RU2479290C2 - Method for combination treatment of open-angle glaucoma following laser hypotension surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology, and may be used for treating open-angle glaucomatous optic neuropathy (GON). Carotid bodies are percutaneously exposed to the rotary field. Pulse frequency, length and amplitude is specified individually for each patient so as to provide a blocking or stimulating effect on the ganglia depending on the tone of the vegetative nervous system. The first procedure is followed by evaluating the relation of eye ground arteries and veins and a Kerdo index; in the case of normalising the index Kerdo and/or changing the arterial-venous relation of the eye ground vessels, the therapeutic course of subconjunctival injections of neuropeptides is prescribed with simultaneously continued sympathetic correction, if the effect of the sympathetic correction procedure is absent, the procedure is repeated.

EFFECT: method provides higher effective neuroprotective therapy following antihypertension laser surgeries due to the fact that the selection of biotropic parameters of the rotating field is performed in accordance with the Kerdo index and recording the vascular pattern changes of the eye ground.

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Description

The invention relates to medicine, specifically to ophthalmology, and can be used to treat glaucoma optical neuropathy (GON). The following factors play an important role in the pathogenesis of glaucoma: mechanical compression of nerve fibers in the area of the ethmoid plate due to increased intraocular pressure with the resulting cascade of pathological reactions and the vascular component (choriocapillaries have a structure identical to the vessels of the brain). Thus, the structure of the method proposed by us involves the impact on all stages of the glaucoma process.

The analogues of the proposed method are various options for physiotherapeutic treatment of degenerative changes in the nerve fibers of the retina and optic nerve [1, 3, 7], for example:

- magnetic infrared laser therapy,

- ultra high frequency electric field therapy,

- magnetotherapy on the eye with a rotating magnetic field;

- laser therapy with low-intensity radiation;

- the impact of a rotating electric field on the region of carotid sinuses.

Magnetic infrared laser therapy produces simultaneous exposure to reflexogenic paraocular points for 1 minute with a frequency of 50 Hz pulsed infrared laser radiation with a power of 5 mW, a frequency of 8-12 Hz, pulsed broadband infrared radiation with a power of 60 ± 30 mW, with a wavelength of 0, 86-0.96 nm, pulsed red radiation with a power of 40 W, with a wavelength of 0.6-0.7 nm, a constant magnetic field with an induction of 35 ± 10 mT. This effect is carried out in parallel with the administration of Encephabol. The course has 20 sessions, 1 procedure per day. [7].

The disadvantage of this method is the difficulty in selecting the effective laser stimulation power, which has therapeutic efficacy and, at the same time, does not cause a damaging effect [9], as well as a large number of side effects of the drug Encephabol in the absence of direct indications for its use [8].

For electric field therapy, an ultra-high frequency is used, through an electrode placed on the eyelids with an amplitude of 25 to 800 μA, a duration of 5 to 15 ms, a repetition rate of 30 to 40 Hz in burst mode, 5 pulses per packet. Packs follow after 1 second, while they are combined in series lasting from 15 to 30 seconds each: during electrical stimulation, from 8 to 10 series of packs are served with an interval between series from 1 to 2 minutes [2]. The parameters of electrical stimulation are selected individually for each patient according to the results of measuring the threshold of electrical sensitivity and electrostability of his visual system, as well as by the nature of electric phosphene - an elementary visual sensation that occurs when an electric current acts on any section of the visual analyzer [4]. The disadvantage of this method is that electrical impulses act directly on only one link in the system that ensures the functioning of the visual analyzer, namely the optic nerve. This limits the possibilities of the method due to the fact that retinal nerve fibers are involved in the glaucoma process.

When applying constant, variable or pulsed magnetic fields [5], a “traveling” magnetic field is dynamically applied with a frequency of change of 50 Hz with a maximum value of the amplitude value of magnetic induction in the operating mode on the surface of the emitter 33 (+ 10%) mT. The impact is carried out by directly applying the working surface of the emitter of the traveling magnetic field to the closed eyelids of each eye in turn. The modulation frequency is 1-2 Hz, the exposure time is 3-7 minutes [6].

The disadvantages of this technique are the short duration of the results, exclusively local impact and the need for a large amount of research for the correct selection of treatment [10].

For transpupillary fundus irradiation with a low-intensity laser, helium is used - neon (wavelength 0.63 μm) and helium - cadmium (wavelength 0.44 μm), as well as semiconductor infrared lasers (wavelength 0.78; 0.85; 1 , 3 μm). According to a number of researchers, the mechanism of the stimulating effect of low-energy laser radiation can be represented as follows: the quantum energy of red coherent light (1.96 EV) is too small to break the energy bonds of a molecule (more than 40 EV), while it is also sufficient to excite an electron. When light is absorbed by a cellular photoreceptor molecule, a photodynamic effect occurs, which is realized by activation of the nuclear apparatus and increased activity of ribosome DNA-RNA. An important role is played by the activation of catalase, superoxide dismutase and cytochrome oxidase, as well as the transformation of oxygen into one of the active forms - the singlet state. The disadvantage of this technique is the surface effect, as a result of which nerve fibers lying deep in the optic nerve are not covered, as well as the significant difficulty in selecting a power regimen that has a therapeutic effect in a particular patient, while not having a damaging effect [9].

With transdermal magnetic laser exposure in the projection of carotid sinuses, the energy of light quanta and the introduction of a magnetic field are introduced, which provides an increase in tissue metabolism and rheological properties of blood. Consistently carry out percutaneous magnetic laser exposure for 2-3 minutes in a dose that improves the rheological properties of blood and improve microcirculation. In the projection of the cervical sympathetic plexus - on both sides for 5-7 minutes in a dose that allows you to get vasodilation of the vessels that feed the optic nerve. The course of treatment is 8-10 procedures. The disadvantages of this technique are: the lack of data on the individual selection of exposure parameters and criteria for selecting the impact factor taking into account the tone of the autonomic nervous system [11], while there are differences in individual sensitivity and instability of the reactions of the body and its systems to the influence of the magnetic field and, as a result, unpredictability of use in all patients. According to the US National Science Foundation, [13] magnetotherapy is not a scientifically proven treatment method.

The closest analogue of the invention is the electrophysical method of restoring the function of the visual analyzer [14]. The method is intended for the treatment of degenerative eye diseases and severe forms of optic atrophy. The method consists of a two-stage effect on the visual analyzer system: at the first stage, the system of regulation of cerebral circulation is corrected by percutaneous exposure to the ganglia of the sympathetic nervous system (upper cervical and stellate) of the sympathetic part of the autonomic nervous system by a rotating field of electric current pulses, which form in the space between the left and right ganglia using two multi-element electrodes consisting of Q partial galvanically isolated from each other angles of conductive elements that perform the functions of cathodes and two anodes that are placed in the projection of the ganglia, moreover, when generating electric current pulses, the partial elements of the multi-electrode electrodes are switched according to the program, in the action they form a pause, the zone of blocking the activity of the ganglia is switched according to the program, the frequency, duration and the amplitude of the pulses is set individually for each patient, so as to ensure numbness of the earlobe. At the second stage, they influence this field in the projection of the optic nerve to improve trophism in the area of the optic nerve head. The treatment procedures for correction of the cerebral circulatory system and electrical stimulation of the visual analyzer continue until the improvement of the function of the visual analyzer is achieved. If necessary, further improve the function of the visual analyzer, the treatment procedures are repeated.

The disadvantage of this method is its use only in the treatment of chronic dystrophic diseases.

Actual is the need to further improve the methods of conservative treatment of glaucoma.

The technical result of the claimed invention is to increase the effectiveness of neuroprotective therapy after antihypertensive laser operations due to the fact that the selection of biotropic parameters of a rotating field of electric current pulses is carried out in accordance with the results of calculating the Kerdo index and recording changes in the vascular pattern in the fundus.

The electrophysical method of the combined treatment of open-angle glaucoma after a laser antihypertensive operation is claimed, including monitoring of the main visual parameters, fundus photography, blood pressure and pulse monitoring, percutaneous exposure of the carotid sinuses to a rotating field, characterized in that the frequency, duration and amplitude of the pulses are set individually for each patient so as to provide a blocking or stimulating effect on the ganglia, depending on the type imbalance of the autonomic nervous system, which is estimated by the blood pressure monitor and pulse counting index Kerdo before treatment. After the fifth and each subsequent procedure, a repeated assessment of the Kerdo index and the dynamics of the arteriovenous ratio is carried out.

Figure 1 shows the structural diagram of the device, where:

1, 2 - multichannel electrodes;

3 - shaper of electric current pulses;

4 - regulator of biotropic parameters of these pulses;

5, 6 - zones in the neck area, in the projection of which are the ganglia of the sympathetic nervous system (upper cervical and stellate);

7, 8 - anodes;

9, 10- switches;

11 is a software device.

Figure 2 presents the treatment algorithm.

It is known that the cerebral circulation system is a complex biophysical structure, the control of which is ensured by the neurogenic, humoral, metabolic and myogenic regulatory circuits that are in dynamic interaction. Their activity is aimed at providing physical homeostasis, determined by the balance of the process of filtering water from blood into brain tissue under the influence of hydrostatic pressure in the arterial segment of the capillary and its absorption in the venous segment of the capillary under the influence of oncotic pressure of blood plasma, and chemical homeostasis of the internal environment of the brain. There is a certain hierarchy and subordination of regulatory loops. With artificial suppression of the activity of individual regulation mechanisms, the role of each of them in the cerebral circulation system is changed. The most important executive link of the neurogenic mechanism in the regulation of cerebral circulation is the efferent innervation of the walls in the cerebral vessels of various calibers: from the main arteries to microvessels. This innervation is ensured mainly with the help of a sympathetic constrictor effect on the cerebral vessels, and the leading role in this process belongs to the effects on the superior cervical and stellate ganglia [12]. Blocking or stimulating the activity of these ganglia is carried out by a rotating field of electrical pulses formed by a multi-element cathode, consisting of Q conductive partial elements isolated from each other, and a single-element anode. The frequency, duration and amplitude of the pulses are set individually for each patient so as to provide a blocking or stimulating effect on the ganglia, depending on the tone of the autonomic nervous system, which is assessed by monitoring blood pressure and pulse with the calculation of the Kerdo index. The procedure for the treatment process is as follows: “FREQUENCY”, “DURATION” and “AMPLITUDE” are set to the leftmost position, turn on the device, then “FREQUENCY” and “DURATION” are transferred to position “5” of the corresponding scale. Further, the position of the AMPLITUDA regulator is slowly changed until the patient feels the influence of an electric field. This mode is used when the vegetative balance index (WB) is <0. If WB> 0, then turn the “AMPLITUDE” knob to the right until anemia of the left or right earlobe occurs, which is assessed with a light touch of a needle. At the same time, a different value of the volumetric current density of electric pulses in the impact zone is provided so that the maximum value of the current density falls on the ganglia of the sympathetic nervous system located in the neck (upper cervical and stellate), in the projection of which the anode is placed. For this, the area of all partial elements of the multi-element cathode should be larger than the area of the anode. The rotation in the space of the influence of the field of electric pulses is provided due to the alternate inclusion in accordance with the specified law of one of the Q partial elements of the multi-element cathode. Before treatment, a laser hypotensive operation is performed (in most cases, selective laser trabeculoplasty), then the functions of the visual analyzer are evaluated using standard ophthalmological methods (visometry, computer perimetry, electrical sensitivity of the retina and electrical lability of the optic nerve, and the fundus is photographed), and arterial fundus photography is performed. pressure and venous pulse for calculating the Kerdo index. The course of treatment consists of several procedures, in each of which an alternation of the cycles of “exposure” is provided, when during the time t1 they are applied by pulses of electric current to the ganglia of the sympathetic nervous system, and “pause” when during the time t2 the exposure is stopped. These procedures are carried out daily or every other day K times. After several procedures, the evaluation of the function of the visual analyzer is repeated using one of the methods mentioned above, and the change in arteriovenous ratio is also evaluated by comparing the data of photographing the fundus. In the presence of visible changes in the arteriovenous ratio, a course of parabulbar injections of Retinalamin begins. In the absence of a vascular response, additional sympathocorrection procedures are performed. At the end of the course, the main visual parameters are evaluated. The treatment algorithm is shown in Fig.2.

Figure 1 shows the structural diagram of a device that implements the proposed electrophysical method of restoring the function of the visual analyzer.

Here are: two multi-channel 1 and 2 electrodes, a shaper of 3 pulses of electric current, a regulator of 4 biotropic parameters of these pulses, zones 5 and 6 in the neck, in the projection of which are the ganglia of the sympathetic nervous system (upper cervical and stellate), anodes 7 and 8 , switches 9 and 10, software device 11. From the first output of the shaper - 3 pulses of electric current are supplied to the multi-element electrodes 1 and 2, each of which consists of Q partial conductive elements galvanically isolated from each other at. Anodes 7 and 8 are structurally combined with multi-element electrodes 1 and 2: in each multi-element electrode, the central partial element performs the function of the anode, the rest as the cathode. Anodes 7 and 8 when installing multi-electrode electrodes 1 and 2 on the patient’s neck are installed in the projection of the left or right zones of the ganglia of the sympathetic nervous system located in the neck (upper cervical and stellate). The areas of each of the partial elements of the multi-element electrodes 1 and 2 and the anodes 7 and 8 are usually equal: the total area of the partial elements is always larger than the area of these anodes. The software device 11 generates a switching algorithm for the switches 9 and 10, through which electric current pulses are supplied to the multi-electrode electrodes 1 and 2 and the anodes 7 and 8: if an anode 7 is used that is structurally combined with a multi-electrode 1, then the partial elements of the multi-electrode 2 perform cathode functions which are switched by the switch 10 (in figure 1, the anode 7 and the partial elements of the dark electrode 2); if an anode 8 is used, which is structurally combined with a multi-element electrode 2, then the cathode functions are performed by the partial elements of the multi-element electrode 1, which are switched by the switch 9. In this case, a rotating field is formed in the space between the anode 7 (or 8) and the corresponding multi-element electrode 2 (or 1) electrical pulses: the pulses are grouped into "packs", the number of pulses in the "pack" is equal to the number of partial elements Q of the multi-electrode electrodes 1 and 2. The software device 11 and the switches 9 and 10 provide They switch the partial elements of the multi-electrode electrodes 1 and 2 according to one of the laws of change in the physical fields of the Earth, as well as the anodes 7 and 8, which are widespread in nature. When switching the partial elements, the direction of the pulse vector changes, and the current density of these pulses per unit volume has the maximum value in the zone of the anode, which is included in the current-forming circuit. If it is necessary to change the blocking of activity of the other branch of the sympathetic nervous system, then, from a software device 11, a switch 10 is turned on, which enables switching of the partial elements of the multi-electrode 1 and connecting the anode 8, or a switch 9, which switches the partial elements of the multi-element electrode 2 and connecting the anode 7. At the command of the software device 11, the switches 9 and 10 disconnect the shaper 3 of the electrical pulses from the multi-electrode electrodes 1 and 2 and the anodes 7 and 8 tric current: a pause is formed in the electrophysical effect on the cervical ganglia.

Here are examples of the treatment of glaucoma optic neuropathy by the proposed electrophysical method: examples 1 and 2 show the results of the restoration of the function of the visual analyzer after correction of the cerebral circulation system.

Clinical example No. 1. As an example of the combined treatment of POAG, we give an extract from the medical history No. 4975 (SOKPNGVV) Patient Sh. 74 years old (medical history No. 4975) was admitted to the 20 ophthalmological department of SOKNGVV 03.25.2010 with a diagnosis of Open-angle III with glaucoma in both eyes, initial cataract of both eyes, coronary heart disease , angina pectoris II functional class. The disease was first detected in December 2009. Since that time, Timolol has been using 0.5% epibulbar morning and evening in both eyes. The patient complained of a significant restriction of the field of view, periodically occurring flashes in front of the eyes and a feeling of heaviness and bursting in both eyes. On admission: Keratopachymetry in the center of the cornea: OD 543, OS 540 microns

TWG OD = 32, TWG OD = 35

VOD = 0.6 n / k, VOS = 0.5 n / k

The treatment was carried out:

selective laser trabeculoplasty in both eyes, sympatocorrection No. 7 with individually selected parameters, Retinalamin 0.5 No. 10 parabulbar in both eyes.

At discharge, the patient subjectively notes an improvement,

TWG OD = 19, TWG OD = 21

VOD = 0.6-0.7 n / k, VOS = 0.6 n / k.

A decrease in the number of absolute and relative cattle is noted.

Clinical example No. 2. Patient L., 58 years old (diagnostic card of the Professors Plus medical clinic on 02/03/2011) came to an appointment on 02/03/2011 with complaints of intermittent discomfort in her right eye. Diagnosis of open-angle IIb glaucoma of the right eye. Objectively: the eye is calm, optical media are transparent, some rarefaction of the pigment border.

TVGD OD = 27,

TVGD OS = 21

VOD = 0.6 + 1.0 = 0.8,

VOS = 0.7 + 1.0 = 1.0

Keratopachymetry in the center of the cornea:

OD 516 μm,

OS 520 μm (+1 to IOP according to the Goldmann IOP correction values table).

The treatment was carried out:

selective laser trabeculoplasty on the right eye, sympatocorrection No. 5 with individually selected parameters, Retinalamin 0.5 No. 9 parabulbar in both eyes.

At discharge, the patient subjectively notes an improvement,

TVGD OD = 19, TVGD OS = 21

VOD = 0.7 + 1.0 = 0.95,

VOS = 0.7 + 1.0 = 1.0

A decrease in the number of absolute and relative cattle is noted. Comparison of the data with the initial one reflects a decrease in the initially expanded borders of the physiological scotoma to the norm and an expansion of the peripheral boundaries of the visual field.

Thus, the essence of the claimed invention is to conduct neuroprotective therapy against the background of correction of the system of regulation of cerebral circulation after laser hypotensive surgery. From the analysis of scientific, technical, patent literature and materials, it follows that the claimed technical solution meets the criteria of "novelty", "inventive step" and "industrial applicability".

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Claims (1)

The electrophysical method of combined treatment of open-angle glaucoma after laser hypotensive surgery, including blood pressure and pulse monitoring, percutaneous exposure of the carotid sinus region by a rotating field, characterized in that the frequency, duration and amplitude of the pulses are set individually for each patient so as to provide blocking or stimulating effect on the ganglia depending on the tone of the autonomic nervous system, which is assessed by controlling arte total pressure and pulse with the calculation of the Kerdo index before and after treatment, in case of normalization of the Kerdo index and / or changes in the arteriovenous ratio of blood vessels in the fundus, they conduct a course of subconjunctival injections of neuropeptides, simultaneously continuing sympathetic correction, if the effect of the sympathetic correction procedure is absent , the procedure is repeated.

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