Surgical treatment of glaucoma: how to defeat the most insidious eye disease?

From September 9 to September 17, Moscow will host a week to combat glaucoma, a group of severe chronic eye diseases that are united by common signs: increased eye pressure, the development of trophic disorders of the optic nerve and retina, decreased visual acuity and narrowed visual fields. The surgeon-ophthalmologist, candidate of medical sciences Andrei Vladimirovich Lapochkin tells about what modern methods help Moscow doctors to successfully operate on glaucoma and for hundreds of patients.

Why is so much attention paid to glaucoma from all ophthalmic diseases?

Firstly, this is a fairly common group of diseases: according to statistics, 2-3% of the world’s population suffers from glaucoma. Secondly, this insidious disease is one of the first places among the causes of incurable blindness. In the early stages, the disease develops imperceptibly: the eye does not hurt, does not blush, does not give cause for concern – but at the same time, a slow, systematic death of the optic nerve and retina gradually occurs. Usually at the moment when the patient notices alarming symptoms – a sharp narrowing of the visual field, visual impairment – we are forced to state that the optic nerve has died by about 70%. In such situations, our only task is to preserve our remaining vision.

Who is primarily at risk for this disease?

Glaucoma is an age-related disease, most often diagnosed in patients who have reached 55-60 years of age. However, now there is a tendency to rejuvenate various chronic diseases all over the world, including diseases of the organs of vision – glaucoma, cataracts. In some cases, glaucoma is diagnosed in patients 35-40 years old. At its core, it is a vascular disease, therefore, patients suffering from diabetes mellitus and arterial hypertension are at risk. In addition, a hereditary factor plays a large role: if one of your older relatives has been diagnosed with glaucoma, you should be more careful about the health of your eyes.

If symptoms appear too late, then how can you protect yourself from glaucoma?

All that can be done so as not to “miss” the onset of the disease is to undergo regular scheduled diagnostic examinations of the organs of vision. If you have no complaints, you are advised to be examined by an ophthalmologist at least 1 time per year. Moreover, the examination must necessarily include a procedure for measuring eye pressure. It is the increased eye pressure that is the main sign of a developing disease. Citizens over the age of 45 are advised to measure eye pressure once a year, regardless of whether they are satisfied with the quality of their vision.

Can routine preventive examinations at the district ophthalmologist help early diagnosis of glaucoma?

Of course, if the necessary equipment is available, the district ophthalmologist will notice the first symptoms of glaucoma in the patient. On the other hand, a detailed examination and eye diagnosis requires an average of 45-50 minutes: an ophthalmologist in a clinic often does not have such a reserve of time. If you encounter any disturbing symptoms, the doctor will refer you to the consultative and diagnostic center, where you can conduct a more detailed examination and get a detailed consultation. In the CDC, the diagnosis is clarified and a decision is made on the need for surgical treatment of glaucoma.

Does glaucoma always have to operate?

Any surgical intervention is justified when other methods are powerless. Fortunately, modern medicine has a large arsenal of therapeutic drugs that can successfully combat the development of glaucoma. First of all, the task of these drugs is to reduce eye pressure, since otherwise the optic nerve and retina are systematically compressed, which is why the patient gradually loses sight. Also, an important part of drug therapy is vascular drugs designed to improve blood circulation to the retina and optic nerve.

However, from an economic point of view, conservative treatment of glaucoma is not the most affordable pleasure. Good anti-glaucoma drugs are expensive, moreover, more often than not, an ophthalmologist cannot limit himself to just one drug: the patient is prescribed up to 4 types of expensive drops that normalize eye pressure. Let’s not forget that our patient, as a rule, is a citizen of retirement age. Therefore, there are frequent situations when the patient cannot afford to maintain his vision with the help of therapy, and then surgery will be the best solution for him.

What is glaucoma surgery?

Glaucoma is a group of diseases that are associated with difficulty in the outflow of eye fluid. There are natural outflow pathways in the eye – trabeculae, due to which a pressure balance is maintained in a healthy eye. With glaucoma, the natural outflow pathways gradually cease to function normally. During a glaucoma operation, an ophthalmologist creates an artificial channel for fluid outflow – a fistula, which will help establish the outflow of ocular fluid for a certain period, from several months to 10-15 years.

Is it possible to predict how effective the operation will be and how long the artificial channel for the outflow of ocular fluid will last?

Unfortunately, modern medicine does not have methods that can predict the effectiveness of this operation. The main problem is that for the body, the fistula we created is a wound that must heal over time. Naturally, after the operation, all patients are required to take special medications, which can slow down the scarring process of artificial pathways of the outflow of eye fluid, but the degree of effectiveness of these medications in each case may be different.

That is, the skill of the surgeon can not provide a high effect of the operation?

The skill of the surgeon is extremely important. Nevertheless, you can brilliantly carry out the operation and succeed for a period of not more than a year or two. Only regular postoperative observation will allow the ophthalmologist to monitor the state of the glaucoma eye. Depending on the condition of the eye after surgery, the doctor decides on how to adjust drug therapy, whether you need to think about reoperation. The situation is complicated by the fact that in elderly patients, as a rule, several pathologies complicating each other develop on the same eye. For example, in 20-30% of cases, glaucoma develops in parallel with cataracts – a disease that also often requires surgical treatment.

Is cataract too difficult to detect in the early stages?

Unlike glaucoma, cataract makes itself felt. Its main symptoms are a gradual decrease, blurred vision, the glasses that he usually wears cease to help the patient.

There are several gradations of cataracts. At the initial stage, when vision decreases slightly, the disease is subject only to close monitoring. However, sometimes already at this stage, patients agree to undergo an operation to get rid of discomfort.

The second stage – “immature cataract” – is the optimal time for surgical treatment: at this stage, the operation will be carried out quickly enough and with a high guarantee of effectiveness. Mature, or complicated cataract, is considered to be a more advanced stage. There are different types of complications: swelling cataract tends to swell like a ball due to absorbed eye fluid; with brown cataract, the lens of the eye literally reaches stone hardness. Mature and complicated cataracts are much more difficult to operate. True, domestic ophthalmologists have quite a lot of experience in surgery at this stage, as it is common for our patients to delay treatment and postpone going to the doctor. Of course, the operation will be easier and will give a better effect, if you do not bring yourself to complete blindness.

Fortunately, with cataracts, vision for the most part needs to be restored. Cataract surgery is much more predictable than in the case of glaucoma: if the patient does not have any concomitant eye diseases, we can expect a good effect.

Often, cataract also reveals glaucoma: the patient begins to complain of decreased vision, undergoes a comprehensive examination – and it necessarily includes measuring eye pressure. Thus, if cataracts and glaucoma develop on the same eye, the first helps to identify the second.

But what if the patient has both diseases in the same eye requiring surgical treatment?

As a rule, in such cases, a combined operation is performed. The difficulty is that cataract and glaucoma operations differ significantly in technology. Therefore, this type of surgery should only be performed by very experienced surgeons.

Standardized cataract surgery – ultrasound phacoemulsification – is performed using ultrasound. This is a modern endoscopic method that allows you to perform an operation through a puncture with a diameter of not more than 2 mm, without further suturing. A flexible artificial lens is implanted into this eye through this small puncture. The recovery period after such an operation is about a month, and the patient sees the first positive results on the second day after the operation.

I must say that although ultrasound is the “gold standard” of cataract surgery, extracapsular cataract extraction is sometimes more predictable – the older method, in which the incision reaches ten millimeters, has to be sutured – but despite this, it is this method that turns out to be more effective in a number of neglected cases.

How accessible are all these ophthalmic surgeries for Muscovites?

Both cataracts and glaucoma, we operate on compulsory medical insurance, with certain indications. If the patient wants to get an operation as soon as possible, or, for example, wants to implant a more expensive model of the lens, he goes to the paid services department.

The waiting period for a queue for cataract surgery under the compulsory medical insurance program is on average 6-8 months: it takes so much from the initial diagnosis by the district ophthalmologist to the day of the operation, including all preoperative examinations. By the way, in comparison with other European countries this is a rather short time: in the UK, for example, an average of about 2 years is expected for a free cataract surgery.

As for glaucoma, here we are talking about irreversible blindness, which means the case is more urgent than cataracts. If the patient has a consistently high level of eye pressure according to the observation results, and conservative treatment does not bring the expected effect, then the patient’s path from diagnosis to surgery will be as short as possible – about two to three weeks. If the situation is less “acute”, the patient will be operated on as planned, usually within two to three months from the time of diagnosis.

For what reason can a patient be refused an ophthalmic surgery?

In the case of both cataracts and glaucoma, the complexity and neglect of the situation is not a contraindication: in any case, the specialists of the Botkin Hospital can cope with such complicated tasks. In general, the Russian surgical experience far exceeds the experience of many Western surgeons, precisely for the reason that we often have to work with very advanced cases.

The main argument in favor of the operation is the progression of the disease. As soon as the patient has glaucoma, we recommend that he undergo follow-up observation: about 3 times a year, he should be examined by a surgeon-ophthalmologist while undergoing drug therapy. If during the examinations we see that the disease has stabilized, it will be possible to postpone the operation, or to avoid it altogether. If the disease progresses, the patient is shown surgical treatment.

Are there any special methods and technologies for the surgical treatment of glaucoma in Russia?

For more than 20 years, the author’s method of glaucoma surgery, which was invented by my father, doctor of medical sciences Vladimir Ivanovich Lapochkin, has been widely used in surgery. The operation was developed on the basis of the rich clinical experience he received in the field of ophthalmology and surgery, and is called DALS: draining autoclap limbsclelectomy). A feature of this operation is the activation of two ways of the outflow of ocular fluid instead of one. Usually, during the anti-glaucoma operation, one pathway of the outflow of eye fluid is formed – under the conjunctiva, that is, under the mucous membrane of the eye. The DALS method provides for a second, uveoscleral outflow channel.

Doctors operation of DALS is performed only by doctors of your dynasty, or do you train other specialists?

Operation DALS refers to experiences that are important and useful to share. Now this method is widely used by Russian ophthalmologists. We often talk about him at professional conferences, record videos for colleagues, which describe, show and explain each stage in detail.

What can be done at the moment to sharpen the method even more, to make it more efficient?

At one time, together with my father and brother (Dmitry Vladimirovich Lapochkin – ophthalmologist, clinical experience of 9 years), we set ourselves the goal of popularizing and standardizing our patented operation. The idea came up to create a unique set of disposable tools for this anti-glaucoma operation. The fact is that each ophthalmologist surgeon in his practice chooses the “favorite” set of instruments – but not always the favorite instrument is optimal. In collaboration with a Russian plant that produces disposable medical instruments, we have begun to develop such a set of instruments. Over the course of a year and a half, we gave ideas and technical tasks, prototypes were sent to us in response, then we tried the instruments on pig’s eyes – and in the end we formed the final set. It has nine disposable instruments that are best suited for glaucoma surgery using the DALS method. At the moment, the set is undergoing the final stage of registration.

What tangible results can be achieved when a set of disposable tools is registered?

The main result is a guarantee that even a young specialist with these tools can easily master the technology. Each tool is designed specifically for a specific operation step, all the tools from the set are dosed to a certain depth – thus, the possibility of “cutting through the eye tissue” beyond the desired level is excluded. Then, a single-use kit reduces the risk of postoperative infection. Finally, this is a significant contribution to the import substitution program in the field of medicine. Currently, the work of Russian ophthalmologists is 95% dependent on imported disposable instruments. In our kit, some instruments simply have no analogues in Europe – while others successfully replace European ones.

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