RU2472476C1 - Method of laser treatment of fused drusen in case of age-related macular degeneration - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to ophthalmology, in particular to methods and devices for treatment of eyes with application of laser and is intended for performing impact on soft drusen by sub-threshold micropulse infrared laser. Laser coagulation with individual selection of power is performed. Sub-threshold micropulse impact with infrared diode 810 nm laser is applied. Coagulants with diameter 1.8 mcm in quantity from 8 to 10 are located in projection of soft drusen around foveolar zone and continuous circular spot is created by their superposition on each other. Each following coagulant overlaps the previous one on 1/8, after which last coagulant is applied in the centre of fovea area.

EFFECT: method makes it possible to perform single impact on macular zone, achieve even distribution of energy in it, reduce treatment terms, reduce number of drusen, increase vision acuity and prevent disease recurrences.

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Description

The invention relates to medicine, in particular to ophthalmology, in particular to methods and devices for treating eyes using a laser, and is intended to affect soft druses by a subthreshold micropulse infrared laser.

A known method of physiotherapeutic correction of early postoperative complications of cataract extraction, in which laser radiation with a wavelength of 633 nm stimulate the cornea of the eye, and laser radiation of 532 nm - structure of the posterior segment of the eye. Moreover, laser stimulation with red and green radiation is carried out alternately after 1 day with a gradual increase in the modulation frequency and duration of the procedure, the treatment course is 4-10 sessions, the session duration is from 3 to 9 minutes, the frequency of modulation of the red and green laser radiation is 0.38 -3.8 Hz, speckle field spot diameter 45 mm (Pat. No. 2417803 RU. Publ. 10.05.2011).

A known method for predicting the course of age-related macular degeneration, in which determine the autofluorescence parameters of the retina. For this, the first contour of the zone of increased autofluorescence is first circled and the area (S1) of increased autofluorescence of the reticular membrane is measured. Then after 3-6 months, the second newly formed contour of the zone of increased autofluorescence is circled and the area (S2) of this zone is measured. If the area of the second contour of the zone of increased autofluorescence in the central region of the retina (S2) is larger than the area of the first contour of the zone of increased autofluorescence (S1), then the progression of the dystrophic process of the pigment epithelium of the retina is predicted (Pat. No. 2386387 RU. Publish. 04.20.2010).

A known method of treating a “dry” form of age-related macular degeneration, comprising administering a suspension of autologous cultured mesenchymal stem cells of one’s own bone marrow in an amount of 1-2 × 107 cells in 0.1 ml of physiological saline (Pat. No. 2375016 RU. Publ. 10.12.2009) .

A known method of treating exudative maculopathy in patients with coats retinitis, including the implementation of laser exposure with a wavelength of = 810 nm on the retina from the vascular arcades and the optic nerve to the periphery of the retina.

The impact is carried out in stages, for 4-6 sessions with an interval between sessions of 1.5-2 months (Pat. No. 2371152 RU. Publ. September 27, 2010).

There is a method of treating age-related macular degeneration, in which a partial vitrectomy of the premacular vitreous humor is performed, and detachment of the posterior hyaloid membrane is induced without removal. The drug Avastin at a dose of 1.25 mg is introduced into the formed retrogyaloid space (Pat. No. 2368359 RU. Publ. September 27, 2009).

A known method of treating diabetic maculopathy, including laser infrared transpupillary thermotherapy directly to the optic nerve head. Exposure parameters: wavelength 810 nm, radiation power 500-700 mW, spot diameter 2.0 mm, exposure for 60-90 seconds. Spend 1-2 treatment sessions with an interval of 1-2 months (Pat. No. 2340320 RU. Publ. 10.12.2008).

A known method of surgical treatment of serous retinal detachment in the macular region with age-related macular degeneration, in which, after performing YAG laser retinopuncture, carried out 2 weeks after the restrictive laser coagulation, intravitreal tamponade of the detached retina with gas is performed. To do this, in the scleral zone 4 mm from the limb, a “port” with a caliber of 25 G is installed and through it with the help of a vitreotome a channel is formed in the vitreous body towards the posterior pole of the eye with exit beyond the posterior hyaloid membrane. The vitreous is removed step by step, each time in a volume of 0.3 ml, replacing it with the same volume of perfluorocarbon gas. Such substitutions, depending on the length of the eye, are performed 2-5. The operation is completed by the introduction of the last portion of gas, then the patient is placed for 1 day face down. 3 days after the introduction of gas, restrictive laser coagulation is performed around the retinopuncture opening (Pat. No. 2361554 RU. Publ. 20.07.2009).

A known method of treating age-related macular degeneration of the retina, including laser exposure and the introduction of retinalamine. To do this, dissolve 5 mg of retinalamine in 1.5 ml of a 2% solution of lidocaine. Parabulbarly injected 75 ml of the resulting solution in each eye. After 5-10 minutes, a laser effect is performed, focusing it on the retina. Influenced by a helium-neon laser continuously contactless. The fiber diameter is 3 mm, the distance from the distal end of the fiber to the front surface of the cornea is 2-4 cm. The exposure power is 2.2-2.6 W. The specified combined effect is repeated daily for ten days. The duration of the first three sessions of laser exposure is 3 minutes, and the next seven sessions of laser exposure are 5 minutes (Pat. No. 2408335 RU. Publ. 10.01.2011).

A known method of laser treatment of soft macular drusen with senile macular degeneration, which consists in conducting subthreshold continuous infrared circular laser coagulation. The coagulates are arranged along the meridians in such a way that 80 coagulates with a diameter of 200 μm have 6 coagulates on the hourly meridians, 7 coagulates on the vertical and horizontal with a distance from the center of the foveolar avascular zone to the first coagulate 200 μm. The last eighth coagulum is applied at a distance of 2800 nm from the foveolar avascular zone (Pat. No. 2340318 RU. Publ. 10.06.2008).

However, the known method provides a systematic arrangement of coagulates by time meridians, increases the effectiveness of treatment, reduces postoperative complications, but its implementation does not provide for an increase in the area of the macular zone and even distribution of energy over it, reduction of treatment time and prevention of relapse.

The objective of the present invention is the possibility of a single exposure to the macular zone by increasing its area and even distribution of energy over it, reducing treatment time, reducing the number of drusen, increasing visual acuity and preventing relapse.

The problem is solved in that in the method of laser treatment of drain friends with age-related macular degeneration, including laser coagulation, arrangement of coagulates, individual power selection, a subthreshold micropulse effect of 810 nm infrared diode laser is used, create a continuous circular spot, for this, coagulates with a diameter of 1, 8 microns in an amount of 8 to 10 are placed in the projection of soft drusen around the foveolar zone, in addition, they are superimposed on each other so that each last blowing coagulum overlaps the previous 1/8, whereupon the latter is applied in the center of coagulum in the fovea.

The present invention is illustrated in the detailed description and clinical examples.

The method of laser treatment of confluent drusen with age-related macular degeneration is as follows.

Before surgery, a comprehensive study of the patient. To do this, use the following examination methods:

- determination of visual acuity with maximum correction;

- ophthalmoscopy with a Reichel Mainstr 1x Retina lens;

- fundus photographing on a Karl-Zeis fundus camera;

- microfundusperimetry;

- optical coherence tomography;

- fluorescence angiography.

After diagnosis, laser treatment is performed for drain drusen with age-related macular degeneration. Before starting treatment, the patient is given local anesthesia using a 0.4% inocaine solution. Then, a subthreshold micropulse effect is carried out, which is carried out using an 810 nm infrared diode laser IRIDEX IQ 810 (USA) using a wide adapter and a Reichel Mainstr 1x Retina lens. With the help of the latter, a continuous circular spot of large diameter is obtained.

In all cases, a spot with a diameter of at least 3.0 mm was preferred. Power is selected individually depending on the degree of pigmentation of the fundus according to the test results. Test coagulates and power selection are carried out in a continuous mode with a spot of 300 μm above the superior temporal vascular arcade at an exposure of 500 ms with a constant increase in power by 100 mW until the appearance of coagulum of the 1st degree (weak gray color). After receiving the test coagulate, the resulting energy is left unchanged, and the exposure is increased 100 times to 5000 ms.

Coagulates from 8 to 10 are positioned so that coagulates with a diameter of 1.8 microns are applied in the projection of soft drusen around the foveolar zone. At the same time, they are superimposed on each other so that each subsequent coagulate overlaps the previous one by 1/8. After that, the last coagulum is applied in the center in the fovea region, thereby creating a continuous circular spot in the area of drain drusen with age-related macular degeneration. A large spot allows laser therapy to be performed with a single exposure to the entire area of the macular zone and evenly distribute the energy created by coagulants.

After the treatment in the immediate period, after six months, and distant, after twelve months, repeated studies of the patient are carried out by the above methods. Studies show that 12 months after laser coagulation, Druze significantly decrease or completely resolve.

Clinical examples.

Example No. 1.

Patient Gorokhova N.L. Born 1942 Diagnosis OU - Age-related macular degeneration, OD - Disciform stage (subretinal neovascular membrane, scarring stage), OS - pre-uniform, drainage drusen. At the time of treatment, visual acuity was OD-0.1 n / a, OS-0.4 (+1.0 D) = 1.0.

The patient underwent a comprehensive examination, including fluorescence angiography. On the left eye, inhomogeneous hyperfluorescence of drains of a draining nature was noted; there was no exit and accumulation of dye. Optical coherence tomography of the retina - under the pigment epithelium identified a large number of drain drusen.

Power was selected individually depending on the degree of pigmentation of the fundus according to the test results. Test coagulates and power selection were carried out in a continuous mode of emission with a spot of 300 μm above the superior temporal vascular arcade at an exposure of 500 ms with a constant increase in power by 100 mW until the appearance of coagulate of 1 degree (weak gray color). After receiving the test coagulate, the resulting energy was left unchanged, and the exposure was increased 100 times to 5000 ms.

We performed laser treatment on the left eye on March 15, 2010 - a subthreshold micropulse exposure with a wide spot in the projection of draining friends, using the following parameters: energy = 1170 mV, exposure = 5000 ms, spot 1.8 nm, pulses 14.

For this, a subthreshold micropulse exposure was performed using an 810 nm IRIDEX IQ 810 infrared diode laser (USA) with an adapter for a wide spot. Coagulates from 8 to 10 were arranged in such a way that coagulates with a diameter of 1.8 μm were applied in the projection of soft drusen around the foveolar zone. At the same time, they were superimposed on each other so that each subsequent coagulate overlapped the previous one by 1/8. After that, the last coagulum was applied in the center in the area of fovea. Thereby created a large spot in the area of drain friends. A large spot made it possible to carry out laser therapy with a single exposure to the entire area of the macular zone. In this case, the energy created by coagulants was distributed evenly.

After the treatment, a month later, upon examination, an increase in visual acuity in the left eye was noted to 0.7 (+1.0 D) = 1.0.

Inspection and research after six months and in the remote, after twelve months, period was performed by such methods as:

- determination of visual acuity with maximum correction;

- ophthalmoscopy with a Reichel Mainstr 1x Retina lens;

- fundus photographing on a Karl-Zeis fundus camera;

- microfundusperimetry;

- optical coherence tomography;

- fluorescence angiography.

All of them showed that visual acuity in the left eye was 0.8 (+1.0 D) = 1.0, optical coherence tomography determined a decrease in the number of drusen. After a year, visual acuity in the left eye was up to 1.0. Ophthalmoscopically confirmed complete resorption of drusen, hyperpigmentation sites. Optical coherence tomography showed the absence of drusen under pigment epithelium. Fluorescence angiography of the left eye noted slight iperfluorescence due to the accumulation of pigment. The patient was satisfied with the treatment.

Example No. 2.

Patient Koval N.D. Born 1934 Diagnosis OU - Age-related macular degeneration, pre-form, drainage drusen. At the time of treatment, visual acuity was OD-0.3 n / a, OS-0.4 n / a. Fluorescence angiography was performed on both eyes; persistent hyperfluorescence of drains of draining nature was noted on a number of angiograms; there was no exit and accumulation of dye; optical coherence tomography of the retina - under the pigment epithelium identified a large number of confluent drusen.

Power was selected individually depending on the degree of pigmentation of the fundus according to the test results. Test coagulates and power selection were carried out in a continuous mode of emission with a spot of 300 μm above the superior temporal vascular arcade at an exposure of 500 ms with a constant increase in power by 100 mW until the appearance of coagulate of 1 degree (weak gray color). After receiving the test coagulate, the resulting energy was left unchanged, and the exposure was increased 100 times to 5000 ms.

Laser treatment was performed on the left eye on 08.04.2010 — a subthreshold micropulse exposure with a wide spot in the projection of drain drusen (Energy = 1500 mV, exposure = 5000 ms, 1.8 nm spot, 14 pulses).

For this, a subthreshold micropulse exposure was performed using an 810 nm IRIDEX IQ 810 infrared diode laser (USA) with an adapter for a wide spot. Coagulates from 8 to 10 were arranged in such a way that coagulates with a diameter of 1.8 μm were applied in the projection of soft drusen around the foveolar zone. At the same time, they were superimposed on each other so that each subsequent coagulate overlapped the previous one by 1/8. After that, the last coagulum was applied in the center in the area of fovea. Thereby created a large spot in the area of drain friends. A large spot made it possible to carry out laser therapy with a single exposure to the entire area of the macular zone and evenly distributed the energy created by coagulants.

On examination after a month, an increase in visual acuity in the left eye was noted to be 0.5 n / k, after 6 months, visual acuity in the left eye was 0.7 n / k.

The following methods were used to study the patient in periods six months after treatment and in the distant twelve months later:

- determination of visual acuity with maximum correction;

- ophthalmoscopy with a Reichel Mainstr 1x Retina lens;

- fundus photographing on a Karl-Zeis fundus camera;

- microfundusperimetry;

- optical coherence tomography;

- fluorescence angiography.

Conducted optical coherence tomography and other studies have determined a decrease in the number of drusen. A year later, visual acuity in the left eye increased to 0.8 n / a. Ophthalmoscopically determined the complete conservation of single druses in the macular zone. Optical coherence tomography determined the presence of single druses under the pigment epithelium. After fluorescence angiography, slight hyperfluorescence was noted on the left eye.

Clinical observations revealed the advantage of the proposed method in comparison with similar ones carried out on a 810 narrow spot laser.

The proposed method of laser treatment of confluent drusen with age-related macular degeneration allows one-time exposure of the macular zone by increasing its area and even distribution of energy over it, shortening treatment time, reducing the number of drusen, in addition, increasing visual acuity and preventing relapse.

The proposed method allows to increase the effectiveness of treatment, to reduce the risk of complications. Clinical studies have shown that 12 months after laser coagulation using the proposed method, the Druze significantly decreased or resolved.

The proposed method is used at the State budget institution "Kurgan Regional Hospital for War Veterans", at the Tyumen State Medical Academy of the Ministry of Health and Social Development of Russia, namely at the faculty of advanced training and professional retraining of specialists.

Claims (1)

A method of laser treatment of confluent drusen with age-related macular degeneration, including laser coagulation, arrangement of coagulates, individual power selection, characterized in that they use a subthreshold micropulse exposure to an 810 nm infrared diode laser, create a continuous circular spot, for this, coagulates with a diameter of 1.8 microns in from 8 to 10 are placed in the projection of soft drusen around the foveolar zone, in addition, they are laid on top of each other so that each subsequent coagulate erekryvaet previous 1/8, after which the latter is applied to coagulate in the center of the fovea.