RU2786140C1 - Method for surgical treatment of recurrent idiopathic macular rupture using a donor descemet's membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of recurrent idiopathic macular hole. To do this, the macular hole is closed with a fragment of the donor cornea's Descemet's membrane with a shape that repeats the shape of the gap, with dimensions not less than 1.0 mm larger than the size of the gap, determined according to preoperative optical coherence tomography (OCT). A fragment of the Descemet's membrane is centered relative to the macular rupture so that it overlaps the area of the rupture by at least 0.5 mm from all sides. Then, one drop of autologous ACP serum is applied to the macular area and a fragment of the Descemet's membrane is fixed to the surface of the retina with a fibrin clot formed intraoperatively from the autologous ACP of the patient's blood serum.

EFFECT: invention provides reduction of invasiveness of surgical intervention, complete closure of a recurrent macular rupture, regardless of the presence or absence of the internal limiting membrane after a previous surgical intervention due to tamponade of the macular rupture by the resulting fibrin clot, which, in turn, blocks intraocular fluid from entering the rupture for a long period , ensuring the closure of the edges of the gap butt-to-butt.

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Description

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of recurrent idiopathic macular hole.

Idiopathic macular holes (MP) are one of the causes of reversible blindness in the elderly. The effectiveness of surgical treatment of this pathology is up to 80-95%, depending on the clinical and anatomical characteristics of the disease. Complete idiopathic large-diameter macular holes have the most unfavorable prognosis, which is associated with a high risk of postoperative recurrence.

Currently, in the course of surgical treatment of MP, the ILM is removed in all cases, resulting in a decrease in the effect of planar tractions [Faizrakhmanov R.R., Shishkin M.M., Pavlovsky O.A., Larina E.A. Surgical treatment of macular rupture. - Ufa: Bashk. Encycl., 2020. - 144 p. Lyskin P.V., Zakharov V.D., Lozinskaya O.L. Pathogenesis and treatment of idiopathic macular holes. The evolution of the issue. Ophthalmosurgery. 2010; 3:52-55].

However, even with a successful surgical intervention and the patient following the recommendations regarding the position of the body face down, given to him in the postoperative period, macular holes do not always close. There are many works on predicting the anatomical outcome of MP treatment. Known methods of prediction, taking into account the duration of existence, the diameter of the MP, the thickness of the retina in the foveal zone [Shpak A.A., Shkvorchenko D.O., Sharafetdinov I.Kh., Yukhanova O.A. Predicting the results of surgical treatment of idiopathic macular rupture. Ophthalmosurgery. 2015; (2):55-61. Zhigulin A.V., Khudyakov A.Yu., Mashchenko N.V. The effectiveness of surgical treatment of idiopathic macular holes depending on the diameter of the gap. New technologies for the diagnosis and treatment of diseases of the organ of vision in the Far East region. 2013:256-261. Kanovsky R., Jurecka T., Gelnarova E. Analysis of prognostic factors of anatomical and functional results of idiopathic macular hole surgery. Cesk. Slov. Oftalmol. 2009;65(3):91-96]. However, even when all predictors are taken into account, the incidence of non-closure of macular holes after vitreoretinal intervention is high. More than 40% of complete large-diameter macular holes do not close after the first operation. From 19% to 39% of the MP remain partially open or filled with glial (scar) tissue, which is regarded as an anatomical success of the operation, but is the cause of low vision in the postoperative period [Frisina R, Gius I, Tozzi L, Midena E. Refractory full thickness macular hole: current surgical management. Eye (Lond). 2021 Jan 21. doi: 10.1038/s41433-020-01330-y. Online ahead of print].

A known method for the surgical treatment of an unclosed macular hole after primary surgery in the absence of the internal limiting membrane (IML) of the retina in the area of maculorhexis, including the installation of three 25 G or 27G trocars, staining of the part of the ILM remaining after the primary intervention around the macula, closing the gap with three free ILM flaps, the introduction of silicone into the vitreous cavity [patent for invention №RU 2722989]. The disadvantages of this method are increased trauma due to the need to form free fragments of the ELM, the need for repeated intervention to remove silicone oil.

The thickness of the ILM varies from the periphery to the center of the retina: in the central parts of the retina, it has a clear border, non-fibrous structure and the greatest thickness, and in the peripheral parts of the retina, the ILM as such is absent [Lyskin P.V. Some aspects of the microanatomy of the internal limiting membrane and vitreoretinal relationships. Modern technologies for the treatment of vitreoretinal pathology. 2013:126-128]. Therefore, with a wide maculorhexis performed during primary surgery, it is not always possible to form an integral free flap, especially of the required diameter, for complete coverage of the MP during reoperation. In addition, the free ILM flap is quite mobile, has a tendency to twist and requires additional fixation in the projection of the macular hole.

Currently, for the surgical treatment of idiopathic macular rupture, platelet-rich plasma is used [Krupina E.A. Surgical treatment of idiopathic macular hole using platelet-rich plasma. Diss. … c.m.s. M., 2019]. However, blood components and sodium citrate, when in contact with the retina and pigment epithelium, can cause the release of free radicals and pro-inflammatory substances [Refractory full thickness macular hole: current surgical management Rino Frisina Irene Gius Luigi Tozzi Edoardo Midena 2021 Jan 21. doi: 10.1038/s41433-020 -01330-y. Eye (bond)].

There is a known method of re-closing a previously operated unclosed macular hole, when the remaining part of the ILM is torn from the lateral side of the macula, opposite the optic nerve head, along the semicircle, and an ILM flap is formed on the “pedicle” in the form of a “sickle”, the maximum width of which is from 0.3 to 1 diameter of the optic nerve head, mechanically moving the free part of the flap into the area of the macular hole, close the macular hole with this flap, then a perfluoroorganic compound (PFOS) is injected into the vitreal cavity until the ILM flap tightly adheres to the retina around the macular hole, then replacement of PFOS with silicone oil [patent No. RU 2615046]. The disadvantages of this method include technical difficulties in cutting out residual fragments of the ILM. The use of PFOS and silicone oil during surgical treatment, which, having low toxicity, must be removed from the eye in a timely manner, requires repeated surgical intervention.

The prototype of the proposed method is a method of surgical treatment of a previously operated unclosed macular hole, in which the ILM flap is completely separated from the lateral side of the macula with a size of 1 × 2 mm using vitreal tweezers, the macular hole is plugged with the formed flap, air tamponade of the vitreal cavity is performed [patent No. RU 2633338]. The disadvantages of this method are the need to identify the free edge of the inner limiting membrane, preserved after the previous intervention, the need for additional membrane peeling, which is especially difficult in advanced fibrous processes on the retina, and often impossible after the use of autologous sera during the previous operation.

The objective of the invention is to develop an effective method for the surgical treatment of recurrent macular rupture.

The technical result of the proposed method is the complete closure of a recurrent macular hole, regardless of the presence or absence of the ILM after a previous surgical intervention, reducing the trauma of surgical intervention.

The technical result is achieved by the fact that, according to the invention, the macular hole is closed with a fragment of the Descemet's membrane of the donor cornea with a shape that repeats the shape of the gap, with dimensions not less than 1.0 mm larger than the size of the gap, determined according to preoperative optical coherence tomography (OCT), fragment Descemet's membrane is centered relative to the macular rupture so that it covers the area of the rupture by at least 0.5 mm from all sides, then one drop of autologous ACP serum is applied to the macular area and a fragment of the Descemet's membrane is fixed to the surface of the retina with a fibrin clot formed intraoperatively from autologous ACP patient's serum.

The technical result is achieved due to the fact that:

1) a fragment of a fresh or preserved donor cornea is used, which makes it possible to close the macular hole, regardless of the presence or absence of the ILM after a previous surgical intervention, as a result of which the MP did not close;

2) the DM fragment has a shape that repeats the shape of the MP, and its dimensions are at least 1.0 mm larger than the dimensions of the MP, determined according to the data of preoperative optical coherence tomography (OCT), which is sufficient to achieve complete closure of the MP;

3) the DM fragment is centered relative to the MP so that it covers the area of the gap by at least 0.5 mm from all sides, which is necessary to achieve complete closure of the MP;

4) one drop of autologous ACP serum is applied to the macular area, from which a fibrin clot is formed intraoperatively, fixing the DM fragment to the retina, this allows prolonging the tamponade of the macular rupture, thereby blocking the ingress of intraocular fluid into it for a long period, which ensures the closure of the edges of the joint rupture at the butt;

5) do not perform manipulations with the ILM, which reduces the invasiveness of the operation.

The method is carried out as follows.

After installing the 25G valve ports and replacing the intraocular fluid with air, the intraocular pressure (IOP) is maintained at 15-18 mm Hg. To close the macular hole using a fragment of the donor's Descemet's membrane (DM). A DM fragment is obtained from fresh or preserved donor cornea from its peripheral parts. The surface of the DM is stained with a solution of methylene blue Membrane DualBlue to facilitate further visualization when working with a DM fragment in the vitreal cavity. Separation of the DM fragment from the stroma of the donor cornea is performed using knitting tweezers. The DM fragment has a shape that repeats the shape of the MP, and its size is at least 1.0 mm larger than the size of the macular hole, determined according to preoperative spectral optical coherence tomography (SOCT). The formed fragment of DM is intercepted with collet tweezers of the "crocodile" type and, having passed through the valve port 25 G, is placed on the rupture zone. Then, residual intraocular fluid is further removed from the surface of the retina using a cannula with a “soft silicone tip” so that the DM fragment is maximally centered relative to the MP and covers the area of the gap by at least 0.5 mm from all sides. After that, one drop of autologous ACP serum is applied to the macular area, which is obtained in advance by centrifuging the patient's whole blood for 5 minutes at a speed of 1500 rpm. The DM fragment, if necessary, is additionally spread with the tip of the tweezers in the ASR medium for 2 minutes, which is necessary to start the formation of a fibrin clot, which fixes the DM fragment to the retina. The operation is completed with an air tamponade of the vitreal cavity, while maintaining the same IOP parameters at a level of no more than 18 mm Hg. In the postoperative period, the patient keeps the position face down for 3 days.

The invention is illustrated by the following clinical data.

Clinical example 1. Patient O., 75 years old. Complaints about low vision of the right eye, distortion of objects. 2 months ago, the right eye was operated on for a through macular hole.

Visual acuity OD - 0.05 n / a. According to spectral optical coherence tomography (SOCT) - through macular hole, D min (minimum diameter)=498 nm, D max (maximum diameter)=935 nm.

The patient underwent surgical treatment using the proposed method.

After installing 25G valve ports and replacing intraocular fluid with air, IOP was set at 15-18 mm Hg. A fragment of DM in the form repeating the shape of MP, with a maximum diameter of 2.0 mm, was formed with knitting tweezers from the peripheral sections of the preserved donor cornea, preserved after separation of the endothelial graft during transplantation of the Descemet's membrane. The surface of the Descemet's membrane fragment was stained for 30 seconds with a solution of methylene blue Membrane DualBlue to facilitate further visualization when working with it in the vitreal cavity. With the help of collet vitreal tweezers of the "crocodile" type, the DM fragment was passed through the valve port 25G and placed on the rupture zone. Then, residual intraocular fluid was removed from the surface of the retina using a “soft tip” cannula so that the DM fragment overlapped the edges of the MP by at least 0.5 mm from all sides. After that, 1 drop of pre-prepared autologous ACP serum was applied to the macular area. Serum was obtained in advance by centrifuging the patient's whole blood for 5 minutes at 1500 rpm. A fragment of the Descemet's membrane was additionally spread with the tip of tweezers in the ACP medium for 2 minutes, under the control of an operating microscope and intraoperative optical coherence tomography. The operation was completed with air tamponade of the vitreal cavity.

During the first 3 days, the patient kept the position face down.

1 month after the operation, the visual acuity of the right eye was 0.1 n/a, after 3 months - 0.2 n/a. According to SOCT, a fragment of the Descemet's membrane in the upper temporal segment of the parafovea is partially adjacent, the macular hole is completely closed with matching of its edges.

Clinical example 2

Patient Sh., 60 years old. Complaints about low vision of the left eye, distortion of objects. About six months ago, the left eye was operated on for a through macular rupture and cataract. The patient underwent vitrectomy, membrane peeling with simultaneous phacoemulsification, IOL implantation, and intravitreal gas tamponade.

Visual acuity OS - 0.05 n/a. According to spectral optical coherence tomography (SOCT) - through macular hole, D min (minimum diameter)=834 nm, D max (maximum diameter)=1145 nm.

The patient underwent surgical treatment using the proposed method.

After installing 25G valve ports and replacing intraocular fluid with air, IOP was set at 15-18 mm Hg. A fragment of the DM in the form repeating the shape of the MP, with a maximum diameter of 2.5 mm, was formed with knitting tweezers from the peripheral sections of a fresh donor cornea. The surface of the Descemet's membrane fragment was stained for 30 seconds with a solution of methylene blue Membrane DualBlue to facilitate further visualization when working with it. Using collet vitreal tweezers of the "crocodile" type, a DM fragment was passed through the valve port 25G into the vitreal cavity and placed on the rupture zone. Then, residual intraocular fluid was removed from the surface of the retina using a “soft tip” cannula so that the DM fragment overlapped the edges of the MP by at least 0.5 mm from all sides. After that, 1 drop of pre-prepared autologous ACP serum was applied to the macular area. Serum was obtained in advance by centrifuging the patient's whole blood for 5 minutes at 1500 rpm. A fragment of the Descemet's membrane was additionally spread with the tip of tweezers in the ACP medium for 2 minutes, under the control of an operating microscope and intraoperative optical coherence tomography. The operation was completed with air tamponade of the vitreal cavity.

During the first 3 days, the patient kept the position face down.

1 month after the operation, the visual acuity of the left eye was 0.08 n/a, after 3 months - 0.1 n/a. According to SOCT data, the edges of the macular hole are adapted with the formation of a focus of atrophy and hyperplasia of the pigment epithelium in the foveolar region. In the fovea, a membrane adjacent to the retina is determined.

Thus, the proposed method provides complete closure of a recurrent macular hole, regardless of the presence or absence of the ILM after a previous surgical intervention, reducing the trauma of surgical intervention.

Claims (1)

A method for the surgical treatment of recurrent idiopathic macular rupture using a donor Descemet's membrane, characterized in that the macular rupture is closed with a fragment of the donor cornea's Descemet's membrane with a shape that repeats the shape of the rupture, with dimensions not less than 1.0 mm greater than the dimensions of the rupture determined from preoperative data. optical coherence tomography (OCT), a fragment of the Descemet's membrane is centered relative to the macular rupture so that it overlaps the area of the rupture by at least 0.5 mm from all sides, then one drop of autologous ACP serum is applied to the macular area and the fragment of the Descemet's membrane is fixed to the surface of the retina fibrin clot, intraoperatively formed from autologous ACP of the patient's blood serum.