RU2294149C1 - Method for predicting tuberculous uveitis therapy in patients of different age groups - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: the present innovation deals with matching medicinal therapy for treating tuberculous uveitis depending upon the age. Due to ultrasound dopplerography it is important to detect the values of circulation in central artery of retina (CAR) and posterior short ciliary arteries (PSCA) to be registered twice till establishing tuberculin tests and 48 h after the above-mentioned test. Moreover, it is necessary to register the alterations of maximal systolic velocity of circulation (Vs), minimal diastolic velocity of circulation (Vd) and index of peripheral resistance - Ri. One should detect the values of circulation in orbital artery (OA). At decreased Vs value in 48 h - by 10% in OA, decreased Vs by 25.7%, Vd by 33.3% and increased Ri - by 4% in CAR and, also, decreased Vs by 43.47% and Vd by 35.71% and decreased Ri by 7.14% in PSCA in combination with pronounced focal reaction in complex therapy it is necessary to prescribe immunosuppressive therapy. At decreased threshold Vs value in 48 h - by 19% in OA, decreased Vs by 29%, Vd by 39.28% and increased Ri - by 3.84% in CAR and, also, decreased Vs by 48.54% and Vd by 55.5% and increased Ri by 15.71% in PSCA in combination with poorly observed focal reaction or its absence to complex therapy it is necessary to prescribe preparations that improve local hemodynamics. The innovation enables to match the most efficient way of therapy, achieve more favorable flow of the disease mentioned due to preventing the development of complications.

EFFECT: highly shortened terms for therapy.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used in predicting drug therapy for tuberculous uveitis.

A known method for the diagnosis of tuberculous uveitis, which consists of staging tuberculin samples for examination at fixed intervals of the fundus pattern, which use ultrasound dopplerography to determine the central artery of the retina (CAC) and posterior short ciliary arteries (CCCA) of blood flow, the change of which is recorded twice - before setting tuberculin samples and after 48 hours, while recording changes in the maximum systolic blood flow velocity - Vs, minimum diast the blood flow velocity - Vd and the peripheral resistance index - Ri, and with a decrease in the threshold value of Vs by 25% and an increase in Ri - by 26% in CAC, as well as a decrease in Vs and Vd by 35% and an increase in Ri by 40% in CACA, they tuberculous etiology of uveitis (Patent No. 2231296, RF. Publ. 27.06.2004).

However, the known method does not allow to predict the use of drug therapy in patients depending on age.

The present invention is to develop a method for predicting drug therapy of tuberculous uveitis, aimed at a differentiated approach to the treatment of tuberculous uveitis, taking into account the age of the patient.

The problem is solved in that in a method for predicting the treatment of tuberculous uveitis in various age groups, including the use of ultrasound dopplerography to determine in the central retinal artery (CAC) and posterior short ciliary arteries (CCCA) blood flow parameters, the change of which is recorded twice - before setting tuberculin samples and after 48 hours, while recording changes in the maximum systolic blood flow velocity - Vs, the minimum diastolic blood flow velocity - Vd and per of peripheral resistance - Ri, blood flow in the orbital artery (GA) is determined in two groups of patients, which are ranked by age, namely: in the first group, the age of the patients is 18-49 years old, and in the second group the age of the patients is 50 -75 years old.

The proposed method is illustrated by a detailed description and clinical examples.

The method is as follows.

Blood flow indices - maximum systolic blood flow velocity - Vs, minimum diastolic blood flow velocity - Vd and peripheral resistance index - Ri, are recorded in the CAC and SSCA using ultrasound dopplerography on a Medison 6000 instrument (ser. No. А3401642) with broadband sensors 7.5 and 10 MHz before tuberculin administration (baseline). After the introduction of tuberculin, the same indicators are measured after a fixed period of time - 48 hours. Next, the level of changes in the value of blood flow indicators is calculated and correlated with the initial values of the indicators calculated on the basis of statistical processing of clinical trial data using the Statistica for Windows software version 5.1 of StatSoft company based on student's parametric criteria and non-parametric Wilcoxon test. With a decrease in Vs over a fixed interval of 10% in GA, a decrease in Vs by 25.7%, Vd by 33.3% and an increase in Ri by 4% in CAC, as well as a decrease in Vs by 43.47% and Vd by 35.71% and a decrease of Ri by 7.14% in the SCCA in the group of patients 18-49 years old in combination with a pronounced focal reaction to complex therapy, immunosuppressive therapy is prescribed. With a decrease in the threshold value of Vs through a fixed interval of 19% in GA, with a decrease in Vs by 29%, Vd by 39.28% and an increase in Ri by 3.84% in CAC, as well as a decrease in Vs by 48.54% and Vd by 55.5% and an increase in Ri by 15.71% in the SCCA in a group of patients aged 50-75 years, in combination with a mild focal reaction or its absence, complex therapy is prescribed drugs that improve local hemodynamics.

The rationale for the claimed method is the data from clinical trials when comparing two groups of patients with tuberculous uveitis in different age groups. The first group included patients aged 18 to 49 years (26 people) with tuberculous uveitis at the stage of maximum activity and initial remission. The second group included patients with tuberculous uveitis aged 50-75 years (27 people). The etiology of tuberculosis in patients of both groups was established on the basis of three main diagnostic criteria, namely: the characteristic clinical picture, the presence of a focal reaction in response to the introduction of tuberculin, and the therapeutic effect of the trial treatment with tuberculostatics.

In the first group, all patients showed a decrease in Vs over a fixed interval of 10% in GA, a decrease in Vs by 25.7%, Vd by 33.3% and an increase in Ri by 4% in CAC, as well as a decrease in Vs by 43, 47% and Vd by 35.71% and a decrease in Ri by 7.14% in WCCA. In the second group, all patients showed a decrease in the threshold value of Vs through a fixed interval of 19% in GA, a decrease in Vs by 29%, Vd by 39.28% and an increase in Ri by 3.84% in CAC, as well as a decrease in Vs by 48 , 54% and Vd by 55.5% and an increase in Ri by 15.71% in WCCA. In addition, different degrees of severity of the focal reaction were noted in different age groups. In the group of young patients (18-49 years old), the focal reaction was pronounced, the exudative component of inflammation predominated. In anterior uveitis, there was an increase in ocular injection, an increase in the number of precipitates, the formation of new synechia, an increase in the number of inflammatory exudate cells in the vitreous body and epiretinally from (+) to (++) - (+++). With chorioretinitis, an increase in perifocal edema and exudation on the surface of the lesion, an increase in the prominence of the chorioretinal lesion, and others were revealed. In older patients (50-75 years), the focal reaction was absent or was weakly expressed, the dystrophic nature of the inflammatory process prevailed.

Example 1 implementation of the claimed method.

Patient D., medical history No. 8635, 33 years old, was admitted to the Department of Eye Microsurgery (MHG) of the Kurgan Regional Clinical Hospital on April 15, 2004 due to peripheral focal chorioretinitis of the left eye, visual acuity of the right eye 1.0, left eye 0.2 not corrected. The field of vision of both eyes is not changed. Pathology in the right eye was not detected. On the periphery of the fundus of the left eye in the lower part, an active rounded focus with fuzzy borders was determined, which mediated into the vitreous body, with pronounced exudation over its surface. Due to pronounced exudative changes in the vitreous, it was not possible to determine the etiology of chorioretinitis reliably from the clinical picture. After achieving stabilization of inflammation and performing clinical, x-ray and laboratory examinations and Doppler ultrasound, on April 26, 2004, the patient was given a Mantoux test of 2 TE. After 48 hours, exudation sharply increased over the surface of the chorioretinal lesion and into the vitreous, and the focus of the lesion into the vitreous increased. Therefore, the focal reaction was recorded as positive. Dopplerography revealed a decrease in Vs in GA, a decrease in Vs and an increase in Ri in CAC, as well as a decrease in Vs and Vd and an increase in Ri in SCCA, reaching a threshold level. Given the pronounced exudative component of inflammation, in addition to anti-tuberculosis (specific) drugs, the patient was prescribed pathogenetic and immunosuppressive therapy. After 18 days, a distinct positive dynamics was noted: the focus became flatter, the boundaries of the inflammatory focus improved, exudation on the surface of the focus and in the vitreous body significantly resolved, due to which visual acuity increased to 0.5.

Thus, taking into account less pronounced changes in local hemodynamics along with a pronounced focal reaction in young patients, it is possible to predict complex drug therapy in patients with tuberculous uveitis in various age groups with the inclusion of immunosuppressive therapy drugs, which, of course, is very important in this severe case of tuberculosis chorioretinitis.

Example 2 implementation of the claimed method.

Patient P., medical history No. 22684, 75 years old, was admitted to the Department of Eye Microsurgery (MHG) of the Kurgan Regional Hospital on November 17, 2004 due to chronic, recurrent, anterior serous uveitis of the right eye. The visual acuity of the right eye of 0.04 is not corrected, the left eye of 1.0. Field of vision of both eyes without pathology. A weakly expressed mixed conjunctiva injection was noted in the right eye, multiple, small and large single precipitates located throughout the area, multiple synechiae were detected on the corneal endothelium, a dense suspension of cellular elements was detected in the anterior and middle layers of the vitreous body (++++). The fundus details were not ophthalmoscopically due to diffuse changes in the vitreous. There are no changes recorded in the left eye. The clinical picture in this patient was not quite typical for tuberculous uveitis, however, the recurring course of the disease and the ineffectiveness of the long-term non-specific therapy made it necessary to exclude tuberculous etiology. On December 10, 2004, against the background of the relative stabilization of the inflammatory process in the eye, achieved by a preliminary course of nonspecific and desensitizing therapy, the Mantoux 2TE reaction was set after a clinical minimum of the examination and Doppler ultrasound. After 48 hours, the patient had a general reaction in the form of subfebrile condition, general weakness, joint pain. Papule 18 mm with vesicles (hyperergic reaction). No focal reaction was observed. The introduction of a larger dose of tuberculin was contraindicated by a TB doctor due to a hyperergic skin reaction. Dopplerography performed after 48 hours showed a decrease in the threshold value of Vs at a fixed interval in GA by 19%, a decrease in Vs by 29%, Vd by 39.28% and an increase in Ri by 3.84% in CAC, as well as a decrease in Vs by 48.54% and Vd by 55.5% and an increase in Ri by 15.71% in WCCA.

On the recommendation of the phthisiatrician, a trial treatment was carried out (6.0 ml of a 10% solution of isoniazid intramuscularly, pyrazinamide 1.0 g by mouth, 0.5 ml of a 3% solution of isoniazid parabulbarno). Against the background of trial treatment, an improvement in the clinical picture was recorded after 20 days, which was manifested in a decrease in the number of precipitates, a decrease in the number of synechiae, and resorption of inflammatory cellular elements to (++). Diffuse coarse chorioretinal foci began to be visible on the fundus. The complex therapy of this patient included drugs that improve local hemodynamics.

Thus, despite the absence of a focal reaction, the tuberculous etiology in this patient was established on the basis of a positive general, local reaction, and a positive effect of test therapy. The registered decrease in blood flow indices, more pronounced than in young patients 48 hours after tuberculin administration, and the absence of a focal reaction suggest that it is necessary to include drugs that improve local hemodynamics in complex drug therapy in patients with tuberculous uveitis in this age group, which certainly, it is very important in this severe case of the course of tuberculous generalized uveitis in patients over the age of.

The proposed method allows to predict and objectify the use of certain groups of drugs used for the complex treatment of tuberculous uveitis based on the state of regional hemodynamics and the severity of the focal reaction in people in different age groups.

In addition, the proposed method is non-invasive and does not pose a threat of infection with serious diseases (hepatitis, AIDS). It can be used for any location and degree of activity of the inflammatory process, it has no contraindications for its use in elderly patients, it can be used on an outpatient basis, well-known diagnostic equipment is used for its implementation, for example, Medison 6000 (ser. No. A3401642 )

The use of this method in predicting the treatment of tuberculous uveitis provides the selection of the most effective therapy, the possibility of a more favorable course of the disease by preventing the development of complications, which in combination can significantly reduce treatment time.

The present invention is used in GOU "Kurgan Regional Clinical Hospital" in the department "Eye Microsurgery".

Claims (1)

A method for selecting therapy for the treatment of tuberculous uveitis depending on age, including the use of ultrasound dopplerography to determine the central artery of the retina (CAC) and posterior short ciliary arteries (CCCA) of blood flow indicators, the change of which is recorded twice before setting tuberculin samples and 48 hours after setting samples, while recording changes in the maximum systolic blood flow velocity - Vs, the minimum diastolic blood flow velocity - Vd and peripheral resistance index ia - Ri, characterized in that blood flow in the orbital artery (GA) is determined and, when Vs decreases after 48 hours, by 10% in GA, Vs decreases by 25.7%, Vd by 33.3% and Ri increases by 4% in CAC, as well as a decrease in Vs by 43.47% and Vd by 35.71% and a decrease in Ri by 7.14% in SCCA in combination with a pronounced focal reaction to complex therapy, immunosuppressive therapy is prescribed, with a decrease in the threshold value Vs after 48 hours - by 19% in GA, a decrease in Vs by 29%, Vd by 39.28% and an increase in Ri by 3.84% in CAC, as well as a decrease in Vs by 48.54% and Vd by 55.5 % and an increase in Ri by 15.71% in SCCA in combination with a weak expression With a local focal reaction or its absence, complex drugs are prescribed drugs that improve local hemodynamics.