ACTUAL PROBLEMS OF PENETRATING AND NON-PENETRATING SURGERY AS METHODS OF CHOICE IN GLAUCOMA

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Abstract


Surgical methods for the treatment of glaucoma are used when other treatments are not effective to maintain intraocular pressure under control. Regardless of the method of choice of surgical treatment of glaucoma, penetrating and non-penetrating surgical intervention violates the integrity of the eyeball and causes a variety of complications. Some of these complications can threaten the vision as a whole. To keep complications to a minimum, it is important to know how to prevent, recognize and treat. One of the main problems of glaucoma surgery is scarring of the previously established ways of outflow of the experiences of all the researchers, who today are in search of new methods of prevention, means and methods for modulation of the process of excessive fibrosis of granulation tissue in the area of operations. The purpose of this article is to give an idea of some of the complications, advantages and disadvantages of the main methods of penetrating and non-penetrating surgical treatment, the use of different types of drains and the creation of new ways of outflow of intraocular fluid, which will help doctors in the future to improve the chosen techniques in the treatment of glaucoma patients in their clinical practice and to develop new methods against early scarring created outflow pathways and the extension of the hypotensive effect after surgery glaucoma.


From the first day of the appearance of concept glaucoma, which was first described more 400-500 years B.C. to present day, appeared a lot of methods for its diagnosis [1], medical and surgical treatment. Today’s medical hypotensive therapy occupies the main space in adjusting intraocular pressure, although surgical treatment with uncontrolled hypertension remains a very pressing issue. In the opinion of many authors, only surgical interventions make it possible to achieve a stable compensation of the ophthalmotonus and, thus, create conditions for the stabilization of visual functions [2, 3]. During the whole period of glaucoma surgery, a large number of operations to combat glaucoma have been proposed, new methods and their modifications are still emerging [4], especially in the development of new outflow pathways. Operations to combat an increased ophthalmotonus, aimed at creating new outflow pathways, can be divided into incisional (penetrating) and non-penetrating surgery [5]. There are following non-penetrating total-fistulized surgery methods: the method of iridosclerotomy developed in 1906 by F. Lagrange, the modified technique of S. Holth in 1909, and the scleral trepanation created in 1910 whose authorship is given to R.H. Eliot, as well as partial-fistulizing operations, of which the most popular was, and to this day, is sinustrabeculectomy. NON-PENETRATING OPERATIONS In 1989, C.H. Fedorov and V.I. Kozlov proposed a more well-known, an operation of non-penetrating deep sclerectomy [5]. One of the first, in 1830, was offered surgical treatment in the form of sclerostomy by the English ophthalmologist W. Mackenzie. Later, in 1856, Albreht von Greafe performed iridectomy for the first time in sectors, although the unstable hypotensive effect facilitated the search for other methods of medical interventions. In 1867 the French doctor L. de Wecker proposed and described the anterior sclerotomy, which became the first operation of the filtering species, due to the “filtering scar” [6, 7]. In 1883, Dianoux added a daily massage of the eyeball after surgery to improve its effectiveness. In 1886, A.N. Maklakov introduced a proposal for oblique sclerectomy, thus creating another way for the outflow of IOF under the conjunctiva. In 1903 Herbert H. proposed the infringement of the basal portion of the iris between the edges of the scleral wound for a longer-term maintenance of normal IOP [8]. In 1906, F. Lagrange helped to avoid blocking the hole by inventing scleriroidectomy [9] and, later, on the enucleated eyes that underwent this operation, demonstrated that the fistulas remained functioning only in cases of pinching the iris tissues in the incision of the sclera. Also in 1906 there appeared the concept of iridenkleysis, a number of sources that give authorship to S. Holth. Initially, during the intervention, the whole iris sector was excised along with the pupillary margin, further fixing it in the fistula of the sclera. This type of iridectomy led not only to a somatic defect, but also to a decrease in vision and even in some cases to sympathetic ophthalmia, in fact, which served as a waiver of this operation [10, 11]. In 1909, R.H Elliot came up with a full-fistulizing operation - end-to-end corneoscleral trepanation. Early complications, in particular, shredding the anterior chamber and the rapid appearance of cataracts due to uncontrolled outflow of intraocular fluid (IOF) under the conjunctiva, limited the use of this operation in medical practice [12]. In 1934 V.P. Filatov suggested a double iridectomy. This combined intervention had the title of three of its founders: the Lagrange-Gault operation in the modification of V.P. Filatova [13]. However, examining the results of postoperative complications, in 50-60% of patients development of persistent cataract processes, limitation of visual fields in 30-50% of patients, acquired chronic uveitis and the appearance of a cystic-modified filtration pad (FP) were noted [14]. In 1968, J.E. Cairns (Great Britain) introduced a proposal for trabeculectomy in the American Ophthalmological Journal in which for the first time published preliminary results on 17 operated eyes by a new method. The device of action was explained by the author by the restoration of the outflow path between the angle of the anterior chamber (AAC) and the Schlemm’s channel through its cleavage clearance [15]. M.M. Krasnov (1969) introduced the proposal to include in the sine mandrake and, bending it by the ends, cut through the inner wall of the sinus and remove the trabecula [16, 17]. A sinusotomy was also presented on the base, which is the idea of vivisection of the venous sinus of the sclera to restore the free outflow of the IOF, which is used with intrascleric retention glaucoma. Various creators offered their own modified models of this operation. It was suggested to combine this operation with thermo-coagulation of the edges of the scleral wound from above and from the sides, which actually promoted the maximum gaping of the outer wall of the incised sinus and reduced the chances of its scarring after a long time. It is experimentally conditioned, in fact, that the opening of the external wall of the venous sinus improves the outflow of the IOF. The positive side of the method was the absence of an opening of the eyeball. A few years later, a subscleral sinusotomy appeared, in which for the increasing of infiltration of the trabeculae the scleral spur was sewn by a thread stretching the trabecular apparatus. A.P. Nesterov highlighted the importance of improving the outflow of the IOP not only through the formed fistula, but also through the uveoscleral path through the eye’s filtration system, after which a plan for creating surgical manipulations forming new outflow pathways was developed, and deep sclerectomy was recommended that was to develop a new direction of outflow of chamber moisture into the vascular system of the eye, which has made a big contribution to the development of glaucoma microsurgery as a whole [18-21]. In 92-94% of patients during 6 years of follow-up, intraocular pressure was persistently maintained within the norm without medication [22, 21]. The high effectiveness of this technique has made it possible for its extensive application and dissemination. According to the data of various authors [23-27], nowadays sinostrabecullectomy (STEC) is on the leading lines among the huge variations of antiglaucoma surgical techniques. The technique of the operation consists in forming a message for the outflow of intraocular fluid from the anterior chamber to the suprachoroidal or subconjunctival space, thus achieving the best and persistent hypotensive effect. However, like any other methods, such an operation is not without its negative moments and complications. One of them is the difficulty in determining the exact location of the trabecular zone and venous sinus. In some cases, there is a high probability of the appearance of a hyphema, iritis, iridocyclitis, a ciliary-choroidal detachment. There are cases of unstable hypotensive effect in the long term after STEC, which is explained by blockage of the formed outflow pathways by scar tissue, associated with intensive proliferation of fibroblasts and production of collagen in the area of the formed filtration pad [28-32]. Non-penetrating microsurgical intervention, originated in the late XX century, being one of the perspective direction of modern surgery for glaucoma treatment [33]. In the course of non-penetrating deep sclerectomy, a deep layer of corneo-scleral tissues and the outer wall of the Schlemm’s canal, releasing the descemet membrane, removes the epithelial layer of the inner wall of the Schlemm’s canal. Through the remaining pore of the trabecular network and Descemet's membrane, an outflow of intraocular fluid (IOF) is carried out [33]. Throughout the years of research, the scientists have drawn conclusions pointing to the short duration of maintaining a normal ophthalmotonus after the classical non-penetrating deep sclerectomy [34-36]. Non-penetrating deep sclerectomy is also not devoid of drawbacks associated with the fibroplastic process. Leading motivations for the inferiority of non-penetrating DSE are excessive formation of connective tissue in the created filtration area (most often sclero-scleral fusion), excessive pigmentation and sclerosis of the trabeculae, reducing its filtration capacity, block root of the iris, pronounced atrophy of its radical part, incorrect determination of indications for surgery [37, 38]. The researcher S.Y. Petrov [39] showed that the operation is applicable to patients with POAG with a predominantly intracleral form of retention, and a significant role in increasing the hypotensive effect of non-penetrating DSE occurs due to an increase in the size of fistulas due to intraoperative perforations. Histomorphological test of biopsy taken during repeated operations proved that the inadequacy of the inner wall of the filtering zone is considered to be a prerequisite for an increase in the ophthalmotonus afterwards. Pseudoexfoliation syndrome is considered a risk factor for ineffectiveness of non-penetrating DSE, in its traditional form. Numerous authors proposed to increase the hypotensive effect of non-penetrating DSE with the help of intracleral micro-drainage according to P.I. Lebehov, [40, 41]. Some scientists introduce elements of anterior cyclodialysis, trabeculotomy, to the technique of the non-penetrating DSE, however, the lack of an internal wall of the Schlemm’s canal is made on either side of the excised deep scleral scrap, that is, outside its projection [42]. Other authors suggest the possibility of enhancing the hypotensive effect of non-penetrating DSE in combination with stretching and drainage of the Schlemm’s canal by hydrogel or collagen drainages [43]. One of the tendencies with a tendency to increase the hypotensive effectiveness of the surgeons interventions, it is considered the use of drains and drainage devices [44]. Drainages, depending on the material, are divided into autotissues (from the patient’s own tissues), allo- (from donor’s own tissues), xeno- (material from animal tissues), explant drains (from polymeric materials of precious metals) [45]. 99 patients (99 eyes) are one of the last methods of surgical treatment of POAG with the use of 3 different modifications of the expander of the Sclemm’s canal. As a result of the study, patients with POAG were integrated. As a result of implantation of expanders of all modifications, was obtained a statistically significant decrease in IOP [46]. Autodrainages are the self donor material. As an autodrainage, autoscleral flaps, lens capsule, cornea, etc. can be used. Their application can lead to the risk of a macrophage reaction in the filtration area, the subsequent substitution of autotissues on the connective tissue scar, and the blockage of the pathways of outflow of intraocular fluid created by the technique. The scientist M. Murata with other authors has recommended, in fact, that drains from autotissue, in particular from the sclera flap, are promptly exposed to the organization, scarring when the necessary outflow of moisture from the anterior chamber is unavailable, and subsequently the outflow paths created by the operation are sequentially blocked. Autodrainages, in particular from the scleral flap, can cause the formation of a macrophage reaction; they are early exposed to the organization, fibrosing or lysis. The outflow paths generated by the operation are blocked [47]. An obvious advantage is accessibility. Thus, in 1964, M.M. Krasnov, used a capsule of the lens to prevent superfluous scarring [48]. In addition to autodrainage, is known the use of allodrainage, who, in 1995, V.P. Smirnov used a solid medulla, a throat cartilage, a perforated bone plate [49]. From the latest modifications of non-penetrating DSE using autodrainage from the autosclera, a modified method for the surgical treatment of glaucoma in combination with cataracts aimed at activating the suprachoroidal pathway of outflow with the help of autoscleral drainage has been developed and introduced in practice (a positive conclusion on the grant of a patent of the Russian Federation for an invention under application No. 2016102350 dated 26.01.2016) [50-52]. This method of surgical treatment contains a number of advantages when choosing a method of surgical treatment, but the disadvantage of the provided method of treating glaucoma as well as at all modifications non-penetrating DSE proposed previously considered it is that actually created non-penetrating outflow path lead to the appearance of fibroplastic process in the filtration zone, which reduce the duration of the hypotensive effect. THE CONCLUSION The treatment of glaucoma is aimed initially to lowering the IOP. The variety of all possible ways of treating glaucoma, including medicamentous, laser, surgical, does not guarantee a stable and persistent lowering of IOP. Always when the possibility of using surgical treatment is affected, there is a risk and danger of a decrease in visual functions due to probable intra- and postoperative complications. Also, an unreasonable refusal of surgical intervention is likely to cause also blindness. Offering the patient an anti-glaucomatous surgery, the doctor assumes a huge responsibility, and as a consequence, an in-depth deliberate analysis is important in concluding the question of indications for surgical treatment, abstract knowledge, the best surgical technique that raises all chances and guarantees a positive end antiglaucomatous surgery and guarantees safety visual functions. According to various literature sources, it can be concluded that in recent years there has been a debate about the benefits and the best choice of the treatment method, among which a special role is played by non-penetrating antiglaucomatous operations, fistulizing type (sinustrabecultomy and its modifications), with and without the use of antimetabolites, various absorbable sutures, drains and drainage devices. In the world practice, surgical treatment comes after the possibilities of drug and laser treatment have been exhausted, which, of course, affects the effectiveness and quality of the results obtained after the operation in comparison with the primary surgery. It is obvious that when we meet with glaucoma treatment, the variety and choice of the “working” technique should not embarrass the physician, should constitute an extensive aspect, and not only in surgical treatment, but also in medication. There should be not only one drug for instillations, and not just one surgical technique for all patients with glaucoma. The question of new methods of intervention, about increasing the effectiveness of innovations will always be open. The most universal technique, effective, simple and with the least potential complications, will be more common and applicable. Analyzing numerous sources, it can be concluded that the effectiveness of surgical treatment is incomparably worse in patients who have been on medication for a long time. This was mainly observed in cases of glaucoma in combination with high degree myopia and, previously, in patients who had previously undergone argon laser trabeculoplasty (A. Behtoille, 1997). Thus, it can be concluded that with a poor prognosis of the glaucomatous process, it is better to proceed to the surgery of glaucoma than to progressively and step by step from drug therapy to laser therapy, and only after to knife surgery. Since the end of the nineteenth century to the present day, all the knowledge and skills of scientists are aimed at the invention of new methods of treatment and, at least, on the improvement of those already having methods of surgical treatment of glaucoma. In the treatment of glaucoma, a special role is given to surgical intervention, based on the conclusions of numerous authors. Surgery of glaucoma is the most impressive way to achieve stable normalization of intraocular pressure. However, any surgical intervention is associated with a certain degree of risk of complications, which in some cases can be a serious threat to visual functions up to the enucleation of the anatomical organ. Thus, the attempts and efforts of scientists in developing such technologies that would be effective, durable and safe are sufficiently clear but not always justified. In each case, it is necessary to take into account not only a variety of information about the technique and its components, but take into account and carefully analyze each case separately, influencing the manifestation of the surgical process, and further on the outcome and the results of the specific treatment. Every year, there are more and more varieties of surgical techniques, various modifications, a vast number and variety of new models of drainage from various materials, and, thanks to this, success in combating this disease causing blindness is somewhere nearby. In spite of the achievements and tremendous success in this direction, we have not yet received results close to 100%. The use of “classical” fistulizing operations often leads to the development of all sorts of postoperative complications, and they prove to be ineffective. The problem of early scarring of the sclera in the zone of the interventional interventions in the non-penetrating and including penetrating glaucoma surgery remains outside of control, which causes their constant improvement, which is most often realized through the technical methods that contribute to the reduction of scarring in the zone of the created filtration. To present day, the scientists searching for an optimal method that would be considered a low-traumatic, safe, promoting stable intraocular pressure stabilization, without the need for using donor material and additional implantable devices. Absolutely, in advanced conditions, surgical intervention is considered a plus, which at the same time resolves financial, social, moral - psychological, financial issues, reduces the number of days of patient presence in the hospital due to early and rapid rehabilitation. Today, the newest techniques and surgical treatment models are used in the treatment of glaucoma, old surgical models are used too, but modified, improved and modified methods. STEC is still the first in the opinion of all practicing ophthalmic surgeons, and this fact is explained by the best published results, however, the main negative side of STEC is the presence of a relatively high risk of developing some complications, including inflammation and episcleral fibrosis of the created pad for intraocular fluid filtration IOF. If scientists and interested parties are able to work out and eliminate these complications in the given direction, then there will remain no doubts in this technique as a gold standard in glaucoma surgery. The presence of a big number of methods and their modifications of antiglaucomatous surgery, speaks of the dissatisfaction of the surgeons with their results, which actually causes the existence of a number of unsolved problems that do not allow extensive and safe application of a certain method as a gold standard in the surgical treatment of POAG and glaucoma in general. Therefore, development and research in this direction should be considered relevant and perspective.

M A Frolov

Peoples’ Friendship University of Russia

Email: dr_ryabey@mail.ru
SPIN-code: 1697-6960

A V Ryabey

Peoples’ Friendship University of Russia

Author for correspondence.
Email: dr_ryabey@mail.ru
SPIN-code: 8447-8762
117198, ul. Miklukho-Maklaya, 6, Moscow, Russia

PhD Student, Department of Eye Diseases, Peoples' Friendship University of Russia

A M Frolov

Peoples’ Friendship University of Russia

Email: dr_ryabey@mail.ru
SPIN-code: 6338-9946

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