Surgical method of treating low-activity fibrovascular membrane with replacing defect of retinal pigment epithelium

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly ophthalmology, and can be used to treat a low-activity fibrovascular membrane of the macular area. The method involves performing subtotal vitrectomy, removing the fibrovascular membrane, packing the retina with a perfluoroorganic compound followed by replacing by air and SF6 gas in an amount of 2 ml and performing and a laser endolasercoagulation of the retina. That is preceded by performing iridectomy and separating the pigment layer of the diameter of 1 mm. That involves preparing a suspension of 0.85% NaCl 0.2 ml and the pigment layer. The prepared suspension is introduced to replace the removed fibrovascular membrane before packing the retina with the perfluoroorganic compound and performing endolasercoagulation.

EFFECT: using the invention provides the partial restoration of the morphological structure and functional adequacy of the retina involved into the developing fibrovascular tissue.

1 ex

 

The invention relates to the field of medicine, particularly ophthalmology, and can be used for the treatment of fibrovascular membranes low activity in the macular region with simultaneous replacement of the defect pigment epithelium of the retina.

Fibrovascular membrane - pathological entity, which is the outcome of this pathological process, as subretinal neovascularization. Most often this pathology manifests itself in the pathology of the foveolar area, particularly in age-related macular degeneration of the retina. In the process of developing neovascular tissue in the Central section of the retina is the proliferation of fibrovascular tissue, replacing the area of neovascularization. The formation of fibrovascular membranes accompanied by severe deformation and atrophy of the pigment epithelium of the retina, and therefore even antimajoritarian therapy often has low efficiency. In addition, angiogenesis blockers can reduce the growth of blood vessels, reducing the area of likeda foveolar tissue. When this area of fibrosis is not amenable to reduction. This leads to the fact that the main therapies of fibrovascular membranes is the surgical removal of the macular area [Bikbov M. M., Faizrakhmanov P. P., Yarmuhametov A. L. the Effectiveness of submacular surgery fibrovascular the membranes in wet form of age-related macular degeneration // Cataract and refractive surgery. - 2013. - So 13. No. 2. - S. 41-44].

From the point of view of morphology, pigment epithelium is located between choriocapillary layer of the choroid and retina plays an important role in photoreception, the formation and metabolism of the latter. Pigment epithelium of the retina becomes pigmented epithelium of the ciliary body and iris, based on their inner surface. The main reason for the development of fibrovascular membranes low activity and neovascularization in the Central section of the retina with age-related macular degeneration is a defect in Bruch's membrane and retinal pigment epithelial. This leads to the fact, that to preserve the visual function of the pigment epithelium of the iris is able to replace the pigment epithelium of the retina, while keeping its functionality.

The prototype of the invention is a method of surgical treatment of fibrovascular membranes of low degree, based on the removal of the membrane from its localization with the use of vitrectomy, retinotomy [Zakharov C. D. - M.: vitreoretinal surgery, 2003]. This method will include the assessment Subtotal vitrectomy, retinotomy the macular region in the projection point of the membrane and its subsequent removal of the subretinal space, as well as the use of tampons vitreal cavity of gas and air. However, the functional is the playing technique is similar to the operation is low, in 27% of cases promptly after treatment visual acuity deteriorates. In addition, in some cases, possible relapse. This low functional result because of fibrovascular tissue in his education partly replaces the pigment epithelium of the retina. After surgical treatment from the point of view of morphology in the foveolar area is located choriocapillary layer of the choroid and deformed layer of photoreceptors. In order to restore the integrity of the destroyed layer retinal pigment epithelial attempted transplantation under the macula cells of the pigment epithelium, aspirated from the peripheral regions of the retina of the patient. However, additional damage to the retina in this procedure, the technical complexity in the formation of the flap pigment epithelium of the retina and the absence of conclusive data about the viability of the transplanted cells contributed to the lack of wide dissemination methods.

The objective of the invention was to develop a method of surgical treatment of fibrovascular membranes low activity, replacing the defect retinal pigment epithelial involved area plot of the pigment epithelium of the iris.

The proposed method of treatment is the removal of fibrovascular membrane is autologous cells of the pigment epithelium of the iris of the eyeball in the affected area of the retina.

The technical result when using the invention, the partial restoration of the morphological structure and the functional usefulness of the area of the retina affected by the development of fibrovascular tissue.

The indication for this method of treatment is fibrovascular membrane low activity with clear boundaries with no signs of edema.

The proposed method of surgical treatment of fibrovascular membranes low activity is carried out in 4 stages.

stage 1. The fence section of leaf pigment epithelium of the iris of the affected eye.

Fence pigmented sheet of the iris is carried out as follows. Form 1 tunnel incision. Filling the anterior chamber with viscoelastic, vitreal scissors 25G form the basal iridotomy iris not less than 1 mm in diameter. Collected material is evacuated from the anterior chamber of the retinal forceps 25G. Separate the pigment epithelium, forming a layer of pigment cells 1 mm in diameter. The cells of the pigment epithelium of the iris is placed in a sterile tube containing 0.2 ml of 0.85% NaCl. The contents of the tubes fill the syringe with a volume of 1 ml By passing the solution with the pigment epithelium through a needle, forming a suspension, due to the fact that cells lose touch under mechanical impact.

stage 2. Holding vitreoretinal the intervention in volume Subtotal vitrectomy using the standard method. Is a three port 25G vitrectomy with removal of the rear hyaloid.

stage 3. Holding retinotomy. Retinotomy is from the temporal side in the area of the projection of the edges of fibrovascular membane to the imaging region. The length of retinotomy must be more than 50% of the radius of the membrane for further evacuation. Then with the help of curved peaks perform the mobilization of the membrane. The membrane is removed by means of horizontally curved tweezers formed through retinotomies hole. The bleeding stopped, lifting the bottle of infusion solution and thereby increasing the intraocular pressure.

stage 4. Irrigation suspension of the pigment epithelium. The suspension of cells of the pigment epithelium of the iris is injected through retinotomy in the location area of fibrovascular membranes in full, thus after removal of fibrovascular tissue is restored to the pigment layer of the retina. Produce tamponade of the retina performancesin connection. Retinotomy close the laser coagulates. To further carry out the substitution performancesthe substances into the air with SF6 gas in a volume of 2 ml

Thus, when using the proposed method removes fibrosarcoma subretinal tissue is the basis of fibrovascular membranes low activity, replacing the defect pigment is on the epithelium of the affected area. This intervention allows for a constant eccentric fixation, reduce metamorphopsia that patients often report subjective improvement of vision. Partially restored the layer of retinal pigment epithelial blocks the possibility of relapse, taking barrier function.

The proposed method was tested in 8 patients with the wet form of age-related macular degeneration with formation of fibrovascular membranes low activity in the macular area of the Proposed method is illustrated by the following clinical example.

The patient Semenov, R. T., 1946 R.

Visual acuity of the right eye: 0,02 N. K. (2%) visual Acuity of the left eye: 0,9 N. K. Objectively right eye: the cornea is transparent, the front camera is average. The pupil is round, movable. The lens is transparent. The fundus of the eye. The optic disc pale pink outlined. In the macular region of fibrovascular membrane low-grade activity that generates the elevation of the retina. Optical coherence tomography: fibrovascular membrane height to 460 microns.

Diagnosis: Age-related macular degeneration, exudative, fibrovascular membrane low degree of activity.

Surgery: removal of fibrovascular membrane with autologous pigment epithelium.

The progress of the operation. Made of basal IRID Tome iris through the tunnel incision retinal scissors 250G. Of the flap is separated pigment epithelium of the iris and formed a plot differentage pigment epithelium 1 mm in diameter, which is placed in 0.2 ml of 0.85% NaCl. From the tube of material collected in a syringe with a volume of 1 ml. Formed suspension. Next, the patient received three port vitrectomy 25G, removed rear of the hyaloid membrane, formed retinotomy. Through retinotomy removed fibrovascular membrane. In the area of localization of the membrane through a needle introduced a cell suspension of the pigment epithelium of the iris. In the vitreal cavity entered performancesee connection, laser coagulation of the retina with subsequent replacement of the fluid in the vitreal cavity into the air and SF6 gas in a volume of 2 ml

The examination is made within 3 months after surgery. Visual acuity of the right eye: 0,07 N. K. (7%) visual Acuity of the left eye: 0,9 N. K. Objectively right eye: the cornea is transparent, the front camera is average. The pupil is round, movable. The lens is transparent. The fundus of the eye. The optic disc pale pink outlined. In the macular region of fibrovascular membrane low activity is absent. Optical coherence tomography: moderate degenerative changes of the retina. Subretinal neovascular membrane is absent.

A method of surgical treatment of fibrovascular membranes with a low degree of activity is involved in the macular region, including Subtotal vitrectomy, removal of fibrovascular membranes, tamponade of the retina performancesin connection with subsequent replacement by air and SF6 gas in a volume of 2 ml, endolasercoagulation of the retina, characterized in that the pre-spend iridotomy produce Department pigment layer with a diameter of 1 mm, and then preparing a suspension of 0.2 ml of 0.85% NaCl and the pigment layer, and the obtained suspension is injected at a location remote fibrovascular membrane before tamponade of the retina performancesin connection and endolasercoagulation.



 

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