RU2531925C1 - Method for surgical management of macular holes colouring internal limiting membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to ophthalmology and can be used for surgical management of macular holes. An internal limiting membrane (ILM) is coloured around the macular hole with preventing the colouring agent from penetrating into the hole borders; that is ensured by first using ports provided with a valve system; second, the colouring procedure involves shutting off saline into the vitreal cavity, while the colouring agent is applied intermittently and under minimum pressure with a distal end of a cannula advancing in a distal direction round a circle a diameter of which matches with that of a planned maculorhexis. After the membrane is coloured, the excessive colouring agent is removed first near the hole by passive aspiration, and then the residual colouring agent is removed with shutting on saline into the vitreal cavity under low pressure. The ILM is peeled off by the maculorhexis that is followed by the final retinal tamponade with gas-air mixture.

EFFECT: method enables reducing the toxic exposure of the colouring agent on the macula.

5 cl, 2 ex

Description

The invention relates to the field of medicine - ophthalmic surgery and can be used in the surgical treatment of macular retinal ruptures using intravitreal dyes.

There are a number of technologies for the surgical treatment of macular ruptures. Currently, the most common treatment method is a minimally invasive (25G, 27G) three-port vitrectomy with excision of the posterior hyaloid membrane (HGM), removal (peeling) of the inner border membrane (VPM) by maculorexis and gas-air tamponade of the vitreous cavity. In the postoperative period, the patient should be face down for 3-5 days. For the purpose of atraumatic and effective peeling of VPM (the membrane is difficult to visualize, since it is a transparent layer of the retina with a thickness of 2-3.5 μm in the macular region), the membrane is pre-stained using the modern Brilliant Blue G intravitreal dye, which is sprayed onto area of the macula by irrigation (Kashtan O.V., Osokin I.G., Solomin V.A. Application of air tamponade in the surgical treatment of idiopathic macular ruptures // VIII Scientific and Practical Conference "Modern treatment technologies vit reoretinal pathology - 2010. - P.69-70. - PROTOTYPE).

Dye “Brilliant Blue G” refers to the new generation of intravitreal dyes used for staining with VPM. This dye has high intraoperative contrasting efficiency, is evenly distributed on the surface of the retina, there is no diffusion into the vitreous body. The cytotoxicity of this dye, in contrast to the previously used dyes, for example methylene blue, is insignificant, but it is still observed. This is stated in a number of foreign works, for example, in the journal Retinal physician (November-December 2012), in an article in this journal “Performance of Retinal Procedures in Previously Vitrectomized Eyes” (P.25-28). When using the dye by inkjet application on the macula, part of the dye will fall beyond the edges of the retinal rupture and there will be, although minimal, damage to the unprotected neuroepithelium and retinal pigment epithelium with a subsequent decrease in the visual functions of the eye.

Known technology for the surgical treatment of macular rupture by performing a closed vitrectomy with staining of the VMP and subsequent peeling of the membrane (RF Patent No. 2389455). In this technology, the fixation point is determined before surgery and, during surgery, after removal of the posterior hyaloid membrane, a drop of organofluorine compound (PFOS) is applied to the localization area of the fixation point, then a dye solution, methylene blue, is supplied to the macular region with a cannula, then after exposure for 20 -60 seconds, remove the stained VPM around the circumference of the macular fracture, except for the region of the fixation point, then remove the drop of PFOS and complete the operation. The authors argue that applying a drop of PFOS to the area of the fixation point allows you to protect this part of the PMF from staining. Our practice has shown that this is an unreliable way to protect the retina from staining in the fovea zone. Firstly, the PFOS drop is very mobile and can easily move from its original location, and secondly, due to the high surface tension, the PFOS drop tends to reduce its surface and acquire a spherical shape, and this shape contributes to the flowing of the dye under the drop.

The objective of the invention is to develop a method for staining VPM so that the intravitreal dye does not fall beyond the edges of the retinal gap and does not have a toxic effect on the layers of the retina that opened in the gap.

The technical result obtained by solving this problem eliminates the reduction in visual function due to the toxic effects of intravitreal dye on the macula.

The specified technical result can be obtained if in the method of surgical treatment of macular discontinuities, including vitrectomy through three-port microaccesses with excision of the posterior hyaloid membrane, staining of the internal border membrane (VPM) in the macular region by feeding endovitreal dye through an irrigation cannula, removing excess dye after exposure , peeling of VPM by maculorexis and the final tamponade of the retina with a gas-air mixture, according to the invention, the coloring of VPM is performed they are painted around the macular fracture, preventing the dye from falling beyond the edges of the fracture, for this, firstly, use ports equipped with a valve system, secondly, during the staining, the flow of saline into the vitreous cavity is completely stopped, and the dye itself is applied discretely and under minimum pressure, sequentially moving the distal end of the cannula around a circle whose diameter corresponds to the diameter of the future maculorexis, and after staining the membrane, excess dye is removed first near the gap by passive spiral, then, turning on the supply of saline into the vitreous cavity under low pressure, the remaining dye is removed.

Clarifying signs:

- as a dye using dye brand "Brilliant Blue G",

- the exposure of the staining membrane is 30-90 seconds,

- low pressure of the irrigation system during removal of excess dye is 12-15 mm Hg

Special cases of using the invention:

- with macular ruptures of stages 2, 3 and 4 after maculorexis, the edges of the rupture are reduced.

Among the essential features characterizing the method, the distinguishing ones are:

- staining VPM perform around the macular gap, not allowing the dye to fall beyond the edges of the gap,

- for this, firstly, use ports equipped with a valve system,

- secondly, during staining, the supply of saline to the vitreous cavity is completely stopped,

- the dye itself is applied discretely and under minimal pressure, sequentially advancing the distal end of the cannula in a circle whose diameter corresponds to the diameter of the future maculorexis,

- after staining the membrane, excess dye is removed first near the gap by passive aspiration, then, by turning on the supply of saline into the vitreous cavity under low pressure, the remaining dye is removed.

Between the totality of essential features and the achieved technical result, there is a causal relationship.

According to a number of sources, the Brilliant Blue G intravitreal dye, which provides the best visualization of the inner boundary membrane during its removal, is considered to have no toxic effect on the macular zone. However, from recent publications - the article "Performance of Retinal Procedures in Previously Vitrectomized Eyes" in the journal Retinal physician (November-December 2012) and several others, it follows that a minimal toxic effect is still detected. Especially should be protected from the effects of the dye layers of the retina, which opened in the gap. That is, it is necessary to stain VPM delicately, not in a jet, but only around the gap, excluding the ingress of dye beyond the edges of the gap. By visually determining the size of a particular macular rupture (stage 1 - min rupture, 2nd, 3rd or 4th), the surgeon knows what diameter maculorexis he will perform after staining the membrane. So, with a rupture diameter of 200 to 450 microns, the diameter of maculorexis will be up to 2000 microns, with a gap diameter of 450 to 700 microns, the diameter of maculorexis will be from 2000 microns to 3500 microns, etc. (RF patent No. 2409332). Thus, it is enough to visualize the VPM exactly where maculorexis will be performed after staining. The dye is applied discretely, i.e. intermittently and under minimal pressure (this eliminates the spreading of the dye), sequentially moving the distal end of the cannula in a circle whose diameter corresponds to the diameter of the future maculorexis. As a result, the applied dye will be located in the form of a ring, not reaching the edges of the gap. In order to obtain such a staining result, it is necessary to create complete immobility of all structures in the vitreous cavity during staining, only the cannula should move, applying a dye to the membrane discretely under minimum pressure, moving along a circle corresponding to the line of the future maculorexis. Complete immobility of structures can be achieved if, firstly, ports that are equipped with a valve system are used (these have appeared recently and provide maximum tightness of the vitreous cavity), and secondly, during staining, the flow of saline into the vitreous cavity should be completely stopped. those. disable irrigation. Eliminating turbulent flows in the vitreal cavity, moving only the cannula around the circumference and applying discrete dye to the membrane, the result will be obtained: the inner boundary membrane will be painted in the form of a ring, the paint will not be beyond the edges of the gap. The exposure (time) of staining is 30-90 seconds, and then excess paint is removed. Incorrect actions during removal of excess dye can also cause the dye to rupture. To prevent this, first the excess dye is removed near the gap by passive aspiration, then, by switching on the supply of saline into the vitreous cavity under low pressure, the remaining dye is removed. The stained membrane contrasts well, with the help of tweezers it is captured and peeling is performed by maculorexis.

As a result of this sequence of actions, the dye does not flow beyond the edges of the gap and toxic effects on the layers of the retina that open in the gap can be avoided.

The method is as follows.

The operation begins with a 3-port 25-27G vitrectomy. All ports that are installed trans-sclerally 4 mm from the limb and through which the light guide, irrigation system and vitreot are inserted have a valve-type design, which ensures the most complete sealing of the vitreous cavity. Vitrectomy ends with the isolation and removal of the posterior hyaloid membrane. The next step is the staining of VPM. Before staining the membranes, the balanced salt solution (BSS) is discontinued through the irrigation system (the system itself is not removed from the port). However, it is displayed by a vitreot and a cannula is inserted into this port on a syringe with DORC Brilliant Blue G dye. VPM staining is performed around the macular fracture, preventing the dye from falling beyond the rupture edges, while the dye is applied discretely and under minimal pressure, successively moving the distal end of the cannula along a circle whose diameter corresponds to the diameter of the future maculorexis. Exposure staining VPM is 30-90 seconds. After staining the membrane, excess dye is removed. First, it is removed near the macular fracture by passive aspiration using an extrusion cannula, then, by turning on the supply of saline into the vitreous cavity under low pressure (12-15 mm Hg), the remaining dye is removed. After this, peeling of the VPM by maculorexis using ILM-forceps (Alcon) using traditional technology is performed. Then perform the final tamponade of the retina with a gas-air mixture. In the postoperative period, the patient is face down for 3-5 days.

In macular ruptures of stages 2, 3 and 4 after maculorexis, the edges of the rupture are reduced by one of the known methods. For small breaks, this procedure is not performed.

EXAMPLE 1. Patient V., 62 years old.

When handling: complaints about the appearance of a translucent spot in the central section of the field of view, visual acuity before surgery: OS - 0.6 with correction.

Diagnosis: OS - Senile idiopathic macular rupture of stage 1b, vitreomacular traction syndrome - established according to optical coherence tomography (OCT).

The operation is carried out according to the invention. During staining with VPM, the Brilliant Blue G dye did not fall beyond the edges of the gap, while the full exposure of the membrane staining was 60 seconds, and the diameter of the maculorexis was about 2000 μm. After peeling the VPM, information on the edges of the macular rupture was not required. The operation ended with tamponade of the retina with a gas-air mixture.

After surgery, after 6 months, the visual acuity on the OS is 0.8 with correction, no complaints. According to OCT OS - vitreomacular traction is absent, macular rupture is not observed.

Example 2. Patient S., 68 years old.

On admission, complaints of a dark spot in the central section of the OD field of vision. Visual acuity before surgery: OD - 0.08 with correction.

Diagnosis OD - Senile idiopathic macular rupture of 4 stages. The final diagnosis was made according to OCT.

The operation was carried out according to the invention, while the exposure of the dye was 90 seconds, and the diameter of the maculorexis was about 4000 microns. After peeling the membrane, the edges of the gap were reduced by extrusion cannula by passive aspiration.

After surgery, after 6 months, the patient noted a change in the transparency of the spot - in the central part of the field of view of the right eye, the spot became translucent, visual acuity OD - 0.2 with correction. According to OCT, the macular gap is blocked, the edges are adapted. It should be noted that by performing a gentle application of the dye to the VPM, the surgeon ensured that the maximum possible visual functions were obtained in this patient.

In the Yekaterinburg Center, the claimed method operated on 9 patients (9 eyes). In all cases, it was possible to carry out the delicate application of Brilliant Blue G dye on the VPM, while in no case did the dye get beyond the edges of the gap and as a result did not have a toxic effect on the unprotected neuroepithelium and retinal pigment epithelium, otherwise it would lead to decreased visual function of the eye.

Claims (5)

1. A method for the surgical treatment of macular discontinuities, including vitrectomy through three-port micro-accesses with excision of the posterior hyaloid membrane, staining of the internal border membrane (VPM) in the macular region by feeding endovitreal dye through an irrigation cannula, removing excess dye after exposure, VPM peeling and macular retinal tamponade with a gas-air mixture, characterized in that VPM staining is performed around a macular rupture, preventing the dye from getting into beyond the edges of the gap, for this, firstly, use ports equipped with a valve system, secondly, during staining, the supply of saline to the vitreous cavity is completely stopped, and the dye is applied discretely and under minimal pressure, sequentially moving the distal end of the cannula along a circle whose diameter corresponds to the diameter of the future maculorexis, and after staining the membrane, excess dye is removed first near the gap by passive aspiration, then by turning on the saline in vitrea nuyu cavity under low pressure to remove remaining dye. 2. The method according to claim 1, characterized in that as a dye using dye brand "Brilliant Blue G". 3. The method according to claim 1, characterized in that the exposure of the membrane staining is 30-90 seconds. 4. The method according to claim 1, characterized in that for macular ruptures of stages 2, 3 and 4 after maculorexis, the edges of the rupture are reduced. 5. The method according to claim 1, characterized in that the low pressure of the irrigation system during removal of excess dye is 12-15 mm Hg