Method for determining nuclear lens density. RU patent 2505812.
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FIELD: medicine.
SUBSTANCE: patient's venous blood serum is analysed for vascular endothelial growth factor (VEGF). If the derived values in the patients suffering type 1 diabetes mellitus is 141-187 pg/ml, degree 1 and very low nuclear lens density are diagnosed; the value of 188-234 pg/ml enables diagnosing degree 2 and low nuclear lens density; and the value of 235-280 pg/ml shows degree 3 and moderate nuclear lens density. In the patients suffering type 2 diabetes mellitus, the VEGF value of 281-330 pg/ml provides diagnosing degree 2 and low nuclear lens density; the derived value of 331-382 pg/ml shows degree 3 and moderate nuclear lens density; if the value is 383-432 pg/ml, degree 4 and high nuclear lens density are diagnosed; the respective value of 433-478 pg/ml provides diagnosing degree 5 and very high nuclear lens density. In the patients diagnosed with no diabetes mellitus, the VEGF value of 290-336 pg/ml ensures diagnosing degree 2 and low nuclear lens density; the value of 337-379 pg/ml provides degree 3 and moderate nuclear lens density; if the value is 380-426 pg/ml, degree 4 and high nuclear lens density are diagnosed; the derived value of 427-465 pg/ml provides diagnosing degree 5 and very high nuclear lens density.
EFFECT: invention provides performing a phacoemulsification using the sparing ultrasound parameters that minimises its impact on the eyeball tissues and reduces a risk of the related postoperative complications in the patients suffering diabetes mellitus.
2 tbl, 2 ex
The present invention relates to medicine, in particular to ophthalmology, and can be used for choosing the most optimal method of cataract surgery. The developed method for accurate preoperative determine the density of the nucleus of the lens allows phacoemulsification using sparing ultrasound characteristics that allows to minimize its impact on the tissues eyeball patterns, and reduce the risk of associated complications in the postoperative period in patients with diabetes and get higher functional results in the postoperative period. With the purpose of optimization of surgical treatment method selection of adequate crushing the nucleus of the lens is reasonable estimation of the density of the nucleus of the lens.
The only effective method of cataract treatment is surgical. The primary method of surgical treatment of cataract today is phacoemulsification with intraocular lens, but its implementation in patients with diabetes is associated with increased risk of complications and inefficiency of conservative therapy of multiple complications in intra - and postoperative periods, which makes the actual optimization of phacoemulsification of cataract patients with diabetes mellitus. The use of excessive ultrasound characteristics of these patients it would be not only unnecessary, but potentially harmful influence of ultrasound on the structure of the eye, including cornea, vascular sheath and retina. This is due to concomitant diseases of the retina associated with diabetes. Use of mainly torsion ultrasound technology OZil on surgical system "Infiniti" ("Alcon") when phacoemulsification cataract allows to reduce time of influence of ultrasound of the eye tissue. This reduces the intensity of post-operative swelling of the cornea, and thus leads to more quickly reach possible visual acuity in the postoperative period.
There is a method of intraoperative determine the density of the nucleus of the lens, which consists in the determination and registration of the human lens materials peaks with the help of ultrasonic study of the eye, wherein the initially estimated height and determine the number of additional human lens materials peaks, and then during the operation instrument, containing its working surface division, jam on the front cortical layers of the natural lens to the moment of his bias on the bundle, if the number of tick marks on a working surface of the tool, sunken in front cortical layers, more than 4, the height of additional lenticular peak less than half the height of the main front lenticular peak, the number of additional human lens materials peaks less than 4, then make a conclusion about the low density of the lens (Nazarenko G.B. Interbranch scientific-technical complex "eye microsurgery").
However, this technique is invasive and is not precise enough. He is accompanied by higher risk, which can lead to complications during surgery. When pressed on the lens, especially if there is a defect lens ligaments possible damage to the ligaments, until lens, vitreous. Also there may be a mechanical trauma of the corneal endothelium as a result of additional intraocular manipulation.
There is a method of determining the density of the nucleus of the lens, ultrasound media of the eye (Friedman .., R.A., MB Ultrasound in ophthalmology. - M: Medicine, 1989, 256 C.).
However, the real biological media (in this case, cataract lens) is markedly heterogeneous and has a resonant, and other properties which strongly distorts the echo. This fact does not allow sufficiently accurately only on data of ultrasound echography interpret cataract lens in his physical density.
To date, the most widely for determining the density of the lens used method Emery J. and Little J. (1979), based on the colorimetric characteristics of the lens.
However, this method is subjective and is not precise enough.
We first developed a way of exact preoperative determine the density of the nucleus of the lens on the index of venous blood.
Survey of 220 patients with cataracts (220 eye): the core group of -1 20 patients with diabetes mellitus (120 eyes), and of these 11 patients with diabetic cataracts (11 eyes) - group 1, 109 - age cataract (109 eyes) against diabetes - 2 group, the control group of 100 patients with age cataract without diabetes (100 patients). All patients received standard ophthalmologic examination. In blood serum of all patients the study of levels of vascular endothelial growth factor (VEGF). He is the stimulator of the migration of endothelial cells from deep layers of the retina, vitreous activation of angiogenesis, cell proliferation, causing increase in vascular permeability, hypertrophy of endothelial cells, leading to narrowing of blood vessels, reducing blood flow and increasing hypoxia. The study was performed in the blood obtained from the cubital vein. Blood samples was performed in patients on an empty stomach in the morning. With the aim of standardizing used tubes for blood collection «Vacuette». For the study of VEGF in blood serum tubes used with activator coagulation (silica) and separating gel, forming a barrier between the serum and coagulating blood after centrifugation.
Microsurgical treatment of cataract patients was conducted: the method of ultrasonic phacoemulsification. Ultrasonic phacoemulsification was conducted using a surgical system "Infiniti" ("Alcon") by standard methods. In the course of the operations registered at the equivalent time ultrasound spent for the fragmentation of the lens. Density cataract was estimated according to the classification J. Emery and Little J. (1979), based on the colorimetric characteristics of the lens of the eye (5 levels density: 1 degree - lens light gray in color, visible fundus of the eye reflex, fundus of the eye , soft core, low density, 2 - the lens is light yellow, fundus of the eye reflex sight, fundus of the eye , soft core, low density, 3 - lens-intensive yellow color with brownish tint, fundus not , moderately dense core, the average density of 4 - lens brown, fundus of the eye reflex is not defined, the fundus not , dense core, a high degree, 5 - the lens of dark-brown color, fundus of the eye reflex is not visible, fundus not , hard core, a very high degree.
Table 1.
The average density of the nucleus of the lens on a scale J. Emery and Little J. (1979) (points)
The density of the nucleus of the lens in groups
Ageup to 20 years
21-40 years
41-50 years
51-6061-70 years
71-80 years
81-90 years
Group 1 (patients with type 1 DM)
1 2 3 - - - -Group 2 (patients with type 2 diabetes)
- - 2 3 4 5 -Control group
- - - 2 3 4 5In the early postoperative period analyzed equivalent time of influence of ultrasound, its capacity and condition of the cornea in various forms of cataract. All the patients underwent morphological, immunocytochemical and immunohistochemical studies capsules and substance of the lens of the human eye with the use of standard methods of coloring to determine the expression of a- (α-A and a-C), beta-, gamma . The dependence of the density of the lens from the age increases as age increases the density of the lens) and presence of diabetes (diabetes mellitus lens density less than that of patients with age cataract in the same age group).
The content of the growth factor in the blood serum of patients with DM and without it, depending on the degree of density of a cataract is presented in the table.
Table 2.The content of the growth factor in the blood serum of patients with DM and without it, depending on the degree of density of cataract
The group surveyed
degree DensityVEGF PG/ml
NormUp to 140
Group 1 (patients with type 1 DM) (20 years)
1 very low 141-187Group 1 (patients with type 1 DM) (21-40 years)
2 low 188-234Group 1 (patients with type 1 DM) (41-50 years)
3 moderate 235-280Group 2 patients with T2DM) (41-50 years)
2 low 281-330Group 2 (patients with type 2 diabetes)
3 moderate 331-382 (51-60)Group 2 patients with T2DM) (61-70 years)
4 high 383-432Group 2 patients with T2DM) (71-80 years)
5very high
433-478The control group (patients without DM) (51-60)
2 low 290-336The control group (patients without DM) (61-70 years)
3 moderate 337-379The control group (patients without DM) (71-80 years)
4 high 380-426The control group (patients without DM) (81 to 90 years)
5very high
427-465Thus, patients with type 1 DM, at the value of the serum VEGF - 141-187 PG/ml = 1 degree and very low density of the nucleus of the lens. Patients suffering from type 1 DM, at the value of the serum VEGF - 188-234 PG/ml corresponds to 2 degrees and the low density of the nucleus of the lens. Patients suffering from type 1 DM, at the value of the serum VEGF - 235-280 PG/ml = 3 extent and moderate density of the nucleus of the lens. In patients with type 2 diabetes, at the value of the serum VEGF - 281-330 PG/ml corresponds to 2 degrees and the low density of the nucleus of the lens. In patients with type 2 diabetes, at the value of the serum VEGF - 331-382 PG/ml = 3 extent and moderate density of the nucleus of the lens. In patients with type 2 diabetes, at the value of the serum VEGF - 383-432-189 PG/ml corresponds to 4 degrees and high density of the nucleus of the lens. In patients with type 2 diabetes, at the value of the serum VEGF - 433-478 PG/ml equivalent to 5 degrees and a very high density of the nucleus of the lens. Patients of the control group without diabetes, at the value of the serum VEGF - 290-336 PG/ml corresponds to 2 degrees and the low density of the nucleus of the lens. Patients of the control group without diabetes, serum VEGF - 337-379 PG/ml = 3 extent and moderate density of the nucleus of the lens. Patients of the control group without diabetes, at the value of the serum VEGF - 380-426 PG/ml corresponds to 4 degrees and high density of the nucleus of the lens. Patients of the control group without diabetes, at the value of the serum VEGF - 427-465 PG/ml equivalent to 5 degrees and a very high density of the nucleus of the lens.
At 1-2 degrees and very low and low density of the nucleus of the lens more effective in terms of reducing the time of influence of ultrasound and its power (in the sum of «dose» of ultrasound technique of «Chip and Flip», «Karusel» and similar. With 3 degrees and moderate density of the nucleus of the lens - «Phaco-Chop», «Stop and Dispute» and such. At 4 degrees and high density of the nucleus of the lens - «Divide and Conquer». At 5 degrees and a very high density of the lens is recommended to remove cataracts method of extracapsular extraction. Phacoemulsification in this case is not desirable because of the possible trauma of all structures of the eye high power ultrasound and long time of its use during the operation. Lower density of the nucleus of the lens in patients with cataracts against diabetes, associated with the peculiarities of crystallin composition of these patients are allowed to conduct the phacoemulsification with the lower energy parameters, as a rule, using primarily torsion ultrasound. Taking into account these features allowed us to perform a phacoemulsification using sparing ultrasound characteristics, which allowed to minimize its impact on the tissues eyeball patterns, and reduce the risk of associated complications in the postoperative period in patients with diabetes and get higher functional results.
Example 1. The patient A., 72 years old, not a suffering diabetes, the study of venous blood serum value of VEGF amounted to 386 PG/ml This level of VEGF corresponds to 4 degrees and high density of the nucleus of the lens. Given the high degree of density of nucleus of the lens, was chosen method of splitting the kernel «Divide and Conquer». For this case study is the most effective and least traumatic for all structures of the eye method. In the course of the operation really the core of the lens was quite hard. Placed us the extent and density of the lens on the number in the venous blood of VEGF coincides with the degree and density of the lens by the method of J. Emery and Little J. Phacoemulsification was carried out without complications and already in the early postoperative period was achieved high functional result.
Example 2. The patient A., 50 years old, suffering from type 2 diabetes, the study of venous blood serum value of VEGF amounted to 342 PG/ml This level of VEGF corresponds to 2 degrees of density of the nucleus of the lens. Placed us the extent and density of the lens on the number in the venous blood of VEGF coincides with the degree and density of the lens by the method of J. Emery and Little J. Given the low density, gentle enough nucleus of the lens, was chosen method of crushing kernel «carousel». For this clinical case this is the most suitable method. Phacoemulsification was carried out without complications and already in the early postoperative period was achieved high functional result.
The method of preoperative determine the density of the nucleus of the lens, which consists in that the patient serum of venous blood to determine the vascular endothelial growth factor and its importance in patients with type 1 diabetes, 141-187 PG/ml diagnose 1 degree and a very low density of the nucleus of the lens, at value - 188-234 PG/ml diagnose 2 degree and a low density of nucleus of the lens, at value - 235-280 PG/ml are diagnosed in stage 3 and moderate density of the nucleus of the lens, patients with type 2 diabetes, a value - 281-330 PG/ml diagnose 2 degree and a low density of nucleus of the lens, at value - 331-382 PG/ml are diagnosed in stage 3 and moderate density of the nucleus of the lens, at value - 383-432 PG/ml diagnose 4 degree and a high density of nucleus of the lens, at value - 433-478 PG/ml are diagnosed in 5 degree and a very high density of nucleus of the lens, in patients without diabetes, a value - 290-336 PG/ml diagnose 2 degree and a low density of nucleus of the lens, at value - 337-379 PG/ml are diagnosed in stage 3 and moderate density of the nucleus of the lens when the value - 380-426 PG/ml diagnose 4 degree and a high density of nucleus of the lens, at value - 427-465 PG/ml are diagnosed in 5 degree and a very high density of nucleus of the lens.