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EVALUATION OF THE EFFECTIVENESS OF ENZYMATIC
TREATMENT IN POSTOPERATIVE COMPLICATIONS WITH
PRIMARY CONGENITAL INFANTILE GLAUCOMA
Yu.A. Kham oe a
Tashken S a e Medical Uni e si y, Tashken , Republic o Uzbekis an
h ps://doi.o g/10.5281/zenodo.17540044
Abs ac . This a icle is de o ed o he s udy o he e ec i eness o enzyma ic he apy in
he ea men o complica ions associa ed wi h ib inoid synd ome in he ea ly pos ope a i e
pe iod o p ima y congeni al in an ile glaucoma. The ollowing me hods and ma e ials we e used
in his s udy: In he oph halmology depa men o he mul idisciplina y child en’s clinic o
Tashken S a e Medical Uni e si y, 16 pa ien s (32 eyes) aged 3 o 10 yea s wi h a diagnosis o
p ima y in an ile glaucoma we e ea ed. Among he pa ien s, he e we e 10 boys (62.5%) and 6
gi ls (37.5%). All pa ien s unde wen su gical in e en ion. In he ea ly pos ope a i e pe iod,
complica ions such as ib inoid synd ome de eloped in some pa ien s. To ea his complica ion,
an enzyme p epa a ion wi h p o eoly ic ac i i y (Chymo ypsin 10,000 IU dilu ed in 4.0 ml o 0.9%
sodium chlo ide solu ion) was applied o he eyes acco ding o a speci ic egimen. Pa ien s who
de eloped complica ions in he ea ly pos ope a i e pe iod we e di ided in o h ee g oups
depending on he ype o complica ion:
G oup I: 8 pa ien s (16 eyes) wi h exuda i e eac ion.
G oup II: 3 pa ien s (6 eyes) wi h pigmen deposi s on he an e io capsule o he lens.
G oup III: 5 pa ien s (10 eyes) wi h hyphema o he an e io chambe .
Keywo ds: p ima y congeni al in an ile glaucoma, lens, in aocula hemo hage.
In oduc ion. Since 1993, epo s ha e appea ed in he li e a u e on he use o domes ically
p oduced u okinase and p ou okinase in oph halmology. These enzymes we e used o he
ea men o in aocula hemo hages and ib inoid synd ome a e lense i ec omy [1,2,3]. In
1996, E.V. Boyko and co-au ho s p oposed he use o a ecombinan p ou okinase p epa a ion o
he same pu pose [3]. The d ug was applied no only in cases o hemoph halmos bu also o o he
in aocula hemo hages such as hyphema, in a e inal, p e e inal, and sub e inal hemo hages. In
1999, his p epa a ion ecei ed he name “Gemase.”
Ini ially, Gemase was de eloped as a h omboly ic agen o he ea men o ca dio ascula
diseases. Howe e , nume ous s udies conduc ed by domes ic esea che s e ealed new po en ial
applica ions o his p epa a ion in oph halmology. Today, Gemase is widely used in he ea men
o acu e ci cula o y diso de s in he e inal essels [4,5], in aocula hemo hages and
pos ope a i e ib inoid synd ome [6,7,8,22], in aocula auma ic hemo hages [5,7],
hemoph halmos in pa ien s wi h diabe ic e inopa hy [8,9,18], as well as in he su gical
managemen o submacula hemo hages [10,11,21] and p oli e a i e diabe ic e inopa hy
[12,13,20].
The ac i e subs ance o Gemase is he ecombinan ib inoly ic p oenzyme p ou okinase,
p oduced by gene ically ans o med Esche ichia coli bac e ia [5]. The mechanism o ac ion o
Gemase is as ollows: unde he in luence o small doses o plasmin, p ou okinase is con e ed
in o he ac i e o m o plasminogen ac i a o —u okinase—which in u n ca alyzes he con e sion
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o plasminogen in o plasmin [6,6]. I is impo an o no e ha in a ib in- ee sys em, u okinase is
he mos ac i e plasminogen ac i a o [3,4].
Gemase is cha ac e ized by an almos comple e absence o alle genic p ope ies and a high
deg ee o speci ici y. I has an inc eased a ini y o ib in and is esis an o plasminogen ac i a o
inhibi o s [5]. Cu en ly, Gemase is widely used in oph halmology o imp o e he e ec i eness o
ea men o hemoph halmos o a ious o igins, hyphema, ib in exuda ion a e ca a ac
ex ac ion and lense i ec omy, h ombosis o he cen al e inal ein and i s b anches, p e-
h ombo ic condi ions, o co ec ing local hemos asis in diabe ic e inopa hy and i s hemo hagic
complica ions, as well as du ing an iglaucoma ous su ge ies o p e en adhesions and blockage o
he il a ion opening. The d ug demons a es high e icacy and almos comple e absence o side
e ec s [2,3,4,5].
Va ious me hods o Gemase adminis a ion ha e been desc ibed in he li e a u e:
subconjunc i al, in o he an e io chambe o he eye, pa abulba a a dose o 5000 IU, in a i eal
(500 IU), o by sub-Tenon implan a ion o a collagen in usion sys em. The highes concen a ion
o he d ug in he i eous body is achie ed wi h in a i eal adminis a ion [5,6,14,15]. Enzyme
he apy has become i mly es ablished in he a senal o oph halmologis s [6,7,8,19]. Enzyme-
based medica ions a e used o ea many diseases and a e especially e ec i e in he lysis o
h ombi and ib in [4–8].
A p esen , one o he main causes o isual impai men leading o disabili y emains he
combina ion o glaucoma and ca a ac . Acco ding o a ious au ho s, his combina ion is obse ed
in 17–76% o cases, and such a iabili y is qui e signi ican [12,13,14,15,16,17]. In 2000, Fedo o
S.N., Malyugin B.E., and Jndoyan G.T. de eloped and in oduced in o clinical p ac ice a new
me hod o ea ing glaucoma in eyes wi h ca a ac — enzyma ic abeculocleaning du ing
phacoemulsi ica ion. An impo an ea u e o his app oach was he in aocula use o enzymes in
he su gical ea men o glaucoma, whe e he in oduc ion o hemazum a a dose o 500 IU in o
he an e io chambe was combined wi h he hyd omechanical componen o abecula cleaning.
The ou come o his new su gical p ocedu e was an imp o emen in isual acui y and a s able
no maliza ion o in aocula p essu e and aqueous humo ou low pa ame e s [5,6]. Thus, he use
o enzyma ic he apy o complica ions in ol ing ib inoid synd ome in he ea ly pos ope a i e
pe iod emains ele an .
Objec i e o he s udy: o e alua e he e ec i eness o enzyma ic he apy o
complica ions wi h ib inoid synd ome in he ea ly pos ope a i e pe iod in p ima y congeni al
in an ile glaucoma.
Ma e ials and me hods. Unde ou obse a ion a he oph halmology depa men o he
mul idisciplina y child en's clinic o Tashken S a e Medical Uni e si y, 16 pa ien s (32 eyes) we e
ea ed, including 10 boys (62.5%) and 6 gi ls (37.5%) aged 3 o 10 yea s wi h p ima y in an ile
glaucoma. All pa ien s unde wen su gical ea men . In he ea ly pos ope a i e pe iod,
complica ions such as ib inoid synd ome we e ea ed using an enzyma ic (p o eoly ic)
p epa a ion adminis e ed in he o m o ins illa ions acco ding o he ollowing scheme:
chymo ypsin 10,000 IU dilu ed in 4.0 ml o 0.9% sodium chlo ide solu ion. The child en wi h
ea ly pos ope a i e complica ions associa ed wi h ib inoid synd ome we e dis ibu ed as ollows:
G oup I: pa ien s wi h ea ly pos ope a i e exuda i e eac ion — 8 pa ien s (16
eyes);
G oup II: pa ien s wi h pigmen deposi s on he an e io capsule o he lens — 3
pa ien s (6 eyes);
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G oup III: pa ien s wi h an e io chambe hyphema — 5 pa ien s (10 eyes).
To assess he con en o cells and p o ein in he aqueous humo , he able o de e mining
he deg ee o p o ein con en in aqueous humo (Hogan M.J. e al., 1959; SUN Wo king G oup,
2005) (Table 1) and he g ading sys em o p o ein concen a ion in he an e io chambe luid by
L.A. Ka snelson and V.E. Tanko sky (2003) (Table 2) we e used.
Table 1. Con en o Cells and P o ein in he Aqueous Humo
S ep
Desc ip ion
0
No exis
1+
Weak
2+
Mode a e ( he i is and lens a e clea ly isible)
3+
P onounced ( he i is and lens a e seen h ough a haze)
4+
Signi ican o in ense ( ib in o plas ic exuda e p esen )
Table 2. Deg ee o P o ein Con en in he Aqueous Humo o he An e io Chambe
S ep
Desc ip ion
0 (noy exis )
Aqueous humo is anspa en
1 (weak)
P o ein p esen in he an e io chambe , bu he s uc u e o he i is
and lens is clea ly isible
2 (p onuonced)
A signi ican amoun o p o ein in he an e io chambe ; he i is and
lens a e seen h ough a haze, bu hei s uc u e emains
dis inguishable
3 (maximum)
A la ge amoun o p o ein and ib in; he s uc u e o he i is and lens
is no dis inguishable
All pa ien s in he s udy g oups ecei ed he enzyma ic p o eoly ic d ug Chymo ypsin as
pa o hei comp ehensi e ea men , ollowing he o icial usage ins uc ions. Be o e su gical
and conse a i e ea men , all pa ien s unde wen a s anda d oph halmologic examina ion, which
included isome y, biomic oscopy, gonioscopy, oph halmoscopy, e ac ome y, onog aphy, and
onome y (10.0 g acco ding o Maklako ). Fo da a analysis, he esul s o he oph halmologic
examina ions we e p ocessed using s a is ical analysis me hods wi h he help o Mic oso Excel
and SPSS so wa e. Di e ences be ween he mean alues (M ± σ) we e conside ed s a is ically
signi ican a P ≤ 0.05.
Resul s and Discussion. Du ing he examina ion, i was es ablished ha in pa ien s o
G oup I— hose wi h exuda i e eac ion (8 pa ien s, 16 eyes)—a mode a e eac ion ( he i is and
lens clea ly isible) appea ed on he second day a e su ge y. In G oup II (3 pa ien s, 6 eyes), wi h
pigmen deposi s on he an e io capsule o he lens, pigmen cells om he i is we e ound in he
an e io chambe on he hi d pos ope a i e day. In G oup III (5 pa ien s, 10 eyes), wi h blood
elemen s (hyphema) in he an e io chambe , changes we e obse ed 4 hou s a e su ge y. To
elimina e ib inoid synd ome, he enzyma ic p o eoly ic d ug Chymo ypsin was added o he
comp ehensi e ea men egimen. On he hi d day, he deg ee o ib inoid synd ome was
e alua ed ac oss he g oups, and he esul s a e p esen ed in Table 3.
Table 3. E alua ion o Fib inoid Synd ome A e Comp ehensi e T ea men
Type o
con en
On he 1s day a e su ge y
On he 3 d day a e su ge y
On he 5 h day
a e su ge y
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Exuda ion
(p o ein)
Mode a e ( he i is and lens
a e clea ly isible) – 6
pa ien s (12 eyes)
Mild – 2 pa ien s (4 eyes)
Absen
Pigmen (i is)
Pigmen elemen s in he
an e io chambe ; he i is
and lens a e seen h ough a
haze, bu hei s uc u e
emains dis inguishable – 2
pa ien s (4 eyes)
Pigmen elemen s in he
an e io chambe , bu he
s uc u e o he i is and lens
is clea ly isible – 1 pa ien
(2 eyes)
Aqueous
humo is
anspa en
Hyphema
(blood
elemen )
A la ge amoun o blood
elemen s (hyphema); he
s uc u e o he i is and lens
is no dis inguishable – 3
pa ien s (6 eyes)
A signi ican amoun o
blood elemen s (hyphema)
in he an e io chambe ; he
i is and lens a e seen
h ough a haze, bu hei
s uc u e emains
dis inguishable – 1 pa ien
(2 eyes
Blood
elemen s
(hyphema) in
he an e io
chambe , bu
he s uc u e o
he i is and
lens is clea ly
isible – 1
pa ien (2
eyes)
Based on he esul s by g oups, exuda ion (p o ein) and pigmen (i is) a e su ge y we e
comple ely elimina ed (100%) in 20 eyes o 10 pa ien s, and by 75% in 2 eyes o 1 pa ien .
Hyphema (blood elemen s) was esol ed by 75% in 8 eyes o 4 pa ien s, and by 50% in 2 eyes o
1 pa ien . Acco ding o he ob ained da a, i can be concluded ha du ing complex ea men a e
an iglaucoma ous su ge y complica ed by he p esence o blood elemen s (hyphema), he hyphema
was esol ed by he 5 h pos ope a i e day, and he pigmen and p o ein elemen s we e elimina ed
by he 5 h day as well. When de e mining he cou se o ea men , i is necessa y o conside he
amoun o p o ein, pigmen , and he le el o hyphema, a e which he enzyma ic p epa a ion wi h
p o eoly ic ac i i y should be added indi idually in each case acco ding o he ins uc ions.
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