RU2846215C1 - Method of surgical treatment of idiopathic through macular rupture of large diameter - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention relates to medicine, specifically to ophthalmology, and can be used for surgical treatment of idiopathic through macular rupture of large diameter. That is ensured by vitrectomy with BSS introduction into a vitreal cavity. In the presence of an internal border membrane, it is removed. Then neurosensory retinal flap is cut out. Thereafter, the BSS solution supply into the eye cavity is stopped; the rupture area is covered with the autograft flap and centred in relation to the centre of the through macular rupture CMP in the BSS medium. That is followed by fixing the flap with autologous conditioned plasma ACP at 10-12 mm from the retinal surface, in a projection of SMP, in amount of 0.1-0.2 ml at 0.8 ml a minute. In 3-5 minutes, the BSS solution supply into the eye cavity is resumed until the eye tone is restored, and a gas tamponade of the vitreal cavity is performed.

EFFECT: invention provides the complete anatomical closure of the through macular rupture, enables reducing a risk of recurrent macular rupture, eliminating a risk of complications caused by the use of PFOC.

2 cl, 3 ex

Description

The invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of idiopathic through macular hole of large diameter.

Idiopathic through and through macular holes (IMP) are one of the causes of a sharp decrease in visual acuity. More often this pathology occurs in people of the older age group. The effectiveness of surgical treatment of the disease reaches 80-95% depending on the clinical and anatomical characteristics of the disease. Large diameter IMP have the most unfavorable prognosis, which is associated with a high risk of postoperative relapses [Velichko P.B., Fabrikantov O.L. Results of surgical treatment of through and through macular holes of various diameters. Modern technologies for the treatment of vitreoretinal pathology - 2011. Vitreoretinal pathology https://eyepress.ru/material/rezul-taty-khirurgicheskogo-lecheniya-skvoznykh-makulyarnykh-razryvov-razlichnogo-diametra)].

The gold standard of surgical treatment for idiopathic macular holes includes vitrectomy, removal of the internal limiting membrane (ILM), and gas tamponade of the vitreous cavity [Kelly N., Wendel R. Vitreous surgery for idiopathic macular holes. Results of a pilot study // Arch Ophthalmol. 1991; 109: 654-9; Benson W., Cruickshanks K., Fong D., Williams G., Bloome M., Frambach D. et al. Surgical management of macular holes: A report by the American Academy of Ophthalmology // Ophthalmology. 2001; 108:1328-35]. Its disadvantages include a high risk of failure to close the rupture if the rupture diameter exceeds 530 μm [Petrachkov D.V., Alkharki L., Matyushchenko A.G., Filippov V.M., Dudieva F.K. Comparison of early treatment outcomes for large full-thickness macular holes using different surgical techniques. Ophthalmology. 2021; 18 (3S): 681-687].

In order to improve the efficiency of surgical treatment of large-diameter retinal detachments, techniques have been developed that include various manipulations with the ILM, the use of autologous conditioned plasma (ACP) [Arsyutov D.G. Use of autologous conditioned plasma rich in platelets in surgery for rhegmatogenous retinal detachment with central and peripheral tears. A eta Biomedica Scientifica. 2019; 4 (4): 61-65. https://doi.org/10.29413/ABS.2019-4.4.8] or platelet-rich plasma (PRP) [patent RU 2685648, 04.05.2018]. One of the disadvantages of the methods using an inverted or free ILM flap, as well as their modifications, is the high mobility of the flap, which can lead to its dislocation, the impossibility of using this technique in operations for recurrent MR in case of ILM removal during the primary operation. A general disadvantage of surgical modifications using ILM and blood plasma is a decrease in efficiency as the rupture diameter increases [Rezende F.A., Ferreira B.G., Rampakakis E, et al. Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group. Int J Retina Vitreous. 2023; 9 (1): 4. Published 2023 Jan 30. doi: 10.1186/s40942-022-00439-4].

There are methods of transplantation and autotransplantation of various tissues that are free from the disadvantages described above. For example, a method of surgical treatment of idiopathic macular hole using donor Descemet membrane. The macular hole is closed with a fragment of Descemet membrane of the donor cornea with a shape repeating the shape of the hole, with dimensions at least 1.0 mm larger than the size of the hole, determined by preoperative optical coherence tomography (OCT). The fragment of Descemet membrane is centered relative to the macular hole so that it covers the area of the hole by at least 0.5 mm on all sides. Then one drop of autologous ACP serum is applied to the macular area to fix the transplant [Patent for invention RU 2786140, 12/19/2022]. The disadvantages of this method are the need to use a donor cornea to obtain a Descemet's membrane flap and the risk of damage to the transplant during implantation into the eye.

The closest analogue of the proposed method is the method of surgical treatment of idiopathic through-and-through macular hole of large diameter [RU 2826123, 04.09.2024]. Using the Navilas laser navigation system, a frontal OCT-A image is superimposed on a photograph of the fundus. Then, a template flap of the neurosensory retina is virtually marked to cover the area of the macular hole with an indentation from the edge of the hole of 1/4 of the diameter of the hole in the largest meridian. The marked template flap is moved to the avascular zone of the superior nasal vascular arcade on the middle periphery of the retina. After that, in accordance with the marking, the boundaries of the neurosensory retina flap are outlined using laser coagulates with a diameter of 110-150 μm, located close to each other with a power sufficient to obtain grade 2 coagulates. At the intraoperative stage, vitrectomy is performed. The marked flap is cut out along the inner edge of the laser coagulates and the area of the through macular hole is covered with it. A perfluoroorganic compound (PFOC) is introduced onto the surface of the flap. The center of the flap is aligned with the center of the through macular hole. Autologous conditioned blood plasma is placed on the flap. The PFOC is removed and the vitreous cavity is tamponed with a gas-air mixture. The disadvantage of this method is the need to use PFOC, which increases the risk of flap loss during the introduction of PFOC, can lead to subretinal migration of a drop of PFOC, and increases the time of surgical intervention.

The objective of the invention is to develop an effective method for closing a through macular hole with a diameter greater than 700 µm.

The technical result of the claimed method is a reduction in the risk of recurrence of macular rupture with the elimination of the possibility of developing complications caused by the use of PFOC.

The technical result is achieved due to the fact that the through macular hole is covered with a flap of the neurosensory retina, followed by covering the flap of the neurosensory retina with autologous conditioned blood plasma (ACP) in a balanced salt solution (BSS) environment.

Stopping the BSS solution supply to the eye cavity after cutting out the flap, introducing ASR into the vitreous cavity at a distance of 10-12 mm from the retinal surface, and the injection rate of 0.8 ml per minute prevent flap dislocation by turbulent fluid flows, the ASR volume of 0.1-0.2 ml allows to completely cover the autotransplantation zone, thereby increasing the reliability of fixation, an exposure of 3-5 minutes is necessary to form a dense ASR plasma clot, which prevents flap dislocation by turbulent fluid flows after resuming the supply of BSS solution into the eye cavity. The combination of the above techniques reduces the risk of relapse of SMR, speeds up the operation, eliminates the risk of complications due to the use of PFOC.

The method is carried out as follows.

Vitrectomy is performed with the introduction of BSS solution into the vitreous cavity. If the internal limiting membrane is present, it is removed. Then, a flap of the neurosensory retina is cut out. After that, the supply of BSS solution into the eye cavity is stopped, the rupture zone is covered with the neurosensory retina flap and centered relative to the center of the SMR. After that, the flap is fixed using ASR as follows: at a distance of 10-12 mm from the retinal surface, in the projection of the SMR, 0.1-0.2 ml of ASR plasma is introduced at a rate of 0.8 ml per minute. After 3-5 minutes, the supply of BSS solution into the eye cavity is resumed until the eye tone is restored and gas tamponade of the vitreous cavity is performed.

This method was used in the surgical treatment of 6 patients, all patients had closure of the macular hole after the intervention, no intraoperative complications were observed. The postoperative period was uneventful, the visual acuity of the patients improved, the macular hole was closed throughout the observation period (2 months), including after complete resorption of the gas-air mixture.

The method is illustrated with clinical examples.

Clinical example 1

Patient M., 64 years old, was admitted with a diagnosis of through-and-through macular hole, pseudophakia of the right eye. The best corrected visual acuity of the left eye (BCVA) is 0.05. According to OCT, the hole diameter is 964 μm. The patient underwent subtotal vitrectomy, removal of the internal limiting membrane around the macular hole, after which a flap of the neurosensory retina was cut out, the supply of BSS solution to the eye cavity was stopped, the area of the through-and-through macular hole was covered with the flap, the center of the flap was aligned with the center of the through-and-through macular hole, at a distance of 10 mm from the retinal surface, in the projection of the SMR, 0.1 ml of ASR plasma was injected at a rate of 0.8 ml per minute. After 5 minutes, the BSS solution was re-introduced into the eye cavity until the eye tone was restored, and gas tamponade of the vitreous cavity (perfluoropropane 12%) was performed. Two months after the operation, the BCVA was 0.3; according to ophthalmoscopy and OCT, complete anatomical closure of the macular hole was diagnosed, adaptation of the autograft in the rupture zone, no intraoperative or postoperative complications were recorded. Thus, the proposed method ensures complete anatomical closure of the through macular hole, no need for repeated surgical intervention due to recurrence, no complications associated with the intraoperative use of PFOC.

Clinical example 2

Patient D., 88 years old, was admitted with a diagnosis of recurrent full-thickness macular hole, pseudophakia of the left eye. The best corrected visual acuity (BCVA) of the left eye was 0.02. The anamnesis included partial vitrectomy, removal of the ILM, and tamponade of the vitreous cavity with gas to close the MR. In the postoperative period, a recurrent MR was detected. According to OCT, the rupture diameter was 882 μm. The patient underwent subtotal vitrectomy, after which a flap of the neurosensory retina was dissected out, the supply of BSS solution to the eye cavity was stopped, the area of the full-thickness macular hole was covered with the flap, the center of the flap was aligned with the center of the full-thickness macular hole, 0.2 ml of ASR plasma was injected at a rate of 0.8 ml per minute at a distance of 11 mm from the retinal surface, in the projection of the MR. After 4 minutes, the BSS solution was re-introduced into the eye cavity until the eye tone was restored, and gas tamponade of the vitreous cavity (12% perfluoropropane) was performed. Two months after the operation, the BCVA was 0.2; according to ophthalmoscopy and OCT, complete anatomical closure of the macular hole was diagnosed, adaptation of the autograft in the hole area, no intraoperative or postoperative complications were recorded. Thus, the proposed method ensures complete anatomical closure of the through macular hole, no need for repeated surgical intervention due to recurrence, no complications associated with the intraoperative use of PFOC.

Clinical example 3

Patient G., 62 years old, was admitted with a diagnosis of through-and-through macular hole, pseudophakia of the right eye. The best corrected visual acuity of the left eye (BCVA) is 0.1. According to OCT, the hole diameter is 1023 μm. The patient underwent subtotal vitrectomy, removal of the internal limiting membrane around the macular hole, after which a flap of the neurosensory retina was cut out, the supply of BSS solution to the eye cavity was stopped, the area of the through-and-through macular hole was covered with the flap, the center of the flap was aligned with the center of the through-and-through macular hole, at a distance of 10 mm from the retinal surface, in the projection of the SMR, 0.2 ml of ASR plasma was injected at a rate of 0.8 ml per minute. After 3 minutes, the BSS solution was re-introduced into the eye cavity until the eye tone was restored, and gas tamponade of the vitreous cavity (perfluoropropane 12%) was performed. Two months after the operation, the BCVA was 0.28; according to ophthalmoscopy and OCT, complete anatomical closure of the macular hole was diagnosed, adaptation of the autograft in the hole area, no intraoperative or postoperative complications were recorded.

Thus, the proposed method ensures complete anatomical closure of the through macular hole, no need for repeated surgical intervention due to recurrence, and no complications associated with the intraoperative use of PFOC.

Claims (2)

1. A method for surgical treatment of an idiopathic through-and-through macular hole of a large diameter, including vitrectomy with the introduction of a BSS solution into the vitreous cavity, cutting out a flap of the neurosensory retina, covering the tear zone with a flap of the neurosensory retina, fixing the flap with autologous conditioned plasma (ACP), gas tamponade of the vitreous cavity, characterized in that after cutting out the flap of the neurosensory retina, the supply of the BSS solution into the eye cavity is stopped, the flap is moved and centered relative to the through-and-through macular hole (TMH) in a BSS medium, and the fixation of the flap of the neurosensory retina is carried out by introducing ACP into the vitreous cavity at a distance of 10-12 mm from the retinal surface in the projection of the TMH in a volume of 0.1-0.2 ml at a rate of 0.8 ml per minute, after 3-5 minutes the supply of the solution into the eye cavity is resumed BSS is performed until the eye tone is restored and gas tamponade of the vitreous cavity is performed. 2. The method according to paragraph 1, characterized in that if there is an internal limiting membrane, it is removed after vitrectomy.