Surgery technique for subretinal haemorrhages combined with age-specific macular dystrophy with subretinal neovascular membrane

FIELD: medicine.

SUBSTANCE: invention refers to ophthalmology and can be used in surgery of subretinal haemorrhages combined with age-specific macular dystrophy with subretinal neovascular membrane. The technique involves subtotal vitrectomy and removal of posterior hyaloid membrane. Bevacizumab and Ranibizumab are injected intravitreally. It is followed with intravitreal injection of tissue plasminogen activator and expanding gas while a patient is pronated.

EFFECT: method allows deploying blood from under retina, ensuring pathogenetic action on haemorrhage source, preventing proliferative processes in vitreal cavity.

2 ex

 

The invention relates to medicine, and more specifically to ophthalmology, and is intended for the surgical treatment of subretinal hemorrhage complicating the course of age-related macular degeneration with subretinal neovascular membrane (CNM).

Age-related macular degeneration ranks third after glaucoma and diabetic retinopathy among the causes of blindness in the second half of life. With increasing life expectancy of the population, the problem of age-related macular degeneration becomes very important. The loss of Central vision and total disability give this disease a large socio-medical significance. In 80-90% of cases of severe loss of Central vision associated with the formation of SNM in the Central zone of the retina. Quite often they are complicated by the appearance of submacular hemorrhage, optionally having toxic effects on sensitive neurosensory retina and significantly reduce the chances of recovery of vision.

Among the surgical techniques of dislocation of blood from beneath the Central area of the retina known: vitrectomy with intravitreal the introduction of tissue plasminogen activator, an isolated pneumatologia, YAG laser retinopathy, submacular surgery, the combined use of gas and tissue plasminogen activator Essence of these interventions is to more completely remove blood clots from the Central region to reduce the toxic effects of products of hemolysis in the photoreceptors and preventing the development of submacular proliferation.

A known method of surgical treatment of submacular hemorrhages by intravitreal injection of the expanding gas and tissue plasminogen activator without needing vitrectomy (Heriot W. Intravitreal gas and tPA: an outpatient procedure for submacular hemorrhage. Presented at: Meeting of the American Academy of Ophthalmology; Chicago: Octouber 1996; Chen C. Management of submacular hemorrhage with Intravitreal injection of tissue plasminogen activator and expansile gas. Retina 2007; 27: 321-328). He is slow intravitreal through the introduction of the flat part of the ciliary body of the diluted solution of a tissue plasminogen activator (TAP) at the dose of 100 mg/0.1 ml and 0.3-0.4 ml of gas perftoran (C3F8or sulfurhexafluoride (SF6). Within two days, the patient observes the position of the face. The contact of the blood clot from the TAP leads to its partial lysis and displacement under the action of gas from the macular area in the lower half of the retina.

The disadvantage of this method is the lack of impact on the etiological component subretinal hemorrhage: directly on subretinal neovascular membrane. Surgical intervention only leads to anatomical disposition of blood from the Central region, reducing its toxic effects on the retina, without affecting the visual prognosis, and functional results of operations, as a rule, limited by the presence in the macular area subretinal neous Blarney membrane. Introduction the expanding gas without prior vitrectomy leads to a change in the structure of the vitreous body, provokes the onset of the proliferative process, which can cause retinal detachment (according to different authors from 3 to 36% of cases).

The objective of the invention is to develop a method of surgical treatment of subretinal hemorrhage on the basis of age-related macular degeneration with the subretinal neovascularization with obtaining the highest functional outcomes and maximum reduction of postoperative complications.

The technical result achieved by using the proposed invention is the anatomical location of blood from the Central region of the retina, the pathogenetic impact on the source of the hemorrhage (subretinal neovascular membrane), preventing the development of proliferative processes in the vitreal cavity, reducing the risk of retinal detachment, which leads to better functional results of surgical intervention in the early and late postoperative periods.

The technical result is achieved in that in the method of surgical treatment of subretinal hemorrhage on the basis of age-related macular degeneration with SNM, including intravitreal injections of similar TAP - recombinant pourakino the s and the expanding gas perftoran (C 3F8or sulfurhexafluoride (SF6with the subsequent positioning of the patient face down, according to the invention before the intravitreal injection perform Subtotal vitrectomy with removal of the posterior hyaloid membrane and the introduction of intravitreal angiogenesis inhibitors (bevacizumab or ranibizumab).

The method allows to significantly increase the percentage of dislocation of blood from the macular region on the background of subretinal neovascularization, to reduce the number of postoperative complications, improve the functional prognosis of the disease, preventing re-bleeding and stabilizing process choroidal neovascularization.

As the active substance that promotes the lysis of subretinal blood clot can be used recombinant PUK ("Gamesa"LLC SPE "TECHNOGEN", patent No. 2216348). "Gamesa" is a lyophilized enzyme preparation containing recombinant PUK and catalyzes the conversion of plasminogen to plasmin is a serine protease that is able to lyse fibrin clots, and high specificity of action, as it activates plasminogen mainly in the area of the clot, which reduces the risk of possible bleeding and hemorrhage.

As action is found substances influencing the process choroidal neovascularization can be used angiogenesis inhibitor (bevacizumab or ranibizumab). This type of drugs are able to block all isoforms factor vascular endothelial growth (VEGF). Anti-VEGF therapy promotes partial regression of subretinal membranes, reducing their activity and stabilizes the process choroidal neovascularization.

As the active substance, affecting mechanical dislocation of blood from the Central region of the retina can be used expanding gas perftoran (C3F8or sulfurhexafluoride (SF6). Performing "massage" the macular area when positioned face down, he contributes to the gradual displacement of the hemorrhage in the lower half of the retina.

To perform Subtotal vitrectomy can be used invasive sutureless vitreoretinal technology caliber 25Ga or 23Ga. Minimizing operative trauma, delicate and well-controlled work vitreal tools, no need for suture fixation make this technology is safe and well tolerated. Destruction of the posterior hyaloid membrane improves the permeability of retinal introduced to drugs and facilitates the deployment of the blood.

The method is as follows.

After retrobulbar the Noah anesthesia and akinesia processing operating margins in the operating conditions perform a three port vitrectomy 25-gauge in the Subtotal volume with removal of the posterior hyaloid membrane. Next, after removing the "ports" - cannulas and restore integrity vitreal cavity by the slight hypotonia intravitreal under visual control through the flat part of the vitreous body in 3-4 mm from the limbus (depending on the anatomical length of the eyeball) with injection needle 30-gauge sequentially injected diluted solution of recombinant prourokinase 500 ME and 0.15 ml involving bevacizumab Then in the eye cavity is injected with 0.4-2.0 ml 100% gas perftoran

(C3F8or sulfurhexafluoride (SF6). Control the tightness of the scleral tunnels, the level of intraocular pressure, perform subconjunctival injection of dexamethasone and gentamicin succinate. Within two hours after surgery, patients observe bed rest on the back contact of the products with subretinal haemorrhage and subsequent positioning face down in 2-3 days, providing the most effective impact of the bubble gas hemorrhage in the macular region.

The indication for the use of the method is subretinal haemorrhage on the background of age-related macular degeneration with SNM when the duration of bleeding is not more than 4 weeks (optimal period not exceeding two weeks).

Example 1. Patient M., 56 years old, with diagnosis OU - high myopia, subretinal neovascular the RNA membrane, OD - and subretinal intraretinal hemorrhage, he began to notice the emergence of a vast spot in front of the right eye and a sharp deterioration of vision in the last 2 weeks. Visual acuity of the right eye was eccentric account of the fingers 30 cm without correction visual acuity of the left eye 0,02 sph-13.5 D=0.4. IOP on Maklakova OD - 18 mm Hg, OS - 16 mm Hg Objectively in the fundus of the right eye was determined massive subretinal haemorrhage, completely overlying the macular area, the upper and lower major vascular arcades. According to the OST revealed extensive hemorrhagic detachment of the pigment epithelium in excess of the scan area. The relative size of the hemorrhage was 8 disc diameters (DD). Absolute scotomas in the Central area corresponds to the area of hemorrhage. According to the In-scan height prominence in the vitreous body of 4.11 mm In the left eye was determined by a small detachment of the pigment epithelium with extrafoveal located subretinal neovascular membrane, peripheral chorioretinal dystrophy, limited by the laser coagulates. According to ERG OD - significant changes in all layers of the retina, including macular area, OS - moderate changes in all layers of the retina with the capture of the Central zone. On the right eye was performed, surgery is on the above-described method, the operation and the postoperative period was uneventful. The effect of shifting subretinal hemorrhage from the macular region was observed already at the second day after surgery. The visual acuity improved to 0.02 n/a, the value of IOP was 17 mm Hg, according to the In-scan was determined dislocation subretinal hematoma in the lower-inner quadrant, height prominence was 2,97 mm In the macular area, free from bleeding, was determined by extensive subretinal neovascular membrane, surrounded by a nimbus of hemorrhages. According to microperimetry in the area of original location of the hematoma remained absolute scotoma, indicators ERG has not changed. At the control examination after 1 month after surgery, the visual acuity OD amounted to 0.03 sph-12.0=0.2, IOP - 19 mm Hg, linear dimensions subretinal neovascular membrane according to optical tomography 2053µ, remained Corolla small hemorrhages around her, acoustically, there was complete seal membranes of eyes. According to microperimetry area absolute scotomas in the Central visual field was reduced to 10°. The presence of extensive SNM required additional intravitreal injection involving bevacizumab 2 months after the initial intervention showed positive visual acuity: OD 0.035 sph-12.0=0.3, sizes CNM socraties is to 1709µ, hemorrhagic activity was absent. When control inspections throughout the entire follow-up period (1 year) visual acuity remained stable, recurrent subretinal hemorrhages were noted, neovascular membrane was at the stage of fibrosis, complications such as retinal detachment was not observed.

Example 2. Patient, 67 years, the diagnosis OU - age-related macular degeneration, primary age-related cataract. OD - subretinal hemorrhage. Prescription sharp deterioration 3 weeks. Visual acuity of the right eye account of the fingers of a person, the visual acuity of the left eye of 0.3 sph+0.5D cyl+1.0 ax 22°=0.4. The magnitude of IOP OD - 16 mm Hg, OS - 18 mm Hg In the macular area of the right eye was determined subretinal haemorrhage dimensions of 5.5 (DD) with areas of subretinal seal. The length of hemorrhagic retinal pigment epithelium according to the OST was 6000µ. According to microperimetry in the Central zone was determined absolute scotoma corresponding to the area of subretinal hemorrhage. On the left eye in the Central region was visualized multiple friends with detachment of the pigment epithelium in length 2060µ. According to electroretinography there was a decrease in function of a cone apparatus in the Central zone, the reduction of macular ERG. On the right eye was performed surgical procedure in the above-described m codice, the operation and the postoperative period was uneventful. On the second day after the operation there was a partial offset hematoma with preservation in the Central zone foci subretinal proliferation. Visual acuity was OD - 0,05. Indicators ERG has not changed. When discharged on the fifth day after surgery was determined complete dislocation hematoma from a Central area of the retina. Visual acuity improved from 0.05 to 0.1. The magnitude of IOP OD - 18 mm Hg After month after surgery in the macular area was determined dense fibrovascular film without signs of activity, with clear contours, sizes subretinal membrane according to the OST was 3278µ, visual acuity was significantly limited subfoveal located SNM and not exceed 0.15 n/K. When control inspections throughout the entire follow-up period (1 year) visual acuity remained stable, recurrent subretinal hemorrhages were noted, neovascular membrane was at the stage of fibrosis, complications such as retinal detachment was not observed.

Thus, the proposed method allows researchers to simultaneously achieve anatomical evacuation of blood from the Central zone of the retina, the stabilization process choroidal neovascularization and minimize the risk of intra - and postoperative complications in early and late p is ridah.

The method of surgical treatment of subretinal hemorrhage on the basis of age-related macular degeneration with subretinal neovascular membrane, including intravitreal injections of tissue plasminogen activator and the expanding gas perftoran (C3F8or sulfurhexafluoride (SF6with the subsequent positioning of the patient's face, wherein the pre-to intra-vitreal injections perform Subtotal vitrectomy with removal of the posterior hyaloid membrane and the introduction of intravitreal bevacizumab or ranibizumab.



 

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