RU2398558C1 - Method of surgical treatment of subtotal retinal detachment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for improvement of functional results of eye in case of retinal detachment in two or three quadrants. Limiting argonlaser coagulation on all border of detached retina in outpatient setting is carried out at first detection of its detachment. After examination patient in stationary conditions is subjected to extrascleral sealing of sclera and in early post-operation period after extrascleral sealing of sclera, argonlaser coagulation is repeated on the edge of bank of depression of sections which lowered as a result of carried out extrascleral sealing, as well as its changed sections, unnoticed during sclera cerclage. Later, after discharge, in case of detecting in patient chorioretinal dystrophy, macula edema or incomplete blockage of rupture, in outpatient setting additional argonlaser coagulation of changed sections of retina along bank of depression is carried out, paravasally and paramacularly during outpatient observation.

EFFECT: method allows to increase treatment efficiency in case of retinal detachment including 2-3 quadrants of eye fundus, to reduce risk of recurrence.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used to improve the functional results of the eyes operated on for retinal detachment (OS), with the capture of two, three quadrants of the fundus.

A known method of barrier laser coagulation of the retina with limited OS with small breaks in the latter. Coagulation is carried out in the mode: spot size 200 microns; exposure time 0.1-0.2 sec. The distinction of the retinal defect is carried out by two rows of medium-intensity laser coagulates (Jack J. Kansky et al. Fundus diseases. MEDpress-inform, 2008, p. 290).

The disadvantage of this method is that only small (limited OS) with small (small) retinal tears can be treated with this technique.

There is also another method for treating OS associated with vitrectomy followed by the introduction of silicone oil into the vitreous cavity (Takhchidi H.P. et al. The role of circular scleral filling in the treatment of retinal detachment by tamponade of the vitreous cavity with silicone oil. Ophthalmosurgery, 2006, No. 3 , p. 6-11).

When using this technique for treating OS, special expensive equipment, PFOS and the conditions of a specialized clinic are required.

In addition to these methods of treating OS, there is a method of treating retinal detachment, including extrascleral filling with a circulating tape from staggered perforated homosklera, which is fixed to its own sclera in each quadrant. An extracleral filling is placed in the projection of the retinal rupture. Homosclera is pretreated with a foaming polymer composition. The method allows for patients with multiple dystrophic and minor retinal tears to achieve a successful anatomical fit of the retina and to obtain high functional results (No. 2144120, 03.20.2001. A method for the treatment of retinal detachment. Neroev VV, Zakharova G.Yu., Kiseleva O.A. ., Ivanova V.V.).

However, this method of treating retinal detachment allows treatment in the presence of a homosclera, an expandable polymer composition, and allows a successful treatment outcome only in patients with multiple dystrophic and small retinal tears.

There is a method of treating retinal detachment, including preliminary YAG - laser reconstructions of the margin of separation, followed by extrascleral filling. Using the proposed method for the treatment of retinal detachment is less traumatic, it serves as a reliable prevention of the development of a retinal detachment recurrence (No. 93038764, 10.01.1997. A method for the treatment of retinal detachment. Kiseleva OA, Stepanov AV, Ivanov AN).

According to the proposed method Kiseleva O.A. et al., 1997, retinal detachments are treated with a solid-state short-pulse YAG laser with a wavelength of 0.532 nm, which allows dissection of the eyeball tissue.

A huge concentration of energy in a limited volume of the eyeball can lead to disruption of the hydro- and hemodynamics of the eye, which can negatively affect the course of the postoperative period and the functional results of the operation.

The purpose of the invention is to increase the functional results of surgery for retinal detachment with the capture of two, three quadrants of the fundus, reducing the risk of relapse.

The essence of the method of surgical treatment of subtotal retinal detachment is that restrictive retinal argonlasercoagulation is performed on the entire border of the detached retina on an outpatient basis for the first detection of retinal detachment, then, after appropriate examination in a hospital, extrascleral filling of the sclera with retinal tamponade is performed using a gas mixture and applying "Face down" in the first day after surgery, after which in the early postoperative period to the patient in st the atarium repeatedly performs argon laser coagulation along the edge of the shaft of the indentation of the areas of the retina adjacent as a result of extrascleral filling, as well as of its altered areas that were not seen during the circular scleral scirling, subsequently after discharge, when the patient revealed during outpatient observation chorioretinal dystrophy, macular edema or incomplete rupture blocking, additional argon laser coagulation of altered sections of the retina along the indentation shaft is performed on an outpatient basis I, paravasal and paramacular.

Argonlaser are green coagulating lasers with a wavelength in the range of 0.457-0.514 nm. Argonlasercolagulation of the retina on the day of its detection is carried out in order to prevent further progression of detachment, consolidate existing functions, create more favorable conditions for the second stage of the operation. In order to dilute the retina, a standard circular scleral circulation is carried out; to enhance the effect of the operation, a gas mixture is injected into the vitreous cavity of the eye with the aim of tamponade of the retina from the inside of the patient to make the patient face down on the first day of the postoperative period.

At the third stage, additional coagulation is carried out along the edge of the shaft of the depression of the sections of the retina adjacent as a result of the circulation, as well as its changed sections, i.e. with signs of edema, dystrophy, and tears that are impossible to notice with a circular scleral circlet. At the fourth stage, when chorioretinal dystrophy, edema of the macula, incomplete blocking of the gap are detected, additional restrictive coagulation along the impression shaft is performed, paravasally and paramacularly, in order to obtain and maintain the highest possible visual functions and prevent the development of relapse of retinal detachment. Phased retinal recovery provides a more consistent treatment result, as each previous stage is preparation for the next and allows for better coagulation.

The method is as follows.

When contacting a consultative clinic immediately when a diagnosis of retinal detachment and the presence of transparent optical media is made outpatiently under local anesthesia Sol.Dicaini 1%, with drug mydriasis, Goldman’s lens performs restrictive argon laser coagulation of the retina in the mode: power 200-500 mW; the exposure time is 0.1-0.2 sec, the spot diameter is 100-200 microns, 300 to 500 coagulates are applied along the edge of the detachment in 3-4 rows, paravasally in 1 row, on the periphery of the retina - 2-3 rows. After a clinical examination, which takes from 2 to 6 days, the patient enters the hospital.

The next day, in a patient’s hospital, the sclera is circulated with a silicone sponge with a diameter of 3 mm and fixed to the sclera with 4 / 0-5 / 0 Mercils stitches in the upper and lower quadrants, then the sclera is trepanated with the release of subretinal fluid, with the introduction of the air mixture into the cavity the vitreous body through the flat part of the ciliary body, after preliminary diathermocoagulation of the sclera, with the obligatory giving the patient’s body the “face down” position on the first day of the postoperative period.

In the early postoperative period (in the first 7 days) after the operation of the circulation, the patient undergoes repeated argonlasercoagulation along the edge of the indentation shaft in 3-4 rows of retinal areas adjacent as a result of extrascleral filling, as well as its changed sections, i.e. with signs of edema, dystrophy, and tears that are impossible to notice with a circular scleral circlet.

If subsequently after discharge from the patient during outpatient observation, chorioretinal dystrophy, macular edema, incomplete blocking of the gap are revealed, additional argon laser coagulation of the altered sections of the retina along the indentation shaft is performed, paravasally and paramacularly on an outpatient basis.

Example 1

09/13/05. Outpatient. Patient P. 67 years. Diagnosis: subtotal retinal detachment of the right eye. Visual acuity of the right eye = 0.02 n / a. Distinctive argon laser coagulation of the retina of the right eye was performed in the regime: power 300 mW, spot diameter 200 μm, exposure time 0.2 s. The number of coagulates is 254. 09/15/05, in the hospital. Circular scleral circulation was performed with trepanation of the sclera at the height of the bladder and the release of subretinal fluid and the introduction of the gas mixture into the vitreous cavity of the right eye with the obligatory giving the patient’s body the “face down” position on the first day of the postoperative period.

09/17/05, To enhance the effect of the operation, an additional peripheral delimiting argon laser coagulation was performed and paravasally in the regime: power 300 mW, spot diameter 200 μm, exposure time 0.2 s. The number of coagulates is 480.

09/25/05. On discharge: right eye - moderately irritated. The conjunctival sutures are clean, the adaptation of the edges of the wound is good. The fundus reflex is pink. In the cavity of the vitreous body, a light suspension of the formed elements of blood. DZN - pale pink, clear borders. The retina lies along the entire periphery, the pigment shaft of the depression of the II-III degree. Visual acuity of the right eye - with a diaphragm of 0.1 n / a.

04.03.06, On an outpatient examination: visual acuity of the right eye - 0.1 with spheres.-3.0 diopters 0.2. The eye is calm, the anterior segment is not changed. The fundus reflex is pink, DZN is pale pink, the borders are clear. The retina is adjacent throughout. On the periphery of the pigment shaft of an impression of IV degree. Pigmented coagulates paravasally and along the periphery of the fundus. In areas of vitriochorioretinal retinal dystrophy, additional argon laser coagulation was performed in the regime: power 300 mW, spot diameter 200 μm, exposure time 0.2 s. The number of coagulates is 254.

04/23/07, Outpatient: visual acuity of the right eye - 0.1 with spheres.-3.0 diopters. - 0.2. The eye is calm. The anterior segment of the eye is not changed. The fundus reflex is pink. DZN - pale pink, clear borders. The vessels are not changed. On the periphery, a pigment shaft of an impression of IV degree. Parasasally, paramacularly and along the periphery of the fundus are multiple pigmented laser coagulates.

An additional local argonlasercoagulation of dystrophic foci of the retina and barrage of the macular region was performed. In the mode: power 250 mW, spot diameter - 200 microns, exposure time - 0.2 sec. The number of coagulates - 467 + barrage: power 200 mW, spot diameter 50 μm, exposure time 0.2 sec, the number of coagulates 47.

Example 2. 05/14/07. Patient D. 66 years. Diagnosis: subtotal detachment of the left eye. On admission, visual acuity of the left eye = eccentricly 0.005 n / a.

05/14/07. Distinctive argon laser coagulation of the retina was performed along the entire edge of the retinal detachment and peripheral delimitation coagulation was performed in the following mode: power 350 mW; spot diameter 200 μm, exposure time = 0.2 sec; the number of coagulates = 320.

05/20/07. Operation: circular scleral circulation with trepanation of the sclera and the release of subretinal fluid at the height of the bladder and the introduction of the gas mixture into the cavity of the vitreous body of the left eye with the obligatory giving the patient’s body the “face down” position on the first day of the postoperative period.

05/27/07. In order to better fix the retina, an additional argon laser coagulation of the retina was carried out along the indentation shaft and paravasally in the mode: power - 350 mW; spot diameter - 200 microns; exposure time - 0.2 sec; with the application of coagulates in an amount of 478.

06/03/07. On discharge: the left eye - the eye is moderately irritated, the conjunctival sutures are clean, the adaptation of the edges of the wound is good. Vis = 0.1 n / k. Optical media are transparent, pink fundus reflex, floating opacities in the vitreous. DZN is pale pink, the borders are clear, the retina lies along the entire length, along the periphery a pigment shaft of pressure of the II-III degree, paravasally pale laser coagulates on the periphery.

07/01/07. An additional argon laser coagulation of the retina of the left eye was performed - paramacularly and paravasally in the regime: power - 250 mW; spot diameter - 200 microns; exposure time - 0.2 sec; inflicted 546 coagulates.

08/27/08. The left eye is calm, the anterior segment of the eye has not been changed, the reflex from the fundus is pink, single floating opacities remain in the vitreous cavity. DZN - pale pink, the boundaries are clear, the vessels are not changed, paravasally, paramacularly and along the periphery of the fundus pigmented lasercoagulates. Visual acuity of 0.3 with an aperture of 0.4-0.5.

Our method provided comprehensive treatment for 37 patients aged 19 to 80 years old, of which 12 were men, 25 were women with common and subtotal retinal detachments. For all patients, the diagnosis of retinal detachment and its localization both in the preoperative and postoperative period was confirmed by ultrasound B-scanning, examination of the fundus using a Skepens binocular ophthalmoscope and a Goldman contact lens, visual acuity examination with and without correction, research CoES and visual fields, tonometry and tonography were performed. In the postoperative period, the condition of the fundus, ophthalmotonus, CoES and perimetry were evaluated in all patients. We studied the effectiveness of laser coagulation depending on the development time of retinal detachment and its localization and area.

According to the proposed method of treatment of retinal detachment, 37 patients were treated: in 18 cases, an improvement in the functional result was noted, in 9 it remained stable, and in 6 cases the result was not achieved (in 2 cases, the retina did not lie down, in 4 cases there was a relapse in the postoperative period).

Advantages of the proposed method: this method allows to reduce the time from the moment of detection of retinal detachment to the beginning of its treatment, since argon-laser treatment performed on an outpatient basis until extrascleral filling is performed circularly reduces the risk of disease progression (increasing the detachment area) from the moment of diagnosis to hospitalization of the patient . And lasercoagulation, performed in the early postoperative period (in the first seven days) after extrascleral filling, minimizes the likelihood of relapse due to the biological effect of argon laser coagulation with increased adhesion of the retina to the underlying membranes of the eye and allows preventive treatment of concomitant pathology (edema, retinal dystrophy) etc.).

Claims (1)

A method of surgical treatment of subtotal retinal detachment, including restrictive argon laser coagulation of the retina and circular extrascleral filling of the sclera with tamponade of the retina with a gas mixture, followed by imparting the patient’s position “face down” on the first day of the postoperative period, characterized in that the restrictive argon laser coagulation of the retina is performed exfoliated retina at the first detection of its detachment, then after appropriate examination to the patient in In a hospital, extra-scleral filling of the sclera is performed and in the early postoperative period after extra-scleral filling of the sclera, argon laser coagulation is repeated along the edge of the shaft of the impression of retinal areas adjacent as a result of extra-scleral filling, as well as altered areas that were not noticed when circulating the sclera. the patient's detection during outpatient monitoring of chorioretinal dystrophy, macular edema or incomplete blocking rupture, outpatiently carry out additional argon laser coagulation of the altered sections of the retina along the indentation shaft, paravasally and paramacularly.