RU2578866C1 - METHOD FOR SURGICAL TREATMENT OF TRAUMATIC RETINAL DETACHMENT WITH SEPARATION FROM DENTATE LINE OVER 180º AND MORE - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used during surgical treatment of traumatic retinal detachments with separation from a dentate line for 180° and more. Intervention is performed through accesses of calibre 27G. After subtotal vitrectomy perfluoro-organic compounds (PFOC) is introduced so as to cover the central zone of the retina to the level of the equator, then peripheral parts of the vitreous body are removed. Vitreal cavity is topped up with air which displaces the liquid from under the retina into the separation zone, and on the PFOC media border - air; then drainage of subretinal liquid is performed. Having received a full contact of the retina, it is necessary to fix the retina by endo-laser-coagulation of the separation edges. Silicone oil is introduced into the vitreal cavity which replaces first the air, and then - PFOC; at that, PFOC is removed from the vitreal cavity by active aspiration.

EFFECT: method makes it possible to quickly restore visual functions due to full retina adhering to underlying tissues, to minimise the surgical wound due to application of minimally invasive technique.

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Description

The invention relates to medicine, more specifically to ophthalmology, and can be used in the surgical treatment of traumatic retinal detachments with a separation from the dentate line for 180 ° or more.

In the sources of information available to us, we did not find any materials describing the stages of surgical treatment of traumatic detachment of the retina with the separation of the retina from the dentate line for 180 ° or more. However, technologies are known when, during microinvasive surgical treatment of retinal detachment, one of the technology steps is retinotomy (destruction of retinal fixation along the dentate line) with the aim of releasing the retina, spreading and subsequent plugging to the underlying structures (RF Patent No. 2441628). Retinotomy is performed circular or partial, it is created by the surgeon during the operation, for example, using a vitreotome, and it is called relaxing. The essence of the operation described in the aforementioned patent is as follows. Microinvasive trocars form three punctures in the flat part of the ciliary body; three ports are installed in them through which a vitreotome, a light guide and an infusion tip are inserted. Through the infusion tip carry out a constant supply of air into the vitreous cavity. Air is used as an environment in which all stages of endovitreal intervention are performed. First, a local vitrectomy is performed, then subretinal fluid is drained through the existing retinal rupture, then endolasercoagulation of the rupture edges is performed and fluorine-containing gas is added to the vitreous cavity. A mixture of gas and air is left in the vitreous cavity at the end of the operation as a plug substance. At the end of the operation, the ports are deleted. In the case when retinal detachment is accompanied by pronounced proliferative changes, partial or complete retinotomy is performed before endolasercoagulation. Retinotomy is performed to adapt the rigid retina to the underlying structures, and in such a situation, air tamponade is sufficient to adapt the released retina to the underlying structures. Another situation is with traumatic retinal detachment with a margin from the dentate line. In this case, the retina is mobile (the detachment is fresh), the separation is located above the equator and the air tamponade will not be able to keep the retina from sliding down. Therefore, this technology cannot be used for traumatic retinal detachment with a separation from the dentate line for 180 ° or more.

A known method of treating retinal detachment with gigantic breaks of 180 ° or more, complicated by proliferative vitreoretinopathy (PVR) - Patent RF №2321381. The essence of technology is as follows. After intravitreal smoothing of the retina using perfluororganic compounds (PFOS), the retina is fixed to the membranes of the eye. In this case, a conjugate of covalently bound chlorin e6 with human serum albumin in a molar ratio of 1: 2.5 is applied to the choroid site in the area of separation along its entire perimeter. Then, the retina is irradiated in the projection zone of the conjugate with continuous laser radiation with a power of 400 mW for 1-2 minutes by fields with a diameter of 2-2.5 mm with a wavelength corresponding to the maximum absorption of light by chlorine e6. A complete anatomical fit of the retina to the underlying tissues is achieved. This technology is quite complex, it is applicable for severe retinal detachments, and in the absence of PVRP it is unreasonable to use it.

Known methods of surgical treatment of complicated retinal detachment, in which the expanded retina against the background of tamponade of the vitreous cavity with gas (H. Mackenzie Freeman. Atlas of vitreoretinal Stuttgart.-New York, - 1990. - P206-209) or organofluorine compound (PFOS) (RF Patent No. 2077296), strengthened by a complex of interrupted sutures. These are quite traumatic technologies and are not gentle, delicate for fresh detachment of the retina.

The closest is a method of microinvasive (25G) surgical treatment of severe retinal detachments complicated by PVR requiring the use of circular retinotomy and retinectomy (VD Zakharov, KD Kurtskhalidze. Treatment of severe retinal detachments complicated by PVR requiring the use of circular retinotomy and retinectomy // Ophthalmosurgery. - 2009. - No. 2. - P. 13-19 - PROTOTYPE). The essence of technology is as follows. Surgery is performed through three transconjunctival punctures in the region of the flat part of the ciliary body with 25G caliber instruments at an angle of 30 ° relative to the sclera towards the limb; install tube ports for introducing an irrigation cannula, a fiber, and a vitreotome. Next, vitrectomy is performed with the posterior hyaloid membrane removed. Next, the anterior vitreous, the anterior hyaloid membrane, moorings, and epiretinal membranes were removed from the surface of the retina. Then, after endocoagulation of the vessels, circular retinotomy was performed along the diathermocoagulation line. PFOS was then administered to straighten the retina. Retinal endolasercoagulation was performed along the edge of the retinotomy. After additional administration of PFOS, PFOS was exchanged for silicone oil (SM). Next, the ports were removed without suturing. After 1.5-3 months, the silicone oil was replaced with saline.

If you apply this technology for traumatic retinal detachment with a margin from the dentate line, then it’s obvious that a number of actions will be superfluous: moorings, membranes are often absent — the detachment is fresh, and the introduction of PFOS in the entire vitreous cavity through micro-accesses, and then excretion through micro-accesses, is significantly increases the duration of the operation and the costs of PFOS. At the same time, 27G minimally invasive surgery has replaced the 25G accesses, therefore, if you use it, the duration of the operation will increase even more.

The objective of the invention is to develop a 27G microinvasive technology for the treatment of traumatic retinal detachment with a separation from the dentate line of 180 ° or more, which will stabilize the movable retina and prevent the peripheral part from rolling to the center, provide reliable retina fixation and will be sensitive in actions (considering that this is a fresh detachment), not long in time and more economical in consumables.

The technical result obtained by solving this problem is the rapid restoration of visual functions due to the full fit of the retina to the underlying tissues, minimizing surgical trauma, reducing postoperative complications, saving consumables.

The specified technical result can be obtained if, in the method of surgical treatment of retinal detachment with a detachment from the dentate line, including microinvasive endovitreal intervention with intravitreal retinal expansion using organo perfluorinated compound (PFOS) and subsequent fixation of the retina to the eye membranes, according to the invention, endovitreal intervention is carried out through caliber 27G, and PFOS is started after subtotal vitrectomy, covering them with the central zone of the retina to the level of the equator, yes Then, the peripheral part of the vitreous is removed, after which the vitreous cavity is filled with air, which displaces the liquid from under the retina into the separation zone, and at the interface of the PFOS media, the air is drained of the subretinal fluid, then, after retina is fully adhered, the retina is fixed by endolasercoagulation of the separation edge then silicone oil is introduced into the vitreous cavity, first replacing it with air, and then PFOS, and PFOS is removed from the vitreous cavity by active aspiration.

An additional sign relates to the situation when retinal detachment with a detachment from the dentate line is accompanied by an inversion of the edge of the retina, then the edge of the retina is straightened with the help of directional feed of PFOS between the sheets of the retina or with a tool at the stage of PFOS injection.

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

- endovitreal intervention is carried out through accesses of caliber 27G,

- PFOS start after subtotal vitrectomy, covering them with the central zone of the retina to the level of the equator,

- further remove the peripheral part of the vitreous body,

- after this, the vitreous cavity is replenished with air, which displaces the liquid from under the retina into the separation zone,

- at the boundary of the media PFOS - air drain the subretinal fluid,

- then, having received a full fit of the retina, the retina is fixed by endolaser coagulation of the margin of separation

- after that, silicone oil is introduced into the vitreous cavity, replacing it with air first, and then PFOS,

- PFOS is removed from the vitreous cavity by active aspiration.

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

The use of microinvasive technology 27G provides the operation at a qualitatively new level, the number of intraoperative and postoperative complications is significantly reduced, and the severity of the inflammatory reaction is reduced. Minimization of intraoperative trauma during surgical treatment and reduction of the postoperative period due to microinvasive technology are indicators of highly effective technology. And the filling of the vitreous cavity of PFOS is not in full, and partially allows, despite the 27G micro-accesses, to cope with the introduction and removal of PFOS promptly, reducing the time operation.

To keep the retina as close as possible after straightening, a combination of plugging substances - PFOS and air - was used. This combination has tamponing properties no worse than just PFOS tamponade (as in the prototype) or just air tamponade (as in the analogue). But at the same time significant advantages appear:

- PFOS is used in less quantity - saving the cost of the operation;

- if only PFOS were used for tamponade, then during its introduction it would be required to conduct additional monitoring of IOP of the eye in order to prevent intraoperative hypertension;

- the 27G micro-access is good, but through this access, all fluids, PFOS and oils are introduced and removed for a long time, and by using a combined tamponade, using also air, the time of these procedures is significantly reduced;

- PFOS was introduced less (only to the equator level) - which means it was withdrawn faster.

The method is as follows. Under local anesthesia in the upper-outer, upper-inner and lower-outer segments of the eyeball, departing from the limb of 3.5 mm, 27G ports are installed. An end illuminator and a vitreotome are inserted through the ports in the upper segment into the vitreous cavity. In the lower outer segment, irrigation is established.

First, subtotal vitrectomy is performed. The retina is freed from the posterior hyaloid membrane, epiretinal membranes (if present). PFOS is applied to the fundus. PFOS is administered to the equatorial level of the eye. Retinal detachment takes place at the dentate line, therefore, the level of PFOS should be below the detachment line, that is, below the dentate line, this will prevent PFOS from getting under the retina. The PFOS introduced into the fundus straightens the retina, correctly adapts it - these actions are important, since the retina is torn off the dentate line over a long distance (180 ° or more). If the separation in length is much less than 180 °, then there are no problems with retinal rolling, and the surgeon has the right to choose a different surgical approach. If there is an inversion - a bend of the edge of the retina, then it is straightened out at the stage of PFOS injection with the help of a directed feed of PFOS between the sheets of the retina or with a microsurgical instrument. After these actions, the vitreous at the periphery is removed. Further, instead of saline BSS (balanced saline solution), air is supplied to the irrigation port. The BSS located above PFOS is completely replaced by air. Incoming air fills the cavity above PFOS and at the same time displaces fluid from under the retina into the separation zone. And at the border of PFOS-air media, subretinal fluid is drained using a vitreotome or cannula. By removing fluid from under the retina, a full fit of the retina is obtained. Tamponade of the vitreous cavity is carried out by two PFOS media (on the fundus) and air (on top). Next, the expanded retina, which returned its anatomical position, is fixed by endolaser coagulation along the edge of the gap to the lining of the eye. At the end of the operation, silicone oil is introduced into the vitreous cavity, first replacing it with air and then PFOS, while PFOS is removed from the vitreous cavity by active aspiration (excretion of PFOS is accelerated). Silicone oil is in the eye, on average, 1-3 months (the time of formation of adhesions), then it is removed.

EXAMPLE 1. Patient K., 24 years old, diagnosis: Post-traumatic retinal detachment, PVR, grade B, right eye. Upon receipt of a complaint about the appearance of a “film” in front of the right eye. Visual acuity of the right eye is 0.01 eccentric, the left eye of 1.0. In the anamnesis, a fall from a height of about 2 meters occurred 10 days ago. Using indirect binocular ophthalmoscopy, retinal detachment was revealed with a separation from the dentate line from 2 to 9 hours.

The operation according to the invention is performed (duration 30 minutes). After 1 month at the control examination, the eye is calm, the retina is adjacent, the gap is blocked, silicone oil in the vitreous cavity. After 3 months, the silicone oil is removed. When examined after 8 months, the eye is calm, the retina is adhering, and the gap is blocked. Visual acuity of the right eye = 0.4.

EXAMPLE 2. Patient R., 47 years old, diagnosis: Condition after contusion: retinal detachment with separation from the dentate line, partial hemophthalmus, traumatic mydriasis of the right eye. Hypermetropia of the 1st degree of the left eye. Complaints about a sharp decrease in vision of the right eye after a concussion (punch). Visual acuity of the right eye is 0.005, the left is 0.5 sph + 1.0 = 0.95. Examination of the fundus using indirect binocular ophthalmoscopy revealed blood in the vitreous humor, retinal detachment with separation from the dentate line from 1 to 10 hours and inversion (bending) of the edge of the retina.

The operation according to the technology described in the invention. The bend of the edge of the retina was eliminated during the introduction of PFOS using PFOS itself (directional supply of PFOS between the retina sheets). Blood was removed during vitrectomy. The retina was expanded using PFOS, which was introduced into the fundus to the level of the equator of the eye (this is below the dentate line), and the second plugging substance was air, which was added to the vitreous cavity. At the end of the operation, both plugging substances were replaced with silicone oil. The operation went without complications. Silicone oil was removed from the vitreous cavity 4 months after surgery. During the observation period (10 months), the eye is calm, the retina is adjacent. Visual acuity of the right eye 0.25.

The inventive method in the Yekaterinburg center performed 12 operations that went without complications, promptly in time, the technology has proven reliable, relapse detachment was not observed. Patients with visual acuity are satisfied.

Claims (2)

1. A method of surgical treatment of retinal detachment with a detachment from the dentate line, including microinvasive endovitreal intervention with intravitreal expansion of the retina using perfluororganic compound (PFOS) and subsequent fixation of the retina to the membranes of the eye, characterized in that the endovitreal intervention is performed through 27G caliber accesses, and П start after subtotal vitrectomy, covering them with the central area of the retina to the level of the equator, then remove the peripheral part of the vitreous, after of this, the vitreous cavity is replenished with air, which displaces the liquid from under the retina into the separation zone, and at the interface between PFOS - air, the subretinal fluid is drained, then, after retina is fully adhered, the retina is fixed by endolasercoagulation of the separation edge, after which silicone is introduced into the vitreous cavity oil, replacing it with air first, and then PFOS, and PFOS is removed from the vitreous cavity by active aspiration. 2. The method according to p. 1, characterized in that if the retinal detachment is accompanied by an inversion of the edge of the retina, then the edge of the retina is straightened using a directed feed of PFOS between the sheets of the retina or with a tool at the stage of PFOS injection.