RU2794860C1 - Method of surgical treatment of hemophthalmia - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: partial vitrectomy of the central parts of the vitreous body is carried out, three ports 25 or 27 G are installed in the area of the flat part of the cilpar body. In this case, partial vitrectomy of the central parts of the vitreous body is carried out within the anterior third of the vitreous cavity. After the level of preretinal heme is reached, vitrectomy is stopped and irrigation is switched to air. The heme is then removed from the surface of the retina using active or passive aspiration. Next, irrigation is turned on and vitrectomy is performed in full, the operation is completed by removing the ports.

EFFECT: method allows performing more sparing vitrectomy, maximum and accurate excision of the cortical layers of the vitreous body and reducing the risk of iatrogenic complications.

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Description

The invention relates to medicine, and in particular to ophthalmology, and is intended for the treatment of hemophthalmia of various origins. Hemophthalmos is one of the most common causes of sudden vision loss. Occurs in 7 cases per 100 thousand population. The most common causes are proliferative diabetic retinopathy, post-thrombotic retinopathy, hypertensive angiopathy, and trauma. Less common causes include vascular occlusive disease, macroaneurysms of the retinal arteries, hemoglobinopathies, age-related macular degeneration, intraocular tumors, and other systemic diseases. (Spraul CW, Grossniklaus HE. Vitreous Hemorrhage. Surv Ophthalmol. 1997 Jul-Aug;42(l):3-39. doi: 10.1016/s0039-6257(97)84041-6. PMID: 9265701; Conart JB, Berrod JP Hemorragies du vitre non traumatiques [Non-traumatic vitreous hemorrhage] J Fr Ophtalmol 2016 Feb 39(2): 219-225 doi: 10.1016/j.jfo.2015.05.011). In the case when the hemorrhage does not resolve spontaneously and is not amenable to conservative treatment, the only way out is to perform surgical treatment (microinvasive subtotal vitrectomy).

In the case of a long-term hemophthalmia, the formation of fibrovascular tissue and epiretinal membranes is possible, which leads to the development of traction retinal detachment.

The task of surgical treatment is the maximum possible removal of the altered vitreous body, its structures, organized blood clots and the prevention of traction retinal detachment. Often, this task is associated with poor visualization and, as a result, possible iatrogenic damage to the retina.

The closest analogue is the "Method of surgical treatment of hemophthalmos" (RF Patent for invention No. 2521832). The method is carried out as follows - under controlled hypotension with ataralgesia, a closed subtotal vitrectomy is performed on the Millenium microsurgical system from Baush & Lomb.

Conjunctival incisions 5 mm long are made in three quadrants of the eyeball 4-5 mm from the limbus, then standard sclerotomes are formed in the lower temporal, upper temporal and upper nasal quadrants for the introduction of vitreotome tips, light guide and irrigation. With the help of the optical system "BIOM II" the vitreous cavity is examined in transmitted light under conditions of endovitreal illumination. Produce a partial vitrectomy of the central parts of the vitreous body. After that, 0.3 ml of vitreosyneretic "Vitrenal" is injected into the vitreal cavity through the sclerotoma. After 5-7 minutes under visual control, the presence of vitreolysis and posterior vitreous detachment is established, after which vitrectomy is completed. The vitreal cavity is filled with sterile saline to a normal tone. Stitches are applied.

The disadvantages of this method are the possibility of iatrogenic complications due to insufficient visualization during vitrectomy, as well as the low availability of vitreosyneretic "Vitrenal", the lack of large randomized studies on the safety of this drug.

The objective of the invention is to create an effective method for the treatment of hemophthalmia, allowing to eliminate the disadvantage of the closest analogue.

The technical result of the proposed method is a more gentle vitrectomy, maximum and accurate excision of the cortical layers of the vitreous body and a reduction in the risk of iatrogenic complications due to improved visualization during vitrectomy.

The method is carried out as follows. Produce standard processing of the surgical field, local combined anesthesia. Three ports 25 or 27 G are installed in the area of the flat part of the ciliary body: one of which is intended for supplying an irrigation solution to the vitreal cavity, the second for introducing an endo-illuminator to visualize the fundus, and the third for introducing a vitreotome. Then produce a partial vitrectomy of the central divisions of the vitreous body within the anterior third of the vitreal cavity. Having reached the level of the preretinal theme, vitrectomy is stopped. Switch irrigation to air. Then, using active or passive aspiration, heme is removed as much as possible from the surface of the retina. Removal of the preretinal topic prevents the “churning” effect during vitrectomy, thereby improving visualization. Further, irrigation is turned on and vitrectomy is performed in full, if necessary, schwartectomy and endolaser coagulation of the retina are performed. The plugging agent is chosen depending on the situation in the fundus. Finish the operation by removing ports.

The advantages of the proposed method are the reduction of "shaking" during surgical treatment, the reduction of the operation time, more accurate and thorough removal of the vitreous body without affecting and damaging the surface of the retina, improved visualization during surgery, the use of smaller caliber ports. The method is illustrated by the following clinical examples.

Example 1

Patient A. 50 years old. Diagnosis: Proliferative diabetic retinopathy of both eyes. Total hemophthalmos of the right eye for 6 months. Related: Diabetes mellitus type 2, hypertension. Complaints about a sharp decrease in visual acuity of the right eye 6 months ago, underwent conservative treatment at the place of residence without positive dynamics. Initial visual acuity: Right eye = movement of the hand near the face. When examining the anterior segment of the right eye behind a slit lamp, the pupil area is homogeneous gray-whitish in color. The reflex from the fundus is completely absent in all quadrants. Ultrasound examination: in the vitreous body, a picture of an organized hemophthalmia is visualized, which occupies almost the entire volume of the vitreous body. The shells are attached. In March 2021, according to the proposed method, a microinvasive 27G operation was performed using active aspiration, air tamponade.

At discharge on day 1: no complaints, Visus OD=0.6, IOP OD=11 mm Hg. (pneumotonometry)

After 30 days in the postoperative period, visual acuity of 0.7, the retina is adjacent. According to the ultrasound scan, the retina is attached, avitria.

Example 2

Patient V., 40 years old. Diagnosis: OD-hemophthalmos post-traumatic stale subtotal. Associated: Hypertension. From the anamnesis: received a blunt injury to the right eye. Complaints about a sharp decrease in visual acuity of the right eye 7 months ago. At the place of residence received medical treatment for hemophthalmos. Despite the ongoing treatment, there was a lack of positive dynamics, and therefore, surgical treatment of hemophthalmia was recommended. The right eye projection of light is correct. Ultrasound: acoustically dense opacity is visualized in the vitreous body - organized hemophthalmus, which occupies almost the entire volume of the vitreous body. According to the proposed method, the patient underwent a microinvasive 25G operation using passive aspiration, air tamponade.

At discharge for 1 day: no complaints, Visus OD=0.5, VGDOO=11 mm Hg. (pneumotonometry)

After 30 days in the postoperative period, visual acuity of 0.7, the retina is adjacent. According to the ultrasound scan, the retina is attached, avitria.

Claims (1)

A method for surgical treatment of hemophthalmia, including partial vitrectomy of the central parts of the vitreous body, characterized in that three ports 25 or 27 G are installed in the area of the flat part of the cilpar body, partial vitrectomy of the central parts of the vitreous body is carried out within the anterior third of the vitreal cavity, while reaching level of preretinal heme, stop vitrectomy and switch irrigation to air, then use active or passive aspiration to remove heme from the surface of the retina, then turn on irrigation and perform vitrectomy in full; end the operation by deleting the ports.