RU2845315C1 - Method of treating retinal detachment complicated by proliferative vitreoretinopathy - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to ophthalmology, and can be used for treating retinal detachment complicated by proliferative vitreoretinopathy, PVR. That is ensured by a two-stage surgical management. First stage involves a minimally invasive approach to the vitreal cavity that is followed by a subtotal vitrectomy and contrast enhancement with MembraneBlue-Dual ILM retinal staining agent. Perfluoroorganic compound PFOC 0.7-2 ml is introduced into the vitreous cavity. ILM is removed in a PFOC medium. That is followed by circumferential diathermocoagulation in the region inwards from the proliferative changed retinal regions. That is followed by a circular retinotomy with guillotine scissors along a diathermocoagulation line. Remains of retina with proliferative tissue on periphery and remains of vitreous body are completely removed. First stage of the surgery is completed with a complete tamponade of the vitreal cavity of PFOC, removal of the ports and suturing of the transconjunctival interrupted sutures. Second stage 3-7 days later involves a minimally invasive approach to the vitreal cavity, retinal laser endocoagulation along a retinotomy border in 1-2 lines, sequential replacement of PFOC with air, and then air with silicone oil. Operation is completed by removing the ports and applying transconjunctival interrupted sutures on their regions.

EFFECT: invention provides a complete anatomical adaptation of the detached retina with a positive functional result, prevents progression of proliferative vitreoretinopathy and recurrent retinal detachment.

1 cl, 2 ex

Description

The invention relates to medicine, namely to ophthalmology, and is intended for the treatment of retinal detachment complicated by proliferative vitreoretinopathy.

Rhegmatogenous retinal detachment (RD) is one of the most severe diseases in ophthalmology, which can lead to a sharp and irreversible decrease in vision, and in some cases - to complete loss. Despite significant advances in the surgical treatment of RD and stable anatomical success of cases, one of the main causes of retinal detachment relapses is the development of proliferative vitreoretinopathy (PVR). The development of PVR as a complication of RD leads to a number of structural changes that complicate surgical intervention and worsen the anatomical and functional results of treatment. The use of primary circular retinotomy in the treatment of retinal detachments in such cases allows for full adaptation of the rigid retina to the underlying structures and subsequent fixation of the edges of the detached retina using endolaser coagulation (ELC). However, most often, surgical treatment using circular retinotomy is performed in one stage with simultaneous ELC and silicone oil tamponade, while ELC is performed in a large volume, in 3-5 rows along the border of retinotomy, due to the pronounced edema of the edges of the retina and the tendency to inversion of the rigid edges of the retina. One of the reasons for the progression of PVR may be the outcome of the inflammatory process, due to the body's reaction to local damage, in particular, to the burn component directly from the ELC of the retina. Recently, in the treatment of RRD, there has been a tendency to search for methods of gentle surgical treatment that prevent excessive thermal damage to the retinal tissue and reduce the risk of intra- and postoperative complications.

A method for treating retinal detachment complicated by proliferative vitreoretinopathy is known (patent RU No. 2 704099), which includes performing vitrectomy with staining the vitreous body with corticosteroids, performing diathermocoagulation of the retinal vessels at the border of the attachment of the posterior hyaloid membrane (PHM) to the retina, circular retinotomy along the line of diathermocoagulates, introducing a perfluoroorganic compound (PFOC), performing endolaser coagulation of the retina and replacing PFOC with silicone oil.

The disadvantages of this method include the following.

Firstly, using the specified method, circular retinotomy and endolaser coagulation of the retina along the border of the retinotomy are performed in one stage, which requires the expenditure of a larger volume of laser energy, increasing the risk of progression of proliferative changes.

Secondly, when performing retinotomy at the border of attachment of the posterior hyaloid membrane to the retina, it is possible that the proliferatively altered retina will remain inward from the border of the retinotomy, which increases the risk of further progression of PVR and recurrence of retinal detachment.

Thirdly, this method does not involve removal of the ILM, which can lead to the development of epiretinal fibrosis and require repeated surgical intervention.

The objective of the invention is to create an effective method for surgical treatment of retinal detachment complicated by PVR using circular retinotomy, temporary tamponade with a perfluoroorganic compound (PFOC) and delayed endolaser coagulation in a reduced volume, which ensures minimization of intra- and postoperative complications, and also reduces the risk of progression of proliferative changes and development of recurrent retinal detachment.

The technical result of the invention is to ensure complete anatomical adhesion of the detached retina with a positive functional result, prevent the progression of proliferative vitreoretinopathy and recurrence of retinal detachment, and create complete adaptation of the retinotomy zone.

The proposed method is implemented as follows.

The operation is performed in two stages under local anesthesia with intravenous administration of pain-relieving sedatives. The surgical field is treated, an eyelid retractor is installed. At the first stage, four ports are installed with trocars: three 25G ports and a fourth 29G port 3-4 mm from the limbus. Ports for surgical instruments are installed as standard at 2 and 10 o'clock. A port for a cannula with balanced irrigation saline solution is installed depending on the eye: for the right eye at 8 o'clock, for the left eye at 4 o'clock. The fourth additional port is installed at 12 o'clock (29G) and is used for permanent installation of an endoilluminator (light source), which allows using the bimanual technique of vitreoretinal intervention. Subtotal vitrectomy is performed, contrasting with the retinal dye MembraneBlue-Dual of the internal limiting membrane (ILM). 0.7-2 ml of perfluororganic compound (PFOC) is introduced into the vitreous cavity, then the ILM is removed in the PFOC medium. Next, the retinotomy border is marked with a diathermocoagulator around the circumference in the zone inward from the areas of the proliferatively altered retina and a circular retinotomy is performed with guillotine scissors along the diathermocoagulation line. The remnants of the retina with proliferative tissue on the periphery and the remnants of the vitreous body are completely removed. The first stage of the operation is completed by complete tamponade of the vitreous cavity with PFOS, removal of the ports and application of transconjunctival interrupted sutures of 8-00 Vicryl to the areas of their installation. A subconjunctival injection of 0.2 ml of dexamethasone and 0.2 ml of antibiotic is performed. A monocular bandage is applied. After which the patient is inpatient treatment in the supine position for 3-7 days. The second stage, 3-7 days later, after the installation of 3 25G ports on the maximally adapted retina, endolaser coagulation is performed in 1-2 rows along the retinotomy border in a PFOS medium and sequential replacement of PFOS with air, then air with silicone oil (viscosity 5700 cSt). The operation is completed by removing the ports and applying 8-00 Vicryl transconjunctival interrupted sutures to the sites of their installation. A subconjunctival injection of 0.2 ml dexamethasone and 0.2 ml antibiotic is administered. A monocular bandage is applied.

The advantages of the proposed method are as follows.

Firstly, temporary tamponade with PFOC for 3-7 days, due to its properties such as high specific gravity and surface tension, allows for maximum adaptation of the retina, pressing of its edges, anatomical alignment of the membranes, reduction of its edema and resorption of subretinal fluid.

Secondly, performing a circular retinotomy inward from the PVR areas ensures maximum removal of all proliferative tissue and reduces the risk of further progression of PVR and recurrent retinal detachment.

Third, the use of guillotine scissors allows for a more controlled retinotomy.

Fourthly, performing endolaser coagulation during the 2nd stage of surgical treatment on the maximally adapted retina allows to reduce the volume of endolaser coagulation for blocking the edge of retinotomy to the minimum necessary, which helps to reduce the risk of developing an undesirable postoperative inflammatory reaction, progression of proliferative changes, and thus the development of recurrent retinal detachment.

Fifth, ILM removal helps prevent the development of epiretinal fibrosis in the eye prone to proliferation. ILM removal in a PFOS environment provides protection of the macular area and easier separation of the ILM from the retina.

The method is characterized by the following clinical example.

Example 1. Patient B., 48 years old. Diagnosis: OD - rhegmatogenous retinal detachment complicated by PVR (stage C, according to the Updated Retina Society Classification proposed by R. Machemer et al.), pseudophakia. BCVA OD = 0.1. OD B-scan data: total V-shaped retinal detachment H = 3.9 mm. According to OD ophthalmoscopy data, retinal detachment with signs of PVR (stage C) was noted. The patient underwent surgical treatment in 2 stages. First stage: 3 25G ports were installed 3 mm from the limbus and an additional port at 12 o'clock, microinvasive subtotal vitrectomy was performed, the ILM was contrasted with the retinal dye MembraneBlue-Dual. Next, a small amount of PFOC (0.7 ml) was introduced, the ILM was removed, and circumferential diathermocoagulation was performed. Circular retinotomy was performed along the diathermocoagulation line with guillotine scissors. During retinotomy, areas of the proliferatively altered retina remained peripheral to the retinotomy borders. Next, complete removal of the remnants of the retina with proliferative tissue at the periphery, remnants of the vitreous body, and temporary tamponade of the vitreous cavity with PFOC were performed. The first stage of the operation was completed by removing the ports and applying transconjunctival interrupted sutures to the areas of their installation. A subconjunctival injection of 0.2 ml dexamethasone and 0.2 ml antibiotic was performed. A monocular bandage was applied. On the 1st day after the first stage of the operation: according to ophthalmoscopy data, the retina is adjacent; According to OCT data, the retina is adjacent and adapted to the retinotomy border in the PFOS environment.

The patient was hospitalized in the supine position for 3 days. The 2nd stage of the surgery was performed 3 days later. After installation of 3 25 Gage ports, ELC was performed in 1 row along the retinotomy border. Then PFOC was removed by active aspiration, and the vitreous cavity was tamponed with silicone oil with a viscosity of 5700 cSt. The second stage of the surgery was completed by removing the ports and applying transconjunctival interrupted sutures to the sites of their installation. A subconjunctival injection of 0.2 ml dexamethasone and 0.2 ml antibiotic was performed. A monocular bandage was applied. On the 1st day after the second stage of the surgery: BCVA OD = 0.25; IOP OD = 19 mm Hg. According to ophthalmoscopy and B-scanning: the retina is adjacent. According to OCT data of the peripheral areas: the retina along the border of the retinotomy in the silicone medium is adjacent and adapted.

One month after the operation: BCVA OD = 0.3; IOP OD = 18 mm Hg. According to ophthalmoscopy: the retina is attached, no signs of PVR. According to B-scan: the retina is attached. According to OCT: the retina along the retinotomy border is adapted, no signs of PVR.

Example 2. Patient K., 56 years old. Diagnosis: OS - rhegmatogenous retinal detachment complicated by PVR (stage C, according to the Updated Retina Society Classification, proposed by R. Machemer et al.), complicated cataract. BCVA OS = 0.15. B-scan data OS: total V-shaped retinal detachment H = 4.3 mm. According to ophthalmoscopy data OS retinal detachment with signs of PVR (stage C) was noted. The patient underwent surgical treatment in 2 stages. First stage: after cataract phacoemulsification with IOL implantation, 3 25G ports were installed 4 mm from the limbus and an additional port at 12 o'clock, microinvasive subtotal vitrectomy was performed, the ILM was contrasted with the retinal dye MembraneBlue-Dual. Next, a small amount of PFOC (2.0 ml) was introduced, the ILM was removed, and circumferential diathermocoagulation was performed. Circular retinotomy was performed along the diathermocoagulation line with guillotine scissors. During retinotomy, areas of the proliferatively altered retina remained peripheral to the retinotomy borders. Next, complete removal of the remnants of the retina with proliferative tissue at the periphery, remnants of the vitreous body, and temporary tamponade of the vitreous cavity with PFOC were performed. The first stage of the operation was completed by removing the ports and applying transconjunctival interrupted sutures to the areas of their installation. A subconjunctival injection of 0.2 ml dexamethasone and 0.2 ml antibiotic was performed. A monocular bandage was applied. On the 1st day after the first stage of the operation: according to ophthalmoscopy data, the retina is adjacent; According to OCT data, the retina is adjacent and adapted to the retinotomy border in the PFOS environment.

The patient was hospitalized in the supine position for 7 days. Seven days later, the 2nd stage of the surgical intervention was performed. After installation of 3 25 Gage ports, ELC was performed in 2 rows along the retinotomy border. Then, PFOS was removed by active aspiration, and the vitreous cavity was tamponed with silicone oil with a viscosity of 5700 cSt. The second stage of the operation was completed by removing the ports and applying transconjunctival interrupted sutures to the areas of their installation. A subconjunctival injection of 0.2 ml dexamethasone and 0.2 ml antibiotic was performed. A monocular bandage was applied. On the 1st day after the second stage of the operation: BCVA OS = 0.2; IOP OS = 17 mm Hg. According to ophthalmoscopy and B-scanning: the retina is adjacent. According to OCT data of the peripheral areas: the retina along the border of the retinotomy in the silicone medium is adjacent and adapted.

One month after the operation: BCVA OS = 0.25; IOP OS = 16 mmHg. According to ophthalmoscopy: the retina is attached, no signs of PVR. According to B-scan: the retina is attached. According to OCT: the retina along the retinotomy border is adapted, no signs of PVR.

Claims (1)

A method for treating retinal detachment complicated by proliferative vitreoretinopathy (PVR) characterized by subtotal vitrectomy, characterized in that 2 stages of surgical treatment are performed, during the first stage 3 25G ports are installed 3-4 mm from the limbus in the lower outer, upper outer and upper inner quadrants of the pars plana and an additional port for 12 hours, then the internal limiting membrane (ILM) is contrasted, 0.7-2 ml of a perfluororganic compound (PFOC) is introduced into the vitreous cavity, the ILM is removed in a PFOC medium, diathermocoagulation is performed circumferentially inward from the areas of the proliferatively altered retina, circular retinotomy is performed with guillotine scissors along the diathermocoagulation line, complete removal of the remnants of the retina with proliferative tissue on the periphery and the remnants of the vitreous body, complete tamponade of the vitreous cavity with PFOS, the second stage, after 3-7 days, on the adapted retina, endolaser coagulation is performed in 1-2 rows along the border of the retinotomy in a PFOS environment and sequential replacement of PFOS with air, then air with silicone oil.