RU2559939C1 - Method for surgical management of thrombosis of central retinal vein and its branches - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves sclera puncture in one of external oblique meridians of an eyeball, epiretinal administration of Gemasa 500 international units as close to an occlusion point as possible and retinal laser coagulation in the postoperative period at power 300-400 mW, exposure time 0.1-0.2 s. Immediately before the enzymatic preparation is introduced, the involved vein is massaged with a hooked end of an injection needle by performing 5-7 motions along the involved vascular stem from a distal to proximal end for 20-30 s. The contact-free retinal laser coagulation follows 2 or 3 days later. Thrombosis of the central retinal vein first requires a macular barrage in the form of a horseshoe open to an optic disk; the coagulates are applied at min. 2550-2600 mcm from a fovea; a spot diameter is 50 mcm in the single flash mode in the number of 20-25 applications; the laser is then taken to an automatic operation; and the other retinal segments are coagulated in the staggered order, thereby increasing a spot diameter up to 80-100 mcm, except for a papillomacular bundle; about 400-450 applications are used in a back pole. Treating retinal vein occlusion is ensured by paravasal laser coagulation; the laser coagulates 80-100 mcm in diameter are applied along the involved branch of the central retinal vein at min. 1600 mcm from each other in the number of 100-140 applications.

EFFECT: method enables producing a stable therapeutic effect.

3 cl, 5 dwg, 13 tbl, 2 ex

Description

The invention relates to the field of medicine, ophthalmology, specifically to methods for the surgical treatment of thrombosis of the central retinal vein (CVC) and its branches.

Closest to the proposed one is a method involving the epiretinal administration of recombinant prourokinase (Hemase) as close to the site of occlusion and subsequent laser coagulation of the retina on days 14-16 using a panfundus lens or a Goldman three-mirror lens after preliminary anesthesia with 0.5% dicainum solution [6]. According to clinical observations, enzymatic thrombolysis is quite effective and does not have a toxic effect on vitreoretinal structures [2, 3, 4, 6, 7, 8], however, the known method does not cause rapid lysis, since the duration of Hemase is 1-3 days [ 2] and does not always ensure effective destruction of a blood clot in connection with an indirect effect on it. Due to the above disadvantages of the method, a significant number of complications are observed - longer resorption of plasmorrhages and hemorrhages in the fundus, increased treatment time, and the clinical effectiveness of surgery.

It should also be noted that laser-assisted retinal coagulation leads to an increased risk of corneal infection, which is impossible in patients with inflammatory, dystrophic diseases of the cornea, as well as in the presence of an allergic reaction to surface anesthetics. In addition, laser coagulation only 14-16 days after surgical treatment increases the risk of developing cystic macular edema in the late postoperative period, increases the time of hemorrhage resorption, which ultimately reduces the clinical and functional results of treatment.

In this regard, there is a need to develop a more effective and less traumatic method for the surgical treatment of thrombosis of CVC and its branches.

A new technical result is obtaining a more stable therapeutic effect, reducing the time of medical and social rehabilitation, reducing the duration and morbidity of surgical intervention, the risk of postoperative complications in the treatment of retinal vein thrombosis.

To achieve a new technical result in a method for the treatment of thrombosis of the central retinal vein and its branches, including puncture of the sclera in one of the external oblique meridians of the eyeball, the epiretinal administration of Hemase at a dose of 500 ME is as close as possible to the occlusion site and the subsequent retinal laser coagulation in the postoperative period with power 300-400 mW, exposure time 0.1-0.2 sec, immediately before the introduction of the enzyme preparation, “massage” the affected vein with the bent end of the injection needle, for which make 5-7 movements along the affected vascular trunk in the direction from its distal to the proximal for 20-30 seconds, moreover, non-contact laser coagulation of the retina is carried out after 2-3 days, and, with thrombosis of the central retinal vein, the macular zone is first barred in the form of " horseshoes ”, opened towards the optic disc, coagulates are applied at a distance of at least 2550-2600 μm from the central fossa, the diameter of the light beam is 50 μm in single flash mode with a total number of 20-25 applications, after which the laser DYT in automatic operation is performed and the remaining parts of the coagulation of the retina in a staggered manner, increasing the diameter of the light beam to 80-100 micrometers, with the exception of the region papillomacular beam just posterior pole is applied about 400-450 appliques. For the treatment of occlusion of the retinal vein, paravasal laser coagulation is used: laser coagulates with a diameter of 80-100 microns are applied along the affected branch of the CVC at a distance of at least 1600 microns from each other, with a total number of 100-140 applications.

The method is as follows. 30 minutes before surgical treatment, the patient is instilled with drugs from the group of mydriatics (tropicamide 1%, cyclomed 1%, irifrin 2.5%, midrimax) three times in order to achieve drug mydriasis. For surface anesthesia, drugs from the group of surface anesthetics (inocaine 0.4%, alkain 0.5%) are used 10-15 minutes before surgery. Hemase is bred immediately before surgery at the rate of 5000 ME in 1.0 ml of isotonic sodium chloride solution. Then 0.1 ml of a solution containing 500 IU of the enzyme is drawn into an insulin syringe onto which a sterile disposable needle 0.6 × 30 mm long and 23 G gauge is inserted, the end of which bends at an angle of 90º.

In the operating room, after standard processing of the surgical field in compliance with the rules of asepsis and antiseptics and surface droplet anesthesia of 0.4% inocaine solution, an eyepiece expander is installed. A “stepped” needle injection is made through the sclera 5 mm from the limbus in one of the external oblique meridians. Under visual control using an NBO-2 head-on binocular ophthalmoscope with a + 20 lens, the OD needle is guided into the epiretinal space as close as possible to the thrombosed vein, after which 5-7 accurate tangential movements are performed with the bent end of the needle along the affected vascular trunk in the direction from its distal department to the proximal within 20-30 seconds. During the “massage” of the retinal vein, a movement of the blood column in the vessel may be observed according to the movements of the needle.

After the “massage”, Hemase is epiretinally injected through a needle previously inserted into the vitreous cavity (Fig. 1 shows a diagram of the epiretinal administration of Hemase), which is then removed. Next, a subconjunctival injection of 0.5 ml of gentamicin solution is performed, and a monocular dressing is applied for 1 day. In the postoperative period, instillations of combined preparations containing an antibiotic and a glucocorticosteroid (toradex, combined duo, maxitrol) are prescribed according to the standard scheme.

2-3 days after the surgery, “gentle” panlasercoagulation during CVC thrombosis or focal lasercoagulation along the obstructed vessel during occlusion of the CVC branch is performed. For this purpose, the VISUAL - 2 OPTON ophthalmic laser is used in conditions of drug mydriasis. Applying applications is carried out in a laser cabinet in a non-contact way under ophthalmoscopic control using a forehead binocular ophthalmoscope (NBO-2) with a lens of +20.0 D.

In case of "gentle" pan-laser coagulation, the macular zone is first barred in the form of a "horseshoe", opened to the side of the optic nerve disk (optic nerve disc). Coagulates are applied at a distance of at least 2550-2600 μm from the central fossa at a power of 300-400 mW, exposure time of 0.1-0.2 seconds, the diameter of the light beam 50 μm in single flash mode with a total number of 20-25 applications. Then the laser is put into automatic operation and coagulation of the remaining parts of the retina in a checkerboard pattern, while increasing the diameter of the light beam to 80-100 microns, with the exception of the area of the papillomacular beam. In total, 400-450 applications are applied in the back pole.

In case of paravasal laser coagulation for the treatment of thrombosis of the CVC branch, the laser beam power is 300-400 mW, the exposure time is 0.1-0.2 sec, the diameter of the light beam is 80-100 microns, the number of applications is 100-140, which are applied at a distance of less than 1600 microns apart.

The proposed method for the treatment of thrombosis of CVC and its branches is based on an analysis of the results of clinical studies. The effectiveness of the proposed method for the treatment of CVT thrombosis is due to the following factors. Since the vitreous has a density of 1.0053-1.0089 g / cm ³ [1], then 5-7 accurate tangential movements with the bent end of the needle along the vascular trunk for 20-30 sec provide a delicate effect on the affected retinal vein, excluding damage the vascular wall and adjacent chorioretinal structures, eliminating, nevertheless, the connection of the thrombus with the endothelium of the vascular wall.

The potential risk of developing thromboembolic complications in the postoperative period after performing a “massage” of CVC is reduced, since, according to the literature [5], the diameter of the veins of the retina of the first order is on average 150 microns, the second order is 50 microns, the caliber of the retinal capillaries is 14.8- 20.1 μm.

Subsequent epiretinal administration of Hemase provides enzyme thrombolysis in the immediate vicinity of the occlusion site. The used dosage of recombinant prourokinase - 500 ME - was selected on the basis of clinical studies [6, 8], proving effective thrombolysis, stable therapeutic effect with a single injection of the drug, the absence of toxic effects of the enzyme on the retina and optic nerve and negative effects on the level of intraocular pressure in the postoperative period.

Earlier dates for retinal laser coagulation — 2-3 days after surgery — when using the radiation parameters proposed earlier [6], can significantly accelerate the process of hemorrhage resorption, prevent or reduce the risk of macular edema, shorten the rehabilitation of patients and obtain stable clinics -functional treatment results.

Clinical studies were conducted among 96 people (96 eyes) with thrombosis of CVC and its branches on the basis of the ophthalmology clinic of the SBEI HPE SibGMU of the Ministry of Health of Russia (Tomsk). Patients with this pathology, depending on the treatment method, were divided into 2 groups:

- the main, 47 people (47 eyes) who underwent a “massage” of the affected vessel, the epiretinal administration of 500 IU of Hemase with laser coagulation of the retina on the 2-3rd day after surgery according to the method described above;

- a comparison group, 49 people (49 eyes) who underwent epiretinal administration of Hemase (500 ME) and subsequent retinal laser coagulation.

Patients of both groups were comparable by sex, age and prescription of the disease.

All patients underwent general phthalmological examination, including visometry, perimetry, biomicroscopy, ophthalmoscopy, fundus photoregistration, electrophysiological studies (electroretinography (ERG), phosphene, lability), fluorescence angiography, optical coherence tomography of the retina, and analysis of blood pressure. The follow-up period was 12 months.

Research results

In the main group of 47 people, CVS thrombosis was diagnosed in 26 patients (26 eyes) - 55.3%, affection of the CVS branch - in 21 patients (21 eyes) - 44.7% (Table 1, which presents comparative characteristics of patients with thrombosis of CVC and its branches).

The comparison group consisted of 49 patients (49 eyes), of which 25 patients (25 eyes) with CVC thrombosis - 51.0% and 24 people (24 eyes) with CVC branch occlusion (Table 1).

The average duration of the disease at the time of treatment (Table 1) in the main group averaged 15.05 ± 1.9 days from the onset of the disease, in the comparison group - 14.8 ± 2 days.

Of the concomitant diseases in patients of both groups, hypertension was most often detected (Table 2, which gives a comparative description of concomitant systemic pathology in patients with thrombosis of CVC and its branches). Also, a significant number of patients in both groups had an initial cataract (Table 3, which gives a comparative description of concomitant ophthalmic pathology in patients with thrombosis of CVC and its branches).

A comparative analysis of the data obtained during the clinical study showed significant effectiveness of the proposed combined method of surgical treatment of retinal vein thrombosis. So, for example, before treatment, the median visual acuity in patients with CVC trunk thrombosis in both groups was 0.03-0.04 (Table 4, showing the dynamics of visual acuity in patients with CVC trunk thrombosis, depending on the treatment method). In the postoperative period, a statistically significant improvement in visual function was observed in patients of both groups. However, in the main group this indicator was higher than in the comparison group (Table 4). On the 7th day after surgical treatment, visual acuity in the main group increased 10.0 times compared with the initial data, while in the comparison group - 3.0 times. On the 14th day after treatment, visual functions in the first group increased 16.7 times compared with visual acuity before treatment, and in the comparison group - 6.7 times from the initial value. 1 month after treatment in the main group, an increase of this indicator by 21.7 times was noted, while in the comparison group - by 13.4 times from the initial level. It should be noted that in the main group, in contrast to the comparison group, there was a further increase in visual acuity in the distant period - 23.3 times from the initial value (Table 4).

When analyzing visual functions in patients with affection of the CVC branch, a significant increase in visual acuity was also observed in the early and late postoperative period (Table 5, which presents the dynamics of visual acuity in patients with CVC branch thrombosis depending on the treatment method). The greatest increase in median visual acuity was noted in the main group during the first 14 days after surgical treatment. So, on the 7th day after surgery, visual acuity in the main group increased 5.5 times from the initial values, and in the comparison group - 4.0 times. On the 14th day, visual functions in the main group increased 6.36 times from the initial level, in the comparison group - 5.0 times from the data before treatment. On the 30th day in both groups there was a further increase in visual acuity - 6.8 times from the initial values in the main group and 5.5 times in the comparison group. In the long-term period, in both groups of patients, visual acuity remained at the achieved level, however, in the main group, visual functions were significantly higher than in the comparison group (Table 5).

The initial perimetric indices (median of the sum of the field of view of the 8 meridians) in patients with CVC thrombosis and its branches were reduced in patients of all groups (Table 6, which reflects the dynamics of perimetric indices in patients with CVC thrombosis depending on the treatment method; Table 7, which characterizes the dynamics of perimetric indices in patients with thrombosis of the CVC branch, depending on the method of treatment).

When analyzing the dynamics of perimetric data and changes in the area of cattle in patients with CVC trunk thrombosis, it was found that the expansion of the boundaries of the visual fields was more significant in patients treated with the new combined method, but not all data are statistically significant (p> 0.01) (Table. 6). On the 7th day after the surgery, the perimetric index in the main group increased 2.0 times from the initial values, and in the comparison group - 1.4 times. On the 14th day there was an increase in this indicator by 2.2 times in comparison with the initial level in the main group and 1.7 times in the comparison group. The perimetric index reached its maximum value by the 30th day after treatment in both groups, and in the main group this indicator increased 2.5 times from the initial level, and in the comparison group - 2.0 times.

After a “massage” of the affected retinal vein and epiretinal administration of Hemase in patients with CVC stem thrombosis, a gradual decrease in cattle area was also noted. 1 week after surgical treatment, the area of the visual field defect decreased by 1.53 times compared with the initial value in patients of the main group and 1.14 times in the comparison group. After 2 weeks, this indicator improved by 1.9 times from the initial data in the main group and 1.6 times in the comparison group. 1 month after treatment, the cattle area decreased 2.17 times from the baseline in the main group and 1.8 times in the comparison group. In the long-term observation period, there was a further slight increase in the studied parameter, which ultimately decreased by 2.3 times from the initial level in the main group and 2.1 times in the comparison group (Table 6).

A comparative analysis of the perimetric data in patients with affection of the CVC branch showed a significant expansion of the visual field boundaries in patients of both groups, however, in the main group this indicator is higher than in the comparison group (Table 7). So, on the 7th day, an increase in the perimetric index was noted 1.2 times from the initial one in the main group and 1.05 times in the comparison group. On the 14th day after treatment, the studied parameter increased 1.25 times from the initial values in the main group and 1.1 times in the comparison group. The maximum increase in the median of perimetric indices was noted 30 days after treatment in patients of both groups, while the main group showed an increase of this indicator by 1.3 times from the initial level and 1.2 times in the comparison group. In addition, against the background of the treatment, a decrease in cattle area was noted in both groups, however, not all data are statistically reliable (Table 7). On the 7th day after treatment, this indicator improved 2.3 times from the initial values in the main group and 1.8 times in the comparison group. On the 14th day, the cattle area decreased 3.8 times from the initial values in the main group and 2.6 times in the comparison group. On the 30th day, the studied parameter improved 5.0 times from the data before treatment in the main group and 4.3 times in the comparison group. It should be noted that the achieved level of cattle area remained stable over a long observation period (Table 7).

The study of the dynamics of visual functions showed that the maximum increase in the studied parameters in patients of the main groups occurred in the first 7 days after surgical treatment using the new combined method, which indicates effective thrombolysis after this surgical intervention (Tables 4, 5, 6, 7) .

During the clinical study, a positive dynamics of the ophthalmoscopic picture was noted: in the main groups after the treatment, fresh hemorrhages were not found in the posterior pole during the entire observation period. On 14 ± 1.2 days in the main groups and on 17 ± 1.1 days in the comparison groups, a significant resorption of retinal edema of the macular region was noted. The ratio of the retinal vessels and their diameter changed: the arteries became wider, the diameter, plethora and tortuosity of the veins decreased. In the posterior pole, resorption of hemorrhage along the vascular arcades is noted. In addition, a comparative analysis of the data revealed that in patients of the main groups for 4.0 ± 0.5 days - unlike patients in the comparison groups - intraretinal hemorrhages and plasmorrhagia resolved faster.

The use of a new combined method of surgical treatment of retinal vein thrombosis had a positive effect on the state of the electrophysiological activity of the retina. At the time of hospitalization, the ERG values in patients with CVC trunk thrombosis were significantly reduced in both groups (Table 8, which shows the electrophysiological parameters (in medians) in patients with CVC trunk thrombosis, depending on the type of treatment). Against the background of the application of the new method of surgical treatment of CVC trunk occlusion, already on the 14th day there was an increase in the wave amplitude a 3.1 times from the initial value, while in the comparison group - 2.3 times; the increase in wave amplitude in the main group is 4.3 times the original, and in the comparison group 3.5 times. The wave-wave ratio also significantly changed: on the 14th day after the treatment, in the main group this indicator increased by 3.7 times, in the comparison group - 2.34 times from the initial one.

In addition, an increase in the phosphene index was observed: 2.1 times in the main group and 1.7 times from the initial in the comparison group (Table 8). The lability index in patients of both groups before treatment was within normal limits. Subsequently, during the entire observation period, this indicator also corresponded to normal values (Table 8).

The results of an electrophysiological study suggest a faster recovery of hemodynamics at the level of the affected retinal vein in the main group due to effective thrombolysis against the background of a new combined method of surgical treatment, and also indicate the absence of toxic effects of Hemase in the selected dosage on the retina and optic nerve.

In patients with thrombosis of the CVC branch in both groups before treatment, the type of ERG was mainly “+” negative or subnormal. On the 14th day after surgical treatment, an increase in the wave amplitude a was observed 1.5 times from the initial level in the main group and 1.46 times in the comparison group, however, the data obtained are statistically unreliable. After surgery, the wave amplitude increased by 1.9 times from the initial value in the main group and 1.6 times in the comparison group. The w / a ratio improved 1.7 times from the initial level in the main group, and 1.3 times in the comparison group (Table 9, which shows the electrophysiological parameters (in medians) in patients with CVC branch thrombosis, depending on type of treatment).

The threshold of electrophosphene also decreased more significantly in the main group - 1.73 times from the indicator before treatment, in the comparison group - 1.5 times from the initial level. The phosphene value was statistically significantly different from the initial indicators in both groups, however, in the comparison group, despite the improvement in the indicator, the data were not statistically reliable. The level of lability in patients of both groups before treatment was within normal limits (table. 9). After the treatment, the studied indicator corresponded to normal values during the entire observation period.

It should be noted that a statistically significant improvement in electrophysiological parameters with the use of a new complex method for the treatment of thrombosis of retinal veins indicates the absence of the damaging effect of “massage” on retinal veins and adjacent chorioretinal structures, as well as the toxic effect of Hemase 500 ME on the retina and optic nerve with epiretinal administration enzyme. Clinical examples of the method.

Example No. 1.

Patient O., 53 years old, complained of decreased vision of the left eye.

Medical history: noted a sharp decrease in vision and the appearance of a "dark spot" in front of the left eye on 10/19/2013 after suffering a hypertensive crisis. After 7 days, he went to the clinic at the place of residence, from where he was sent to the ophthalmology clinic of the SBEI HPE SibGMU in Tomsk. I did not receive treatment before admission to the hospital.

Objective inspection:

Visus OD = 0.06 s -4.5 D = 0.9-1.0, Visus OS = 0.04 n / k

AWP R sph-4,5 cyl-1,25 Ax 79 L sph-4,25 cyl-0.75 Ax 119

Biomicroscopy: the anterior segment of both eyes is calm. In the lens of both eyes, the phenomenon of flooding of the crystalline sutures, spoke-like opacities in the core and cortex.

Ophthalmoscopy: The right eye - without gross pathology.

The left eye is a vitreous transparent. DZN is pale, monotonous, the borders are stained throughout. In the macular region and along the vascular arcades, there is retinal edema. Arteries are narrowed, veins are sharply expanded, convoluted, full-blooded. In the posterior pole, a large number of plasma and hemorrhages of various shapes and sizes (in Fig. 2, presented the condition of the fundus of patient O. at the time of hospitalization).

The main diagnosis: thrombosis of CVS of the left eye,

Concomitant diagnosis: moderate myopia in both eyes.

Initial nuclear cortical cataract in both eyes.

Hypertension of the I-II stage, degree of arterial hypertension 2 (achieved), risk 3.

Treatment: On October 24, 2013, the surgical intervention was performed according to the proposed method, during which a “massage” of the thrombosed CVC of the left eye was performed in the amount of 7 movements for 30 seconds, followed by the epiretinal administration of Hemase at a dose of 500 ME.

10/25/2014, non-contact panlasercoagulation of the retina of the left eye was performed.

Dynamics of the course of the disease: starting from 5 days after treatment with a new combined method for the treatment of CVT thrombosis, the patient noted an improvement in visual acuity, a decrease in the “dark spot” in front of the left eye. A significant increase in visual acuity - 12.5 times from the initial level - was noted on the 14th day from the start of treatment. In the future, this indicator remained stably high - 0.6-0.7 - throughout the entire observation period (6 months) (Table 10, shows data showing the dynamics of visual acuity with correction in patient O. during treatment of CVC thrombosis). the proposed method).

Objective status on the 14th day of treatment; on the fundus of the left eye of patient O., swelling of the optic nerve disc and retina along the vascular arcades significantly decreased, however, pastiness remained in the macular region. Arteries were narrowed. The size of the veins and their tortuosity decreased. Hemorrhages at the posterior pole practically resolved, fresh hemorrhages were not detected (Fig. 3, shows the condition of the fundus of the left eye of patient O. on the 14th day after treatment of CVC thrombosis using the proposed method of treatment).

Against the background of treatment, a positive dynamics of the electrophysiological functions of the retina was noted. On the 14th day after surgical treatment, the retinal response of the left eye returned to normal: the activity of the central and peripheral parts of the retina increased in comparison with these indicators before surgery (in table 11, data were presented showing the dynamics of changes in the electrophysiological parameters of patient O. during treatment of CVC thrombosis new combined method).

Thus, the application of the proposed method of treatment provided consistently high clinical and functional results throughout the observation period. In the postoperative period, no development of any complications was revealed. It should be noted the good subjective tolerance of the proposed method of surgical intervention.

Example No. 2.

Patient X., 63 years old, complained of decreased vision and distortion of objects in front of his left eye.

Anamnesis of the disease: Visual acuity of the left eye decreased 12/06/2013 after suffering a hypertensive crisis, after which the patient turned to the ophthalmic clinic of SBEI HPE Tomsk State Medical University.

Objective inspection:

Visus OD = 1.0; Visus OS = 0.1 n / a

AWP R sph + 0.5 cyl + 1.0 Ax 8 L sph + 1.25 cyl + 1.0 Ax 17

Biomicroscopy: the anterior segment of both eyes is calm, without features.

Ophthalmoscopy: the right eye - without gross pathology.

The left eye is a vitreous transparent. DZN pale pink, clear boundaries throughout, excavation 0.4 pd. In the macular region, edema and hemorrhage. The inferior temporal vein is sharply expanded, convoluted, full-blooded. A large amount of plasma and hemorrhage of various shapes and sizes is found along the vein (Fig. 4, reflecting the condition of the fundus of the left eye of patient X. at the time of hospitalization).

The main diagnosis: thrombosis of the lower temporal branch of the central eye of the left eye.

Concomitant diagnosis: mild hyperopia of both eyes. Complex hyperopic astigmatism in both eyes.

Hypertension of the II stage, the achieved degree of arterial hypertension 2, left ventricular hypertrophy, risk 3. Impaired carbohydrate tolerance.

Treatment: On 12/11/2013, the treatment was carried out according to the proposed method, including “massage” of the thrombosed branch of the central eye of the left eye, 5 movements with the bent tip of the needle 0.6 × 30 mm, caliber 23 G for 20 seconds, followed by epiretinal administration of Hemase in a dose 500 ME.

12/13/2013, non-contact paravasal laser coagulation of the retina of the left eye was performed.

Dynamics of the course of the disease: improvement of the patient’s visual functions was noted already on the 3rd day after surgical treatment and reached its maximum by the 30th day - 7 times from the magnitude of visual acuity to surgical treatment (Table 12 shows the dynamics of the patient’s visual acuity X. against the background of a new combined method of surgical treatment of thrombosis of the lower temporal CVS). This level of visual acuity remained stable throughout the observation period - 6 months.

Objective data on the 14th day of treatment: optic nerve disc pale pink, clear boundaries. Significantly decreased retinal edema in the central departments. Hemorrhages in the macular region of the retina were practically resorbed. Some narrowing of the inferior temporal artery is observed. The diameter, plethora, and tortuosity of the lower temporal branch of the CVC decreased. Hemorrhages along the affected vessel almost resolved, fresh hemorrhages were not detected (Fig. 5, reflecting the condition of the fundus of the left eye of patient X. on the 14th day after treatment of thrombosis of the lower temporal branch of CVS using a new combined method).

When analyzing the data of electrophysiological studies before treatment and after applying the new combined method of surgical treatment of thrombosis of the inferior temporal branch of CVC in patient X, a positive dynamics was noted compared to the initial data: the macular response and activity of all layers of the retina of the left eye increased, the electrophosphene index improved (in table. 13, the data on the dynamics of the electrophysiological parameters of patient X. are given against the background of the treatment of thrombosis of the lower temporal branch of the CVC by the proposed method).

After treatment of thrombosis of the CVC branch with the proposed method, patient X. visual acuity increased, positive dynamics were observed during ophthalmoscopy: there was a resorption of plasma and hemorrhage in the fundus, and ERG indices also improved. During the entire observation period, no complications of this technique were revealed. The patient subjectively well underwent surgery in combination with laser coagulation.

Thus, the application of the proposed method for surgical treatment of retinal vein thrombosis provides a quick and lasting therapeutic effect, reduces surgical trauma, and also significantly reduces the risk of complications in the early and late postoperative period.

Table 1 Comparative characteristics of patients with thrombosis of CVC and its branches

Table 2 Comparative characteristics of concomitant systemic pathology in patients with thrombosis of CVC and its branches

Table 3 Comparative characteristics of concomitant ophthalmic pathology in patients with CVC thrombosis and its branches

Table 4 The dynamics of visual acuity in patients with thrombosis of the stem of the CVC, depending on the method of treatment

Note: * a significant difference was noted with the initial values and data of the comparison group, p <0.05

Table 5 The dynamics of visual acuity in patients with thrombosis of the branch of CVC, depending on the method of treatment

Note: * a significant difference was noted with the initial values and data of the comparison group, p <0.05

Table 7 The dynamics of perimetric indicators in patients with thrombosis of the branch of CVC, depending on the method of treatment

Note: * a significant difference was noted with the initial values and data of the comparison group, p <0.05

Table 8 Electrophysiological indicators (in medians) in patients with CVT stem thrombosis, depending on the type of treatment

Note: * a significant difference was noted with the initial values and data of the comparison group, p <0.05

Table 9 Electrophysiological indicators (in medians) in patients with thrombosis of the CVC branch, depending on the type of treatment

Note: * a significant difference was noted with the initial values and data of the comparison group, p <0.05

Table 10 Dynamics of visual acuity in patient O. during treatment of CVC thrombosis with a new combined method

Table 11 Dynamics of electrophysiological parameters of patient O. during treatment of CVC thrombosis with a new combined method

Table 12 The dynamics of visual acuity of patient X. on the background of a new combined method of surgical treatment of thrombosis of the lower temporal branch of CVC

Table 13 The dynamics of the electrophysiological parameters of patient X. on the background of treatment of thrombosis of the lower temporal branch of CVC with a new combined method

FIG. 1 Scheme of epiretinal administration of Hemase

FIG. 2 The condition of the fundus of the patient O. at the time of hospitalization

FIG. 3 The condition of the fundus of the left eye of patient O. on the 14th day after treatment of CVC thrombosis using a new combined method of surgical treatment

FIG. 4 The condition of the fundus of the left eye of patient X. at the time of hospitalization

FIG. 5 The condition of the fundus of the left eye of patient X. on the 14th day after treatment of thrombosis of the lower temporal branch of CVC using a new combined method

Table 1 Main group Comparison group CVT Thrombosis (n = 26) CVT branch thrombosis (n = 21) CVT Thrombosis (n = 25) CVT branch thrombosis (n = 24) Average age, years 62.3 ± 2.1 65.7 ± 2.8 57.3 ± 2.2 55.1 ± 1.9 Male / female ratio 10 (38%) / 16 (62%) 7 (34%) / 14 (66%) 11 (44%) / 14 (56%) 14 (58%) / 10 (62%) Average terms of circulation, days 16.5 ± 1.8 13.6 ± 1.9 15.4 ± 2.1 14.2 ± 2 table 2 Concomitant pathology Main group Comparison group CVT Thrombosis (n = 26) CVT branch thrombosis (n = 21) CVT Thrombosis (n = 25) CVT branch thrombosis (n = 24) Hypertension stage I-III 22 (84.6%) 21 (100%) 19 (76.0%) 24 (100%) Type 2 diabetes mellitus without diabetic retinopathy 4 (15.4%) 2 (9.5%) 3 (12.0%) 2 (8.3%) Table 3 Concomitant pathology Main group Comparison group CVT Thrombosis (n = 26) CVT branch thrombosis (n = 21) CVT Thrombosis (n = 25) CVT branch thrombosis (n = 24) Myopia 8 (30.8%) 5 (23.8%) 6 (24.0%) 9 (37.5%) Hypermetropia 9 (34.6%) 7 (33.3%) 5 (20.0%) 8 (33.3%) Corneal astigmatism more than 1.0 D inclusive 12 (46.2%) 15 (71.4%) 13 (52.0%) 11 (45.8%) Initial cataract 24 (92.3%) 17 (80.9%) 17 (68.0%) 19 (79.2%) Table 4 Group of patients Before treatment Duration of observation, days one 3 5 7 fourteen thirty 6 months 12 months Main group 0,03 0.04 * 0.1 * 0.3 * 0.3 * 0.5 * 0.65 * 0.7 * 0.7 * Comparison group 0.04 0.04 * 0.05 * 0.06 * 0.09 * 0.2 * 0.4 * 0.4 * 0.4 *

Table 5 Group of patients Before treatment Duration of observation, days one 3 5 7 fourteen thirty 6 months 12 months Main group 0.11 0.2 * 0.3 * 0.45 * 0.6 * 0.7 * 0.75 * 0.75 * 0.75 * Comparison group 0.1 0.2 * 0.3 * 0.3 * 0.4 * 0.5 * 0.55 * 0.55 * 0.55 * Table 6 Patient group: Before treatment Duration of observation 7 days 14 days 30 days 6 months Main group line of sight 189 378 * 415.8 * 472 * 475 Scotomas 63 41 33 * 29th 27 * Comparison group line of sight 199 278.6 * 338 * 398 * 411 Scotomas 64 56 * 40 35 thirty* Table 7 Patient group: Before treatment Duration of observation 7 days 14 days 30 days 6 months Main group line of sight 392 470 * 490 * 495 * 483 Scotomas 65 28 17 * 13 13* Comparison group line of sight 391 413 * 430 * 470 * 481 Scotomas 64 35 * 24 fifteen 17 Table 8 Electroretinography Phosphene, μA. Lability, Hz Wave amplitude a, μV Wave amplitude in, μV W / A ratio Norm 30-60 200-300 > 4 40-60 45-50 Observation period Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Main group 3.63 11.25 * 45 184.9 * 1.25 3.9 * 98 46.7 * 45 fifty

Comparison group 3,7 8.0 * 43 145 * 1.3 3.05 * one hundred 60 * 45 fifty Table 9 Electroretinography Phosphene, μA. Lability, Hz Wave amplitude a, μV Wave amplitude in, μV W / A ratio Norm 30-60 200-300 > 4 40-60 45-50 Observation period Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Main group 28.7 43.3 144 269 * 3.3 5.45 * 78 45 * fifty fifty Comparison group 28.9 42.3 143 232 * 3.23 4.2 * 67 45 * fifty fifty Table 10 Visual acuity with correction Duration of observation after treatment Before treatment 3 day 5 day 7 day 14 day 30 day 6 months 0.04 0.1 0.2 0.3 0.5 0.65 0.7 Table 11 Electroretinography Phosphene, Lability, Wave amplitude a, μV Wave amplitude in, μV Ratio
in \ a μA. Hz Norm 30-60 200-300 > 4 40-60 45-50 Observation period Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Indicators 3.63 28.5 89 202 1.4 5.2 65 55 45 45

Table 12 Vis before treatment, with correction Duration of observation 1 day 3 day 5 day 7 day 14 day 30 day 6 months 0.1 0.2 0.25 0.6 0.65 0.7 0.7 Table 13 Electroretinography Phosphene, μA. Lability, Hz Wave amplitude a, μV Wave amplitude in, μV Ratio
in \ a Norm 30-60 200-300 > 4 40-60 45-50 Observation period Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Before treatment On the 14th day Indicators 35.7 45.5 167 258 3.69 5.45 65 55 fifty fifty

Sources of information taken into account when compiling the description:

1. Vit V.V. The structure of the human visual system.- M .: Astroprint, 2003. - 727 p.

2. Dal G.A., Vartanian I.P., Emelyanova E.S. A new fibrinolytic in ophthalmology // Physiotherapy - an actual direction of modern medicine: Sat. scientific Proceedings / SPb., 2007. - P. 82-84.

3. Danilichev V.F. Ophthalmology: enzyme therapy and extracorporeal hemocorrection - 2nd ed., Ext. - SPb., 2002 .-- 310 s.

4. Danilichev V.F., Knorring G.Yu. Proteolytic enzyme therapy for eye pathology: guidelines. - SPb., 2005 .-- S. 312.

5. Zapuskalov IV, Krivosheina OI Blood circulation mechanics. - Tomsk, 2005 .-- 112 p.

6. Zapuskalov IV, Krivosheina OI, Petrachkov DV A method for the treatment of thrombosis of the central retinal vein and its branches, Bull. No. 31, 2008, S. 1-9. RU 2337656 C1.

7. Katsnelson L.A., Forofonova T.I., Bunin A.Ya. Vascular diseases of the eye. - M.: Medicine, 1990 .-- 272 p.

8. Petrachkov D.V. The effectiveness of epiretinal administration of hemase in thrombosis of the central retinal vein and its branches: dis. Cand. honey. sciences. - Tomsk, 2008 .-- S. 80-81.

Claims (3)

1. A method for the treatment of retinal vein thrombosis, including puncture of the sclera in one of the external oblique meridians of the eyeball, the epiretinal administration of Hemase at a dose of 500 ME as close to the occlusion site and the subsequent laser coagulation of the retina in the postoperative period at a power of 300-400 mW, exposure time 0 , 1-0.2 sec, characterized in that immediately before the administration of the enzyme preparation, a “massage” of the affected vein is performed with the bent end of the injection needle, for which 5-7 movements along the affected vascular with the trunk in the direction from its distal to the proximal for 20-30 seconds, and non-contact laser coagulation of the retina is carried out after 2-3 days. 2. The method according to claim 1, characterized in that in case of central retinal vein thrombosis, the macular zone is first barred in the form of a “horseshoe” opened towards the optic disc, the coagulates are applied at a distance of at least 2550-2600 μm from the central fossa, diameter a light beam of 50 μm in a single flash mode with a total number of 20-25 applications, after which the laser is switched to automatic mode and the other parts of the retina are coagulated in a checkerboard pattern, increasing the diameter of the light beam to 80-100 μm, except During the study of the area of the papillomacular bundle, about 400-450 applications are applied in the posterior pole. 3. The method according to claim 1, characterized in that paravasal laser coagulation is used for retinal vein thrombosis, while laser coagulates with a diameter of 80-100 μm are applied along the affected CVC branch at a distance of at least 1600 μm from each other, with a total number of 100-140 applications .

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