RU2630614C1 - Method for prediction of laser coagulation necessity for premature retinopathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: to predict the necessity of laser coagulation in case of premature retinopathy, the body weight of the newborn is measured, the transaminase index, which is the ratio of the aspartate aminotransferase level to the alanine aminotransferase level (AST/ALT), and the amount of the fast phase protein are determined. When the body weight of the newborn is less than 1364 grams, the transaminase index is above 0.52 and the fast phase protein amount is above 9.9 mg/l, the need for laser coagulation is predicted.

EFFECT: use of the invention allows for timely laser coagulation of the avascular zones of the retina, thus ensuring further development of the eye, stabilized visual functions and improved quality of life of premature infants.

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Description

The invention relates to medicine, namely to ophthalmology, and can be designed to predict laser coagulation during retinopathy of premature infants (PH).

In Russia, annually about 70-75 thousand premature infants are registered and in children with a body weight of 500 to 1000 pH is found in 88-95% [babyglazky.ru> ROP.htm; zreni.ru> 1548-retinopatiya-nedonoshennyh.html].

Until now, the main method of treating the threshold stages of retinopathy of prematurity, leading to blindness and low vision, is transpupillary laser coagulation of the retina [O. V. Kolenko et al. The effectiveness of laser coagulation of the retina at the threshold stages of retinopathy of premature infants // IX Congress of Ophthalmologists of Russia: abstract. doc. - M., 2010 .-- S. 436; Kolenko O.V. et al. Laser treatment of the posterior aggressive form of retinopathy of premature infants // IX All-Russian scientific-practical conference with international participation "Fedorov readings - 2011": Sat. Abstracts / Under the General Ed. H.P. Tahchidi. - M.: Ophthalmology Publishing House. - 2011 .-- S. 57; Tereshchenko A.V. et al. Features of diagnosis and treatment of posterior aggressive retinopathy of premature infants // Ophthalmosurgery. - 2010. - No. 1. - S. 29-33].

A known method for predicting the course of the early stages of retinopathy of prematurity [RF patent No. 2303942 from 08/10/2007]. This method is intended to predict the course of retinopathy of premature infants in the early stages, but criteria for the need for laser retinal coagulation are not presented.

A known method for predicting the development of posterior aggressive retinopathy in premature infants [RF patent No. 2441593 of 02/10/2012]. The method allows to predict the development of a posterior aggressive form of retinopathy in premature infants, but does not allow to predict the feasibility of laser retinal coagulation.

A method for the diagnosis of retinopathy of preterm IV-V stage is described [RF Patent No. 2358656 dated 06/20/2009]. The proposed method allows to diagnose retinopathy of preterm terminal stages, when laser retinal coagulation is no longer required.

The analysis of immunological data to predict the development of retinopathy of prematurity [RF patent No. 2216740 from 11/20/2003]. The authors do not take into account the main criteria that indicate the need for laser coagulation of the retina in the development of the pathological process.

A known method for predicting regression of the II and III stages of retinopathy of prematurity after laser retinal coagulation [RF patent No. 2532497 C1 of 10.11.2014]. The description of the method does not provide data to predict the need for laser retinal coagulation in children.

Currently, an unresolved problem is to reduce the risk of complications and adverse effects on the part of the organ of vision with the development of retinopathy in premature infants, which results in retinal detachment. A modern method for the prevention of retinal detachment is laser coagulation of the avascular zones of the retina. Therefore, the identification of criteria to predict the need for laser retinal coagulation is relevant.

The closest technical solution that we have chosen as a prototype is a method for predicting the development of retinopathy of premature babies by determining the body weight of the newborn [RF patent No. 2338193 of 10.11.2008]. However, the method does not describe criteria to predict the need for laser coagulation of the retina in premature babies.

The objective of the present invention is to determine the criteria for the somatic status of the child with retinopathy of premature babies, allowing to predict the need for laser retinal coagulation.

EFFECT: simple, low-cost material, including determination of body weight, transaminase index (IT) and fast phase protein (CRP), which stimulates the body's immune response to the inflammatory process.

The technical result is achieved by the fact that according to the invention, a method for predicting the need for laser coagulation in retinopathy of premature infants, comprising determining the body weight of the newborn, characterized in that when the body weight of the newborn is less than 1364 grams, the transaminase index, which is the ratio of aspartate aminotransferase to alanine aminotransferase (AST / ALT ), above 0.52, the amount of fast phase protein above 9.9 mg / l predict the need for laser coagulation.

The proposed method is as follows: in premature infants with a birth weight of less than 1364 grams with a history of retinopathy of premature infants, a blood test is performed to determine the transaminase index and acute phase protein.

Children take blood from a vein in an amount of 5 ml and determine IT and the amount of CRP.

The calculation of the transaminase index is carried out according to the following formula:

IT = AST / ALT, where ACT is aspartate aminotransferase (one of the protein metabolism enzymes in the body; ALT is alanine aminotransferase (endogenous enzyme, from the transferase group and the aminotransferase subgroup).

With transaminase index values above 0.52 and CRP above 9.9 mg / L, the need for laser retinal coagulation is predicted.

Examples of practical use of the proposed method

Example 1

A child Z., with a gestational age of 30 weeks (premature), with a birth weight of 1059 grams and an Apgar score of 5/6 points, was admitted to the neonatal pathology department of GBUZ TO OKB No. 2. A history of signs of necrotic enterocolitis was noted. Conducted laparotomy, removal of double enterostomy, elimination of eventation.

Ophthalmologist examination 05.08.2014 (post-conceptual age 34 weeks).

OU - the adnexa is correctly formed, the eye is calm, intraocular pressure is normal by palpation, the cornea and moisture of the anterior chamber are transparent, the anterior chamber is medium deep, the iris is calm, drug mydriasis is sufficient, the optical media are transparent, the reflex from the fundus is pink.

The fundus (Ret Cam): OU of the optic nerve disc is gray-pink with clear boundaries, the vascular bundle in the center, the vessels in the central zone are moderately dilated, the convolutions are more convoluted at the periphery, “brush-like” divide, in the inner and upper inner segments in zone 1 there is a demarcation line along the 5-hour meridians, delimiting the avascular zones.

Diagnosis: Retinopathy of premature stage I of both eyes, zone 1, active period. Conservative therapy was prescribed to treat retinopathy of premature infants: a dexamethasone solution of 0.1% - 6 times a day, an emoxipine solution of 1% - 6 times a day were epibulbarly injected into both eyes.

The child received 5 ml of venous blood from a deep venous line and the level of CRP, ACT, ALT was determined by a quantitative method using a high-tech analyzer of the Synchron CX-5 PRO Becman Coulter brand.

Results of biochemical analysis: urea 3.42 mmol / L, creatinine 40 μmol / L, ACT 14 IU / L, ALT 17 IU / L, total protein 47 g / V, alkaline phosphatase 780 U / L, CRP 25 mg / L. Calculated IT = AST \ ALT = 14/17 = 0.82;

Ophthalmologist examination 08/19/2014 - post-conceptual age (PCV) 36 weeks. Against the background of conservative therapy, progression of retinopathy of premature infants was noted. In the dynamics of the fundus (Ret Cam): optic nerve disc gray-pink with clear boundaries, the vessels are more convoluted on the periphery, arteriovenous shunts are formed. OD - in all segments in zone 2, a demarcation line with hemorrhages in the outer segment, delimiting the avascular zones. OS - in the inner segment in zone 2, a forming shaft along the 4-hour meridians, in the remaining segments, a demarcation line delimiting the avascular zones.

Diagnosis: Retinopathy of premature stage II of both eyes, zone 2, active period. Pre- “plus” disease.

Based on the medical history, the clinic and the results of laboratory tests, the patient was asked to perform laser coagulation of the retina, taking into account the identified diagnostic criteria for laboratory tests: birth weight 1059, IT 0.82; CRP 25 mg / L.

Laser coagulation of avascular areas of the retina of both eyes was performed.

Results of remote observations of the child:

Ophthalmologist examination in dynamics 09.09.2014, PCV at the time of examination 38 weeks. St. oculorum. OU - calm, intraocular pressure by palpation is normal, the cornea is transparent, the anterior chamber is of medium depth, moisture is transparent, the iris is calm, drug mydriasis is sufficient, there is no rigidity of the pupil, optical media are transparent, the reflex from the fundus is pink. The fundus (RetCam): optic nerve disc gray-pink with clear boundaries, the vascular bundle in the center, the vessels in the central zone are moderately dilated, convoluted, the vessels are more convoluted at the periphery, “brush like” divide, forming arteriovenous shunts, OD - in all segments in the zone 2 demarcation line with hemorrhages in the resorption stage in the outer segment, delimiting avascular zones delimited by fresh, wealthy laser coagulants of the II-III degree; OS - in the inner segment in zone 2, a forming shaft along the 4-hour meridians, in the remaining segments, a demarcation line delimiting the avascular zones, delimited by fresh, wealthy laser coagulants of the II-III degree.

Diagnosis: Retinopathy of premature stage II of both eyes, zone 2, active period. Pre- “plus” disease. Condition after laser coagulation of the retina of both eyes. Stabilization of the process.

The child was placed under observation at the Regional Ophthalmologic Dispensary.

Thus, the given clinical example clearly shows that in a premature baby with a birth weight of 1059 grams, having retinopathy of premature infants, IT 0.82 and CRP indices of 25 mg / l, changes in the fundus develop that require laser retinal coagulation.

Example 2

In the neonatal pathology department of GBUZ TO OKB No. 2, a baby T. was admitted deeply premature (gestational age 28 weeks), with an Apgar score of 5-6 points, with a birth weight of 1190 grams. A history of necrotic enterocolitis, laparotomy, resection of the ileum, removal of the double enterostomy, and the application of an intestinal anastomosis were noted. In the postoperative period, bilateral pneumothorax, high-frequency mechanical ventilation for 8 days, mechanical ventilation for 5 days, NCPAP for 14 days. During treatment, transfusion of erythrocyte mass No. 4, freshly frozen plasma No. 2.

Ophthalmologist examination on 06/17/2014 and 07/16/2014 (PKV 32 and 36 weeks). St. Oculorum. OU - calm, intraocular pressure by palpation is normal, the cornea is transparent, the anterior chamber is medium deep, moisture is transparent, the pupil is dilated medically, there is no rigidity of the pupil, the reflex from the fundus is pink. Ocular fundus OU (Ret Cam): optic nerve disc gray-pink, clear borders, vascular bundle in the center, vascular course and caliber unchanged, macular zone without pathology, narrow avascular zones without clear boundaries on the periphery, vasculogenesis continues.

Diagnosis: Risk group for the development of retinopathy of premature infants. Ophthalmologist examination 07/30/2014 (PKV 38 weeks): St. oculorum. The fundus of the OU in dynamics: optic nerve disc gray-pink, clear borders, vascular bundle in the center, the course and size of the vessels in the central departments are not changed, the vessels are convoluted at the periphery, the macular zone without pathology divides, in the inner segment in zone 2-3 a demarcation line is formed, in the remaining segments avascular zones without clear boundaries.

Diagnosis: Retinopathy of prematurity, active phase, stage 1, zone 2 of both eyes. Conservative therapy was prescribed to treat retinopathy of premature infants: a dexamethasone solution of 0.1% - 6 times a day, an emoxipine solution of 1% - 6 times a day were epibulbarly injected into both eyes.

The child received 5 ml of venous blood from a deep venous line and the level of CRP, ACT, ALT was determined by a quantitative method using a high-tech analyzer of the Synchron CX-5 PRO Becman Coulter brand. Results of biochemical analysis: urea 5.84 mmol / L, creatinine 46 μmol / L, ACT 17 IU / L, ALT 20 IU / L, CRP 50 mg / L. Transaminase index AST / ALT = 17/20 = 0.85.

Based on the history, clinic and laboratory results, there are reasons for laser coagulation of the retina, taking into account the identified diagnostic criteria for laboratory tests: birth weight 1190, IT 0.85; CRP 50 mg / L.

Conservative treatment and observation by an ophthalmologist is recommended.

Results of remote observations of the child:

The child was discharged under the supervision of the Regional Ophthalmologic Dispensary in connection with the stabilization of the somatic state, however, during the observation, despite the conservative treatment, the progression of retinopathy of premature infants was noted. He was sent on an emergency order to the children's ophthalmology department of GBUZ TO OKB No. 2 in PKV 42-43 weeks.

Ophthalmologist examination in PCV for 43 weeks. 09/03/2014. St. oculorum: Visus - the gaze fixes, behaves sighted. Dynamics of the fundus of the eye (RetCam) OU: crest with extraretinal growth in zone 2 on the right in the upper outer, outer, and lower outer segments over the 6-hour meridian, crest with extraretinal growth in the upper left, outer segments over the 4-hour meridian .

Diagnosis: Retinopathy of premature stage III, zone 2 of both eyes, active period.

The child underwent laser coagulation of the avascular zones of the retina of both eyes.

Thus, the clinical example cited shows that in a premature baby with a birth weight of 1190 grams having retinopathy of premature infants, an IT of 0.85 and an CRP of 50 mg / L develop changes in the fundus requiring laser retinal coagulation. Conducted conservative treatment was not effective.

Example 3

Premature baby M., from 2 pregnancies, 1 operative preterm birth, was admitted to the neonatal pathology department of GBUZ TO OKB No. 2. Gestational age 29 weeks, birth weight 1383 g. From birth, the condition is serious, due to morpho-functional immaturity. An IVL was carried out for 11 days. He was admitted to the ARF OKB No. 2 on the 18th day of life with a diagnosis of perinatal pathology of the central nervous system, posthemorrhagic hydrocephalus, polycystic brain disease, anemia of the premature, at risk for premature retinopathy. Surgical treatment: ventriculoperitoneal bypass surgery.

Ophthalmologist examination 01.06.2012, PCV 32-33 weeks.

OU - the adnexa is correctly formed, the eye is calm, TP N, the cornea and moisture of the anterior chamber are transparent, the anterior chamber is medium deep, the iris is calm, drug mydriasis, the optical media are transparent, the fundus reflex is pink, the fundus is (Opt Cam): pale pink with clear boundaries, retinal vessels are narrow, their course is rectilinear, the general background of the fundus is pale, wide avascular zones.

Diagnosis: Risk group for the development of retinopathy of premature infants. Inspections 1 time in 2 weeks are recommended.

Ophthalmologist examination 06/19/2012, PCV 35-36 weeks.

OU in the dynamics of the fundus (Ret Cam): optic nerve disc with clear boundaries, the vascular bundle in the center, the vessels are narrow, their course in the central zone is not changed, it becomes more convoluted to the periphery, MH without pathology, on the periphery of OD in the upper outer , the outer segment, OS in the upper, upper outer segment - a pronounced line of demarcation, in front of it the vessels branch, convoluted, behind it - wide avascular zones.

Diagnosis: Retinopathy of premature stage I active period of both eyes.

The child received 5 ml of venous blood from a deep venous line and the level of CRP, ACT, ALT was determined by a quantitative method on a high-tech analyzer of the Synchron CX-5 PRO Becman Coulter brand. Results of biochemical analysis: urea 7.17 mmol / L, creatinine 26 μmol / L, ACT 3 IU / L, ALT 10 IU / L, CRP 5 mg / L.

Transaminase Index (IT = AST / ALT) = 3/10 = 0.3.

Based on anamnestic data and laboratory results, the patient did not identify criteria for predicting laser coagulation for retinopathy of premature infants (birth weight 1383 g., IT 0.3; CRP 5 mg / l), it is recommended that an ophthalmologist observe 1 time per week. Conservative therapy was prescribed to treat retinopathy of premature infants: a dexamethasone solution of 0.1% - 6 times a day, an emoxipine solution of 1% - 6 times a day were epibulbarly injected into both eyes.

Ophthalmologist examination 06/26/2012, PCV 36-37 weeks.

In the dynamics, the ocular fundus is OU (Ret Cam): the optic nerve disc is pale pink with clear boundaries, the vascular bundle is in the center, the vessels are narrow, their course in the central zone is not changed, it becomes more convoluted to the periphery, the MH without pathology, on the periphery of OD in II- In the III zone of the outer segment, the demarcation line, in the upper-outer, upper segment, the demarcation line with a tendency to form a shaft, the vessels in front of the line are convoluted, brush-like divide, behind the line avascular zones; on the periphery of the OS in the II-III zone of the outer segment, a demarcation line with a tendency to form a shaft, a flat shaft is formed in the upper-outer, upper segment, the vessels in front of it are convoluted, brush-like divide, followed by avascular zones.

Diagnosis: Retinopathy of premature I-II stage of the right eye, II stage of the left eye active period.

LKS at the time of examination is not shown, it is recommended to continue conservative treatment.

The child was discharged under the supervision of the Regional Ophthalmologic Dispensary; in the long term, spontaneous regression of retinopathy of premature infants was observed.

Thus, the given clinical example clearly shows that a premature baby with a body weight at birth above 1364 g. (1383 gr.), With retinopathy of premature infants, IT below 0.52 (0.3) and CRP indices less than 9.9 mg / l (5 mg / l), no changes in the fundus requiring laser retinal coagulation occur spontaneous regression of ophthalmic changes under the influence of a conservative method of treatment.

So, the proposed method for predicting laser coagulation with retinopathy of premature infants allows timely and high-quality treatment of patients.

Laser coagulation at the present stage is one of the main and most effective (up to 80%) methods of treating and preventing the progression of retinal detachment. Using the criteria to predict the need for laser coagulation for retinopathy of premature babies does not require large material costs for medical institutions involved in the treatment and rehabilitation of premature babies.

Laser coagulation of avascular areas of the retina provides further development of the eye, stabilization of visual functions and improves the quality of life of premature babies.

Over 2.5 years, 1126 children were examined by an ophthalmologist in the neonatal pathology department of GBUZ TO OKB No. 2, an ophthalmologist, and 44 (3.9%) developed retinopathy of premature infants. In 15 (39.5%) children with retinopathy of premature infants, laser coagulation was not required to stabilize the process (group 1), in 23 (60.5%) laser retinal coagulation was required (group 2). Statistical analysis of the results is presented in the table.

This method for predicting laser coagulation in retinopathy of premature infants was introduced at the Tyumen Oblast State Budgetary Healthcare Institution “Regional Clinical Hospital No. 2” and the Department of Ophthalmology, Tyumen State Medical University, State Budgetary Educational Institution of Higher Education, Ministry of Health of the Russian Federation.

The proposed method allows to predict the need for laser coagulation in premature infants with a reliability of 95% of cases.

According to the RF Pension Fund (2014), the maintenance of one disabled child is 66,000 rubles per year (social payment to parents). Over 18 years, the costs will amount to 1,188,000 rubles.

For the maintenance of one visually impaired person during the period of life from 18 to 60 years, the state spends about 2750000 rubles. Total total cost per child will be 3938 thousand rubles. Using effective treatment of patients based on the proposed forecasting method will save 393 million rubles in the treatment of 100 patients.

Claims (1)

A method for predicting the need for laser coagulation in retinopathy of premature infants, including determining the body weight of the newborn, characterized in that when the body weight of the newborn is less than 1364 grams, the transaminase index, which is the ratio of the level of aspartate aminotransferase to the level of alanine aminotransferase (AST / ALT), is higher than 0.52, the amount fast phase protein above 9.9 mg / l predict the need for laser coagulation.