RU2521844C1 - Method for selecting laser treatment options in absolute glaucoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention aims at an individual selection of laser energy options in transcleral diode laser cyclophotocoagulation (TDLC) in the patients suffering absolute painful glaucoma. A ciliary body thickness is measured by ultrasonic biological microscopy (UBM). If the ciliary body thickness is 0.54 mm or less, 6 laser applicates are marked through a circular arc of 90° in an upper section and through a circular arc of 90° in a lower section at power 1.2 Wt, pulse energy 3.6 J. If the ciliary body thickness is more than 0.54 mm, 8 laser applicates are marked through a circular arc of 135° in the upper section and through a circular arc of 135° in the lower section at power 1.8 Wt, pulse energy 5.4 J. The exposure in both cases are contact transcleral with using a diode laser in a continuous mode at wavelength 810 nm and exposure time 3.0 sec. The applicates are marked 1-2 mm from the limb and equally spaced from each other.

EFFECT: method provides a differential approach to selecting the laser energy options taking into account the condition of the ciliary body visualised by UBM which enables avoiding severe complications of TDLC, provides relieving pain syndrome, and reduces an initial intraocular tension.

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Description

The invention relates to medicine, namely to ophthalmology, the section of eye microsurgery, and is intended for the individual choice of laser energy parameters for transscleral diode-laser cyclophotocoagulation (TDCC) in patients with terminal painful glaucoma.

Recently, transscleral diode-laser cyclocoagulation (TDCC) of the ciliary body has been recognized by ophthalmologists in the treatment of terminal painful glaucoma due to the simplicity, non-invasiveness, effectiveness of the technique and the possibility of repeated use. The ability to relieve pain in this disease has been proven. (Robustova O.V., Immortal AM, Chervyakov A.Yu. Cyclodestructive interventions in the treatment of refractory glaucoma // Glaucoma - 2003. - No. 1. P.40-46; Iliev ME, Gerber S. Long-term outcome of trans- scleral diode laser cyclophotocoagulation in refractory glaucoma // Br. J. Ophthalmol. - 2007; 91: 1631-1635.)

However, TDCC does not exclude the possibility of serious complications. The most serious complications after TDCC include: eyeball subatrophy, choroid detachment, hemophthalmus, hyphema, recurrent uveitis, and fibrinous iridocyclitis. (Walland MJ Diode laser cyclophotocoagulation: longer term follow up of standardized treatment protocol \ Clin. Exp. Ophthmomo . - Vol.26. - No.2. - P.135-139 .; Lin SC, Chen MJ, Lin MS et al. Vascular effects on ciliary tissue from endoscopic versus trans-scleral cyclophotocoagulation. Br J Ophthalmol. 2006 Apr; 90 (4): 496-500.)

Severe complications of laser exposure are associated with an overdose of laser energy, the parameters of which (power, exposure and the number of applicates) vary over a wide range. (Gaasterland DE, Pollack IP Initial experience with a new method laser transscleral cyclophotocoagulation for ciliary ablation in severe glaucoma // Tr. Am. Ophth. Soc. - 1992. - Vol.LXXXX. - P.225-246; Khomchik O.V. ., Ambartsumyan A.R., Bolypunov A.V., Droshneva M.V., Yerichev V.P., Ilyina T.S., Poleva R.P. Ultrasound biomicroscopy of tissues of the anterior part of the eye after transscleral diode laser cyclophotodestruction. // Ophthalmology. Eastern Europe. - 2011; No. 4 (11); pp. 50-53.)

The authors do not know how to choose the parameters of laser treatment of terminal forms of glaucoma.

The objective of the invention is to develop a method for preoperative selection of laser energy parameters based on measuring the thickness of the ciliary body according to ultrasound biomicroscopy (UBM).

The technical result is the removal of pain, a decrease in the initial ophthalmotonus by 10-12 mm Hg, a decrease in the proportion of severe complications of TDCC, such as subatrophy of the eyeball, recurrent uveitis, ciliochoroid retinal detachment, hyphema and hemophthalmus, prevention of atrophy of the ciliary body and thereby eye death due to a differentiated approach to the selection of laser energy parameters, taking into account the state of the ciliary body, visualized by the UBM method.

The technical result is achieved by the fact that in the method of selecting parameters for laser treatment of terminal glaucoma, including measuring the thickness of the ciliary body using the UBM method, with a thickness of the ciliary body of 0.54 mm or less, 6 laser applicates are applied at the same distance from each other along a circular arc 90 ° - in the upper and in an arc of a circle 90 ° - in the lower hemisphere 1-2 mm from the limb with a power of 1.2 W with an pulse energy of 3.6 J, and with a ciliary body thickness of more than 0.54 mm, 8 laser applications are applied at the same distance from each other n arc of a circle of 135 ° - in the upper and in a circular arc of 135 ° - in the lower hemisphere, with a power of 1.8 W, with an energy of a pulse of 5.4 J. Impact in both cases is performed by contact - transsclerally using a diode laser in a continuous mode with a wavelength 810 nm and an exposure of 3.0 seconds.

For the first time in real time, using the UBM method, we revealed the features of the ciliary body of patients with terminal glaucoma - the presence of a significantly (p <0.05) lesser thickness of the ciliary body of the terminal eye compared to the paired eye, which was 0.54 ± 0.1 mm (from 0.41 to 0.74 mm) and 0.76 ± 0.12 mm (from 0.56 to 1.08 mm), respectively, which was regarded as atrophy of the ciliary body of the terminal eye of varying severity. The data on the thickness of the ciliary body are taken as a basis in the differentiated choice of laser energy parameters. When using the above laser energy parameters, the expressed thinning of the ciliary body of 0.54 mm or less (pronounced atrophy of the ciliary body) is especially important and informative, where 0.54 mm is the average calculated parameter.

In the UBM study, in all cases after TDCC, a decrease in the thickness of the ciliary body of varying severity was noted. Signs of a decrease in the thickness of the ciliary body can be detected in each patient before the operation and at various times after it. In the postoperative period, a correlation was observed between the complications of the early postoperative period between the total laser exposure energy and the thickness of the ciliary body (the higher the total laser energy, the smaller the thickness of the ciliary body). When the ciliary body was thinned in the postoperative period to a level of 0.3 mm or less, subatrophy of the eyeball was clinically diagnosed, and this thickness was taken as atrophy of the ciliary body (RF patent for the invention No. 2360654). Taking into account the thinning of the ciliary body diagnosed by the UBM method, the energy parameters of laser radiation are calculated, which make it possible to reduce the level of the initial ophthalmotonus by 10-12 mm Hg. and to avoid complications such as hemophthalmus, recurrent uveitis, hypotension with a transition to subatrophy of the eye, and eliminate pain.

The obtained data formed the basis for the differential determination of the laser energy parameters of the TDCC.

The advantage of the proposed method is the differential effect on the ciliary body and its processes, which reduces the possibility of excessive laser exposure with a pronounced initial thinning of the ciliary body, leading to subatrophy of the eyeball and other formidable complications. In the long-term follow-up when applying the above parameters, we noted that the thickness of the ciliary body of the operated patients was more than the average critical (0.3 and less mm).

The results of applying a differentiated approach in choosing the laser energy parameters of TDCC provide: relief of pain, a decrease in the initial ophthalmotonus of 10-12 mm Hg, a decrease in the proportion of severe complications of TDCC - subatrophy of the eyeball, recurrent uveitis, ciliochoroid detachment, hyphema and hemophthalmus, warn atrophy of the ciliary body (i.e., its thinning less than 0.3 in the postoperative period) and thereby eye death.

Example 1

In the clinic of FSBI “MNTK“ Eye Microsurgery ”named after Acad. S.N. Fedorova ", the Ministry of Health of Russia, patient B., aged 64, was diagnosed with terminal pain 4-C glaucoma of the left eye. Complaints of pain in the left eye with radiation to the head and temple, not stopped by the strongest analgesics. No surgical procedures were performed. According to the anamnesis, glaucoma on OS for 8 years. Used antihypertensive therapy - Alfagan 1 drop 3 times a day, Azarga 1 drop 2 times a day. Concomitant diseases: Stage 2 hypertension.

When examining Vis OS = 0 zero. IOP (according to Maklakov) = 41 mmHg With biomicroscopy: moderate congestive injection of the eyeball, edema of the cornea 2 degrees. The anterior chamber is uniform, 3.0 mm deep, its moisture is transparent. The iris is subatrophic. The pupil is round, there is no reaction to light. Pseudoexfoliation syndrome 3 degrees. Moderate opacities in the nucleus and cortical layers of the lens. Filamentous destruction of the vitreous body. Deep-seated formations are not visible (corneal edema).

The results of additional research methods:

Ultrasound biomicroscopy of the anterior eye: the thickness of the ciliary body is 0.41 mm, the length of the ciliary processes is 0.34 mm. CPC open, medium width. The thickness of the ciliary body less than 0.54 mm was taken into account in the choice of TDCC parameters. An ALOD-1 diode laser (Russia) with a wavelength of 810 nm was used. After preliminary hypotensive blockade of the pterygopalatine ganglion - 2% Lidocaine solution in combination with 5% Pentamine solution and conjunctival instillation of a 1% Alcain solution on the sclera 2 mm from the limbus, 12 coagulates were applied at the same distance from each other, 6 of which were drawn along an arc of a circle 90 ° in the upper hemisphere and 6 in a circular arc of 90 ° in the lower hemisphere. The laser radiation power was 1.2 W, with an exposure of 3 seconds, while the tip was tightly applied perpendicular to the sclera. In the postoperative period, Indocolly was prescribed 1 drop 3 times a day (1 month) and Diacarb orally 1 tablet 1 time per day (3 days after surgery).

Control examination was carried out after 1, 3, 14 days, at 3 and 6 months. During the examination, the patient did not complain. The pain syndrome is stopped. When examining Vis OS = 0 (zero). IOP after 1 month - 24 mm Hg Instillations saved: Alfagan 1 drop 2 times a day.

During biomicroscopy: the eye is calm, the cornea regained its transparency, the anterior chamber of medium depth is uniform, moisture is transparent, and there are no signs of inflammation.

The results of additional research methods. UBM of the iridociliary zone: the thickness of the ciliary body is 0.34 mm, single ciliary processes are 0.18 mm long.

In this clinical case, using a differentiated approach in choosing the laser energy parameters of TDCC, the pain was removed, a decrease in the initial ophthalmotonus by 17 mm Hg was noted. and no severe complications of TDCC — subatrophy of the eyeball, recurrent uveitis, ciliochoroidal detachment, hyphema, and hemophthalmus — were noted. The cornea regained its transparency.

Example 2

In the clinic of FSBI “MNTK“ Eye Microsurgery ”named after Acad. S.N. Fedorova, the Ministry of Health of Russia, patient E., 65 years old, came with a diagnosis of secondary uncompensated painful glaucoma in the right eye. Thrombosis of the central retinal vein was noted 1 year ago. Tonometry (according to Maklakov) OD = 45 mm Hg Complaints on admission to severe pain in the right temporal region. Antihypertensive therapy included instillation - Fotil-Forte 1 drop 2 times a day, Dorzopt 1 drop 2 times a day.

Concomitant diseases: Chronic coronary heart disease. Hypertension of the 1st degree.

Survey data.

Vis OD = 0. With biomicroscopy, the anterior part of the eye is irritated, stagnant injection of the eyeball. Corneal edema - 2 degrees. On the limbal edge of the cornea, superficial neovascularization is noted. The anterior chamber is of medium depth, its moisture is transparent. The iris is subatrophic, rubeosis. The pupil is round, there is no reaction to light. Pseudoexfoliation along the edge of the pupil. Moderate opacities in the nucleus and cortical layers of the lens. Filamentous destruction of the vitreous body. Deep-seated formations are not visible (corneal edema).

The results of additional research methods.

UBM of the iridociliary zone. The thickness of the ciliary body is 0.62 mm, the length of the ciliary processes is 0.31 mm.

Given the relative safety of the thickness of the ciliary body - 0.62 mm (more than 0.54 mm), then for the transsclerical diode-laser cyclophotocoagulation, an ALOD-1 diode laser (Russia) with a wavelength of 810 nm was used. After preliminary hypotensive blockade of the pterygopalatine ganglion - 2% Lidocaine solution in combination with 5% Pentamine solution and conjunctival instillation of 1% Alcain solution. Considering that the thickness of the ciliary body is more than 0.54 mm, using a diode laser, 8 laser applicates were applied to the sclera 1-2 mm from the limb, at the same distance from each other along an arc of a circle of 135 ° in the upper and along a circular arc of 135 ° in the lower hemisphere, the laser radiation power was 1.8 W, with a pulse energy of 5.4 J, with an exposure of 3 seconds, while the tip was tightly applied perpendicular to the sclera. In the postoperative period, Indocolly was prescribed 1 to 3 times a day (1 month), Korneregel 1 laying 3 times a day for 2 weeks and Diacarb 1 tablet orally 1 time per day (3 days).

Control examination was carried out after 1, 3, 14 days, at 3, 6 months. During the examination, the patient did not complain. The pain syndrome is completely stopped.

Survey data.

Vis OD = 0. Tonometry according to Maklakov (after 1 month) = 23 mmHg, with the installation of Alfagan 1 drop 2 times a day. In the future, negative dynamics during observation up to 6 months were not noted. Biomicroscopy: the stagnant injection of the eyeball disappeared, regression of neovascularized vessels of the iris was noted, and corneal edema disappeared.

The results of additional research methods.

UBM of the iridociliary zone of the eye. The thickness of the ciliary body is 0.35 mm, the length of the ciliary processes is 0.2 mm.

The result of the application of a differentiated approach in choosing the laser energy parameters of TDCC was the removal of the pain syndrome, a decrease in the initial ophthalmotonus by 22 mm Hg, in the absence of severe complications of TDCC, such as subatrophy of the eyeball, recurrent uveitis, ciliochoroid detachment, hyphema and hemophthalmus.

Thus, on the basis of UBM data, it was possible to identify various degrees of thickness of the ciliary body of the eyes with terminal glaucoma. The obtained data formed the basis for a differentiated choice of TDCC parameters. With severe atrophy of the ciliary body, whose thickness was less than the average calculated value (less than 0.54 mm), more delicate parameters of the total laser energy were used. In no case was a “critical” value observed in the development of subatrophy of the eyeball (ciliary body thickness 0.3 mm or less). With a relatively unchanged initial thickness of the ciliary body of the eye (0.54 mm or more) with terminal glaucoma and the preservation of the structure of the ciliary processes, parameters of a higher intensity of laser exposure were used. The decrease in the thickness of the ciliary body after 6 months also did not reach the level of 0.3 mm or less, at which the probability of developing subatrophy of the eyeball is high.

In the postoperative period with the differentiated application of laser energy parameters depending on the thickness of the ciliary body: the pain syndrome was stopped, corneal edema disappeared, hemorrhagic complications (hyphema and hemophthalmus) were not noted, we did not reveal any cases of subatrophy of the eyeball. According to UBM, the ciliary body decreased on average (after 6 months) to 0.39 mm, IOP (after 6 months) on average to a level of 28.7 mm Hg.

Thus, a differentiated approach in choosing the parameters of laser exposure to TDCC, the use of average and maximum parameters of laser energy made it possible to minimize complications, relieve pain and reduce the level of ophthalmotonus to the level of subcompensation. The procedure is technically simple and is an effective technique for the treatment of severe forms of terminal painful glaucoma.

Claims (1)

A method for selecting parameters for laser treatment of terminal glaucoma, including measuring the thickness of the ciliary body in mm by ultrasound biomicroscopy, and if the thickness of the ciliary body is 0.54 mm or less, then 6 laser applicates are applied along a 90 ° circular arc in the upper hemisphere and 6 laser applicates per a circular arc of 90 ° in the lower hemisphere with a power of 1.2 W with a pulse energy of 3.6 J, and if the thickness of the ciliary body is greater than 0.54 mm, then 8 laser applicates are applied along a circular arc of 135 ° in the upper hemisphere and 8 laser applications atoms along an arc of a circle of 135 ° in the lower hemisphere, with a power of 1.8 W, with a pulse energy of 5.4 J; in this case, the effect is produced by contact-transsclerally using a diode laser in a continuous mode with a wavelength of 810 nm and an exposure of 3.0 seconds, and the applications are applied 1-2 mm from the limb at the same distance from each other.