RU2212214C2 - Surgical method for treating the cases of ophthalmic toxoplamosis by administering alloplant material - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making standard conjunctival incision in inferior eyeball sector between direct muscles. Episcleral flap is cut out with retained blood vessel 13-15 mm far from limb. A through cut is made near the flap base to suprachoroid space. The episcleral flap is introduced into suprachoroid space and Alloplant material is introduced with the flap penetration. The surgical intervention is carried out when immunoglobulin G titer is reduced to toxoplasmosis 1.5-2.5 times as low relative to the initial one. EFFECT: complete removal of cellular parasites from vascular eye tunic and cystoid lysis achievable; improved vision function. 3 dwg

Description

 The invention relates to medicine, more specifically to ophthalmology, and can be used in the treatment of toxoplasmosis, central, disseminated, diffuse chorioretinitis, neurochorioretinitis.

 A known method of treating ocular toxoplasma / 1 /, which consists in conservative treatment using antimalarials, antibiotics, sulfonamides in the form of three courses of 5-10 days with an interval of 7-14 days.

 The disadvantage of this method is the toxic effect of drugs on the bone marrow with damage to the hematopoietic system. The treatment is expensive and the medicine is not always available for patients. In addition, conservative treatment is not an effective defense against relapse, as medical preparations hardly penetrate the blood-ophthalmic barrier and the elimination of the exudative lesion is difficult. As a result, a cicatricial form of toxoplasmosis chorioretinitis occurs, which leads to a sharp decrease in vision.

 The closest technical solution to the claimed is autolymphosorption - a method of treating diseases of the retina, choroid, vitreous body / 2 /. This method represents surgical treatment for chorioretinitis, retinitis, uveitis, etc. in the presence of exudative, transudative phenomena in the membranes of the eye. Autolymphosorption is performed in the lower external sector of the eyeball, the conjunctiva is cut, the lower and external rectus ocular muscles are taken on the suture-holders, between the muscles they are incised to 1/3 of the sclera depth 9-15 mm long, 8-12 mm wide and 6-10 mm from the limb. An episcleral flap is cut out from these notches using a keratomic blade, which is folded, and a double linear incision of the sclera is made to the suprachoroidal space to the width of the flap and an episcleral flap is inserted into it, and an alloplant for autolymphosorption, which is fixed with episcleral sutures, is placed on the surgical area.

 In the known method, the scleral incision is distant from the posterior pole and the biomaterial is not introduced into the suprachoroidal space, as a result of which a revascularizing and lymphosorbing effect on the exudative lesion does not occur, i.e. this method is ineffective in the treatment of toxoplasmosis.

 With toxoplasmosis of the eye, a chronic, recurrent course is observed. The cause of repeated relapses of the disease is the formation of cystozoids, which under certain conditions (trauma, stress, decreased immunity, etc.) can burst and cause new lesions. With each relapse of the disease, more gross, destructive changes develop in the retina and choroid, which leads to a sharp decrease in vision, up to complete blindness and loss of the eye as an organ.

 The aim of the proposed technical solution is to improve the function of vision (visual acuity, visual fields, physiological parameters), local eye immunity and prevention of recurrence of ocular toxoplasmosis due to the complete elimination of intracellular parasites from the choroid and lysis of cystozoids.

 This goal is achieved by the fact that in the inventive method, a conjunctival incision is made in the lower sector of the eyeball between the rectus muscles. At a distance of 13-15 mm from the limb, an episcleral flap with a preserved blood vessel is cut out, which is folded, a through incision is made at its base to the suprachoroidal space into which an episcleral flap with a blood vessel is inserted. Along the flap, Alloplant biomaterial is introduced into the suprachoroidal space. Sutures are placed on the incision area of the conjunctiva. Surgical treatment is carried out with a decrease in the titer of immunoglobulin G 1.5-2.5 times from the original.

 Comparative analysis with the prototype show that the inventive method is characterized in that the episcleral flap contains a blood vessel and it is cut out at a distance of 13-15 mm from the limbus, the biomaterial is introduced along the flap into the suprachoroid space, and surgical treatment is carried out with a titer reduction of 1.5 -2.5 times from the original. This technical solution meets the criterion of "novelty." When the Alloplant biomaterial is introduced along the flap into the suprachoroidal space, the existing blood vessel in the flap grows into the biological tissue. In this case, there is a massive growth of the blood and lymphatic channels in the tissue and the underlying areas of the choroid and retina. Cutting out of the episcleral flap is carried out at a distance of at least 13 mm from the limb, because in this case, the revascularizing, lymphosorbing and draining effect of Alloplant reaches the site of localization of the posterior exudative chorioretinal lesion. The distance from the flap to the limb more than 15 mm creates technical difficulties online access. Surgical treatment is carried out in the subacute period, which, as shown by clinical trials, is adjusted with a decrease in the titer of immunoglobulin G by 1.5-2.5 times from the original. A decrease in the titer of immunoglobulin by less than 1.5 times does not reliably indicate the transition of acute into the subacute period. In the acute period, operations are contraindicated according to all surgical rules. A decrease in the titer of immunoglobulin G by more than 2.5 times indicates the transition of the process to a chronic form, in which non-absorbable exudative chorioretinal foci turn into a scar form. In this case, this surgical treatment does not give the desired result. Histological studies revealed that the Alloplant biomaterial, after close contact with the surrounding tissue, is resorbed (within 2-6 months) by its macrophages and replaced by newly formed tissue, which in architectonics approaches the fibers of the surrounding tissue. Fibroplasts, macrophages, a network of newly formed blood capillaries and a lymphatic network were found in the spaces between collagen fibers.

 It is known that toxoplasmosis of the eye is an infection-parasitic disease, recurs in 75%. This is due to the fact that endozoids, intracellular parasites, are able to turn into cystozoids, which, in turn, rupture, form new exudative foci. Surgical treatment according to the claimed method allows lysing the cyst membrane together with lysis of the Alloplant biomaterial, opening the blood-phthalmic barrier, i.e. drain the exudative chorioretinal lesion, improve venous outflow with excretion of pathogens and products of their vital activity, partially restore blood circulation in the organized chorioretinal lesion.

 After surgical treatment, as shown by clinical trials, in 100% of cases there is no relapse of the disease toxoplasmosis. This is also indicated by the fact that the titer of immunoglobulin G is in the range of negative and intermediate titers.

 In addition, to determine the tendency of the process to relapse in the pre- and postoperative period, immunological studies of the tear are carried out by the method of radical diffusion according to Manchin / 3 /, which consists in determining the ratio of titers of immunogloulin G and A, by which the local immunological background of the eye is judged. Prior to surgical treatment, an increase in the titer of immunoglobulin G and a decrease in immunoglobulin A are noted, which indicates the tendency of the process to recur. After treatment according to the claimed method, their ratio remains at 6: 1, which is considered as a favorable prognosis.

 Thus, the interaction of essential features results in a new technical result, namely, complete elimination of intracellular parasites from the choroid and lysis of cystozoids. That is, this technical solution meets the criterion of "inventive step".

 In FIG. 1 shows the introduction of an episcleral flap into the suprachoroidal space. Figure 2 shows the introduction of biomaterial "Alloplant" in the suprachoroidal space along the flap. Figure 3 shows the fixation of the biomaterial "Alloplant" with suturing on the scleral incision.

 The inventive method is as follows. A conjunctival incision is made 7-10 mm from the limbus, stupidly separated, and the external rectus muscles are taken to the suture-holders. Conjunctiva sutures are placed on the depth of the lying “lip” to open the operative field. The diathermocoagulant outline the boundaries of the episcleral flap 6-7 mm wide, 6-7 mm long and 13 mm from the limb while maintaining the blood vessel. After that, non-through scleral incisions are carried out with a keratotomy blade. The episcleral flap is separated in one layer and folded towards the limb. At the base of the episcleral flap, a linear through incision of the sclera is performed and, using spatulas, the flap is inserted into the suprachoroid space. Along the flap, Alloplant biomaterial is introduced into this space for autolymphosorption. A U-shaped seam is applied to the incision area with the capture of the Alloplant edge. On the conjunctiva impose nodal sutures or a continuous suture. Before surgical treatment, conservative therapy is carried out in order to transfer the acute phase of the disease into the subacute, which corresponds to a decrease in the titer of immunoglobulin G by 1.5-2.5 times from the original.

Example 1
Patient A. S. A., 30 years old, was admitted with a diagnosis of disseminated chorioretinitis with edema of the makult of the left eye.

On examination:
Immunoglobulin titer G = 130 IU / ml
The ratio of immunoglobulin G and A-10: 0
Visual acuity: left eye 0.2 n.k.

 right eye 1.0 n.k.

Fields of vision (totaling 8 meridians): left eye 385
right eye 505.

Electrophysiological studies:
a) Threshold of electrical sensitivity: left eye 100 mA
right eye 55 mA
b) Electrical lability: left eye 32 Hz
right eye 40 Hz
c) Electroretinography: 90/350 μV left eye
right eye 50/250 uV.

Conducted conservative therapy with rheomycin, sulfodimizine, vitamins B ₁ , B ₂ , aloe extract / 1 /.

 3 weeks after conservative treatment, the titer of immunoglobulin G was 53.3 IU / ml.

After surgical treatment:
After 30, 90, 180 days, the titer of immunoglobulin G was 50, 35, 25 IU / ml, respectively;
The ratio of immunoglobulin G to A is 6: 1;
Visual acuity after 30, 90, 180 days: left eye 0.5, 0.6, 0.8 n.k. accordingly, the right eye is unchanged;
Fields of vision (totaling 8 meridians) after 30, 90, 180 days: left eye 440, 450, 475, respectively, right eye - unchanged;
Electrophysiological studies:
a) The threshold of electrical sensitivity: the left eye is 60 mA, the right eye is unchanged;
b) Electric lability: left eye - 30 Hz, right eye - unchanged;
c) Electroretinography: left eye 30/210 μV, right - unchanged.

Example 2
Patient T.N. 40 years old, diagnosis: Recurrent chorioretinitis of toxoplasmosis etiology, central diffuse chorioretinopathy, cicatricial form of both eyes.

On examination:
The titer of immunoglobulin G 170 IU / ml
The ratio of immunoglobulin G to A - 12: 0
Visual acuity: right eye 0.1 n.k.

 left eye 0.08 n.k.

Fields of view for the sum of 8 meridians: right eye 300
left eye 440.

Threshold of electric sensitivity: right eye: 220 mA,
left eye: 240 mA;
Electrical lability: right eye 28 Hz,
left eye 26 Hz.

 Conducted conservative treatment according to the known method / 1 /. 3 weeks after this, the titer of immunoglobulin G 84 IU / ml

Conducted surgical treatment. For 5 years, the patient is under observation. Up to 3 months after surgical treatment, visual functions gradually improved, and from 3 months to the present, they are stored on these figures:
Visual acuity: right eye 0.2-0.3 n.k.

left eye 0.1 n.k .;
Fields of view: right eye 380
left eye 460.

Threshold of electrical sensitivity: right eye 120 mA
left eye 130 mA
Electrical lability: right eye 36 Hz,
left eye 34 Hz.

The titer of immunoglobulin G for the entire observation period is 47.0-12.2 IU / ml
The ratio of immunoglobulin G to A is 6: 1.

 Before surgical treatment in a patient, relapses were repeated 2-3 times a year. After surgical treatment, relapses were not observed.

 The above examples show that the treatment according to the claimed method is most effective after the first exacerbation of the toxoplasmosis process, because visual functions stabilize at a higher level.

Sources of information
1. Shpak N.I. Toxoplasmosis of the eye. - M .: "Medicine", 1978, p.125-139.

 2. Galimova V.U. Autolymphosorption is a method of treating diseases of the retina, choroid, vitreous. - Abstracts of the scientific-practical conference Actual problems of ophthalmology. - Izhevsk, 1995, p. 226-227.

 3. Somov E.E., Brzhesky V.V. A tear. Physiology. Research Methods. Clinic. - St. Petersburg: Science, 1994, p.110-113. (monograph).

Claims (1)

 A method of surgical treatment of eye toxoplasmosis with the use of Alloplant biomaterial, which consists in making a conjunctiva in the lower sector of the eyeball between the rectus muscles, cutting out an episcleral flap that is folded and making a through incision at its base to the suprachoroid space with further introduction into it episcleral flap, sutures are applied to the incision area of the conjunctiva, characterized in that the episcleral flap contains a blood vessel and is cut out at a distance and 13-15 mm from the limbus and biomaterial "biomaterials" is introduced in the course of the flap into the suprachoroidal space, the surgery is performed after the reduction in the titer of immunoglobulin G patients 1.5-2.5 times of the original.

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