RU2844407C1 - Method of treating infectious corneal damages based on modified uv cross-linking using antiseptic agent with silver nanoparticles with reparative-regenerative properties - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, specifically to ophthalmology, and can be used to treat infectious corneal damages based on modified UV cross-linking. Method according to the invention involves UV corneal cross-linking and administration of an antiseptic with silver nanoparticles having reparative-regenerative properties. Under the intraoperative control of optical coherence tomography, the affected corneal tissues are removed using a scarifier and for 30 minutes at 2-minute intervals is instilled antiseptic agent with silver nanoparticles with reparative-regenerative properties. Antiseptic agent with silver nanoparticles with reparative-regenerative properties for treating infectious lesions of cornea based on modified UV cross-linking is a solution, containing finely dispersed silver nanoparticles with an average particle size of 27.5 nm, obtained by dispersion in an electric arc discharge in distilled water, in concentration of 25 ± 5 mg/l, sodium salt of carboxymethyl cellulose – 0.1 g/l in amount of 9 parts and aqueous solution of riboflavin mononucleotide in concentration of 10 mg/ml in amount of 1 part.

EFFECT: use of inventions allows to achieve reduction and stabilization of inflammatory process, removal of accessible layers of affected tissues, as well as possibility of keratoplasty in remote period.

2 cl, 3 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of severe infectious lesions of the cornea.

Infectious corneal ulcers are a group of pathological conditions where the inductor is corneal infiltration in response to an infectious pathogenetic stimulus. The inflammatory reaction can lead to significant edema, melting of the corneal epithelium and stroma, resulting in ulcers involving the underlying structures of the eye. This is a life-threatening condition that often leads to the death of the eye due to the development of endophthalmitis and panophthalmitis. There are various methods for treating infectious corneal ulcers. In the case of bacterial corneal ulcers, massive antibiotic therapy is used. However, the increase in the number of antibiotic-resistant strains of microorganisms, as well as the development of severe toxic-allergic reactions with frequent instillations of antibacterial drops significantly complicates treatment (Garg P., Rao G.N. Therapeutic keratoplasty. Corneal Surgery theory technique and tissue. 4th edition, 2009. Editor F. Brightbill. Mosby Elsevier: 439-449). Frequent instillations of antiseptic, anti-inflammatory and antimicrobial drops are also used in the treatment of acanthamoeba ulcers. But, given the long-term persistence of acanthamoeba cysts, even after clinical recovery, long-term use of the above drugs is required, which in turn increases the risk of developing toxic-allergic reactions and the addition of a secondary antibiotic-resistant infection. Along with drug therapy, there are also surgical methods for treating infectious corneal ulcers, such as excimer laser phototherapeutic keratectomy (Deshmukh R, Reddy JC, Rapuano CJ, Vaddavalli PK. Phototherapeutic keratectomy: Indications, methods and decision making.) and ulcer microdiathermocoagulation (Kasparova EA, Zaitsev AV, Kasparova EA, Kasparov AA. Microdiathermocoagulation in the treatment of infectious corneal ulcers). The methods are quite effective, but their scope of application is limited to the stages of superficial corneal lesions. In all cases of infectious corneal lesions, the most radical treatment method is penetrating keratoplasty. However, it is worth noting the high percentage of complications and the relatively low percentage of transparent graft engraftment in cases of keratoplasty performed during acute inflammation. The method does not ensure the removal of the infectious agent, which can lead to its spread to other structures of the eye, changes in the autoimmune background and rejection of the corneal transplant.

A method of surgical treatment of fungal corneal ulcers is known, including conservative treatment and UV crosslinking. The first stage involves instillation of antifungal, antimicrobial, anti-inflammatory, tear-substituting and reparative drops for 7 days. On the 8th day, UV crosslinking is performed with a one-stage instillation of a 0.1% riboflavin solution and antifungal agents during irradiation. (RU 2782494). However, due to the diversity of fungal infections, antifungal drugs in monotherapy are often insufficiently effective, which requires a combination of both drug administration methods and a combination of several types of drugs in the treatment of severe fungal infections.

A method for treating purulent corneal ulcers using UV crosslinking is known. During UV crosslinking, the installations of a photosensitizer and a broad-spectrum antibiotic or antifungal agent are alternated. Ultraviolet radiation is applied directly to the purulent infiltrate zone (RU 2635454). The method is effective in treating severe fungal and bacterial ulcers, but the effect only on the infiltrate zone does not exclude the possibility of new infiltrates forming in the zone of potentially affected surrounding corneal tissues, which remain intact during irradiation.

The closest analogue of the proposed invention is a method including performing UV crosslinking of the cornea by instilling riboflavin diluted with water for injection every 2 minutes for 30 minutes and irradiation with ultraviolet light, wavelength 365 nm, with radiation intensity of 3 mW/cm2 for 30 minutes with a total radiation dose of 5.4 J/cm2. The most effective for performing UV crosslinking is a 0.1% riboflavin solution. During the irradiation process, Riboflavin is also instilled every 2 minutes. (Said D., Elaly M., Gatzioufas Z., ElZakzouk E., Hassan M., Saif M, MD, Zaki A., Dua H., Hafezi F. Collagen Cross-Linking with Photoactivated Riboflavin (PACK-CXL) for the Treatment of Advanced Infectious Keratitis with Corneal Melting. Ophthalmology. 2014 Jul; 121(7): 1377-82). The essence of the UV cross-linking method is the cross-linking of corneal stromal fibers as a result of the combined effect of a photosensitizing substance in the form of Riboflavin (vitamin B2) and ultraviolet radiation. This technique was presented mainly for the treatment of keratectasia of various origins. Currently, cross-linking is also used in the treatment of corneal pathology of infectious origin. Under the influence of UV, damage to the DNA of the infectious agent occurs. UV-activated riboflavin causes chemical modification of the functional groups of DNA nucleic acids, making replication impossible (EyeWorld, 2010, no. 3, p. 39). The photochemical reaction leads to the formation of singlet oxygen species, activating molecular pathways associated with oxidative stress, which in turn leads to the destruction of cell membranes. (Hafezi F., Randelman B.J. "Corneal collagen crosslinking", 167 p., 2013, SLACK Incorporated). In vitro experiments have shown that crosslinking also changes tissue properties, resulting in an increase in collagen denaturation temperature during hydrothermal treatment (Rama PI, Di Matteo F, Matuska S, Paganoni Q Spinelli A. /// J Cataract Refract Surg. 2009 Apr;35(4):788-91. doi: 10.1016/ j.jcrs.2008.09.035. // Acanthamoeba keratitis with perforation after corneal crosslinking and bandage contact lens use.), as well as an increase in resistance to various enzymes responsible for collagen degradation (Said DG1, Elalfy MSI, Gatzioufas Z2, El-Zakzouk ESI, Hassan MA3, Saif MY3, Zaki AA1, Dua HS4, Hafezi F5 //// Ophthalmology. 2014 Jul; 121 (7): 1377-82. doi: 10.1016/j.ophtha. 2014.01.011. Epub 2014 Feb 25. /// Collagen cross-linking with photoactivated riboflavin (PACK-CXL) for the treatment of advanced infectious keratitis with corneal melting). The above properties provide the therapeutic effect of UV cross-linking in infectious lesions of the cornea. In relation to photosensitizers, chemical crosslinking with aliphatic β-nitro alcohols has been studied; however, with this method it is difficult to localize the effect and, according to the researchers, crosslinking of adjacent structures (trabecular meshwork, sclera, conjunctiva, etc.) may occur (Paik DC, Wen Q, Airiani S, Braunstein RE, Trokel SL. Aliphatic β-nitro alcohols for non-enzymatic collagen crosslinking of scleral tissue. Exp Eye Res. 2008; 87: 279-285). One of the options of choice was rose bengal. However, the penetration depth of rose bengal into the corneal stroma does not exceed 100 µm, which is not optimal in the case of severe infectious lesions, with the presence of ulcerative infiltrate in the deep layers of the cornea (Kuznetsov A.V. Study of the possibility of improving the method of cross-linking corneal collagen (clinical and experimental study): author of dis. candidate of medical sciences / A.V. Kuznetsov.-M., 2014.-24 p).

It is worth noting that currently in the Russian Federation there is no registered and approved for use, stabilized photosensitizer drug capable of increasing the thickness of the cornea, which is necessary in the treatment of infectious corneal ulcers due to the presence of thinning zones and, consequently, a high risk of endothelial death due to UV radiation. In such cases, when performing UV crosslinking, a 1% solution of riboflavin mononucleotide is diluted with water for injection. However, clinical practice shows that UV crosslinking as an independent method and in combination with instillations of antifungal and antimicrobial drops has disadvantages due to the increase in the number of antibiotic-resistant strains of microorganisms, the development of severe toxic-allergic reactions, a variety of bacterial and fungal infections, the duration of persistence of acanthamoeba cysts and long-term reepithelialization.

The objective of the invention is to create a method based on the use of an antiseptic agent with silver nanoparticles with reparative-regenerative properties for carrying out UV crosslinking in the treatment of infectious corneal lesions in adults and children.

The technical result of the proposed invention is the relief and stabilization of the inflammatory process, the removal of accessible layers of affected tissue, as well as the possibility of performing keratoplasty in the late period if indicated.

The technical result is achieved by carrying out UV crosslinking using an antiseptic agent with silver nanoparticles with reparative-regenerative properties, which is a solution containing highly dispersed silver nanoparticles with an average particle size of 27.5 nm, obtained by dispersion in an electric arc discharge in distilled water, at a concentration of 25±5 mg/, sodium carboxymethylcellulose - 0.1 g/l in an amount of 9 parts and an aqueous solution of riboflavin mononucleotide at a concentration of 10 mg/ml in an amount of 1 part.

This method of obtaining nanoclusters ensures the absence of toxic conglomerates in the form of silver salts, the absence of silver ions penetration into the systemic bloodstream, which minimizes the risk of toxic-allergic reactions. An antiseptic agent with reparative-regenerative properties containing highly dispersed silver nanoparticles has a bactericidal, bacteriostatic, antiviral, antifungal and antiseptic effect on more than 500 pathogenic microorganisms, yeast fungi and viruses. The mechanism of action of silver nanoparticles is based on the following properties: 1. Destruction of the cell membrane and leakage of cellular contents of the infectious agent. 2. Generation of ROS and shutdown of respiratory chains. 3. Destruction of DNA structure and blocking of DNA replication. 4. Inactivation of enzymes and denaturation of proteins. Along with this, the antiseptic agent has reparative and desensitizing effects that activate the regenerative function of the cornea.

Thus, the use of an antiseptic agent with reparative-regenerative properties, which is a solution containing highly dispersed silver nanoparticles and riboflavin mononucleotide, increases the effectiveness of UV crosslinking by enhancing antiseptic properties, the absence of toxic-allergic reactions and the activation of regenerative functions.

The method is carried out as follows. The procedure is carried out under local drip anesthesia. De-epithelialization with a diameter of 7.5-8 mm, stratification and removal of accessible layers of the ulcer are performed using a scarifier under intraoperative control of optical coherence tomography (OCT) with subsequent instillation of an antiseptic agent with silver nanoparticles with reparative-regenerative properties, which is a solution containing highly dispersed silver nanoparticles and riboflavin mononucleotide for 30 minutes at 2-minute intervals. In the case of fungal ulcers, antifungal drugs are instilled alternately.

The cornea is then irradiated with a device that allows for the establishment of different variations in the power and duration of ultraviolet radiation (UVR) taking into account a stable wavelength: at a power of 3 mW/cm2 for 30 minutes with continued instillation of an antiseptic agent with reparative-regenerative properties at 2-minute intervals (standard Dresden protocol) or 10 minutes and 9 mW/cm2 or 5 minutes and 18 mW/cm2 (accelerated UV crosslinking protocols).

Postoperative drug therapy is carried out taking into account the etiopathogenetic factor. An important role is played by the prescription of the above-mentioned antiseptic, reparants and tear substitutes. Observation includes monthly monitoring of the corneal thickness using OCT, assessment of the condition using biomicroscopy and confocal microscopy. When the inflammatory process stabilizes, monitoring is carried out every 3 months. With progressive thinning of the cornea and damage to less than 2/3 of the cornea, anterior lamellar keratoplasty is performed, and with damage to more than 2/3, penetrating keratoplasty is performed.

This method allows to stop inflammatory processes and provides the opportunity to delay penetrating keratoplasty if necessary.

The method is confirmed by clinical examples.

Patient V., 12 years old.

Admitted with complaints of pain, lacrimation and gradual decrease in visual acuity in the left eye for 6 months. For two years, she used orthokeratological lenses to correct myopia. During a vacation at sea, she noticed redness in her left eye. The condition of the eye worsened over two months. She consulted an ophthalmologist at her place of residence. The diagnosis was: Corneal ulcer of the left eye. After unsuccessful drug treatment, excimer laser phototherapeutic keratectomy (PLK) was performed twice, which also turned out to be ineffective. Visual acuity on admission was counting fingers at a distance of 10 cm. Biomicroscopy revealed an ulcerative corneal infiltrate with an area of 1x2 mm, up to 2/3 of the corneal thickness in depth. The corneal stroma was edematous, but taking into account the previous PTK, the minimum corneal thickness was 442 μm. Confocal microscopy confirmed the acanthamoeba etiology of the corneal ulcer. A 3-day course of conservative treatment was administered, followed by UV crosslinking using an antiseptic with reparative and regenerative properties, which is a solution containing highly dispersed silver nanoparticles with an average particle size of 27.5 nm, obtained by dispersion in an electric arc discharge in distilled water, at a concentration of 25±5 mg / l, sodium carboxymethylcellulose - 0.1 g / l in an amount of 9 parts and an aqueous solution of riboflavin mononucleotide at a concentration of 10 mg / ml in an amount of 1 part (radiation time - 5 minutes, UVR power - 18 mW / cm2). As a result of 12 months of observation, the patient did not have a relapse of acanthamoeba keratitis and corneal ulcer. The patient is under observation. Visual acuity is 0.4. Penetrating keratoplasty is planned due to the risk of developing secondary ectasia and the presence of a residual superficial focus of opacity in the optical zone of the cornea.

Patient Sh., 45 years old.

The patient sought consultation with complaints of loss of object vision in the left eye, photophobia, and lacrimation. According to the anamnesis, the left eye was injured by a branch, after which complaints of pain, photophobia, lacrimation, and a gradual decrease in visual acuity began. Visual acuity at the time of admission was counting fingers near the face. Biomicroscopy revealed total opacity of all layers of the cornea. Confocal microscopy confirmed the fungal etiology of the corneal lesion. A 5-day course of conservative treatment was administered, followed by UV crosslinking using an antiseptic with reparative and regenerative properties, which is a solution containing highly dispersed silver nanoparticles (99%) and riboflavin mononucleotide (0.1%), according to the standard Dresden protocol (radiation time - 30 minutes, UVR power - 3 mW/cm2). During the procedure, antifungal drugs were instilled alternately. The suppression of the inflammatory process made it possible to perform successful penetrating keratoplasty. As a result of 9 months of observation, the patient has not had a relapse of fungal keratitis and corneal ulcer, the corneal transplant is transparent, the sutures are consistent, and visual acuity is 0.7.

Patient B., 32 years old

He sought consultation with complaints of lack of object vision in the right eye, lacrimation, photophobia, and a foreign body sensation. In 2022, he visited an ophthalmology clinic, where he was diagnosed with bacterial corneal ulcer of the right eye. Despite the drug treatment, at the time of examination, an ulcerative corneal infiltrate with an area of 2x3 mm and a depth of more than 1/3 of the corneal thickness was visualized. A course of conservative treatment was carried out lasting 5 days, then UV crosslinking using an antiseptic with reparative and regenerative properties, which is a solution containing highly dispersed silver nanoparticles (1%) and riboflavin mononucleotide (0.1%) according to the accelerated UV crosslinking protocol (radiation time - 10 minutes, UVR power - 9 mW / cm2). During the first week, positive dynamics were noted in the form of a reduction in the infiltration zone and regression of corneal and pain syndromes. During the following month, the ulcerative infiltrate was resorbed, and opacity formed. The relief of the inflammatory process made it possible to perform successful anterior deep lamellar keratoplasty. After the operation, recurrence of keratitis and corneal ulcers were not observed. Six months after PGPK, the corneal transplant is transparent, the sutures are consistent, and visual acuity is 0.6.

Claims (2)

1. A method for treating infectious corneal lesions based on modified UV crosslinking by introducing an antiseptic agent with silver nanoparticles with reparative-regenerative properties, characterized by performing UV crosslinking of the cornea, characterized in that, under intraoperative control of optical coherence tomography, the affected corneal tissues are removed using a scarifier and an antiseptic agent with silver nanoparticles with reparative-regenerative properties is instilled for 30 minutes at 2-minute intervals, which is a solution containing highly dispersed silver nanoparticles with an average particle size of 27.5 nm, obtained by dispersion in an electric arc discharge in distilled water, at a concentration of 25±5 mg / l, sodium carboxymethylcellulose - 0.1 g / l in an amount of 9 parts and an aqueous solution of riboflavin mononucleotide at a concentration of 10 mg/ml in the amount of 1 part. 2. An antiseptic agent with silver nanoparticles with reparative-regenerative properties for the treatment of infectious lesions of the cornea based on modified UV crosslinking, which is a solution containing highly dispersed silver nanoparticles with an average particle size of 27.5 nm, obtained by dispersion in an electric arc discharge in distilled water, at a concentration of 25±5 mg/l, sodium carboxymethylcellulose - 0.1 g/l in an amount of 9 parts and an aqueous solution of riboflavin mononucleotide at a concentration of 10 mg/ml in an amount of 1 part.