RU2766755C1 - Method for surgical management of unclosed macular hole - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to ophthalmology. For the treatment of unclosed macular hole (UMH) following the primary surgical intervention, three ports 25G or 27G are inserted, staining the portion of the internal limiting membrane (ILM) remaining after the primary intervention around the macula and closing the hole. After staining, maculorexis of ILM is performed up to vascular arcades, which is 1–2 mm more than diameter of maculorexis made during primary surgical intervention. Three equally spaced arched notches are made along the edge of the UMH. Further, using a vitreous tube in aspiration mode, fluid is removed from the vitreal cavity with replacement with air. Then, using the cannula, passive aspiration is performed over the UMH zone, bringing the UMH edges closer together. A rich platelet mass in concentration of 0.05 % is introduced into the region of the UMH edge, thus closing the hole. Tamponade is carried out with a gas-air mixture.

EFFECT: method improves visual functions, reduces retinal injuries and postoperative complications, as well as reduces the length of postoperative rehabilitation.

1 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of recurrent macular retinal tears.

It is difficult to surgically treat an unclosed macular hole after primary surgery, which is due to the absence of an internal limiting membrane (ILM) in the maculorhexis area. In the treatment of primary macular hole in most cases, the ILM is removed. To date, there are several methods of surgical treatment of unclosed macular hole (NMR) after primary surgery.

A known method for the treatment of macular holes, including the use of three-port surgery. To close the macular hole produce a mechanical effect on the retina, bringing together the edges of the macular hole from the periphery to the center (RF patent for invention No. 2258491).

This method is based on the impact directly on the retinal tissue itself, which reduces the functional result after surgical treatment, in addition, it is not always possible to close such a defect. In 20% of cases, there is an increase in macular hole after reoperation due to retinal injury.

The closest analogue is a method for the treatment of NMR after primary surgical intervention, while in the absence of retinal ILM in the maculorhexis zone, three 25G or 27G trocars are installed, the part of the ILM around the macula that remains after the primary intervention is stained, the gap is closed, and silicone is introduced into the vitreal cavity. To close the gap, three ILM flaps are formed, which are completely torn off from the base, the fluid is replaced with air in the vitreal cavity, after which the NMR is tamponed with folded flaps to the level of the retinal tissue. EFFECT: method provides reduction of traumatization and improvement of functional results of the central part of the retina, complete morphological closure of the NMR after primary surgical intervention in the absence of an internal limiting membrane in the maculorhexis zone (RF patent for invention No. 2722989).

The disadvantage of this method is the technical complexity associated with the isolation of the ILM flap, as well as significant trauma, which leads to the need for long-term silicone tamponade, which can lead to postoperative complications.

The objective of the invention is to develop a less traumatic and effective technology for the surgical treatment of NMR of the retina, which allows to reduce postoperative complications, achieve higher functional results and reduce the recovery time after surgery.

The technical result achieved by using the invention is the improvement of visual functions, the reduction of trauma to the retina and postoperative complications, as well as the reduction of the rehabilitation period.

The technical result is achieved by the fact that in the method for treating NMR after primary surgical intervention, including the installation of three ports 25 G or 27G, staining of the part of the ILM around the macula remaining after the primary intervention, closing the gap, according to the invention, after staining, maculorhexis of the ILM is performed to the vascular arcades, on 1-2 mm larger than the diameter of the maculorhexis made during the primary surgical intervention, three arcuate incisions are made equidistant from each other along the edge of the NMR, fluid is aspirated from the vitreal cavity, placing a passive aspiration cannula over the NMR zone, bringing together the edges of the NMR, a rich platelet mass is injected at a concentration 0.05% to the edge of the HMP, thus closing the gap; carry out tamponade with a gas-air mixture.

There is a causal relationship between the set of essential features and the claimed technical result.

The advantage of this method of surgical treatment of macular rupture is the reduction of retinal trauma as a result of a reduction in the number of mechanical actions, due to the expansion of the maculorhexis zone and the application of three arcuate notches along the edge of the NMR, which makes the retina more pliable, the closure of the NMR occurs at the time of passive aspiration of fluid above the rupture zone. .

By introducing a rich platelet mass into the NMR zone, as well as by using a gas-air mixture for tamponade, the rehabilitation period is shortened, and the likelihood of postoperative complications is reduced.

Distinctive features of the proposed method, namely, that this method does not use silicone for tamponade of the vitreal cavity, there is no detachment from the base and folding of the ILM flaps, maculorhexis is performed with a large diameter, arcuate notches are made along the edge of the NMR, a passive aspiration cannula is used to bring the edges of the NMR closer together , the introduction of a rich platelet mass to close the NMR, the operation ends with tamponade of the vitreal cavity with a gas-air mixture. After the operation, the rehabilitation period is significantly reduced. The method was carried out as follows.

Under local anesthesia through three scleral valve punctures in the flat part of the ciliary body, retreating from the limbus 3.5-4 mm, three ports 25G or 27G are installed with trocars. Two ports for surgical instruments are installed as standard at 2 and 10 o'clock. The port for the cannula with the supply of a balanced irrigation saline solution is installed depending on the eye in the lower-outer segment. Right eye at 8 o'clock, left eye at 4 o'clock. Through one of them, the membraneblue-dual dye is injected to stain the part of the ILM around the NMR remaining after primary surgery to the level of the vascular arcades. To ensure retinal compliance, maculorhexis is performed to the level of vascular arcades 1-2 mm larger than the diameter of maculorhexis during primary surgical intervention. Next, using endovitreal scissors, cut the edge of the NMR at an angle of 20-30 degrees to it with three arcuate notches at twelve, eight and four hours. After that, the retina becomes more pliable. With the help of a vitreotome in the aspiration mode, fluid is removed from the vitreous cavity and replaced with air. Then, with the help of a cannula, passive aspiration is carried out over the HMR zone, while the edges of the HMR come closer together, after which a rich platelet mass is injected at a concentration of 0.05% into the region of the HMR edge. The vitreal cavity is tamponade with a gas-air mixture. Three transscleral 8-0 vicryl sutures are placed at the site of the ports.

The proposed method is illustrated by the following clinical examples.

Example 1

Patient M., 40 years old. Visual acuity of the right eye 0.05 does not correct (n/a).

Visual acuity of the left eye 0.7 n/K.

From the anamnesis: the right eye was operated on for macular rupture 2.5 months ago.

Objectively, the right eye: the cornea is transparent, the anterior chamber is small, the lens is transparent, avitria. Optical coherence tomography revealed NMR after primary surgical intervention - 589 µm in diameter.

Diagnosis: NMR after primary surgery.

An operation was performed according to the invention: installation of three 25G ports, microinvasive revision of the vitreal cavity with maculorhexis of the ILM 1 mm larger than the diameter of the maculorhexis made during the primary surgical intervention, arcuate notches were applied along the edge of the NMR, fluid was replaced with air, using a passive aspiration cannula at the same time the edges of the NMR approached each other, a rich platelet mass was introduced into the area of the closed macular rupture, and tamponade with a gas-air mixture was performed.

After operation:

Visual acuity of the right eye 0.2 n/a.

Visual acuity of the left eye 0.7 n/K.

Objectively, the right eye: the cornea is transparent, the anterior chamber is small, the lens is transparent, avitria. With ophthalmoscopy, the macular hole is blocked, which is confirmed by optical coherence tomography (OCT) data.

At the control after three months:

Objectively, the right eye: the cornea is transparent, the anterior chamber is small, the lens is transparent, avitria. On ophthalmoscopy, the macular hole was blocked, which was confirmed by OCT data.

Visual acuity of the right eye 0.3 n/a.

Visual acuity of the left eye 0.7 n/K.

Example 2

Patient M., 57 years old. Visual acuity of the left eye 0.3 n/K.

Visual acuity of the right eye 0.6 n/a.

From the anamnesis: the left eye was operated on for macular rupture 4 months ago.

Objectively, the left eye: the cornea is transparent, the anterior chamber is of medium depth, the posterior chamber IOL is in the capsular bag, in the correct position, avitria. Ophthalmoscopy revealed NMR after primary surgery - 600 µm in diameter.

Diagnosis: NMR after primary surgery.

An operation was performed according to the invention: installation of three 27G ports, microinvasive revision of the vitreal cavity with maculorhexis of the ILM 2 mm larger than the diameter of the maculorhexis made during the primary surgical intervention, arcuate notches were applied along the edge of the NMR, fluid was replaced with air, using a passive aspiration cannula at the same time the edges of the NMR approached each other, a rich platelet mass was introduced into the area of the closed macular rupture, and tamponade with a gas-air mixture was performed.

After operation:

Visual acuity of the left eye 0.4 n/K.

Visual acuity of the right eye 0.6 n/a.

Objectively, the left eye: the cornea is transparent, the anterior chamber is of medium depth, the posterior chamber IOL is in the capsular bag, in the correct position, avitria. On ophthalmoscopy, the macular hole was blocked, which was confirmed by OCT data.

At the control after three months.

Objectively, the left eye: the cornea is transparent, the anterior chamber is of medium depth, the posterior chamber IOL is in the capsular bag, in the correct position, avitria. On ophthalmoscopy, the macular hole was blocked, which was confirmed by OCT data.

Visual acuity of the left eye 0.5 n/a.

Visual acuity of the right eye 0.6 n/a.

The developed method was tested in 15 patients operated on for NMR after primary surgery. All operated patients underwent NMR closure using this technique. In all cases, positive functional results were obtained. Thus, the proposed method is reliable and less traumatic, providing a quick rehabilitation of the patient.

Claims (1)

A method for the treatment of an unclosed macular hole (NMR) after primary surgical intervention, including the installation of three ports 25G or 27G, staining of the part of the internal limiting membrane (ILM) around the macula remaining after the primary intervention, closing the gap, characterized in that, after staining, maculorhexis of the ILM is performed to the vascular arcades, 1-2 mm larger than the diameter of the maculorhexis made during the primary surgical intervention, three arcuate incisions are made equidistant from each other along the edge of the NMR, then with the help of a vitreotome in the aspiration mode, the fluid is removed from the vitreal cavity with replacement with air, then with the help of cannulas passively aspirate over the HMR zone, bringing the edges of the HMR closer together, inject a rich platelet mass at a concentration of 0.05% into the region of the HMR edge, thus closing the gap; carry out tamponade with a gas-air mixture.