RU2500340C1 - Method of determining degree of blepharoconjunctival form of dry eye syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to ophthalmology and is intended for determining degree of blepharoconjunctival form of dry eye syndrome (DES). Index of Norn test is determined and estimation of quantity and functional state of meibomian glands on upper and lower eyelid is carried out simultaneously. 0.1% solution of fluorescein is instilled into conjunctival cavity. In case of 1-8 occluded meibomian glands on upper eyelid, 1-5 on lower eyelid and index of Norn test 9 sec in average, mild degree of blepharoconjunctival DES form is diagnosed. In case of 9-15 occluded meibomian glands on upper eyelid, 6-12 on lower eyelid, sclerosing of 1-3 meibomian glands, which are not located one after another, on either eyelid, and Norn test index 7 sec in average and lower, medium degree of blepharoconjunctival DES form is diagnosed. In case of more than 15 occluded meibomian glands on upper eyelid, more than 12 on lower eyelid, sclerosing of more than 3 meibomian glands on either of the eyelids, presence of "bald" section, if glands are sclerosed and are not identified at least on one eyelid, if contour of posterior rib of either eyelid of any length is present, and index of Norn test in 5 sec in average, severe degree of blepharoconjunctival DES form is diagnosed. Method ensures simplicity of implementation due to short-lasting influence in combination with minimal discomfort for patient and low economical cost.

EFFECT: results of the method make it possible to perform selection of adequate treatment tactics, estimation of performed treatment efficiency and prediction of further disease course.

3 ex, 12 dwg

Description

The present invention relates to ophthalmology and is intended to determine the degree of blepharoconjunctival form of dry eye syndrome (CVH) by assessing the number of meibomian glands and their functional state by staining the ciliary edge of the eyelids with 0.1% fluorescein solution and the Norn test parameters in order to optimize treatment.

State of the art

In the structure of dry eye syndrome, the blepharoconjunctival form occupies a leading position and ranges from 65 to 76%. The development of the blepharoconjunctival form of SSH is based on the dysfunction of the meibomian glands. It is known that the physiological function of the meibomian glands is the production of lipids that make up the outer part of the precorneal lacrimal film. Changes in the qualitative and quantitative composition of lipids leads to thinning and destabilization of the lipid layer, increased evaporation of tears from the surface of the eye and the formation of dry eye syndrome (Tiffany JM The role meibomian secretion in the tears Trans Ophthalmol Soc UK 1985. - v.l04. - No. 4 p .396-401.) If the lipid layer is not changed, evaporation occurs slowly and in small quantities. (Mathers WD. Evaporation from the ocular surface. Exp Eye Res. - 2004. - v. 78. - 389-394). In the absence or decrease in the number of lipids and their uneven distribution over the surface of the cornea, the evaporation of the tear increases 4 times. (Craig IP, Tomlinson A. Importance of the lipid layer in human tear film stability and evaporation. Optom Vis Sci. - 1997. - v.74. - No. 1 - p.8-13). With age, there is a change in the composition of the secretion of the meibomian glands ((Mathers WD, Lane JA, Zimmerman MB. Tear film changes associated with normal aging. Cornea. - 1996. - v.15 - p.229-234. Pated S., Farrell JC. Age-related changes in precorneal tear film stability. Optom Vis Sci - 1989. - v.66. - p.175-178. Sullivan BD, Evans JE, Dana MR, Sullivan DA. Influence of aging on the polar and neutral lipid profiles in human meibomian and secretions. Arch Ophthalmol. - 2006.- v.124. - p.276-292). This is reflected in the performance of the Norn test, which is estimated to determine the qualitative composition of the tear film. According to Somova E.E. Norn test parameters for 16-35 years old are 21.1 +/- 2.0, for 60-80 11.6 +/- 1.9. Treatment tactics, estimates the effectiveness of treatment and the prognosis depend on the severity of changes in the lipid layer.Therefore, it is important to establish the degree of dysfunction of the meibomian glands, which reflects the severity of the blepharoconjunctival form of CVH. You can judge the function of the meibomian glands by the state of their mouths (V.V. Brzhesky, E.E.Somov / Corneal conjunctival xerosis (diagnosis, clinic, treatment) // St. Petersburg, Lefty. St. Petersburg ”, 2003. - 120 p., P. 63.)

The state of the mouths of the meibomian glands can be determined by biomicroscopy followed by a compression test (patent RU 2373832, 2009). The method consists in obtaining prints of secretion in the region of the lower and upper edges of the eyelids, followed by staining. To obtain prints using millipore filter strips corresponding to the shape of the edge of the eyelid. Fingerprints are placed in pairs of a 5% solution of osmic acid for 5 minutes. The functional state of the meibomian glands is determined by the number of colored mouths of the excretory ducts of the meibomian glands, the width of the connecting jumpers and the degree of their staining. However, using this test, it is possible to determine the general functional state of the meibomian glands, while their quantitative assessment is absent and the degree of their functional impairment is not distinguished. In addition, this test cannot be called screening and simple to perform. Its implementation requires expenditure of consumables, which may not always be available, in particular, in outpatient practice. A solution of fluorescein in various concentrations is widely used for medical procedures, such as fluorescence angiography, staining of the cornea to determine the localization of damage to its surface, diagnosis of anterior uveitis, determination of the stability of the precorneal layer of the tear film - Norn test (patent RU 2404811, 2010, patent RU 2354335, 2009).

To diagnose diseases and injuries of the cornea of the eye, it is proposed to use an aqueous solution of fluorescein in order to ensure the formation of a prolonged-action precorneal dye film (patent RU 2404811, 2010). However, in this method, only the condition of the cornea is evaluated using dye.

In the clinical classification of meibomian gland dysfunction (DMF) in CVD, which includes 5 clinical forms (EA Mironkova, Role of meibomian gland dysfunction in the pathogenesis of corneal lesions in dry eye syndrome, abstract of dissertation for the degree of candidate of medical sciences Moscow, 2008, pp. 5, 9-11), it is proposed to take into account the clinical characteristics of each form of meibomian gland dysfunction; quantitative and qualitative changes in tear production (tear film); xerotic changes in the conjunctiva and cornea; indicators of local and general immune status (IgA, slgA, IgG, IgM, IFN-y, TNF-a). Clinical forms of breast cancer include:

- DMF I - abnormal hypersecretion of the meibomian glands against the background of cystic changes in the excretory ducts of the meibomian glands;

- DMF II - a combination of hyperkeratotic filling of the excretory ducts of the meibomian glands and hypersecretion of the meibomian glands;

- DMF III - hyperkeratous filling of the excretory ducts of the meibomian glands;

- DMF IV - a combination of hyperkeratous filling of the excretory ducts of the meibomian glands and cicatricial changes in the excretory ducts of the meibomian glands;

- DMF V - cicatricial changes in the excretory ducts of the meibomian glands and the edges of the eyelids.

To determine the functional changes in the meibomian glands with CVD associated with infectious (bacterial) blepharitis, demodectic invasion, hormonal imbalance, meibomian gland dysfunction without bacterial or demodectic lesions of the eyelids, this method is proposed to consider both the functional state of the meibomian glands themselves and the change in rupture time lacrimal film, lacrimal meniscus index, xerotic changes in the bulbar conjunctiva and cornea, the condition of the corneal epithelium and the edges of the eyelids. Thus, the degree of dysfunction of the meibomian glands is evaluated exclusively in combination with other parameters, their quantitative parameters are not taken into account. In this method, a characteristic of the state of the secret of meibomian glands and a change in the mouth of their excretory ducts are given. However, there is no analysis of the number of functioning and / or “precipitated” meibomian glands, which reflects the degree of change in the lipid layer of the precorneal lacrimal film and characterize the degree of blepharoconjunctival form of CVH, which is necessary to optimize patient treatment. Assessing the condition of the patient's eyelids according to this classification in outpatient settings is very time-consuming.

In the dissertation work Zabegailo A.O. (dissertation for the degree of kmn Zabegailo AO Modern possibilities for the prevention and treatment of blepharoconjunctival form of the dry eye syndrome of demodectic etiology, Moscow 2009) an attempt was made to consider the degree of blockage of the meibomian glands in points (0 - no stagnation; 1- 1/3 of the glands of each eyelid are clogged; 2 - about half of the glands of each eyelid are clogged; 3 - all ducts of the glands of each eyelid are clogged, the posterior edge of the eyelid is destroyed; 4 - the glands are stagnant, the mouths are outstretched, inflammation is observed around them, the posterior edge of the eyelid is destroyed). Together with subjective and other objective assessment methods, this gradation helped in determining the condition of the patient's eyelids and, therefore, making a diagnosis, prescribing short or long-acting tear substitutes, and evaluating the effectiveness of treatment. However, in this method, the number of affected meibomian glands is determined only approximately, since they are difficult to accurately calculate without dye. Also, the work did not emphasize the dependence of the state of the meibomian glands on the stage of the disease.

In available sources of information, no information was found on determining the degrees of the blepharoconjunctival form of CVH.

Disclosure of the invention.

The objective of the invention is to develop a method for determining the degree of blepharoconjunctival form of dry eye syndrome.

The technical result of the proposed method is the selection of adequate treatment tactics, assessment of the effectiveness of the treatment and the prognosis of the further course of the disease depending on the degree of blepharoconjunctival form of CVH, as well as ease of implementation due to the short exposure, combined with minimal discomfort for the patient and low economic costs.

The technical result is achieved by determining the degree of blepharoconjunctival form of SSH using a quantitative assessment of the state of the meibomian glands of both eyelids under the influence of the dye fluorescein in combination with the parameters of the sample Norn.

The following vital dyes are used for intravital staining of various tissues of the anterior segment of the eyeball: lissamine green, Bengal pink and fluorescein. Our studies have shown that to visualize the excretory ducts of the meibomian glands, it is possible to use only fluoroscein, since Bengal pink (in addition to being poorly tolerated by patients) and lissamine green do not stain the mouth of the meibomian glands.

Currently, in ophthalmology, a 0.1% fluorescein solution is widely used in various studies for the production of diagnostic tests and samples. However, to date, it has not been proposed to stain the ciliary edges of the eyelids with a fluorescein solution to study the condition of the breast, despite the fact that the solution is non-toxic for the eyelids and gets on the eyelids with various tests and samples.

As it turned out, a 0.1% fluorescein solution is able to stain tissue defects, the mouth of the meibomian glands and their secret, is quickly evacuated with physiological saline - sodium chloride - from the surface of the eye and eyelids, leaving no residue on the skin. The listed properties of this dye allowed us to use for the first time a 0.1% fluorescein solution for staining meibomian glands in order to determine the nature of not only their qualitative, but also quantitative changes. This, in turn, allowed us to identify certain degrees of severity of the blepharoconjunctival form of CVH.

Fluorescein staining of the edges of the eyelids to diagnose the degree of CVH in accessible sources of information was not found by us.

In the presented method for determining the degree of the blepharoconjunctival form of dry eye syndrome, the relationship between the indicators of the Norn test and the state of the meibomian glands is first examined. This allows you to get a comprehensive result when simultaneously conducting 2 diagnostic tests in the conditions of a single injection into the conjunctival cavity of 0.1% fluorescein solution, which is necessary to assess the severity of the pathological process in patients suffering from CVD, reduces the time spent on research, consumables, the risk of complications, increases the likelihood the correct assessment of the condition of a patient with a blepharoconjunctival form of dry syndrome, and, therefore, determines the subsequent choice of optimal tactics to treat Nia. The combination with the Norn sample minimizes the irritating effect of the dye on the eye tissue.

The distribution of the dye occurs quickly, with blinking movements of the eyelids. Thus, the test and evaluation of the result takes no more than 2-3 minutes and can be performed during the initial examination of the patient at the outpatient clinic.

The method is as follows.

To stain the anterior segment of the eyeball, a dye installation is used - 0.1% fluorescein.

First, a drop of 0.1% solution of fluorescein is installed in the conjunctival cavity with a pipette to the patient, then they are asked to blink 3-4 times. Conduct a test of Norn. Then assess the condition of the mouths, the presence of stagnant secretion and calculate the number of clogged meibomian glands using biomicroscopy at a standard magnification (10x, 16x, 25x) in a cobalt filter. If necessary, carry out photo-registration.

A mild blepharoconjunctival form of CVH is determined in the presence of 1-8 clogged meibomian glands in the upper eyelid and 1-5 in the lower eyelid. In this case, the average values of the Norn sample are on average 9 s.

The average degree of blepharoconjunctival form of SSH is determined in the presence of 9-15 clogged meibomian glands in the upper eyelid and 6-12 in the lower eyelid, sclerosis of 1-3 meibomian glands, not arranged in a row, on any eyelid. The Norn sample rate averages 7 s. and less.

The severe degree of blepharoconjunctival form of CVH is determined in the presence of more than 15 clogged meibomian glands in the upper eyelid and more than 12 in the lower eyelid, sclerosis of more than 3 meibomian glands in any eyelid - the presence of a “baldness” site - the glands are sclerotized and cannot be detected even in at least one eyelid with changing the contour of the hind rib of any eyelid of any length. The Norn sample rate is 5 s. and less.

After completing the test, the patient should rinse the conjunctival cavity with a solution of sodium chloride - saline (or 1: 500 furatsilinom), removing excess dye with a cotton swab.

The remainder of the fluorescein solution is evacuated through the lacrimal canals without harm to the patient.

The procedure for assessing the state of the meibomian glands can be repeated many times even on the same day without side effects in the absence of an allergic reaction to fluorescein in the patient.

Example 1. Patient G., a / c No. 9,05310 Complaints of discomfort and redness of the eyes towards evening in the course of 3.5 years. The degree of blepharoconjunctival form of SSH was determined by visualizing the mouths of the excretory ducts of the meibomian glands, instilling a 0.1% fluorescein solution in the conjunctival sac and performing biomicroscopy in a cobalt filter. The presence of 6 clogged meibomian glands on the upper eyelid and 5 on the lower eyelid, the Norn test index of 9 s. Allowed to establish a mild degree of blepharoconjunctival form of CVH. (Figure 1 - Visualization of the lower eyelid before staining with 0.1% fluorescein solution; Figure 2 - Visualization of both eyelids before staining with 0.1% fluorescein solution; Figure 3 - Visualization of both eyelids after staining with 0.1% fluorescein solution in a cobalt filter; Figure 4 - Visualization of the lower eyelid after staining with a 0.1% fluorescein solution in a cobalt filter).

The treatment was carried out: blepharogel-2 according to the scheme 2 times / day 1.5 months and Hilabac 1 to 4 times / day 1.5 months in both eyes. The choice of treatment tactics - the appointment of a minimum number of drugs, a short-term course of treatment - is due to the patient's mild blepharoconjunctival form of CVH. The prognosis of the disease is favorable. A repeated examination after 1.5 months showed that this treatment was sufficient for a stable remission (the absence of relapse was confirmed by subsequent follow-up for six months).

Example 2. Patient M, a / c No. 98.05162. Complained of a feeling of pain, a burning sensation in the eyes, intensifying towards evening; periodically a feeling of fogging images, lack of tears. Symptoms progressed gradually over 7 years. The degree of the blepharoconjunctival form of SSH was determined by visualizing the mouths of the excretory ducts of the meibomian glands, instilling a 0.1% fluorescein solution in the conjunctival sac and performing biomicroscopy in a cobalt filter. The presence of 12 clogged meibomian glands on the upper eyelid and 9 on the lower eyelid, with more than 3 clogged meibomian glands in a row, the Norn sample indicator of 3 s allowed to establish a severe degree of blepharoconjunctival form of CVH. (Figure 5 - Visualization of the upper eyelid before staining with 0.1% fluorescein solution; Figure 6 - Visualization of both eyelids before staining with 0.1% fluorescein solution; Figure 7 - Visualization of the lower eyelid after staining with 0.1% fluorescein solution in a cobalt filter; Figure 8 - Visualization of the upper eyelid after staining with 0.1% fluorescein solution in a cobalt filter).

The treatment was carried out: blepharogel-2 according to the scheme 2 times / day 3 months, physiotherapy, hilabac 1 to 4 times / day 3 months, vidisic gel 2 times / day 3 months in both eyes, antihistamines inside for 7 days. Recommended observation, supportive therapy between relapses in order to reduce the frequency of relapses (blepharolotion 2 times a day, hilabak 1 to 4 times a day), repeated courses of treatment (approximately once every six months) when relapse occurs.

The choice of such treatment tactics - the appointment of a significant number of drugs, including long-acting tear substitutes, a long-term course of treatment - is due to the patient's severe blepharoconjunctival form of CVH. The prognosis of the disease is severe, frequent relapses are likely. A repeated examination after 3 months showed that although this treatment was sufficient for the onset of remission, the likelihood of relapse within six months due to the severity of the blepharoconjunctival form of CVH and in the case of cancellation of maintenance therapy (in the form of blepharolosion and hilabact) remained. This was an indication for a second course of treatment and the extension of maintenance therapy. Upon further observation for six months, there was no relapse.

Example 3. Patient P., a / c No. 4.01125. Complained of a burning sensation, discomfort and redness of the eyes constantly for 5 years. The degree of blepharoconjunctival form of SSH was determined by visualizing the mouths of the excretory ducts of the meibomian glands, instilling a 0.1% fluorescein solution in the conjunctival sac and performing biomicroscopy in a cobalt filter. The presence of 11 clogged meibomian glands on the upper eyelid and 6 on the lower eyelid, sclerosis of 3 meibomian glands, not arranged in a row, on each eyelid, the Norn sample index of 7 seconds allowed us to establish the average degree of blepharoconjunctival form of CVH. (Fig. 9 - Visualization of both eyelids before staining with 0.1% fluorescein solution; Fig. 10 - Visualization of the lower eyelid before staining with 0.1% fluorescein solution; Fig. 11 - Visualization of the lower eyelid after staining with 0.1% fluorescein solution in a cobalt filter; Fig. 12 - Visualization of the upper eyelid after staining with a 0.1% fluorescein solution in a cobalt filter).

The treatment was carried out: blepharogel-2 according to the scheme 2 times / day 3 months, Hilabac 1 to 4 times / day 3 months, Vidisic gel n / night 3 months in both eyes.

The choice of this treatment tactic - prescribing drugs for a long time - is due to the patient's moderate degree of blepharoconjunctival form of CVH. The prognosis of the disease - relapses are likely. Repeated examination after 3 months showed that this treatment was sufficient for the occurrence of remission. Subsequently, constant supportive local therapy was recommended - Hilabac 1 cap. 4 times a day. In the monitoring process, relapse was noted a year later with the patient independently canceling a supportive course of treatment. This required a second course of treatment.

Thus, the proposed method allows the selection of adequate treatment tactics, assessment of the effectiveness of the treatment and the prognosis of the further course of the disease depending on the degree of blepharoconjunctival form of CVH, as well as ease of implementation due to the short exposure, combined with minimal discomfort for the patient and low economic costs.

Claims (1)

A method for determining the degree of the blepharoconjunctival form of dry eye syndrome (CVH), which includes determining the Norn test index and assessing the number and functional state of the meibomian glands on the upper and lower eyelids simultaneously, with a 0.1% fluorescein solution being installed in the conjunctival cavity and 1 -8 clogged meibomian glands on the upper eyelid and 1-5 on the lower eyelid, the average Norn sample value is 9 s. - determination of the mild blepharoconjunctival form of CVH; in the presence of 9-15 clogged meibomian glands on the upper eyelid and 6-12 on the lower eyelid, sclerosing of 1-3 meibomian glands that are not arranged consecutively, on any of the eyelids, the Norn test index averages 7 s. and less - determination of the average degree of blepharoconjunctival form of CVH; if there are more than 15 clogged meibomian glands on the upper eyelid and more than 12 on the lower eyelid and sclerotization of more than 3 meibomian glands on any of the eyelids and the presence of a “baldness” area - the glands are sclerotic and not detected - at least on one eyelid, when the contour of the back rib is changed any century of any length, the Norn test index is on average 5 s. and less - determination of the severe degree of blepharoconjunctival form of CVH.

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