RU2180204C2 - Method for treating the cases of hemophthalmia - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves exposing vitreous body to YAG-laser radiation. Treatment mode is selected for preventing vitreous body fibrils destruction and causing circulation inside of the vitreous body to take place. Fibrinolytic agent is injected under the conjunctiva after performing surgical intervention. EFFECT: full-scale hemophthalmia resorption; reduced risk for destructive formation, detachment of the retina and repeated hemorrhages to arise.

Description

 The present invention relates to medicine, namely to ophthalmology, and can be used to treat hemophthalmus.

 It is known that the most common cause of destruction of the vitreous body is intraocular hemorrhage, noted in 20-75% of all cases of eye injuries (R. Gundorova - Penetrating wounds and eye contusions. // M., - 1975, - S. 133-145 ), and that hemophthalmus leads to the subsequent formation of a bollard in the vitreous body, which play a role in the pathogenesis of post-traumatic retinal detachment and subatrophy of the eyeball (R. Gundorova et al., Eye injuries. // M., - Medicine, -1986, - 310 s.).

 Vitreous degeneration is observed already from the second week after traumatic hemorrhage (P. Lebehov - Intravitreal enzyme therapy and early vitreous transplantation in experimental hemophthalmia. // Bulletin of Ophthalmology, -1980, - 2, - P. 26).

 Various treatment methods are used. Some authors recommend conservative treatment (A. Romashchenko - Hematocoagulating and fibrinolytic factors of the eye and their role in the pathogenesis of resorption of traumatic hemophthalmus. // Diss .... Candidate of Medical Sciences, - M., - 1978, - 180 p. ) and suggest the use of trypsin, papain, fibrinolysin, urokinase, streptokinase, streptodecase (Gundorova R.A. et al. - Free radical oxidation and pathogenetically oriented treatment of traumatic hemophthalmus. // M., ed. VNIIMI, -1988, -176 p.).

 Others are supporters of surgical interventions using devices - vitreophages or vitreotomes (Fedorov S.N. et al. - Removal and replacement of the vitreous body with physiological saline using vitreotomy. // Bulletin of Ophthalmology, - 1974, - 3, - P. 24-27 ) But even closed operations are not completely atraumatic. After posterior vitrectomy, repeated vitreous hemorrhage, postoperative retinal detachment is observed, and after anterior closed vitrectomy, a hyphema and severe descemetitis (Krasnov M.M. et al. - Questions of reconstructive vitreous surgery. // Reconstructive ophthalmosurgery, - M., - 1979, S. 115-119).

 Along with the insufficient effectiveness of therapy for extensive hemorrhages, the development of enzyme-surgical treatment methods for hemophthalmus and other opacities of the vitreous body is promising.

 The desire to maximize the preservation of the unchanged vitreous body and the data of experimental hemolysis and organization of hemophthalmus presented the possibility of artificial enhancement of hemolysis of the remaining blood before surgery for partial hemophthalmus. For this, an immobilized streptodecase enzyme was selected that does not affect healthy vitreous fibrils and other tissues (A. Romashchenko et al. - Vitrectomy in the treatment of traumatic hemophthalmus. Actual issues of eye surgery. // Sb. Scientific Scientific Research Institute of Ch. diseases, - Ufa, -1986, - S. 93-97). Clinically, the very next day, signs of violent hemolysis are determined. 2-3 days after the administration of the drug, a sclera is cut in the flat part of the ciliary body and using the vitreophage, the tip of which is inserted into the vitreous body through this cut, the vitreous is perfused in the aspiration mode and only occasionally the cutting mechanism is activated when obstruction of the suction opening occurs . The operation is completed after restoration of the vitreous transparency. The use of this method allows you to save not deleted more than 2/3 of the volume of the vitreous body during such an operation, without any side effects and the formation of dense opacities in the postoperative period (A. S. S. U. 1309980, - 1985). This method is taken as a prototype.

 A method has been proposed that includes crossing the moorings formed after organizing the hemophthalmus in the vitreous, using a Q-switched YAG laser to weaken the traction effect on the retina and form an optical channel in the central part of the vitreous (Fankhauser F. - The Q-switched laser : principles and clinical results.// Trokel SL (ed.). YAG laser ophthalmic microsurgery. - Appleton-Century-Craefts, -1983, -P. 101-146).

 The above works have proved to be excellent for the treatment of hemophthalmus and its consequences. However, surgical treatment of hemophthalmus is associated with a risk of repeated bleeding and the formation of retinal detachment. Even the method proposed by V.P. Bykov et al, with a change in the thick structure of hemorrhage to a liquid substance and its removal by aspiration, requires an surgical incision in the membranes of the eye, which will lead to collapse of the eyeball and additional complications. YAG laser destruction of cords and membranes of organized hemophthalmus, as a result of impact on the moorings, leads to retinal detachment or bleeding from neovascular vessels in the thickness of the mooring line.

 The proposed method is based on the fact that the treatment of hemophthalmus is carried out in the initial period after the occurrence of hemophthalmus, without compromising the integrity of the eyeball, strictly dosed under the supervision of an ophthalmic surgeon in the optimal energy YAG laser mode without affecting the moorings, vitreous membranes and the retina and in sufficient creating circulation within the vitreous body. The introduction of a fibrinolytic solution under the conjunctiva immediately after the YAG laser exposure enhances the hemolysis process many times against the background of mixing the vitreous body, increases the volume of exposure to fibrinolytic and ionization products after laser irradiation.

 The technical result of the method is to achieve resorption of blood in the vitreous body without surgical instrumental intervention.

 The technical result is achieved due to the fact that the YAG laser destroys the initial clots (without violating the integrity of the vitreous fibrils) and increases the area of contact of blood and fibrinolytic by circulating the vitreous fluid by a hydrodynamic wave generated by the YAG laser impact on the vitreous body, followed by the introduction of fibrinolytic under the conjunctiva, thereby accelerating the process of fibrinolysis due to fragmentation, mixing of the initial hemophthalmus and enhancing oxidative restoration processes in the vitreous body after YAG laser irradiation and exposure.

 The method is as follows.

 After conducting a clinical examination and localization of hemophthalmus according to ultrasound data (clarification of the volume, density of opacities in the vitreous body), a YAG laser is applied to the vitreous body under conditions of maximum mydriasis under outpatient conditions under local anesthesia in a mode that does not allow destruction of the vitreous fibrils and causing movement of the vitreous body by a shock or hydrodynamic wave. Immediately after the YAG laser exposure of the blood in the vitreous body, a fibrinolytic solution in a therapeutic dose is administered under the conjunctiva, allowing you to resolve the hemorrhage independently. It requires a dose of fibrinolytic less than with its usual use. If necessary, the session is repeated until the hemophthalmus phenomena are eliminated. In between sessions, the standard instillation scheme used after any YAG laser treatment and IOP control are used.

 Example. Patient S., 35 years old, turned to a specialized ophthalmological institution with complaints of a lack of objective vision of the OS. From the anamnesis: I received a dull concussion when a ski stick hit the left eye, the same day I went to the ophthalmologist at the place of residence, where it was noted: visual acuity OD / OS = 1.0 / 0.4 n / a, IOP OD / OS = 22/20 mmHg. Objectively: OD - irritated, erosion of the cornea and wound of the conjunctiva in the lower quadrant, descemetitis. The anterior chamber is uneven and deeper below, hyphema 2 mm. The pupil is shifted down. The lens is intact in the vitreous body without visible hemorrhage. The fundus reflex is uniform. Assign and conduct a course of blood-absorbing therapy. Within 3 weeks, the state of the OS returned to normal.

 After 2 months, the patient developed OS hypotension - 16 mm Hg, visual acuity decreased to 0.02. Blood appeared in the vitreous. The patient was hospitalized for medical treatment according to the scheme. When an ultrasound study was performed 4 months after the injury, a conglomerate of destructive changes up to 2/3 of the vitreous volume, located in the middle section of the eyeball, is noted. After 1 month of active treatment, the eye condition did not improve.

 At 11 months after the injury, the patient turned for re-examination. Objectively: OD is calm, OS is irritated, pronounced conjunctival injection, conjunctival scar in the lower quadrant. The anterior chamber of uniform depth, with mydriasis, the appearance of destructive changes in the vitreous body associated with blood streaks is noted. On the periphery in the vitreous humor is a uniformly fine suspension. Fundus: not ophthalmoscopic. According to ultrasound: in the left eye there is a thickening of the outer shells, there is no retinal detachment. In the vitreous body, diffuse suspension and fixed turbidity up to 2/3 of the volume of the vitreous body, retinal detachment is not noted. According to electrophysiology, inhibition of the retinal excitation threshold is observed in the left eye. Visual acuity OD / OS = 1.0 / 0.01 n / k, IOP OD / OS = 24/16 mm Hg After analysis of the data obtained, the patient is offered surgical treatment of hemophthalmus.

 At the end of 11 months after the injury, the patient was admitted for re-treatment. The patient abstained from the recommended surgical treatment due to the risk of repeated hemorrhage at the time of vitreotomy.

 Under the conditions of an outpatient YAG laser cabinet, against the background of maximum mydriasis under the control of a contact lens, the patient undergoes YAG laser destruction (using a short-pulse neodymium YAG laser) of destructive vitreous conglomerates mixed with blood elements of different hemolysis intensities. The first session is completed with indicators: number of pulses 76, total energy 425 mJ with an average pulse energy of 5.6 mJ. After 15 minutes in the treatment room, the patient is administered 10,000 units under the conjunctiva. streptodekase.

 2 days after the operation, the OS condition is satisfactory - slightly irritated, the cornea is calm and spherical, the anterior chamber is of moderate depth, the iris is calm, the pupil's reaction is satisfactory to light, the vitreous suspension is moderate. Reflex from the fundus is expressed evenly. In the control ultrasound study, the membranes retain a thickening, there is no retinal detachment. OS visual acuity - 0.04 n / a. IOP OS within normal limits. At these indices, the YAG laser exposure was repeated at a pulse power of 4.9 mJ, a total energy of 289 mJ, and the number of pulses 63. Repeated subconjunctival injection of streptodease 10,000 units.

 1 week after the start of the course, single coarse fragments and a uniform weak suspension are noted in the vitreous body. Visual acuity of the OS - 0.2 n / a, IOP OS - the norm. According to ultrasound, there is no negative dynamics.

 3 months after the operation - the OS is calm, the anterior segment without dynamics. According to ultrasound, retinal detachment, a ciliary body were not detected, EFI - normalization of the main parameters. Visual acuity OS - 0.6 n / a, IOP OS - 20 mm Hg Recurrence of hemorrhage is not detected.

 As a result of the application of this method, it is possible to achieve resorption of hemorrhage in the vitreous body by the action of YAG laser radiation on the vitreous body with the movement of blood structures and the vitreous body without damaging the vitreous fibrils, which increases the area of active exposure of fibrinolytic and laser irradiation ionization products.

Claims (1)

 A method of treating fresh hemophthalmus, including the use of fibrinolytic, characterized in that the hemorrhage is first exposed to radiation by a short-pulse YAG laser in a regime that excludes the destruction of vitreous fibrils and allows circulation inside the vitreous.