RU2739131C1 - Method of surgical treatment of foveoshisis with preservation of foveal fragment of internal limiting membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology. Three-port chromovitrectomy is performed using Triamcinolone acetonide dye. Internal limiting membrane (ILM) is contrast-enhanced with membrane blue 0.15 % dye. Using endovitreal tweezers, ILM is captured 2 mm from an upper temporal arcade, and an ILM flap is formed in the form of a strip with length of 8–10 mm, with width of 1–2 mm. One of edges of this flap is grasped as in fig. 1, it is separated by direction to center of fovea, not reaching 2.0 mm to fovea zone. That is followed by successively forming three flaps of ILM in the form of lobes as follows: the first one – along the edge of the formed flap in the form of a strip. Then the second, and the third – from the remaining ILM section. All the flaps are separated towards the center of the fovea. Further, the vitreous cutter cuts edges of all ILM flaps, leaving a foveal region of a rounded foveal ILM fragment with diameter of 4 mm. Operation is terminated by removing the ports.

EFFECT: method enables eliminating retinal traction, reducing intraoperative injuries, preserving an anatomical profile of the fovea region, reducing the rehabilitation period and improving the quality of vision of high-degree myopia.

1 cl, 3 ex, 1 dwg

Description

The invention relates to ophthalmology and can be used to treat patients with myopic foveoschisis.

Myopic foveoschisis (MF) is increasingly recognized as one of the main causes of vision loss in patients with high myopia. The term myopic foveal retinoschisis (foveoschisis) was coined by Takano and Kishi in 1999 to describe the cleavage of the inner retinal layers in the macula in patients with high myopia and posterior staphyloma. Myopic foveoschisis is a retinal dissection at the level of the neuroepithelium with the formation of slit cavities and characteristic vertical bridges.

Today, there are no clear indications for surgical treatment of MF, therefore, the main selection criteria for surgical treatment are complaints of metamorphopsia and decreased visual acuity. Treatment of this pathology is carried out by the method of three-port microinvasive vitrectomy with the removal of the internal boundary membrane (IPM) and subsequent gas tamponade. At the same time, the key point of vitrectomy for foveoschisis is membrane peeling and peeling of the VPM, which weakens traction on the retina and restores its anatomical structure. However, IPM peeling remains a controversial stage of surgical intervention, as it leads to trauma and partial removal of Mueller cells that perform a supporting and trophic function for photoreceptors, thereby maintaining the structure of the macular zone. As a result, in the postoperative period in this group of patients there is a high likelihood of such complications as: macular rupture, cattle in the field of view due to a defect and dissociation of the layer of nerve fibers. At the same time, the preservation of the VPM can lead to the development of proliferative tissue on the surface of the retina.

Therefore, today, the issue of developing a foveo-sparing VPM peeling with a minimum effect on the fovea zone in order to prevent trauma to the retinal tissue is a topical issue - the VPM peeling technique with preservation of the foveal fragment.

A known method of choosing tactics for the treatment of retinoschisis, while with retinoschisis stage I, characterized by limited splitting of the retina, vascular elevation and the presence of intraretinal fluid, laser diode laser barriers are performed along the borders of the cyst, over the entire area of the cyst and along the vessels in the area of retinoschisis. In stage II retinoschisis, characterized by the progression of retinoschisis without a clear boundary between schizis and the intact retina, stage-by-stage progressive laser coagulation of the retina with a diode laser is carried out until the limited area of retinoschisis is completely blocked or the intraretinal fluid is completely resorbed; in the presence of bullous retinoschisis, a barrier is performed without a demarcation line. In stage III retinoschisis, characterized by the fact that retinoschisis occupies two or more quadrants with the presence of extensive cavities, ruptures, hemorrhages and the possibility of transition to a limited retinal detachment, stage-by-stage progressive retinal laser coagulation with a diode laser is performed (RF patent for invention No. 2526884).

The disadvantages of this method are the impossibility of complete blocking of stage III retinoschisis with laser coagulations, the need to use progressive step-by-step laser coagulation, the lack of the desired effect in the presence of concomitant local retinal detachments, and a long rehabilitation period.

The closest analogue is a method of treating myopic retinoschisis by performing a microinvasive three-port 25 gauge vitrectomy with peeling of the posterior hyaloid membrane carried out using Triamcinolone acetonide. Maculorexis was performed with contrasting of the inner border membrane with Brilliant Blue G. After tamponade of the vitreous cavity with liquid PFOS, one patient with the most common foveoschisis underwent a laser barrage of the macular zone (Stebnev BC, Malov V.M., Stebnev S.D. Results of vitreoretinal surgery of foveoschisis / / Bulletin of OSU. - 2012 - No. 12 (148). - S. 191-193).

The disadvantage of this method is the pilling of the inner boundary membrane in the fovea zone, which disrupts the architectonics of the retina, the supporting function of Muller cells and the likelihood of postoperative cattle and metamorphoses.

The objective of the claimed invention is to develop a method for the surgical treatment of foveoschisis, which makes it possible to improve the anatomical and functional results in the postoperative period as soon as possible after the treatment.

The technical result is the elimination of retinal traction, reducing the trauma of surgery, maintaining the anatomical profile of the fovea zone, reducing the rehabilitation period and improving the quality of vision in patients with high myopia.

The specified technical result is achieved by the fact that in the method of surgical treatment of foveoschisis, including three-port chromovitrectomy using the Triamcinolone acetonide dye, contrasting the internal boundary membrane (IPM) with membrane blue dye 0.15%, according to the invention, using endovitreal forceps capture the IPM in 2 mm from the superior temporal arcade and form a flap of the VPM in the form of a strip 8-10 mm long, 1-2 mm wide, capture one of the edges of this flap, not reaching 2.0 mm to the fovea zone; then three flaps of the VPM are sequentially formed in the form of petals as follows: the first two - along the edges of the formed flap in the form of a strip, and the third - from the remaining section of the VPM, all the flaps are separated towards the center of the fovea, then the edges of all the flaps of the VPM are cut off with a vitreotome, leaving above the area of the fovea is a rounded foveal fragment of the VPM with a diameter of 4 mm; the operation ends with the removal of the ports.

There is a cause-and-effect relationship between the set of essential features and the achieved technical result. The use of the “strip-petal” technique allows to reduce the frequency of capture of the VPM, which reduces the risk of dissociation of nerve fibers in the fovea zone, thereby preserving the architectonics of the retina, and achieving rapid rehabilitation. Removal of the VPM flap in the form of a "strip" technically facilitates the capture of the first fragment of the VPM, since a clear boundary between the underlying retina and the edge of the VPM is visualized. This reduces the risk of iatrogenic retinal damage. The centripetal removal of the formed flaps contributes to the preservation of an intact foveal fragment of a rounded shape, which corresponds to the anatomical foveal profile, prevents trauma to the fovea, maximizes postoperative photosensitivity of the macular zone, decreases metamorphopsias and scotomas.

The advantage of this method of surgical treatment of foveoschisis is the preservation of the foveal fragment, which leads to a decrease in the traumatic effect on the foveal zone, the absence of cell damage in this zone, with the preservation and subsequent increase in the light sensitivity of the retina. This method will improve the anatomical and functional results as soon as possible after the treatment.

The method is illustrated by the figure. Position 1 denotes a strip-like VPM flap, 2 - petal-shaped VPM flaps, 3 - the remaining foveal fragment of a rounded VPM.

The method is carried out as follows.

Treatment of the operating field and anesthesia are performed. A standard three-port 25-27 G chromovitrectomy is performed, including the execution of 3 scleral incisions in the area of the flat part of the cilpar body: one of the incisions is designed to supply irrigation fluid into the vitreous cavity, the second is to introduce an endo-illuminator to visualize the fundus, and the third is to introduce tools. The vitreous tip is used to remove the layers of the vitreous body, moving gradually to the posterior pole, forming an access for removal of the VPM, having previously stained the vitreous with Triamcinolone acetonide (Bristol-Myers Squibb., USA). Next, the membrane blue 0.15% dye (Dorc, Netherlands) is applied to the macular area, the exposure is maintained for 15 seconds and it is aspirated with cannulas, after which the VPM is removed, using endovitreal forceps, the VPM is captured 2 mm from the superior temporal arcade and a flap is formed in the form of a strip 1 8-10 mm long, 1-2 mm wide, capture one of the edges of this flap and separate it towards the center of the fovea, not reaching 2.0 mm to the fovea zone; then three flaps of the VPM are sequentially formed in the form of petals 2, symmetrical relative to the center of the fovea, as follows: the first two - along the edges of the formed flap in the form of strip 1, and the third - from the remaining portion of the VPM, then the edges of all flaps of the VPM are cut off with a vitreotome, leaving above the area fovea is a rounded foveal fragment of 3 VPM with a diameter of about 4 mm, centered at the center of the fovea; the operation is completed by removing the ports.

Clinical example 1

Patient Z., 70 years old.

Diagnosis: OU High myopia. Artifakia. Condition after laser coagulation of the retina. OD Myopic foveoschisis. Epiretinal membrane.

Complaints about low vision, image distortion on OD. Preoperative visual acuity OD = 0.2 sph -1.0 cyl -1.0 ax 105 = 0.3 Preoperative OCT OD: foveolar retinal dissection in the outer plexiform layer. Myopic cysts in the neuroepithelium. Epiretinal membrane. The operation was performed: OD microinvasive subtotal vitrectomy + removal of the epiretinal membrane + removal of the internal border membrane, according to the invention, while a flap was formed in the form of a strip 8 mm long, 1 mm wide with preservation of the foveolar fragment.

There were no complications during the operation or in the postoperative period.

Postoperative visual acuity OD = 0.3 sph -1.0 = 0.4 Postoperative OCT: borderline retinal thickening in the fovea. Druze. Borderline thinning of the retina in the parafoveolar temporal segment.

The patient subjectively notes an improvement, a decrease in distortions by OD / Discharged from the hospital on day 3.

Clinical example 2

Patient B., 65 years old.

Diagnosis: OU High myopia. Epiretinal membrane OS Artifakia OD Initial age-related cataract OS Myopic foveoschisis.

Complaints about low vision, image distortion on OS. Visual acuity before surgery OS = 0.3 sph -2.25 cyl -1.25 aх 115 = 0.4 Preoperative OCT OS: foveolar retinal dissection in the outer plexiform layer. The foveolar zone is thickened, preretinal inclusions, in the lower parts of the retinal detachment with a height of 150 μm. Myopic cysts in the neuroepithelium. Epiretinal membrane

The operation was performed: OS microinvasive subtotal vitrectomy + removal of the epiretinal membrane + removal of the internal border membrane, according to the invention, a flap was formed in the form of a strip 10 mm long and 2 mm wide, while preserving the foveolar fragment.

There were no complications during the operation or in the postoperative period.

Postoperative visual acuity OS = 0.4 sph -2.25 = 0.4 Postoperative OCT: borderline retinal thickening in the fovea, preretinal inclusions

The patient subjectively notes an improvement, a decrease in distortion on the OS. Discharged from the hospital for 3 days.

Clinical case 3

Patient K., 72 years old.

Diagnosis: OU High myopia. OU Artifakia. OD Myopic foveoschisis. Epiretinal membrane.

Complaints about low vision OU, OD> OS. Preoperative visual acuity OD = 0.2 sph -2.0 cyl -0.75 ax 98 = 0.3 Preoperative OCT OD: foveolar retinal dissection in the outer plexiform layer. The foveolar zone is thickened, preretinal inclusions, in the lower parts of the retinal detachment with a height of 200 μm.

The operation was performed: OD microinvasive subtotal vitrectomy + removal of the epiretinal membrane + removal of the internal border membrane, according to the invention, a flap was formed in the form of a strip 9 mm long, 2 mm wide, while preserving the foveolar fragment.

There were no complications during the operation or in the postoperative period.

Postoperative visual acuity OD = 0.2 sph -2.0 cyl 0.75 = 0.4 Postoperative OCT: borderline retinal thickening in the fovea

The patient subjectively notes an improvement, a decrease in distortion at OD. Discharged from the hospital for 3 days.

Claims (1)

A method of surgical treatment of foveoschisis, including a three-port chromovitrectomy using the Triamcinolone acetonide dye, contrasting the internal boundary membrane (VPM) with membrane blue dye 0.15%, characterized in that using endovitreal tweezers, the VPM is captured 2 mm from the superior temporal arcade of the VJ and a flap is formed in the form of a strip 8-10 mm long, 1-2 mm wide, capture one of the edges of this flap, as in Fig. 1, separating it towards the center of the fovea, not reaching 2.0 mm to the fovea zone; then three flaps of the VPM are sequentially formed in the form of petals as follows: the first - along the edge of the formed flap in the form of a strip, then the second, and the third - from the remaining section of the VPM, all the flaps are separated towards the center of the fovea, then the edges of all the flaps of the VPM are cut off with a vitreotome, leaving a rounded foveal fragment of the VPM with a diameter of 4 mm above the fovea, the operation ends with the removal of the ports.

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