RU2261659C2 - Method for diagnostics and predicting reserves of eyeball's circulation in case of ischemic opticopathies of optic nerve in patients of gerontological age - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: the present innovation deals with methods for diagnostics of vascular pathology of optic nerve (ischemic opticopathies) and, also, predicting vascular pathology of optic nerve lesion and counterlateral eyeball. One should perform dopplerographic registration of circulatory parameters: peak systolic velocity PSV cm/sec and end diastolic velocity EDV cm/sec on the 2^nd, 3d min both before and at the background of functional loading: dealing with lifting legs up to 90° in area of internal carotid artery, central retinal artery and ciliary artery. Moreover, calculation of resistant index RI c. u. should be performed by the following formula (PSV cm/sec - EDV cm/sec)/PSV cm/sec and reactivity index RY c.u. by the following formula PSV cm/sec after loading/PSV cm/sec before loading. At RI value being above 0.7 and RY value being below 1.0 one should detect deterioration of visual functions and the absence of circulatory reserves in tested eye and counterlateral one. At RI value being below 0.7 and RY value being above 1.0 it is possible to detect the maintenance of visual functions and circulatory reserves in tested and counterlateral eyes. The innovation enables to accelerate and simplify the trial and carry out it with available physical loading for a patient without applying any additional appliances and medicinal preparations.

EFFECT: higher efficiency and accuracy of diagnostics and prediction.

6 dwg, 3 ex, 2 tbl

Description

The invention relates to medicine, namely to ophthalmology, to methods for diagnosing vascular pathology of the optic nerve (Ischemic opticopathies), as well as predicting vascular pathology of damage to the optic nerve, the contralateral eyeball.

The purpose of the invention is the proposal of a method for the diagnosis of vascular pathology of the optic nerve in gerontological patients with dyscirculatory encephalopathy, taking into account the age of the patients (60 years of age and older), the presence of many concomitant diseases, it is desirable to conduct the study as quickly as possible, easier, with accessible physical activity for the patient , without the use of additional devices and drugs, so as not to cause a deterioration in the patient’s condition with his studies.

The essence of the invention is to register blood flow parameters (peak systolic velocity (PSV cm / s), final diastolic velocity (EDV cm / s), resistance index (RI cu), reactivity index (RY cu)) with dopplerography on the background of the functional load of a physical nature.

Formula number 1

RI y.e. = (PSV cm / s - EDV cm / s): PSV cm / s

Formula number 2

RY y.e. = PSV cm / s after loading / PSV cm / s before loading

When conducting a study on the lesion side, we diagnose Ischemic opticopathies; when conducting on the contralateral side of the lesion, we predict the vascular reserves of the eyeball of the contralateral side.

1. A known method for determining the assessment of the reserves of blood circulation of the heart and brain in patients with coronary and carotid atherosclerosis using a modified antiorthonload test (AONP) with the location of the lower extremities on a stand at an angle of 60 ° to a horizontal surface. Registration of hemodynamic parameters is carried out at rest and at the 5-10th minute of the load. When using AONP, the functional response of the circulatory system depends on its reactivity, which determines its functional reserve, the quantitative assessment of which is the reactivity index (IR), as the ratio of the blood flow index against the background of the functional test to the initial value.

The disadvantage of this method is the volume of the study: the authors observe changes in the indicators of reactivity of cardiac output, ejection fraction; changes in systolic and diastolic myocardial function are observed, the volumetric blood flow velocity in the stenosing vessel is recorded, the total blood flow in both internal carotid arteries is determined. The authors predict the hemodynamic effectiveness of coronary artery bypass surgery by examining the increase in the ejection fraction of the left ventricle in AONP, as well as dopplerography of the internal carotid artery (Vorozhtsova I.N. Reserves of the blood circulation of the heart and brain in patients with coronary carotid atherosclerosis: Abstract. Dis ... d- pa medical sciences .-- Tomsk, 2000 .-- 53 p.).

2. Test with hypercapnic hypoxia by breathing through additional dead space. Changes in the gas composition of the blood were achieved by breathing for 3 minutes through an additional dead space, the role of which was played by a horizontally located elastic tube (3.0 cm in diameter, 145 cm long, 1.0 l in volume) equipped with a mouthpiece; in the horizontal position of the patient in the initial state and at the peak of the sample, the linear blood flow velocity in the system of cerebral arteries is measured using the method of ultrasonic transcranial dopplerography. To exclude nasal breathing, a clip was applied to the wings of the nose. To study the dynamics of the blood gas composition in the initial state and at the peak of the test in the arterial capillary blood, the oxygen and carbon dioxide contents were estimated using the Astrup micromethod on a BMS-3 microanalyzer of the Radiometr firm (Denmark). (Astanina I.A. Comprehensive radiation morphofunctional study of the blood supply to the brain in patients with coronary heart disease and arterial hypertension with asymptomatic atherosclerotic lesions of the carotid arteries: Author's abstract. Dis .... Candidate of Medical Sciences. - Tomsk, 2001. - 29 p.) .

The disadvantages of this method are the need for research on 2 devices using an elastic tube, which is a reusable item, the need for constant sterilization, the absence of nasal breathing, not everyone can breathe quietly in a confined space, and the need to specially manufacture this tube.

Given the age of our patients (60 years and older), the presence of many concomitant diseases, it is advisable to conduct the study as quickly as possible, easier, with affordable physical activity for the patient, without the use of additional devices and medications, so as not to cause the patient to worsen with his research .

The proposed technique is carried out using a Toschiba-270 ultrasonic A-B scanner with a convex sensor of 4.5 Mhz, a linear sensor of 7.5 Mhz, for surface structures, the scanning depth is up to 6 cm (Petrukhin A.N., Loskutov I .A. The study of blood flow velocity in orbital vessels in glaucoma // Clinical journal of the company Medison on ultrasonography. - 1999. - Issue 5. - S.60-65), (see Figure 1-6)

In the horizontal position of the patient, the internal carotid artery (ICA), the central retinal artery (CAS), and the posterior ciliary arteries (CCA) were examined. Peak systolic velocity (PSV cm / s), final diastolic velocity (EDV cm / s), resistance index (RI cu) or reactivity index (RY cu), were determined (see Table No. 2).

The measurement was carried out in the position of the patient lying on his back, before the study for at least 6 hours the patient did not receive vasoactive drugs and physiotherapeutic procedures. The sensor is located in the cranial direction at an angle of about 60 ° to the blood flow line in the vessel during transverse examination of the vessel and parallel to the vessel 90 °, with longitudinal examination of the vessel. (Agadzhanova L.P. Ultrasound diagnosis of diseases of the aortic arch and peripheral vessels: Atlas. -M.: Vidar, 2000 - 176 p.).

When examining the carotid arteries, the patient’s chin is slightly raised and the face is turned away from the studied artery.

The site of bifurcation of the carotid artery is determined at the intersection of the medial surface of the edge of the sternocleidomastoid muscle and vocal cords.

The internal carotid artery is located under the edge of the lower jaw.

The ocular artery was located 15 mm from the posterior pole of the eyeball under the optic nerve, it is easy to visualize when the patient is looking to the right side on the left eye and when the patient is looking to the left side on the right eye. (Harlap S.I. Anatomical and diagnostic parallels of the state of the vessels of the eye and orbital space according to the results of color Doppler mapping // Vesti. Ophthalmol. - 2000. - No. 1. - P.45-48).

The central retinal artery was located in the surface of the optic nerve about 5-10 mm from the posterior pole of the eyeball.

The posterior ciliary arteries were located in the optic nerve from the medial or lateral side 5-10 mm from the posterior pole of the eyeball.

The load test consists in raising the patient upwards legs bent at the knees to 90 °, while the hemodynamic parameters are recorded at the 2nd - 3rd minute.

A group of patients was studied - 51 people (72 eyes) with ischemic opticopathy. In the first group with the phenomena of posterior ischemic opticopathy (ZIOP) - 39 patients (56 eyes). The average age composition in this group is 72 years. The second group with the phenomena of anterior ischemic opticopathy (PIOP) - 12 people (16 eyes). The average age composition in this group is 73 years.

The control group consisted of 25 people (50 eyes). The average age composition of this group is 77 years (see table 2).

Blood flow indicators before and after AONP.

Significance of differences in results P <0.05

Table number 1 Control group ZIOP PIOP PSV cm / s EDF cm / s PSV cm / s EDF cm / s PSV cm / s EDF cm / s ICA before 0.29 + 0.06 0.11 + 0.04 0.23 + 0.06 0.08 + 0.02 0.25 + 0.06 0.09 + 0.02 after 0.34 + 0.07 0.13 + 0.04 0.24 + 0.06 0.08 + 0.02 0.23 + 0.07 0.08 + 0.02 CAC to 0.10 + 0.02 0.03 + 0.01 00.8 + 0.02 0.03 + 0.01 0.06 + 0.02 0.02 + 0.01 after 0.12 + 0.02 0.03 + 0.01 0.09 + 0.02 0.03 + 0.01 0.05 + 0.02 0.02 + 0.01 ZCA to 0.14 + 0.03 0.04 + 0.01 0.11 + 0.03 0.03 + 0.01 0.08 + 0.02 0.03 + 0.01 after 0.15 + 0.03 0.05 + 0.01 0.11 + 0.03 0.03 + 0.01 0.08 + 0.02 0.03 + 0.01

Table No. 2 RY PSV metrics ICA CAC CA Control group 1.17 + 0.06 1.2 + 0.02 1.07 + 0.03 ZIOP 1.04 + 0.06 1.07 + 0.02 0.96 + 0.03 PIOP 0.92 + 0.07 0.9 + 0.02 1.0 + 0.02

Significance of differences in results P <0.05

Example 1

Clinical case study:

Vetlugin Anatoly Yakovlevich, 75 years old. Outpatient card No. 479/95.

On January 25, 01, when contacting an optometrist, it was registered:

Vis = 1.0 / 1.0 intraocular pressure = 17/17 mmHg The field of view was determined by the Ferster perimeter, a white object of 0.5 cm is the norm.

Objectively: Both eyes (OU) - Anterior segment without features. Biomicroscopic: Both eyes are focal opacities in the lens. Fundus: Disks of the optic nerve (optic nerve disc) are pale pink, the borders are clear, the arteries are narrowed, convoluted. The veins are dilated.

Diagnosis: OU - Initial age-related cataract. Retinal vascular angiosclerosis.

August 9, 01, Complaints of a sharp decrease in vision in the left eye.

Objectively: OU-1,0 / arm movement. Front segment without feature. Biomicroscopic: Both eyes are focal changes in the lens. Fundus: Right eye (OD) -DZN - pale pink, clear borders. The left eye (OS) - DZN - pale, fuzzy borders, retinal edema in the posterior pole.

Diagnosis: Ischemic opticopathy OS.

The patient was examined by a neurologist. Diagnosis: Discirculatory atherosclerotic encepholopathy II - stage, amniostatic syndrome.

Ultrasonic duplex scanning: Right side Left-hand side To load after loading to load after loading CAC-0.10-0.03 0.11-0.04 0.08-0.02 0.08-0.02 ZCA-0.11-0.03 0.13-0.05 0.09-0.03 0.09-0.03 VSA-0.36-0.10 0.42-0.12 0.27-0.06 0.25-0.05

After the study, we calculate the indices: Ri Ri Ri Ri To load after loading before load after load CAC 0.7 0.6 0.8 0.8 ZCA- 0.7 0.6 0.7 0.7 ICA 0.6 0.7 0.8 0.8

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s CAC 1,1 1.3 1,0 1,0 ZCA- 1,2 1.3 1,0 1,0 ICA 1,2 1,2 0.9 0.8

03/15/02. Complaints about low vision OS. A course of vascular, trophic therapy takes place 2-3 times a year.

Objectively: Vis - 1.0 / 0.2 ex. OU-Anterior segment unchanged, clouding of the nuclear-cortical layers of the lens. The fundus of the eye: OD-DZN - pale pink. The contours are clear. OS- DZN - pale, the contours are clear. OU - Arteries are sclerotic.

Diagnosis: Ischemic opticopathy OS.

Ultrasonic duplex scanning: Right side Left-hand side To load after loading to load after loading CAC-0.12-0.04 0.14-0.05 0.14-0.04 0.14-0.04 ZCA - 0.14-0.04 0.16-0.05 0.10-0.03 0.10-0.03 ICA-0.42-0.22 0.48-0.22 0.23-0.07 0.23-0.07

After the study, we calculate the indices: Ri Ri To load after loading before load after load CAC-0.6 0.6 0.7 0.7 ZCA - 0.7 0.7 0.7 0.7 ICA 0.5 0.5 0.7 0.7

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s CAC-1.2 1,0 1,0 1,0 ZCA - 1.1 1,0 1,0 1,0 ICA 1.1 1,0 1,0 1,0

On the example of this patient, good vasodilation reserves from the ICA, CAC, ZCA from the contralateral side RI-0.7 and less, RY more than 1.0; and the lack of response to the load on the part of the damage to the vessels of the eyeball RI-0.7 and more, RY-1.0 and less. This reaction of the vascular bed is observed during patient circulation and in dynamic observation during the year, high visual functional parameters of the contralateral eyeball and the lack of restoration of high functions of the affected eye are preserved.

Example 2

Stashkov Valentin Stepanovich, 79 years old. Outpatient card number 006179.

01/19/00 years when contacting an ophthalmologist registered:

Vis - 0.4-1.0 Diopters (D) = 0.5 / 0.1-20 D = 0.5 IOP-16 mm Hg / 27 mmHg

The visual field OD is the norm, OS is 10 degrees above, 10 degrees from the bow, 10 degrees from below, and 70 degrees from the temporal side.

Objectively: OU-thinning pigment rim. Biomicroscopic: nuclear-cortical opacities in the lens. The fundus of the eye: OD-DZN is pale pink, the borders are clear, the arteries are sclerotic, the veins are full-blooded. OS- DZN is pale, monotonous, the borders are clear, the arteries are sclerosed, the veins are full-blooded.

Diagnosis: OU- Initial age-related cataract, retinal vascular sclerosis. OS-Subatrophy of vascular genesis of optic disc disease, suspected open-angle glaucoma. The patient was examined by a neurologist. Diagnosis: Discirculatory atherosclerotic encepholopathy of the II-III stage, micro-focal symptoms. Arterial hypertension.

After the study, we calculate the indices: Ri Ri To load after loading to load after loading CAC-0.6 0.6 0.7 0.7 ZCA - 0.7 0.7 0.7 0.6 ICA 0.7 0.6 0.5 0.5

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s CAC-1.0 1,0 1,0 1,0 ZCA - 1.0 1,0 1,0 1,0 ICA 1.0 1,0 1,0 1,0

01/15/01, Complaints of a gradual decrease in vision during the year in both eyes.

Objectively: V _is -0.1 does not correct (n / a) / 0.1n / k IOP - 18 mmHg / 18 mmHg

The field of view of the OS OS is 15 degrees above, 15 degrees from the nose, 15 degrees below, 25 degrees from the temporal side, 5 degrees from the top, 5 degrees from the nose, and 5 degrees below, from the temporal sides - 25 degrees. OU is the thinning of the pigment rim. Biomicroscopic: nuclear-cortical opacities in the lens. The fundus of the eye: OD - optic nerve discs are pale pink, monotonous, the borders are clear, the arteries are sclerotic, the veins are full-blooded. OS - DZN pale, monotonous, clear boundaries, arteries sclerotic, veins full-blooded.

Diagnosis: OU- Initial age-related cataract, retinal vascular sclerosis. OU- Subatrophy D.Z.N. vascular origin. OS- Stage II open-angle glaucoma compensated.

Ultrasonic duplex scanning: Right side Left-hand side To load after loading to load after loading CAC - 0.07-0.02 0.07-0.02 0.05-0.02 0.05-0.02 ZCA - 0.09-0.02 0.09-0.02 0.07-0.02 0.07-0.02 ICA-0.26-0.10 0.24-0.10 0.17-0.09 0.17-0.09

After the study, we calculate the indices: Ri Ri To load after loading before load after load CAC-0.7 0.7 0.06 0.6

ZCA - 0.8 0.8 0.7 0.7 ICA 0.6 0.6 0.5 0.9

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s CAC-1.0 1,0 1,0 1,0 ZCA - 1.0 1,0 1,0 1,0 VSA-0.9 1,0 1,0 1,0

On the example of this patient, the absence of vasodilation reserves from the ICA, CAC, and ZCA on the load on both sides — RI-0.7 and more, RY-1.0 and less, despite the good functional performance of the contralateral right eyeball, is clearly visible when handling , and the sharp negative dynamics of the contralateral eyeball during the year, which led to the phenomena of ZIOP and, as a consequence, the subatrophy of D.Z.N. left eyeball.

Example 3

Kurochkin Pavel Leonidovich, 75 years old. Outpatient card number 73/85.

02/18/00 years when contacting an ophthalmologist registered:

Vis - 0.5 + 1.0 Diopters (D) = 0.7 / 0.5 + 1.0D = 0.7 IOP-18 mmHg / 18 mmHg No complaints at the time of inspection.

The OD field of view from above is 50 degrees, from the fore side - 50 degrees, from below - 55 degrees, from the temporal side - 80 degrees.

OS on top - 50 degrees, on the bow side - 50 degrees, bottom - 55 degrees, on the temporal side - 80 degrees.

Objectively: OU - anterior chamber of medium depth, dystrophic changes in the stroma of the iris. Biomicroscopic: nuclear-cortical opacities in the lens. The fundus of the eye: OU-DZN is pale pink, the borders are clear, the arteries are sclerotic, the veins are full-blooded, in the macular zone of the drusus.

Diagnosis: OU- Initial age-related cataract, retinal vascular sclerosis. Central involutional dystrophy of the retina. Patient examined by a neurologist - Diagnosis: Atherosclerotic encepholopathy of the II stage.

Ultrasonic duplex scanning: To load after loading to load after loading CAC-0.13-0.04 0.14-0.04 0.12-0.03 0.13-0.04 ZCA - 0.15-0.07 0.16-0.08 0.14-0.04 0.15-0.05 ICA 0.34-0.18 0.42-0.19 0.26-0.12 0.32-0.14

After the study, we calculate the indices: Ri Ri To load after loading to load after loading CAC-0.5 0.7 0.7 0.7 ZCA - 0.6 0.5 0.6 0.6 ICA 0.6 0.5 0.5 0.5

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s

CAC-1.2 1,0 1,2 1.3 ZCA - 1.1 1,1 1,0 1.3 ICA 1.1 1,1 1,1 1,2

06/19/01, when contacting an optometrist, it was registered:

Vis - 0.4 + 1.0 Diopters (D) = 0.7 / 0.7 + 1.0D = 0.9 IOP - 19 mm Hg / 19 mm Hg

No complaints at the time of inspection.

The OD field of view is 50 degrees above, 50 degrees from the bow, 55 degrees from below, and 70 degrees from the temporal side.

OS on top - 50 degrees, on the bow side - 50 degrees, below - 55 degrees, on the temporal side - 70 degrees.

Objectively: OU- anterior chamber of medium depth, dystrophic changes in the stroma of the iris. Biomicroscopic: nuclear-cortical opacities in the lens. The fundus of the eye: OU-DZN is pale pink, the borders are clear, the arteries are sclerotic, the veins are full-blooded, in the macular zone of the drusus.

Diagnosis: OU- Initial age-related cataract, retinal vascular sclerosis. Central involutional dystrophy of the retina.

Ultrasonic duplex scanning: Right side Left-hand side To load after loading to load after loading CAC - 0.08 0.03 0.09-0.04 0.09-0.03 0.10-0.04 ZCA - 0.10-0.03 0.11-0.04 0.11-0.03 0.12-0.04 ICA-0.22-0.08 0.30-0.10 0.22-0.08 0.34-0.10

After the study, we calculate the indices: Ri Ri To load after loading to load after loading CAC-0.6 0.6 0.6 0.6 ZCA - 0.6 0.6 0.6 0.7 ICA 0.7 0.7 0.7 0.7

Ry Ry PSV cm / s EDV cm / s PSV cm / s EDV cm / s CAC-1.1 1.3 1,1 1.3 ZCA - 1.1 1.3 1,1 1.3 VSA-1.4 1.3 1,5 1.3

This patient has good circulatory reserves of the eyeball on both sides, which is confirmed by RY above 1.0 at all measurement points, RI 0.7 and below before the load and after the test; good functional performance is maintained throughout the observation period.

The proposed method for diagnosing and predicting the reserves of blood circulation of the eyeball with ischemic opticopathy of the optic nerve in people of gerontological age is faster, easier, with affordable physical activity for the patient, without the use of additional devices and drugs, so as not to cause a deterioration of the patient’s condition with his studies.

A correlation between RY, RI and circulatory reserves was noted: with an increase in RI greater than 0.7 and a decrease in RY less than 1.0, a deterioration in visual function is observed in the examined and contralateral eye, with a decrease in RI less than 0.7 and an increase in RY greater than 1.0 good visual functions and circulatory reserves in the examined and contralateral eye.

Claims (1)

A method for determining the reserves of blood circulation and visual functions of the eyeball during ischemic opticopathy of the optic nerve in people of gerontological age, including dopplerographic registration of blood flow parameters: peak systolic velocity PSV cm / s and final diastolic speed EDV cm / s at the 2nd, 3rd minute before and against the background of the functional load, which consists in raising the legs to 90 degrees in the region of the internal carotid artery, central retinal artery and ciliary artery, the calculation of the resistant index RI . according to the formula (PSV cm / s - EDV cm / s) / PSV cm / s and reactivity index RY by the formula PSV cm / s after loading / PSV cm / s before loading and when the RI value is more than 0.7 and RY is less than 1.0, deterioration of visual functions and the absence of blood circulation reserves in the examined and contralateral eyes are determined, and when the RI value is less than 0, 7 and RY greater than 1.0 determine the preservation of visual functions and circulatory reserves in the examined and contralateral eyes.

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