RU2770114C1 - Method for surgical treatment of primary end-to-end macular rupture with the formation of an upper invertible fragment of the inner boundary membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely ophthalmology. Preoperative calculation of individual parameters for each patient and the localization zone of the upper invertible fragment (UIF) of the inner boundary membrane (IBM) is performed. The data obtained as a result of the calculation are applied to the individual processing map of the patient’s fundus. At the same time, in order to preserve the point of visual fixation, the zone of the foveolar intact fragment (FIF) of the IBM is determined, which is a rounded section of IBM located concentrically to the minimum diameter of MP and captures the point of visual fixation, determined by microperimetry data, so that it is located in the middle between the edge of MP and the outer border of the IBM FIF. At the same time, the maximum width of the IBM FIF concentrically to the macular hole does not exceed 500 microns. The IBM UIF has the shape of a square, the sides of which are equal to the diameter of the circumference of the IBM FIF and is located on top relative to MP. During the surgical intervention, based on the preoperative calculation, the IBM UIF is formed using the method for step-by-step formation of IBM fragments, namely: from the side of the inferior vascular arcade 2.5 mm from the edge of the rupture, the IBM tear is performed with a tweezer and its local fragment is separated from the retina. Next, the IBM is separated along the arc of an imaginary circle with a macular hole in the center, the length of the removed fragments of the IBM is 3 hour meridians. At the same time, the area of the retina at a distance of 1.2 mm from the edge of the gap is kept intact. Next, the separated IBM is intercepted at the end point and, by moving along the radius of the circle to the center of the MP, the IBM is separated without reaching the edge of the gap by the preoperatively calculated width of the IBM FIF. Then the next interception is performed at the end point and the IBM is separated from the surface of the retina for 3 hour meridians in the opposite direction. The removal of a fragment of the IBM is completed by a movement directed along the radius, in the direction of the original point. The above-described algorithm of movements is repeated, thereby forming an IBM FIF concentrically to the macular hole. The last section of the IBM is removed in such a way as to prevent the closure of the IBM removal site at a distance equal to the preoperatively calculated width of the IBM UIF located on the side of the upper vascular arcade relative to the macular opening. Then the IBM UIF is separated: the separation of the IBM UIF from the retina surface is carried out to the upper border of the IBM FIF. Next, the IBM UIF is turned over and placed on the macular hole. After that, the liquid is replaced with an air mixture; drainage of the subretinal fluid through the gap is not carried out.

EFFECT: method makes it possible to create a single-layer flap of an IBM of the required shape, size and localization with an upper invertible fragment, complete closure of the macular opening, restore the integrity of the retina in the fovea, reduce the traumatic nature of surgical intervention, minimize the risk of intra- and postoperative complications, achieve high visual functions.

1 cl, 1 ex, 3 dwg

Description

SUBSTANCE: invention relates to medicine and can be used for surgical treatment of primary penetrating macular retinal tears of any (small, medium, large) diameter with the formation of an upper inverted fragment of the inner limiting membrane (ILM).

Primary penetrating macular holes (MP) of the retina still remain an urgent problem in terms of achieving anatomical closure and, no less important, a high functional result after treatment. Vitreoretinal surgery is a pathogenetically substantiated method of treatment of retinal MP, providing a good anatomical and functional result, the development of which contributes to the continuous improvement of the technology of surgical interventions on the retina and in the vitreous body (Faizrakhmanov P.P., Pavlovsky O.A., Larina E.A. The method of closing macular 2020; 136(1):73-79 Pavlovsky O.A., Larina E.A. Closing of large macular holes with preservation of the inner limiting membrane. Modern technologies in ophthalmology. 2019; 139(1): 139-144).

At the same time, removal of the ILM is a complex procedure even for an experienced vitreoretinal surgeon. Failure to comply with the ILM removal technology can lead to iatrogenic alterations of the superficial and deep layers of the retina, which can cause irreversible loss of visual functions, and damage to the retinal vessels - hemorrhagic complications during the operation (Toropygin S.G. Surgery of thin intraocular structures. Tver: IP Orlova Z .P.; 2014. S. 62.)

Despite the active development of vitreoretinal technologies, there is currently no single generally accepted approach to the treatment of primary retinal MPs. This surgery still requires a highly qualified ophthalmic surgeon, modern high-precision equipment and special premium instruments.

S., Fuentes Т., Nasini F. Inverted internal limiting membrane flap technique for macular hole surgery without extra manipulation of the flap. Retina. 2017; 26; 1097-1099; Kase S., Saito W., Mori S., Saito M., Ando R., Dong Z., Suzuki Т., Noda K., Ishida S. Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique. Clin Ophthalmol. 2016; 11: 9-14; Michalewska Z., Michalewski J., Adelman R., Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010. 117(10):2018-2025).Recently, the technique of the “inverted flap” of the ILM (classical multilayer or single layer) has received an active distribution in the surgery of primary MPs. It allows you to treat the edges of the MP delicately and maintain the adhesion of the ILM to the edge of the macular hole, excluding the use of mechanical methods for bringing its edges closer together. In addition, the above technique allows prolonging MP tamponade in the postoperative period, increasing the likelihood of its closure (Casini G., Mura M., Figus M., Loiudice P., Peiretti E., De

S., Fuentes T., Nasini F. Inverted internal limiting membrane flap technique for macular hole surgery without extra manipulation of the flap. retina. 2017; 26; 1097-1099; Kase S., Saito W., Mori S., Saito M., Ando R., Dong Z., Suzuki T., Noda K., Ishida S. Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique. Clin Ophthalmol. 2016; 11:9-14; Michalewska Z., Michalewski J., Adelman R., Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology. 2010.117(10):2018-2025).

The disadvantage of this method is damage to the formed point of visual fixation along the edge of the tear, uncontrolled formation of the ILM fragment, and a high probability of spontaneous detachment of the inverted ILM flap from the retinal surface at the attachment site along the tear edge.

The prototype of the proposed method is the technology of surgical treatment of large macular holes using the technique of phased formation of the ILM fragment (Patent RU 2563452). The disadvantage of this method is: the lack of accurate localization of the retinal area for the formation of a single-layer ILM flap for MP closure, personalized calculation of the parameters of the ILM flap, its exact size and shape based on spectral optical coherence tomography (SOCT) and microperimetry data.

The objective of the invention is to improve the anatomical and functional efficiency of the treatment of primary end-to-end MP.

The technical result of the claimed technology is the creation of a single-layer upper inverted fragment of the ILM of the required shape, size and localization, complete closure of the macular hole, restoration of the integrity of the retina in the fovea, reduction of the trauma of surgical intervention, minimization of the risk of intra- and postoperative complications, achievement of high visual functions.

The technical result is achieved by the fact that, according to the invention, a preoperative calculation of the parameters individual for each patient and the area of localization of the upper inverted fragment (HIF) of the EIM is performed, the data obtained as a result of the calculation are applied to an individual technological map of the patient's fundus, while maintaining the point of visual fixation determine the zone of the foveolar intact fragment (FIF) of the ELM, which is a rounded area of the ELM located concentrically to the minimum diameter of the MP and capturing the point of visual fixation, determined according to microperimetry, so that it is in the middle between the edge of the MP and the outer border of the FIF of the ELM, while the maximum width of the FIF ILM concentric to the macular hole does not exceed 500 µm; VIF VPM has the shape of a square, the sides of which are equal to the diameter of the circle FIF VPM and is located above the MP; in the course of surgical intervention, based on the preoperative calculation, the IMF of the ILM is formed using the method of gradual formation of fragments of the ILM, namely: from the side of the inferior temporal vascular arcade, 2.5 mm from the edge of the rupture, the ILM is torn with microtweezers and its local fragment is separated from the retina, then the ILM is separated along an arc of an imaginary circle with a macular hole in the center, the length of the removed fragments of the ILM is 3 hour meridians, while the retinal area at a distance of 1.2 mm from the edge of the gap is kept intact, then the separated ILM is intercepted at the end point and moving along the radius of the circle to the ILM is separated from the center of the MP, not reaching the edge of the gap for the preoperatively calculated FIF width of the ILM, then the next interception is performed at the end point and the ILM is separated from the surface of the retina along 3 hour meridians in the opposite direction, the removal of the ILM fragment is completed with a movement directed along the radius, in direction to lane starting point; the above algorithm of movements is repeated, thereby forming the FIF ILM concentric to the macular hole; the last section of the ILM is removed in such a way as to prevent the closure of the ILM removal site at a distance equal to the preoperatively calculated width of the VIF of the ILM located above (from the side of the superior temporal vascular arcade) relative to the macular hole; then VIF ELM is separated: separation of VIF ELM from the surface of the retina is carried out to the upper border of FIF ELM; then the VIF VPM is turned over and placed on the macular hole, after which the fluid is replaced with an air mixture; drainage of subretinal fluid through the gap is not carried out.

The technical result is achieved due to the fact that:

- saved FIF of the ILM of sufficient size, calculated before the operation, so that it includes a point of visual fixation, determined according to microperimetry, allows minimizing the mechanical intraoperative impact on the edges of the MP; do not drain the subretinal fluid through the macular hole in order to exclude additional trauma to the retina along the edge of the MP. All this ensures the preservation of the point of visual fixation and a high functional result of surgical treatment, as well as the preservation of central vision and the acceleration of visual rehabilitation of patients;

- VIF ELM of sufficient size, calculated preoperatively, is able to provide sufficient prolonged blockade of the macular hole, even after resorption of the air mixture, minimizing the possibility of fluid entering the macular hole in the postoperative period. This is necessary for complete resorption of subretinal fluid and cystic edema along the edge of the MP, which ensures a high anatomical result of surgical treatment in the form of closing the edges of the macular hole "butt to butt" due to their concentric convergence. HIM VIF remains on the surface of the retina, minimizing the risk of MP recurrence in the long term;

- "inversion line", the length of which is equal to the pre-calculated width of the VIF ELM and the diameter of the FIF ELM, provides a sufficient extent of attachment to the retina of the VIF ELM. This guarantees its stable position on the retinal surface at the moment of replacing the fluid with air, minimizing the displacement of the flap to the nasal or temporal side, reducing the risk of twisting "into a tube" or detachment of the IMF from the retina during the operation;

- the location of the VIF of the ILM from the side of the superior temporal vascular arcade ensures a stable position of the flap on the surface of the retina even when the patient assumes a vertical position in the early postoperative period under the conditions of the flow of continuously produced intraocular fluid and remnants of the vitreous body from top to bottom along the surface of the retina and VIF of the ILM. Residual fluid from under the VIF ILM flows down freely under the force of gravity, thereby contributing to the dense adhesion of the flap to the retina. This is also facilitated by the air mixture, which exerts pressure on the VIF VLM from the side of the vitreal cavity. Thus, the residual liquid from under the VIF ELM is removed by two factors: the pressure of the air mixture on the inverted fragment of the ELM from the side of the vitrel cavity and gravity. All this ensures tight adhesion of VIF ELM to the surface of the retina and reliable prolonged tamponade of the macular hole, which is necessary for its closure. The above allows you to save the patient from the need for prolonged tamponade of the vitreal cavity with various long-term absorbable gases or silicone oil, as well as from the need for the patient to be in the face down position.

The method is carried out as follows.

Produce preoperative calculation of individual parameters for each patient and the area of localization of VIF VLM.

The calculation algorithm is as follows.

1. On a spectral optical coherence tomograph (SOCT) in automatic mode in black and white, one-by-one scanning of all layers of the neurosensory retina is performed and the state of the vitreomacular interface is assessed. The main indicator for the subsequent calculation of the inner limiting membrane flap is determined, which is the minimum MP diameter corresponding to the smallest size of the macular hole between its edges.

2. Using the fundus microperimeter, the zone of the preferred retinal locus is determined, corresponding to the formation of a new point of visual fixation (TVF), - the area of the retina located peripherally to the macular hole, which the patient chooses subjectively and which is a compensatory reaction of the central vision function. The acquisition data is stored and transferred to an external electronic medium.

3. Then, on a black-and-white photo of the fundus, obtained with fundus microperimetry, with TTP marked on it in automatic mode, a circle is applied corresponding to the minimum MP diameter (Figure 1). The shortest distance is determined from the above circle to the TSP and manually measured. This distance is necessary for the subsequent determination of the width of the FIF ILM, which will be located concentrically with the MP (Figure 2).

4. From the edge of the MP in the direction of the TSP, twice the shortest distance between the edge of the MP and the TSP is set aside and a point is determined that corresponds to the outer boundary of the FIF VPM. In this case, the TDF is located in the middle between the edge of the MP and the outer border of the FIF of the ILM, and the maximum width of the FIF of the ILM concentric to the macular hole should not exceed 500 μm.

5. Through the obtained point corresponding to the outer boundary of the FIF VPM, concentric to the minimum diameter MP, a circle is drawn with a center corresponding to the center of MP. Thus, the FIF VLM is a ring enclosed between two circles: a circle corresponding to the minimum diameter MP, and a circle corresponding to the outer boundary of the FIF VLM.

6. "Line of inversion" (reversal of the VIF VLM) is the lower edge of the VIF VLM and the boundary along which the inversion (flip) of the VIF is performed. The "line of inversion" is drawn tangentially to the upper border of the circle corresponding to the outer border of the FIF of the ILM (the border, which is located on the side of the superior temporal vascular arcade) and parallel to the horizontal line passing through the center of the MP. The width of the lower edge of the VIF VPM is equal to the diameter of the circumference of the outer boundary of the VIF VPM.

7. Next, determine the border of the upper edge of the VIF VPM. To do this, from the lower border of the VIF VLM, perpendicular to it, in the direction of the upper temporal vascular arcade, a value equal to the diameter of the circumference of the outer border of the VIF VLM is set aside. A line is drawn through the obtained point, parallel to the lower edge of the VIF VPM. The width of the top edge of the inverted ILM fragment is equal to the width of its bottom edge.

8. A line is drawn along the temporal boundary of the VIF HLM through the extreme temporal points of its upper and lower edges until it touches the outer boundary of the FIF HLM. This line corresponds to the temporal edge of the ELM VIF.

9. The nasal border of the VIF ILM is determined similarly from the side of the optic nerve (the line is drawn through the extreme nasal points of the upper and lower edges of the VIF ILM until it comes into contact with the outer border of the FIF ILM).

During the surgical intervention, under retrobulbar anesthesia, a standard transconjunctival 3-port 27G subtotal vitrectomy is performed. The frequency of cuts is from 5000 to 10000. The posterior cortical layers of the vitreous body are separated by aspiration, starting from the optic nerve head. Vacuum - from 0 to 650 mmHg

Staining of the ILM is carried out using the dye "MembranBlue" in a volume of 0.1 ml. The exposure of the dye, sufficient for staining the ILM, is 15 seconds.

Based on the preoperative calculation, the IMF of the ILM is formed using the method of gradual formation of the ILM fragments, namely: from the side of the lower temporal vascular arcade, 2.5 mm from the edge of the rupture, the ILM is torn with microtweezers and its local fragment is separated from the retina, then the ILM is separated along an imaginary arc circle with a macular hole in the center, the length of the removed fragments of the ILM is 3 hour meridians, while the retinal area at a distance of 1.2 mm from the edge of the gap is kept intact, then the separated ILM is intercepted at the end point and the ILM is separated by moving along the radius of the circle to the center of the MP, not reaching the edge of the gap for the preoperatively calculated FIF width of the ILM, then the next interception is performed at the end point and the ILM is separated from the surface of the retina for 3 hour meridians in the opposite direction, the removal of the ILM fragment is completed with a movement directed along the radius towards the initial point. The above algorithm of movements is repeated several times, thereby forming the FIF ILM concentric to the macular hole; the last section of the ILM is removed in such a way as to prevent the closure of the ILM removal site at a distance equal to the preoperatively calculated width of the VIF of the ILM located above (from the side of the superior temporal vascular arcade) relative to the macular hole. Next, the VIF ELM is separated from the surface of the retina to the upper border of the FIF ELM; then the VIF VPM is turned over and placed on the macular hole, after which the fluid is replaced with an air mixture. Drainage of subretinal fluid through the gap is not carried out. Surgical treatment is completed with the removal of ports. Sclerotomy openings are self-sealing.

The invention is illustrated by figures 1-3.

In FIG. 1 shows the boundaries of the FIF (circles) and VIF (rectangle) of the ILM flap.

In FIG. Figure 2 shows a picture of SOCT of a patient with primary penetrating macular retinal holes 2 weeks after surgery according to the proposed method: a defect at the level of the ellipsoidal zone of photoreceptors of 196 μm.

In FIG. Figure 3 shows a snapshot of the SOCT of a patient with primary penetrating macular retinal holes 3 months after surgery according to the proposed method: a defect at the level of the ellipsoidal zone of photoreceptors of 40 μm.

The invention is illustrated by the following clinical example.

Patient K., 48 years old. Diagnosis: OS - primary penetrating macular hole of the retina of large diameter. Complaints about the distortion of lines and objects, low vision near and far.

Upon admission to the clinic, BCVA 0.1 is eccentric. According to microperimetry, the central photosensitivity is 18.8 dB. Visual fixation is stable. The point of visual fixation is located along the upper temporal edge of the MP at a distance of 195 µm from the edge.

According to SOCT data: the minimum rupture diameter is 618 µm, the maximum diameter is 972 µm, the height of the rupture is 446 µm, and the average thickness of the retina in the fovea is 380 µm.

Based on the obtained objective data, the parameters of the ILM flap with the upper inverted fragment were calculated for the subsequent application of the obtained flap parameters to the technological map of the patient's fundus.

According to the calculation, the diameter of the VIF VPM was 1008 µm (618 µm+(195*2) µm=1008 µm), respectively, the width and height of the VIF VPM were also equal to 1008 µm. The obtained parameters were plotted on the technological map of the patient's fundus, markers-landmarks on the fundus were determined. The resulting map was printed on paper to be used as a technological map during the operation.

Next, surgical treatment was performed using the proposed method of surgical treatment of primary penetrating MP of the retina with the formation of VIF ILM.

During the surgical intervention, under retrobulbar anesthesia, a standard transconjunctival 3-port 27G subtotal vitrectomy was performed. The frequency of cuts is from 5000 to 10000. The posterior cortical layers of the vitreous body were separated by aspiration, starting from the optic nerve head. Vacuum - from 0 to 650 mmHg

Staining of the ILM was carried out using the dye "Membran Blue" in a volume of 0.1 ml. The dye exposure was 15 seconds.

Based on the preoperative calculation, the IMF of the ILM was formed using the method of stage-by-stage formation of the ILM fragments, namely: from the side of the inferior temporal vascular arcade, 2.5 mm from the edge of the rupture, the ILM was torn with microtweezers and its local fragment was separated from the retina, then the ILM was separated along an imaginary arc circle with a macular hole in the center, the length of the removed fragments of the ILM was 3 hour meridians, while the retinal area at a distance of 1.2 mm from the edge of the gap was kept intact, then the separated ILM was intercepted at the end point and the ILM was separated by moving along the radius of the circle to the center of the MP, not reaching the edge of the gap by the preoperatively calculated FIF width of the ILM, then the next interception was performed at the end point and the ILM was separated from the surface of the retina along 3 hour meridians in the opposite direction, the removal of the ILM fragment was completed with a movement directed along the radius towards the initial point. The above algorithm of movements was repeated 3 times, thereby forming FIF ILM concentric to the macular hole; the last section of the ILM was removed in such a way as to prevent the closure of the ILM removal site at a distance equal to the preoperatively calculated width of the ILM VIF, located on the side of the superior temporal vascular arcade relative to the macular hole. Next, the VIF ILM was separated from the surface of the retina to the upper border of the FIF ILM; then VIF VPM was turned over and placed on the macular hole, after which the fluid was replaced with an air mixture. Drainage of subretinal fluid through the gap was not performed. Surgical treatment was completed with the removal of the ports. The sclerotomy holes were self-sealing.

There were no intraoperative complications.

Positive dynamics was observed 2 weeks after the operation. According to SOCT, the closure of the macular hole was recorded with the preservation of the defect at the level of the ellipsoidal zone of photoreceptors with a length of 196 μm. The maximum correctable visual acuity (BCVA) increased to 0.3. Central photosensitivity increased to 22.5 dB, according to microperimetry. Visual fixation is stable.

After 1 month, according to SOCT, MP is closed, the defect in the ellipsoidal zone of photoreceptors has decreased to 78 microns. BCVA - 0.6. An increase in central photosensitivity up to 23.4 dB was noted, according to microperimetry. Visual fixation is stable.

After 3 months, according to SOCT, MP is closed, the defect in the ellipsoidal zone of photoreceptors has decreased to 40 μm. BCVA - 0.6. Central photosensitivity - 26.3 dB, according to microperimetry. Visual fixation is stable. There were no complications during the observation period.

Thus, the claimed method ensures the creation of a single-layer VIF of the ILM of the required shape, size and localization, complete closure of the macular hole, restoration of the integrity of the retina in the fovea, reduction of the trauma of surgical intervention, minimization of the risk of intra- and postoperative complications, achievement of high visual functions.

Claims (1)

A method for the surgical treatment of primary end-to-end macular retinal rupture with the formation of an upper invertible fragment of the inner limiting membrane, characterized in that preoperative calculation of individual parameters for each patient and the area of localization of the upper invertible fragment (HIF) of the EIM is performed, the data obtained as a result of the calculation are applied to an individual technological map of the patient’s eye fundus, while in order to save the point of visual fixation, the zone of the foveolar intact fragment (FIF) of the ILM is determined, which is a rounded area of the ILM located concentrically to the minimum diameter of the MP and capturing the point of visual fixation, determined according to microperimetry data, so that it is in the middle between the edge of the MP and the outer border of the FIF ILM, while the maximum width of the FIF ILM concentric to the macular hole does not exceed 500 μm; VIF VPM has the shape of a square, the sides of which are equal to the diameter of the circle FIF VPM and is located above the MP; in the course of surgical intervention, based on the preoperative calculation, the IMF of the ILM is formed using the method of gradual formation of fragments of the ILM, namely: from the side of the inferior temporal vascular arcade, 2.5 mm from the edge of the rupture, the ILM is torn with microtweezers and its local fragment is separated from the retina, then the ILM is separated along an arc of an imaginary circle with a macular hole in the center, the length of the removed fragments of the ILM is 3 hour meridians, while the retinal area at a distance of 1.2 mm from the edge of the gap is kept intact, then the separated ILM is intercepted at the end point and moving along the radius of the circle to the ILM is separated from the center of the MP, not reaching the edge of the gap for the preoperatively calculated FIF width of the ILM, then the next interception is performed at the end point and the ILM is separated from the surface of the retina along 3 hour meridians in the opposite direction, the removal of the ILM fragment is completed with a movement directed along the radius, in direction to lane starting point; the above algorithm of movements is repeated, thereby forming the FIF ILM concentric to the macular hole; the last section of the ILM is removed in such a way as to prevent the closure of the ILM removal site at a distance equal to the preoperatively calculated width of the ILM VIF, located on the side of the upper temporal vascular arcade relative to the macular hole; then VIF ELM is separated: separation of VIF ELM from the surface of the retina is carried out to the upper border of FIF ELM; then the VIF VPM is turned over and placed on the macular hole, after which the fluid is replaced with an air mixture; drainage of subretinal fluid through the gap is not carried out.

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