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Antonio M. Fea, 1 Andrea Gilardi, 1 Davide Bovone, 1 Michele Reibaldi, 1 Alessandro Rossi, 1 Earl R. Craven21 Diploma ya Scientific Ophthalmological University of Turin, Turin, Italy;2 Johns Hopkins University, Baltimore, Maryland, USA Elmer Eye Institute Glaucoma Center of Excellence Wolemba wina: Antonio M. Fea, +39 3495601674, imelo [imelo yotetezedwa] Abstract: PRESERFLO™ MicroShunt ndi chipangizo chatsopano chopangira opaleshoni ya glaucoma yochepa (MIGS) ) kuikidwa ab externo, kuseketsa kwamadzi kumatsanuliridwa mu danga la subconjunctival.Yapangidwa ngati chithandizo chotetezeka komanso chosavutikira kwambiri kwa odwala omwe ali ndi glaucoma (POAG) yosalamulirika.Njira yachikale ya kuyika kwa MicroShunt imaphatikizapo njira zingapo zovuta, kuphatikiza kupanga kathumba kakang'ono ka scleral ndi tsamba la 1mm, kuyika singano ya 25G (25G) kudzera m'thumba la scleral muchipinda cham'mbuyo (AC), kenako ndi mipanda yopyapyala ya 23-gauge ( 23G ) Cannula imatulutsa stent.Komabe, kuyika singano mu thumba la scleral kumapanga njira yolakwika, zomwe zimapangitsa kuti zikhale zovuta kulumikiza chipangizocho.Cholinga cha nkhaniyi ndikupereka njira yophweka yoyikamo.Njira yathu ikuwonetsa kupanga scleral tunnel pogwiritsa ntchito singano ya 25G mwachindunji ndikugwiritsa ntchito singano iyi ya 25G mu limbus kuti ikankhire pang'ono sclera mu AC.MicroShunt idasonkhanitsidwa pa cannula ya 23G yomwe idalumikizidwa ndi syringe ya 1ml.Chipangizocho chikhoza kutulutsidwa ndi syringe.Chifukwa chake, kutuluka kumatha kutsimikiziridwa nthawi yomweyo powona madontho amadzi akutuluka kuchokera kunja kwa stent.Njira yatsopanoyi ikhoza kukhala ndi zopindulitsa zosiyanasiyana monga kulamulira bwino malo olowera, kupewa ndime zabodza, kuchepetsa kapena kuthetsa chiopsezo cha kutuluka kwa lateral kwa nthabwala zamadzimadzi, kupititsa patsogolo njira yofanana ndi ndege ya iris, ndi liwiro lalikulu.Mawu ofunikira: MIGS, glaucoma yotseguka, Preserflo, MicroShunt, opaleshoni ya glaucoma, kusefera kwapakati pa conjunctival.
M'zaka zingapo zapitazi, opaleshoni yocheperako kapena yochepa kwambiri (MIGS) yatulukira pa opaleshoni ya glaucoma.1-5 Zida za MIGSzi zidapangidwa kuti zithandizire odwala osayang'aniridwa ndichipatala omwe ali ndi glaucoma yotseguka (POAG) kuti apititse patsogolo chitetezo ndikusunga mphamvu yotsitsa intraocular pressure (IOP).Zida za 1-5 MIGS zitha kugawidwa kukhala: trabecular, suprachoroidal, ndi subconjunctival.1,3 Subconjunctival outflow imatsanzira njira ya trabeculectomy.Poyerekeza ndi trabeculectomy, imapereka kutsika kwapambuyo kwa postoperative, kumapereka njira zokhazikika komanso chitetezo chokulirapo.1-5 Zida zonse za subconjunctival zimachokera ku tubule implantation.Makulidwe a lumen a zida izi adayerekezeredwa pogwiritsa ntchito Hagen-Poiseuille laminar flow equation.1 Nthawi zambiri, lumen imasankhidwa kuti iteteze kutsika kwamphamvu kwa hypotension ndipo ndi yayikulu mokwanira kuti ipewe kutsekeka.
Ngakhale pali mkangano wokhudza MicroShunt ngati MIGS, pazolinga za chikalatachi, mawu akuti MIGS adzagwiritsidwa ntchito kwa iwo.The Preservlo TM MicroShunt implant yatulutsidwa posachedwa.6 Shunt imakhala ndi chipika cha polystyrene, chipika cha isobutylene, styrene polima chomwe chinkagwiritsidwa ntchito kale ngati coronary stent chifukwa chimayambitsa kutupa kochepa komanso kutsekemera.7,8 Chipangizocho ndi cha 8.5 mm kutalika ndipo chimakhala ndi lumen ya 70 µm kuwongolera kuyenda ndikusunga IOP pamwamba pa 5 mmHg.(ndi madzi apakati).8 Kutalika kwa chipangizochi kumapangitsa kuti madzi azituluka kwambiri kumbuyo, kotero kuti kudulidwa kwakukulu kumalimbikitsidwa.
Kawirikawiri, oblique quadrant ndi malo omwe amawakonda kwambiri kuti apangidwe chifukwa amapewa kupeza minofu yapamwamba ya rectus.Kukhazikika kwa Mitomycin-C (MMC) ndi nthawi zowonekera zimasiyanasiyana kutengera zomwe zimayambitsa chiwopsezo kapena zomwe dokotala wachita opaleshoni.9-16
Chidule chachidulechi chikufuna kufotokozeranso zosintha zina panjira yokhazikitsira mwachangu komanso kosavuta kwa MicroShunt.
Kuwunikiridwa kwa zolemba zachipatala kunavomerezedwa ndi Komiti ya Ethics ya University of Turin.Chifukwa uku kunali kuyang'ana m'mbuyo kwa zolemba zachipatala, komiti ya chikhalidwe cha anthu inasiya kufunika kopeza chilolezo cholembedwa kuti achite nawo kafukufukuyu.Komabe, onse omwe adatenga nawo mbali adapereka chilolezo cholembedwa asanayambe opaleshoni.
Kuti zitsimikizire zachinsinsi za odwala, zambiri zawo sizidziwika pogwiritsa ntchito zizindikiritso zapadera.Ndondomeko yophunzirira inatsatira mfundo za Declaration of Helsinki ndi Guidelines for Good Clinical Practice / International Coordinating Committee.
Kafukufuku wapano adaphatikizapo odwala POAG otsatizana ≥zaka 18 zakubadwa ndi odwala omwe amamwa mankhwala osokoneza bongo omwe ali ndi preoperative IOP ≥23 mmHg omwe adadzipangira yekha MicroShunt implantation.
PRESERFLOTM MicroShunt (Santen ex Innfocus, Miami, FL, USA) imaperekedwa mu phukusi losabala lomwe lili ndi 3 mm scleral marker, 1 mm triangular blade, 3 LASIK Shields TM (EYETEC, Antwerp, Belgium), chikhomo ndi kukula 2 singano (25G).
Musanagwiritse ntchito MicroShunt, wopanga amalimbikitsa kudzaza ndi cannula ya 23G, yomwe siyikuphatikizidwa mu kit.
Ngakhale ndizophatikizanso kuti maopaleshoni a glaucoma amadziwa bwino njira yopangira implant, zina mwazomwe zimakhala zovuta.Makamaka, pamene singano ya 25G ikudumpha, nsonga yake ikhoza kupanga njira yolakwika / yolakwika mu ndege ina kapena kulowa m'chipinda cham'mbuyo popanda kufika pamwamba pa scleral tunnel.Ndizovuta kwambiri kuwongolera njira ya singano ya 25G chifukwa danga mkati mwa ngalande ya scleral ndi yeniyeni, kapena yochepa kwambiri (onani mkuyu 1).
Chithunzi 1. Kufotokozera mwachidule magawo akuluakulu a njira yatsopano ya opaleshoni.(A) Singano idapangidwa kuti ilowe mu sclera 3 mm kuchokera m'mphepete.(B) Singano ikafika pachimake, imakankhidwira pansi.(C) Singano imalowa m’chipinda cham’mbuyo.(D) Pambuyo popanga ngalande yokhala ndi tsamba la katatu, njira ya singano yomwe imagwiritsidwa ntchito polowera m'chipinda cham'mbuyo sichingatsatire njirayo, ndikupanga njira yonyenga.
Nthawi zina, vutoli lingapangitse kuyika microshunt mu chipinda cham'mbuyo (AC) kukhala kovuta chifukwa nsonga yake yatsekedwa mumsewu.Kuonjezera apo, kusintha kumeneku kungakhale kovuta kwambiri m'maso ndi limbal anatomy yachilendo.
Komanso, ngati kuyesa kwachiwiri kukulepherabe, dokotalayo akhoza kukakamizidwa kuika chipangizocho mwadongosolo lopindulitsa.Tsambali limakonda kukhala ndi zipsera zotsatira chifukwa cha kupezeka kwapamwamba kwa rectus abdominis.
Pofuna kupewa vutoli, njira imodzi ndiyo kubaya AK ndi nsonga ya microknife yomwe imagwiritsidwa ntchito popanga thumba la scleral.Ngakhale njirayi imapulumutsa nthawi ndikulepheretsa kupanga ndime zolakwika, zingakhale zovuta kulingalira kutalika kwa AC yomwe ikubwera.Kuonjezera apo, mawonekedwe a katatu a tsamba amatanthauzira njira yokulirapo, yomwe imapangitsa kuti pakhale kutuluka kwapakati pa nthawi yoyambirira ya postoperative.Malingana ndi lamulo la Poiseuille, kutuluka kwapakati kumalepheretsanso kuyesa kupanga kutuluka kwa madzi kuchokera ku AC, zomwe zingathandize kuti chitukuko cha hypotension chikhale chochepa.
Njira yathu yopangira opaleshoni imapereka kusintha kuwiri kuposa njira zachikhalidwe zopangira opaleshoni.Choyamba ndikugwiritsa ntchito mwachindunji singano ya 25G ngati ngalande.Monga kusintha kwachiwiri, njira yathu ikufuna kulumikiza cannula ya 23G, yomwe imagwiritsidwa ntchito kwambiri popanga mafuta a silicone, kumapeto kwa MicroShunt.Choncho, dokotala akhoza kutulutsa chipangizochi mwachindunji panthawi yoika ulusi.
Kugwiritsa ntchito singano ya 25G kupanga ngalande kumapangitsa kuti opaleshoniyo ikhale yosavuta chifukwa imachotsa kufunikira kwa thumba la scleral ndipo imachepetsa kwambiri scleral area yomwe ikukhudzidwa ndi njirayi.Kuonjezera apo, kusintha kumeneku kumathandiza kuchepetsa kuwonongeka kwa nthawi yaitali kwa maselo a endothelial mwa kukanikiza sclera pamene ikuyandikira limbus, potero kulowa mu iris mu ndege yofananira (onani Chithunzi 1 ndi kanema yowonjezera).
Kusintha kwachiwiri koperekedwa ndi ukadaulo watsopano ndiko kugwiritsa ntchito 23 G cannula, yofanana ndi cannula yomwe imagwiritsidwa ntchito kwambiri pakulakalaka mafuta a silicone.Cannula ya 23G iyi imakonza MicroShunt bwino ndipo imapangitsa kuti ikhale yosavuta kutulutsa.Kuphatikiza apo, madzimadzi omwe amalowetsedwa mu AC amawonjezeranso kupanikizika, zomwe zimapangitsa kuti nthabwala zamadzi ziziyenda kumapeto kwa chipangizocho (onani Chithunzi 1 ndi kanema wowonjezera).
Zomwe takumana nazo pachipatala zidaphatikizapo maso a 15 kuchokera kwa odwala 15 OAG omwe adakhala ndi microshunt yodziyimira pawokha ndipo adatsatiridwa kwa miyezi itatu.Ngakhale pali deta yokhudzana ndi mankhwala ochepetsa kuthamanga kwa intraocular komanso mankhwala ochepetsa kuthamanga kwa intraocular, cholinga chathu chachikulu chinali kuyang'ana kwambiri zovuta zomwe zimachitika pambuyo pa opaleshoni.
Odwala onse anali Caucasian, zaka zapakati (interquartile range, IqR) zaka 76.0 (zosiyana 71.8 mpaka 84.3) zaka, 6 (40.0%) zinali akazi.Makhalidwe ofunikira a kuchuluka kwa anthu komanso azachipatala akufotokozedwa mwachidule mu Gulu 2.
Median (IqR) IOP idatsika kuchoka pa 28.0 (27.0 mpaka 32.5) mm Hg.Art.kumayambiriro kwa phunzirolo kufika pa 11.0 (10.0 mpaka 12.0) mm Hg.Art.pambuyo pa miyezi 3 (Hodges-Lehman kusiyana kwapakati: -18.0 mmHg, 95% nthawi yodalirika: -22.0 mpaka -14.0 mmHg, p = 0.0010) (Mkuyu 2).Mofananamo, chiwerengero cha ophthalmic antihypertensive mankhwala chinachepa kwambiri kuchokera ku 3.0 (2.2-3.0) mankhwala pachiyambi mpaka 0.0 (0.0-0.12) mankhwala pa miyezi 3 (Hodges-Lehman amatanthauza kusiyana: -2.5 mankhwala) Mankhwala, 95% CI: -3.0 ku -2.0 Mankhwala, p = 0.0007).Pambuyo pa miyezi itatu, palibe odwala omwe adamwa mankhwala ochepetsa IOP.
Chithunzi 2 Kutanthauza kuthamanga kwa intraocular panthawi yotsatila.Mipiringidzo yoyima imayimira milingo ya interquartile. *p <0.005 poyerekeza ndi chiyambi (mayeso a Friedman ndi post hoc kusanthula kwa mafananidwe awiriwa adachitidwa ndi njira ya Conover). *p <0.005 poyerekeza ndi chiyambi (mayeso a Friedman ndi post hoc kusanthula kwa mafananidwe awiriwa adachitidwa ndi njira ya Conover). * p <0,005                                                                                                           ] * p <0.005 poyerekeza ndi zoyambira (mayeso a Friedman ndi kusanthula kwa post hoc kwa mafananidwe awiriwa adachitidwa ndi njira ya Conover). *p < 0.005 与基线相比（弗里德曼检验和成对比较的事后分析是使用Conover 方法完成的）. p<0.005 * p <0,005                                                                                                                                                              . * p <0.005 poyerekeza ndi chiyambi (mayeso a Friedman ndi post hoc kusanthula kwa mafananidwe awiriwa anachitidwa pogwiritsa ntchito njira ya Conover).
Kuwoneka bwino kunachepa kwambiri pa tsiku la 1, sabata la 1, ndi mwezi wa 1 poyerekeza ndi zikhalidwe zoyendetsera ntchito, koma adachira ndikukhazikika kuyambira mwezi wa 2 (mkuyu 3).
Mpunga.3. Kubwereza za median maximally corrected distance visual acuity (BCDVA) panthawi yotsatila.Mipiringidzo yoyima imayimira milingo ya interquartile. *p <0.01 poyerekeza ndi zoyambira (mayeso a Friedman ndi kusanthula kwa post hoc kwa mafananidwe awiriwa adachitidwa ndi njira ya Conover). *p <0.01 poyerekeza ndi zoyambira (mayeso a Friedman ndi kusanthula kwa post hoc kwa mafananidwe awiriwa adachitidwa ndi njira ya Conover). *p < 0,01                      (критерий Фридмана ndi апостериорный анализ для попарных сравнений были выполнены по методу). *p <0.01 poyerekeza ndi zoyambira (mayeso a Friedman ndi kusanthula kwa post hoc kwa mafananidwe awiriwa adachitidwa pogwiritsa ntchito njira ya Conover). *p < 0.01 与基线相比（Friedman 检验和成对比较的事后分析是使用Conover 方法完成的）. *p<0.01 *p < 0,01   . *p <0.01 poyerekeza ndi chiyambi (mayeso a Friedman ndi post hoc kusanthula kwa mafananidwe awiriwa anachitidwa pogwiritsa ntchito njira ya Conover).
Ponena za chitetezo, maso awiri (13.3%) adapanga hyphema (pafupifupi 1 mm) pa tsiku loyamba la postoperative, lomwe linathetsedwa kwathunthu mkati mwa sabata.Zotumphukira za choroidal detachment zidachitika m'maso atatu (20.0%), zomwe zidathetsedwa bwino ndi chithandizo chamankhwala mkati mwa mwezi umodzi.Palibe odwala omwe amafunikira chithandizo chowonjezera cha opaleshoni.
Zomwe zilipo pakali pano zoyesa mphamvu ndi chitetezo cha MicroShunt zikuwonetsa zotsatira zabwino, ngakhale zili zochepa.9-16 Zochitika za opaleshoni ndi zotsatira zachipatala ndizofunikira kuti pakhale kusintha ndi kuphweka kwa njira za opaleshoni.
M'nkhaniyi, tikufuna kuwonetsa njira yachangu, yosasinthika, komanso yosavuta yoyika chipangizochi.Deta yachipatala ya njirayi idapangidwa kuti iyang'ane zovuta zoyambirira zomwe zingagwirizane ndi njirayi, osati kusanthula momwe zimagwirira ntchito.
Chipangizocho chili ndi nthiti ziwiri zam'mbali, ntchito yongoyerekeza yomwe ndikuletsa kutuluka kwa mbali ndikuyenda kwa MicroShunt.6,8 Njira zachikhalidwe zimaphatikizapo kugwiritsa ntchito tsamba la triangular kuti apange thumba lopanda scleral kumbuyo kwa limbus ndi 3 mm pafupi ndi limbus kuti agwirizane ndi zipsepse zam'mbalizi.Komabe, kutalika kwake komanso kuti thumba la scleral limayambira 3 mm kuchokera ku limbus kumapangitsa kuti chipangizocho chituluke kwambiri m'chipinda cham'mbuyo.Chifukwa cha izi, nthawi zambiri sitimayika zida zokhala ndi nthiti m'munsi mwa thumba la scleral tikamagwiritsa ntchito njira zakale kuti tipewe kukula kwa chipangizocho m'chipinda cham'mbuyo.
Ndi teknoloji yathu, stent ndi yaufulu kusuntha ndi kusuntha monga nthiti zimapezeka pansi pa capsule ya Tenon.Komabe, ziyenera kutsindika kuti palibe kusuntha komwe kunachitika mu zitsanzo zathu.
Kugwiritsiridwa ntchito kwa singano popanga ma scleral tunnel a zida zoyikira ngalande sikwachilendo.Albis-Donado et al.[17] adanenanso za zotsatira zabwino zachipatala kwa odwala omwe amaikidwa ndi Ahmed valve implantation ya glaucoma kudzera mumtsinje wa scleral wopangidwa ndi singano popanda kugwiritsa ntchito chigamba chophimba chubu.
M'njira yathu, tidagwiritsa ntchito 25G yokhala ndi mainchesi akunja a 0.515 mm ndi kutalika kwa 3 mpaka 4 mm, zomwe zinali zokwanira kusunga chipangizocho mosamala.Poganizira kukula kwa MicroShunt kwa 0.35mm, kugwiritsa ntchito cholembera chaching'ono kumatha kupangitsa kuti ikhale yolimba komanso kuyenda pang'ono.Singano 26 (0.466), 27G (0.413), kapena 28G (0.362) ingagwiritsidwe ntchito, koma tilibe chidziwitso chokhala ndi singano zazing'ono.Maphunziro ena apakati ndi apakati ndi aatali akufunika kuti awunike zosankhazi.
Vuto lina lomwe lingakhalepo ndi njira iyi ndi kukokoloka kwa scleral.Komabe, ziyenera kudziwidwa kuti njira yofananira yogwiritsira ntchito tsamba la 20G18 microvitreoretinal kapena singano yaikulu ya 22-23G17 yafotokozedwa kwa ma implants a Molteno popanda kusamuka kapena kukokoloka18 ndi Ahmed wokhala ndi chubu chochepa (4/186).17
Njira ya singano ili ndi maubwino angapo kuposa njira zachikhalidwe zoikamo, monga njira yofulumira, kusintha kosalala pakati pa conjunctiva ndi cornea, komanso kuchepa kwa matuza opweteka komanso opweteka.17,18 Kuphatikiza apo, maphunziro onsewa adawonetsa kuti kusakhalapo kwa dzimbiri kumalumikizidwa ndi chitoliro cholimba pakati pa chitoliro ndi ngalande, zomwe zimapangitsa kuchepa kwamphamvu komanso kuvala.17.18
Pankhani ya chitetezo, kuchuluka kwa zovuta zomwe zimachitika pambuyo pa opaleshoni zikuwoneka kuti ndizokwera kwambiri kuposa zomwe zafotokozedwa m'nkhani zina, koma ziyenera kukumbukiridwa kuti tachita chisamaliro chapadera kuti tifotokoze ngakhale zovuta za prosaic m'nkhaniyi, koma palibe zovuta zonsezi zomwe zinali zofunikira pachipatala. .
Ngakhale kuti zochitika za ngalande zabodza sizinafotokozedwe m'maphunziro apitalo9-16, vutoli la intraoperative likhoza kuchitika ndikupangitsa kuti pakhale njira ina yowonjezera, kuonjezera chiopsezo cha hyphema komanso mwinamwake kutenga malo.malo ocheperako.
Lipoti lachidule ili lili ndi zofooka zingapo zomwe ziyenera kutchulidwa.Mwa izi, zofunika kwambiri ndi kukula kwachitsanzo chochepa, nthawi yochepa yotsatila, ndi kusowa kwa gulu lolamulira.Komabe, nkhaniyi ikufotokoza njira yomwe imathandizira kwambiri kuyika kwa microshunt ndi mlingo wofanana wa intraoperative ndi mavuto oyambirira pambuyo pa opaleshoni monga njira zochiritsira.9-16
Pomaliza, kugwiritsa ntchito singano kupanga njira ya intrascleral kwawonetsa zotsatira zabwino m'gulu laling'ono la odwala.Kugwiritsa ntchito kwake kungakhale kothandiza makamaka ngati kupezeka kwa zida zina kumalepheretsa malo.Kufufuza kwina kumafunika kuti mudziwe kukhazikika kwa nthawi yayitali kwa njirayi komanso phindu la singano zing'onozing'ono.
Ntchito zolembera zachipatala ndi zolemba zimaperekedwa ndi Antonio Martínez (MD), Ciencia y Deporte SL, ndi ndalama zopanda malire zochokera ku yunivesite ya Turin.
Olembawo akufunanso kuthokoza A Mazzoleni, L Guazzone, C Caiafa, E Suozzo, M Pallotta, ndi M Grindi chifukwa cha mgwirizano wawo panthawi yophunzira.
Dr. Antonio M. Fea ndi mlangizi wa Glaukos, Ivantis, iSTAR, EyeD, ndi mlangizi wolipidwa kwa AbbVie, kuwonjezera pa ntchito yomwe yaperekedwa.Dr. Earl R. Craven panopa ndi wogwira ntchito ku AbbVie ndipo amafotokoza ndalama zaumwini kwa Santen kuwonjezera pa ntchito yomwe yaperekedwa.Olembawo akunena kuti palibe mikangano ina ya chidwi mu ntchitoyi.
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7. Pinchuk L, Wilson J, Barry JJ et al.Kugwiritsa ntchito mankhwala kwa poly(styrene-block-isobutylene-block-styrene) ("SIBS").biomatadium.2008;29(4):448–460.doi:10.1016/j.biomatadium.2007.09.041
8. Beckers Yu.M., Pinchuk L. Opaleshoni yochepa ya glaucoma yowononga kwambiri pogwiritsa ntchito Ab-exerno subconjunctival shunt - udindo ndi kubwereza mabuku.European Ophthalmological Edition 2019;13(1):27–30.doi: 10.17925/EOR.2019.13.1.27