RU2803007C1 - Method of surgical treatment of macular hole - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: vitrectomy is performed with the isolation and removal of the posterior hyaloid membrane, a drop of a perfluoroorganic compound is applied to the macular rupture, around which the inner limiting membrane is stained, which is then removed. Next, a drop of perfluoroorganic compound is aspirated and the balanced salt solution (BSS) is replaced with air, while active and then passive aspiration of the residual fluid is carried out. After that, a drop of blood plasma enriched with platelets is applied to the area of the macular rupture. Passive aspiration of the residual fluid is carried out within the lower and upper temporal vascular arcades above the zone where the inner limiting membrane has not been removed without contact with the retina, and after applying a drop of blood plasma enriched with platelets to the rupture area, it is left for 1 minute to form a film fibrin. Then, a drop of a perfluoroorganic compound is applied to the fibrin film and left for 5 minutes. After that, a drop of perfluororganic compound is removed by passive aspiration and the air is replaced with BSS.

EFFECT: method allows to achieve complete and stable anatomical closure of the macular retinal hole and reduce the risk of intra- and postoperative complications.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of idiopathic macular holes in the retina.

There is a known method of surgical treatment of macular holes using autologous platelet-rich plasma, described in patent RU No. 2606338, (application 11/19/2015, published 01/10/2017), according to which vitrectomy is performed, including removal of the posterior hyaloid membrane, removal of the internal limiting membrane of the retina and tamponade of the vitreous cavity with gas, for which the previously introduced irrigation solution is exchanged for air, first by active aspiration of the solution, and then the remaining layer of solution, corresponding to 2-3 diameters of the macula, is aspirated passively using a cannula, inside of which there is a silicone tube with cuts forming petals. The macular defect is blocked by applying autothrombomass to the area of the rupture, and finally changing the air to gas. In this case, active aspiration of the solution is performed in two approaches: first, the solution is aspirated to the level of the equator, then no action is performed for 5 minutes, that is, the vitreous body is “dried,” after which the remaining solution is again actively aspirated to a level at which the diameter of the remaining layer corresponds to 2-3 diameters of the macula, then switches to passive aspiration, brings together the edges of the macular hole, and blocks the hole with autologous platelet-rich plasma.

There is a known method for treating macular hole (RU patent No. 2620929, application 08.18.2016, publ. 05.30.2017). The method includes performing vitrectomy with isolation and excision of the posterior hyaloid membrane. The pre-stained internal limiting membrane is also removed. Active and after 5-7 minutes additional passive aspiration of the remnants of the vitreous body above the rupture is carried out without mechanical reduction of the edges of the rupture. Platelet-rich blood plasma (PRBP) is administered and final retinal tamponade is carried out with air. In this case, the area of the macular hole is treated with sulfated glycosaminoglycans at a concentration of 1 to 5% before the administration of PRP and at a concentration of 0.05% after the administration of PRP.

There is a known method for treating large macular retinal holes without tamponade of the vitreal cavity (RU patent No. 2735465, application 06/29/2020, publ. 11/02/2020). A 25G vitrectomy is performed, and the internal limiting membrane (ILM) is stained and peeled. Apply to the area of platelet-rich blood plasma (PRP) rupture. The application of PRP with its subsequent six-minute exposure is carried out under a bubble of perfluorodecalin. Removal of the vitreous is carried out in the direction from the anterior sections to the optic nerve head (OND). The posterior layers of the vitreous are stained with a vital dye and separated from the surface of the retina using aspiration techniques, starting from the optic disc, lifting them to the periphery. After staining the ILM, it is mobilized. Circular membranorrhexis is performed around the foveola, measuring 2 times the diameter of the optic disc. The ILM is separated from the periphery to the center in separate sections along the meridians, collecting it over the gap and removing it with tweezers. Subsequent approximation of the edges of the macular hole is carried out using an extrusion cannula in a perfluorodecalin environment using the method of passive aspiration, within the ILM peeling zone using the distal end of the cannula installed above the hole zone. The prepared PRP with a volume of 0.1 ml is applied with a six-minute exposure under a perfluorodecalin bubble. Perfluorodecalin is removed by passive aspiration; after removal of the sclerostomy ports, the sclerostomy is sutured, and the operation is completed without tamponade of the vitreal cavity.

The disadvantages of the known methods are mechanical damage to retinal tissue during passive aspiration over a retinal break and the formation of an irregular foveal profile after surgery. At the time of evacuation of residual fluid over the rupture, the edges of the rupture may “tighten”, which can lead to trauma to the retinal tissue. In addition, if this manipulation involves tightening the edges of the tear, this can lead to trauma in the form of hemorrhagic complications, retinal tears and other intraoperative complications, which leads to disruption of the restoration of the vitreomacular interface zone in the postoperative period.

The closest analogue, adopted as a prototype, is a method of surgical treatment of idiopathic macular hole using platelet-rich blood plasma (Krupina E.A., Dissertation for the degree of candidate of medical sciences: 01/14/07 - Moscow, 2019 ). The method involves performing vitrectomy, during which the posterior hyaloid membrane was separated from the surface of the retina, stained and the ILM was removed. Next, the intraocular fluid was removed only above the optic nerve head. After sequential fluid/air replacement, without reducing the edges of the rupture, PRP was administered intravitreally through a 27G cannula in the volume of one drop. Under visual control, passive aspiration of excess PRP was performed, ensuring its localization in the fovea. The operation was completed with normotension and tamponade of the vitreal cavity with air. After surgery, the patient was advised to remain in a face-down position until the evening of the day of surgery.

The disadvantage of this method is the high risk of traumatic effects on the optic nerve head, and damage to the central retinal vein and central retinal artery by the vitreal cannula during removal of intraocular fluid above the optic nerve head. Damage to the optic disc can lead to deterioration of functional results in the postoperative period, especially in patients with previously diagnosed diseases: partial optic atrophy, glaucoma and others. Damage to the central retinal vein and central retinal artery can cause massive intra- or postoperative hemorrhage into the eye cavity.

The problem of the claimed invention is the development of an atraumatic method for the surgical treatment of macular retinal holes, which makes it possible to achieve complete and stable anatomical closure of the gap and achieve higher functional results.

The technical result of the claimed invention is to reduce trauma to the retina, reduce intra- and postoperative complications.

To achieve the stated technical result in the method of surgical treatment of a macular retinal hole, including performing vitrectomy with isolation and removal of the posterior hyaloid membrane, applying a drop of a perfluoroorganic compound to the macular hole, around which the internal limiting membrane is painted, which is then removed, then a drop of the perfluoroorganic compound is aspirated and replaced balanced salt solution (BSS) in air, while active and then passive aspiration of residual fluid is carried out, after which a drop of platelet-rich blood plasma is applied to the area of the macular hole; according to the invention, passive aspiration of residual fluid is carried out within the lower and superior temporal vascular arcades without contact with the retina, and after applying a drop of platelet-rich blood plasma to the area of the rupture, wait one minute to form a fibrin film, then apply a drop of PFOS to the fibrin film, wait five minutes, then remove the drop of PFOS by passive aspiration and replace it air on BSS.

The method is carried out as follows.

The operation begins with a three-port 25-27G vitrectomy in the presence of an irrigating solution, which is a balanced salt solution BSS. All ports have a valve-type design, which ensures the most complete sealing of the vitreal cavity and makes it possible, if necessary, to shut off the process, for example, the supply of irrigation fluid during staining of the internal limiting membrane. Vitrectomy is completed by isolating and removing the posterior hyaloid membrane. A drop of perfluoroorganic compound (PFOS) is then applied to the macular hole using a 27G cannula to protect the retinal layers in the macular area from exposure to the dye. The diameter of a PFOS drop is 1.5-2.0 diameters of the macular hole. Next, the flow of BSS solution through the irrigation system is stopped (the system itself is not discharged from the port). In this case, a vitreotomy is removed from the adjacent port and a cannula on a syringe with a dye, for example, brilliant blue (“Brilliant BlueG” from DORC), is inserted into the port. The inner limiting membrane around the PFOS drop is stained, which is then removed using ILM tweezers. Next, a drop of PFOS is aspirated. Then the BSS solution, which filled the vitreal cavity, is replaced with air. After active aspiration of the BSS solution, immediately perform additional passive aspiration of residual fluid within the inferior and superior temporal vascular arcades above the area where the internal limiting membrane was not removed, without contact with the retina. Carrying out passive aspiration not over the optic disc and the macular hole of the retina, but within the vascular arcades, eliminates the possibility of traumatizing the optic disc and the edges of the macular hole. After “drying” the fundus, a drop of platelet-rich blood plasma is applied to the area of the macular hole. One minute after application, a fibrin film forms in the area of the rupture, and a drop of PFOS is placed on top of this film. After which the air is immediately replaced with a BSS solution. The PFOS drop is exposed for five minutes, after which the PFOS drop is removed by passive aspiration. The operation is completed, the vitreal cavity is filled with BSS solution, which is not a tamponing substance, but the macular hole has been successfully eliminated.

The method makes it possible to achieve complete and stable anatomical closure of the macular retinal hole and reduce the risk of intra- and postoperative complications.

Example 1

Patient A., 62 years old, applied on January 20, 2022 with complaints of a “spot” in front of the left eye, metamorphopsia of the left eye for 4 months.

When examining the left eye: The anterior segment is without features; when examining the fundus: the optic disc is pale pink, the boundaries are clear, there is a gap in the macular zone.

Visual acuity of the left eye 0.1 sph -1.5 = 0.2 Cyl -1.25 Ax165 = 0.15; IOP (Pi) 14 mm Hg.

Visual acuity of the right eye 0.8 sph -0.75= 0.85 Cyl -1.0 Ax10 = 0.9; IOP (Pi) 15 mm Hg.

Optical coherence tomography confirmed a macular hole measuring 414 μm.

Diagnosis : Stage 4 macular hole in the left eye.

The operation was carried out according to the stated method.

When examined on the second day after surgery, the anterior segment was without any features. According to optical coherence tomography, the macular hole is closed. Corrected visual acuity was 0.25 n/k; IOP (Pi) = 6 mm Hg.

The patient was discharged home.

When examined 5 weeks after surgery, when examining the fundus: the macular hole is closed. Visual acuity of the left eye was 0.4 n/k; IOP (Pi) = 18 mm Hg.

According to optical coherence tomography, the macular hole is closed. The patient was sent under the supervision of an ophthalmologist at his place of residence.

Example 2

Patient L., 69 years old, applied on February 17, 2022 with complaints of “distortion” in front of the left eye for 8 months.

When examining the left eye: The anterior segment is without features; when examining the fundus: the optic disc is pale pink, the boundaries are clear, there is a gap in the macular zone.

Visual acuity of the left eye 0.1 sph n/c Cyl -1.0 Ax165 = 0.2; IOP (Pi) 8 mm Hg.

Visual acuity of the right eye 0.2 sph -1.5 = 0.5 Cyl -0.75 Ax15 = 0.75; IOP (Pi) 9 mm Hg.

Optical coherence tomography confirmed a macular hole measuring 654 μm.

Diagnosis : Stage 4 macular hole in the left eye.

The operation was carried out according to the stated method.

When examined on the second day after surgery, the anterior segment was without any features. According to optical coherence tomography, the macular hole is closed. Corrected visual acuity was 0.2 n/k; IOP (Pi) 6 mm Hg.

The patient was discharged home.

When examined 1 month after surgery, when examining the fundus: the macular hole is crushed. Visual acuity was 0.35 n/k, IOP (Pi) 8 mm Hg.

According to optical coherence tomography, the macular hole is closed. The patient was sent under the supervision of an ophthalmologist at her place of residence.

At JSC EC MNTK Eye Microsurgery, 29 eyes were operated on using the stated method. All operations were successful, and in all cases the macular hole was eliminated. The result was a higher functional outcome.

Claims (1)

A method of surgical treatment of a macular retinal hole, including performing vitrectomy with isolation and removal of the posterior hyaloid membrane, applying a drop of a perfluoroorganic compound to the macular hole, around which the internal limiting membrane is stained, which is then removed, then aspirating a drop of the perfluoroorganic compound and replacing the balanced salt solution (BSS) into the air, while active and then passive aspiration of the residual fluid is carried out, after which a drop of platelet-rich blood plasma is applied to the area of the macular hole, characterized in that passive aspiration of the residual fluid is carried out within the lower and upper temporal vascular arcades above the area where the internal limiting membrane has not been removed without contact with the retina, and after applying a drop of platelet-rich blood plasma to the area of the rupture, wait 1 minute to form a fibrin film, then apply a drop of a perfluoroorganic compound to the fibrin film, wait 5 minutes, then by passive aspiration removes a drop of perfluoroorganic compound and replaces the air with BSS.