RU2230537C1 - Surgical method for treating the cases of exudative senile maculodystrophy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves forming subtenon canal to the posterior eye pole. Injection needle is introduced through a pierce in flat ciliary body part. The needle is set on syringe filled with physiological salt solution in the amount of 0.3-0.5 ml and sterile air. The needle is moved as far as the posterior eye pole and the physiological salt solution is injected until retinal central artery pulsations cease. Retina is pierced at a point of maximum retina detachment level without hurting foveal zone through choroid and sclera to perforate the latter. The needle is brought back to the eye cavity creating in this way subretinal fluid discharge conditions via the so formed sclerotomy in retrobulbar way. Laser coagulation is carried out. Eye cavity is filled with sterile air in concurrently forcing the subretinal fluid via the formed subtenon canal outward.

EFFECT: improved vision acuity; reduced risk of post-surgical complications.

3 dwg

Description

The invention relates to medicine, ophthalmology, and specifically to methods for surgical treatment of exudative senile macular degeneration.

Known methods of treating exudative senile macular degeneration, which include the appointment of drugs [1], laser coagulation [2], radical surgery [3, 4]. However, the above methods have the following disadvantages: the use of drug mono or complex (lipotropic, vasodilator, angioprotective, anticoagulant, enzyme, vitamin therapy, hormonal, oxygen, tissue, etc.) conservative therapy requires long-term inpatient treatment, has a short-term therapeutic effect and has a positive effect only and has a positive effect only and has a short-term therapeutic effect in the initial stages of the development of exudative senile macular degeneration, most of the drugs used have a number of serious pro tivopoindications and the possibility of developing individual intolerance; laser coagulation is effective only in the very early stages of the development of senile macular dystrophy to exudative retinal detachment; radical surgical methods (removal of transvitreal subretinal fluid) due to their technological complexity do not allow their widespread use in clinical practice.

The closest to the proposed method for the treatment of exudative senile macular degeneration by the achieved positive effect is the method of photodynamic therapy, which consists in irradiating the newly formed vessels of the macular zone with a low-intensity laser when the photosensitive Visudyne passes through them (the drug is injected intravenously), when exposed to laser radiation, the drug absorbing , activates and destroys damaged microvessels, thus hindering the further process from degeneration, but the application of the above method is not accompanied by an increase in visual acuity of patients and does not exclude the possibility of further progression of retinal degenerative process [5].

A new technical result - an increase in visual acuity and a decrease in the number of complications associated with drug intolerance, as well as a decrease in the percentage of complications arising from intravitreal surgical interventions - is achieved by a new method of surgical treatment of exudative senile macular degeneration, which consists in the effect on choroid vessels, and under the general an anesthesia and / or local anesthesia form a subtenoneal channel leading to the posterior pole of the eye, for which a quadrant nectives with a tenon shell from the sclera, then in the region of the flat part of the ciliary body, an injection needle is inserted through the sclera, dressed in a 5 ml syringe filled with saline in a volume of 0.3-0.5 ml, and sterile air, and under the control of a binocular ophthalmoscope with a laser nozzle; the needle is advanced to the posterior pole of the eyeball, then intraocular pressure is increased by injecting saline until the pulsation of the central retinal artery ceases, then, moving the needle forward, a puncture through the retina is made at the point of the highest level of detachment, without touching the foveal zone, through the choroid and sclera before the perforation of the latter, after the through hole in the sclera is formed, the needle is returned to the eye cavity, creating the possibility of outflow of subretinal fluid through the resulting sclerotomy trobulbar, after retinal expansion, laser coagulation is performed around retinotomy and, if necessary, other types of laser coagulation depending on the area of the detached retina, after laser coagulation, the syringe piston is moved further, filling the eye cavity with sterile air, squeezing out fluid from the eye cavity into the retrobulbar space and through the formed subtenoneal channel outward, after which the needle is removed from the eye, a nodal suture is placed on the conjunctivotomy, subconjunctival is introduced and antibiotic treatment, and dexamethasone in standard dosages. During the day, the patient is recommended to be face down.

The method is as follows. Preoperative medical history and necessary laboratory tests of blood and urine, the full therapeutic treatment of concomitant vascular pathology (if possible), determination of visual acuity, biomicrophthalmoscopy (as far as possible fluorescence angiography); before surgery, the patient is measured blood pressure on both hands; dilate the pupil; conduct preoperative premedication; in the operating room, the surgical field is treated, retrobulbar anesthesia; fix eyelids with an expander; the operation is carried out under the control of an ophthalmoscope with a laser nozzle.

The operation is carried out in 2 stages:

At the first stage, with the help of conjunctival scissors, a conjunctivotomy and tenonotomy are performed from above from outside the limbus with the formation of a subtenoneal channel going to the posterior pole of the eye; In the area of the flat part of the ciliary body, an injection needle is inserted, dressed in a 5 ml syringe filled with 0.3-0.5 ml of saline, and sterile air, and under the control of a binocular ophthalmoscope with a laser nozzle, the needle is inserted to the posterior pole of the eyeball, then an increase intraocular pressure due to the introduction of saline until the pulsation of the central retinal artery ceases (Fig. 1); then the needle is passed through the retina, making a puncture at the point of the highest level of detachment, without touching the foveal zone, through the choroid and sclera until the latter is perforated (Fig. 2), after the through hole in the sclera is formed, the needle is returned to the subretinal space, creating the possibility of outflow of subretinal fluid through the resulting sclerotomy retrobulbar; after reaching the retina contact with choroid, the needle is removed into the preretinal space.

At the second stage, after the retina is flattened, laser coagulation is performed around the retinotomy and, if necessary, depending on the area of the detached retina, other types of laser coagulation (barrage of the macular zone of the retina, laser coagulation in the form of a “lattice”, etc.), after the laser coagulation is performed, the syringe piston is advanced further, filling the eye cavity with sterile air, simultaneously squeezing the fluid from the eye cavity into the retrobulbar space and through the formed subtenoneal channel to the outside, after which the needle is removed from the eyes a; a nodal suture is applied to conjunctivotomy, antibiotic and dexamethasone are administered subconjunctively in standard dosages. The patient is recommended to be face down during the day to improve contact between the retina and choroid.

Example Patient Ch., 79, retired, was admitted to the clinic of eye diseases of the Siberian State Medical University on February 26, 2002 with a diagnosis of senile wet macular degeneration with exudative retinal detachment of the left eye. Objectively: ECG - normal position of the axis of the heart, sinus rhythm, moderate diffuse changes in the myocardium; AD-140/80 mm Hg; OAK and OAM without pathology; Visus - OS-0.01; perimetric data - central scotoma within 5-30 ° from the fixation point; fundus picture - exudative retinal detachment extending beyond the vascular arcade of the macular zone. 03/26/2002, the operation was performed on the left eye according to the proposed method according to the claims. Patient care is carried out according to generally accepted standards. Objectively after surgery: on the 10th day, the air was replaced by intraocular fluid; additional laser coagulation of the macular zone; visual acuity - 0.06; absolute scotoma disappeared, the retina is adjacent throughout.

Justification of the method: the specified technical result is achieved by using the proposed surgical techniques to create conditions for optimal contact between the retina and the choroid, which allows you to cause an adequate laser burn in the macular zone, thus creating sufficient scars between the retina and the choroid to obtain strong fixation.

Thus, the proposed method can significantly increase visual acuity by 2-6 times, to prevent the severe consequences of senile macular degeneration. Clinical observations include 6 patients with subsequent postoperative follow-up from 6 months to 1 year, during which no complications were detected.

Sources of information

1. Selitskaya T.I. Central atherosclerotic chorioretinopathy. - Tomsk: Publishing house Tom. University, 1985 .-- 112 p.

2. Ismankulov A.O. Methods of rehabilitation of patients with macular lesion: Abstract. dis ... doctor. honey. sciences. - M., 1999 .-- 52 p.

3. Eandi C.M., Piccolino F.C., Ventre L.,. Grignolo F.M. Subthreshold Diode Laser Grid Photocoagulation For Treatment of Adult Vitelliform Macular Degeneration // ARVO Ann. Meet. Abst, May, 2002. - No. 1233.

4. Ormerod L.D., Puklin J.E., Frank R.N. Long-term outcomes after the surgical removal of advanced subfoveal neovascular membranes in age-related macular degeneration // Ophthalmology. - 1994. - Vol. 101. - No. 7. - P. 1201-1210.

5. Photodynamic Therapy. - http://www.ahaf.org./macular/about/mawhtnew.htm1.

Claims (1)

A method of surgical treatment of exudative senile macular degeneration, including the removal of subretinal transudate, characterized in that they form a subtenoneal canal that goes to the posterior pole of the eye by separating the quadrant of the conjunctiva with the tenon sheath of the sclera, then injecting an injection needle into the ciliary body, putting on a needle, put on filled with saline in a volume of 0.3-0.5 ml and sterile air, the needle is advanced to the posterior pole of the eyeball under the control of a binocular ophthalmoscope with a laser adic, then inject the saline solution until the pulsation of the central retinal artery ceases, the needle is advanced to the retina, a puncture through the retina is made at the point of the highest level of detachment, without touching the foveal zone, through the choroid and sclera until the latter is perforated, after the through hole in the sclera is formed, the needle is returned to the eye cavity, creating the possibility of outflow of subretinal fluid through the resulting sclerotomy retrobulbarly, after retinal straightening, laser coagulation around retinotomy is performed and, if necessary other types of laser coagulation depending on the area of the detached retina, the eye cavity is filled with sterile air, while squeezing the fluid from the eye cavity into the retrobulbar space through the formed subtenoneal channel to the outside.

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