclitis (inflammation of the iris tissue), perforation and perforation of the cornea, etc.
The main danger of glaucoma lies in its minimal clinical manifestations. If nothing bothers the patient, then he is in no hurry to see a doctor. However, at this moment, there may be an increase in the fundus pathological changes, and visual acuity decreases. That's why preventive examinations Even absolutely healthy people should see an ophthalmologist once a year.
After glaucoma is diagnosed, it is necessary to see an ophthalmologist at least 2 or even 3 times annually (the frequency of visits to a specialist is determined by the individual characteristics of the course of the disease). Regular ophthalmological examinations, receiving complex treatment with timely correction of planned therapy, they make it possible to avoid progression of the disease, and hence the onset of blindness.
The prognosis for vision in end-stage glaucoma is very unfavorable. This means that the changes in the fundus of the eye that have occurred cannot be corrected medically - they are irreversible, and it is impossible to restore vision.
The main goal of therapy for the terminal stage of the disease is:
Today there is an active implementation of minimally invasive surgical methods treatment of glaucoma, which allows normalizing intraocular pressure by improving the drainage function of the organ of vision, which makes it possible to save the eye.
If it is impossible to perform organ-preserving surgery, enucleation (removal) of the eye is performed.
The Moscow Eye Clinic conducts comprehensive diagnostics glaucoma, with the development of an individual treatment regimen for any stage of the disease. The extensive clinical experience of our specialists and the availability of modern technical means, allow you to get the maximum possible positive results even in the most advanced cases of the disease.
At the medical center "Moskovskaya" Eye Clinic» Anyone can undergo examination using the most modern diagnostic equipment, and based on the results, receive advice from a highly qualified specialist. We are open seven days a week and work daily from 9 a.m. to 9 p.m. Our specialists will help identify the cause of vision loss and conduct competent treatment identified pathologies. Experienced refractive surgeons, detailed diagnostics and examination, as well as the extensive professional experience of our specialists allow us to ensure the most favorable result for the patient.
Among the undoubted advantages of our clinic for patients is our experienced staff, who have earned an impeccable reputation over many years of work. The clinic employs specialists who have excellent theoretical training and many years of practical experience in leading clinics and research institutes in Moscow: diagnostics and drug therapy diseases deals with Ph.D. Kolomoitseva Elena Markovna (author of more than 45 scientific works and 1 patent) and Shchegoleva Tatyana Andreevna (graduate student of the Federal State Budgetary Institution Research Institute of Eye Diseases of the Russian Academy of Medical Sciences).
A specialist with 30 years of experience in laser methods treatment of glaucoma is Estrin Leonid Grigorievich.
Surgical interventions conducted by professor, doctor medical sciences, Head of the Surgical Department of the Moscow Clinical Clinical Hospital
