RU2614105C1 - Method for macular edema treatment for patients with retinal vascular disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: laser retina coagulation is carried out in the form of subthreshold "focal lattice" in combination with medication, comprising administration of 0.3-0.5 ml of dalargin under the conjunctiva or parabulbarly for 5-10 days after laser coagulation. Additional administration of 0.3-0.5 ml of dalargin under the conjunctiva or parabulbarly is performed for 5-10 days prior to laser coagulation. Vessel Due F 600 LE is also introduced intramusculary for 10 days prior to laser coagulation and Vessel Due F 250 LE or Sulodexide 250 LE is administered orally 2 times a day for 30 days after laser coagulation.

EFFECT: method allows to increase the efficiency of macular edema treatment for patients with retinal vascular disease.

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Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the treatment of macular edema in patients with venous, arterial retinal occlusion, diabetic retinopathy (NDPR, PDDR).

A known method of treating macular edema of various origins (patent No. 2393824 C1, IPC A61F 9/00, A61M 1/34, A61K 39/44, A61P 27/02, published on 07/10/2010, bull. 19), including 6 sessions exchange plasmapheresis with an interval of 2 days. After its completion, an additional intravitreal administration of the antivasoproliferative drug Avastin at a dose of 1.25 mg or lucentis at a dose of 0.5 mg is additionally carried out.

The disadvantages of the method are:

1. increased intraocular pressure,

2. endophthalmitis,

3. the need for repeated administration of avastin, lucentis in patients with high diffuse cystic macular edema,

4. common complications - cerebral stroke, myocardial infarction, angina attacks,

5. The high cost of the drug.

Plasmophoresis is also not safe and is indicated only for certain patients, who also need to first thoroughly examine hemostasis for the presence of lupus anticoagulant (VA). It injures the formed elements of the blood, and there is also a danger of thrombosis. Danger of contracting HIV infection, hepatitis C.

A known method of treating diseases of the retina of the eye in diabetes mellitus (patent No. 2452443 C1, IPC A61F 9/007, publ. 10.06.2012, bull. 16). The drug is injected into the vitreous cavity of the eye. Laser retinal coagulation is performed. In this case, ranibizumab is used as a medicine, which is administered at a dose of 0.4 mg into the lentico-macular canal of the vitreous body. Laser coagulation is carried out with a laser radiation power of 100-200 mW, an exposure of 0.1-0.2 seconds, a spot diameter of 200-300 microns. The number of coagulates in this case is 250-300.

The disadvantages are:

1. increased intraocular pressure,

2. endophthalmitis,

3. the need for repeated administration of lucentis in patients with high diffuse cystic macular edema,

4. the risk of cerebral stroke, myocardial infarction, attacks of angina pectoris,

5. laser coagulation of the retina additionally damages pathologically altered retinal pigment epithelium in patients with macular edema,

6. The high cost of the drug.

This method is shown only in the treatment of flat focal macular edema, it does not restore the normal potential of the retinal vascular endothelium; therefore, complete regression of edema is not achieved, there is a local effect on the retinal pigment epithelium, while not all VEGF isoforms are suppressed. In patients with proliferative retinopathy in the vitreous body and in the moisture of the anterior chamber, low VEGFA and high PEDF. Therefore, the introduction of angioginesis inhibitors further inhibits VEGFA, which acts as a pro-inflammatory cytokine and is a procoagulant. Thus, the prerequisites for thrombosis and autoimmune inflammation are created, both locally and in the body as a whole.

There is a method of treating macular edema of various origins (Ignatova N.V. Local administration of glucocorticosteroids for macular edema of various origins: abstract of thesis, Candidate of Medical Sciences: 14.00.08. - M, 2008.), which consists in the subtenon administration of high doses of triamcinolone on a collagen hemostatic sponge in the postoperative period.

The disadvantages are:

1. increased intraocular pressure,

2. increased tendency to thrombosis,

3. corticosteroids - contra-hormonal hormones that increase blood glucose,

4. the need for repeated administration of triamcinolone,

5. complications - endophthalmitis.

The closest in technical essence to the claimed invention is a method of treating eye diseases (patent No. 2198641 C2, IPC A61F 9/008, A61K 38/33, publ. 02.20.2003). Eye exposure is a combination of laser therapy - laser stimulation or laser coagulation and dalargin administration. Laser stimulation is carried out against the background of injections of a dalargin solution under the conjunctiva, and with laser coagulation, the solution is administered under the conjunctiva 1-3 days after the end of laser therapy. With damage to the retina and optic disc, dalargin is administered parabulbarno. The introduction of dalargin is carried out in the form of a 0.1% solution by injection of 0.3-0.7 ml for 10-15 days.

The disadvantages are:

1. the absence of a direct effect on the vascular endothelium,

2. increased permeability of the microvasculature of the retina,

3. the possibility of treating only focal flat macular edema.

The technical result of the invention is to improve the treatment of macular edema in patients with vascular pathology of the retina.

The technical result is achieved by the fact that in the method of treating macular edema in patients with vascular pathology of the retina, subthreshold laser retinal coagulation is used in the form of a “focal lattice” of the macular region. LKS is combined with medication, including the administration of dalargin 0.3-0.5 ml under the conjunctiva or parabulbar for 5-10 days before and after laser coagulation, as well as the introduction of Wessel Duet F 600 LU intramuscularly for 10 days before laser coagulation and Wessel Douay F 250 LU or Sulodexide 250 LU orally 2 times a day for 30 days after laser coagulation.

The invention is illustrated by graphic materials, where in FIG. 1 shows the dynamics of retinal edema of the macula, depending on the complex treatment (significant difference with the norm of p≤0.05); in FIG. 2, 3 - fundus and optical coherence tomography (OCT) of a patient with PPDD with diffuse flat cystic diabetic macular edema (DME), before treatment and laser coagulation (LC); in FIG. 4, 5 - the fundus and OCT of the macula of the patient with PPD with resolving DMO after complex treatment; FIG. 6, 7 - fundus and fluorescence angiography of the retina (FAG) of the patient at the beginning of treatment after LC; FIG. 8, 9 - fundus and OCT of a patient with partial thrombosis of the superior temporal branch of the central retinal vein (CVS), with flat focal cystic macular edema, after treatment after 1.5 months; FIG. 10, 11 - fundus and OCT of a patient with partial thrombosis of the upper temporal branch of CVC, with focal flat cystic macular edema, after treatment and LC after 3 months; FIG. 12, 13 - fundus and OCT of a patient with resolved partial thrombosis of the upper temporal branch of CVC and resolved focal macular edema, after treatment and LC after 6 months; FIG. 14, 15 — fundus and phage of a patient with retinal arterial occlusion of the lower temporal branch of the central retinal artery (CAS) before treatment; FIG. 16, 17 — fundus and OCT of a patient with partial optic atrophy, central macular degeneration after complex treatment.

A method of treating macular edema in patients with retinal vascular pathology is as follows: patients with macular edema in the presence of diabetic retinopathy, venous and arterial retinal occlusion before and after laser coagulation (LC) are given complex conservative treatment. The treatment regimen: the administration of dalargin 0.3-0.5 ml under the conjunctiva or parabulbar for 5-10 days before and after laser coagulation. With a decrease in the lower limit of dalargin, the effect is weak, and when the upper limit is exceeded, dalargin may affect other organs, which is undesirable.

Also, Wessel Douay F 600 LU is administered intramuscularly before LK for 10 days, while after LK they switch to Wessel Douay F 250 LU or Sulodexide 250 LU orally 2 times a day for 30 days. Wessel Douai F and Sulodexide are based on the active substance - sulodexide - and are essentially the same drug.

Laser coagulation of the retina in the form of a "focal lattice" of the macular region was performed on a laser installation of the company "NiDEK" (Japan) Nd: YAG λ = 532 nm. Laser coagulation of the retina was performed with a Goldman lens, on an outpatient basis, after drug-induced mydriasis, under local anesthesia. Coagulation was carried out using a wavelength of 532 nm.

Subthreshold laser retinal coagulation was carried out with preliminary testing of the intensity of laser burns nasal than the optic nerve disk (optic nerve disc) with 2-4 laser coagulates with an exposure of 0.2 sec and a spot diameter of 200 μm with a power of 120-140 mW. With each subsequent coagulate, the power decreased by 10-20 mW until a barely visible coagulate was obtained. Using this method, the laser exposure power was determined, which is the main one for further subthreshold laser coagulation in the form of a "focal grating".

The next stage of the subthreshold laser coagulation of the "focal grating" consisted of applying 2-3 rows of laser coagulates that are located paraferally with the capture of the edge of the avascular zone, with a spot diameter of 50-100 μm and an average power of 60-120 mW. Temporary exposure was reduced from 0.2 sec to 0.1 sec.

While maintaining residual macular edema, the LK was performed repeatedly in the same mode.

Subthreshold laser coagulation of the retina in the form of a "focal grating" allows you to choose the individual value of the laser power in each case. This plays an important role when performing laser coagulation of the retina of patients with macular edema, whose energy parameters in general and power in particular are directly dependent on the degree of retinal pigmentation, its thickness and the degree of decrease in the transparency of optical media.

The following are examples of the use of complex treatment and laser coagulation of macular edema in patients with vascular pathology of the retina.

Clinical example 1. Treatment of diffuse planar macular edema in a patient with preproliferative diabetic retinopathy.

Using optical coherence tomography of the retina (OCT) revealed a flat diffuse retinal edema up to 300 microns thick, solid exudates in the retina. To improve microcirculation and retinal neuroepithelial function, dalargin was introduced in the form of a 0.1% solution of 0.5 ml under conjunctiva No. 5 to the LKS; and Wessel Douay F 600 LE intramuscularly No. 5 to normalize the potential of vascular endothelium. After that, laser retinal coagulation (LKS) was performed — in the form of a subthreshold “focal grating” on a NIDEK laser system (Japan) Nd: YAG, λ = 532 nm according to the proposed method with parameters: coagulate diameter 100 μm, exposure 0.1 -0.15 sec, the number of coagulates - 200. After LKS, dalargin was injected under the conjunctiva, the amount of solution per injection was 0.5 ml. The course of treatment lasted 10 days to obtain a pronounced positive effect. Sulodexide in capsules of 250 LU of the drug orally 2 times a day for 30 days, also after LKS. As a result of the comprehensive conservative treatment and LKS, the visual function improved by 0.3, the thickness of the retina decreased by 75 μm (Fig. 1).

A high and reliable correlation of endothelial dysfunction with the thickness of the retina in the macula after complex conservative treatment of DME in combination with LC (0.89-0.84) indicates the correct treatment tactics (Fig. 2-5).

Clinical example 2. The treatment of focal flat cystic macular edema in a patient with partial thrombosis of the upper temporal branch of the CVC (Fig. 6-13).

Using optical coherence tomography of the retina (OCT), a flat focal edema with small cystic cavities of retinal edema up to 224-428 microns thick is revealed. To improve microcirculation and the function of the retinal neuroepithelium, dalargin was introduced in the form of a 0.1% solution of 0.5 ml parabulbar No. 5 to LKS; as well as Wessel Douay F 600 LE, intramuscularly No. 10 to normalize the potential of vascular endothelium. After that, laser retinal coagulation (LCS) is performed - in the form of a subthreshold “focal grating” on a NIDEK laser machine (Japan) Nd: YAG, λ = 532 nm according to the proposed method with parameters: coagulate diameter 100 μm, exposure 0.1 -0.15 sec, the number of coagulates is 400. After LKS, dalargin injections were continued parabulbarly, the amount of solution per injection can be 0.5 ml. The course of treatment lasted 10 days to obtain a pronounced positive effect. Sulodexide in capsules of 250 LU of the drug orally 2 times a day for 30 days, also after LKS. As a result of the comprehensive conservative treatment and LKS, the visual function improved by 0.5, the thickness of the retina decreased by 62 microns.

Clinical example 3 (Fig. 14-17). Treatment of acute obstruction of the lower temporal branch of the CAC.

Using optical coherence tomography of the retina (OCT) revealed a flat diffuse retinal edema with a thickness of up to 280 microns in the retina. To improve microcirculation and the function of the retinal neuroepithelium, dalargin was introduced 0.5 ml parabulbarno No. 5 to LKS; as well as Wessel Douay F600 LE, intramuscularly No. 10 to normalize the potential of vascular endothelium. After that, laser retinal coagulation (LKS) was performed — in the form of a subthreshold “focal grating” on a NIDEK laser system (Japan) Nd: YAG, λ = 532 nm according to the proposed method with parameters: coagulate diameter 100 μm, exposure 0.1 -0.15 sec, the number of coagulates - 200. After LKS, dalargin injections were continued parabulbarly, the amount of solution per injection was 0.5 ml No. 5. Sulodexide in capsules of 250 LU orally 2 times a day - 30 days, also after LKS. As a result of the comprehensive conservative treatment and LKS, the visual function improved by 0.2, and the thickness of the retina decreased by 100 μm. After 3 months after acute arterial retinal occlusion, a second course of dalargin is required according to the above scheme.

Claims (1)

A method for the treatment of macular edema in patients with vascular pathology of the retina, including laser coagulation of the retina in the form of a subthreshold "focal lattice" in combination with medication consisting in the administration of dalargin 0.3-0.5 ml under conjunctiva or parabulbar for 5-10 days after laser coagulation, characterized in that they additionally administer dalargin 0.3-0.5 ml under the conjunctiva or parabulbar for 5-10 days before laser coagulation, and also inject Wessel Douay F 600 LU intramuscularly for 10 days by laser coagulation and Wessel Douay F 250 LU or Sulodexide 250 LU orally 2 times a day for 30 days after laser coagulation.

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