A method for predicting excessive scarring after antiglaucomatous surgery

 

(57) Abstract:

The invention relates to medicine, namely to ophthalmology, and is intended for forecasting of excessive scarring of the newly created pathway for aqueous outflow after antiglaucomatous operations. The method consists in the fact that the preoperative and early postoperative period in serum to determine the concentration of transforming growth factor - 1 and when saving or reduction in early postoperative period predict excessive scarring. The technical result - the method provides the possibility of application of known measures to combat excessive regeneration in the early postoperative stage, before the appearance of signs of scar blockade of the newly established ways of aqueous outflow in patients with identified risk of the occurrence of this complication.

The invention relates to medicine, namely to ophthalmology, and is intended for forecasting of excessive scarring of the newly created pathway for aqueous outflow after antiglaucomatous operations, such as sinusotrabeculactomy.

It is known that the success of antiglaucoma surgery is determined by the normalization of intraocular pressure is after antiglaucomatous surgery scarring newly established ways of aqueous outflow is recognized as one of the main.

The objective of the invention is to develop a predictor of excessive scarring after antiglaucomatous surgery in patients with advanced stages of primary open-angle and secondary postoiannoi glaucoma.

According to different authors, excessive scarring in the area of the newly created pathway for aqueous outflow leads to increased intraocular pressure in the postoperative period in 15-45% (Lebedev, O. I. Clinical and experimental validation, prediction and regulation of reparative processes in surgery of primary glaucoma. Diss. Prof. the honey. Sciences. 1990, S. 56-70). To cope with this complication is quite difficult, the use of antimetabolites has its limitations and cannot be applied to all patients. Often we have to offer follow-up operation. Therefore, the relevance of the search for the causes of excessive regeneration in the area of surgical intervention and the possibility of its prevention is one of the important aspects of the success of surgical treatment of glaucoma.

To prevent this complication are available intraoperative prevention in the form of cytostatic agents, antimetabolites and surgical modifications of sinusotrabeculactomy. However, their performance is not obschestva postoperative prevention of this complication, in addition to the known widespread use of corticosteroids, cytotoxic agents, antimetabolites, the technique of instalaci autologous natural complex of cytokines derived from blood of the patient in the conjunctival cavity in the early postoperative period (RU # 2122385, 1996). The proposed methodology typically used in patients conventionally called risk group (young age, re-operated patients, patients with postoiannoi glaucoma) during surgery or immediately after surgery. However, it does not account for the peculiarities of the immune status of patients, which, according to the latest years, can have a significant impact on the postoperative course and outcome of antiglaucomatous operations (j.N. Lopace. Clinical and immunological prediction and surgical prevention of excessive scarring after antiglaucomatous surgery. Diss. Kida. the honey. of Sciences, 2000, S. 55-70). Found that immunological examination can assist the surgeon in determining the risk of adverse outcome antiglaucomatous operations. So, there is a method of predicting excessive scarring after antiglaucomatous operact antibodies of class G antibodies to collagen type III and, in the absence predict the risk of excessive scarring in the postoperative period (nearest equivalent). However, this method has some significant limitations. Its use does not take into account the possibility of postoperative changes in immunological parameters because of a reaction to surgical trauma, which reduces the predictive information content of the survey. In addition, the described method is applicable only in patients with POAG, then, as it is known that early scarring zone created during sinusotrabeculactomy ways of aqueous outflow in secondary glaucoma develops much more often, and the application of this method of prediction in these patients is not possible.

The proposed method provides not just a definition of the investigated parameter before surgery and in the early postoperative period (7-9 days), but control of its dynamics, which is more objective with regard to the influence of surgical trauma on the overall proliferative processes. The investigated parameter is one of the main modulators of proliferation - transforming growth factor-beta 1 (TGF-1), having a direct impact on postoperative regeneration. In addition, to carry out the proposed research is twice reduced the required number of test priznachena.

The interest in studying the role of TGF-1 in eye surgery, especially in patients with glaucoma have increased in recent years due to the latest experimental and preliminary clinical data on the role of growth factors in the regulation of post-operative scarring (M. F. Cordero, N. Kwan. et. al. Effect of TGF-1 antisense oligonucleotide in conjunctival scarring - a potencial new antiscarring surgery strategy. VI Congress of the European Glaucova Society, 2000, p.124).

The technical result of the invention is the possibility of application of known measures to combat excessive regeneration in the early postoperative stage, before the appearance of signs of scar blockade of the newly established ways of aqueous outflow in patients with identified risk of this complication.

The technical result is achieved by analysis of the content of transforming growth factor - 1 in the serum of patients prior to scheduled antiglaucoma surgery and early after surgical intervention (7-9 days). When you save and/or aggravation of pre-operative deficit is projected scarring newly established ways of aqueous outflow.

When evaluating using ELISA content of transforming growth factor-1 revealed that it is to the use of the proposed method for predicting the outcome of antiglaucomatous operations was revealed worsening of the deficit after sinusotrabeculactomy under adverse outcome of surgical intervention with scar blockade formed ways of aqueous outflow. Holding antiglaucomatous operation causes the response of the immunological reaction, manifested by changing the system of production TFF-1.

The method is as follows: serum diluted in phosphate-saline buffer (pH 7,2) 1:100, using ELISA to determine the content of transforming growth factor-1. Use commercial test system for ELISA, production Promega, USA, or its analogs. The serum in patients with primary open-angle glaucoma has been the traditional way to antiglaucoma surgery and in the early postoperative period (7-9 days).

Patients underwent antiglaucomatous operation-sinusotrabeculactomy. Before and after surgery (7-9 days) studied the content of transforming growth factor-1 (total) in serum. Inspection in the postoperative period was carried out after 2, 4, 6, and 8 weeks after the operation. During the traditional clinical examination, special attention was paid biomicroscopy filtration pillows and gonioscopic inspection formed fistula operated eye. The possibility of forecasting the result of the operation on the proposed indicators allows the surgeon prima moisture in the early postoperative period: the use of instalaci autologous natural complex of cytokines, subconjunctival injections of corticosteroids, which, according to some authors, enhance the expression of specific isoforms of TGF-1 in vitro in vivo dissection of scar technique “needling”.

Thus, the possibility of prediction of the results of surgical treatment of glaucoma based on the identification of immunological markers of the risk of excessive scarring of the newly established ways of outflow of the contents of TGF-1 serum in the dynamics before and after the operation. Preservation and/or worsening the deficit rate in the early postoperative period is an adverse prognostic sign of excessive regeneration in the intervention area. Increased production of TGF-1 in the same period compared to cooperationin indicators were associated with favorable outcomes antiglaucomatous operations.

Clinical examples.

Example 1. Patient M., 1941, was admitted with a diagnosis of right eye - open-IIB glaucoma, high myopia; the left eye is open Ia glaucoma, high myopia.

Visual acuity:

right eye - 0,08 with Corr.-7,0=0,7

left eye - 0.05 s Corr. -7,0=0,7

IOP before pergamena operation of the right eye - sinusotrabeculactomy. One month after surgery, the observed increase in IOP of up to 32 mm Art. RT, scarring of the filtration pillows and fistula, which is confirmed by gonioscopic. Transforming growth factor-1 in serum was before the surgery 4480 PCG/ml and 3040 PCG/ml in the early postoperative period. Negative dynamics of TGF-1 postoperative period against the background of its minor deficit before surgery was associated with early scarring intervention zone and adverse outcome of the operation. Proposed and re-sinusotrabeculactomy modification.

Example 2. Patient K., 1924, was admitted with a diagnosis of right eye - open-IIIA operas. glaucoma, primary cataract; the left eye is open IIIA glaucoma, almost Mature cataract.

Visual acuity:

right eye - 0.2 with Corr. - 1,0=0,4

the left eye is not 0,02 Corr

IOP before surgery:

the right eye is 19 mm Art. RT

left eye 18 mm Art. RT

Produced antiglaucoma surgery of the left eye - sinusotrabeculactomy. 3 weeks after surgery, the observed increase in IOP to 35 mm RT. article, scarring of the filtration pillows and fistula confirmed gonis week after it. The reduction of the content of TGF-1 in the postoperative period compared with before the operation associated with scar blockade in the intervention area. Proposed and re-surgery - sinusotrabeculactomy modification.

Example 3. Patient S., 1925, was admitted with a diagnosis of right eye - open IV and operated glaucoma, primary cataract; the left eye is open W glaucoma, primary cataract.

Visual acuity:

the right eye is 0

left eye - 0,2 not Corr

IOP before surgery:

right eye 17 mm Art. RT

left eye - 27-28 mm Art. RT

Produced antiglaucoma surgery of the left eye - sinusotrabeculactomy. Transforming growth factor-1 in serum was before the operation 1440 PCG/ml and 4480 PCG/ml through week after it. Filtration bleb during the whole period was spilled, and IOP operated eye compensated throughout the observation period. Thus, the elevated levels of TGF-1 in the serum after antiglaucomatous surgery compared with preoperative indicators is prognostically favorable sign.

tobalina S glaucoma, uveitis (remission), immature cataract.

Visual acuity:

right eye - 0.4 with Corr. + 1,5=0,9

left eye -0,4 not Corr

IOP before surgery:

right eye - 18-21 mm Art. RT

left eye - 31 mm Art. RT

Produced antiglaucoma surgery of the left eye-sinusotrabeculactomy. Before the operation, transforming growth factor-1 in serum was not detected, and in the postoperative period amounted to 1600 PCG/ml In the postoperative period on the background of active anti-inflammatory therapy exacerbation of primary uveal process is not revealed. Filtration bleb during the whole period was spilled, and IOP operated eye compensated. In this case, the indicators TGF-1 before the operation were below the sensitivity of the test (330 PCG/ml), possibly associated with changes in the immunological picture on the background of the General inflammatory process. However, in the early postoperative period marked growth TGF-1 in comparison with the preoperative indicators that were associated with a favorable outcome of the performed operation.

A method for predicting excessive scarring after antiglaucomatous surgery by research spywareantispyware growth factor -1 and when saving or reduction in early postoperative period predict excessive scarring.

 

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