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Antonio M. Fea, 1 Andrea Gilardi, 1 Davide Bovone, 1 Michele Reibaldi, 1 Alessandro Rossi, 1 Earl R. Craven21 Impamyabumenyi ya kaminuza y’ubumenyi bw’amaso ya Turin, Turin, mu Butaliyani;Kaminuza ya Johns Hopkins, Baltimore, Maryland, muri Amerika Ikigo cya Elmer Eye Institute Glaucoma Centre of Excellence Umwanditsi wandikiraga: Antonio M. Fea, +39 3495601674, imeri ) yatewe ab externo, urwenya rwo mumazi rujugunywa mumwanya muto.Yatejwe imbere nk'ubuvuzi bwizewe kandi butagabanuka ku barwayi bafite ubuvuzi bwa mbere butagenzuwe na glaucoma (POAG).Uburyo bwa kera bwo gushira MicroShunt burimo intambwe zitandukanye zingenzi, harimo gukora umufuka muto wa scleral ufite icyuma cya 1mm, kwinjiza urushinge rwa 25G (25G) unyuze mu mufuka wa scleral mu cyumba cyimbere (AC), hanyuma uruzitiro rukomeye 23-gauge ( 23G) Urumogi rusunika stent.Ariko, kwinjiza urushinge mumufuka wa scleral birema umuyoboro utari wo, bigatuma bigora guhuza igikoresho.Intego yiyi ngingo ni ugutanga uburyo bworoshye bwo gutera.Uburyo bwacu butanga igitekerezo cyo gukora umuyoboro wa scleral ukoresheje urushinge rwa 25G mu buryo butaziguye no gukoresha uru rushinge rwa 25G mu gihimba kugirango usunike gato sclera muri AC.MicroShunt yahise ikusanyirizwa kuri 23G ya kanseri yari ifatanye na siringi ya 1ml.Igikoresho kirashobora guhindurwa hamwe na syringe.Rero, gusohoka birashobora kwemezwa ako kanya nukwitegereza ibitonyanga byamazi biva mumbere ya stent.Ubu buryo bushya bushobora kugira inyungu zinyuranye nko kugenzura neza urubuga rwinjira, kwirinda ibice bitari byo, kugabanya cyangwa gukuraho ingaruka zo gusohoka kuruhande rwurwenya rwamazi, kuzamura inzira ibangikanye nindege ya iris, n'umuvuduko mwinshi.Amagambo shingiro: MIGS, glaucoma ifunguye, Preserflo, MicroShunt, kubaga glaucoma, kuyungurura subconjunctival.
Mu myaka mike ishize, kubaga byoroheje cyangwa kubaga byoroheje (MIGS) byagaragaye mubijyanye no kubaga glaucoma.1-5 Ibi bikoresho bya MIGS byakozwe kugirango bivurwe n’abarwayi batagenzuwe n’ubuvuzi bafite glaucoma yambere ifunguye (POAG) kugira ngo barusheho kunoza umutekano mu gihe bakomeza gukora neza kugira ngo bagabanye umuvuduko w’imitsi (IOP).1-5 ibikoresho bya MIGS birashobora kugabanywamo: trabecular, suprachoroidal, na subconjunctival.1,3 Subconjunctival isohoka yigana uburyo bwa trabeculectomy.Ugereranije na trabeculectomy, itanga umuvuduko ukabije wimbere yimitsi, itanga inzira zisanzwe numutekano mwinshi.1-5 Ibikoresho byose bya subconjunctival bishingiye kubitera tubule.Ibipimo bya lumen byibi bikoresho byagereranijwe ukoresheje ingero ya Hagen-Poiseuille.1 Mubisanzwe, lumen ihitamo gukumira hypotension idakira kandi ni nini bihagije kugirango wirinde kwifata.
Nubwo hari impaka zijyanye no gutekereza MicroShunt nka MIGS, kubwiyi nyandiko, ijambo MIGS rizakoreshwa kuri ryo.PreserfloTM MicroShunt yatewe vuba aha.6 Shunt igizwe na polystirene, blok ya isobutylene, polymer styrene yahoze ikoreshwa nka coronary stent kuko itera umuriro muke na encapsulation.7,8 Igikoresho gifite uburebure bwa mm 8,5 kandi gifite lumen ya 70 µm yo kugenzura imigendekere no gukomeza IOP hejuru ya 5 mmHg.(hamwe n'umusaruro ugereranije w'amazi).8 Uburebure bwigikoresho butuma amazi yinyuma asohoka, bityo rero birasabwa gutembera inyuma.
Muri rusange, quadrant ya oblique ni urubuga rwatoranijwe rwo gushyirwaho kuko rwirinda kugera kumitsi yo hejuru ya rectus.Imyitozo ya Mitomycin-C (MMC) hamwe nigihe cyo guhura cyatandukanye bitewe nimpamvu ziterwa nuburambe cyangwa kubaga.9-16
Muri make incamake igamije kwerekana ibindi byahinduwe muburyo bwo kwihuta kwa MicroShunt.
Gusubiramo inyandiko zubuvuzi byemejwe na komite ishinzwe imyitwarire ya kaminuza ya Turin.Kubera ko iyi yari isubiramo ryisubiramo ryubuvuzi, komite ishinzwe imyitwarire yanze icyifuzo cyo kubona uruhushya rwanditse rwanditse rwo kwitabira ubushakashatsi.Ariko, abitabiriye amahugurwa bose batanze uruhushya rwanditse mbere yo kubagwa.
Kugirango umenye neza abarwayi, amakuru yabo ntamenyekana hifashishijwe ibiranga byihariye.Porotokole y’ubushakashatsi yakurikije amahame y’itangazo rya Helsinki n’amabwiriza ngenderwaho y’ubuvuzi bwiza / Komite mpuzabikorwa mpuzamahanga.
Ubu bushakashatsi bwarimo abarwayi ba POAG bakurikiranye bafite imyaka 18 y’amavuko n’abarwayi bavuwe n’ibiyobyabwenge bafite IOP ≥ 23 mmHg mbere yo kubagwa batewe MicroShunt yigenga.
PRESERFLOTM MicroShunt (Santen ex Innfocus, Miami, FL, USA) itangwa mubikoresho bipakira sterile birimo marike ya mm 3 ya scleral, icyuma cya mm 1 ya mpandeshatu, 3 LASIK ShieldsTM (EYETEC, Antwerp, Ububiligi), ikimenyetso nubunini bwa 25 urushinge (25G).
Mbere yo gukoresha MicroShunt, uwabikoze arasaba kuzuza urumogi rwa 23G, rutashyizwe mubikoresho.
Mugihe ari inyongera kubaganga ba glaucoma bamenyereye uburyo bwa kera bwo gutera, zimwe muntambwe zirashobora kuba ingorabahizi.By'umwihariko, iyo urushinge rwa 25G rwanyerera, inama yarwo irashobora gukora umuyoboro utari wo / utari wo mu ndege itandukanye cyangwa ukinjira mu cyumba cy'imbere utageze hejuru y'umuyoboro wa scleral.Nukuri biragoye kugenzura inzira y'urushinge rwa 25G kuko umwanya uri imbere ya tunnel ya scleral ni virtual, cyangwa byibuze unanutse cyane (reba Ishusho 1).
Igicapo 1. Incamake yibyiciro byingenzi byubuhanga bushya bwo kubaga.(A) Urushinge rwashizweho kugirango rwinjire muri sclera 3 mm kuva kuruhande.(B) Urushinge rumaze kugera mu gihimba, rusunikwa hasi.(C) Urushinge rwinjira mucyumba cyimbere..
Rimwe na rimwe, iki kibazo gishobora gutuma kwinjiza microshunt mucyumba cyimbere (AC) bigoye kuko inama yacyo yafunzwe muri tunnel.Byongeye kandi, iyi manipulation irashobora kuba ingorabahizi mumaso hamwe na anatomiya idasanzwe.
Na none, niba igerageza rya kabiri ryananiwe, umuganga abaga ashobora guhatirwa gushyira igikoresho muburyo bwiza.Uru rubuga rukunze gukomeretsa nyuma kubera ko hari inda nini yo mu nda.
Kugira ngo wirinde iki kibazo, inzira imwe ni ugutera AK hamwe nisonga rya microknife ikoreshwa mugukora umufuka wa scleral.Mugihe ubu buryo butwara igihe kandi bukabuza kurema paragarafu zitari zo, birashobora kugorana kugereranya uburebure bwa AC yinjira.Byongeye kandi, imiterere ya mpandeshatu yicyuma isobanura inzira nini, itera urujya n'uruza mugihe cyambere yo gutangira.Dukurikije amategeko ya Poiseuille, urujya n'uruza kandi rutesha agaciro kugerageza gukora amazi yatanzwe muri AC, ashobora kugira uruhare mu iterambere rya hypotension.
Tekinike yacu yo kubaga itanga ibintu bibiri kunoza uburyo bwo kubaga gakondo.Icya mbere ni ugukoresha mu buryo butaziguye urushinge rwa 25G nk'umuyoboro.Nkiterambere rya kabiri, tekinike yacu itanga igitekerezo cyo gufatira urumogi rwa 23G, rusanzwe rukoreshwa mubyifuzo byamavuta ya silicone, kumpera yinyuma ya MicroShunt.Kubwibyo, umuganga ashobora guhanagura igikoresho mugihe cyo gushiraho urudodo.
Gukoresha urushinge rwa 25G kugirango ukore umuyoboro worohereza uburyo bwo kubaga kuko bikuraho ibikenerwa mu mufuka wa scleral kandi bigabanya cyane agace ka scleral kagira uruhare mubikorwa.Byongeye kandi, iri terambere rifasha kugabanya kwangirika kwigihe kirekire kwangirika kwingirabuzimafatizo ya endoteliyale mugukanda sclera mugihe yegereye ingingo, bityo ikinjira muri iris mumurongo ugereranije (reba Ishusho 1 na videwo yinyongera).
Iterambere rya kabiri ritangwa nikoranabuhanga rishya ni ugukoresha urumogi 23 G, rusa na kanseri isanzwe ikoreshwa mu kwifuza amavuta ya silicone.Iyi 23G cannula ikosora neza MicroShunt kandi ikoroha guhindagurika.Byongeye kandi, amazi yatewe muri AC nayo yongera umuvuduko, bigatuma urwenya rwamazi rutembera mumpera ya kure yigikoresho (reba Ishusho 1 na videwo yinyongera).
Ubunararibonye bwacu mubuvuzi bwarimo amaso 15 yabarwayi 15 ba OAG batewe microshunt yigenga bakurikiranwa amezi 3.Nubwo hari amakuru yerekana umuvuduko ukabije wibiyobyabwenge bigabanya imiti nigitutu cyimitsi igabanya imiti, intego yacu nyamukuru kwari ukwibanda kubibazo bitangiye nyuma yo kubagwa.
Abarwayi bose bari Caucase, median (interquartile range, IqR) imyaka yari 76.0 (intera 71.8 kugeza 84.3), 6 (40.0%) bari abagore.Ibyingenzi byingenzi biranga demokarasi nubuvuzi byavuzwe mu mbonerahamwe ya 2.
Hagati (IqR) IOP yagabanutse kuva 28.0 (27.0 kugeza 32.5) mm Hg.Ubuhanzi.mu ntangiriro yubushakashatsi kugeza 11.0 (10.0 kugeza 12.0) mm Hg.Ubuhanzi.nyuma y'amezi 3 (Itandukaniro rya Hodges-Lehman: -18.0 mmHg, 95% intera yicyizere: -22.0 kugeza -14.0 mmHg, p = 0.0010) (Ishusho 2).Mu buryo nk'ubwo, umubare w'imiti igabanya ubukana bw'amaso wagabanutse cyane uva ku miti 3.0 (2.2-3.0) ku bipimo fatizo ugera ku biyobyabwenge 0.0 (0.0-0.12) mu mezi 3 (Hodges-Lehman bivuze itandukaniro: -2.5 ibiyobyabwenge) Ibiyobyabwenge, 95% CI: -3.0 kugeza -2.0 Ibiyobyabwenge, p = 0.0007).Nyuma y'amezi 3, ntanumwe mu barwayi wafashe imiti ya sisitemu kugirango agabanye IOP.
Igishushanyo 2 Bisobanura umuvuduko w'amaraso mugihe cyo gukurikirana.Utubari duhagaritse twerekana intera intera. * p <0.005 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kubigereranya byombi byakozwe nuburyo bwo Guhindura). * p <0.005 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kubigereranya byombi byakozwe nuburyo bwo Guhindura). * p <0. * p <0.005 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kubigereranyo byombi byakozwe nuburyo bwa Conover). * p <0.005 与 基线 相比 （弗里德曼 检验 和 比较 的 over over over Guhindura 方法 完成 的）。 * p <0.005 * p <0. * p <0.005 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya hoc kubigereranyo byombi byakozwe hakoreshejwe uburyo bwa Conover).
Ubushishozi bugaragara bwaragabanutse cyane kumunsi wa 1, icyumweru 1, nukwezi 1 ugereranije nagaciro mbere yo gutangira, ariko byagaruwe kandi bihinduka kuva mukwezi kwa 2 (Ishusho 3).
Umuceri.3. Gusubiramo median ikosowe cyane intera igaragara (BCDVA) mugihe cyo gukurikirana.Utubari duhagaritse twerekana intera intera. * p <0.01 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kubigereranya byombi byakozwe nuburyo bwo Guhindura). * p <0.01 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kubigereranya byombi byakozwe nuburyo bwo Guhindura). * p <0. * p <0.01 ugereranije na baseline (Ikizamini cya Friedman na post hoc yo kugereranya byombi byakozwe hakoreshejwe uburyo bwa Conover). * p <0.01 与 基线 相比 （Friedman 检验 和 成对 比较 的 事后 分析 是 over Guhindura 方法 完成 的）。 * p <0.01 * p <0. * p <0.01 ugereranije na baseline (Ikizamini cya Friedman hamwe nisesengura rya post hoc kugereranya byombi byakozwe hakoreshejwe uburyo bwa Conover).
Ku bijyanye n’umutekano, amaso abiri (13.3%) yagize hyphema (hafi mm 1) kumunsi wambere wibikorwa, byakemuwe burundu mugihe cyicyumweru.Igice cya choroidal periferique cyabaye mumaso atatu (20.0%), cyakemuwe neza nubuvuzi mugihe cyukwezi kumwe.Nta n'umwe mu barwayi wasabye ko habaho ubundi buryo bwo kubagwa.
Amakuru aboneka muri iki gihe asuzuma imikorere n'umutekano bya MicroShunt yerekana ibisubizo bitanga icyizere, nubwo ari bike.9-16 Ubunararibonye bwo kubaga nibisubizo byubuvuzi nibyingenzi mugutezimbere no koroshya tekinike yo kubaga.
Muri iyi ngingo, tugamije kwerekana tekinike yihuse, ihamye, kandi yoroshye yo gushira iki gikoresho.Amavuriro yubuvuzi yateguwe kugirango ashakishe ibibazo hakiri kare bishobora kuba bifitanye isano nuburyo, kandi ntibisesengure imikorere yabyo.
Igikoresho gifite imbavu ebyiri zuruhande, imikorere yibikorwa byayo ni ukurinda urujya n'uruza rwa MicroShunt.6,8 Uburyo bwa gakondo burimo gukoresha icyuma cya mpandeshatu kugirango habeho umufuka muto wa scleral umufuka winyuma wa limbus na mm 3 zegeranye na limbus kugirango wakire utwo dusimba twuruhande.Nyamara, uburebure bwacyo no kuba umufuka wa scleral utangira mm 3 uvuye mu gihimba bituma igikoresho gisohoka cyane mu cyumba cyimbere.Kubera iyo mpamvu, ni gake dushyira ibikoresho byimbavu munsi yumufuka wa scleral mugihe dukoresheje tekinike ya kera kugirango twirinde gukura kwicyuma mubyumba byimbere.
Hamwe nikoranabuhanga ryacu, stent ni ubuntu kwimuka no kwimuka nkuko imbavu zishobora kuboneka munsi ya capon ya Tenon.Ariko, twakagombye gushimangira ko nta dislokisiyo yabayeho murugero rwacu.
Gukoresha inshinge zo gukora tunnel ya scleral kubikoresho byamazi byatewe ntabwo ari shyashya.Albis-Donado n'abandi.[]
Muri tekinike yacu, twakoresheje 25G hamwe na diametre yo hanze ya mm 0,515 mm hamwe n'uburebure bwa metero 3 kugeza kuri 4, byari bihagije kugirango igikoresho kibe neza.Urebye diameter yo hanze ya MicroShunt ya 0.35mm, ukoresheje stylus ntoya bishobora kuvamo gufata neza no gutembera kuruhande.Urushinge 26 (0.466), 27G (0.413), cyangwa 28G (0.362) rushobora gukoreshwa, ariko ntabwo dufite uburambe hamwe ninshinge nto za diameter.Iyindi nyigisho yo hagati nigihe kirekire irakenewe kugirango dusuzume aya mahitamo.
Ikindi kibazo gishobora guterwa nubu buhanga ni isuri ya scleral.Ariko, twakagombye kumenya ko tekinike nkiyi ikoresheje microvitreoretinal ya 20G18 cyangwa urushinge runini 22-23G17 rwasobanuwe kubitera Molteno nta kwimuka cyangwa isuri18 na Ahmed hamwe no gukuramo imiyoboro mike (4/186).17
Tekinike ya inshinge ifite ibyiza byinshi muburyo bwo guhinduranya gakondo, nkuburyo bwihuse, inzibacyuho ishimishije hagati ya conjunctiva na cornea, hamwe no kuba hasi yibibyimba byuzuye kandi bibabaza.17,18 Byongeye kandi, ubushakashatsi bwombi bwerekanye ko kutabora kwangirika bifitanye isano no guhuza imiyoboro n'umuyoboro, bikaviramo kugabanuka no kwambara.17.18
Ku bijyanye n’umutekano, igipimo cy’ibibazo nyuma yo kubagwa bigaragara ko kiri hejuru cyane ugereranije n’izindi ngingo, ariko twakagombye kumenya ko twitaye cyane ku gutanga raporo ndetse n’ibibazo biterwa na porosike muri iyi ngingo, ariko nta nimwe muri izo ngorane yari ifite akamaro k’ubuvuzi. .
Nubwo ikibazo cya tunnel zitigeze zivugwa mubushakashatsi bwabanje9-16, iyi ngorane idahwitse irashobora kubaho kandi igatera kurema undi muyoboro wuruhande, byongera ibyago bya hyphema kandi birashoboka ko byafata umwanya.umwanya muto.
Iyi raporo ngufi ifite aho igarukira igomba kuvugwa.Muri ibyo, icy'ingenzi ni urugero ntarengwa rw'icyitegererezo, igihe gito cyo gukurikirana, no kubura itsinda rishinzwe kugenzura.Nyamara, iyi ngingo isobanura uburyo butezimbere cyane kwinjiza microshunt hamwe nigipimo kimwe cyibibazo bitangirana na operasiyo hakiri kare hamwe nuburyo busanzwe.9-16
Mu gusoza, gukoresha urushinge kugirango habeho inzira idasanzwe yerekanaga ibisubizo bitanga umusaruro muri iri tsinda rito ryabarwayi.Imikoreshereze yacyo irashobora kuba ingirakamaro cyane mugihe hariho ibindi bikoresho bigabanya umwanya.Ubundi bushakashatsi burakenewe kugirango hamenyekane igihe kirekire cyubu buhanga hamwe ninyungu zishobora guterwa inshinge nto.
Serivisi zo kwandika no kwandika zitangwa na Antonio Martínez (MD), Ciencia y Deporte SL, hamwe n'inkunga itagabanijwe na kaminuza ya Turin.
Abanditsi kandi barashimira A Mazzoleni, L Guazzone, C Caiafa, E Suozzo, M Pallotta, na M Grindi ku bufatanye bwabo mu gihe cyo kwiga.
Dr. Antonio M. Fea ni umujyanama wa Glaukos, Ivantis, iSTAR, EyeD, akaba n'umujyanama uhembwa AbbVie, usibye n'akazi katanzwe.Dr. Earl R. Craven kuri ubu ni umukozi wa AbbVie kandi atanga raporo kuri Santen ku giti cye usibye imirimo yatanzwe.Abanditsi bavuga ko nta yandi makimbirane ashimishije muri iki gikorwa.
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2. Bar-David L., Blumenthal EZ Ubwihindurize bwo kubaga glaucoma mumyaka 25 ishize.Rambam Maimonides Med J. 2018; 9 (3): e0024.DOI: 10.5041 / RMJ.10345.
3. Mathew DJ, waguzwe na YM.Kubaga byibuze glaucoma kubaga: gusuzuma kunenga ibitabo.Annu Rev Vis Sci.2020; 6: 47-89.doi: 10.1146 / annurev-iyerekwa-121219-081737
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5. Pereira ICF, van de Wijdeven R, Wyss HM n'abandi.Glaucoma gakondo hamwe nibikoresho bishya bya MIGS: gusubiramo byimazeyo amahitamo agezweho hamwe nicyerekezo kizaza.Ijisho.2021; 35 (12): 3202–3221.doi: 10.1038 / s41433-021-01595-x
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7. Pinchuk L, Wilson J, Barry JJ n'abandi.Gukoresha ubuvuzi bwa poly (styrene-blok-isobutylene-block-styrene) (“SIBS”).ibinyabuzima.2008; 29 (4): 448–460.doi: 10.1016 / j.ibinyabuzima.2007.09.041
8. Beckers Yu.M., Pinchuk L. Kubaga byibuze glaucoma ukoresheje uburyo bushya bwa Ab-exerno subconjunctival shunt - imiterere nibisubirwamo.Igitabo cy’amaso y’iburayi 2019; 13 (1): 27-30.doi: 10.17925 / EOR.2019.13.1.27