RU2644751C1 - Method of minimally invasive retinal detachment surgery by temporal ballooning - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely ophthalmosurgery. For minimally invasive surgery of retinal detachment by time ballooning, a tunnel in the subtenon space is formed in the area of the retinal rupture projection. Balloon is injected into the tunnel and inflated with saline until the sclera pressing bank is formed. Further, after the retina adheres, the patient is seated at the laser unit and the retinal laser coagulation is performed at the edge of the rupture. On day 7, after blocking the rupture edge, the balloon is smoothly deflated and taken out. In the absence of a complete adhesion of retina on the 1st and then on the 2nd day after the balloon is inserted, intravitreal injection of a 100 % concentration gas through the pars plana, in a volume of 0.3 ml, is performed on the 2nd day using an insulin syringe with a needle 29–31G. In case of retinal detachment, if rupture extends from 10 to 2 hours – SF6 gas is injected, if rupture extends from 8 to 10 hours or from 2 to 4 – C3F8 gas is injected, with the delimitation laser coagulation of the retina carried out the next day after the injection of gas. If increased intraocular pressure is detected on the day after the gas injection, then the pressure is reduced before performing the delimitation laser coagulation of the retina by promptly discharging saline out of the balloon in a volume of 0.1–0.3 ml.

EFFECT: method makes it possible to increase the effectiveness of extra-scleral ballooning by injecting gas into the vitreous cavity by achieving a complete adhesion of the retina to the underlying tissues, blocking of the rupture, rapid restoration of visual functions, microinvasivity of the technology as a whole.

3 cl, 2 ex, 1 tbl

Description

The invention relates to medicine, in particular ophthalmic surgery, and can be used in the treatment of fresh regmatogenic retinal detachment, that is, tear detachment, by extrascleral temporary ballooning of the sclera.

Scleral ballooning with fresh retinal detachment is achieved by temporary installation in the subtenon space, in the fracture projection zone, of a special catheter balloon, when pumped with saline, the sclera impression shaft appears, and as a result, the subretinal fluid is absorbed, the retina is adjacent. Then, retinal laser coagulation is performed. This technology is called minimally invasive surgery.

A professor from Germany, Ingrid Kreissig, devoted several books to minimally invasive retinal surgery, in one of which she describes extrascleral ballooning technology (Ingrid Kreissig. Minimal retinal detachment surgery // Practical Guide (translated from English). - M. - 2005. - volume No. 2. - S. 2-18 - PROTOTYPE). The main stages of this technology: the formation of a tunnel in the subtenon space in the zone of the projection of the retinal rupture, the introduction of a deflated balloon into the tunnel and inflation of the balloon using saline to create a scleral depression shaft. Then, on the first day after the operation, a laser setting uses a laser to isolate the retina along the edge of the gap using a Goldman three-mirror lens, which is installed on the eye. On the 7th day, after the formation of chorioretinal adhesions, the balloon is gently deflated and taken out.

Lack of technology. In practice, there are cases when it is found that after the installation of the balloon there is no complete fit of the retina on the first day, as well as on the second and third, i.e. an indentation shaft has been created, but its volume is insufficient, since retinal detachment with weakly positive fitting dynamics is maintained. To increase the volume of a balloon of more than 2.0 ml to increase the area of its action on the fundus is dangerous, due to the high risk of constriction of the vessels of the optic disc and, as a consequence, a decrease in visual acuity (max allowable volume of a swollen balloon is 2.0 ml, it is known from sources literature). Also, in the conditions when the patient has a balloon installed, it is impossible to talk about additional installation of extrascleral filling (sponge), since, based on the meaning of this operation, the sponge should be located strictly in the projection of the gap, and this place is already taken by the balloon. The transition to more radical methods of treatment, such as vitrectomy, and the introduction of a tamponous substance into the vitreous cavity, is theoretically possible, however, this eliminates all the positive effects of the ballooning operation: minimal invasiveness, maximum therapeutic effect, economic feasibility.

The objective of the invention is using minimally invasive surgery to increase the efficiency of extrascleral ballooning by introducing gas into the vitreous cavity.

The technical result obtained by solving this problem is the full fit of the retina to the underlying tissues, blocking the gap, the rapid restoration of visual functions, the microinvasiveness of the technology as a whole.

The specified technical result can be obtained if, in a method of minimally invasive surgery, retinal detachment by temporary ballooning, including the formation of a tunnel in the subtenon space in the area of the projection of the retinal rupture, insertion of the balloon into the tunnel and inflation of the balloon with saline solution until the sclera is pressed, then, after adjoining the retina, seat the patient behind the laser unit and carry out a laser restrictive retinal coagulation along the edge of the gap, and on day 7 after blocking the edge of the gap the balloon is gently deflated and brought out, according to the invention, in the absence of a full retina fit on the 1st and then on the 2nd day after the balloon is installed, on the 2nd day, intravitreal gas injection of 100% concentration through a pars plana is carried out, in a volume of 0 , 3 ml, using an insulin syringe with a 29-31G needle, moreover, when retinal detachment with a rupture of 10 to 2 hours is introduced, SF6 gas is injected, and when an retinal detachment with a rupture of 8 to 10 hours or from 2 to 4- x inject C3F8 gas, while the retinal laser coagulation is performed the next day by after the introduction of gas.

Special cases of execution and specifying signs:

- if, on the day after the injection of the gas, increased intraocular pressure is detected, before performing the restrictive laser coagulation of the retina, the pressure is reduced by promptly releasing saline from the balloon in a volume of 0.1-0.3 ml,

- instead of C3F8 gas, C2F6 gas can be used.

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

- in the absence of a full fit of the retina on the 1st and then on the 2nd day after the installation of the balloon, on the 2nd day intravitreal gas injection is carried out;

- gas of 100% concentration is injected through a pars plana, in a volume of 0.3 ml, using an insulin syringe with a 29-31G needle;

- moreover, when retinal detachment with a gap of 10 to 2 hours, SF6 gas is introduced;

- and during detachment with a gap length from 8 to 10 hours or from 2 to 4, C3F8 gas is introduced;

- restrictive laser coagulation of the retina is carried out the day after the introduction of gas.

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

When the surgeon, after installing the balloon in the subtenon space, observes an incomplete retinal fit: retinal detachment with weakly positive fit dynamics is maintained on both the 1st and 2nd days, then in this situation, on the 2nd day through the pars plana, 0 are introduced into the vitreous cavity , 3 ml of gas of 100% concentration. Gas is used at a 100% concentration, since it is about a gas of 100% concentration that the characteristics are known: an increase in volume, time to reach maximum volume, half-life.

The maximum volume of injected gas is 0.3 ml (our practice) - this volume is safe in terms of a sharp increase in IOP. After introduction, the gas increases in volume and occupies the entire cavity. The maximum tamponade of all structures occurs at the very beginning, full retina snugness in the area of the impression shaft is ensured, and this is the condition that is necessary to perform high-quality laser retinal coagulation around the gap. By the half-life of the gas, an adequate chirioretinal adhesion around the gap is already formed (the adhesion forms on average in 7-12 days). The therapeutic effect is achieved. Gas resolves over time. Therefore, for a situation of simple detachment (gap length from 10 to 2 hours - the upper zone), SF6 gas is used, with a half-life of 6-7 days. The gas always rises, and although in the lower zones it will no longer exist over time (it partially dissipated), it is not important, since the gap is located in the upper sector and the remaining gas, which is located at the top, is enough to keep the tamponade, and, as a result, a good adhesion was formed and the gap was closed. In case of complex detachment (lateral): C3F8 gas is introduced with a gap length from 8 to 10 hours or from 2 to 4, its time to reach the maximum volume and half-life is longer than that of SF8 gas. The characteristics of this gas or C2F6 gas, which can be used on a par with C3F8, will provide retinal tamponade prolonged. And again, the necessary conditions for laser coagulation will be created. It should be noted that during the detachment in the lower sector, this technology is not used, the necessary tamponade with the help of gas cannot be obtained.

The method is as follows.

In the operating room, under local anesthesia, extrascleral ballooning is performed on the eye with fresh detachment. A balloon catheter (manufactured according to TU 9398-001-99696001-2010, LLC Victor MedFarm) is inserted into the subtenon space through a conjunctiva and tenon membrane section 1-2 mm long and is located on the sclera at the location of the retinal rupture. Then the balloon catheter is filled with saline to 1.5-2.0 ml under visual control, observing the appearance of the impression shaft and the condition of the central retinal artery (introducing more than 2 ml of physiological saline into the balloon is unacceptable, since it can lead to obstruction of the central arteries of the retina).

On examination on the first day after surgery: the gap is on the sclera impression shaft, the amount of subretinal fluid decreased, but the retina did not fit completely. The patient is invited the next day for examination in dynamics. On the second day after ballooning, when examining the fundus of the positive dynamics in the fit of the retina is not observed again.

Next, carry out the following actions. 0.3 ml of SF6 gas is injected into the vitreous cavity through a pars plana in a 100% concentration using an insulin syringe with a 31G needle. This gas is introduced at the location of the gap from 10 to 2 hours, and at the location of the gap from 8 to 10 hours or from 2 to 4, C3F8 or C2F6 gas is introduced (they are equivalent). Determine intraocular pressure. If intraocular pressure is slightly inflated (21 mm Hg or more) - antihypertensive drops are prescribed. Appearance to the patient after the introduction of gas is prescribed the next day.

In 95% of cases, IOP is normal and the patient the next day after the introduction of gas behind the laser unit perform restrictive laser coagulation of the retina along the edge of the gap. 7 days after blocking the rupture edge, the balloon is deflated and taken out. The operation is completed.

In a situation when, after the introduction of gas, the IOP was increased, and remained elevated on antihypertensive drops and by the next day - more than 21 mm Hg. (a single 2 cases), then before performing a restrictive laser coagulation of the retina, they reduce the pressure by promptly releasing saline from a balloon in a volume of 0.1-0.3 ml. 7 days after this procedure, the balloon is deflated and taken out.

Example 1. Patient K., 52 years old, turned 12.01.2016 with complaints of deterioration in visual acuity of the right eye, loss of field of view in the lower sector.

On examination: The anterior segment is without features, on examination of the fundus: the optic disc is pale pink, the borders are clear, the retina is detached from 10 to 1:30 hours, with a gap of 12 hours. Visual acuity of the right eye = 0.45 n / a; IOP (Pi) = 18 mm Hg.

Visual acuity of the left eye = 1.0; IOP (Pi) = 19 mm Hg.

Diagnosis: Fresh subtotal retinal detachment of the right eye.

2 days after treatment, the operation was performed according to the proposed method by ballooning.

On examination on the first day after surgery: the gap is on the sclera impression shaft, the amount of subretinal fluid has decreased, and the retina does not fit completely. The best visual acuity with correction was 0.3; IOP (Pi) = 16 mm Hg. The patient is invited the next day for examination in dynamics.

On the second day after the ballooning operation, when examining the fundus of the eye, there were no positive dynamics in the fit of the retina.

It was decided to inject 0.3 ml of SF6 gas through a pars plana in 100% concentration using an insulin syringe with a 31G needle. When viewed an hour after the introduction of gas, the best visual acuity with correction was 0.05; IOP (Pi) = 17 mm Hg.

When viewed the day after the introduction of gas: the gap is blocked, located on the impression shaft, the retina is adjacent, a gas bubble is determined in the vitreous cavity. Objectively, the best visual acuity with correction was 0.05; IOP (Pi) = 18 mm Hg. For the laser installation on the same day, a restrictive laser coagulation of the retina along the edge of the gap was performed.

On the 7th day after the differential laser coagulation, the patient arrived at the clinic for re-examination and removal of the balloon. When examining the fundus - the retina is adjacent, the gap is blocked, located on the impression shaft, surrounded by pigmented coagulates, gas remains in the vitreous cavity. Objectively, the best visual acuity with correction was 0.3; IOP (Pi) = 17 mm Hg. The balloon was removed, the patient was released home.

At the control examination after 1 month - the retina is adjacent, the gap is blocked, surrounded by pigmented coagulates, there is no gas in the vitreous cavity. There are no active complaints from the patient. Objectively, the best visual acuity with correction was 0.95; IOP (Pi) = 15 mm Hg.

The patient was sent under the supervision of an ophthalmologist at the place of residence.

Example 2. Patient T., 41 years old, came on 02/18/2016 with complaints of deterioration in visual acuity of the left eye, “flash” in front of the left eye, which appeared 1 week ago.

On examination: the anterior segment is without features, on examination of the fundus: the optic nerve disc is pale pink, the borders are clear, the retina is detached from 2 to 4 hours, with a gap at 2:30 hours. The best visual acuity with correction was 0.2; IOP (Pi) = 17 mm Hg.

Visual acuity of the right eye 0.4 sph-4.0 = 1.0; IOP (Pi) = 19 mm Hg.

Diagnosis: Fresh retinal detachment of the left eye. Myopia of the second degree of the right eye.

It was decided to immediately carry out the ballooning operation as described above.

When viewed on the first day after surgery, the gap is in the projection of the sclera depression shaft, the retina did not fit completely. Objectively, the best visual acuity with correction was 0.25; IOP (Pi) = 18 mm Hg.

Given the absence of a full retinal fit, the surgeon decided to inject 0.3 ml of C3F8 gas through a pars plana in 100% concentration using an insulin syringe with a 29G needle. When viewed an hour after the introduction of gas, the best visual acuity with correction was 0.08; IOP (Pi) = 29 mm Hg. Given the increase in intraocular pressure, hypotensive drops (Combigan) were prescribed to reduce IOP. The patient is invited the next day for examination in dynamics.

When viewed the day after the introduction of gas: the gap is blocked, located on the impression shaft, the retina is adjacent, a gas bubble is determined in the vitreous cavity. Objectively, the best visual acuity with correction was 0.08; IOP (Pi) = 26 mm Hg. Due to the lack of compensation for intraocular pressure, the surgeon decided to remove 0.2 ml of physiological saline from the balloon. Two hours after this manipulation, IOP (Pi) = 15 mm Hg. After that, on the same day, a laser retinal laser coagulation along the edge of the gap was performed behind the laser unit.

The patient was discharged home.

When examined on the 7th day after the restrictive laser coagulation, the patient arrived at the clinic for re-examination and removal of the balloon. When examining the fundus - the retina is adjacent, the gap is blocked, located on the impression shaft, surrounded by weakly pigmented coagulates, gas in the vitreous cavity. Objectively, the best visual acuity with correction was 0.09; IOP (Pi) = 17 mm Hg. The balloon was removed, the patient was released home.

At the follow-up examination after 1 month - the retina is adjacent, the gap is blocked, surrounded by pigmented coagulates, the remains of gas in the vitreous cavity. There are no active complaints from the patient. Objectively, visual acuity 0.3 sph-3.5 = 0.8; IOP (Pi) = 16 mm Hg.

The patient was sent under the supervision of an ophthalmologist at the place of residence.

In this way, 8 operations were performed at the Yekaterinburg Center, all of them were successful. As a result, a full fit of the retina was obtained, the gap was blocked, and high visual acuity was obtained. In the distant period, the retina is adjacent, vision is stable. The technology refers to minimal surgery for retinal detachment.

Claims (3)

1. A method of minimally invasive surgery for retinal detachment by means of temporary ballooning, which includes forming a tunnel in the subtenon space in the area of the projection of the retinal rupture, inserting the balloon into the tunnel and inflating the balloon with saline solution until the sclera is impressed, and then, after the retina is attached, the patient is seated with a laser installation and carry out restrictive laser coagulation of the retina along the edge of the gap, and on the 7th day after blocking the edge of the gap, the balloon is gently deflated and brought out, characterized in that then, in the absence of a full fit of the retina on the 1st and then on the 2nd day after installation of the balloon, on the 2nd day intravitreal injection of gas of 100% concentration through a pars plana is carried out in a volume of 0.3 ml using an insulin syringe with a needle 29-31G, moreover, when retinal detachment with a rupture of 10 to 2 hours is introduced, SF6 gas is introduced, and when an retinal detachment with a rupture of 8 to 10 hours or from 2 to 4, C3F8 gas is introduced, Distinctive laser coagulation of the retina is carried out the day after the introduction of gas. 2. The method according to p. 1, characterized in that, if the intraocular pressure is detected the next day after injection of the gas, the retina is reduced before performing a restrictive laser coagulation, by quickly releasing saline from the balloon in a volume of 0.1-0.3 ml. 3. The method according to claim 1, characterized in that instead of C3F8 gas, C2F6 gas is possible.