Surgical method for treating edematic hemorrhagic forms of diabetic retinopathy

FIELD: medicine.

SUBSTANCE: method involves carrying out vitrectomy with posterior hyaloid membrane and interior boundary membrane in the central retina zone being withdrawn. Vitreal cavity tamponade with perfluororganic compound and retinal endoscopic laser coagulation are carried out. The perfluororganic compound is removed or substituted with physiologic saline or silicon oil in the course of operation. Tunnel is formed in sub-Tenon space after having sealed the eyeball and restored intraocular pressure. Flexible polymer implant covered with hydrogel material is introduced into the tunnel with flat insert manufactured from magnetic material producing permanent magnetic field of 3.5-5 mTesla units with multipolar reversed magnetization. Distal end of the implant having magnetic insert is extrasclerally arranged in the central retina zone edema projection area. The proximal end is sutured to sclera in equatorial zone. 3-5 weeks later, the implant is withdrawn.

EFFECT: enhanced effectiveness of treatment; accelerated retinal edema resorption.

5 cl, 3 dwg

 

The invention relates to medicine, namely to ophthalmology, and can be used in the surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy.

Edematous-hemorrhagic form of diabetic retinopathy is one of the most severe, adverse prognostic and difficult to treat forms of the disease (Glinchuk YA et al., 1995; Bresnick H.G., 1986), characterized by retinal edema in the Central region, the deposition of exudates and hemorrhages. Drugs virtually ineffective in this disease and can only be used as auxiliary measures (A.D. Semenov et al., 1979; Bresnick H.G., 1986). The positive effect transpupillary coagulation of the retina is not more than 50% (Pluhova O.A., 1988). The most effective is surgical treatment. But only vitrectomy is not possible to achieve complete and rapid resorption of swelling of the retina in the Central region. Therefore, swelling and hemorrhagic forms of diabetic retinopathy requires an integrated approach to their treatment.

A known method of surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy (Abinbev Z.K. Surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy (using performancesin compounds): Diss. ... candles. the honey. Sciences. - M., 1997. - S-70), including vitrectomy with removal of the posterior hyaloid membrane, tamponade vitreal cavity performancesin connection (PFOS) and endolaser coagulation of the retina.

The disadvantage of this method is that it does not ensures complete and rapid resorption of swelling of the retina in the Central region.

The objective of the invention is to provide a method that can improve the efficiency of surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy.

The technical result is to accelerate the resorption of swelling of the retina, the stabilization of the pathological process improvement and preservation of visual function.

The technical result is achieved in that in the method of surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy, including vitrectomy with removal of the posterior hyaloid membrane, tamponade vitreal cavity of PFOS and endolasercoagulation of the retina, according to the invention when performing vitrectomy additionally remove internal border membrane (VPM) in the Central area of the retina. PFOS remove and replace the saline or silicone oil during the operation. After sealing the eyeball and recovery IOP in Sultanova space forms a tunnel into which is injected an implant made of elastic polymer material, for example, and biologicial polymer, for example on the basis of polyorganosiloxane or silicone rubber covered with a hydrogel material, length 20 mm, width 8 mm, thickness 2 mm

The implant is made in the form of a flat rectangular plate with one rounded end. Inside of the implant from the rounded end is placed flat insert, for example, in the form of an ellipse or a rectangle of magnetic material, such as system samarium-cobalt or Neodym-iron-boron with the induction of a constant magnetic field of 3.5-5 MT with multi-pole reversing the magnetization. The area of the magnetic insert is 1/3 of the area of the implant. The thickness of the magnetic insert is 1 mm, the magnetization of the magnetic material of the insert may be produced, for example, as described in the patent of Russian Federation №2187162.

The distal end of the implant with magnetic insert feature extrascleral in the area of the projection of the swelling of the Central area of the retina, and the proximal end is stitched to the sclera in the Equatorial region, in 3-5 weeks, the implant is removed.

When incomplete resorption of edema in the postoperative period after 2-4 weeks spend transpupillary additional laser coagulation of the retina in the area of localization of edema by standard methods (restrictive or “lattice”). In such cases, the implant is removed 7-10 days after coagulation. The period of 7-10 days according to what corresponds to the length of time which is the complete formation of coagulates.

Swelling of the retina IV-V class (classification of Diss. ... candles. the honey. Sciences Subanbaeva Z.K. “Surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy (using performancesin compounds). - M., 1997. - P.42) it is necessary that the magnetic insert possessed through specialized multi-pole reversing the magnetization with the induction of a constant magnetic field of 5 MT.

Swelling of the retina II-III degree, it is advisable that the magnetic insert had bilateral subsurface multi-pole reversing the magnetization with the induction of a constant magnetic field of 3.5-5 MTL.

Swelling of the retina of the I degree rather one-sided subsurface multi-pole reversing the magnetization with the induction of a constant magnetic field of 3.5 MT.

Induction of a constant magnetic field less than 3.5 MT insufficient to reduce swelling, and with the induction of more than 5 MT you may experience irreversible changes in the underlying tissues of the eye.

The term implant removal through 3 to 5 weeks after implantation is determined by the severity of macular edema.

The technical result is achieved due to the fact that:

1. Additional removal during vitrectomy VPM eliminates vitreoretinal traction in macular area.

p> 2. The removal of PFOS and replacing it on the saline or silicone oil during operation to reduce the risk of toxic effects of PFOS on intraocular structures.

3. The placement of the magnetic insertion of the implant directly in the zone of edema can improve microcirculation and tissue tropism, which accelerates resorption of edema of the retina.

4. Magneto-orientational effect of a constant magnetic field (White Y.A., Tereshchenko A.V., Khoroshilova-Maslova I.P., Zakharova G.P., Isaeva GT, Squarcina D.O., Volodin P.L., Novikov S.V. Experimental substantiation of application of the polymer elastic magnetic implants in the surgical treatment of Central chorioretinal dystrophies // Ophthalmosurgery. - 2003. No. 2. - P.10-13) magnetic insertion of the implant facilitates the ordering and restoration of cell-cell interactions, thereby leading to stabilization of the pathological process, improvement and preservation of visual function.

The invention is illustrated by drawings. In figure 1, figure 2 shows the implant 1 with magnetic insert 2. Figure 3 shows the layout of the implant 1, where the distal end 3 of the implant 1 with magnetic insert 2 is extrascleral in the area of the projection of the swelling of the Central retina area 4, and the proximal end 5 of the implant 1 is filed to the sclera 6 in the Equatorial region 7.

The method is as follows. After processing the surgical field and conduct of regional anesthesia by a standard procedure in verhnovodjane and upper outer quadrants 4 mm from the limbus perform incision of the conjunctiva length 6-8 mm concentric limbu. In ninananajna quadrant 4 mm from the limbus perform incision of the conjunctiva length of 6 mm concentric limbu and with a spatula to form a tunnel in Sultanova space towards the rear pole of the eye. Perform Subtotal vitrectomy using the standard method. Then, in the cavity of the eye is administered PFOS (DK-164), vitreal tweezers remove the back of the hyaloid membrane, the inner boundary membrane, followed by endolaser coagulation of the retina of the diode laser. Then PFOS as opposed to isotonic (0.9%) saline or silicone oil. On sclerotomies holes impose nodal joints.

After sealing the eyeball and recovery of intraocular pressure (IOP) in a pre-formed in Sultanova space tunnel towards the posterior pole of the eye impose the implant 1. With the introduction of the implant 1 with a spatula is sclerocornea to localize the position of the implant 1 with constant control using the operating microscope. Magnetic box 2, located on the dis is real end 3 of the implant 1, place in the area of the projection of the swelling of the Central area of the retina 4. The proximal end 5 of the implant 1 is fixed to the sclera 6 in the Equatorial region 7 two interrupted sutures. The conjunctiva is sutured with a continuous suture. Under the conjunctiva injected antibiotic solution and deksona. The eye is superimposed aseptic bandage.

After 2-4 weeks, the implant 1 is removed. The removal of the implant 1 is as follows. After standard processing operating margins in ninananajna quadrant 4 mm from the limbus perform incision of the conjunctiva length 3-4 mm concentric limbu. Using scissors allocate the proximal end 5 of the implant 1 from surrounding tissues. Remove hub seams, fixing the proximal end 5 of the implant 1. The implant 1 grab the tweezers and remove. The conjunctiva is sutured with a continuous suture. Under the conjunctiva injected antibiotic solution and deksona.

In case of replacement of PFOS silicone oil removed 10 months after introduction into the vitreal cavity by a standard method.

The invention is illustrated by the following examples.

Example 1. Patient I., 68 years. Treated in the Kaluga branch of IRTC “eye microsurgery”. From the anamnesis: suffering from diabetes type II 12 years (the diagnosis of endocrine - diabetes mellitus type II moderate severity at the stage of subcompensation). Takes oral sharoni the surrounding drugs. Comorbidities: coronary artery disease, myocardial infarction, arterial hypertension, myocardial infarction in 2002. In the past two years, notes a gradual reduction of vision in both eyes. On the left eye vision has sharply dropped a month ago.

Diagnosis: OD - nonproliferative diabetic retinopathy, edema-hemorrhagic form of retinal edema II degree, the initial complicated cataract; OS - nonproliferative diabetic retinopathy, edema-hemorrhagic form of retinal edema III, partial hemophthalmus, the initial complicated cataract.

Examination: OD - calm, cornea smooth mirror, front camera normal depth, the initial lens opacities under the rear capsule, gross destruction of the vitreous body, the optic disc pale pink, clear boundaries; in the macular area of no reflexes, swelling of the retina II degree, deposition of hard exudates, small retinal hemorrhages around the eye bottom, the ratio of artery-vein 1:3, veins moderately dilated, tortuous; OS - calm, cornea smooth mirror, front camera normal depth, the initial lens opacities under the rear capsule, partially organized hemophthalmus the optic disc pale, clear boundaries, swelling of the macular area of the retina of the III degree, deposits the solid EXS the date in paramacular region, small hemorrhages around the eye bottom, microaneurysms vessels.

Vis:OD=0.2+1.5 D=0,3; OS=0,08 n/K.

Ultrasonic b-scanning: OD - rough floater, swelling of the retina in the Central zone of 0.5 mm, OS - partially organized hemophthalmus acoustically average density, swelling of the retina in the Central zone to 0.6 mm

The patient is operated on the left eye on the proposed method. PFOS during the operation replaced by a saline solution, a magnetic insertion of the implant with the multi-pole reversible bilateral subsurface magnetization with the induction of a constant magnetic field 4 MT.

The operation and the postoperative period was uneventful. At discharge: left eye moderately annoyed, the fundus of the eye reflex pink, shell adjacent remains swelling of the macular zone of the II degree. Vis: OS account of the fingers of the person with aperture with a+6D=0,08.

The patient is re-examined after 4 weeks. The left eye is almost calm. Ultrasonic b-scanning: OS - shell adjacent, the swelling is not defined. Vis:OS-0,08+1,5 L=0,12. The implant was removed. The patient was observed during the year with a frequency of 1 every 3 months. During the whole period of monitoring the condition of the fundus, visual function remained stable.

Example 2. Patient R., aged 65. Treated in the Kaluga branch of IRTC “eye microsurgery”. Of Anan is for: suffering from diabetes type II 9 years (diagnosed endocrinologist - diabetes mellitus type II moderate severity at the stage of subcompensation). Takes oral hypoglycemic drugs. Accompanying diseases: ischemic heart disease, arterial hypertension. In the past year, notes the reduction of vision in both eyes. Was treated conservatively by place of residence: cardiovascular drugs, antioxidants, spazmolitiki, disaggregants.

Diagnosis: OD - nonproliferative diabetic retinopathy, edema-hemorrhagic form of retinal edema IV-V degree, partial hemophthalmus, the initial complicated cataract; OS - nonproliferative diabetic retinopathy, edema-hemorrhagic form of retinal edema, grade II partial hemophthalmus, the initial complicated cataract.

Examination: OD - calm, cornea smooth mirror, front camera normal depth, the initial lens opacities under the rear capsule, partial hemophthalmus, the fundus of the eye reflex dull, details of the fundus is not visualized; OS - calm, cornea smooth mirror, front camera normal depth, the initial lens opacities under the rear capsule, partially organized hemophthalmus, optic disc pale, clear boundaries, swelling of the macular area of the retina of the II degree, deposition of hard exudates in paramacular area, small hemorrhages around the eye bottom, MIC the aneurysm.

Vis:OD=right. svetoproekt; OS=0.2 s+1D=0,32.

Ultrasonic b-scanning: OD - partially organized hemophthalmus akusticheskii average density, swelling of the retina in the Central zone to 0.8 mm, OS - partially organized hemophthalmus akusticheskii average density, swelling of the retina in the Central zone to 0.3 mm

The patient operated on the right eye on the proposed method. PFOS during the operation replaced by silicone oil, a magnetic insertion of the implant with the multi-pole reversible end-to-end core magnetization with magnetic field of 5 MT.

The operation and the postoperative period was uneventful. At discharge: right eye moderately annoyed, the fundus of the eye reflex pink, shell adjacent remains swelling of the macular zone of the III degree. Vis: OD account of the fingers of a person.

The patient is re-examined after 3 weeks. The right eye is almost calm, swelling persists I-II degree. Vis: OD - 0,s+6D=0,09. In connection with the preservation of retinal edema the patient underwent transpupillary laser coagulation of the retina by type “grid” by the standard method.

The implant was removed 4 weeks after implantation.

The patient was examined 5 weeks after the first operation. Vis: OD - 0,06c+6D=0,1, during fundus examination the swelling was not determined.

Silicone oil was removed after 10 months of using the standard method.

PA is ant was observed in 18 months with a frequency of 1 every 3 months. During the whole period of monitoring the condition of the fundus of the eye and visual function remained stable.

Thus, the invention provides an effective method of surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy, providing faster resorption of edema of the retina. An additional effect is achieved through the use of an implant with an insertion, with constant magnetic field. The use of the method according to the described method allows to stabilize the disease process and to improve and preserve visual function of the patient.

1. The method of surgical treatment of edematous-hemorrhagic forms of diabetic retinopathy, including vitrectomy with removal of the posterior hyaloid membrane, tamponade vitreal cavity performancesin connection (PFOS) and endolasercoagulation of the retina, characterized in that when performing vitrectomy additionally remove internal border membrane in the Central zone of the retina, PFOS remove and replace the saline or silicone oil during the operation, after sealing of the eyeball and recovery of intraocular pressure (IOP) in Sultanova space forms a tunnel into which is injected an implant made of elastic polymer material, covered with a hydrogel material in the form of PLoS is Oh rectangular plate with one tip end and placed it flat insert of magnetic material with the induction of a constant magnetic field of 3.5-5 MTL, with multi-pole reversible magnetization, while the distal end of the implant with magnetic insert feature extrascleral in the area of the projection of the swelling of the Central area of the retina, the proximal end is stitched to the sclera in the Equatorial region, after 3-5 weeks, the implant is removed, in the case of substitution of PFOS in silicone oil, silicone oil removed after 10 months after its introduction into the vitreal cavity.

2. The method according to claim 1, characterized in that in the case of incomplete resorption of edema within 2-4 weeks after implantation spend transpupillary additional laser coagulation of the retina.

3. The method according to claim 1, characterized in that the magnetic insert has end-to-end core magnetization.

4. The method according to claim 1, characterized in that the magnetic insert has bilateral subsurface magnetization.

5. The method according to claim 1, characterized in that the magnetic insert has odnostronnem subsurface magnetization.



 

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FIELD: medicine.

SUBSTANCE: method involves applying trans-scleral laser radiation to avascular zones and cushion. Size and location of avascular zones and cushion are transpupillarily determined. Conjunctiva and Tenon's capsule incision is carried out in perpendicular to limb 2-3 mm far from it. Pocket is formed with spatula in parallel to limb in avascular zones and cushion projection area. Photosensibilizer agent is intravenously introduced into one of cubital veins and avascular zones and cushion photosensibilizer agent saturation degree is determined by applying photodynamic fluorescent diagnosis method. Maximum avascular zones and cushion saturation level being achieved, trans-scleral scanning laser radiation is applied to the avascular zones and cushion projection area with wavelength of 661-666 nm during 60-120 s with radiation dose being equal to 40-80 J/cm2. The operation is finished without placing sutures over conjunctiva.

EFFECT: enhanced effectiveness of treatment.

2 cl

FIELD: medicine.

SUBSTANCE: method involves transpupillarily determining size and location of avascular zones and cushion. Conjunctiva and Tenon's capsule incision is carried out in perpendicular to limb 2-3 mm far from it and pocket is formed with spatula in perpendicular to limb in avascular zones and cushion projection area using laser probe set in the formed pocket. Preliminary trans-scleral laser irradiation is applied to the avascular zones and cushion projection area with pulsating and continuous non-collimated beam of laser radiation of low intensity and wavelength of 800-950 nm having mean power of 5-20 mW at probe end during 5-10 min. Photosensibilizer agent is introduced into one of cubital veins and avascular zones and cushion photosensibilizer agent saturation degree is determined by applying photodynamic fluorescent diagnosis method. Maximum avascular zones and cushion saturation level being achieved, trans-scleral scanning laser radiation is applied to the avascular zones and cushion projection area with wavelength of 661-666 nm during 30-90 s with radiation dose being equal to 20-60 J/cm2. The operation is finished without placing sutures over conjunctiva.

EFFECT: enhanced effectiveness of treatment.

2 cl

FIELD: medicine.

SUBSTANCE: method involves carrying out circular sclera packing with ribbon manufactured from non-biodegradable material, making sclera incision(s) to vascular tunic and piercing the vascular tunic to let subretinal fluid discharge. In carrying out circular sclera packing, the ribbon manufactured from non-biodegradable material is sutured to sclera in applanation way with required number of episcleral pockets being formed depending on retina ruptures number. Gelatin sponge as the local packing non-biodegradable material is implanted into the pockets. The sclera incision(s) to let subretinal fluid discharge is (are) done with small area in deep sclera layers under superficial scleral flap being excised and vascular tunic is revascularized with autotissue.

EFFECT: enhanced effectiveness of treatment.

4 dwg

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