RU2244530C1 - Method for treating rhegmatogenous retinal detachment - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: the present innovation deals with suprachorioidal blocking the retinal detachment with a filling out of collagen hemostatic sponge. The latter should be introduced into suprachorioidal space through two parallel linear scleral incisions in rupture area and, additionally, one should transpupillarly perforate chorioidea at the slope of its pressing shaft due to laser radiation followed by transpalpebral massage of patient's eyeball. The method enables to decrease traumaticity of operative interference.

EFFECT: higher efficiency of therapy.

2 dwg, 1 ex

Description

The present invention relates to ophthalmology and is intended for the treatment of regmatogenous retinal detachment.

Retinal detachment is a disease characterized by cleavage of the photoreceptor layer of the retina from its pigment epithelium. The main type of this disease that requires surgical rehabilitation is regmatogenous retinal detachment, the trigger of which is the retinal rupture with the subsequent development of the proliferative component. Detached surgery, by and large, is surgery for retinal rupture, since its blocking blocks the access of pigment epithelial cells, which are the main morphological substrate for the progression of proliferative vitreoretinopathy, into the vitreous cavity (Kreissig I. A practical guide to minimal surgery for retinal detachment. - Thieme , 2000. - Vol. 1. - P.2-6).

Blocking the retinal rupture is ensured by successively filling it (adapting the edge of the torn retina to the choroid) and retinopexy of its edge (fixing the adapted edge of the rupture to the aforementioned membrane) (Takhchidi H.P. Selected sections of eye microsurgery. Vitreous body. - M., 2002. - S.40-46).

Adaptation of the edge of the retinal gap to the underlying tissues in exfoliated surgery is performed ab externo, ab interno, or a combination of these techniques. Endovitreal filling of the gap is more reliable than indirect blocking from the outside. However, such operations are much more traumatic, therefore they are performed only when filling the ab externo rupture seems ineffective (with regmatogenous retinal detachment with large and giant retinal ruptures, ruptures located in the posterior pole of the eyeball, multiple ruptures that cannot be adequately blocked by the approach ab externo, proliferative vitreoretinolatia stage D) (Hilton GF et al. Retinal Detachment. - San Francisco. - 1989. - P.116-125).

Filling with the ab externo approach is carried out by pressing the membranes in the area of the retinal rupture inside the eyeball, while the choroid is pressed to the edges of the retinal rupture, which ensures its adaptation. Typically, such an impression is produced by the use of implants that are fixed episclerally (episcleral filling), intrascleral (intrascleral filling) or subscleral (suprachoroidal filling). The ideal filling material is implants that create a temporary (necessary for the period of fixing the edge of the retinal gap) indentation shaft and do not require further explantation (Schepens CL Retinal Detachment and Allied Diseases. - Philadelphia, 1983. - Vol.1. - P.333- 344).

Fixation of the edge of a torn retina is achieved by damaging the tissue of the inner shells by physical or chemical means, which leads to the formation of a chorioretinal adhesion. Optionally dosed fixation of the edge of a torn retina with minimal trauma to the eyeball tissue allows laser retinopexy. However, it does not guarantee the absence of complications, it requires expensive equipment of the operating unit. Such retinopexy is technically difficult and unsafe for medical personnel (Boyko E.V. et al. Diode laser in an ophthalmic operating room: Method. Recommendations / Military Medical Academy. - St. Petersburg, 2000. - S.5-28). That is why it is necessary to consider promising studies aimed at developing alternative retinopexy options that do not require additional operating equipment and are technically simple; in this case, the development of blocking the retinal rupture, in which the filling, in addition to adapting the rupture edge, also performs the function of retinopexy, would be an ideal option.

The foregoing requirements are fully met by the well-known method for preventing the development of retinal detachment by suprachoroidal blocking of the retinal rupture in the area of diascleral removal of a foreign body by a collagen hemostatic sponge (Toropygin S.G. Suprachoroidal blocking of the retina by collagen filling in the process of diaskleral extraction of intraocular non-ocular foreign rehabilitation and treatment of complications of injuries of the organ of vision in emergency situations: Collection of scientific papers - M., 2 003. - S.121-123). At the same time, it was proved in the experiment that a collagen seal implanted in the suprachoroidal space at the site of the retinal rupture and forming a temporary shaft for pressing the inner membranes not only mechanically adapts (that is, performs filling), but also, causing aseptic inflammation with subsequent formation of the chorioretinal adhesion, fixes the edge of the retinal rupture to the choroid (that is, performs retinopexy). At the same time, the period (20 days) during which adequate filling of the retinal rupture is performed is sufficient for the formation of a dense chorioretinal adhesion, which occupies the entire area of the shaft of the impression of the inner shells. Therefore, the production of traditional retinopexy when performing this operation is not required. Having adhesive activity, a collagen sponge allows you to create a depot of any medication introduced into its thickness. In addition, the collagen sponge itself is a hemostatic and antibacterial drug, and also stimulates the repair of damaged tissues. Taking into account its bioinertness (the sponge loses antigenic properties after factory radiation treatment), ease of modeling, lack of need for sterilization (available in factory sterile packaging), availability (it is a cheap domestic drug available in any operating room), collagen hemostatic the sponge is an ideal implant for insertion into the suprachoroidal space to block retinal rupture. The implantation of a collagen filling to block the retinal rupture precisely in the suprachoroidal space allows the introduction of a pharmacologically active drug (sponge) directly to the chorioretinal defect on the one hand and to the scleral wound on the other. In this case, it becomes possible to deliver any medication administered under the conjunctiva after surgery into the suprachoroidal space by soaking it with extrasclerally located tips of the sponge. In addition, such an intervention is refractively neutral, since it does not deform the sclera and, accordingly, does not lead to the development of clinically significant corneal astigmatism. The episcleral excretion of the ends of the collagen filling in the form of two “wicks” allows, among other things, to ensure rigid fixation of the sponge in the suprachoroidal space and to exclude the possibility of its migration in the early postoperative period. Fixation of a collagen seal parallel to the limb makes it possible to obtain a radially oriented shaft of the impression of the inner membranes when immersed with a scleral flap, which prevents the appearance of meridional folds of the retina and the development of a leakage phenomenon in the postoperative period. This method of blocking retinal rupture is applicable, in principle, in the treatment of regmatogenous retinal detachment, however, opening the sclera makes the intervention more invasive compared to episcleral surgery. In addition, the method does not provide drainage of the subretinal fluid, if necessary.

With regmatogenous retinal detachment, it was proposed to block its rupture with air introduced into the suprachoroid space (Smith R. Suprachoroidal air injection for detachment retina. Preliminary report // Brit. J. Ophthalmol. - 1952. - Vol. 36. - No. 7. - P. 385). The local choroidal detachment formed in this case is benign and disappears as it dissolves. However, due to the lack of rigid fixation, air is able to migrate in the suprachoroidal space, causing the unlocking of the retinal rupture and vascular detachment for a considerable length; therefore, such an operation is not widespread in the clinic. We have taken this method for the treatment of regmatogenous retinal detachment as the closest analogue.

On the issue of external drainage of subretinal fluid in retinal detachment surgery using the ab externo approach, there are two polar points of view - to always release fluid (Schepens CL Retinal Detachment and Allied Diseases. - Philadelphia, 1983. - Vol.1. - P.409-416) and not never release (Kreissig I. A practical guide to minimal surgery for retinal detachment. - Thieme, 2000. - Vol.1. - P.2-6). Supporters of compulsory drainage manage to achieve reposition of the detached retina already on the operating table, while their opponents do not seek to achieve intraoperative anatomical success. They put forward the thesis of spontaneous resorption of subretinal fluid with adequate blocking of all retinal breaks; in this case, the surgical intervention is not abdominal, which excludes the development of complications characteristic of external drainage of subretinal fluid (hemorrhagic syndrome, vitreous prolapse and infringement in the wound, retinal injuries, retinal ruptures intraoperative, intraocular infection in the early postoperative period and proliferative vitreoretin retinopathy later). Studies by other authors (Hilton G.F. et al. Retinal Detachment. - San Francisco. - 1989. - P.108-111), as well as their own clinical experience, indicate the need for a differentiated approach to solving this problem. When a gap is localized at the top of the bubble of a detached retina, its edge can not be adapted to the choroid indentation shaft; in this case, the subretinal fluid must be drained. In cases where during the filling of a retinal rupture with the ab externo approach on the operating table, it is possible to achieve full (the entire perimeter of the rupture) adaptation of its edge, the release of subretinal fluid is not required.

If during the operation a decision was made to drain the fluid, then after performing a linear incision of the sclera, perforation of the vascular is traditionally done with pricking and cutting instruments under the control of transillumination, which avoids the intersection of large choroid vessels (Schepens CL Retinal Detachment and Allied Diseases. - Philadelphia, 1983. - Vol.1. - P.409-416). Nevertheless, it is difficult to imagine how it is possible to perforate a shell consisting entirely of vessels without damaging them.

During the operation of episcleral filling of retinal rupture of the retina, it was proposed to release subretinal fluid from the sclera using a Ho-YAG laser to perforate the choroid after scleral incision (Boyko E.V. Justification and efficiency of using infrared (0.81-2.09 μm) lasers in the surgical treatment of severe pathology of the posterior segment of the eye (experimental clinical study): Abstract of thesis ... Doctoral Medical Sciences - St. Petersburg, 2001. - P.5-38). According to the author, laser vascular perforation is less traumatic compared to instrumental. However, the laser destructor does not have a pronounced hemostatic effect; in addition, the risk of developing complications characteristic of instantaneous depressurization of the eyeball does not decrease.

An unconventional solution to the problem of fluid release was proposed from the cavity of the retinal cyst (Kiseleva O.A. Prevention and treatment of complications of scleroplastic surgery of traumatic retinal detachment: Abstract of thesis ... of a doctor of medical sciences. - M., 2000. - P. 44- 46). The author drains the retinal cyst by opening the outer wall with a YAG laser during detachment of the retina and outer wall, choroid and sclera without retinal detachment. In the first case, after emptying the cyst into the subretinal space (before the operation), classical external drainage of the subretinal fluid (during the operation) is performed, achieving anatomical fit of the exfoliated and exfoliated retina. The author recommends blocking the primary retinal rupture by its episcleral filling and cryoretinopexy. Obtained during laser manipulation, an additional rupture of the retina (the outer wall of the cyst) is blocked in the same way. In the second case, according to the author, surgery is not required at all, since the contents of the cyst are spontaneously emptied under the conjunctiva, leading to the fit of the stratified retina, after which argon-laser coagulation of the entire area of the cyst is performed, which ensures blockade of the rupture of its outer wall. However, such an intervention during its conduct leads to depressurization of the eyeball and the risk of developing complications characteristic of cavity surgery.

Our proposed method is based on the fact that the blocking of retinal rupture during regmatogenous retinal detachment is carried out by a collagen hemostatic sponge inserted into the suprachoroidal space through a less traumatic scleral incision, and external drainage of the subretinal fluid is performed by transpupillary perforation of the choroid with laser radiation; in this case, the implanted sponge simultaneously serves as a drainage for the subretinal fluid.

The technical result of the proposed method is to reduce the morbidity of surgical intervention for regmatogenous retinal detachment.

The technical result is achieved due to the transformation of abdominal surgery for regmatogenous retinal detachment into incomplete by blocking the retinal rupture ab externo with the help of suprachoroidal introduction of a collagen hemostatic sponge filling followed by external drainage of the subretinal fluid by means of laser transpupillary perforation of choroid radiation.

The method is as follows.

Intraoperatively after peritomy and taking the rectus muscles on the ligatures, the retinal gap (s) are localized by ophthalmoscopy with sclerocompression.

At the site of projection of the retinal rupture on the fibrous capsule, a double linear through section of the sclera is formed perpendicular to the limb (the length of the linear sections and the distance between them exceed the dimensions of the retinal rupture by the amount necessary to create an indentation shaft of inner membranes, adequate in area to block the rupture). The choroid is detached from the brown scleral plate (i.e., chorodialysis) in the area between the linear sections using a spatula (Fig. 1). The exfoliated vascular is irrigated with a 1% solution of mesatone to prevent bleeding from the vessels of the sclera and choroid.

From a collagen hemostatic sponge of industrial production, a filling of the required size is simulated, which is impregnated with a drug solution (antibiotic, hemostatic, glucocorticoid) and implanted in a suprachoroidal space in the bed of the formed chorodialysis, so that the seal is parallel to the limb, and its tips protrude extrasclerally in the form of two "wicks". For the convenience of implanting a sponge filling, a wide spatula is used, which is inserted into one incision and removed from another; in this case, the seal is captured with tweezers and inserted into the choriodialysis bed along the surface of the spatula, which in this case performs the function of glide, protecting the vascular from mechanical trauma.

With ophthalmoscopy, the adequacy of the resulting shaft of the impression of the inner membranes (height, area and position) is monitored and, if necessary, corrected. Traditional retinopexy does not produce rupture margins. Tenon's capsule and conjunctiva are sutured in layers; inject the antibiotic solution under the conjunctiva.

Directly on the operating table, before suturing of the tenon capsule and conjunctiva or after surgery, an external release of subretinal fluid is performed. To do this, transpupillary through a retinal rupture, perforate (one or more) the choroid on the slope of its indentation shaft by sequential use of a laser-coagulator and a perforator (Fig. 2). After that, to accelerate the evacuation of subretinal fluid, an artificial increase in intraocular pressure is produced by performing transpalpebral manual massage of the eyeball. Massage is performed with quantum satis until the edge of the retinal rupture is completely adapted to the choroid indentation shaft, after which strict bed rest is prescribed with a dependent head position for the period necessary for complete (or almost complete) resorption of the residual subretinal fluid.

To the above advantages of the suprachoroidal block of the retinal rupture of the collagen hemostatic filling, it is necessary to add that the double linear through incision of the sclera is convenient from the point of view of implantation of the sponge, does not require suture sealing and makes it possible to ensure rigidity of fixation of the implant inserted into the suprachoroid space.

External drainage of subretinal fluid in the postoperative period by transpupillary laser perforation of the choroid on the ramp of its indentation shaft allows for metered release of fluid sufficient to fully adapt the edge of the retinal rupture to the choroid inlet shaft. In this case, the implanted sponge (in addition to the function of blocking retinal rupture) simultaneously serves as drainage for the subretinal fluid, and the cavity intervention turns into an operation, in fact, without depressurization of the eyeball, which prevents the development of related complications. The consistent use of coagulator and destructor lasers for perforation of the choroid allows for its atraumatic opening due to the hemostatic effect of the coagulator and the perforating effect of the destructor, which makes it possible to avoid hemorrhagic complications in the intra- and postoperative periods.

Note that the proposed operation does not require special additional equipment for the operating room and is technically simple.

The method is indicated for regmatogenous retinal detachment requiring drainage of subretinal fluid, with:

1) retinal ruptures not exceeding 40 degrees in length;

2) retinal ruptures located on the middle and far periphery of the fundus;

3) single retinal ruptures;

4) proliferative vitreoretinopathy stages AC.

The prerequisite for the implementation of the proposed method is the transparency of optical media, allowing to perform intraoperative ophthalmoscopic localization of the retinal rupture and transpupillary laser intervention.

The method is not indicated for regmatogenous retinal detachment, when a priori it is possible to avoid subretinal fluid drainage.

The method is contraindicated in regmatogenous retinal detachment with:

1) large (40-70 degrees) and giant (more than 70 degrees in length) retinal ruptures;

2) retinal ruptures located in the posterior pole of the eyeball;

3) multiple retinal ruptures that cannot be adequately blocked by local filling with the ab externo approach;

4) proliferative vitreoretinopathy stage D,

as well as with increased sensitivity of the patient to the ingredients of the collagen hemostatic sponge, namely to the drugs of the nitrofuran series (furacilin) and boric acid.

Thus, the proposed method is a simple low-traumatic pathogenetically targeted surgical intervention and is recommended for implementation in clinical practice for the treatment of regmatogenous retinal detachment.

Example. Patient A., 23 years old, was admitted with a diagnosis of OU - moderate myopia, peripheral vitreochorioretinal dystrophy; OD - Regmatogenous A retinal detachment.

From the anamnesis: suffering from myopia since childhood, 4 days ago after intense physical exertion I noticed a veil from the lower nasal side in front of the OD, after which I turned to the Institute.

Vod = 0.01 excerta n.k.

Vos = 0.06 sph-4.0 D = 1.0.

Objectively:

IOP od = 14 mm Hg

IOP os = 18 mmHg

OU - calm, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent, the iris is not changed in color and pattern, the pupil is round, drug mydriasis, the crystalline lens is transparent, the optic disk is pink, the borders are clear, the myopic cone is up to ј DD, vessels in diameter and throughout unchanged, more peripheral to the equator, are multiple zones of peripheral vitreochorioretinal dystrophy that do not require preventive laser retinal coagulation.

OD - common (in the upper outer and lower quadrants), without folds, with valve to 1 DD equatorial rupture along the edge of ethmoid dystrophy at 9-00, retinal detachment.

According to an ultrasound scan on OD, a common (in the upper outer and lower quadrants) retinal detachment; plus-fabric is not determined.

According to electrophysiological studies on OD - a sharp decrease in electrophysiological indicators.

Considering the presence of regmatogenous without folds, retinal detachment with valve up to 1 DD equatorial rupture located on a highly exfoliated retina, the patient is offered the operation of suprachoroidal blocking of the retinal rupture of a collagen hemostatic sponge followed by external drainage of the subretinal fluid by laser perforation of the choroid on OD.

Intraoperatively after peritomy and taking the rectus muscles on the ligatures, localization of the retinal rupture by ophthalmoscopy with sclerocompression is performed.

At the site of projection of the retinal rupture on the fibrous capsule, a double linear through section of the sclera is formed perpendicular to the limb (the length of the linear sections and the distance between them exceed the size of the retinal rupture by 2 mm). Choriodialysis is performed with a spatula on the area between linear sections. The exfoliated vascular is irrigated with a 1% solution of mesatone.

A 4.0 × 4.0 × 6.0 mm filling is cut out from the collagen hemostatic sponge, which is impregnated with a solution of 0.4% dexazone solution and implanted into a suprachoroidal space in the bed of the formed chorodialysis, so that the seal is parallel to the limb and its ends protruded beyond the sections extrasclerally in the form of two “wicks”.

With ophthalmoscopy, the adequacy of the resulting shaft of the impression of the inner shells is monitored. Tenon's capsule and conjunctiva are sutured in layers; inject the antibiotic solution under the conjunctiva.

The day after surgery, an external release of subretinal fluid is performed. For this, transpupillarly, using a Goldman lens, two perforations of the choroid on the slope of its indentation shaft are produced through a retinal rupture by successive use of a laser-coagulator and a perforator. After that, to accelerate the evacuation of subretinal fluid, an artificial increase in intraocular pressure is produced by performing transpalpebral manual massage of the eyeball. Massage is carried out until the edge of the retinal gap is fully adapted to the choroid indentation shaft, after which strict bed rest is prescribed in the position on the left side.

On the second day after surgery, Vod w / o = 0.2, the eye is moderately irritated, the sutures are clean, the cornea is transparent, the anterior chamber is of medium depth, its moisture is transparent, the iris in color and pattern is not changed, the pupil is round, drug mydriasis, the crystalline lens is transparent, the optic disk is pink, the borders are clear, the vessels in diameter and throughout are not changed, the retinal rupture is adequately blocked by the moderate shaft of the impression of the inner membranes, the retina is in the upper quadrants and in the center, the residual sub-division is observed in the lower quadrants, IOP is normal ma (palpation).

On the 3rd day after surgery, Vod w / o = 0.3, the eye is almost calm, the anterior segment is unremarkable, the retina lies along the entire length, the gap is blocked by a moderate shaft of the impression of the inner membranes, IOP is normal (by palpation).

On the 7th day after the operation, the impression shaft maintains the previous height; initial pigmentation phenomena appear along the edge of the gap.

On the 25th day after the operation, the impression shaft is not determined; around the gap there is a focus of gentle chorioretinal atrophy with moderate pigmentation.

3 months after the operation, Vod = 0.04 sph-4.0D = 0.8, the eye is calm, the anterior segment is without features, the retina lies along the entire length, at the surgical site there is a chorioretinal lesion with pigmentation, IOP = 18 mm RT .art.

Thus, as a result of the application of this method, it was possible to achieve not only the anatomical fit of the detached retina, but also to obtain a high functional result.

Claims (1)

A method of treating regmatogenous retinal detachment by suprachoroidal blocking of retinal rupture with a seal from a collagen hemostatic sponge, characterized in that the seal is inserted into the suprachoroidal space through two parallel linear sections of the sclera in the rupture zone and additionally transpupillaryly perforate the choroid on the slope of its laser radiation shaft using which produces transpalpebral massage of the eyeball.

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