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the Chapter VI. DISCUSSION of the RECEIVED DATA

Our clinical experience, the analysis of the foreign scientific literature testify that occurrence of modern diagnostic equipment and microsurgical technologies do not solve a problem of occurrence and treatment of a postoperative malignant glaucoma.

In numerous publications it is underlined necessity of carrying out in case of development of such complication - a lobby vitrektomii. In the literary review and in our researches it is shown, that this operation solves the important problem - liquidation of the formed cavities in the vitreous chamber of an eye, to shift iridohrustalikovoj diaphragms back, homings to normal anatomo-morphological parities. A side benefit of this operation is low to 17 % frequency of postoperative complications. It allows to recommend to leading experts in the field of a glaucoma this operation as pathogenetically focused operation [13,15, 51, 113].

However, the lobby vitrektomija does not solve a problem of full aftertreatment of patients at which owing to development of the postoperative malignant glaucoma, accompanying its hyphemas, formations of forward synechias, shifts of internal structures of an eye to front, rotation tsiliarnogo bodies forward, and also an additional surgical intervention on elimination of these complications it is considerably accelerated kataraktogenez. On our data correlation communication of occurrence of a cataract at the patients operated thus the high.

As other inducing motive of working out of the combined operative measure at patients initial, and the fact of presence has served in two observations of an unripe cataract which reduce, and in some cases do not allow is high-grade to carry out observation over lobby carrying out vitrektomii against an edema of a cornea, hyphema presence, in addition to an available cataract of optical mediums of an eye reducing a transparency.

In this connection as a prototype we took carrying out of the combined operation described Tsai J.C. et al. [122] and considerably modified by us.

In the algorithm developed by us including:

1. Carrying out vitrektomii, allowing to lower an ophthalmotonus and to deepen the forward chamber;

2. Microinvasive fakoemulsifikatsiju with implantation IOL Akreos M I60 and Asgu Sof Natural. Fakoemulsifikatsija also allowed to deepen the forward chamber, and modern intraokuljarnye lenses provided the big transparency, than the initial cataract which as a rule was available for the patient;

3. If necessary lobby continuation vitrektomija with destruction of a forward hyaloid membrane.

Thus, novelty of the combined treatment offered by us consists not only that stages of operation offered by foreign authors have been modified. For example, Bitrian E et al. In article Pars plana anterior vitrectomy, hyaloido-zonulectomy and iridectomy for aqueous humour misdirection suggest to combine a lobby vitrektomiju with gialoidzonulektomiej and corectomy. We consider, that our way is more effective, as he suggests to spend and implantation intraokuljarnoj lenses.

At implantation IOL Akreos M I60 a little more positive dynamics of all studied parametres which do not have, however, statistically authentic differences in comparison with outcomes of implantation IOL AdySof Natural was observed. Therefore in this research we did not begin to allocate separate groups of observation on character implanted IOL.

For a substantiation of efficiency of application of the combined operation developed by us vitrektomii in a combination with fakoemulsifikatsiej and implantation IOL, destruction of a forward hyaloid membrane at the developed postoperative malignant glaucoma we have spent
Research on 8 parametres also have convincingly shown, that the surgical intervention offered by us is more effective in comparison with spent vitrektomiej, spent separately on such indicators as visual acuity improvement, ophthalmotonus indemnification, an excavation of the forward chamber and augmentation of its angle.

Carrying out isolated vitrektomii has appeared more effective only in one parametre - more the low interest of postoperative complications in the first day after operation. Carrying out fakoemulsifikatsii, necessity of elimination of the forward synechias, at times insufficient washing away of the forward chamber viskoelastika cause in the early postoperative period higher percent keratopaty and oftalmogipertenzy which, as a rule, after medicamental therapy disappear for 3-4 day after operation. Besides, in the analysis of postoperative complications in favour of carrying out of the combined operation absence of a partial hemophthalmia is important. In our observations it was observed its full rezorbtsija. However according to the literature the partial hemophthalmia can lead to numerous complications, up to development of a lobby proliferative vitreoretinopaii and amotio of a retina [35].

Observation in group of patients by which after the developed malignant postoperative glaucoma it has been executed vitrektomija has shown, that in 66 % within a year by it was carried out fakoemulsifikatsija, caused by advance of a cataract available for patients, and also acceleration of its maturing owing to operative measures. Reduction of quantity of surgical interventions is an additional argument in favour of carrying out of the combined operation at developed postoperative malignant glaucoma.

Besides, fakoemulsifikatsija not only promotes improvement of a transparency of mediums during lobby carrying out vitrektomii, but also promotes an excavation of the forward chamber, disclosing raduzhno-corneal
Angle also eliminates the additional factors promoting development of a postoperative malignant glaucoma.

Thus, the combined surgical algorithm combining carrying out by a lobby partial vitrektomii, fakoemulsifikatsii cataracts with implantation IOL, in need of repeated vitrektomii with destruction of a forward hyaloid membrane, is the effective and pathogenetically proved way of treatment of a malignant glaucoma as influences various links of a pathogenesis of disease.

However the considerable quantity of the complications resulting application of combined surgery has caused the problem decision on working out of preventive operation. We have spent comparison of 10 parametres used by us at the retrospective analysis as group of patients at which the postoperative malignant glaucoma has developed, and groups of patients at which in the postoperative period this complication has not developed. The retrospective analysis has allowed to allocate a number of the signs having high prognostic ability. It is age is more senior 60 years at which against a glaucoma there is a cataract, metabolism disturbances are accelerated. Besides, 4 signs - an angle of the forward chamber 15 ° and are less, perednezadny the axial size of an eye of 22 mm, the frontback size of a lens of 4,5-5 mm, amotio of a back hyaloid membrane and especially their combination cause high risk of development of a postoperative malignant glaucoma.

In the same group it is necessary carried patients at whom on one eye the postoperative malignant glaucoma already developed.

At high risk of development of a postoperative malignant glaucoma we develop the combined operative surgical intervention including:

- fakoemulsifikatsiju cataracts with implantation IOL,

- vitrektomiju with destruction of a forward hyaloid membrane and

- Deep scleroticectomy.

The first stage of operation: fakoemulsifikatsija with implantation IOL (fig. 24, 25) allows to raise a transparency of optical mediums and to liquidate as the lens factors promoting development of a postoperative malignant glaucoma, and also to improve outflow tracts of an intraocular liquid.

Fig. 24. The first stage of the combined preventive operation: fakoemulsifikatsija at a postoperative malignant glaucoma.

Fig. 25. The first stage of the combined preventive operation: implantation IOL.

Last years the question on expediency of excision of a transparent lens is activly discussed at a malignant glaucoma. However, the contingent operated by us already has, as a rule, an initial cataract. Besides, excision of a transparent lens underlies ophthalmosurgery modern lines. It leaves at threat of development of a lobby proliferative vitrektomii, diabetic complications [8, 35]. Necessity of excision of a transparent lens, both at an angle-closure glaucoma, and at development the majority of researchers answers a malignant postoperative glaucoma in the affirmative [13, 31, 51, 113].

The lobby vitrektomija with destruction of a forward hyaloid membrane is the leading factor (fig. 30), in this case, development prophylaxes pooperatsionnoj a malignant glaucoma.

Fig. 26. The second stage of the combined preventive operation:

Partial a lobby vitrektomija with destruction of a forward hyaloid membrane.

This stage does not cause now objections. In the literary review by us it is full enough reflected, that vitrealnyj the block is the leader in development of a postoperative malignant glaucoma.

Fig. 27. The third antiglaukomatoznyj a stage of the combined operation.

Deep skleretomija provides additional outflow tracts of a watery moisture from the forward chamber (fig. 31).

It is the most disputable component - necessity of carrying out of filtering operation after carrying out fakoemulsifikatsii. Many authors, operating patients with an angle-closure glaucoma, specify that cataract excision renders hypotensive effect and an additional surgical intervention it is not necessary [27, 119]. However, that at the analysis of dissertational research of M.M.Pravosudovoj we have found out, that 8 % of cases the malignant postoperative glaucoma [27] has developed. It is represented to us, that having applied our technique, it would be taped, that these patients have high risk of development of a postoperative malignant glaucoma. And having executed the technique offered by us, the author would change a way of operative treatment.

Besides, researches J. Matlach et al. [90], and also data of own researches convincingly show expediency of performance of this component.

Therefore in case of high risk of development of a malignant glaucoma to which we have carried and 12 patients operated by us, we consider
Necessary to spend the preventive complex treatment developed by us including and this component, improving drainage function of an eye.

Performance of the preventive combined operation provides high visual functions, the field of vision allows to stabilise, to compensate an ophthalmotonus, provides satisfactory morphological a parity of internal structures of an eye and preventive maintenance of development of a postoperative malignant glaucoma and is appreciable (more than 20 %) the quantity of postoperative complications reduces.

All it also allows to recommend us carrying out of the developed surgical intervention at persons with high risk of development of a postoperative malignant glaucoma.

We certainly give the report, that preventive the combined surgical treatment does not allow to avoid in 100 % of cases development of a postoperative malignant glaucoma. This complication can develop and at those patients at whom the doctor has not to the full estimated risk of its development. Moreover, this complication can be shown not only in the early postoperative period, but also even through long time after carrying out antiglaukomatoznoj operations or fakoemulsifiktsii.

In these cases we can recommend carrying out of the combined surgical intervention, which efficiency we have shown in the chapter III.

THE CONCLUSION

Working out of complex surgical treatment at patients at whom the malignant postoperative glaucoma has developed was incentive motive of our research.

Patients get to this category with the developed complication but whereas according to the literature surgical treatment has a considerable quantity of complications, it was represented expedient to carry out the analysis of histories of illnesses at which the postoperative malignant glaucoma has developed, and also at what the postoperative current was without complications.

In this connection before us there was an object in view to develop system of forecasting, complex treatment and preventive maintenance of a postoperative malignant glaucoma. Research problems are stated in introduction to the dissertation.

During the decision of these problems we were convinced, that the combined surgical treatment developed by us including carrying out fakoemulsifikatsii, implantations IOL, a lobby partial vitrektomii with destruction of a forward hyaloid membrane is effective, promotes high-grade aftertreatment of patients. The quantity of the complications arising at surgical treatment, is comparable to the results described in the scientific literature, and on such parametres as visual acuity, ophthalmotonus indemnification, depth of the forward chamber, size iridokornealnogo, the quantity of surgical interventions obviously surpasses vitrektomiju with destruction of a forward hyaloid membrane. Moreover, carrying out of last operation on eyes with already developed postoperative malignant glaucoma, a becoming complicated hyphema, formation of forward synechias, etc. factors accelerate kataraktogenz and doom the patient to carrying out of the second stage - carrying out fakoemulsifikatsii. We are supporters of a single-step operative measure.

Nevertheless, a considerable quantity of the complications developing as a result of surgical treatment bring an attention to the question on necessity of working out of the preventive combined treatment. On the basis of the retrospective analysis of histories of illnesses of those patients at which this terrible complication has developed, and also patients at whom it has not developed to tap the factors promoting development of a malignant postoperative glaucoma. It

- Short PZO (20 yo 1,2мм),

- iridokornealnyj an angle no more than 15 °, - back amotio of a vitreous,

- The forward-back size of a lens more than 4,5 mm.

It is necessary to notice, that these factors are described and in the scientific literature. However we have not met works to which the statistical estimation of the factors would be spent, allowing to predict development of a postoperative malignant glaucoma, and also the preventive complex surgical intervention is developed, allowing to avoid development of this complication. The model developed by us has shown high ability of the forecast of development of a postoperative malignant glaucoma. Also it can be used in clinical practice.

The preventive combined surgical treatment developed by us allows patients to avoid development of a postoperative malignant glaucoma, allows to reduce quantity of operative measures and to spend high-grade aftertreatment of the patients having high risk of development of postoperative complication.

Efficiency of a surgical intervention is shown by us in the present research.

We consider, that in case of the developed complication it is necessary to spend the combined treatment, and in case of revealing of high risk of development of complication - to perform the preventive combined operation.

Thus, tasks in view are executed, and the purpose of our research is reached.

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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

Other medical related information the Chapter VI. DISCUSSION of the RECEIVED DATA:

  1. THE TABLE OF CONTENTS
  2. Chapter 4 Discussion of the received results
  3. THE TABLE OF CONTENTS
  4. Chapter 7 DISCUSSION of RESULTS of RESEARCH
  5. CHAPTER 8. THE CONCLUSION (DISCUSSION OF THE RECEIVED RESULTS)
  6. INTRODUCTION
  7. CHAPTER №5 DISCUSSION
  8. Chapter 7 DISCUSSION of RESULTS of RESEARCH
  9. THE TABLE OF CONTENTS
  10. CHAPTER 4. THE CONCLUSION (DISCUSSION OF THE RECEIVED RESULTS)
  11. Chapter 7 DISCUSSION of RESULTS of RESEARCH
  12. CHAPTER 4. DISCUSSION of the RECEIVED RESULTS
  13. THE MAINTENANCE
  14. the Chapter VI. DISCUSSION of the RECEIVED DATA
  15. INTRODUCTION