Method of infectious keratitis treatment

FIELD: medicine.

SUBSTANCE: invention concerns ophthalmology and is intended for treatment of infectious diseases of a cornea. Photodynamic therapy with the use of gel containing an octacation phthalocyanine of zinc in concentration of 1-3 mg/ml, which is applied on a cornea as a photosensitinogen, is performed. The conjunctival cavity is washed out after 30 - 40 minutes and influenced with a laser radiation with a wavelength of 675 nm with a light dose 20 - 60 J/cm2 in of 5 minutes, once a day. 1-8 sessions during each course.

EFFECT: method allows destroying the originator of keratitis in a cell with the maximum safety of surrounding tissues of the cornea.

2 tbl, 3 dwg, 1 ex


The present invention relates to ophthalmology and is intended for the treatment of infectious diseases of the cornea.

According to epidemiological analysis, patients with inflammatory lesions of the eyes occupy the first place among applicants on outpatient reception (40,2%), accounting in the Russian Federation, about 16 million people per year [Yuzhakov A.M. "the Main directions in the elimination of avoidable blindness in the Russian Federation" Ophthalmology 2003; 44(4), 6, S.; Michuk Û.F. corneal Ulcer // Ophthalmologist. - 1999, №4. P.9-14]. With inflammatory diseases linked up to 80% of cases of temporary disability, up to 50% of hospitalizations, and 30% of blindness. To date estimated for Russia among the total number of patients with inflammatory diseases of the eye keratitis accounts for 4.2% of the patients. Corneal blindness is one of the first three causes of sudden vision loss [Michuk Û.F. "Principles of the world who initiatives for the elimination of avoidable blindness. Possible ways of their use in the Russian Federation". Ophthalmology 2003; 44(4), 7 C.].

Severe ulcerative keratitis and persistent corneal opacity in the outcome of diseases and injuries of 10% lead to blindness. Among the serious diseases of suppurative corneal ulcers account for 17% [Starkov GL, Sokolova R.S. epidemiology, prevention and screening ophthalmologic patients with external inflammatory diseases Vestn. oftalmol. - 1988, No. 1. volume 104 C.3-5]. In the treatment of bacterial keratitis prescribe broad-spectrum antibiotics in the form of drops, ointments and medical films. In severe ulcerative lesions of the cornea, which are often aureus and Pseudomonas aeruginosa, antibiotics enter subkonyunktivalno, intramuscularly or intravenously. Difficulties in the treatment of microbial infections of the cornea cause changed in recent years, the nature of the microflora and increase its virulence [Keratitis and erosion. Edited Lckoseao, Apostolova, Iagora "GEOTAR-Media", 2006 page 27]. Separately, the problem is the treatment of keratomycosis (keratitis, caused by a fungal infection). Keratomycosis have a tendency to chronicity and some resistance even to the most modern methods of treatment [Walsh, TJ. (1987) Recent advances in the treatment of systemic fungal infections Methods Find Exp Clin Pharmacol 9, 769-778]. Thus, despite the availability of a wide spectrum of antibacterial drugs, the percentage of severe outcomes suppurative keratitis is still high. This is due to the presence of antibiotic resistance of pathogenic microorganisms, the development of toxic and allergic reactions to their introduction, dysbiosis and indigocarminata, suppression of the immune system.

The closest analogue of the present invention is a method for the same purpose is, includes treatment of the affected area of the cornea aqueous solution of sodium hypochlorite [the Feasibility and clinical efficacy of sodium hypochlorite in the complex treatment of patients with extremely severe suppurative keratitis. V.v.egorov, Gposnova, Elaraby, Ioualalen. Clinical ophthalmology. 2005, volume 6, str-156]. According to the authors, the drug is a broad-spectrum antiseptic and manifests bactericidal effect against gram-positive, gram-negative organisms and fungi. However, the method is not without disadvantages.

1. Systemic and local routes of administration of sodium hypochlorite have some significant drawbacks. These include: toxic effects on the cornea, the violation of its natural protective film, conjunctival Allergy, pain, trauma, irritation of eye medications.

2. In addition, instalatii sodium hypochlorite do not provide the necessary therapeutic concentrations of drugs in the affected area.

3. Sodium hypochlorite, despite the wide range of actions, which are not antibiotics, had only a bactericidal effect and is unable to penetrate the microbial cell.

4. Necroticism action of sodium hypochlorite can have a negative impact on healthy tissue of the cornea, p is Evodia to the dimness of the stroma. The objective of the invention was to develop a highly effective treatment of infectious keratitis various etiologies with minimal risk of complications.

The technical result of the invention is the complete elimination of the causative agent of keratitis in its various forms directly inside the cell while the maximum preservation of the tissue of the cornea.

The technical result is achieved due to the photodynamic effect with the use of a photosensitizer (PS) gel content actication phthalocyanine zinc applied to the entire surface of the cornea.

Photodynamic therapy (PDT) has been successfully applied in various fields of medicine: in Oncology, in ophthalmology for the treatment of age-related macular degeneration, etc. In recent years in foreign literature began to appear in publications about the use of PDT in the treatment of local skin infectious diseases [Soukos N.S. Targeted antimicrobial photochemotherapy, Antimicrob Agents Chemoterapy, 1998, 42, 2595-601 Zak O. Animal infection models - the perfect infection model, J Antimicrob Chemother. 1993, 31, 193-205]. Of great importance is the fact that unlike chemotherapy multiple potential targets for oxidative degradation (primarily structural proteins, enzyme systems, unsaturated fatty acid residues of lipids) in antimicrobial photodynamic therapy inhibits p is the development of cellular resistance. We investigated the efficacy of photoinactivation using cationic photosensitizers cultured gram-negative bacteria Campylobacter jejuni, Helicobacter pylori, Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus. In accordance with the descending order of effectiveness of photoinactivation in the processing of 2 μg/ml of Holocene and 5 j/cm2red light is built the following way: gram(+) Staphylococcus aureus > gram(-) microaerophile Helicobacter pylori ≥ Campylobacter jejuni > gram(-) aerobes Escherichia coli > Pseudomonas aeruginosa. It is shown that the highest value of the minimum inhibitory concentration actication phthalocyanine zinc (1.7 µg/ml, about 1 μm) is observed for Pseudomonas aeruginosa.

However, in the treatment of infectious keratitis PDT has not been previously used. Considering literature data, the task was to use the possibilities of PDT using actication phthalocyanine zinc in the treatment of infectious keratitis. Because the cornea has its own structural features (sphericity, transparency) and washed by tears, we used actication phthalocyanine zinc in gel form to increase the contact time of the drug with the surface of the cornea. For this purpose, our research has found different proportions gel photosensitizer. Carried out researches have allowed to find the optimal concentration of FCS in the gel and the optimal parameters of laser irradiation.

After application of the photosensitizer in the mix with the gel on the cornea initiated photodynamic effect of laser radiation with a wavelength of 675 nm and a light dose of 20-60 j/cm2. As our investigations have shown, the light dose is less than 20 j/cm2insufficient to initiate a photodynamic effect, and more than 60 j/cm2may cause damage to the corneal stroma. To achieve the optimal therapeutic effect of the number of sessions was chosen depending on the extent of damage to the cornea. The larger size of the lesion, the greater the number of sessions. Sessions of photodynamic therapy (PDT) is conducted once a day for no more than 8 days.

We experiment the treatment of keratitis mild severity.

Rabbits with the generated model of keratitis mild severity is divided into groups:

A - control group, not receiving antifungal therapy;

B - group receiving conventional medical treatment: in the instillation of Amphotericin b × 4 times, ointment Ketoconazole × 2 times a day;

In experimental group, receiving PDT.

All animal groups on the cornea applied the gel content actication phthalocyanine zinc at a dose of 2 mg/ml over the next 30 minutes is the interaction of a photosensitizer (PS) with pathogenic microflora. Then the cornea is washed from excess FS 09% solution of sodium chloride. The next stage laser effect. For PDT, the used laser system for photodynamic therapy LFT-630/675-01 "BIOSPEC" GOST R 50460-92. A light dose of 40 j/cm2when the duration of the session 5 minutes.

In animals served as control (group a)developed bilateral endophthalmitis. Histological examination revealed the melting of the cornea, its investirovanie by leukocytes, eosinophils, necrotic damage to the stroma, the appearance of newly formed vessels. Sharp dilation and the plethora of vessels, the formation of a fibrinous exudation into a single conglomerate characterized picture of endophthalmitis. In stroma half-sections, each drug were found budding yeast fungi. This fact was mentioned by activity infectious process.

The results of the treatment of keratomycosis rabbit after PDT were compared with those obtained with traditional treatment. The evaluation criteria were the terms of the clinical and microbiological disappearance purulent discharge, corneal syndrome, epithelization of the cornea and attenuation of the inflammatory response.

The results of experimenal presented in table 1. After carrying out of conservative treatment on histological sections were marked hyperplasia of the epithelium, intra - and su the epithelial edema, the increase in the number of keratocytes, fungal colonies enclosed in fibrinous case (figure 2), indicating that the encapsulation of the pathogen and low effectiveness of therapy. After PDT, the pathogen was not detected in any of the examined eye. It was noted complete epithelialization of the corneal defect with transparency stroma. In the result we can say that the PDT of keratomycosis more effectively compared with the standard antifungal therapy. Also, work was performed to study the efficacy of PDT in the treatment of keratomycosis moderate severity.

A - control group, not receiving antifungal therapy;

B - group receiving conventional medical treatment: in the instillation of Amphotericin b×4 times, ointment Ketoconazole × 2 times a day;

In experimental group, receiving PDT. As in the treatment of keratitis mild severity, PDT keratomycosis more effectively compared with the standard antifungal therapy. The results of the experiments are presented in table 2.

All animals in the group And developed clinical and histological picture of endophthalmitis. On histological sections (Figure 1) shows the melting of the cornea, its investirovanie by leukocytes, eosinophils, necrotic damage stroma (stained with hematoxilin-EA is different, magnification × 60).

From complications of ulcers in the subgroup (B) observed only the posterior synechia in 16% of cases. Analysis of the results of treatment according to the degree of recovery of corneal transparency showed that surface avascular turbidity was formed in 75% of cases, and gentle slovakukrainian 25%, while in the second subgroup (In) in addition to the posterior synechia 66% in one eye (13%) detected descemetocele. Gentle slovakukrainian opacities in the outcome of the keratitis was observed in 66%.

Table 1
The dynamics of the pathological process in the first group (in days, M±m).
The parametersSubgroup B (n=3)Subgroup (n=3)
The timing of the disappearance of pus2,00±0,173,27±0,30
The timing of the disappearance pericorneal injectionsto 3.73±0,244,12±0,43
Time epithelialization4,33±0,145,00±0,17

Table 2
The speaker is a pathological process in the second group (in days, M±m).
The parametersSubgroup B (n=3)Subgroup (n=3)
The timing of the disappearance of pus5,00±0,416,37±10,23
The timing of the disappearance pericorneal injections11,00±0,4613,15±0,46
Time epithelialization6,23±0,428,64±0,21
Resorption of hypopyon7,01±0,328,64±0,21

Example 1.

The rabbit with the generated model of keratitis moderate severity on the cornea applied the gel content actication phthalocyanine zinc at a dose of 2 mg/ml over the next 30 minutes is the interaction of a photosensitizer (PS) with pathogenic microflora. Then the cornea is washed from the surplus of the Federal Assembly of 0.9% solution of sodium chloride. The next stage was carried out by laser irradiation. For PDT, the used laser system for photodynamic therapy LFT-630/675-01 "BIOSPEC". A light dose of 40 j/cm2when the duration of the session - 5 minutes. The treatment was performed 1 time per day should the 3 days. On day 7 was produced histological examination of the obtained materials.

On histological sections revealed a moderate increase in the density of keratocytes in superficial stromal layers, the absence of inflammatory cells, a small zone of lysis in the stroma (figure 3), which proves the high efficiency of therapy.

Because the rabbit is the optimal model for reconstruction and development schemes of treatment of keratitis, we can say that the developed method can be successfully extrapolated into clinical practice. Thus, our proposed method for the treatment of keratitis is quite effective and safe for the surrounding tissue and can be used in daily ophthalmic practice.

The method of treatment of infectious keratitis, characterized in that the conducting photodynamic therapy using as a photosensitizer gel containing actication phthalocyanine zinc at a concentration of 1-3 mg/ml, which is applied to the cornea after 30-40 min, washed into the conjunctival cavity and irradiated by laser radiation with a wavelength of 675 nm with a light dose of 20-60 j/cm2duration : 5 min, once a day, at a rate of 1-8 sessions.


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