RU2381774C1 - Method of treatment of morphofunctional disturbance of central zone of retina following vitreoretinal surgery of retinal detachment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, and particularly to ophthalmology and aims at treatment of pathological changes caused by incomplete adaptation of neuroepithelial layers of retina following the vitreoretinal surgery of retinal detachment. The vitreoretinal surgery of retinal detachment is followed with "ФАГ" on a tamponade of the vitreal cavity of "СМ" provided complete retinal attachment on ophthalmoscopic findings, low visual acuity in early postoperative period and observed region of morphofunctional disturbance according to "ОКТ" and "КМП". If hyperfluorescence is visualised in macule, subthreshold "ЛКС" is carried out at pulse duration 0.02-0.1 sec, spot diametre 50-100 mcm, power 50-120 mWt, wavelength 561 nm with applying 20-60 coagulates on the whole surface of the hyperfluorescence area without the central avascular zone. If hyperfluorescence is visualised in macule and thereout, the subthreshold "ЛКС" is combined with threshold "ЛКС" at pulse duration 0.05-0.1 sec, spot diametre 100-200 mcm, power 80-140 mWt, wavelength 561 nm with applying 50-200 coagulates on the whole surface of the hyperfluorescence zone. If hyperfluorescence is visualised in macule and thereout, with accompanying "ДЗН" hyperfluorescence, the subthreshold and threshold "ЛКС" is combined with the threshold "ЛКС" with the same parametres with applying 20-80 coaguales in 2-4 lines at the distance 1000 mcm from a "ДЗН" edge in nasal direction, thus all the coagulates are staggered and spaced for at least 1.5 of the coagulate diametres.

EFFECT: method ensures restoration of maximum possible visual acuity and improved vision quality.

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Description

A method for the treatment of morphological and functional disorders of the central zone of the retina after vitreoretinal surgery of retinal detachment.

The invention relates to medicine, and in particular to ophthalmology, and is intended for the treatment of pathological changes caused by incomplete adaptation of the neuroepithelial layers of the retina after vitreoretinal surgery of retinal detachment.

Modern methods of treating retinal detachment in most cases make it possible to achieve its anatomical fit, confirmed by ophthalmoscopy and an ultrasound method. However, often visual acuity after surgery remains at the same level or rises slightly, scotomas also appear and patients complain of poor quality of vision. Such functional results can be explained by the lack of articulation of the outer and inner segments of the photoreceptors, incomplete adaptation of the retinal layers due to intrastromal edema, fluid accumulation in the form of gaps and small cysts. As a result, there is a local incomplete fit of the neuro- and pigment epithelium. Also, after the operation, there are phenomena of neuropathy with powerful edema along the perineural pathways, the prominence of the optic nerve disc (optic disc) into the vitreous body, caused by the plugging of the vitreoretinal cavity. The most pronounced changes are found when using silicone oil (SM).

The closest analogue is a method for achieving the functional result of surgical treatment of retinal detachment (RF patent No. 2308921), where the scleral filling method was used, however, this method is not effective enough, since laser coagulation is performed on the nasal side of the retina in a staggered manner in two rows in the shape of a horseshoe facing the optic disc, and not in the area of detected morphological and functional disorders.

The problem solved by the invention is the creation of an effective method for the treatment of disorders associated with incomplete adaptation of all layers of the retina after vitreoretinal surgery of retinal detachment.

The technical result is to restore the maximum possible visual acuity and improve the quality of vision.

The technical result is achieved by the fact that in the method of treating morphological and functional disorders of the central area of the retina after vitreoretinal surgery of the retinal detachment, on the tamponade of the vitreous cavity of the SM, provided that the retina is completely snug according to ophthalmoscopy, low visual acuity in the early stages after surgery ) and the presence of a zone of morphological and functional disorders according to optical coherence tomography (OCT) and computer microperimetry (CMP) perform fluorescence angiography (FAG).

If hyperfluorescence is visualized in the macula, then subthreshold retinal laser coagulation (LSC) is performed with a pulse duration of 0.02-0.1 s, a spot diameter of 50-100 μm, a power of 50-120 mW, a wavelength of 561 nm, applying 20-60 coagulates on the entire surface of the hyperfluorescence zone, excluding the central avascular zone.

If hyperfluorescence is visualized in the macula and beyond, then in addition to the subthreshold LKS, a threshold LKS is performed with a pulse duration of 0.05-0.1 s, a spot diameter of 100-200 μm, a power of 80-140 mW, a wavelength of 561 nm, applying 50-200 coagulates on the entire surface of the hyperfluorescence zone.

If hyperfluorescence is visualized in the macula and beyond, with concomitant hyperfluorescence of the optic disc, then in addition to the subthreshold and threshold LKS, a threshold LKS is performed with the same parameters, applying 20-80 coagulates, in 2-4 rows, departing 1000 microns nasally from the edge of the optic nerve disc , while all coagulates are applied in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other.

The method is as follows.

Under the condition of complete retinal fit according to ophthalmoscopy after vitreoretinal surgery, retinal detachment, tamponade of the SM vitreous cavity, low visual acuity in the early stages after surgery (5-10 days) and the presence of a zone of morphological and functional disorders according to OCT and CMP are performed by phage.

Phage can clearly identify and visualize areas of increased vascular permeability, incomplete fit of the neuroepithelium, the edema zone, neuropathy, which are manifested by hyperfluorescence in various phases of the study. With incomplete adherence of the neuropigmented epithelium of the retina - in the early phase of the phage appears hyperfluorescence of the area of incomplete adherence with a gradual expansion of the borders. With edema in the macular zone - in the arteriovenous phase, moderate hyperfluorescence, with an increase in intensity in the late venous phase with the fusion of individual foci of dye exit. With severe retinal edema, hyperfluorescence can spread along the arcades of the fundus. In the presence of detachment of the pigment epithelium, a clearly delimited area of hyperfluorescence is visualized in the venous phase with amplification in the late phase without changing the size of the focus. In case of neuropathy with edema along the perineural pathways, in the late phase, hyperfluorescence of optic nerve disc with dye diffusion. The results obtained affect the tactics of the LKS.

LKS is performed on a multi-wavelength laser photocoagulator MS-300 (Nidek, Japan).

With the help of mydriatics, maximum expansion of the pupil is achieved. After epibulbar anesthesia, a three-mirror Goldman universal lens is installed on the patient's eye. Using coaxial illumination, the macular region is examined through the central part of the three-mirror Goldman lens and the site of exposure is marked.

With hyperfluorescence in the macula, subthreshold LKS in the macular zone is performed. Apply 20-60 coagulates in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone, excluding the central avascular zone (fovea). It is necessary to obtain coagulate, which is manifested in the third second after exposure to a laser. The range of laser exposure depends on the severity of retinal edema. Subthreshold LKS is carried out with a pulse duration of 0.02-0.1 s, a spot diameter of 50-100 μm, a power of 50-120 mW, a wavelength of 561 nm. The use of a short exposure time and spot diameter is necessary to obtain an invisible coagulate and prevent the formation of a larger defect in area. Thus, the risk of paracentral cattle in the postoperative period is reduced.

If the hyperfluorescence zone in the macula extends beyond its limits, according to the FAG, then in addition to the subthreshold LKS, a threshold LKS is performed. Impact parameters vary. It is necessary to obtain visible coagulates of the 1st degree, which are weakly manifested in the first second, after exposure to a laser. A threshold LKS is carried out with a pulse duration of 0.05-0.1 s, a spot diameter of 100-200 μm, a power of 80-140 mW, and a wavelength of 561 nm. Apply 50-200 coagulates in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone. The number of coagulates depends on the extent of the hyperfluorescence zone according to the phage.

If the zone of hyperfluorescence in the macula extends beyond it and the hyperfluorescence of the optic disc is visualized according to the phage, then in addition to the subthreshold and threshold LKS, a threshold LKS is performed nasally from the optic disc with a pulse duration of 0.05-0.1 s, a spot diameter of 100-200 μm, and power 80-140 mW, wavelength 561 nm. Apply 20-80 coagulates, in 2-4 rows, departing 1000 microns nasally from the edge of the wound in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other.

The invention is illustrated by the following examples.

Example 1

Patient B. was operated on with vitreoretinal surgery for regmatogenous retinal detachment. With ophthalmoscopy, the retina is completely attached. On day 6 after surgery, the visual acuity of the right eye was 0.5. According to OCT and ILC, a zone with morphological and functional disorders in the central region of the retina was diagnosed. According to OCT, there is no articulation of the external and internal segments of the photoreceptors, diffuse edema of the central zone of the retina. The retina thickness in foveal minimum is 260 microns, in the zone from 0.5 to 1.0 mm 280 microns, in the zone from 1.0 to 3.0 mm 330 microns, in the zone from 3.0 to 6.0 360 microns. Relative scotomas with photosensitivity from 8 to 12 dB in the macula area were found by ILC. In other areas, photosensitivity ranged from 14 to 18 dB.

By phage in the arteriovenous phase, moderate hyperfluorescence in the macular zone, with an increase in intensity in the late venous phase.

We performed a subthreshold LKS of the macula in the hyperfluorescence zone on an MS-300 multiwave laser photocoagulator (Nidek, Japan). 43 coagulates were applied in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone, excluding the central avascular zone (fovea). Impact parameters: pulse duration 0.05 s, spot diameter 50-80 μm, power 50-90 mW, wavelength 561 nm.

After 1.5 months, visual acuity was 0.9. By OCT, the retina is fully adapted. According to the ILC, the photosensitivity ranged from 16 to 20 dB.

Example 2

Patient L. was operated on with vitreoretinal surgery for regmatogenous retinal detachment. With ophthalmoscopy, the retina is completely attached. On day 8 after surgery, the visual acuity of the left eye was 0.3. According to OCT and ILC, a zone with anatomical and functional disorders in the central region of the retina was diagnosed. According to OCT, there was a lack of articulation of the outer and inner segments of the photoreceptors, small cystic edema, a site with an incomplete fit of the neuropigmented epithelium with a height of 0.2 mm in the zone from 1.0 to 3.0 mm in the lower temporal quadrant. The thickness of the retina in the foveal minimum 260 microns, in the lower temporal quadrant in the zone from 0.5 to 1.0 mm 350 microns, in the zone from 1.0 to 3.0 mm 460 microns, in the zone from 3.0 to 6, 0 mm 490 microns. The presence of relative scotomas with photosensitivity from 4 to 10 dB in the localization of small cystic edema and the zone of incomplete adjoining of the neuropigmented epithelium in the lower temporal segment was detected by CMP. In remote areas, photosensitivity ranged from 10 to 16 dB.

According to the phage in the early phase, hyperfluorescence was visualized in the macular zone, with an increase in intensity in the late venous phase and hyperfluorescence of the zone of incomplete adherence of the neuro pigment epithelium with a gradual expansion of the borders.

We performed a subthreshold LKS of the macula in the hyperfluorescence zone on an MS-300 multiwave laser photocoagulator (Nidek, Japan). 36 coagulates were applied in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone, excluding the central avascular zone (fovea).

Impact parameters: pulse duration 0.05 s, spot diameter 50 μm, power 60-70 mW, wavelength 561 nm.

In areas in which hyperfluorescence spread beyond the macula, in the lower temporal segment, in addition to the subthreshold LKS, a threshold LKS was performed with a pulse duration of 0.08-0.1 s, a spot diameter of 110 μm, a power of 80-100 mW, and a wavelength of 561 nm Applied 54 coagulate in a checkerboard pattern at a distance of not less than 1.5 diameter of the coagulate from each other on the entire surface of the hyperfluorescence zone.

After 3 months, visual acuity was 1.0. By OCT, the retina is fully adapted. According to the ILC, the photosensitivity ranged from 16 to 20 dB.

Example 3

Patient P. was operated on with vitreoretinal surgery for recurrence of regmatogenous retinal detachment. With ophthalmoscopy, the retina is completely attached. On the 7th day after the operation, the visual acuity of the right eye was 0.2. According to OCT and ILC, a zone with morphological and functional disorders in the central region of the retina was diagnosed. According to OCT, there is no articulation of the external and internal segments of the photoreceptors, diffuse edema of the central zone, 3 cysts in the upper nasal quadrant are visualized. Retinal thickness in foveal minimum 380 microns, in the upper nasal segment in the zone from 0.5 to 1.0 mm 400 microns, in the zone from 1.0 to 3.0 mm 480 microns, in the zone from 3.0 to 6.0 mm 520 microns. One absolute scotoma in the localization region of the central cyst and relative scotomas with photosensitivity from 2 to 12 dB were found by ILC in the upper nasal segment. In the area of other segments, photosensitivity ranged from 10 to 16 dB.

By phage in the arteriovenous phase - moderate hyperfluorescence, with an increase in intensity in the late venous phase with the fusion of individual foci of dye exit, the picture of a "flower" in the macular zone, in the region of the upper nasal segment - diffuse dye exit and hyperfluorescence of optic dislocation in the late phase.

We performed a subthreshold LKS of the macula in the zone of cystic edema (“flower”) on a multi-wavelength laser photocoagulator MS-300 (Nidek, Japan) with parameters: pulse duration 0.05 s, spot diameter 50 μm, power 120 mW, wavelength 561 nm. 45 coagulates were applied in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone, excluding the central avascular zone (fovea).

Outside the macula, in the upper nasal quadrant in the hyperfluorescence region, a threshold LKS was performed with a pulse duration of 0.1 s, a spot diameter of 100-200 μm, a power of 130-140 mW, and a wavelength of 561 nm. 86 coagulates were applied in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other on the entire surface of the hyperfluorescence zone.

Also, 50 coagulates were added, nasally departing 1000 μm from the edge of the optic disc with the same parameters in 2-4 rows in a checkerboard pattern at a distance of at least 1.5 coagulate diameters from each other.

After 10 days, visual acuity was 0.6. After 4 months, visual acuity was 0.8. By OCT, the retina is almost completely adapted. According to the ILC, the photosensitivity ranged from 14 to 20 dB.

Claims (1)

A method for the treatment of morphological and functional disorders of the central zone of the retina after retinal detachment surgery, including laser retinal coagulation (LKS), characterized in that for 5-10 days after surgery on the tamponade of the vitreous cavity with silicone oil (SM) in the area of detected morphological and functional disorders perform fluorescence angiography (FAG), and if hyperfluorescence is visualized in the macula, then subthreshold LKS is performed with a pulse duration of 0.02-0.1 s, a spot diameter of 50-100 μm, a power of 50-120 mW, a wavelength of 561 nm, applying 20-60 coagulates on the entire surface of the hyperfluorescence zone, excluding the central avascular zone, if hyperfluorescence is visualized in the macula and beyond, then in addition to the subthreshold LKS, a threshold LKS with a pulse duration of 0.05-0.1 s, a spot diameter of 100-200 microns, with a power of 80-140 mW, a wavelength of 561 nm, applying 50-200 coagulates to the entire surface of the hyperfluorescence zone, if hyperfluorescence is visualized in the macula and beyond, with concomitant hyperfluorescence of the optic nerve head (optic disc), then to the subthreshold and threshold LKS, a threshold LKS is performed with the same parameters, applying 20-80 coagulates, in 2-4 rows, departing 1000 μm nasally from the edge of the optic nerve head, while all coagulates are staggered at a distance of at least 1.5 diameters coagulate from each other.