RU2801859C1 - Method of intraoperative induction of posterior vitreous detachment using preoperative spectral optical coherence tomography data - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: preoperatively, using spectral optical coherence tomography (SOCT), an area is determined in the parapapillary zone, outside the zone of the papillomacular bundle and the macular region, where there is a local detachment of the posterior hyaloid membrane (PHM) with a distance between the PHM and the retina of at least 150 μm. Intraoperatively, in the above zone at a distance of 300–500 microns from the border of the optic nerve head (OD), a microperforation is applied in the BGM with a vitreotomy. In this case, the distance from the edge of the vitreotome to the surface of the retina is 0.3–0.5 mm, and the window of the vitreotome is placed parallel to the surface of the retina and directed opposite the center of the optic disc. Then, in vacuum mode, the fibers of the vitreous body (VB) are aspirated into the vitreotome window until a semilunar fold of the PHM appears along the edge of the optic disc. Further, leaving the vitreous motionless for 2–3 seconds, local vitrectomy is performed with the capture and perforation of the BGM. Then, in the vacuum mode, by movements from the optic disc to the periphery, the cortical layers of the optic nerve are lifted by the aspiration method and the PHM is torn off from the edge of the optic disc, separating the optic nerve from the surface of the retina from the center to the periphery.

EFFECT: method provides rapid intraoperative induction of posterior vitreous detachment without the risk of iatrogenic damage to the fundus structures and without the use of dyes.

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Description

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for predictive intraoperative induction of posterior vitreous detachment (PVD) using preoperative spectral optical coherence tomography (SOCT) data during vitreoretinal surgical interventions.

Features of the anatomy of the vitreous body (VT): varying degrees of adhesion to different structures of the fundus, the close relationship of collagen fibers of the ST, Muller cell membranes and the internal pathogenesis of many vitreoretinal diseases [Li X, Shi X, Fan J. Posterior vitreous detachment with plasmin in the isolated human eye. // Graefes Arch Clin Exp Ophthalmol. 2002; 240:56-62. Banach MJ, Hassan TS, Cox MS, et al. Clinical course and surgical treatment of macular epiretinal membranes in young subjects. Ophthalmology. 2001 Jan; 108(1): 23-6. Joshi M.M., Ciaccia S., Trese M.T. Posterior hyaloid contracture in pediatric vitreoretinopathies // Retina. 2006 Sep; 26 (7Supl): s 38-41. Fang X, Chen Z, Weng Y, et al. Surgical outcome after removal of idiopathic macular epiretinal membrane in young patients. Eye (Lond). Nov 2008; 22(11): 1430-5]. Therefore, most vitreoretinal interventions for various pathologies begin with the induction of detachment of the posterior hyaloid membrane (PHM) and the removal of the posterior cortical layers of the ST in various volumes.

The problem of removing BGM and posterior cortical layers of STs began to be dealt with as early as the 80s of the 19th century [Zinn K.M. Surgical management of vitreoretinal membranes in proliferative diabetic retinopathy. // Bull NY Acad Med. - 1982. - Vol. 58(4). - P. 382-398].

To induce OST, it was proposed to use special scissors for fragmenting BGM, a microvitreal knife in combination with a blunt hook, a metal aspiration cannula, a spatula in combination with a light guide and a cannula with a silicone tip, a diathermic probe (Han D., Abrams G.W., Aaberg T.M. Surgical exscision of the attached posterior hyaloids // Arch. Ophthalmol. - 1988.- Vol. 106. - P. 998-1000; Mein C. E., Flynn J. Recognition and removal of the posterior cortical vitreous during vitreoretinal surgery for impending macular hole // Am. J. Ophthalmol. - 1991. - Vol. 111. - P. 61 l-613; Vander J. F., Kleiner R. A method for induction of posterior vitreous detachment during vitrectomy // Retina. - 1992. - Vol. 12. - P. 172-173; Stolyarenko G.E., 1995; Sdobnikova S.V., 1996; Alpatov S.A., 2002). These methods of separation of the posterior vitreal cortex are traumatic and do not always allow to achieve the desired result.

With the development of vitreoretinal surgery and the improvement of instruments, new techniques for inducing PVD have been proposed. So Shinoda K. et al. in 1999 suggested using a 32G cannula for BSS infusion into the retrohyaloid space. Later, techniques were developed using a retinal spatula in combination with PFOS, specially designed cannulas for BMS hydroseparation, a diamond-tipped scraper, a special flexible loop, and a special hook made from a 23G injection needle. (Takhchidi Kh.P., 2002; Zakharov V.D., 2008; Lyskin P.V., 2008; Nazaryan M.G., 2009; Takeuchi M. Br J Ophthalmol 2012; 96: 1378-1379. Espinosa L.A. Retinal Cases & Brief Reports: Spring 2020 - Volume 14 - Issue 2 - p 137-140; Tang WY Int J Ophthalmol, vol 14, No. 4. Apr 18. 2021). However, separation of the posterior vitreal cortex using these instruments was associated with a high risk of retinal injury and did not always achieve the desired result.

With the development of vitreoretinal surgery and the improvement of instruments, new techniques for inducing PVD have been proposed. Shinoda K. et al. in 1999 suggested using the 32G cannula for BSS infusion into the retrohyaloid space. Later, techniques were developed using a retinal spatula in combination with PFOS, specially designed cannulas for BGM hydroseparation, a diamond-coated scraper, a special flexible loop, and a special hook made from a 23G injection needle (Takhchidi Kh.P., 2002; Zakharov V. Espinosa L.A. Retinal Cases & Brief Reports: Spring 2020 - Volume 14 - Issue 2 - p 137-140; Tang WY Int J Ophthalmol, vol 14, No. 4. Apr 18. 2021). The proposed techniques did not have sufficient efficiency and were unnecessarily traumatic.

Most of the methods of intraoperative OST induction mentioned above involve the use of various dyes (membrane blue dual, triamcinolone acetonide, Vitreocontrast, etc.), but the ideal contrast agent does not yet exist. In addition, dyes can have a toxic effect on the structures of the eye, as well as lengthen the duration of the surgical intervention due to the time required to remove the contrast agent (Kislitsyna N.M., 2018, Shkvorchenko D.O., 2016, Kashtan O.V., 2010, Peyman G.A., 2000, Matsumoto H., 2007).

Chemical vitreolysis as the first stage of OST induction has not become widespread due to the possible toxicity of enzyme preparations, their high cost, autoimmune reactions, the risk of hemorrhagic complications and proliferative vitreoretinopathy (PVR).

Thus, all known surgical techniques for OST induction are somehow associated with increased trauma when working with instruments in close proximity to the retina or with the use of chemical compounds (enzymes, dyes), which can potentially have a toxic effect on the structures of the eye and increase the duration of surgery.

Therefore, it is relevant to search for new methods for separating PHM and posterior cortical layers from the retina as the first stage of surgical treatment of various vitreoretinal pathologies.

The objective of the invention is to develop a method for predictable intraoperative induction of OST as the first stage of surgical treatment of various vitreoretinal pathologies using preoperative spectral optical coherence tomography (SOCT) data during vitreoretinal surgical interventions.

The technical result of the proposed method is the rapid intraoperative induction of OST without the risk of iatrogenic damage to the fundus structures and without the use of dyes.

The technical result is achieved by the fact that, according to the invention, preoperatively using SOCT, a site is determined in the parapapillary zone, outside the zone of the papillomacular bundle and the macular region, where there is a local detachment of the BM with a distance between the BM and the retina of at least 150 μm; intraoperatively in the above area at a distance of 300-500 microns from the border of the optic disc with a vitreotomy, microperforation is applied in the BGM; while the distance from the edge of the vitreotome to the surface of the retina is 0.3-0.5 mm, and the window of the vitreotome is placed parallel to the surface of the retina and directed in the direction opposite to the center of the optic disc; then, in vacuum mode, CT fibers are aspirated into the window of the vitreotomy until the appearance of a characteristic BGM wave along the edge of the optic disc; then, leaving the vitreous motionless for 2-3 seconds, local vitrectomy is performed with the capture and perforation of the BGM; after that, in the vacuum mode, movements from the ONH to the periphery by the aspiration method raise the cortical layers of the ST and tear off the PHM from the edge of the ONH, separating the ST from the surface of the retina from the center to the periphery.

The technical result is achieved due to the fact that:

1) SOCT is performed preoperatively and an area in the parapapillary zone is determined, where there is a local detachment of the BM with a distance between the BM and the retina of at least 150 μm;

2) with local detachment of the PHM, the closed cavity between the PHM and the ILM of the retina (retrohyaloid space) is completely filled with intraocular fluid, and at the moment of separation of the posterior vitreal cortex by the aspiration-traction method, a “membrane-vacuum effect” occurs: a negative pressure occurs in the retrohyaloid space, preventing separation BGM and cortical layers of ST from the retina. And this resistance is the greater, the larger the area of the membrane at the same time the surgeon tries to raise. At the same time, the force holding the BGM at the place of its attachment along the edge of the optic disc is much weaker than the force indicated above. According to Pascal's law, to balance the pressure on both sides of the BM, it is necessary to ensure the flow of fluid into the retrohyaloid space. To do this, it is necessary to violate its integrity. When applying microperforation in BGM, the necessary conditions are created for the flow of fluid into the retrohyaloid space and induction of OST. After that, the separation of BGM from the edge of the optic disc does not cause difficulties;

3) manipulation of the vitreotome tip at a distance of 300-500 microns from the surface of the retina and the edge of the ONH, as well as the direction of the vitreotome window parallel to the surface of the retina, minimizes the risks of iatrogenic damage to the above structures of the fundus even at high vacuum, provided that the retina is in these areas;

4) by aspirating the posterior cortical layers of the CT parapapillary during the operation of the vitreotome in vacuum mode, it becomes possible to visualize the translucent structures of the posterior cortical layers of the CT. With active aspiration of the ST along the edge of the ONH, a characteristic wave appears, which is a fold of the posterior hyaloid membrane of the ST parapapillary, as well as an area of tension of the PHM in the place of its strong attachment along the edge of the ONH. This is because the posterior cortical layers of the ST are tightly fused to the edge of the ONH, but not to the parapapillary retina, where the elevation of the PHM occurs. When the vacuum impact on the cortical layers of the ST is concentric to the ONH and the tension of the ST in the area of attachment to the ONH, it is possible to visualize the Weiss ring, which has not yet been separated from the ONH. This makes it possible to induce OST without the use of dyes that have a toxic effect on the structures of the fundus, as well as to reduce the time required for the introduction and subsequent removal of the dye from the vitreal cavity;

5) change of operating modes of the vitreotome "vacuum" and "cutting" at a fixed position of the tip of the vitreotome makes it possible to visualize the translucent posterior cortical layers of the vitreous body in the parapapillary zone without the use of dyes.

The method is carried out as follows.

Preoperatively, a detailed study of the vitreoretinal interface is performed using the Solix device (Optovue, USA) using the Full Range Retina protocol with a scan length of 16 mm, the results of which assess the degree of vitreomacular (VMA) and vitreopapillary adhesion (VPA). At the first stage of the study, a linear scan is performed, passing through the foveola and the center of the ONH. In the course of the study, the degree of VPA and VMA is determined in zones with a diameter of 16 mm with a center in the projection of the optic disc and the foveolar region. If there is a linear scan passing through the center of the optic disk and the center of the foveola, and SMA and VPA, further research is also performed by a linear scan circularly on the optic disk and the foveola area with the location of these structures in the centers of the scans. Next, on the obtained images, the distance between the BGM and the inner surface of the retina is estimated. The optimal areas for intraoperative OST induction are parapapillary areas with a distance between the BGM and the inner surface of the retina of at least 150 μm, located outside the zone of the papillomacular bundle and the macular region as a whole, and in the nasal or lower or upper parapapillary quadrant. The data obtained are the basis for choosing a quadrant concentric to the ONH, at a distance of 300-500 microns from the border of the ONH, to induce OST most quickly and safely. The standard transconjunctival 3-port surgery technique 25-27G is used. Vacuum parameters - 650 mm Hg. The frequency of cuts is 5000 per minute. 3D mode. After the standard transconjunctival installation of ports, proceed directly to the stages of the proposed method of induction of PVD. The optic disc is conditionally divided into 4 quadrants, like a circle: upper and lower, as well as nasal and temporal. Manipulations to separate the posterior cortical layers of the ST are performed in the area determined preoperatively according to SOCT data. I don't use dyes. The vitreotome tip is brought to the surface of the retina parapapillary (300-500 µm from the border of the optic disc) in the area preoperatively determined according to SOCT data, the distance from the edge of the instrument to the surface of the retina is 300-500 µm. The window of the vitreotome is directed in the direction opposite to the center of the optic disc. After setting the tip of the vitreotome to the desired position, a maximum vacuum (650 mm Hg) is created to aspirate the CT fibers into the window of the vitreotome until a characteristic wave appears in the form of a semilunar fold along the edge of the ONH, illustrating the occlusion of the vitreotome window, the rise of the CT above the retina and the tension of the attachment area ST along the edge of the optic disc. Further, without displacing the vitreotome, they switch from the vacuum mode to the cut mode with a frequency of 5000 cuts per minute and maximum vacuum (650 mm Hg) in 3D mode and perform local vitrectomy, leaving the vitreotome motionless, for 2-3 seconds. Thus, the posterior hyaloid membrane is perforated in the selected area of the parapapillary zone. Then, in the vacuum mode, movements from the optic disc to the periphery pull up the cortical layers of the CT and separate the PHM from the retina and the optic disc from the center to the periphery.

The invention is illustrated by the following clinical data.

Clinical example

Patient K., 57 years old. She complained of decreased vision and distortion in the right eye for 3 months. On admission, the maximum corrected visual acuity (BCVA) was 0.2 n/a. According to SOCT data: primary penetrating macular hole (MP) of the retina, the minimum hole diameter is 410 µm. No pathology was found in the fellow eye. Diagnosis: primary penetrating macular hole of the retina of large diameter.

The patient underwent a detailed preoperative diagnosis of the vitreomacular interface using the Solix device (Optovue, USA) using the Full Range Retina protocol with a scan length of 16 mm. The degree of vitreomacular and vitreopapillary adhesion was assessed. The most suitable area for the subsequent induction of PVD was determined (lower quadrant of the parapapillary zone with a maximum distance between the PHM and the ILM of the retina of 420 µm).

The patient was operated on using the proposed method. Intraoperative OST was induced in 10 seconds, there was no damage to the structures of the fundus, no dyes were used. High postoperative functional and anatomical results were achieved. MP closed 1 month after surgery. MKO3-0.3. 3 months after the operation MP is closed, BCVA 0.7. 6 and 12 months after the operation, the condition was without significant dynamics.

Using the proposed method, 35 patients with macular retinal tears, idiopathic epiretinal fibrosis, post-thrombotic retinopathy, retinopathy of prematurity, rhegmatogenous retinal detachment and non-proliferative diabetic retinopathy were operated on. In all cases, OST was induced in 10-15 seconds, there was no damage to the fundus structures, no dyes were used.

Thus, the proposed method provides rapid intraoperative induction of OST without the risk of iatrogenic damage to the fundus structures and without the use of dyes.

Claims (1)

A method for intraoperative induction of posterior vitreous detachment using data from preoperative spectral optical coherence tomography, which consists in preoperatively using spectral optical coherence tomography (SOCT) to determine the area in the parapapillary zone, outside the zone of the papillomacular bundle and the macular region, where there is a local detachment of the posterior hyaloid membrane (HM) with a distance between the HM and the retina of at least 150 microns; intraoperatively in the above area at a distance of 300-500 microns from the border of the optic nerve head (OD), a microperforation is applied in the BM with a vitreotomy; while the distance from the edge of the vitreotome to the surface of the retina is 0.3-0.5 mm, and the window of the vitreotome is placed parallel to the surface of the retina and directed in the direction opposite to the center of the optic disc; then, in vacuum mode, the fibers of the vitreous body (ST) are aspirated into the vitreotome window until a semilunar fold of the PHM appears along the edge of the optic disc; then, leaving the vitreous motionless for 2-3 seconds, local vitrectomy is performed with the capture and perforation of the BGM; after that, in the vacuum mode, movements from the ONH to the periphery by the aspiration method raise the cortical layers of the ST and tear off the PHM from the edge of the ONH, separating the ST from the surface of the retina from the center to the periphery.