RU2704705C1 - METHOD OF TREATING CENTRAL VENOUS BRANCH VEIN THROMBOSIS COMPLICATED BY MACULAR EDEMA, WITH INDIVIDUAL SELECTION OF PARAMETERS OF MICROIMPULSE MODE ON NAVIGATION LASER INSTALLATION NAVILAS 577s - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology. For treatment of central venous branch (CVB) thrombosis complicated by macular edema laser retinal coagulation is performed. Preliminary optical coherence tomography (OCT), including angio-mode, and fluorescent angiography (FAG) for determining the region of edema, followed by a color photograph of an eye ground on a navigation laser unit (NLU) Navilas 577s using software to superimpose and compare digital images of OCT and/or FAG with a color photograph of the eye ground. If the edema is localized and spread from the region of vascular arcades to the foveal avascular zone (FAZ), laser coagulation is performed, for this purpose, patterns are selected in software of NLU Navilas 577s and placed on a matched eyeball with OCT and/or FAG data in staggered order at distance of 2–3 diameters from each other, completely covering the edema zone – in the presence of an edema in the area of vascular arcades with pre-macular zone distribution, the following parameters are selected: spot diameter – 100, 200 mcm, exposition – 0.05–0.1 s, power – 80–300 mW. In the presence of edema in the macular area, excluding the avascular region, the following parameters are selected: spot diameter – 50, 100 mcm, exposition – 0.01–0.05 s, power – 50–150 mWt. In the presence of the edema in the FAZ, the treatment is carried out in a selective microimpulsive mode, a pattern of several applicants is selected closely to each other and placed on a matched eyeball photo with OCT and/or FAG data, completely covering the edema area. To determine individual energy parameters required for treatment, micro-pulse mode parameters are calculated, which are calculated by Navilas 577s computer simulation at NLU: microimpulse duration – 50–150 mcs, pulse interval – 2,000 mcs, packet duration – 10–30 ms, number of pulses in packet – 5–15, spot diameter – 100 mcm, power – 0.4–1.9 Wt, length waves – 577 nm, then each patient is tested: three applicants are applied on an intact retina in an upper or lower vascular arcade: with transparent optical media – microimpulse duration – 50 mcs, duration of micropulse packet – 10 ms, power – from 0.4 to 1.9 Wt, with step of 0.1 Wt. In the presence of low-intensity opacity of optical media – duration of the microimpulse – from 50 to 150 mcs, with step of 10 mcs, duration of the packet of microimpulsions – 10 ms, power – 1.9 W; while reducing transparency of optical media – duration of the microimpulse – from 50 to 150 mcs, with step of 20 mcs with duration of the packet of microimpulsions of 20 ms, power – 1.9 W. After testing, all patients are examined short-wave autofluorescence and selected applicants applied with minimum energy parameters, in which visualized injuries of retinal retinal pigment epithelium on autofluorescence, they are placed into pre-selected patterns and treated.

EFFECT: method provides resorption of edema and hemorrhages, reduced thickness of retina, disappearance of cysts, increased visual acuity and light sensitivity, as well as reduced duration or complete elimination of long-term use of drug preparations and multiple intraocular injections of angiogenesis inhibitors.

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Description

The invention relates to the field of medicine, namely to ophthalmology, and can be used to treat thrombosis of the central retinal vein (CVS) branch complicated by macular edema.

According to the Central Vein Occlusion Study Group (Retinal Vein Occlusion (RVO) Guidelines, Eye (2015), 1-6), from 60 to 100% of patients with temporal thrombosis of the temporal branches of CVC have macular edema, and in 2/3 of them it persists for years and becomes chronic, being the main reason for the decrease in visual acuity. The prolonged existence of edema leads to the development of dystrophic changes, which are accompanied by degenerative changes in the layers of the retina, a decrease in the number of photoreceptors, and reactive changes in the retinal pigment epithelium. The severity of changes in the macula depends on the localization of occlusion, the caliber of the affected vessel, and the condition of the perifovolar capillaries. The course of edema is different. It can be completely resorbed, however, it often takes a chronic course and is complicated by the formation of cystic cavities, epiretinal fibrosis, and often lamellar rupture with a sharp decrease in central visual functions. Drug therapy with corticosteroids, non-steroidal anti-inflammatory drugs, angiogenesis inhibitors does not always lead to a sufficient clinical effect, since it does not affect the pathological process. With prolonged persistence of edema, irreversible changes in the structure of the chorioretinal complex occur, leading to a steady decrease in visual functions, so treatment should be carried out as soon as possible.

Laser retinal coagulation is an effective way to treat CVT thrombosis complicated by macular edema, in which thermal damage to the neuroepithelium inevitably occurs, which can lead to chorioretinal atrophy and livestock in the visual field, which is unacceptable for exposure to the foveal avascular zone (PHAS). However, if treatment is not performed in this area, the effect of treatment may not be complete.

The closest analogue of the invention is a method for the treatment of thrombosis of the central retinal vein and its branches (RF patent No. 2603318), including laser coagulation of the retina in the area of edema.

This method has several disadvantages.

In this method, treatment is not carried out in the phase, therefore, when it is damaged, there is no complete effect on the pathological process. It should be noted that laser treatment is carried out without targeted, topographically oriented exposure, which can lead to incomplete resorption of edema and low visual functions.

The objective of the invention is to provide an effective and safe method for the combined laser treatment of thrombosis of the CVC branch, complicated by macular edema, with individual selection of parameters of the micropulse mode on the Navilas 577s laser unit.

The technical result of the proposed method is the resorption of hemorrhages and edema, a decrease in retinal thickness, disappearance of cysts, increased visual acuity and photosensitivity, as well as a decrease in the duration or complete exclusion of prolonged use of drugs and multiple intraocular injections of angiogenesis inhibitors.

The technical result is achieved by the fact that in the method for the treatment of CVC thrombosis complicated by macular edema, including laser coagulation of the retina, according to the invention, optical coherence tomography (OCT) is preliminarily performed, including angio mode, and fluorescence angiography (FAG) to determine the area of edema, then color photograph of the fundus on the Navilas 577s navigation laser system (NLU), using software, overlay and match digital OCT and / or phage images with color photographs of the eyes bottom; when localizing edema with spreading from the arcade region to the PHAS, laser coagulation is performed, for which patterns are selected in the Navilas 577s NLU software and placed on a matching photograph of the fundus with OCT and / or FAG data in a checkerboard pattern at a distance of 2-3 diameters from the other, completely covering the edema zone - in the presence of edema in the vascular arcade region with propagation to the macular zone, the following parameters are selected: laser spot diameter - 100, 200 μm, exposure - 0.05-0.1 s, power - 80-300 mW ; in the presence of edema in the macular zone, excluding the foveal avascular region, the following parameters are chosen: spot diameter - 50, 100 μm, exposure - 0.01-0.05 s, power - 50-150 mW; with the involvement of FAS, the treatment is carried out in a selective micropulse mode, a pattern of several applicates is chosen, close to each other, and placed on a comparable photograph of the fundus with OCT and / or FAG data, completely covering the edema region; To determine the individual energy parameters required for treatment, the parameters of the micropulse mode calculated by computer simulation on the Navilas 577s NLU are tested: the micropulse duration is 50-150 μs, the interval between pulses is 2000 μs, the packet duration is 10-30 ms, the number of pulses in the bag - 5-15, spot diameter - 100 μm, power - 0.4-1.9 W, wavelength - 577 nm, then each patient is tested: three applicates are applied to the intact retina in the region of the upper or lower vascular arcade : When transparent optical media - duration micropulses - 50 microseconds, the duration of micropulses packet - 10 ms, power - from 0.4 to 1.9 watts with 0.1 watts step; in the presence of low-intensity opacities of optical media, the duration of the micropulse is from 50 to 150 μs, in increments of 10 μs, the duration of the packet of micropulses is 10 ms, and the power is 1.9 W; with a decrease in the transparency of optical media, the duration of the micropulse is from 50 to 150 μs, in increments of 20 μs with the duration of the packet of micropulses - 20 ms, power - 1.9 W; after testing, all patients undergo a study of short-wavelength autofluorescence and select applicates applied with the minimum energy parameters, in which RPE damage to autofluorescence is visualized, install them in pre-selected patterns and carry out treatment.

With this method, the maximum effect on the RPE of the retina and the minimum damage to adjacent structures occur in the phase of the PHA, which is achieved using the micropulse mode. Another important component of treatment is the impact on the area of the pathological process. Using Navilas 577s NLU, it is possible to conduct topographically oriented treatment taking into account the data of modern diagnostic research methods. Precision of the effect is provided by preliminary planning of the operation, after applying the phage and / or OCT images to the fundus photograph of the patient and comparing the data of digital images. This method allows treatment to be carried out quickly and safely, to completely eliminate the subjective factor and the deviation of the laser beam from a predetermined, pre-planned target.

Using highly informative modern diagnostic methods, topographic localization and prevalence of edema are determined. The results of OCT and / or FAG are superimposed on a color fundus photograph, performed on NIL Navilas 577s with a full comparison of anatomical landmarks. Based on the data obtained, the localization of edema relative to the color photograph of the fundus is determined and a treatment plan is made. Due to this, it is possible to clearly, precisely, with minimal energy parameters affect the area of the pathological process without affecting the surrounding tissue.

Carrying out computer simulation allows you to determine the range of the selective and effective micropulse mode implemented on the Navilas 577s NLU with the most selective effect on the RPE without heating the adjacent structures. Using testing on images of short-wavelength autofluorescence, foci of laser exposure detected with minimal energy parameters are detected, leading to visible damage to the chorioretinal complex, which are subsequently used for treatment.

Thanks to calculations and testing, it is possible to conduct treatment and selectively act on RPE with minimum energy parameters sufficient to achieve a clinical effect for each patient.

The method is as follows.

For a personalized, targeted, topographically oriented laser treatment of macular edema caused by thrombosis of the CVC branch, with an individual selection of the parameters of the micropulse mode on the Navilas 577s laser unit, first of all, it is necessary to clearly determine the topographic location of the edema zone for further laser exposure. To do this, first conduct OCT, including angio mode, and phage, then perform a color photo of the fundus on the NIL Navilas 577s, using software, overlay and compare digital images of the OCT and / or phage with a color photograph of the fundus. Based on the data obtained, the localization and prevalence of edema in a color photograph of the fundus is determined and a treatment plan is made. When edema is localized from the region of the vascular arcades to the PHAs, laser coagulation is performed, for this, patterns are selected in the Navilas 577s NLU software and placed on a matching photograph of the fundus with OCT and / or phage data in a checkerboard pattern at a distance of 2-3 diameters from each other completely covering the area of edema. In the presence of edema in the vascular arcade region, with propagation to the macular zone, the following parameters are chosen: spot diameter - 100, 200 μm, exposure - 0.05-0.1 s, power - 80-300 mW. In the treatment of edema in the macular zone, excluding the avascular region, the following parameters are used: spot diameter - 50, 100 μm, exposure - 0.01-0.05 s, power - 50-150 mW. If there is edema in the PHAS, the treatment is carried out in a selective micropulse mode, a pattern of several applicates is chosen close to each other, and they are placed on a matching fundus photograph with OCT and / or PHAG data, completely covering the edema region. In addition, two security zones are installed in the areas of the fundus, which should not be exposed to laser radiation. One security zone is installed on the optic nerve head, and the other is in the PHAS area. When the edema is localized in the PHAS, the safety zone is set nearby in an arbitrary place, outside the edema zone. The setting of two security zones is necessary for the operation of the auto tracking system. To determine the individual energy parameters necessary for treatment, the parameters of the micropulse mode calculated by computer simulation on the Navilas 577s NLU are tested: the micropulse duration is 50-150 μs, the interval between pulses is 2000 μs, the packet duration is 10-30 ms, the number of pulses in the packet - 5-15, spot diameter - 100 microns, power -0.4-1.9 W, wavelength - 577 nm. Next, each patient is tested: three applicates are applied to the intact retina in the region of the upper or lower vascular arcade: with transparent optical media: the duration of the micropulse is 50 μs, the duration of the packet of micropulses is 10 ms, and the power is from 0.4 to 1.9 W , in increments of 0.1 W; in the presence of low-intensity opacities of optical media, the duration of the micropulse is from 50 to 150 μs, in increments of 10 μs, the duration of the packet of micropulses is 10 ms, and the power is 1.9 W; with a decrease in the transparency of optical media, the duration of the micropulse is from 50 to 150 μs, in increments of 20 μs, with the duration of the packet of micropulses - 20 ms, power - 1.9 W; after testing, all patients undergo a study of short-wavelength autofluorescence and select applicates applied with minimal energy parameters, in which RPE damage on autofluorescence is visualized.

Before treatment, individually selected energy parameters are set in the patterns on Navilas 577s NLU, they include a laser activation mode with an auto tracking system, and pressing the pedal applies laser applicates according to a given plan. They cover the entire area of edema detected according to OCT and phage by applying staggered laser coagulates, excluding the phase. In FAZ, laser applicates with individually selected parameters in the micropulse mode are applied close to each other. Laser treatment went quickly, comfortably, safely and without installing a contact lens.

The invention is illustrated by the following clinical examples.

Example 1. A 53-year-old patient complained of a gradual decrease in visual acuity of the left eye over the past 3 months, was treated on an outpatient basis with a slight positive effect. 2 years ago he underwent cataract phacoemulsification with implantation of an intraocular lens. As a result of the examination, the diagnosis was made: OS - Thrombosis of the upper temporal branch of CVC, diffuse macular edema, artifact. Visual acuity with correction was 0.6. When examining the fundus, moderate expansion and tortuosity of the upper temporal branch of the CVC, multiple intraretinal hemorrhages, and edema with the capture of PHAS were noted. On OCT, cystic edema was detected, capturing the upper part of the macular and phase, with a maximum thickness of the retina in the edema zone of up to 358 μm. According to microperimetry, a decrease in photosensitivity was noted, on average, to 24.1 dB. When conducting phage, an increase in venous perfusion time, pronounced areas of hyperfluorescence due to extravasal dye output, revealed areas of hypofluorescence. The patient was treated according to the method described above. Laser coagulation was performed in the area of the affected branch of the CVC and edema that spreads from the vascular arcades to the PHAS. Laser coagulates were staggered at a distance of 2 diameters from each other. The following parameters were used in the vascular arcade and to the macular zone: spot diameter - 100 μm, exposure - 0.05 s, power - 140 mW. When treating in the macular zone, excluding the PHAS, the following parameters were used: spot diameter - 100 μm, exposure - 0.05 s, power - 100 mW. Optical media were transparent in the patient; therefore, the micropulse mode was tested in the lower vascular arcade in the power range from 0.4 to 1.9 W. As a result, according to autofluorescence data, all applicates applied during testing with a power of 1.4 W or more were visualized. Laser treatment was carried out in a selective and effective range of energy parameters of the micropulse mode at the Navilas 577s NLU according to the method described above with a selected power of 1.4 watts. Applied 27 laser applications in micropulse mode throughout the zone of edema in the phase. After 3 months, visual acuity in the left eye increased to 0.8. According to OCT, the thickness of the retina decreased, single cysts remained in the macula. Photosensitivity increased to 26.3 dB. When ophthalmoscopy in the phase of the phase of chorioretinal atrophy after laser treatment was not determined. After 6 months, visual acuity was 1.0. According to OCT, the restoration of the architectonics of the retina is noted. When conducting computer microperimetry, the photosensitivity increased to 27.9 dB, scotomas and areas with reduced photosensitivity were absent. Thus, the patient did not need to use various medications for a long time, perform intraocular injections of angiogenesis inhibitors, and the risk of the formation of epiretinal fibrosis and refractory macular edema, which often lead to an irreversible decrease in visual functions, is reduced.

Example 2. A 75-year-old patient complained of decreased visual acuity of the left eye. These complaints for 2 months, was treated on an outpatient basis at the place of residence, without effect. As a result of the examination, the diagnosis was made: OS - thrombosis of the lower temporal branch of CVC, diffuse macular edema, initial age-related cataract. Visual acuity with correction was 0.5. When examining the fundus in the affected sector, retinal edema, there was a significant expansion and tortuosity of the lower temporal branch of the CVC, multiple intraretinal hemorrhages. On OCT, cystic macular edema was detected, capturing the lower part of the macular zone and the entire avascular zone, with a maximum retinal thickness of up to 410 μm. According to microperimetry, a decrease in photosensitivity was noted, on average, to 20.2 dB. When conducting phage, an increase in the time of venous perfusion, pronounced areas of hyperfluorescence due to extravasal dye output, revealed areas of hypofluorescence. The patient was treated according to the method described above. Laser coagulation was carried out in the area of the affected branch to the avascular zone in a checkerboard pattern at a distance of 3 diameters from each other. In the laser treatment of edema in the vascular arcade region, with propagation to the macular zone, the following parameters were used: spot diameter - 200 μm, exposure - 0.1 s, power - 190 mW. When treating in the macular zone, excluding the avascular region, the following parameters were used: spot diameter - 100 μm, exposure - 0.05 s, power - 130 mW. Laser treatment in the PHAS was performed in micropulse mode after preliminary testing. Since the patient had low-intensity opacification of optical media, the micropulse mode was tested using the upper vascular arcade with a micropulse duration of 50 to 150 μs, a micropulse packet duration of 10 ms, and a power of 1.9 W. According to the autofluorescence data, the applicates applied during testing with a micropulse duration of 90 μs or more were visualized. Laser treatment was carried out with a micropulse duration of 90 μs on Navilas 577s NLU according to the method described above. 32 laser applications were applied in micropulse mode throughout the edema zone in the foveal zone. After 3 months, visual acuity in the left eye increased to 0.6. According to OCT, the thickness of the retina decreased, single cystic cavities remained in the macula. Photosensitivity increased to 23.5 dB. During ophthalmoscopy in the phase-dependent phase, foci of chorioretinal atrophy were not observed. After 6 months, visual acuity was 0.8. According to OCT, a restoration of the architectonics of the retina is noted. According to computer microperimetry, photosensitivity increased to 25.1 dB, scotomas and areas with reduced photosensitivity were absent. With ophthalmoscopy, a significant decrease in edema and hemorrhages was noted. Thus, the patient did not need to use various medications for a long time, administer intraocular injections of angiogenesis inhibitors, and the risk of epiretinal fibrosis and refractory macular edema, which often lead to an irreversible decrease in visual functions, was reduced.

Example 3. A 67-year-old patient complained of a decrease in visual acuity of the right eye, for 3 months, was treated on an outpatient basis with a slight positive effect. As a result of the examination, the diagnosis was made: OD - Thrombosis of the upper temporal branch of the CVC, diffuse macular edema, complicated cataract. Visual acuity with correction was 0.3. When examining the fundus in the affected sector, retinal edema, marked expansion and tortuosity of the upper temporal branch of CVC, multiple intraretinal hemorrhages with the capture of the entire macular zone were noted. On OCT, cystic macular edema was determined with a maximum retinal thickness in the edema zone of up to 610 μm. According to microperimetry, a decrease in photosensitivity was detected, on average, to 19.6 dB. During phage, an increase in venous perfusion time was revealed, extensive areas of hyperfluorescence due to extravasal dye output, and there are also areas of hypofluorescence. The patient was treated according to the proposed method. Laser coagulation was carried out in a checkerboard pattern at a distance of 2 diameters from each other in the area of the affected branch and macular zone, excluding the phase. When treating edema in the vascular arcade region, with propagation to the macular zone, the following parameters were used: spot diameter - 200 μm, exposure -0.1 s, power -260 mW. When treating in the macular zone, excluding the PHAS, the following parameters were used: spot diameter -100 μm, exposure -0.05 s, power -150 mW. Laser treatment in the PHAS was performed in micropulse mode after preliminary testing. Since the patient showed a decrease in the transparency of optical media, the micropulse mode was tested on the intact retina in the region of the lower vascular arcade with a micropulse duration of 50-150 μs, a micropulse packet duration of 20 ms, and a power of 1.9 W. According to the autofluorescence data, the applicates applied during testing with a micro pulse duration of 70 μs or more were visualized. The treatment was carried out with a micro pulse duration of 70 μs according to the method described above. 36 laser applications were applied throughout the avascular zone. After 3 months, visual acuity in the left eye increased to 0.6. According to OCT, the thickness of the retina decreased. Photosensitivity increased to 20.7 dB. During ophthalmoscopy in the PHAS foci of chorioretinal atrophy after laser treatment were not observed. After 6 months, visual acuity was 0.7. According to OCT, a restoration of the architectonics of the retina is noted. According to computer microperimetry, the photosensitivity increased to 21.9 dB. With ophthalmoscopy, a significant decrease in the area and severity of edema and hemorrhages was noted. Thus, the patient did not need to use various medications for a long time, administer intraocular injections of angiogenesis inhibitors, and the risk of formation of epiretinal fibrosis and refractory macular edema, which often lead to an irreversible decrease in visual functions, was reduced.

Claims (1)

A method for the treatment of thrombosis of a branch of the central retinal vein (CVS) complicated by macular edema, including laser coagulation of the retina, characterized in that optical coherence tomography (OCT) is preliminarily performed, including angio mode, and fluorescence angiography (FAG) to determine the region of the edema, then a color photograph of the fundus on the Navilas 577s navigation laser system (NLU), using software, superimpose and compare digital images of OCT and / or phage with a color photograph of the fundus; when edema is localized with spreading from the vascular arcade region to the foveal avascular zone (FAS), laser coagulation is performed, for which patterns are selected in the Navilas 577s NLU software and placed on a matching fundus photograph with OCT and / or phage staggered data at a distance 2-3 diameters from each other, completely covering the zone of edema - in the presence of edema in the vascular arcade region with propagation to the macular zone, the following parameters are chosen: spot diameter - 100, 200 μm, exposure - 0.05-0.1 s, power b - 80-300 mW; in the presence of edema in the macular zone, excluding the avascular region, the following parameters are selected: spot diameter - 50, 100 μm, exposure - 0.01-0.05 s, power - 50-150 mW; in the presence of edema in the PHAS, the treatment is carried out in a selective micropulse mode, a pattern is selected from several applicates, close to each other, and placed on a comparable photograph of the fundus with OCT and / or PHAG data, completely covering the edema region; To determine the individual energy parameters required for treatment, the parameters of the micropulse mode calculated by computer simulation on the Navilas 577s NLU are tested: the micropulse duration is 50-150 μs, the interval between pulses is 2000 μs, the packet duration is 10-30 ms, the number of pulses in the bag - 5-15, spot diameter - 100 μm, power - 0.4-1.9 W, wavelength - 577 nm, then each patient is tested: three applicates are applied to the intact retina in the region of the upper or lower vascular arcade : When transparent optical media - duration micropulses - 50 microseconds, the duration of micropulses packet - 10 ms, power - from 0.4 to 1.9 watts with 0.1 watts step; in the presence of low-intensity opacities of optical media, the duration of the micropulse is from 50 to 150 μs, in increments of 10 μs, the duration of the packet of micropulses is 10 ms, and the power is 1.9 W; with a decrease in the transparency of optical media - the duration of the micropulse is from 50 to 150 μs, in increments of 20 μs with a duration of the packet of micropulses of 20 ms, power - 1.9 W; after testing, all patients undergo a study of short-wavelength autofluorescence and select applicates applied with the minimum energy parameters, in which damage to the retinal pigment epithelium of the retina for autofluorescence is visualized, set them in pre-selected patterns and carry out treatment.