RU2779790C1 - Method for prevention of anterior ischemic ophthalmopathy after circular episcleral filling - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used to prevent anterior ischemic ophthalmopathy after circular episcleral filling. The edges of the filling are sutured with a thread of absorbable suture material with Z-shaped sutures during the operation of circular episcleral filling. In this case, stitching is performed in the opposite quadrant from the projection of the retinal rupture onto the sclera.

EFFECT: method makes it possible to reduce the compressive effect of the circling tape on the sclera after biodegradation of the suture material fixing the edges of the tape, in terms sufficient for the formation of chorioretinal foci, and while maintaining the residual height of the depression shaft.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used to prevent anterior ischemic ophthalmopathy after circular episcleral filling.

For the first time circular sealing of the sclera (circlage) as an episcleral method for the treatment of rhegmatogenous retinal detachment was proposed by Arruga and Schepens in the 1950s. Eyeball circling is a method in which a circular circling tape is applied to the outer shell of the eye, providing a circular depression of the sclera. As a result, peripheral retinal breaks are blocked, traction on the retina is reduced, and an additional artificial jagged line is created. All this allows you to restore the original position of the retina and create favorable conditions for the restoration of vision.

As a material for applying circling in modern surgery, an elastic band or a fine-mesh silicone sponge is used [Schepens CL, Okamura ID, Brockhurst RJ (1958) The scleral buckling procedures. V. Synthetic sutures and silicone implants. ArchOphthalmol 60:1003. Lincoff HA, Baras I, McLean J (1965) Modifications to the Custodis procedure for retinal detachment. Arch Ophthalmol 73:160].

Circular episcleral sealing is the primary method of choice in the treatment of rhegmatogenous retinal detachment with the location of one or more breaks in the periphery, the transparency of the optical media, the severity of proliferative vitreoretinopathy (PVR) no more than stage 2. This is minimal extrascleral non-cavitary surgery, justified from the point of view of the biomechanics of the eye.

As clinical practice shows, this method is also widely used in combination with vitrectomy (analogous to circular retinotomy) in the treatment of retinal detachment and with severe PVR, in the treatment of traction retinal detachment in PDR, fixed vitreal traction, peripheral retinoschisis, widespread retinofibrosis, active and cicatricial retinopathy premature. In other words, in such pathological conditions of the fundus, when it is necessary to reduce the volume of the vitreal cavity, create an impression shaft, reduce the traction component, achieve adherence of the retina to the underlying choroid, thereby stopping the pathological process and maintaining visual functions.

Professor Ingrid Kreissig (Germany) devoted several books to minimal retinal detachment surgery, in one of which she describes minimal extraocular retinal detachment surgery, in particular, in the section on the use of circling, the features of this technique are described [Ingrid Kreissig. Minimally invasive retinal detachment surgery. Practical guide, - M., 2015. - S. 195]. So, the amount by which the eyeball should be squeezed is 10%, that is, the length of the circling tape, corresponding to the circumference of the eyeball, should be reduced by 10%.

If the eyeball is excessively squeezed with a circling tape, then an ischemic process will occur in the tissues of the eye. If the necessary compression is not created, then a relapse will occur, since the retina will not completely adhere to the underlying tissues, and repeated intervention will be required. The above value of 10% is sufficient to elevate the filling by approximately 1 mm.

The question of a precision shaft of impression in case of circular filling, sufficient for a blocking effect and not causing side ischemic consequences, remains relevant today.

Underdosed circular compression of the sclera leads to eruption of the suture inside the eye and narrowing of the palpebral fissure [Dark AJ, Rizk SNM (1965) Untoward sequels of Arruga encirclement for retinal detachment. Br J Ophthal 49:259], but more often to symptoms of ocular ischemia: eyelid oedema, chemosis, uveitis, and hypotension, also described as "string syndrome" [Manson N (1964) The "String Syndrome" seen as a complication of Amiga's cerclage suture. Br J Ophthal 48:70].

A group of authors developed a formula for the length of the circling tape depending on the eyeball PZO, in order to obtain an optimal impression shaft sufficient for a blocking effect and minimizing the complications of this method (high personalization of this method) [RF patent 2728263]. However, even a dosed height of the impression shaft with a permanent circular implant does not exclude the development of a number of complications, such as induced myopia and astigmatism, filling protrusion, scleral erosion, extrusion, doubling and ischemic ophthalmo- and neuropathy [Kreissig I (1971) Kryopexie in der Ablatio-Chirurgie . Klin Monatsbl Augenheilk 159:737-741].

These complications are combated by dissecting the circling tape one month after application in order to reduce the circular pressure on the sclera, mainly in the opposite quadrant from the rhegmetogenic retinal tear, so as not to unblock it due to a reduced impression shaft. Given the elastic properties of the silicone tape, it shrinks, its length and pressure on the sclera decrease. The disadvantages of dissection of the circumferential tape are: the need for additional surgical intervention, the risk of dissection of the tape in the projection of the gap, the risk of recurrent retinal detachment due to the appearance of an area without an impression shaft [Lincoff H, Kreissig I, Parver L (1976) Limits of constriction in the treatment of retinal detachment. Arch Ophthalmol 94:1473-1477. Dobbie JG (1980) Circulatory changes in the eye associated with retinal detachment and its repair. Trans Am Ophthalmol Soc 78:503-563. Yoshida A, Feke GT, Green GJ, Coger DG, Matsuhashi M, Jalkh AE, McMeel JW (1983) Retinal circulatory changes after scleral buckling procedures. Am J Ophthalmol 95:182-188].

The objective of the invention is to create an atraumatic method that does not require additional surgical intervention for the prevention of anterior ischemic ophthalmopathy after circular episcleral filling.

The technical result of the proposed method is to reduce the squeezing effect on the sclera of the circling tape after biodegradation of the suture material that fixes the edges of the tape, in time sufficient for the formation of chorioretinal foci, and while maintaining the residual height of the depression shaft.

The technical result is achieved by the fact that in the method for preventing anterior ischemic ophthalmopathy after circular episcleral filling, according to the invention, during the operation of circular episcleral filling, the edges of the seal are sutured with a thread of absorbable suture material using Z-shaped sutures, while the stitching is performed in the opposite quadrant from the projection of the retinal rupture on sclera.

The technical result is achieved due to the fact that:

- no additional surgical intervention is required to cut the circling tape;

- weakening of the depression shaft due to resorption of the suture material in a timeframe sufficient for the formation of chorioretinal foci, eliminates undesirable ischemic complications of circular filling;

- the impression shaft is preserved, which is necessary for pronounced dystrophic foci on the periphery, a continuing increase in the length of the eye, the presence of areas of retinofibrosis fixed by vitreal tractions;

- there is no risk of complications that may occur during the dissection of the filling or its partial / complete removal (depressurization of the gap, recurrence of retinal detachment, hemorrhagic complications, increased PVR, protrusion of the circling tape).

The method is carried out as follows.

At 3-4 mm from the limbus, a circular incision of the conjunctiva is made concentric to the limbus, then Tenon's membrane and rectus muscles are isolated, which are taken on the seams of the handles. The projection of the retinal tear (if any) is localized on the sclera using indirect binocular ophthalmoscopy. During ophthalmoscopy, a rupture is visualized and the sclera is pressed with the tip of tweezers in the projection of the rupture zone. The depressed area is clearly visible during ophthalmoscopy in the form of a grayish tubercle. The site on the sclera is marked with a marker and cryocoagulation of the rupture zone is carried out; this stage is controlled ophthalmoscopically. A porous silicone filling with a diameter of 3.5 mm is fixed to the sclera with U-shaped sutures with 5/0 silk thread (Alcon, USA) in four oblique meridians. The edges of the filling are sutured with a thread of absorbable suture material, for example, Vicryl 6/0 (Johnson & Johnson, USA), with Z-shaped sutures, while suturing is performed in the opposite quadrant relative to the projection of the retinal tear on the sclera or maximum pathological changes in the fundus, with obligatory ophthalmological control over the position of the depression shaft. The operation is completed by suturing the conjunctiva with Vicryl 7/0 thread (Johnson & Johnson, USA) and subconjunctival injection of antibiotic and dexamethasone.

The invention is illustrated by the following clinical examples.

Clinical example 1. Patient N., 23 years old, complains of the appearance of "curtains" from below the nose before OD 5 days ago after lifting weights (visited the gym). Research data: OD - 0.05 - 7.5=0.8; OS - 0.01 - 8.0=0.8; IOP OU=16 mm Hg. Art.; PZO OD=25.98 mm; OS=26.29 mm. Objectively: OU eyes are calm, optical media are transparent. The fundus of the eye: a pink reflex, the optic nerve head (OND) is pale pink, on the periphery there are pronounced dystrophic changes in the type of lattice, redistribution of pigment, thinning of the retina, in OD - at 11 o'clock, a valvular rupture in the periphery and local retinal detachment from 9 to 13 o'clock . Diagnosis: OD - rhegmatogenous retinal detachment, OU - high complicated myopia, peripheral vitreochorioretinal dystrophy (PVCRD). Recommended: OD - episcleral circular filling, OS - peripheral panretinal retinal laser coagulation (PPLC).

The patient underwent a surgical operation on the right eye - circular sealing of the sclera using the proposed method for the prevention of anterior ischemic ophthalmopathy after circular episcleral sealing. After localization of the retinal rupture in the scleral projection, a circling tape was applied, the edges of the circling tape were sutured in the lower inner quadrant at 5 o'clock with Vicryl 6/0 absorbable suture material (Johnson & Johnson, USA), with Z-shaped sutures. Subretinal fluid was drained, cryocoagulation was performed along the edge of the gap to form a chorioretinal scar. The retina is fully attached. The operation was completed by suturing the conjunctiva and subconjunctival injection of an antibiotic and dexamethasone. He underwent inpatient treatment for 2 days with 4 single instillations of dexamethasone, nevanak, cyclomed, tsipromed. After 2 days, he was discharged for outpatient follow-up care (at discharge, the retina of the right eye was completely attached). At the control examination after 30 days: the right eye is calm, the sutures on the conjunctiva have resolved, the optical media are transparent, the fundus: the retina is adjacent to its full extent, the depression shaft contours along the entire perimeter of the periphery of the fundus.

After 2 weeks, when examining the fundus of the right eye in the lower inner quadrant at 5 o'clock, a characteristic rupture of the depression shaft lasting 1.5-2 hours was determined, which is identical to that when dissecting the circling tape. The retina is adjacent throughout.

Thus, after 45 days, the fixing threads of the edge of the circling tape resolved, the seal, due to elasticity, decreased, reducing the pressure on the sclera, which confirms the achievement of the claimed technical result.

Clinical example 2. Patient Z., 16 years old, complaining about the appearance of flashes, lightning in front of the left eye for 1.5 months, applied to the clinic at the place of residence, from where he was sent to a specialized ophthalmological center. From the anamnesis: born prematurely at 29 weeks, weight 1178 grams, was in the intensive care unit of the perinatal center for 2 weeks. He did not go to ophthalmologists, there was no surgical treatment and no injuries. According to the preoperative study: VISUS OD - 0.05 - SPH - 4.5; cyl - 1.5, ax 89°=0.6; OS - 0.1 -SPH - 2.0; cyl - 0.5, ax 122°=0.4; IOP OU=14 mm Hg. Art., PZO OD=25.23 mm; OS=25.04 mm. Objectively: OU - the eyes are calm, the optical media are transparent, the fundus: a pink reflex, the ONH is pale pink, the vessels have an uneven course, there is pigment deposition on the periphery, pronounced dystrophic changes, on the temporal side in the projection of the proliferation shaft there is scar fibrous parietal tissue with traction zones retina, on OS, the height of retinal detachment was 0.5 mm, extending from 1 hour to 5 hours, multiple small retinal breaks at the extreme periphery in the projection of the avascular zone. Diagnosis: OU - cicatricial retinopathy of prematurity, stage III-IV, moderate myopia, complex myopic astigmatism. Recommended: OU - episcleral circular filling (OS - treatment of rhegmatogenous traction retinal detachment (OS); OD - prevention of OS and reduction of tractions). A surgical operation was performed on both eyes with an interval of 7 days: episcleral circular sealing using the proposed method for the prevention of anterior ischemic ophthalmopathy. Surgical interventions were performed without complications. In both eyes, the lace tape was sutured in the upper-inner quadrant, opposite to the projection of maximum dystrophic changes in the retina, with absorbable suture material Vicryl 6/0 (Johnson & Johnson, USA), Z-shaped sutures.

During a scheduled examination after 45-50 days, a characteristic interruption of the impression shaft in the inner upper quadrants was ophthalmoscoped, which confirms the resorption of the suture material at the edges of the circling tape, the reduction of the pressure effect of the circular seal and the preservation of the impression shaft over a larger extent (new dentate line), which it is extremely important for severe dystrophic changes in the fundus.

Thus, the claimed method provides a reduction in the squeezing effect on the sclera of the circling tape after biodegradation of the suture material fixing the edges of the tape, in time sufficient for the formation of chorioretinal foci, and while maintaining the residual height of the depression shaft.

Claims (1)

A method for preventing anterior ischemic ophthalmopathy after circular episcleral filling, characterized in that during the operation of circular episcleral filling, the edges of the filling are sutured with a thread of absorbable suture material using Z-shaped sutures, while the suturing is performed in the opposite quadrant from the projection of the retinal rupture onto the sclera.