RU2776768C1 - Method for treatment of macular retinal folding - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: at the first stage, laser coagulants are applied in chessboard order along each retinal fold with laser radiation with a wavelength of 577 nm. Power is 50-70 mW, pulse duration is 0.05-0.07 s, spot diameter is 100 mcm, distance between laser coagulants is 150 mcm. At the second stage, 1 week after, micro-pulse laser impact is conducted on a coagulation area, with a wavelength of 577 nm, duration of pulse package of 30 ms, duration of micro-pulse of 50 mcs, duty cycle of 4.7%, spot diameter of 100 mcm, power of 50 mW. Micro-pulse impact is conducted 3 times with an interval of 1 month.

EFFECT: method allows for the elimination of metamorphopsia, improvement and stabilization of visual functions, retinal photosensitivity, recovery of macular area and retinal architectonics.

1 cl, 2 ex

Description

Technical field

The invention relates to medicine, and more specifically to ophthalmology, and can be used for the treatment of macular retinal folding in the postoperative period of retinal detachment.

State of the art

Macular retinal folding is a rare but serious complication that occurs after surgical treatment of retinal detachment. The main risk factors for the formation of retinal folding in the postoperative period include the use of intravitreal gas tamponade, "fresh" rhegmatogenous retinal detachment, the use of large and wide tapes for episcleral filling, the presence of "bullous" rhegmatogenous retinal detachment with tears in the upper quadrants, transscleral drainage of subretinal fluid, rhegmatogenous retinal detachment with macular involvement. The severity of the manifestation of clinical symptoms caused by retinal folding depends on its location and severity. In the case of folding in the macular zone, the most common symptoms are visual field defects, diplopia, metamorphopsia, decreased visual acuity.

Currently, the most effective treatment for retinal folds is re-surgery [Barale P, Mora P, Errera MH, Ores R, Paques M, Sahel J-A. Treatment of macular folds complicating retinal detachment surgery using air for retinal unfolding. Retin Cases Br Reports. 2014; 0 (0): 1-3].

The disadvantage of repeated surgical treatment is the risk of complications in the early postoperative period: hemophthalmos, inflammation, secondary glaucoma, cataracts, recurrences of rhegmatogenous retinal detachment, macular holes, retinal vascular occlusion, etc. In addition, repeated surgical intervention is possible only after complete reabsorption gas-air mixture in the vitreal cavity, while apoptosis of the photoreceptor layer and thinning of the outer nuclear layer begins 1 week after macular translocation [Hayashi A, Usui S, Kawaguchi K, et al. Retinal changes after retinal translocation surgery with scleral imbrication in dog eyes. Investig Ophthalmol Vis Sci. 2000; 41 (13): 4288-4292].

A known method of treating retinal folds against the background of an existing traction retinal detachment, including performing subtotal vitrectomy, removing the epiretinal membrane, introducing a perfluorogranic compound (PFOS), covering only the central zone of the retina to the level of the fold, installing an additional microinvasive port under the retina in the flat part of the ciliary body in areas of retinal duplication, without piercing it, with the introduction of a small amount of saline under pressure. Then, with full expansion of the duplication, fluid is evacuated from under the retina through the existing gap or a point retinotomy is formed on the extreme periphery with a vitreotomy. Further, PFOS is additionally introduced, endolaser coagulation of the retina is performed, PFOS is replaced with silicone or an air-gas mixture (RU 2452442, 06/10/2012).

However, this method of treatment is applicable only in the treatment of peripheral retinal folds.

A known method for the treatment of subretinal proliferation in the form of retinal folds (Kertes P.J., Peyman G.A. Management of dry retinal folds // Int Ophthalmol. 1997. - Vol. 21. - No. 2. - P. 53-55), including vitrectomy and removal of epiretinal membranes, introduction of PFOS into the vitreal cavity. Then, a cannula with a silicone tip is used to smooth the retinal tissue in the area of the fold under the thickness of PFOS.

However, the method is not applicable for macular folds of the retina that have arisen after surgical treatment of retinal detachment. The use of a cannula to remove the retinal fold in the central zone can lead to the formation of multiple iatrogenic retinal tears and a high risk of vision loss, to the development of rhegmatogenous retinal detachment.

The closest analogue of the claimed invention is a method for the treatment of macular retinal folding, including endovitreal puncture of the retina around the fold zone outward from the macula and the introduction of a subretinally balanced saline solution until retinal detachment in this zone, the introduction of PFOS into the vitreal cavity until the fold is straightened, removal of the internal boundary membrane and replacement PFOS for gas-air mixture (patent RU 2638292, 03/20/2017)

The disadvantage of this method is the risk of secondary epiretinal fibrosis, the development of iatrogenic retinal breaks, rhegmatogenous retinal detachment and secondary macular rupture.

In this regard, the objective of this invention is the need to develop a new treatment strategy aimed at early restoration of morphological and functional results and reducing the risk of postoperative complications in a patient with macular retinal folding.

To solve this problem, we propose a method for the treatment of macular retinal folding, which consists in the fact that at the first stage, laser coagulates are applied in a “checkerboard pattern” along each retinal fold with laser radiation with a wavelength of 577 nm, a power of 50-70 mW, and a pulse duration 0.05-0.07 s, spot diameter 100 μm, distance between laser coagulates 150 μm, at the second stage, after 1 week, a micropulse laser effect is performed on the coagulation area with a wavelength of 577 nm, a pulse packet duration of 30 ms, a micropulse duration of 50 μs , a duty cycle of 4.7%, a spot diameter of 100 μm, a power of 50 mW, micropulse exposure is carried out 3 times with an interval of 1 month.

The technical result is as follows. The use of low energy modes - with a wavelength of 577 nm provides the maximum selectivity of exposure to RPE cells, since they account for the peak absorption of laser energy. At the same time, the radiation of this wave is not absorbed by the xanthophilic pigments of the macula, which significantly reduces the risk of damage to the neurosensory retina.

The use of threshold laser coagulation with a wavelength of 577 nm makes it possible to obtain a chorioretinal adhesion, which ensures the maintenance of the frame function of Muller cells. Laser radiation with such a wavelength provides the maximum selectivity of action in relation to the cells of the pigment epithelium, since they have a peak in the absorption of laser energy. At the same time, the radiation of this wave is not absorbed by the xanthophilic pigments of the macula, which significantly reduces the risk of damage to the neurosensory retina.

The use of micropulse laser exposure makes it possible to carry out a thermal effect on the cells of the chorioretinal complex without raising the temperature in them to a lethal level, which is accompanied by the production of anti-inflammatory and anti-angiogenic factors by these cells. The choice of a micropulse duration of 50 μs and a duty cycle of 4.7% ensures local heating of the pigment epithelium cells without collateral spread to neighboring cells and adjacent layers of the chorioretinal complex, and the use of a micropulse packet duration of 30 ms ensures the subthreshold nature of the laser exposure, in which there is no summation of the thermal effect and, as a result, thermal damage to the neurosensory retina and pigment epithelial cells.

Thus, the proposed invention is based on a combination of two methods that differ in the mechanism of action: threshold laser coagulation of the retina, which stabilizes the structure of the retina, and micropulse laser exposure with its pronounced stimulating anti-inflammatory and anti-angiogenic effects. Thanks to this effect, the elimination of metamorphopsias, the improvement and stabilization of visual functions, the photosensitivity of the retina, the restoration of the macular region and the architectonics of the retina are ensured.

Disclosure of the essence of the invention

The combined laser exposure is carried out as follows: after reaching the maximum drug mydriasis (for example, a single installation of a 1% solution of Midriacil and a 2.5% solution of Irifrin) and the installation of an anesthetic solution (for example, oxybuprocaine), a Goldman contact lens is installed on the patient's eye. Laser exposure is carried out on an IRIDEXIQ 577 device (IRIDEX Corporation, Mointain, USA). The first stage is laser coagulation along the retinal fold, excluding the avascular zone, laser coagulates are applied in a "checkerboard pattern" in several rows along the retinal folds, with one row of laser coagulates corresponding to one retinal fold, while the distance between the rows can be from 150 to 400 µm. Exposure parameters: laser coagulation is carried out at the lowest possible parameters to obtain a laser coagulate of the 1st degree - a power of 50-70 mW, a pulse duration of 0.05-0.07 s, a spot diameter of 100 microns, a wavelength of 577 nm, a distance between laser coagulates of 150 microns .

The second stage after 1 week is micropulse laser exposure with a wavelength of 577 nm, a packet duration of 30 ms, a micropulse duration of 50 μs, a duty cycle of 4.7%, a spot diameter of 100 μm, and a power of 50 mW. Micropulse laser exposure is carried out in the amount of 3 sessions, with an interval of 1 month.

Implementation of the invention

The invention is illustrated by the following clinical examples:

Clinical example No. 1.

Patient 3, 56 years old. Diagnosis OD Macular retinal folding. Operated rhegmatogenous retinal detachment. Artifakia. Complaints about decreased visual acuity, curvature of objects in front of the right eye.

According to a comprehensive ophthalmological examination: BCVA 0.1, BCVA 0.7. Intraocular pressure 15 mm Hg. Central light sensitivity of the retina 23.2 dB.

макулярной зоны, преимущественно снизу. Калибр ретинальных сосудов не изменен. Паравазально по ходу верхне- и нижне-височной аркадах визуализируется «целлофановый блеск» (эпиретинальный фиброз). На периферии сетчатки разрывы в верхнем квадранте блокированы пигментированными лазерными коагулятами.With ophthalmic biomicroscopy OD: the anterior segment is without pathological changes, the intraocular lens is centered. The optic disc (OND) is pale pink with clear boundaries; Peripapillary on the nasal side, a bubble of a perfluoroorganic compound (PFOS) with a diameter of 756 μm is determined. From the temporal edge of the ONH in the direction of 8 o'clock, a rough compact retinal folding (3 retinal folds), 633 µm wide, ending in a subretinal PFOS bladder with a diameter of 977 µm, is visualized. Folding captures

macular zone, mainly from below. The caliber of the retinal vessels is not changed. Paravasally along the upper and lower temporal arcades, a “cellophane sheen” (epiretinal fibrosis) is visualized. At the periphery of the retina, breaks in the upper quadrant are blocked by pigmented laser coagulates.

According to optical coherence tomography: the macular profile is deformed, the fovea is contoured; parafoveolarly from the nasal side, a convex deformity is visualized - a “complete” dominant retinal fold up to 637 microns high.

The combined laser treatment according to the invention was carried out.

At the first stage, laser coagulation was carried out along the retinal fold, while laser applicators were applied in a “checkerboard pattern” in 3 rows along the course of each retinal fold, in its most protruding part, based on the number of retinal folds, excluding the avascular zone. Exposure parameters: laser coagulation was carried out at the lowest possible parameters to obtain a laser coagulate of the 1st degree - power 50 mW, pulse duration 0.05 s, spot diameter 100 μm, wavelength 577 nm, distance between laser coagulates 150 μm. The second stage, 1 week after laser coagulation, was micropulse laser exposure - laser applications were applied in 3 rows along the course of each retinal fold, in its most protruding part, excluding the avascular zone with a wavelength of 577 nm, a packet duration of 30 ms, a micropulse duration of 50 μs, duty cycle 4.7%, spot diameter 100 µm, power 50 mW. Spent 3 sessions of micropulse laser exposure with an interval of 1 month.

On examination 6 months after the combined laser treatment, the patient noted the absence of metamorphopsia in the right eye. According to the inspection: OD NCHO - 0.2; BCVA - 0.7. According to ophthalmic biomicroscopy OD: the anterior segment is without pathological changes, the intraocular lens is centered. The optic disc is pale pink with clear borders. The retinal fold "smoothed out", the dominant retinal fold is practically not defined. On the surface of the retina, in the area of the former rough pronounced retinal folding, a “wavy” barely noticeable change in the relief of the surface of the retina with a width of up to 1371 microns is determined. In the macular zone, excluding the avascular zone, weakly pigmented laser coagulates are visualized.

On the OCT tomograms of the right eye: the macular profile is restored, the architectonics of the retinal layers is restored, the microfolding of the inner layers of the retina is determined paramacularly. An increase in the average value of the central light sensitivity of the retina up to 26.7 dB was noted.

Clinical example No. 2.

Patient Ch, 63 years old. Diagnosis: OS Macular retinal folding. Operated rhegmatogenous retinal detachment. Artifakia.

According to a comprehensive ophthalmological examination: BCVA 0.05, BCVA 0.4 n/k. Intraocular pressure 13 mm Hg. The central light sensitivity of the retina is 21.4 dB.

Ophthalmic biomicroscopy OS: the anterior segment without pathological changes, the intraocular lens is centered. The optic disc is pale pink with clear borders. From the temporal edge of the ONH in the direction of 9 o'clock, retinal folding (2 retinal folds) with a width of 358 µm is visualized. Folding captures 1/3 of the macular zone, mainly from above. The caliber of the retinal vessels is not changed. On the periphery of the retina in the upper sector, the gap was blocked by pigmented laser coagulates.

According to optical coherence tomography: the macular profile is deformed, the fovea is smoothed, convex deformation is visualized from the nasal side parafoveolarly - a “complete” dominant retinal fold up to 546 μm high

The combined laser treatment according to the invention was carried out.

At the first stage, laser coagulation was carried out along the retinal fold, while laser applicators were applied in a “checkerboard pattern” in 2 rows along the course of each retinal fold, in its most protruding part, based on the number of retinal folds, excluding the avascular zone. Exposure parameters: laser coagulation was carried out at the lowest possible parameters to obtain a laser coagulate of the 1st degree - power 70 mW, pulse duration 0.07 s, spot diameter 100 μm, wavelength 577 nm, distance between laser coagulates 150 μm Second stage 1 week after laser coagulation, micropulse laser exposure was carried out - laser applications are applied in 2 rows along the course of each retinal fold, in its most protruding part, excluding the avascular zone with a wavelength of 577 nm, a packet duration of 30 ms, a micropulse duration of 50 μs, a duty cycle of 4.7%, spot diameter 100 µm, power 50 mW. Spent 3 sessions of micropulse laser exposure with a multiplicity of 1 month.

On examination 8 months after the combined laser treatment, the patient notes the absence of metamorphopsia in the left eye, an increase in visual acuity. According to the inspection: OS NKHOZ - 0.1; BCVA - 0.8 i / k. According to OS ophthalmic biomicroscopy: the anterior segment is without pathological changes, the intraocular lens is centered. The optic disc is pale pink with clear borders. The retinal folding has "smoothed out", in the macular zone, excluding the avascular zone, weakly pigmented laser coagulates are visualized.

On the OCT tomograms of the left eye: the macular profile was restored, the architectonics of the retinal layers was restored. An increase in the average value of the central light sensitivity of the retina up to 27.2 dB was noted.

Using the claimed method, 21 patients with retinal macular folding were treated after an operated retinal detachment. After the treatment, the elimination of metamorphopsias, improvement and stabilization of visual functions, retinal photosensitivity, restoration of the macular area and retinal architectonics were observed, due to the "plastic" effect obtained using combined laser treatment.

Claims (1)

A method for the treatment of macular retinal folding, which consists in the fact that at the first stage, laser coagulates are applied in a "checkerboard pattern" along the course of each retinal fold with laser radiation with a wavelength of 577 nm, a power of 50-70 mW, a pulse duration of 0.05-0, 07 s, spot diameter 100 μm, distance between laser coagulates 150 μm, at the second stage, after 1 week, micropulse laser exposure is performed on the coagulation area with a wavelength of 577 nm, pulse duration 30 ms, micropulse duration 50 μs, duty cycle 4.7% , a spot diameter of 100 μm, a power of 50 mW, micropulse exposure is carried out 3 times with an interval of 1 month.