RU2344764C1 - Method of ciliary body and anterior ocular chamber angle examination and method of gravity assessment for dull eye injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: optical coherent tomography is performed by contact method with scanning ray direction perpendicular to limb. Examination is performed in 12, 3, 6 and 9 hour directions at 1, 2, 3 and 4 mm from limb. During scanning at 1 mm distance from limb 1 mm of contact miniprobe surface is located over limb zone, while the rest is over sclera; during scanning at 2, 3 and 4 mm distance from limb central part of contact miniprobe surface matches scanning point. Gravity assessment of dull eye injury is performed by obtained tomograms. If tomogram features two or more of the following indications - hyporeflexion and signal damping at muscular layer level, swelling of muscular layer in ciliary body (CB), swelling of CB vascular layer, impossible differentiation of trabecualr apparatus and ciliary canal during visualisation of utmost anterior chamber corner (ACC), medium gravity of dull eye injury is diagnosed. Such tomogram indications as supraciliary space forming, disorder of CB muscular layer structure aligned with hyporeflecting loci of irregular shape, increased signal absorption by CB vascular layer, total absence of tomographic indicators of CB and ACC structures at the usual scanning zones, prohibited ACC visualisation, presence of tomographic ACC recession indicators combined with or without tomographic indicators of medium degree contusion, then severe eyeball contusion is diagnosed.

EFFECT: enhanced accuracy of biological structure examination, gravity assessment for dull eye injury in early post-injury period.

2 cl, 18 dwg, 2 tbl, 2 ex

Description

The proposed group of inventions relates to medicine, namely to research for diagnostic purposes, and can be used in ophthalmology to assess the state of eye structures and assess the severity of blunt trauma.

The ciliary body (CT) is the middle section of the choroid of the eyeball and consists of two main parts. The ciliary part of the CT is located in front, adjacent to the iris and carries 70-80 oblong crest-shaped processes, oriented radially towards the lens. In the ciliary part of the CT, an accommodation muscle is made up of fibers of the Brucke, Müller and Ivanov muscles, the vascular layer and pigment epithelium. The flat part of the CT has a smoother surface and includes a portion of Brücke muscle, the vascular layer and pigment epithelium. Of the main functions of the ciliary body, the following can be distinguished: support for the lens, participation in the act of accommodation, production of intraocular fluid, thermal collector of the anterior segment of the eye.

The front camera angle (CCP) is the narrowest part of the front camera. The anterior wall of the CPC is formed by the Schwalbe ring, trabecular apparatus and scleral spur, the posterior by the root of the iris, the apex by the base of the ciliary corona. The structures located in the CPC constitute the drainage system of the eye and provide for the regulation of intraocular pressure.

Based on the anatomical and topographic features and functions of CT and CPC, it can be said with confidence that these structures are involved in almost all pathological processes in the eyeball, in particular this concerns diseases of the anterior segment of the eye, vascular pathology and disturbances in the hydrodynamics of intraocular fluid. Therefore, the study and assessment of the state of these structures is of great value for early diagnosis, treatment correction and dynamic monitoring of pathological conditions of the eyeball.

However, examination of the ciliary body and the anterior chamber angle presents certain difficulties, since these structures are closed from external examination by a translucent limb and sclera. Visualization is possible only with the help of gonioscopy and cycloscopy - techniques that require special conditions and do not allow a complete examination of these structures.

Along with the routine imaging methods of CT and CCP, there are methods of radiation diagnostics that are the most informative due to their high resolution.

A known method of studying the structures of the eye by ultrasound biomicroscopy (UBM) (Clinical physiology of the organ of vision: Essays / Edited by A.M. Shamshinova. - M .; T.M. Andreeva, 2006. - 956 p.).

The study is carried out in a specialized office. During the study, the patient is in a sitting position. A special gel is applied to the contact surface of the ultrasonic sensor. The study is carried out by contact through the eyelids of the patient. Received UBM image is reflected on the monitor screen in real time. The most informative snapshots of areas of interest are stored in computer memory. The main advantages of this method are:

- the ability to penetrate deep into opaque biological tissues;

- the possibility of obtaining a panoramic picture;

- the ability to observe moving structures.

However, to obtain an image, the sensor needs contact with the eyeball, the signal penetration depth is 5 mm, the spatial resolution is up to 20 microns, visualization is limited by the organ level and does not allow evaluation at a morphological level comparable to the histological picture.

For the prototype of the proposed method, a well-known method for studying the ciliary body and the anterior chamber angle of the eye by optical coherence tomography (Optical coherent tomography in ophthalmology / D.A. Averyanov, S.A. Alpatov, V.V. Bukina et al. / Ed. A.G. Shchuko, V.V. Malysheva. - Irkutsk, 2005. - 112 p.).

Optical coherence tomography for the anterior segment (Visante OST Carl Zeiss) is a non-invasive method for studying biological structures, which allows one to obtain in vivo a two-dimensional image of transverse optical sections of biological tissues.

The known method is as follows. The patient's position is sedentary. The patient's chin is fixed on the chin, the forehead is pressed against a special arch. The patient's gaze should be fixed. The resulting optical slices are stored in computer memory.

The main advantages of this method:

- non-contact research method;

- high resolution - 10-15 microns with a radiation source of 1300 nm;

- scanning through the sclera and muddy environments allows you to get an image of the anterior chamber, including the angle, cornea, lens;

The disadvantages of this method include the following:

- non-contact research method causes the complexity of targeted scanning of specified structures;

- the impossibility of repeating the scan at the same point;

- not applicable in intraoperative conditions. The device takes a survey picture, which affects the detail of layered structures;

- due to the panoramic image, there is a decrease in the clarity of differentiation of layers and ultrastructures of the studied object.

The objective of the proposed method for the study of CT and CPC is to provide the possibility of a more accurate study of the biological structures of CT and CPC.

The problem is solved in that in the known method for examining CT and CLC of the eye, including optical coherence tomography, optical coherence tomography is carried out by the contact method with the direction of the scanning beam perpendicular to the limb, the study is carried out at 12, 3, 6 and 9 hours at 1, 2, 3 and 4 mm from the limb, while when scanning 1 mm from the limb, the 1 mm contact surface of the mini-probe is on the limbal zone, the rest is on the sclera, when scanning 2, 3 and 4 mm from the limb, the central part of the contact surface miniprobe ti corresponds to the point of scanning.

The present invention meets the criteria of the invention of "novelty" and "inventive step", as the patent information research did not identify sources of patent and scientific and technical information that would discredit the novelty of the proposed method, as well as technical solutions with essential features of the proposed method.

The authors of this application have developed the following techniques: OCT is carried out in a contact way, while the direction of the scanning beam is directed perpendicular to the limb; when scanning 1 mm from the limb, the 1 mm contact surface of the mini-probe is located in the limbal zone, the rest on the sclera; when scanning 2, 3 and 4 mm from the limb, the central part of the contact surface of the mini-probe corresponds to the scanning point.

The present invention allows using the following positive effect.

The proposed method for studying the ciliary body and the anterior chamber angle of the eye for the first time allowed us to differentiate and visualize the layered structure of the ciliary body and ultrastructure of the anterior chamber angle in vivo.

To conduct the study, we used a domestic optical coherent tomograph created at the Institute of Applied Physics of the Russian Academy of Sciences (Nizhny Novgorod). The total size of the tomograph in this configuration is 15 × 40 × 40 cm, its weight is about 10 kg. During operation, the device was connected to a standard AC network and consumed no more than 20 watts of power, the time for receiving and demonstrating an image with the number of elements 200 × 200 was about 1 second.

The functional diagram of the tomograph includes: an optical radiation source (using light from a broadband near-IR frequency range), a Michelson interferometer with a single-mode polarization-preserving optical fiber, an electron-optical scanning system along the depth of an object due to modulation of the arm lengths of the interferometer, an electromechanical scanning system in directions along the surface object (optical probe), receiving device for photo-detection of interference signal, electronic system for anal fire processing and a computer complex for digital signal processing, real-time image demonstration and overall tomography operation control.

Superluminescent semiconductor diodes with a central radiation wavelength of 1.3 μm, a bandwidth of 30 nm to 50 nm, and a radiation power in a single-mode fiber output of 1 to 10 mW are used as radiation sources in the device.

These parameters of the light source provide the required spatial resolution of 15 μm. Miniature superluminescent emitters allow you to create compact portable tomographs and ensure stable operation of devices in a clinical setting. The radiation from the sounding source is transmitted through a beam splitter to the input of a Michelson fiber-optic interferometer containing the measuring and reference arms. The OCT interferometer is assembled on a polarizing fiber. Our tomographs use a single-mode polarization-preserving fiber of the PANDA type, through which the radiation propagates in the form of a fixed waveguide mode with a given polarization. Radiation along the fiber part of the measuring arm enters the optical probe, which focuses the light on the object under study and at the same time carries out the return input of the radiation scattered by the object under study. The fiber part of the support arm provides radiation to the reference mirror and its transportation back to the beam splitter. The radiation scattered by the object under study interferes on a beam splitter with radiation reflected from the reference mirror, and the total optical signal is supplied to the photodiode.

The radiation from the focusing beam is focused by a lens system with a certain increase in the spot size of 10-20 microns inside the object at a depth that can be changed mechanically. The movement of the optical beam along the surface of the object under study is performed by a two-coordinate transverse scanning device located inside the optical probe at the end of the subject arm of the interferometer. Scanning is carried out by moving the tip of the optical fiber carrying the probe radiation in the focal plane of the lens system. The scanning process is fully automated and computer controlled.

The receiving device for photodetection of the interference signal is a photodiode with a fiber optic input. After the stage of analog processing, the signal is transmitted through an analog-to-digital converter to a computer, which performs further processing, recording information, and demonstrating images.

Unlike most other methods of obtaining images in muddy environments, reconstructing an image from a signal does not require solving a complex inverse problem. Each resolution element in depth corresponds to a certain time of light propagation to it and back, that is, a certain travel difference in the interferometer. This determines both the relative simplicity of the interpretation of the resulting images and the possibility of their visualization in real time, i.e. during the scan.

The study uses a contact mini-probe with a diameter of 2.7 mm, equipped with a fiber waveguide and an end quartz window. The probe is equipped with a pilot beam of the visible range (630 nm, 0.1 mW), which makes it possible to determine the position of the scanning beam on the surface of the tissue in the projection of the structures under study. Due to its tightness and the nature of the materials used, the probe design allows sterilization according to the generally accepted protocol.

To differentiate the structures of the CPC and the layers of CT, tomograms were compared with digital images of histological preparations. Histological examination was performed on eyeballs removed due to a neoplasm of the choroid with an intrinsic to the oncological process of the CPC and CT. After enucleation on the eyeballs, reference points were made at the sites of tomograms (perpendicular to the limbus at 12, 3, 6 and 9 hours) to conduct sections along the studied structures. Prepared 6 micron sections obtained using a sled microtome, after dewaxing, were stained with hematoxylin and eosin. To establish a diagnosis, histological preparations were examined using a binocular microscope with a magnification of 600x (lens - 40, eyepiece - 15). Images of histological preparations (75 × magnification) in their horizontal dimensions corresponded to a standard tomogram.

Figure 1, 3, 5 shows the histological preparations of the profile of the CPC and CT normal (figure 1), the ciliary part of the CT is normal (figure 3) and the ciliary and flat parts of the CT (figure 5) is normal.

Figure 2, 4, 6 shows the OCT image of the profile of the CPC is normal (figure 2), the ciliary part of the CT is normal (figure 4) and the flat part of the CT is normal (figure 6).

In figure 1, 2 is indicated:

1 - angle of the anterior chamber of the eye;

2 - the front portion of the Brucke muscle;

3 - trabecular apparatus;

4 - helmets channel;

5 - the root of the iris;

6 - peripheral cornea.

7 - limb.

In figure 3, 4 is indicated:

8 - ciliary part of the CT;

9 - muscle layer of CT;

10 - vascular layer of CT;

11 - pigment epithelium;

12 - sclera;

13 - bulbar conjunctiva.

In Fig.5.6 indicated:

14 - portion of the Bruce CT muscle;

15 - the flat part of the ciliary body.

The CPC was visualized 1 mm from the limb. In this case, a classical profile of the angle of the anterior chamber 1 was formed, formed by the peripheral part of the cornea 6 and limb 7 (anterior wall) and the root of the iris 5 (posterior wall). Also, in most tomograms, the structures of the CPC drainage system were visualized - the trabecular apparatus 3, the schlemm canal - 4.

2 mm from the limb (Fig. 4), the ciliary part of CT - 8 was visualized, dividing in layers into the muscle layer - 9, the vascular layer - 10, pigment epithelium 11.

At 3 mm (Fig. 6) from the limb, the flat part of CT 15 was visualized, in which a portion of the Bruche 14 muscle, the vascular layer of CT 10 and the pigment epithelium 11 were differentiated.

There was no CT muscle layer 4 mm from the limb, vascular layer 10 and pigment epithelium 11 were visualized. The location of the ciliary 8 and flat 15 parts of the CT on tomograms of 2 mm, 3 mm and 4 mm from the limb corresponds to the anatomical landmarks indicated in the literature. On all tomograms of the ciliary and flat parts of the ciliary body, the bulbar conjunctiva 13 and sclera 12 outward from the CT were visualized.

For a descriptive assessment of the obtained tomograms, a scheme was used, which was based on the terminology generally accepted in the world and domestic literature in optical coherent tomography of the posterior segment of the eye.

- subjective assessment of the thickness of the layer,

- the intensity of reflection or absorption of the OCT signal,

- the nature of the surface of the layers,

- contrast between layers,

- discontinuity of the layer boundary,

- the presence or absence of additional interstitial formations.

Normally, three main layers of the ciliary 8 and the flat part 15 of the ciliary body are determined on the tomograms. The muscle layer of CT 9 looks like a structure with an average signal reflection intensity, smooth, contrasting continuous boundaries. The vascular layer of CT 10 is visualized in the form of a hyporeflexive layer with uneven, non-contrast, intermittent borders. Pigmented epithelium 11 is characterized by hyperreflectivity, uneven, continuous, contrasting borders, with a flat or scalloped lower border.

In the CPC, two main structures were distinguished: a trabecular apparatus 3 — a hyperreflecting structure with contrasting, continuous, uneven borders and helmets; channel 4 — an arcuate slit with average signal reflection and continuous, uneven, contrasting borders.

The proposed method is as follows.

Examine both eyes. The patient is in a sitting position. The contact mini-probe is fixed in an aluminum tubular fixture for the convenience of the investigator and to prevent displacements of the scanning beam. Under local installation anesthesia with a solution of dicaine, a 1% mini-probe is fixed with the contact surface on the bulbar conjunctiva at 12, 3, 6, 9 hours, 1, 2, 3.4 millimeters from the limb at each hourly meridian. The distance from the limb is measured by a surgical compass on a millimeter scale. Given the diameter of the contact surface of the mini-probe 2.7 mm and its scanning surface of 2.0 mm, when scanning 1 mm from the limb, 1 mm of the contact surface of the mini-probe is in the limbal zone, the rest of 1 mm on the sclera. When scanning at 3.4 mm from the limb, the central part of the contact surface of the probe corresponds to the scanning point. Taking into account the topographic specificity of the studied structures, it is mandatory to take into account the direction of the scanning beam. The most informative tomograms are obtained during the course of the beam perpendicular to the limb.

For the prototype of the proposed method for assessing the severity of blunt eye injuries, a well-known method was selected that includes a set of standard research methods: studying complaints and medical history, external examination, examination in transmitted light, visometry, biomicroscopy, ophthalmoscopy, gonioscopy, perimetry, tonometry (Stepanov A.V., Zelentsov S.N. Eye contusion. // St. Petersburg, 2005).

The study of complaints and medical history.

External and external inspection.

Analysis of complaints and anamnesis allows you to establish the prescription and nature of the injury, as well as to orient the doctor on further tactics in terms of patient research. External and external examination are a subjective assessment of the condition of the eye.

Visometry

The method consists in determining visual acuity. Subjectively gives information about the functional activity of the retina, and also in the subsequent distant period is one of the main criteria for determining the severity of contusion based on the degree of restoration of visual functions.

Study by side (focal) lighting.

The method is intended to detect subtle changes in the anterior eyeball. The study is carried out in a dark room using a table lamp mounted to the left and front of the patient, as well as using a magnifier 13.0 or 20.0 diopters. The method does not visualize intraocular structures.

Transmission Study

The method is used to examine optically transparent media of the eyeball (mainly for the lens and vitreous body).

The study is conducted in a dark room using a light source installed to the left and rear of the patient, as well as using a specular ophthalmoscope, directing a beam of light into the pupil of the patient’s eye. The method has low detail and does not provide a detailed assessment of intraocular structures.

Biomicroscopy

Biomicroscopy, or live eye microscopy, has been used in ophthalmology since 1911. The method is based on illuminating the structures of the eyeball with a narrow, sharply delimited and homogeneous beam of light with the phenomenon of light contrast (Tyndall phenomenon). Biomicroscopy is performed using a slit lamp, which includes a light source and a binocular stereoscopic microscope with various magnification systems. Non-contact biomicroscopy is an atraumatic research method, it makes it possible to evaluate the condition of the mucous membrane, sclera, cornea, anterior chamber of the eye, iris, lens and anterior vitreous humor with good magnification; photo and video images can be obtained, which allows documenting pathological changes.

Ophthalmoscopy

A method for the study of the retina, optic nerve and choroid in the rays of light reflected from the fundus. Two methods of ophthalmoscopy are used - reverse and direct. Also, with the help of a slit lamp and an aspherical lens, it is possible to conduct a detailed examination of the retina and the optic nerve head, and assess the degree of transparency of the vitreous body. The method can be fully used only with a wide pupil and transparency of optical media, which is not always possible with eyeball contusions.

Gonioscopy

Gonioscopy (examination of the structures of the angle of the anterior chamber of the eye using a system of mirrors by means of a slit lamp). An important point for assessing the ciliary body, namely, possible cyclodialysis, is the presence of a cyclodialysis gap, which does not allow to fully visualize the ciliary body. However, with severe hypotension, gonioscopy presents significant difficulties, since the cornea is significantly deformed, there are folds of the descemet sheath, which makes it difficult to examine the structures of the anterior chamber angle.

Perimetry

Method for assessing visual fields using the perimeter. The loss of visual fields may indicate retinal detachment or the presence of Berlin clouding, but with ciliochoroidal detachment, the visual fields do not suffer.

The study of intraocular pressure

The level of intraocular pressure can be measured in various ways: by palpation, using applanation-type tonometers, as well as in a non-contact way. There is also applanation tonometry (using a Maklakov tonometer with a 10 gram weight) to detect more subtle violations of intraocular pressure. Intraocular pressure in the post-concussion period largely depends on the state of the anterior chamber angle, the state of the ciliary body, and also on the neurovascular changes in the reflex order of the eyeball. Persistent concussion hypotension may indicate ciliochoroidal detachment, but without morphological confirmation this is an indirect sign. Intraocular hypertension may indicate a recession of the corneal-iris angle. Periodic fluctuations in the direction of hypo- and hypertension may be the result of vasomotor reactive reactions of the vascular eyeball to contusion. However, tonometry can only ascertain the fact of violation of the hydrodynamics of the eye, but not reveal the cause of the violations. The known method allows to obtain complete information about the state of the eyeball.

The disadvantages of the method include the fact that the method takes a lot of time, as well as the fact that not all studies included in the examination complex can be carried out in the early post-concussion periods (mainly due to incomplete transparency of the optical media or damage to the anterior segment of the eye). A classification of the clinical assessment of the severity of a blunt eyeball injury is known (classification by G.A. Petropavlovskaya (1975), improved by A.V. Stepanov and S.N. Zelentsov (2005)).

Table Light concussion Moderate concussion Severe concussion Reversible changes in the appendages of the eye and eyeball, does not cause a decrease in vision during recovery: subconjunctival Change in eye structures with minor irreversible changes: deep erosion of the cornea, Tears and detachments of the inner membranes of the eye (ruptures of the reticular and choroid; angle recession, cyclodialysis; ciliochoroid hemorrhage, mild swelling and erosion of the cornea; Hyphema to 1/3 of the anterior chamber, Fossius ring; accommodation spasm, Berlin retinal clouding. Intraocular pressure is the norm. causing the formation of clouding of the cornea; subluxation and dislocation of the lens; contusion cataract; pronounced tears of the sphincter of the pupil; paralytic mydriasis; intraocular hemorrhage. Intraocular pressure - hypotension
or hypertension, is stopped medically. detachment; retinal detachment) leading to functional and anatomical death of the eye. Intraocular pressure - Persistent hypotension or hypertension requiring surgical intervention.

This classification was used by the author of the present invention, taking into account its greatest prevalence in ophthalmic clinics of the Russian Federation and the ease of its use in clinical practice. In the given classification, the anatomical localization of injuries of the eyeball and its adnexa, the reversibility of existing injuries, and the prospects for the restoration of visual functions are taken into account.

However, using the above classification and data obtained by routine examination methods, it was not always possible to assess the severity of the resulting eye injury, since it was difficult to examine the structures of the anterior and posterior segments due to the opacity of the optical media, and the reversibility of existing changes in the dynamics was evaluated subjectively based on biomicroscopy, gonioscopy and ophthalmoscopy, i.e. standard techniques. This made it difficult to differentiate the severity of the resulting eye contusion in the early stages, that is, from 1 to 7 days.

The task of the invention is to provide an opportunity to assess the severity of blunt eye injury in the early post-concussion period.

The problem is solved in that in the known method for assessing blunt eye injury, including a comprehensive clinical examination and analysis of the results of the study, conduct optical coherence tomography by the contact method with the direction of the scanning beam perpendicular to the limb, the study is carried out at 12, 3, 6 and 9 hours at 1, 2, 3 and 4 mm from the limb, while when scanning 1 mm from the limb, the 1 mm contact surface of the mini-probe is in the limbal zone, the rest is on the sclera, when scanning 2, 3 and 4 mm from the limb, the central part the contact surface of the mini-probe corresponds to the scanning point and if there are two or more of the following signs on the tomograms: hyporeflection and attenuation of the signal at the level of the muscle layer, thickening of the muscle layer of the CT, thickening of the vascular layer of the ciliary body, impossibility of differentiating the trabecular apparatus and the helmet of the channel when visualizing the very front angle cameras diagnose moderate severity of blunt eye injury; in the presence of tomographic signs, such as the appearance of a superciliary space, violation of the structure of the muscle layer of the ciliary body by the type of appearance of hyporeflexing lesions of irregular shape, increased signal absorption by the vascular layer of the ciliary body, the complete absence of tomographic signs of the structures of the ciliary body in the usual scanning areas, the inability to visualize the anterior chamber angle , the presence of tomographic signs of recession of the anterior chamber angle in combination with or without tomographic recognition s contusion moderate severity diagnosed with a contusion of the eyeball and severe.

The present invention meets the criteria of the invention of "novelty" and "inventive step", as the patent information research did not reveal the sources of patent and scientific and technical information that would discredit the novelty of the proposed method. The search did not reveal technical solutions with significant features of the proposed solution.

The proposed method is as follows.

Examine both eyes. The patient is in a sitting position. The contact mini-probe is fixed in an aluminum tubular fixture for the convenience of the investigator and to prevent displacements of the scanning beam. Under local installation anesthesia with a solution of dicaine, a 1% mini-probe is fixed with the contact surface on the bulbar conjunctiva at 12, 3, 6, 9 hours at 1, 2, 3, 4 millimeters from the limb at each hourly meridian. The distance from the limb is measured by a surgical compass on a millimeter scale. Given the diameter of the contact surface of the mini-probe 2.7 mm and its scanning surface of 2.0 mm, when scanning 1 mm from the limb, 1 mm of the contact surface of the mini-probe is in the limbal zone, the rest of 1 mm on the sclera. When scanning 2, 3, 4 mm from the limb, the central part of the contact surface of the probe corresponds to the scanning point. Taking into account the topographic specificity of the studied structures, the direction of the scanning beam is taken into account. The most informative tomograms are obtained during the course of the beam perpendicular to the limb.

If there are two or more of the following signs on the tomograms: hyporeflexia and attenuation of the signal at the level of the muscle layer, thickening of the muscle layer of the CT, thickening of the vascular layer of the ciliary body, the inability to differentiate the trabecular apparatus and the helmet of the channel during visualization of the anterior chamber angle, a moderate severity of blunt trauma is diagnosed eyes; in the presence of tomographic signs such as the appearance of a superciliary space, violation of the structure of the muscle layer of the ciliary body by the type of appearance of hyporeflexing lesions of irregular shape, increased signal absorption by the vascular layer of the ciliary body, the complete absence of tomographic signs of the structures of the ciliary body in the usual scanning areas, the inability to visualize the anterior chamber angle, the presence of tomographic signs of a recession of the anterior chamber angle, in combination with or without it, with a tomographic sign A mild concussion diagnoses a severe eyeball contusion.

Below is a table of tomographic signs of OCT according to the severity of a blunt eye injury.

Tomographic signs Mild Medium grade Severe degree The emergence of supraciliary space + Violation of the structure of the muscle layer of the ciliary body by the type of appearance of hyporeflexing lesions of irregular shape + Hyporeflection and attenuation of the signal at the level of the muscle layer + + Thickening of the muscle layer of CT + + Increased signal absorption by the vascular layer of the ciliary body + Thickening of the vascular layer of the ciliary body + + The complete absence of tomographic signs of the structures of the ciliary body in the usual scanning zones (ciliochoroidal detachment) + Structures of the anterior angle (trabecular apparatus, Helmet canal), cameras do not differentiate when visualizing the very angle of the anterior chamber + + Inability to visualize the front camera angle + The presence of tomographic signs of recession (stratification) of the anterior chamber angle +

The present invention is supplemented by graphic materials. Figures 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18 show OCT tomograms with tomographic signs of blunt eye injury of varying severity.

Figure 7 presents the OCT image of the flat part of CT during mild eyeball contusion and is indicated by:

16 - thickened vascular layer of CT.

On Fig presents the OCT image of the CPC with a concussion of the eyeball of moderate degree and is indicated:

17 - the ultrastructure of the CPC is not visualized.

Figure 9 presents the OCT image of the ciliary part of the CT with a concussion of the eyeball of moderate degree, indicated:

18 - attenuation of the OCT signal at the level of the muscle layer of the CT.

Figure 10 presents the OCT image of the flat part of the CT with a concussion of the eyeball of medium degree, indicated:

19 - thickening of the muscle layer of the CT;

20 - thickening of the vascular layer of CT.

Figure 11 presents the OCT image of the ciliary part of the CT during a concussion of the eyeball of a severe degree, indicated:

21 - hyporeflexive focus in the muscle layer of the CT;

22 - expanded suprociliary space.

On Fig presents the OCT image of the ciliary part of the CT with a concussion of the eyeball severe degree, indicated:

23 - dispersion of the OCT signal at the level of the muscle layer of the CT.

On Fig presents the OCT image of the ciliary part of the CT during a concussion of the eyeball of a severe degree, is indicated:

24 - expanded suprociliary space.

On Fig presents the OCT image of the ciliary part of the CT when the shell of the eyeball is severe, indicated:

25 - absorption of the OCT signal by the vascular layer of CT.

On Fig presents the OCT image of the CPC with contusion of the eyeball of a severe degree, indicated:

26 - hyphema (blood clot in the anterior chamber).

On Fig presents the OCT image of the ciliary part of the CT with contusion of the eyeball of a severe degree, indicated:

27 - lack of tomographic signs of CT (ciliochoroidal detachment).

On Fig presents the OCT image of the CPC with a contusion of the eyeball of a severe degree, indicated:

28 - iridodoneson (separation of the iris at the root).

On Fig presents the OCT image of the CPC with contusion of the eyeball of a severe degree, indicated:

29 - recession (stratification) of the CPC.

The present invention allows to obtain the following positive effect. The proposed evaluation method improves the accuracy of diagnosis in the early post-concussion period.

Using the proposed method for assessing the severity of blunt eye injuries, the authors of the application examined 99 people aged 18 to 78 years, only 118 eyes. Of the group of patients examined in 27 patients with clinically and routine examination methods (visometry, biomicrophthalmoscopy, ophthalmoscopy, gonioscopy, Maklakov tonometry), no eye pathology was detected. Tomograms obtained in patients of this subgroup were taken as normal. 64 patients had a dull eyeball injury of varying severity. The pair eye was examined, but was not taken at the norm. It was revealed that with moderate to severe concussion, tomographic signs of concussion are also detected in the paired eye.

With contusion injuries of the eyeball, the pathology at the morphological level was clearly visible both in the injured eye and in the paired. In the paired and shell-shocked eyes, a supraciliary space appeared, which is normally not visible, appeared sectoral hyporeflection of the muscle layer of CT 21 (Fig. 11). In the eyes with concussion, hyporeflexia and signal attenuation were observed at the level of the muscle layer of CT 18 (Fig. 9). It became impossible to visualize the pigmented epithelium due to 17 (Fig. 8) thickening of the muscle layer and intensive absorption of the signal by the vascular layer of CT 25 (Fig. 14). The consequence of the above changes was the loss of hierarchy in the layers of central heating. CCP with concussion in 80% was not visualized 17 (Fig. 8), in some patients, recession of CCP 29 was detected (Fig. 18), trabecula was not visualized. In three patients with persistent hypotension in the early post-concussion period, a detachment of the ciliary body 27 was revealed (Fig. 16) in the form of a solid section of the absence of reflection of the signal, occupying from 2 to 3 sectors, 2 and 3 mm from the limbus. Based on the data obtained using optical coherence tomography, taking into account the clinical data, OCT signs of the severity of contusion damage to the eyeball were determined.

When comparing clinical and tomographic signs of injury severity in the early post-concussion period, the authors of the application concluded that the severity of a blunt eye injury, determined by standard methods, did not always correspond to the severity of the OCT signs.

In 70% of cases, the clinically stated severity of the injury coincided with the tomographic signs of the severity of the concussion.

In 10%, both clinically and tomographically, the early diagnosis was controversial, i.e. between severe and moderate, and only dynamic tomographic control during treatment allowed to make a final diagnosis against the background of OCT stabilization of tissue structures of the ciliary body.

In 20% of patients, clinical signs of moderate severity were diagnosed, but already in the early post-concussion periods, all tomographic characteristics spoke for a severe degree of blunt trauma, which was confirmed later.

Two-time dynamic control in the period from 15 to 20 days and from 20 to 45 days made it possible to objectively evaluate the effectiveness of the therapy, as well as to make sure that even taking into account clinically positive dynamics against the background of adequate therapy at the morphological level, gross postcontusional changes in the ciliary body and anterior angle are preserved chambers, which, despite the importance of these structures, can lead to unexpected, but well-known, clinically unpredictable post-concussion complications leading to the death of the eye as an organ, but the alleged volume graphically, and therefore preventable.

Examples of specific performance are given in the form of extracts from medical records. Clinical example No. 1

Patient Sh., 38 years old, No. East. bol. 0609884, received on an emergency basis at the State Educational Institution of the National Clinical Hospital named after N.A.Semashko about a concussion of moderate severity of the left eye (an injury in everyday life on 04/14/06).

Upon receipt, the right eye visus is 0.7 n / a, the left eye visus is 0.3 n / a. Left eye: a mixed injection of the eyeball, from the center of the cornea to its peripheral parts from II to VI hours. Extensive erosion. Iridodoneson. With drug mydriasis, the pupil is irregular in shape. IOP palpation normal. In the early post-concussion period, it was not possible to make a gonioscopic examination to clarify the causes of pupil deformity due to corneal erosion. However, it was possible to do an OCT study of the anterior segment of the eyeball. The results obtained were interpreted as follows.

The muscular layer of the ciliary part of the CT is subjectively thickened compared to the paired eye, has hypooreflecting local areas in some departments, the pigment epithelium in such sectors is not visualized due to scattering of the OCT signal, the boundaries between the muscular and vascular layers of the ciliary body are faded. At III hours, the recession of the anterior chamber angle was clearly defined. Thus, already in the early stages of diagnosis, the patient’s injury, taking into account OCT signs from a moderate category, was defined as severe concussion.

Clinical example No. 2

Patient M., 30 years old, No. East. bol. 0629442, entered on an emergency basis at the State Educational Institution of the National Clinical Hospital named after

N.A.Semashko about a combined injury: severe concussion of the right eye, chemical burn of the conjunctiva and cornea of the 1st degree, complicated by hyphema, hemophthalmus, subluxation of the lens of the right eye.

Upon receipt, the right eye visus is 0.01 n / a, the left eye visus is 1.0 b / c.

Right eye: swelling of the eyelids, mixed injection of the eyeball, extensive erosion of the cornea, anterior chamber deep, hyphema 0.5 mm. Vitreous body in anterior chamber with blood smears. Iridodialysis for XII hours. The pupil is narrow, deformed, does not respond to light. The fundus is not visible. IOP palpation - 1. The patient was done A and B - scan. A-scan showed no signs of ablation. B-scan showed the presence of hyperechoic movable structures in the vitreous body, not associated with the inner membranes of the eyeball. There was insufficient data for retinal detachment. At the same time, an OCT study was carried out, on which it was revealed: in the projection of the ciliary and flat parts of the ciliary body, in all sectors, a continuous hyporeflexing cavity was visualized without signs of a layered structure, which could indicate ciliochoroid detachment, in some sectors 5 and 6 mm from the limb from the inner side of the sclera, homogeneous structures were determined with hyper- and average reflection of the OCT signal, with clear, uneven boundaries that were differentiated as parietal blood clots. In the anterior chamber, the boundaries of the hernia of the vitreous body were clearly defined as a structure with clear, wavy borders outward with an average degree of reflection of the OCT signal and not reflecting the signal with the bulk. Due to this visualization, it was possible to accurately determine the presence of contact between the vitreous body and the corneal endothelium.

Thus, in this example, the OCT method allowed us to diagnose ciliochoroidal detachment, being an alternative to emersion ultrasound imaging and ultrasound biomicroscopy.

Claims (2)

1. A method for examining the ciliary body (CT) and the angle of the anterior chamber of the eye, including conducting optical coherence tomography, characterized in that the optical coherence tomography is carried out by the contact method with the direction of the scanning beam perpendicular to the limb, the study is carried out for 12, 3, 6 and 9 hours 1, 2, 3 and 4 mm from the limb, while when scanning 1 mm from the limb, the 1 mm contact surface of the mini-probe is in the limbal zone, the rest is on the sclera, when scanning at 2, 3, and 4 mm from the limb, the central part of the contact turn NOSTA miniprobe corresponds to the point of scanning. 2. A method for assessing the severity of blunt eye injury, including a comprehensive clinical examination and analysis of the results of the study, characterized in that they conduct optical coherence tomography in a contact manner with the direction of the scanning beam perpendicular to the limb, the study is carried out for 12, 3, 6 and 9 hours in 1, 2 , 3 and 4 mm from the limb, while when scanning 1 mm from the limb, the 1 mm contact surface of the mini-probe is in the limbal zone, the rest is on the sclera, when scanning 2, 3 and 4 mm from the limb, the central part of the contact surface the mini-probe corresponds to the scanning point, if there are two or more of the following signs on the tomograms: hyporeflexion and attenuation of the signal at the level of the muscle layer, thickening of the muscle layer of the CT, thickening of the vascular layer of the ciliary body, the inability to differentiate the trabecular apparatus and the schlemm canal when diagnosing the very angle of the anterior chamber moderate severity of dull eye injury; in the presence of tomographic signs such as the appearance of a supraciliary space, a violation of the structure of the muscle layer of the ciliary body by the type of appearance of hyporeflexing lesions of irregular shape, increased signal absorption by the vascular layer of the ciliary body, the complete absence of tomographic signs of the structures of the ciliary body in the usual scanning areas, the inability to visualize the anterior chamber angle , the presence of tomographic signs of recession of the anterior chamber angle in combination with or without tomographic recognition s contusion moderate severity diagnosed with a contusion of the eyeball and severe.

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