RU2521832C2 - Method of surgical treatment of hemophthalmus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to ophthalmology and can be applied for surgical treatment of hemophthalmus by closed subtotal vitrectomy. Partial vitrectomy of central parts of the vitreous body is carried out. Vitreosyneretic "Vitrenal" in a dose of 0.3 ml, preliminarily dissolved in a physiological solution in the ratio 0.5 g per 100 ml, is introduced into the vitreous cavity. After 5-7 minutes the presence of vitreolysis and posterior detachment of the vitreous body are determined under visual control, after which vitrectomy is completed.

EFFECT: method makes it possible to reduce trauma and toxicity.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of hemophthalmus.

It is known that hemophthalmus occurs in 20-75% of cases of eye injuries, leading in 27.3% of cases to functional and in 5.7% to anatomical death of the eye.

Surgical treatment of hemophthalmus - closed subtotal vitrectomy is the only way out with the ineffectiveness of conservative treatment. The objective of surgical treatment is the maximum possible removal of the altered vitreous body, its structures and organized blood clots, otherwise, incomplete dissection of the fibrovascular tissue and epiretinal membranes leads to the development of traction retinal detachment. Often, this task is associated with iatrogenic damage to the retina due to blood organization and the formation of proliferative tissue tightly fixed to the retina.

There is a method of surgical treatment of hemophthalmus, in which a closed subtotal vitrectomy is performed with the introduction of a corticosteroid into the vitreous cavity during surgery (Zakharov V.D. Vitreoretinal surgery, M., 2003, pp. 61-64). The use of corticosteroids in this method provides visualization of the cortical layers of the vitreous body and the posterior hyaloid membrane, which allows for more radical surgical intervention.

However, this method is traumatic, since the removal of the vitreous body and the posterior hyaloid membrane (HGM) is carried out mechanically, which leads to iatrogenic retinal ruptures and bleeding. It can subsequently cause the development of traction retinal detachment as a result of the progression of proliferative vitreoretinopathy, which develops due to the fact that the preparations used in this method do not cause vitreolysis and do not regulate proliferation processes. In addition, the method is not safe for the tissues of the eye, since the drugs used are highly toxic.

The objective of the invention is to prevent tractional detachment of the retina, reduce the invasiveness of the method, reduce the number of iatrogenic ruptures and bleeding during surgery, eliminate toxicity to eye tissues, and increase visual function in the postoperative period.

The technical task is to increase the efficiency of surgical treatment of hemophthalmus by the additional introduction of vitreosineretic, which provides atraumatic removal of the vitreous body with ZGM and inhibits the proliferation process.

The problem is solved by the proposed method, including closed subtotal vitrectomy and the introduction of a biochemical substance into the altered vitreous body and according to the invention, a partial vitrectomy of the central parts of the vitreous is preliminarily performed, after which Vitrenal vitreosineretic is introduced in an amount of 0.3 ml, which is previously diluted in saline in the ratio of 0.5 g per 100 ml. Then, after 5-7 minutes, the presence of vitreolysis and posterior vitreous detachment is established under visual control, after which vitrectomy is completed.

New in the claimed solution is the introduction into the altered vitreous body of vitreosineretics "Vitrenal" after a preliminary partial vitrectomy of the central parts of the vitreous body.

Vitrenal is a vitreosineretic based on the chitosan polymer; it is a powdery substance from white to light yellow; it is easily soluble in aqueous solutions of both mineral and organic acids.

Based on the conducted experimental studies, a sanitary-epidemiological conclusion No. 41-02 \ 34-169 dated April 3, 2007 and No. 41-02-34-997 dated March 12, 2008 that Vitrenal vitroosineretic complies with sanitary and hygienic rules was obtained and guidelines for use in ophthalmology.

Clinical trials of vitrenosinerstic Vitrenal are recommended by the Expert Council of the RSE National Center for Expertise of Medicines, Medical Devices and Medical Equipment: the clinical trial protocol has been drawn up in accordance with the requirements of the order of the Ministry of Health of the Republic of Kazakhstan No. 53 dated 02/14/05 and recommended for approval (pr No. 29 dated 07/18/08).

Vitrenosineretic “Vitrenal” was approved by order of the Chairman of the Pharmaceutical Control Committee of the Ministry of Health of the Republic of Kazakhstan dated September 12, 2008 No. 219 “On Approving the List of Medicines Recommended for Clinical Tests” as vitreosineretic in the surgical treatment of retinal detachment complicated by proliferative vitreoretinopathy.

The technical result is achieved by introducing Vitrenal vitreosyneretic, which reacts with a complexation with the vitreous components, inhibits fibroplastic proliferation by inhibiting fibroblast cells, provides wrinkling and spontaneous, non-traumatic detachment of the vitreous from the retina. As a result, the method allows to reduce the number of complications, such as the progression of proliferative vitreoretinopathy and the development of tractional retinal detachment, which helps to increase visual function after surgery.

The method is as follows - under controlled hypotension with ataralgesia, a closed subtotal vitrectomy is performed on a Baush & Lomb microsurgical system from Millenium.

Conjunctival incisions are made 5 mm long in three quadrants of the eyeball 4-5 mm from the limbus, then standard sclerotomes are formed in the lower temporal, upper temporal and upper nasal quadrants for introducing the tips of the vitreotome, the light guide and irrigation. Using the BIOM II optical system, the vitreous cavity is examined in transmitted light under conditions of endovitreal illumination. Partial vitrectomy of the central parts of the vitreous body is performed. After that, 0.3 ml of Vitrcnal vitreosineretic is injected into the vitreous cavity through the sclerotome. After 5-7 minutes, the presence of vitreolysis and posterior vitreous detachment is established under visual control, after which vitrectomy is completed. The vitreal cavity is filled with sterile saline to normal tone. Suture.

A specific example of the method.

Patient Sh., 32 years old. I was hospitalized at the Kazakh Research Institute of Eye Diseases from 08/03/09 to 08/19/09 with a diagnosis of the right eye - Hemophthalmus post-traumatic stale subtotal in the organization stage. Subluxation of the lens of the 1st degree.

From the anamnesis: I received a dull injury to the right eye in an accident on 06/26/09. At the place of residence, he received medication for severe eyeball contusion, hemophthalmus. Despite the treatment, there was a lack of positive dynamics, and therefore surgical treatment of hemophthalmus was recommended.

Visual acuity of the right eye - p.l. certae, left eye 1.0. Sonography of the right eye - anteroposterior size 23.65; depth of anterior chamber 2.86; lens thickness 4.01 mm; in the vitreous cavity, echo signals characteristic of hemophthalmus. Biomicroscopy of the right eye - the anterior segment is calm, the anterior chamber is of normal depth, the crystalline lens is transparent, in the vitreous body a suspension of blood cells, sedentary, moorings are visualized. The fundus is not ophthalmoscopic. Ophthalmoscopy of the left eye - optic nerve discs of pale pink color with clear boundaries, the course and caliber of blood vessels are not changed, reflexes are preserved in the macula.

On 04/04/09, an operation of the right eye was performed - closed subtotal vitrectomy with the introduction of Vitrenal 0.5% vitreosyneretics in a quantity of 0.3 ml. Organizing massive vitreous hemorrhages fixed to the retina were revealed intraoneratively during vitrectomy in the posterior vitreous. After the introduction of Vitrenal “Vitrenal”, compaction and contraction of preretinal fibrous tissue was observed, which facilitated the implementation of vitrectomy. The operation and the postoperative period without complications.

Control examination of the right eye: visual acuity - 0.4 n / a. Biomicroscopy: outwardly calm, refractive media are transparent. Ophthalmoscopy: the retina lies along the entire length, the optic disc is pale pink with clear boundaries, the arteries are convoluted, sharply narrowed, the veins are full-blooded, the macular reflex is faded.

As a result of applying this method in the near term of observation in a patient with hemophthalmus, the following results were obtained:

the transparency of optical media was restored, visual acuity increased to 0.4 n \ k, vitreoretinal traction was eliminated.

Follow-up after 6 months on an outpatient examination. Visual acuity of the right eye of 0.5 n / a, biomicroscopy: anterior segment without features, optical media are transparent. Ophthalmoscopy: The retina lies along the entire length, the optic nerve disc is pale pink with clear boundaries, the arteries are convoluted narrowed, the veins dilated are full-blooded, the macular reflex is faded.

Thus, as a result of surgical treatment of hemophthalmus with the proposed method, the following results were obtained: an increase in visual acuity to 0.5 n \ k, the absence of tractional detachment of the retina and the preservation of its anatomical integrity.

Under observation were 20 patients (20 eyes) with hemophthalmus of various origins who made up the test group, and 20 patients (20 eyes) who made up the control group. The average age of patients in the control group was 42 years ± 0.3, in the main group 49 years ± 0.5.

In the control group, surgical treatment was performed in a known manner: closed subtotal vitrectomy with the introduction of the diprospan iptoperative corticosteroid. In the main group - the proposed method. The results of surgical treatment in both groups are presented in the table.

Table The results of surgical treatment of hemophthalmus Groups Visual acuity Total field of view Number of complications control Before treatment After treatment Before treatment After treatment 5 0.02 ± 0.05 0.2 ± 0.05 73 ° ± 0.8 178 ° ± 1.6 the main 0.015 ± 0.05 * 0.4 ± 0.05 * 69 ° ± 0.7 * 312 ° ± 1.9 * 0 * - the difference with the data before treatment is statistically significant (P <0.05)

As can be seen from the table, there is a significant increase in visual acuity after surgery in patients of the main group from 0.015 ± 0.05 to 0.4 ± 0.05, i.e. on average, 26.6 times, of the total field of view from 69 ° ± 0.7 to 312 ° ± 1.9, i.e. 4.5 times on average. Whereas in the control group, visual acuity increased from 0.02 ± 0.05 to 0.2 ± 0.05, i.e. an average of 10 times, and the total field of view increased from 73 ° ± 0.8 to 178 ° ± 1.6, i.e. 2.4 times on average. In the control group, 5 patients experienced complications, of which 2 during the operation in the form of bleeding from iatrogenic retinal breaks and 3 cases of tractional retinal detachment. In patients of the main group, in no case of complications was observed.

As follows from the foregoing, in the main group there was a 2 times greater increase in visual acuity, 1.75 times the total zero of vision and the absence of complications compared with the control. Detachment of the vitreous and ZGM achieved in 100% of cases.

Claims (1)

A method of surgical treatment of hemophthalmus, which consists in a closed subtotal vitrectomy, characterized in that a partial vitrectomy of the central parts of the vitreous is preliminarily performed, after which Vitrenal vitreosineretic is injected in the amount of 0.3 ml, which is previously diluted in physiological saline in the ratio of 0 5 g per 100 ml, then after 5-7 minutes, the presence of vitreolysis and posterior vitreous detachment is established under visual control, after which vitrectomy is completed.