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INTRODUCTION

Urgency

The malignant postoperative glaucoma is a terrible complication, after antiglaukomatoznyh the operations, meeting according to different authors in 0,4 - 6 % of cases when after short-term depression VGD in the postoperative period appreciable lifting VGD with crushing and oporozhneniem the forward chamber of an eye [7, 12, 13, 31, 41 becomes perceptible, 98].

The malignant glaucoma can arise at any time, more often after operation - both in the first day, and in some years after a surgical intervention. It develops as in the presence of own lens (as a rule, at elderly patients with a hypermetropia), but can be observed and at afakii/artifakii [17, 21, 25, 50, 63].

The reasons of occurrence of a malignant glaucoma precisely are not established till now. The first description of a malignant glaucoma has been made by one of founders of modern scientific ophthalmology Albrecht a background Gref in 1869 It described its occurrence after surgical peripheric corectomy. "Malignant" it meant the bad forecast of disease by the term [62].

In process of expansion of a surgical arsenal the list of the operations the given clinical situation can be which complication, has considerably replenished. As a rule, it appears after fistulizirujushchih operations, cases of a malignant glaucoma after a cataract ex-traction (less often - with implantation intraokuljarnyh lenses), tsiklofotokoaguljatsii, allodrenirovanija however are observed - i.e. surgical interventions, as a main objective of many of which depression of level of an ophthalmotonus, and also use miotikov [25, 66, 69, 73, 75, 88, 97, 105, 106] serves.

According to the majority of researchers, development of a malignant glaucoma is bound to changes in vitrealnoj the cavities, leading to formation of pathological cavities, and further formation
vitrealnogo or viterohrustalikovogo the block, changes tsiliarnogo bodies. [5, 6, 10, 22, 29, 41, 51, 54, 56].

Considering the contribution as vitrealnyh, and lens processes in a pathogenesis of its development [41, 54, 56, 64, 76, 102], for surgical treatment of a malignant glaucoma following versions of operations on a vitreous (vitreoaspiratsija, a lobby vitrektomija, total vitrektomija, deep vitreotomija), on a lens (ekstrakapsuljarnaja and intrakapsuljarnaja an ex-traction, fakoemulsifikatsija), and also the combined interventions combining vitrektomiju with lensektomiej now are used. However, and it is widely shown in the world literature, the isolated operations - an ex-traction of a cataract or vitrektomija - in the outcome are difficult prognosticated, do not give necessary depression of level of an ophthalmotonus and high-grade aftertreatment of visual functions [25, 27, 28, 33, 43, 52, 90, 126]. At the same time, the combined surgical interventions at fakichnoj to the postoperative malignant glaucoma, combining fakoemulsifikatsiju cataracts with vitrektomiej, are represented more safe and effective. However, similar data are individual [51,113]. We consider, that the best effect is a carrying out of preventive operation. However we have not met in the scientific literature of the description of similar operations.

According to the majority of researchers, development of a malignant glaucoma is bound to changes in vitrealnoj the cavities, leading to formation of pathological cavities, and further with formation vitrealnogo or viterohrustalikovogo the block, with changes tsiliarnogo bodies [9, 14, 24, 34, 40, 60, 79, 84, 99, 108, 121].

Considering the contribution as vitrealnyh, and lens processes in a pathogenesis of its development [24, 34, 40, 60, 79, 84, 99], for surgical treatment of a malignant glaucoma following versions of operations now are used: on a vitreous (vitreoaspiratsija, a lobby vitrektomija, total vitrektomija), on a lens (ekstrakapsuljarnaja and
intrakapsuljarnaja an ex-traction, fakoemulsifikatsija), and also the combined interventions combining vitrektomiju with lensektomiej. However, and it is widely shown in the world literature, the isolated operations - an ex-traction of a cataract or vitrektomija - in the outcome slozhnoprognoziruemy, do not give necessary depression of level of an ophthalmotonus and high-grade aftertreatment of visual functions [16, 18, 31, 51, 113].

At the same time, the combined surgical interventions at fakichnoj to the postoperative malignant glaucoma, combining fakoemulsifikatsiju cataracts with vitrektomiej, are represented more safe and effective. It is represented, that the best effect is a carrying out of preventive operation. However we have not met in the scientific literature of the description of similar operations.

Degree of a readiness of a theme of the dissertation

Carrying out of the combined surgical interventions at fakichnoj to a malignant glaucoma according to some authors is effective, however, a mention of similar surgical interventions are individual [51, 113, 126]. Considering fast advance of surgical technologies, working out reducing risk of complications, the microinvasive, combined algorithm of an operative measure is extremely important at the malignant glaucoma, process influencing pathogenetic links.

In spite of the fact that as a result of complex surgical treatment the satisfactory functional anatomic result is reached, high frequency of postoperative complications (to 53 %), the developing in early and late periods after operation [15, 52, 112, 114] remains.

In this connection actual working out of the preventive surgical combined intervention which would allow to warn development of a postoperative malignant glaucoma is represented and
To lower frequency and gravity of postoperative complications. It is expedient to put factors already described in the literature in a basis of the forecast of development of a postoperative malignant glaucoma: the short frontback axial size of an eye, the fine forward chamber, a narrow corneoscleral angle, changes in tsiliarnom a body and in vitrealnoj cavities [13, 25, 26, 70, 93, 103, 104, 111, 122]. However we have not met works which would allow, on the basis of the statistical analysis of risk factors, to prognosticate development of a postoperative malignant glaucoma, and, taking into account this analysis, to develop the preventive complex surgical intervention, allowing to avoid development of this complication.

Thus, it is obviously important to spend the further studying of necessity of introduction of the combined surgical treatment at the developed postoperative malignant glaucoma. Besides it is necessary to carry out the discriminant analysis allowing to tap prediktnye signs of development and on their basis to develop a preventive surgical intervention of a postoperative malignant glaucoma with application of all modern possibilities of sparing microinvasive surgery. The urgency of the given problem and its insufficient level of scrutiny have served as stimulus to performance of research with veneering of its basic results in the form of dissertational work.

Research objective:

To develop techniques of the combined surgical treatment and preventive maintenance of a postoperative malignant glaucoma.

Research problems:

1. To prove expediency of introduction of the combined approach to operative treatment of a postoperative malignant glaucoma.

2. On the basis of the comparative retrospective analysis of successfully operated patients with an angle-closure glaucoma and at patients with the developed postoperative malignant glaucoma to select
The most informative clinical signs and to construct model for forecasting of development of complication.

3. To develop the combined method of surgical preventive maintenance of a postoperative malignant glaucoma.

4. To prove clinical efficiency of a surgical intervention for preventive maintenance of development of a postoperative malignant glaucoma.

Scientific novelty of work:

1. For the first time application of the combined surgical method of treatment of the postoperative malignant glaucoma including is proved:

- Carrying out partial vitrektomii for the purpose of depression of an ophthalmotonus and an excavation of the forward chamber,

- Carrying out microinvasive fakoemulsifikatsii with a corneal cut of 1,8 mm with implantation IOL,

- Destruction of a forward hyaloid membrane.

2. For the first time by means of the discriminant analysis the model of forecasting of development of a postoperative malignant glaucoma is constructed.

3. For the first time the technique of carrying out of the preventive combined microinvasive surgical operation at patients with high risk of development of a postoperative malignant glaucoma is developed and proved.

The theoretical and practical importance of work:

The technique of the single-step microinvasive combined operative measure concerning the postoperative malignant glaucoma, providing depression of an ophthalmotonus and achievement of satisfactory functional result is developed.

The developed mathematical model of forecasting of development in the postoperative period of a malignant glaucoma on the basis of the discriminant analysis spent by us has allowed to define criteria of risk of development of a malignant glaucoma, to frame system of forecasting of its development and to allocate a category of patients with high risk of development of it
Complications. The combined preventive operation combining carrying out vitrektomii, destruction of a forward hyaloid membrane, performance fakoemulsifikatsii with implantation IOL, and a deep sclerotomy is proved and is applied in practice. Carrying out of such surgical intervention is the effective and pathogenetically proved way of preventive maintenance of development of this complication at patients having high risk of development of a postoperative malignant glaucoma.

In practice of ophthalmology of techniques of a single-step microinvasive complex operative measure at the developed postoperative malignant glaucoma and the combined operation on preventive maintenance of this complication efficiency and safety of treatment of a postoperative malignant glaucoma allow to raise introduction, to improve functional and morphological outcomes.

The developed techniques can be recommended for use in the hospitals equipped with necessary technics for carrying out of microinvasive operations.

Methodology and research methods

Methodological basis of dissertational work was consecutive application of methods of scientific knowledge. Work is executed in design of comparative open research with use of clinical, tool, analytical and statistical methods. The substantive provisions which are taken out on protection:

1. Surgical treatment of a postoperative malignant glaucoma should have complex character and include not only vitrektomiju with destruction of a forward hyaloid membrane, but also fakoemulsifikatsiju with implantation IOL.

2. The calculated multidimensional discriminant mathematical model on the basis of the signs characterising value short PZO, size iridoyo
Corneal angle, the size of a lens, presence of back amotio of a vitreous allows to prognosticate probability of risk of development of a postoperative malignant glaucoma with high degree of reliability.

3. For the purpose of preventive maintenance of development of a postoperative malignant glaucoma it is expedient to carry out the combined microinvasive surgical operation including a lobby vitrektomiju, destruction of a forward hyaloid membrane, fakoemulsifikatsiju with implantation IOL and a deep scleroticectomy.

Degree of reliability and approbation of results of research:

Degree of reliability of results of the spent researches is defined by quantity of clinical observations with use of an arsenal of modern methods of research and confirmed in the course of statistical processing of a material. The importance of differences of average value of quantity indicators was estimated by means of parametrical t-criterion Stjudenta and a method of confidential intervals. Scientific positions, conclusions and the references formulated in the dissertation, are given strictly reason and logically follow from the system analysis of results of clinical and tool researches.

Dissertational work is approved on faculty meeting of ophthalmology FGBU «the National medicochirurgical Center of N.I.Pirogova» Ministry of Health of Russia on May, 7th, 2014.

The basic results and work positions are reported and discussed at scientifically-practical conference of ophthalmologists of Southern Federal district (Astrakhan, 2011), V Inter-regional scientifically-practical conference "Autumn ophthalmologic readings" (Voronezh, 2011), VI Inter-regional Scientifically-practical conference «Spring-chernozeme - 2012» (Voronezh, 2012).

Introduction of results of work in practice:

Results of work are used in educational process on chair of ophthalmology FGBU «National medicochirurgical the Center of N.I.Pirogova» Ministry of Health of Russia, successfully used in practice of clinic of laser medicine "Sphere" of Moscow, the ophthalmologic centre, Lipetsk.

Personal participation of the competitor in reception of the scientific results stated in the dissertation

The author independently develops design and the research program. Showed immediate participation in inspection and treatment of the patients included in research. The author has mastered the modern techniques applied to reception and an estimation of results, the statistical analysis and the description of results of the basic clinical and tool researches has made, the discriminant analysis for working out of model of development of a postoperative malignant glaucoma has made, has formulated conclusions and the substantive provisions which are taken out on protection.

Volume and dissertation structure:

The dissertation is stated on 116 pages of the typewritten text, consists of five heads, the conclusion, conclusions, practical references, the literature and appendix index. In the list of the literature of 126 sources, from them 36 domestic and 90 foreign authors. Work is illustrated by 32 tables, 27 drawings.

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Scientific source Tarasov Konstantin Leonidovich. COMPLEX SURGICAL TREATMENT of the POSTOPERATIVE MALIGNANT GLAUCOMA. The dissertation on competition of a scientific degree of the candidate of medical sciences. Moscow, 2014. 2014

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