RU2810243C1 - Method for removing inner boundary membrane in vitreo-macular traction syndrome in patients with proliferative diabetic retinopathy - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: invention relates to medicine, namely ophthalmology. The internal boundary membrane (IBM) is removed in vitreo-macular traction syndrome in patients with proliferative diabetic retinopathy (DR). The areas of the IBM around the fovea are separated with the formation of a retinal zone without IBM in the form of a horseshoe-shaped figure located between the vascular arcades. In this case, the separation is carried out with a concatenating vitreal tweezers in fragments in the direction from one end of the horseshoe-shaped figure to the other. In case of tearing of the fragment to be removed during separation, the adjacent edge of the IBM is captured with tweezers and the membrane is continued in the same direction until the horseshoe shape is reached, while preserving the IBM section in the center of the fovea and in the papillo-macular zone bundle located between the ends of a horseshoe-shaped figure. In this case, the area of the retina without IBM is located with an indentation inward from the vascular arcades at a distance of at least 0.5 of the diameter of the optic nerve disc (OND), and the distance between the ends of the horseshoe-shaped figure is 1-1.5 of the diameter of the OND.

EFFECT: method allows to obtain a high functional result (visual acuity) in the postoperative period with a decrease in traumatism, surgical and postoperative complications due to the local removal of IBM in the form of a horseshoe flap without peeling the papillomacular bundle and the fovea zone, reduces retinal trauma, since the light perception zone and the area of the main visual bundle of nerve endings are not affected.

1 cl, 3 dwg, 2 ex

Description

Field of technology to which the invention relates

The invention relates to the field of medicine, in particular ophthalmology, and can be used for surgical treatment of vitreomacular traction syndrome in patients with proliferative diabetic retinopathy.

State of the art

Currently, pathology of the macular region of the retina steadily occupies a leading position in the structure of vision loss in the adult population in various countries of the world. Another negative trend is the increase in patients with diabetes and its eye complications. The unfavorable development of proliferative diabetic retinopathy, leading to irreversible visual impairment due to retinal detachment, is traction vitreomacular syndrome. Despite the fact that in recent years, the improvement of surgical techniques has made it possible to stop the development of retinal detachment and loss of central vision, the functional effect after surgical treatment does not sufficiently satisfy either the patient or the doctor.

There is a known method for removing the epiretinal membrane, in which three cannulas are installed in the membranes of the eyeball and a vitreotome, irrigator and illuminator are introduced into them (RF patent for invention No. 2335269). Then the vitreous body is removed, a tunnel is formed between the epiretinal membrane and the retina with an endovitreal spatula, and a vitreotome is inserted into the formed tunnel. The epiretinal membrane is fragmented. After this, in the aspiration mode, the edge of the fragment of the epiretinal membrane is lifted using a vitreotome and the tip of the vitreotome is brought to the place of attachment of the fragment of the epiretinal membrane. In this case, the tip is rested on the retina and the site of attachment of the membrane remnants is subjected to traction, stretched, removed from the retina and then removed. In this case, part of the membrane is left for coagulation of bleeding vessels. The disadvantages of this method are the excessive tractional traumatic effect of the vitreotome tip on the retina and the preservation of the internal limiting membrane (ILM), which can lead to relapse of the epiretinal membrane in the late postoperative period.

There is a known method of surgical treatment of patients with macular edema complicated by an epiretinal membrane in diabetes mellitus (RF patent for invention No. 2687592), where the authors, under the intraoperative control of optical coherence tomography, perform circular peeling of the ILM, starting from the place with the least photosensitivity according to microperimetry. The disadvantages of the method include a fairly large volume (more than 2 mm in diameter) round-shaped ILM removal fragment with elements of the papillo-macular bundle of retinal fibers.

The closest to the claimed is a method for removing the ILM during the surgical treatment of macular edema of various etiologies (RF patent for invention No. 2563438 of 2015). The method includes gradual removal of the ILM in small sections in the form of petals (allows to minimize the traumatic effect on the retina), removal of the ILM in an area from 2.0-2.5 mm to 0.5-0.8 mm around the foveola is carried out to eliminate horizontal tractions of the retina ( Fig. 1). Preservation of the foveal fragment of the ILM eliminates thinning of the retina in the macular region, which helps improve visual functions and preserve central vision.

To do this, a transconjunctival 3-port 25G vitrectomy is first performed using a standard technique, using standard dyes to detail the structure of the posterior cortical layers of the vitreous body (VT) and ILM. The very technique of forming the foveal fragment of the ILM is reminiscent of removing the petals of a flower and is performed in several series of techniques, including a repeating set of actions. First, the point on the retina is determined from where the formation of the first ILM lobe will begin: 2.0-2.5 mm to the inferotemporal arcade from the foveola. At this point, using microtweezers, the tip of the ILM is separated from the retina with a pinch. Then, grasping the tip of the ILM with tweezers, the membrane is separated over 2-3 hour meridians with a movement directed along the arc of an imaginary circle with the center in the foveola. Next, following the described technique, several series of removal of ILM petals are sequentially performed in a clockwise circle, the number of which varies from 5 to 7 depending on the density of ILM adhesion to the retina, the severity of ILM fibrosis, and the presence of epiretinal membranes tightly associated with the ILM. As the ILM petals are removed, a foveolar fragment of the ILM is formed around the fovea, surrounded by a retinal zone without the ILM in the form of an open ring. The last petal is removed so as to preserve a small bridge and prevent closure of the ring, in order to prevent spontaneous separation of the foveal fragment of the ILM. The remaining bridge is carefully lifted with microtweezers by the edge at the outer border and separated towards the center, stopping at a distance of 0.5-0.8 mm from the foveola, and the ILM bridge is removed using a vitreotome.

However, the disadvantages of this method are the excessive tractional traumatic effect of the vitreotome tip on the retina and the removal of part of the fibers of the papillo-macular bundle, since peeling of this area of the retina is undesirable at the histological level due to the close connection of the ILM with Müller cells.

The technical problem is the development of a method for surgical treatment of vitreomacular traction syndrome in patients with proliferative diabetic retinopathy in diabetes mellitus, devoid of the above disadvantages.

Disclosure of the invention

The technical result to which the claimed invention is aimed is to obtain a higher functional result (visual acuity) in the postoperative period while reducing trauma, operational and postoperative complications due to local removal of the ILM in the form of a horseshoe flap without peeling the papillo-macular bundle and the foveal area, which significantly reduces retinal trauma (the area of light perception and the area of conduction of the main visual bundle of nerve endings are not affected).

The technical result is achieved by implementing a method for removing the internal limiting membrane (ILM) for vitreomacular traction syndrome in patients with proliferative diabetic retinopathy (DR), including separating sections of the ILM around the fovea with the formation of a retinal zone without the ILM in the form of a horseshoe-shaped figure located between the vascular arcades, while separation is carried out with end-grabbing vitreal tweezers in fragments in the direction from one end of the horseshoe to the other; in the event of a tear in the removed fragment during separation, a new grasp of the edge of the ILM is carried out with tweezers and the removal of the membrane continues in the same direction until the shape of a horseshoe is achieved, preserving the area of the ILM in the center fovea and in the area of the papillo-macular bundle, located between the ends of the “horseshoe” and with an indentation of at least 0.5 optic disc diameter (ONH) inward from the vascular arcades, and the distance between the ends of the horseshoe is 1-1.5 optic disc diameter.

Preferably, the retinal area without the ILM is formed in such a way that the maximum distance (between remote points) from top to bottom of the horseshoe-shaped figure vertically is 3-4 optic disc diameters, the right-to-left horizontal distance is 4-5 optic disc diameters, the width of the removed horseshoe fragment is up to 1 diameter of the optic disc in the area of the ends of the horseshoe (arches) and up to 1-1.5 diameter of the optic disc in the central part of the horseshoe.

Brief description of drawings

The invention is illustrated by drawings, where in Fig. Figure 1 shows a diagram of the VMP circular peeling zone (RF patent for invention No. 2563438). The macula area remains intact, the ILM above the projection of the maculopapillary bundle is removed. In fig. Figure 2 schematically shows the proposed ILM peeling scheme for the left eye, where 1 - optic nerve head (ONH), 2 - upper and lower vascular arcades, 3 - vertical distance from top to bottom is 3-4 optic disc diameters, 4 - right-to-left distance horizontally is 4-5 diameters of the optic disc, 5 - the distance between the arms of the horseshoe from top to bottom is 1-1.5 diameters of the optic disc, in Fig. 3 - diagram of the VMP peeling zone for the right eye.

Carrying out the invention

The proposed method of surgical treatment of vitreomacular traction syndrome in patients with proliferative diabetic retinopathy is carried out as follows. A patient with diabetes mellitus and proliferative diabetic retinopathy undergoes standard treatment of the surgical field. After this, transconjunctival 3-port 25G vitrectomy is performed according to the standard technique (cut frequency - from 7500 to 10,000 per minute, vacuum - from 5 to 650 mm Hg) using standard dyes [Shkvorchenko D.O. et al. Contrast agents for chromovitrectomy - Ophthalmosurgery - No. 2 - 2016] to detail the structure of the posterior cortical layers of the CT and ILM. The separation of the posterior hyaloid membrane is carried out using aspiration technique, starting from the optic disc, gradually lifting it to the periphery. During vitrectomy, special attention is paid to removing the base of the vitreous body near the dentate line with careful examination of this area. External compression of the sclera is allowed for better visualization of the specified area. The diameter of the optic disc is measured using standard methods (Katsnelson L.A., Lysenko V.S., Balishanskaya T.I. Clinical atlas of fundus pathology. Moscow: GEOTAR-Media; 2008). The average size of the optic disc in humans is 1.76 mm horizontally and 1.92 mm vertically.

Next, the formation of a section without the ILM begins in the form of a horseshoe-shaped open figure. Formation begins from one of the ends of the “horseshoe”, depending on where the VMF contours better after staining. At a distance of at least 0.5 times the size (or magnitude) of the diameter of the optic disc (ONH) from the vascular arcades and from the fovea, using end-grabbing vitreal tweezers, sections of the ILM in the shape of a horseshoe are separated, with their base facing the ONH. Separating (rexis) is carried out in fragments, in the direction from one end of the horseshoe to the other. At the same time, it is monitored that the area of the retina at a distance of one optic disc diameter from the foveola remains intact. Figure 2 schematically shows the peeling area of the ILM relative to the vascular arcades and optic disc for the left eye. It is important that the width of the removed horseshoe-shaped ILM flap is up to 1 diameter of the optic disc in the area of the ends of the horseshoe (arches) and up to 1-1.5 diameter of the optic disc in the central part of the horseshoe. The distance between the ends of the horseshoe is 1-1.5 times the diameter of the optic disc. The diagram clearly shows that the area of the papillo-macular bundle and fovea is not affected by the ILM peeling, that is, it remains intact. Figure 3 shows the ILM peeling area for the right eye.

If, during the separation of the ILM, the removed flap is torn, then a new grasp of the edge of the ILM is carried out with tweezers and the removal of the membrane continues in the same direction along a horseshoe-shaped arc until the planned figure is achieved.

The top and bottom boundaries of the flap are a conventional arc, passing inside from the vascular arcades with an indentation of a distance equal to 0.5 of the diameter of the optic disc. It is important to emphasize that the area of the papilomacular bundle remains intact, that is, the nerve fibers of this area are not affected during removal of the horseshoe-shaped portion of the ILM (Figs. 2 and 3).

After completion of ILM removal using the proposed method, tissue can be re-stained with standard dyes for better visualization of the result obtained. Then, at low vacuum levels (150-200 mm Hg), the fluid is replaced with air up to 1/3 of the vitreal cavity tamponade. At the discretion of the surgeon, it is possible to replace the air with 20% SF ₆ gas or silicone oil.

The operation is completed by washing the conjunctival cavity with a 2% povidone-iodine solution and applying an aseptic monocular dressing. In the postoperative period, the patient receives generally accepted local anti-inflammatory therapy in the form of drops.

A distinctive feature of the proposed method is the elimination of traction vitreomacular syndrome without peeling the area of the papillo-macular bundle and the preservation of the anatomical and physiological configuration of the retina in the fovea, which leads to higher functional results, and also reduces operational and postoperative complications. Such a horseshoe-shaped figure of the removed ILM helps to improve the functional result of the operation (postoperative visual acuity) due to the preservation of visual cells in the very central zone (fovea) and in the papillo-macular fascicle, which remain intact and their anatomical-functional connections are not disturbed.

The developed method was tested in 8 patients with type 2 diabetes mellitus who were operated on for traction vitreomacular syndrome in proliferative diabetic retinopathy. All operated patients underwent three-port 25G vitrectomy with local ILM peeling in the shape of a horseshoe, leaving the fovea and papillo-macular nerve bundle intact. In the early and late postoperative period, better functional results were obtained (visual acuity, reduction of scotomas during perimetry, more preserved foveal area during optical coherence tomography). Thus, the proposed method is reliable and less traumatic for the retina than previously proposed methods.

Examples

Example 1. Patient Yu., born in 1964, was treated with a diagnosis of: OI - proliferative diabetic retinopathy, epiretinal fibrosis, pseudophakia, OS - vitreomacular traction syndrome, type 2 diabetes mellitus, hypertension, sensorineural hearing loss.

Upon admission, visual acuity of the right eye: 0.6 with a correction of 1.0, of the left eye - 0.2 with a correction of 0.4. Objectively, the left eye: the cornea is transparent, the anterior chamber is deeper than the middle one, pseudophakic, the lens is centered in the capsular bag. Optical coherence tomography revealed a traction component in the macula, the thickness of the retina in the central zone was 367 - 474 µm. Diagnosis: epiretinal fibrosis and vitreomacular traction component of the left eye. A three-port vitrectomy with removal of epimacular fibrosis and horseshoe peeling of the ILM was planned.

During the operation, standard installation of 25G trocars was performed. Access to the central fovea of the macula (foveola) was created through a 3-port vitrectomy. The posterior hyaloid membrane was peeled off, followed by its excision, and the adjacent posterior layers of the vitreous body and epiretinal membranes were removed with maximum release of the foveola from various tractions. After standard contrasting of the ILM, at a distance of 1 optic disc diameter (2 mm) from the fovea, a horseshoe-shaped flap was separated, the horizontal and vertical dimensions of which were 8.0 mm and 7.0 mm, respectively, and the width was 1.5-2.0 mm. Peeling of the papillo-macular bundle and foveal zone was not performed. Then the fluid was replaced with air, 1/3 of the volume of the vitreal cavity.

After the operation on the 3rd day, visual acuity of the right eye: 0.6 with correction 1.0, of the left eye - 0.4 with correction 0.5. Objectively, the left eye: the cornea is transparent, the anterior chamber is deeper than the middle one, pseudophakic, the lens is centered in the capsular bag. There is a small air bubble in the vitreous cavity.

When monitored after 3 months, visual acuity of the right eye: 0.5 with correction of 0.9, of the left eye - 0.5 with correction of 0.8. When performing optical coherence tomography of the left eye, the thickness of the retina in the central zone was 267 - 324 µm. Thus, the patient did not have any intraoperative or postoperative complications.

Example 2. Patient V., born in 1965, was treated with a diagnosis of: OI - proliferative diabetic retinopathy, initial cataract, condition after laser coagulation of the retina, OD - subtotal hemophthalmos, type 2 diabetes mellitus, distal diabetic polyneuropathy, multinodular goiter , dyslepidemia.

Upon admission, visual acuity of the right eye: counting fingers near the face, n/c, left eye - 0.6 n/c. Objectively, the right eye: the cornea is transparent, the anterior chamber is of medium depth, there are hemorrhagic floating opacities in the vitreous. Details of the fundus are not ophthalmoscoped due to hemophthalmos. According to ultrasound examination, there is a local retinal detachment in the paramacular zone. Diagnosis: proliferative diabetic retinopathy, fresh almost total hemophthalmos and vitreomacular traction component of the left eye. A three-port vitrectomy was planned with removal of hemophthalmos, schwartectomy, horseshoe peeling of the ILM and injection of air into the vitreous cavity.

During the operation, standard installation of 25G trocars was performed. Hemophthalmos was removed with the removal of moorings and epiretinal membranes with maximum release of the foveola from various tractions. After standard contrasting of the ILM, at a distance of 1.5 times the diameter of the optic disc (3 mm) from the fovea, a horseshoe-shaped flap was locally removed, the horizontal and vertical dimensions of which were 7.5 mm and 6.5 mm, respectively, and the width was 1.5-2.0 mm. Peeling of the papillo-macular bundle and foveal zone was not performed. Then the liquid was replaced with gas.

After the operation on the 3rd day, visual acuity of the right eye: counting fingers near the face, n/c, left eye - 0.6 n/k. Objectively, the left eye: the cornea is transparent, the anterior chamber is of medium depth, initial cortical opacities in the lens. There is a large gas bubble in the vitreous cavity.

When monitored after 3 months, visual acuity of the right eye: 0.2 with correction 0.4, of the left eye - 0.7 n/k. When performing optical coherence tomography of the right eye, the thickness of the retina in the central zone was 287 - 326 µm. The patient did not have any intraoperative or postoperative complications.

Claims (1)

A method for removing the internal limiting membrane (ILM) during vitreomacular traction syndrome in patients with proliferative diabetic retinopathy (DR), including separating sections of the ILM around the fovea with the formation of a retinal zone without ILM in the form of a horseshoe-shaped figure located between the vascular arcades, while the separating is carried out end-grasping vitreal tweezers with fragments in the direction from one end of the horseshoe-shaped figure to the other; in case of tearing of the removed fragment during separation, grasp the adjacent edge of the ILM with tweezers and continue removing the membrane in the same direction until a horseshoe shape is achieved, preserving the area of the ILM in the center of the fovea and in the papillo zone -macular bundle located between the ends of the horseshoe-shaped figure, while the retinal area without the ILM is located indented inward from the vascular arcades at a distance of at least 0.5 of the diameter of the optic nerve head (ONH), and the distance between the ends of the horseshoe-shaped figure is 1-1.5 diameter of the optic disc.