RU2353341C2 - Therapy of recurrent aching bullous keratopathy following phototherapeutic glaucoma eye keratectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to ophthalmology and aims at therapy of recurrent aching bullous keratopathy following excimer laser phototherapeutic glaucoma eye keratostromectomy. Each bulla is pricked with a pointed microdiathermocoagulating microelectrode needle thereby forming cicatrical canal between bulla and anterior layers of cornea stroma. Manipulation is carries out at temperature +80°C and current strength 1.0-2.0 mA.

EFFECT: method allows for rapid relief of pain syndrome, for stopped recurrent bullae and for reduced risk of cornea bacillosis.

1 ex, 2 dwg

Description

The present invention relates to ophthalmology and is intended for the treatment of relapse of painful bullous keratopathy arising after excimer laser phototherapeutic keratostromectomy in the eyes with glaucoma.

II. The prior art.

Bullous keratopathy (CD) along with herpesvirus keratitis is the most common cause of corneal blindness in Russia (Kasparov A.A. Ophthalmogerpes. / M .: Medicine, 1994, p. 244). CD is a polyetiological disease associated with the loss of corneal endothelial cells. The corneal endothelium is a monolayer consisting of approximately 350-500 thousand hexon cells. The endothelium is involved in the synthesis of proteins, controls the penetration of substances from aqueous humor into the stroma of the cornea (barrier role) and participates in active transport, providing normal stroma hydration, necessary to maintain its transparency. Damage to endothelial cells leads to the development of chronic edema of the cornea with subsequent violation of its trophism, the formation of persistent opacities, a decrease in visual acuity up to blindness and the development of pain syndrome of varying severity from sensation of a foreign body to severe pain. The development of the pain syndrome is associated with the appearance of many bullas - epithelial blisters, filled with fluid sweating through the stroma of the cornea, periodically tearing them and is clinically classified as one of the types of recurrent corneal erosion.

With developed painful CD, numerous bullae cover a large surface of the cornea. With spontaneous opening of the bull, the patient sometimes experiences unbearable pain in the eye. As is known, the very presence of numerous bullae and their rupture are accompanied by severe eye pain, lacrimation and photophobia (Payrau P. at all Medical treatment of comeal edema. Jit Ophthalmol Clin. 1968 Fall; 8 (3): 601-10). Constantly occurring recurrent erosion observed in patients with advanced stage of CD are the entrance gate to a secondary infection. Purulent processes (corneal ulcers, iridocyclitis) that occur in 5% of patients with CD using bandage lenses, corticosteroids and antibiotics can in some cases lead to death (Luchs JI et all. Ulcerative keratitis in bullous keratopathy / Ophthalmology /, USA , 1997, May, Vol. 104: 5, p. 816-22).

Patients with CD have a history of surgical operations on the eyeball (secondary CD after cataract extraction without or with implantation of an intraocular lens (IOL), repeated antiglaucomatous operations, vitrectomy, etc.), less often mechanical and burn injuries of the cornea, repeated relapses of herpes simplex. The disease is often of a hereditary-family nature (primary CD, endothelial-epithelial dystrophy of Fuchs, etc.). The development of CD is a stereotypic response to significant endothelial cell loss caused by various causes. The peak of development of BC in the former USSR was observed in the 70-80s, was associated with the use of anterior chamber IOL and iris-clip lenses with attachment to the iris. The development of CD during the first five years after cataract extraction surgery with this type of IOL implantation was observed in 4-16% of cases (Olsen EO et all. Comeal thickness and endothelial damage after intraocular lens implantation / Act. Ophtal./ 1980, Vol. 58, p. 773-786). An increase in the number of cases of this disease was correlated with the intensification of intraocular surgery. The cause of CD is considered to be both the invasiveness of the surgical intervention and the ongoing loss of corneal endothelial cells in the presence of IOL in the postoperative period (IOL shift, sluggish iridocyclitis, etc.). There is a direct correlation between the invasiveness of the intervention and the loss of endothelial cells. The greatest loss of endothelial cells occurs with intracapsular cataract extraction with anterior chamber IOL implantation, and the lowest loss of endothelial cells occurs with extracapsular cataract extraction with posterior chamber IOL implantation. In the treatment of CD, conservative therapy methods, including the use of hyperosmotic and vitamin agents, therapeutic soft contact lenses (MKL), performing bandage functions and helium-neon laser stimulation, were effective only in the initial stages of the disease. The possibilities of conservative therapy are limited by the low proliferative activity of the endothelium and the irreversible nature of the dystrophic changes in the edematous cornea (Magden Yu. Technology optimization and long-term results of end-to-end reconstructive keratoplasty in case of bullous keratopathy. Diss. ... Ph.D. in medical sciences, M. - 1998, p.4).

Surgical methods are much more effective, among which two groups can be distinguished: 1) transplantation and 2) non-transplantation. Transplantation treatment methods are pathogenetically substantiated and include various modifications of keratoplasty: percutaneous keratoplasty, layer-by-layer keratoplasty (“reverse fungus”), posterior pass-through and posterior layer-by-layer keratoplasty, intralamellar capsulokeratoplasty, followed by ceramoplastoplastoplastic and ceramoplastoplastoplastoplastic plastic. According to domestic authors, the most popular of the above operations is through keratoplasty with a large diameter transplant (7.0-9.0 mm) performed simultaneously in combination with other reconstructive operations (Kopaeva V.G. Modern aspects of end-to-end subtotal keratoplasty / Abstract. Diss. ... doctor of medical sciences / M., 1982, p. 32; Kasparov A.A. A one-stage reconstruction of the anterior part of the eye based on a through corneal transplant. / Abstract of the VI Congress of Russian Ophthalmologists. M., 1994, p. 301 ) According to foreign authors, CD is one of the first places among corneal diseases requiring transverse keratoplasty, accounting for 14-26% of the total number (Balbs E.et all. Penetrating keratoplasty for pseudophakic bullous keratopathy / Acta Chir / Hung., 1997, Vol .36: 1, p.11-13; Frucht Pery J. et all. Thirty years of penetrating keratoplasty in Israel / Cornea / 1997 Jan /., Vol.16: 1, p.16-20). However, with CD, the percentage of transparent engraftment of large-diameter transplants is significantly lower than with other types of corneal pathology (Ermakov N.V. Diagnostic and prognostic value of endothelial specular microscopy during corneal transplantation / Author. Diss. ... Ph.D. Medical Sciences / 1988, p. 5). Along with transplantation methods that allow a radical approach to the treatment of CD by replacing the affected endothelium and achieving a significant increase in visual acuity, non-transplantation techniques are being actively studied.

The use of non-transplant techniques is indicated in elderly patients with severe pain syndrome and a burdened general status that does not allow them to undergo corneal transplantation. It is known that pain sensations of varying severity are noted in 50-75% of patients with CD (Gorgiladze L.T. Cross-cutting keratoplasty with cryopexy in the treatment of bullous keratopathy. Author. Diss. ... Candidate of Medical Sciences / M., 1987, p. 7 ) An important advantage of these methods is their use on an outpatient basis, as well as the ability to postpone end-to-end keratoplasty in case of difficulties in obtaining high-quality donor material. Non-transplant methods for treating painful CD include: intralamellar cauterization (Payrau P. Treatment des keratopathies ademateuses chroniques / Ann. Oculist., 1973. - V.206. - n.10 - p.749-752), diathermoplasty followed by the use of MKL ( Kasparov A.A. et al. Diathermokeratoplasty using a hydrogel contact lens in the treatment of the terminal stage of bullous keratopathy / Reconstructive surgery / M., 1979, p. 44-48), carbon dioxide laser coagulation (Bolshunov A.V. et al. Ophthalmologich. Journal, 1985. No. 8. - p. 470-472), anterior stromal puncture (Cormier G. et all. // Arch. Ophtalmol., 19 96, June, Vol. 114: 6, p.654-658), excimer laser phototherapeutic keratostromectomy (Kasparov A.A. et al. Excimer laser phototherapeutic keratostromectomy (FTK) in the treatment of bullous chronic keratopathy. Ophthalmologic Journal, 1999, Ukr. No. 4 (369), p.197-200).

All these methods are aimed, first of all, at creating a cicatricial biological barrier at the level of the bowman shell and the anterior layers of the corneal stroma. Diathermoplasty followed by the use of MKL, intralammal cauterization and anterior stromal puncture give a good anti-edematous effect, however, they do not have an optical effect due to the development of severe corneal opacification.

Excimer laser FTK is carried out to a depth of not more than 70-120 microns after removal of the epithelium by a scraper. 4-15 days after surgery, corneal epithelization occurs. Excimer laser FTK stops the progression of CD and effectively eliminates the accompanying pain due to the formation of a semipermeable fibrocellular membrane in the anterior stroma, which “strengthens” the cornea and prevents the formation of new bullae. It should be noted that excimer laser FTK performed for painful CD, in contrast to diathermoplasty of the cornea with subsequent use of MKL in CD, does not enhance the existing corneal clouding in CD. On the contrary, the cornea becomes more transparent, and in all patients there is an increase in visual acuity with correction up to 0.04-0.2. However, in 8% of patients with glaucoma eyes in the postoperative period (after 2-4 weeks), despite the relief of pain, a repeated occurrence (relapse) of bullous changes in the cornea was observed. As a rule, these were single bullae of the cornea, causing a feeling of a foreign body in the patient's eye. Apparently, relapses of bulla of the cornea in the eyes with subcompensated or uncompensated glaucoma are associated with increased sweating of the anterior chamber through the cornea under the influence of intraocular pressure.

A known method of treating bullous keratopathy, including conducting anterior stromal puncture of bulla cornea. The technique of anterior stromal puncture (PSP) consists in piercing bulla of the cornea and anterior stroma with a sterile needle from a syringe. Dozens, and sometimes hundreds of punctures, are applied to the cornea, depending on the number of bullae. Anterior stromal punctures applied to the cornea create a cicatrical biological barrier at the level of the bowman membrane and the anterior layers of the corneal stroma (Sridhar MC et all. Anterior stromal puncture in bullous keratopathy: a clinicopathologic study. Cornea, 2001 Aug; 20 (6): 573-9) .

At the same time, for patients with painful bullous keratopathy, stromopunction is less effective, because does not have an optical effect due to the formation of pronounced clouding of the cornea, and also due to the large number of punctures of the cornea, there is a risk of corneal infection.

According to the literature, relapse of bulla of the cornea after anterior stromopuncture occurs in 25% of cases (Magden Yu. Optimization of technology and long-term results of end-to-end reconstructive keratoplasty in case of bullous keratopathy. Diss. ... Candidate of Medical Sciences, M. - 1998, p.4). There is a palliative method for treating CD, which consists in using a soft contact lens (MKL). According to the authors who first applied MKL in CD in domestic practice, wearing MKL does not cure CD, but leads to an improvement in the condition of the diseased eye and delays the development of the disease in 50% of cases (Krasnov M.M., Kasparov A.A., Oganesyants V. A. Experience with the use of MKL for various diseases of the cornea / Vestn. Oftalmol. / 1975, No. 6, p. 38-41). However, the improvement when wearing MKL in patients with CD are short-term, because this method is palliative (bandage role of the MCL) and does not interrupt the process of bull. (Volkov V.V., Dronov M.M. To the development of a surgical method for the treatment of endothelial-epithelial corneal dystrophy / Eye Microsurgery / Tbilisi, 1976, pp. 132-135; Paton D / Penetrating keratoplasty with surgical aphakia: Current concepts in cataract surgery (Selected proceedings of the Forth Biennial Cataract Surgical Congress / 1976, p. 749-752). There are reports of the development of complications when wearing MKL (keratoconjunctivitis, corneal erosion, corneal vascularization, keratoiridocyclitis, etc.), and against the background of wearing MKL in CD, 5% of patients experience formidable complications such as purulent corneal ulcers and purulent iridocyclitis (Luchs J Cohen EJ, Rapuano CJ, Laibson PR Ulcerative keratitis in bullous keratopathy / Ophthalmology / USA, 1997, May, Vol. 194, p. 443-445.). A known method for the treatment of relapses of CD after FTK, including wearing MKL (Kasparov AA et al. Excimer laser phototherapeutic keratostromectomy (FTK) in the treatment of bullous chronic keratopathy, Ophthalmologic. Journal, 1999, Ukr., No. 4 (369), p.197 -200).

However, against the background of wearing therapeutic MKL after excimer laser FTK, a number of patients with subcompensated glaucoma continue to complain of pain and a foreign body feeling in the eye, because the formation and rupture of bullae of the cornea continues under the lens. This significantly reduces the quality of life of this (usually elderly) patient population. Moreover, in the literature available to us, we did not find indications for the treatment of relapses of painful BC after FTK in the eyes with subcompensated glaucoma.

III. Disclosure of the invention.

The theoretical premise of the invention in the recurrence of painful CD, which occurred after excimer laser FTC in the eyes with glaucoma, was the idea of creating a micro-scar (a point portion of fibrosis) in the anterior stromal layers of the cornea due to microdermatocoagulation, which allows locally densifying the anterior stromal layer of the cornea, preventing subsequent occurrence repeated bulls in the place of its formation.

This idea is confirmed by our clinical observations. In the treatment of patients with relapse of corneal bulls in the postoperative (excimer laser FTC) period in all cases, the pain syndrome quickly stopped and the appearance of corneal bulls stopped.

The technical result of the invention is:

rapid relief of pain, as well as stopping the recurrence of bulls with a decrease in the risk of activating a bacterial infection of the cornea against the background of subcompensated glaucoma.

The technical result is achieved due to:

the formation of local superficial fibrosis of the anterior layers of the stroma of the cornea (punctate tender scar, less intense than with PSP), through microdermatopuncture of the bulla and anterior layers of the corneal stroma in a certain mode. Thus, local compaction of the anterior stromal layers of the cornea prevents the subsequent occurrence of relapses of the bulls at the site of its formation.

It is known to use microdermatocoagulation performed in a certain mode (current strength of 4.0-6.0 mA) for herpetic ulcers of the cornea to “smooth” (coagulate) the vertical edges of the corneal ulcer and then remove the necrotic sections of the cornea (the so-called scab) with an electrode -scarifier (Kasparov A.A. “Ophthalmogerpes” / Medicine, Moscow, 1994, p.167-169).

When microdermatofunction of recurrent corneal bullae after FTK in the eyes with subcompensated glaucoma, we selected such a gentle microdermatocoagulation regimen (current strength of 1.0-2.0 mA), which causes coagulation of corneal tissue, has a penetrating and bactericidal effect, allows for quick and reliable healing and at the same time allows to achieve the formation of a more tender scar of the cornea, not causing intense opacification, while maintaining the transparency of the cornea. Microditerothermal bull is carried out using a pointed needle electrode. The tip of the microelectrode, heated to + 80 ° C, makes it easy to puncture the cornea.

IV. The implementation of the invention:

The method is as follows: after three instillation anesthesia an eyelid is inserted. Microditerothermal bull is performed on an outpatient basis, under the control of a slit lamp. Using a pointed needle electrode, the bulla is punctured (punctured), including the anterior stromal layer of the cornea (Fig. 1). After the corneal microdermatopuncture procedure, an antibacterial ophthalmic ointment is placed over the lower eyelid and an eye patch is applied for a period of 12 hours to stimulate corneal epithelization. The patient is prescribed drops of an antiseptic or antibiotic in order to avoid the attachment of a secondary infection. To carry out this technique, we use a microdermatocoagulator EHVCh 20-01 MTUSI, a current strength of 1.0-2.0 mA and a pointed needle microelectrode.

The method is illustrated by figures 1 and 2, where 1 is the cornea, 2 and 3 are the bullae of the cornea, 4 is the needle electrode of the microdermatocoagulator, with the help of which microdermatopuncture of the bulla is produced, including the anterior stromal layer of the cornea, 5 is the formed tender scar of the cornea at the site of diathermopuncture of the bulla.

We give a clinical example:

Patient Yanova T.N., born in 1928 (medical history No. 12439/05), complained of severe pain, photophobia and lacrimation of the left eye. A year ago, cataract extraction with implantation of an intraocular lens was performed on the left eye. On examination, OS is irritated (mixed injection of the eyeball), photophobia and lacrimation, the cornea is diffusely edematous, multiple bullae of the cornea are large and medium in size. Diagnosis: OS - artifact, secondary painful bullous keratopathy, subcompensated glaucoma. For painful bullous keratopathy, an excimer laser FTK was performed on an OS-2000 excimer laser on an OS. To normalize intraocular pressure (IOP), a 0.5% solution of Arutimol (antihypertensive drug) was prescribed. In the postoperative period, 1 month after FTK, the patient noted a periodic sensation of a foreign body in the OS, when examining the OS, it was calm, complete epithelialization of the cornea, 4 bullae of the small and medium sizes were visualized on the periphery of the cornea along the meridian from 5 to 8 hours. Microdermal puncture (MDP) of the cornea bull OS was performed using a needle electrode, and an eye patch with antibacterial ointment was applied to the eye.

A week after TIR, corneal bull relapses were not observed. The follow-up period after TIR was 1 month. On the periphery of the cornea, at the site of the previously performed microdermatopuncture, dotted tender opacities are visible in the anterior stromal layers. The patient does not use MKL. There are no complaints of pain and a feeling of a foreign body.

Thus, the use of micro-diathermopuncture (with a sparing micro-diathermocoagulation mode with a current strength of 1.0-2.0 mA) in the eyes with secondary painful CD and glaucoma prevents the subsequent occurrence of relapse of bullous cornea.

Claims (1)

A method of treating relapse of painful bullous keratopathy that occurs after phototherapeutic keratostromectomy in patients with glaucoma, characterized in that each bulla, including the anterior stromal layer of the cornea, is pierced with a microdermatocoagulator at a temperature of + 80 ° C and a current strength of 1.0-2.0 ma

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