RU2288681C2 - Method for carrying out scleroplastic operation - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: the present innovation deals with introducing a biological tissue into Tenon's space, moreover, it is necessary to apply a homotisue of cerebral white substance, it should be taken in a donor not later than 24 h after the onset of clinical lethal. The innovation is directed for the increase of sclerostrengthening effect of operation due to rapid development of fibrous tissue in area of ocular posterior pole in case of introducing bioactive material - homotissue of cerebral white substance.

EFFECT: higher efficiency of operation.

1 cl, 1 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used during scleroplastic operations. Progressive myopia, as well as its complications, is a complex and highly relevant problem. For the prevention of progressive myopia, scleroplastic operations are successfully used, which play the main role as a pathogenetically directed type of treatment. For this purpose, various materials and methods of surgical intervention are used (Shamkhalova E.Sh. Scleroplasty with progressive myopia and prediction of the effect of surgery. Long-term results. // Dis. Cand. Medical Sciences. - M., 1989). The effectiveness of operations according to various authors varies from 32.3% to 100% (Avetisov E.S., Tarutta E.P. et al. Tactics of sclerotherapy for myopia in children with an increased risk of its progression. // Recommended. Ophthalm. Inf. - No. 5 - 2000. - C.36-43; Shamkhalova E.Sh. Scleroplasty with progressive myopia and prediction of the effect of the operation. Long-term results // Diss. Candidate of Medical Sciences - M., 1989). However, a wide variety of scleroplastic operations indicates incomplete satisfaction of surgeons and the constant search for the optimal and most effective way to treat progressive myopia and its complications. In addition, scleroplastic surgery performed using various grafts can lead to a number of serious complications, such as improper placement of the graft on the sclera surface (Curtin BJ, Whitmore WG Long-term results of scleral reinforcement surgery. // Amer. J. Ophthalmol. , - 1987. - vol. 103. - p. 544-548), trauma to extraocular muscles. Also described are the occurrence of hemophthalmus and retinal detachment, glaucoma, iridocyclitis, corneal ulcers, optic nerve edema (Muller WW, Borly WE Surgical treatment of degenerative myopia. Scleral reinforcement. // Am. J. Ophthalmol. - 1964. - vol. 57, No. 5 - p. 896-910). These complications can arise as a result of the fact that the tenon space (episcleral space according to the new nomenclature) borders on such highly differentiated and physiologically responsible structures as the optic nerve, vorticose veins, and tendons of extraocular muscles. Rough or dense introduction of various tissues into this space can create a kind of tamponade and lead to the above complications (Shamkhalova E.Sh. Scleroplasty with progressive myopia and predicting the effect of surgery. Long-term results. // Diss. Cand. Medical Sciences. - M. 1989 pg. 33-34). Therefore, some surgeons prefer to introduce through a tenon space to the back pole suspensions of various tissues (dried homosklera, homokhryaschil, "polymer composition") in the 4th, 2nd or even 1st meridian (Pivovarov KN and others. Prevention of the progression of myopia with using modified scleroplasty of Remizov-Gryaznov // Vestn. Ophthalmol. - 1985 - No. 2 - p. 36-39; Remizov M.S. et al. // Vestn. Ophthalmol. - 1981 No. 3 p. 26-29; Avetisov E . S. and others. Non-surgical method of strengthening sclera with progressive myopia. // Vestn. Ophthalmol. - 1985. - No. 2 - p.31-36).

At the same time, the clinical effectiveness of such operations does not suffer, and these complications can be avoided (Avetisov E.S., Tarutta E.P. et al. Tactics of sclerotherapy for myopia in children with an increased risk of its progression. Method. Recommended. Ophthalmus. Info. No. 5 - 2000 - p. 36-46; Shamkhalova E.Sh. Scleroplasty with progressive myopia and prediction of the effect of the operation. Long-term results // Diss. Candidate of Medical Sciences. Pages 33-34. - M., 1989). It is known to use various transplantation tissues with the so-called patchwork methods of scleroplasty, which involve the collection, processing and preservation of transplants. This is fraught with certain difficulties, as not always able to take a sufficient amount of the right material. In addition, the methods of their processing and preservation are very laborious. Patchwork operations are carried out in a narrow tenon space, where there are vortical veins, ciliary arteries, the optic nerve, therefore, the introduction of tissues in the form of flaps into this space creates a kind of tamponade, which can lead to trauma to these elements (ibid., P. 33). It is known the introduction of tissue suspensions into the tenon space during scleroplasty, which excludes the development of such complications (Remizov MS, Gryaznov AI Method for the surgical treatment of progressive myopia. Vestn. Ophthalmol. - 1981, No. 3, p. 26-29). The authors used shredded homosclera or homo-cartilage on saline, introduced into the tenon space in 4 meridians. However, this method is also not without drawbacks: 1) for grinding tissue requires a special device and technology; 2) since the crushed homosklera or cartilage are in suspension in saline (do not form a homogeneous mass), when introduced into the tenon space, tissue particles are unevenly distributed in it and, due to gravity, fall into the lower sections, delaying in the tendon region of the extraocular muscles and sticking directly to the tenon capsule. 'These shortcomings give reason to consider this method time-consuming and not effective enough. It is known that non-biological substances are also used for introducing into the tenon space, for example, “polymer composition” (Avetisov S.E., Khoroshilova I.P., Savitskaya N.F. and others. Non-surgical way to strengthen the sclera with progressive myopia. Vestn. Ophthalmol . - 1985, - No. 2, p.31-36). The method is quite simple, but since the substance is not bioactive and resolves quickly enough, it does not have a lasting positive effect.

It is known to use 18% hydroxyappatite paste injected through a conjunctiva and tenon capsule incision 2 mm long (hereinafter non-sutured) in an amount of 0.3 ml into each quadrant of tenon space using a curved cannula connected to a syringe (Mudzhi Ur Rahman Parrey. Prevention of myopia progression with the use of hydroxyappatite. - Abstract of the dissertation of the candidate of medical sciences, M., 2002, p. 25). The disadvantage of this method, in our opinion, is also the chemical origin of the substance used, which does not exclude the development of allergic reactions in a number of patients. In addition, the absence of sutures can lead to the release of a certain amount of substance during the movements of the eyeball, closing of the eyelids during sleep and, as a result, getting it on the cornea, which is very undesirable.

The closest analogue of the invention is a method of scleroplasty using auto-cartilage (a piece of auricle with a diameter of 5 mm). After grinding with a scalpel in a Petri dish, it is inserted with a spatula through the incision in the conjunctiva and tenon capsule in the lower temporal quadrant (Pivovarov NN et al. Prevention of myopia progression using the modified Remizov-Gryaznov method. - Vestn. Oftalmol. - 1985, No. 2, pp. 36-39). The disadvantage of this method is the application of additional surgical trauma, which not all patients agree to. The second and more significant drawback can be considered an insignificant amount of cartilage tissue introduced into one quadrant, and, as a result, insufficient sclero-strengthening effect with progressive myopia.

The technical result of the proposed method is to increase the scleral effect of the operation due to the rapid formation of fibrous tissue in the posterior pole of the eye. The technical result is achieved by introducing into the tenon space a bioactive plastic material - homotissue of the white matter of the brain, which quickly transforms into fibrous tissue.

The theoretical justification of the proposed method can be considered the great disagreements among surgeons in the use of materials and methods used in scleroplastic surgery, the lack of optimal material and the desire of ophthalmic surgeons to non-invasive methods of treating progressive myopia.

To satisfy all the requirements, the material must be biologically active, easily homogenized and injected. Through a long experimental search, we opted for autopsy white matter of the brain, obtained mainly from donors no older than 25 years, because, in our opinion, it meets all these requirements. In addition, it can be taken in the required quantity for several dozen operations, avoiding the time-consuming processing methods, since it is initially sterile.

The method is as follows. The donor has fresh autopsy material (no later than 24 hours after clinical death) as a result of trepanation of the skull, the dura mater is separated, traces of blood are removed with sterile tampons. The white matter of the brain is taken with a sterile surgical spoon or a syringe with a wide cannula (depending on the age of the donor), placed in a sterile dish with a ground lid and stored in the refrigerator.

The method was tested on 8 eyes of chinchilla rabbits, the controls were intact eyes, into the tenon space of which saline was injected in the same volume. A suspension of the medulla of rabbits was prepared immediately after decapitation and opening the cranium of the animal. From the parietal region, a brain tissue was aspirated with a wide cannula syringe. Freshly obtained material in the form of a homogeneous mass was injected into the tenon space of 8 eyes of rabbits of the same species. After surgery, 0.25% solution of chloramphenicol and 0.25% solution of dexamethasone were instilled into the conjunctival sac three times a day. In all animals in the first three days, a mild inflammatory reaction was noted on the part of the conjunctiva, which completely disappeared by the 5-7th day. Animals were removed from the experiment after 2-4 weeks and 3-4 months.

2 weeks after injection into the subtenon space of the homotissue of the white matter of the brain on histological preparations, necrotic changes were observed in the remnants of the injected substance surrounded by an inflammatory wall of leukocytes, including eosinophils and macrophages. Along the periphery of the focus of inflammation, there was a network of newly formed vessels with dilated full-blooded capillaries and active transmural emigration of leukocytes and monocytes and transudation of serous fluid in the area of inflammation. Puffiness, expressed in the center of inflammation, to some extent affected the surrounding tissues, including the conjunctiva and the paralimbal zone of the cornea. Vascular and retina without signs of inflammation. In the anterior chamber, cell precipitates were absent.

After 4 weeks, swelling decreased sharply, as a result of which the focus of inflammation became more compact. At its center, a small volume was occupied by half-absorbed necrotic masses - the remnants of the injected material surrounded by an enlarged dense inflammatory shaft, consisting, along with neutrophilic and eosinophilic leukocytes, mainly from macrophages. Noteworthy was the appearance in the external parts of the inflammatory shaft of linearly located fibroblasts, actively synthesizing a loose extracellular matrix. A small swelling of the conjunctiva in the projection of the site of inflammation remained. Histologically, the cornea practically did not differ from that in the control group. The inner membranes and the environment of the eyeball are within normal limits.

After 3 months, a loose, unformed connective tissue was located in the injection zone of the material. Among the cellular elements of the tissue, fibroblasts immersed in the extracellular matrix predominated, and in the central zone, clusters of hypertrophic macrophages among individual fragments of necrotic tissue predominated. On the periphery of the focus, especially on the scleral side, the density of fibroblasts was increased, they acquired an ordered orientation parallel to the surface of the eyeball. The number of newly formed vessels was significantly smaller. The remnants of the vasculature could only be observed on the side facing the conjunctiva. The remaining structures of the eye remained unchanged.

After 4 months, the entire area of introduction of the material was filled with dense fibrous tissue, adjacent to the sclera, separated from it by a slit-like space intersected by many thin collagen fibers interwoven into the scleral tissue. In some places, the sclera and the newly formed fibrous scaffold were practically inseparable and indistinguishable in structure and susceptibility to dyes. Newly formed vessels are completely reduced, inflammatory cells did not differentiate.

Example. Rabbit number 4 breed of chinchilla. The conjunctiva and tenon capsule were punctured in the outer quadrant of the right eye using a wide injection needle after preliminary local anesthesia. Then, a syringe with the accumulated brain substance in the amount of 0.7 ml + 0.1 ml of antibiotic (ampicillin) was attached and by moving the needle along the upper and lower arches, the contents were introduced slowly, which were evenly distributed around the circumference of the eye. The needle was removed, holding the injection site with a spatula. The next day, a weak injection of conjunctival vessels and minor chemosis was noted. Throughout the entire period of the experiment, 0.25% solution of levomycentin and 0.25% solution of dexamethasone were instilled 3 times a day into the conjunctival sac. On the 3rd day, an increase in chemosis was noted, which did not prevent, however, the closure of the palpebral fissure, and a slight increase in the injection of conjunctival vessels. Starting from the 4th day, vascular injection and conjunctival chemosis decreased and by the 7th day all clinical signs of inflammation completely disappeared.

Thus, the obtained experimental data showed that the homogeneous brain substance introduced into the subtenon space of the eyes of experimental animals is replaced within 4 months by a compact, non-vascular, small-cell connective tissue resembling a sclera in structure. The exposure zone and the subsequent transformation of the introduced substance is limited to the area of introduction of the material and does not affect the inner shells and the environment of the eye. The results obtained allow us to consider it appropriate to extrapolate the proposed method to the conditions of the clinic.

Claims (2)

1. The method of scleroplastic surgery, including the introduction into the tenon space of biological tissue, characterized in that the tissue is used homotissue of the white matter of the brain, taken from the donor no later than 24 hours after the onset of clinical death. 2. The method according to claim 1, characterized in that after taking a homotissue, a broad-spectrum antibiotic is added to it.