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Левицкая Г.В., Абдулхади Мохаммад. Эффективность нового метода лечения больных регматогенной отслойкой сетчатки, осложненной отслойкой сосуд
09.08.2014, 16:12

Резюме
Левицкая Г.В., Абдулхади Мохаммад. Эффективность нового метода лечения больных регматогенной отслойкой сетчатки, осложненной отслойкой сосудистой оболочки.
У 63 больных регматогенной отслойкой сетчатки, осложненной отслойкой сосудистой оболочки, оценена эффективность хирургического лечения в зависимости от типа проводимой предопрационной подготовки: у 39 человек с интравитреальным введением 4 мг триамцинолона ацетонида (ТА) или ТА в сочетании с перфторпропаном, и у 24 человек с традиционной противовоспалительной терапией (контрольная групппа). Разработанный метод с интравитреальным введением позволил повысить частоту прилегания сетчатки после однократной витрэктомии до 94,8 % по сравнению с 70,8 % в контрольной группе, снизить количество повторных витрэктомий в 4,9 раз, частоту послеоперационных ранних осложнений в 2,6 раза, поздних послеоперационных осложнений в 4,6 раз, повысить остроту зрения в 1,9 раз.
Ключевые слова: регматогенная отслойка сетчатки, отслойка сосудистой оболочки, ВГД, триамцинолона ацетонид, перфотпропан, прилегание сетчатки, послеопрационные осложнения, острота зрения.

Резюме
Левицька Г.В., Абдулхаді Мохаммад. Ефективність нового методу лікування хворих на регматогенне відшарування сітківки, ускладнене відшаруванням судинної оболонки.
У 63 хворих на регматогенне відшарування сітківки, ускладнене відшаруванням судинної оболонки, оцінено ефективність хірургічного лікування залежно від типу проведеної предопраціонной підготовки: у 39 чоловік з інтравітреальним введенням 4 мг тріамцинолону ацетоніду (ТА) або ТА в поєднанні з перфлюоропропаном, і у 24 осіб з традиційною протизапальної терапією (контрольна групппа). Розроблений метод з інтравітреальним введенням дозволив підвищити частоту прилягання сітківки після одноразової вітректоміі до 94,8% порівняно з 70,8% у контрольній групі, знизити кількість повторних вітректомій в 4,9 раз, частоту ранніх післяопераційних ускладнень в 2,6 рази, пізніх післяопераційних ускладнень в 4,6 раз, підвищити гостроту зору в 1,9 разів.
Ключові слова: регматогенне відшарування сітківки, відшарування судинної оболонки, ВОТ, триамцинолону ацетонід, перфлюоропропан, прилягання сітківки, послеопраціонні ускладнення, гострота зору.

Summary
Levytska Galina, Abdulhadi Mohammad. Efficacy of a new method of treatment of patients with rhegmatogenous retinal detachment complicated by choroidal detachment.
63 patients with rhegmatogenous retinal detachment complicated by choroidal detachment, evaluated the efficacy of treatment depending on the type of preoperative preparation: in 39 people with 4 mg of intravitreal triamcinolone acetonide (TA) or TA in combination with, perfluoropropane, and 24 people with traditional anti-inflammatory therapy (control group). The new developed method with intravitreal injection to increase attechment of the retina after a single fit vitrectomy to 94.8% compared with 70.8% in the control group, to reduce the number of repeat vitrectomy 4.9 times, the rate of postoperative complications in the early 2.6 times, later postoperative complications in 4.6 times, increase in visual acuity of 1.9.
Key words: rhegmatogenous retinal detachment, choroidal detachment, IOP, triamcinolone acetonide, perfluoropropane, attechment of the retina, postoperative complications, visual acuity.

Рецензент: д.мед.н., проф. А.М. Петруня

УДК 617.735-007.281-06:617.723-007.281-089.168

ГУ «Институт глазных болезней и тканевой терапии им. В.П. Филатова НАМН Украины» (Одесса)

SI “The Filatov Institute of Eye Diseases and Tissue Therapy of the National Academy of Medical Sciences of Ukraine”  (Odessa)

g.levytskaya@mail.ru, dr_abdul5@bk.ru

It is known that rhegmatogenous retinal detachment (RRD) is the result of getting liquid under the retina through its break (H.33.0), which is the reason why this form of detachment could be attributed to dystrophic diseases of the eye. However, in 2.0-4.5% of cases, for unknown reasons, ROS is complicated by development of intraocular inflammation and choroidal detachment (CD). Clinically it is manifested by development of pain, conjunctival injection, deepening of the anterior chamber, and irido-facodonezis, posterior synechiae, vitreous opacities, severe hypotension (sometimes less than 5 mm Hg.), choroidal detachment, greenish appearance of the iris. In the literature to denote the form described as RRD, complicated with choroidal detachment [5, 7, 9, 11, 12].

This is a severe type of retinal detachment, proved by the fact that such patients usually exclude of clinical studies on the effectiveness of RRD treatment. Thus, the efficacy of a single intervention by episcleral sealing is only 32.4 - 52.1%, slightly increased during vitrectomy - up to 66.7% [4-7].

Feature of surgery in these patients is the high rate of complications, including hemorrhages, exudative reaction in the early postoperative period, and subsequently - proliferative vitreoretinopathy, which manifests itself in the development of epimacular membranes (24%) and more massive epiretinal membranes, which leads to detachment recurrence (up to 45% cases) [4-7].

The reason of described complications is initial intraocular inflammation, against which the surgery is performed. In this regard, some authors consider it advisable to conduct glucocorticoid therapy as a subconjunctival injection and systemically at a dose of 1 mg per kg body weight for 1 to 3 weeks [4,10] prior to vitrectomy. However, it prolongs the existence of macular detachment, adversely affects the functional results, has a number of side effects.

We have proposed a method of treatment comprising performing on the first stage before vitrectomy intravitreal injection of triamcinolone acetonide (TA) or a combination of TA with perftorpropanom (C3F8) [2], which resulted in all patients elimination of signs of intraocular inflammation in 1-2 days, choroidal detachment in period from 1 to 4 days before vitreoretinal intervention [1,3,8].

Aim of our study was to investigate the effectiveness of the proposed method of RRD treatment complicated by choroidal detachment.

Material and methods. The study included 63 patients (63 eyes), with RRD complicated by CD who underwent vitrectomy in order to eliminate retinal detachment. Depending upon the type of pre-operative patients were divided into main (39 patients) and control groups (24 patients). In 39 patients of the main group preoperative conducted by the proposed method: intravitreal injection of 4 mg of washed TA crystals or 4 mg TA + S3F8 (up to normotension) depending on the severity of the initial state [3]. Intraviteal injection was performed according to standard procedures: 3.5 -4 mm from the limbus in the projection of the height of the lowest choroid detachment, the perfluoropropene injection preferred to perform in the top half (from 10 to 2:00) of conditional dial. The control group consisted of 24 patients who underwent traditional preoperative preparation, including 40 mg of dexamethasone as a subconjunctival (or parabulbar injection) and systemically, diclofenac sodium 75 mg intramuscularly once a day for 4-10 days. Before vitrectomy patients from both groups underwent standart topical cycloplegia, patients with the presence of adhesions was performed 1-3 subconjunctival mezaton injection to destroy posterior synechiae. In addition, patients in both groups received topical anti-inflammatory therapy (steroid and non-steroid anti-inflammatory drops).

The main and control groups were comparable for sex, age, features characterizing the state of the eyes and severity of the clinical course of retinal detachment (see Table. 1). Groups did not differ also in severity of uveitis.

Table 1

Initial clinical state of patients with RRD complicated by CD in main and control groups

Clinical sign

Main group

n = 39 (%)

Control group,

n = 24 (%)

Average age, years, (SD)

56,5 (14,0)

51,4 (9,9)

Degree of myopia:

low

average

high

 

8 (20,5)

2 (5,1)

23 (59,0)

 

2 (8,3)

4 (16,7)

13 (54,2)

Aphakia

pseudophakia

2 (5,1)

11 (28,2)

2 (8,3)

7 (29,2)

RRD duration, days, (SD)

20,6 (11,1)

18,1 (6,9)

RRD length:

2 quadrants

3 quadrants

4 quadrant

 

2 (5,1)

11 (28,2)

26 (66,7)

 

2 (8,3)

12 (50,0)

10 (40,0)

Type of break:

valve

atrophic

atrophic + valve

giant

not detected

3 and more

 

16 (41,0)

-

13 (33,3)

1 (2,6)

----

7 (17,9)

 

13 (54,2)

2 (8,3)

5 (20,8)

----

1 (4,2)

3 (12,5)

PVR stage:

A

B

CP 1 – 3 type 1,2

 

3 (7,7)

25 (64,1)

11 (28,2)

 

2 (8,3)

18 (75,0)

4 (16,7)

Extent of choroidal detachment

2 quadrants

3 quadrants

4 quadrants

 

 

2 (5,1%)

11 (28,2%)

26 (66,7%)

 

 

3 (12,5)

9 (37,5)

12 (50,0)

Mean IOP,

mm Hg. (SD)

 

6,4  (1,5)

 

7,5 (1,1)

Visual acuity:

wrong LP

right LP

detected VA

 

5 (12,8)

22 (56,4)

12 (30,8)

 

1 (4,2)

9 (37,5)

14 (58,3)

Mean visual acuity, (SD)

0,023 (0,014)

0,029 (0,013)

 

 

Complex intravitreal intervention was performed in both groups according to standard 3 port 20-G vitrectomy. Lens was saved in 25 of 26 phakic patients (96.2%) of main and 16 of 17 patients (94.1%) of control groups. Retina reattaching was performed by fluid gas exchange in 36 eyes (92.3%) in main group and in 20 eyes (83.3%) in control group. In all cases was performed circular diode endolasercoagulation with blocking all breaks and peripheral retinal degeneration. In the majority of patients was performed perfluoropropene tamponade - 37 of 39 people (94.5%) of main and 22 of 24 people 91.7% ) in control groups; silicone tamponade - 2 persons in each group. All patients in both groups after vitrectomy had full retina reattachment.

A conservative therapy with steroid and non-steroid anti-inflammatory drugs was performed postoperatively for 3-7 days, depending on the presence and severity of postoperative complications. At hospital discharge, all patients received conventional anti-inflammatory treatment as instillation of steroid and non-steroid drops for 2-3 weeks.

Effectiveness of treatment was evaluated on achievement of anatomic result (retina reattachment) as a result of single vitrectomy, on the IOP normalization, on the degree of postoperative visual acuity, frequency, type and severity of complications that developed in the early postoperative period and at 3 and 6 months after the intervention. All of these criteria were studied in patients with different types of preoperative preparation.

Statistical analysis was performed using STATISTICA-8 package.

Results. In the early postoperative period following complications were observed: hyphema, exudative reactions varying severity, which manifested by the deposition of single threads of fibrin on the lens or IOL (mild), pupillary membrane formation (medium), the formation of massive pupillary membrane impedes biomicroscopy deeper eye departments and also accompanied by the deposition of fibrin in the anterior chamber (severe). Partial hyphema occurred in 2 patients (8.3%) in the control group and did not require surgery. Exudative reaction occurred in both groups, but was significantly less in patients with preoperative intravitreal therapy: in 7 patients (17.9%) vs 16 patients (66.7%) (p = 0.0002). Analysis of the severity of the exudative reaction showed that severe degree of this complication was noted only in the control group (Table 2).

Table 2.

The type and frequency of early postoperative complications in patients of main and control groups

Type of early postoperative complications

Main group

n = 39 eyes (%)

Control group,

n = 24 eyes (%)

Significant difference, p

hyphema

-

2 (8,3)

 

exudation degree

mild

average

heavy

 

5 (12,8)

2 (5,1 )       7 (17,9)

-

 

5 (20,8 )

4 (16,7)        16 (66,7)

7 (29,2)

0,0002

Total

7 (17,9)

18 (75,0)

0,0001

 

The cumulative incidence of early postoperative complications in the main group was 2.6 times lower compared with the control group (χ2-28, 4, p = 0.0001) (Table 2).

Retina was attached was on 3 months after vitrectomy in 97.3% (38/39 people) in the main group and 79.2% (in 19/24 patients) in the control group (p = 0,004).

During this period in one patient (2.6%) in the main group and in 5 patients (20.8%) in the control group occurred recurrent retinal detachment. Cause of recurrent in all patients in both groups was the PVR progression. After intravitreal interventions retina reattached in 1 patient in the main and in 4 patients in the control groups.

Clinical status of patients eye in 3 months after vitrectomy were: corneal dystrophy developed in one case (2.6%) with aphakia in the main group and in one case (4.7%) with the previous phaco with IOL implantation in the control group.

Lens opacities increased in 16 of 25 eyes (64.0%) in the main group and in 9 of 16 eyes (56.3%) in the control group.

In the control group peripheral retinal detachment within zone of circumferential laser coagulation was also noted in 3 cases (12.5%), it was accompanied 2 eyes (8.3%) by hypotension. In one of these eyes developed iris rubeosis, hemophthalm recurrence and secondary glaucoma. What required repeated vitrectomy, which resulted in more peripheral retina reattachment  fit shaft depressions, reduction and subsequent relief of iris rubeosis and hemorrhagic complications. In two cases in the control group developed hypotension with full retina reattachment, stimulating course of medical treatment was performed.

In the main group in one patient remained hypotonia (9.0-10.0 mm Hg.) with full retina and choroid, reattachment but according to the ultrasound examination slit-like detachment of the ciliary body remained. A silicone oil tamponade was performed with a salvage eye purpose.

Epimacular membrane with reattached retina developed in 1 patient (2.6%) in the main and 3 patients (12.5%​​) in the control groups.

Preretinal proliferation occurred in 2 patients (5.1%) in the main and 4 patients (16.7%) in the control groups in the retina more peripheral than zone of circumferential laser coagulation and / or base of the vitreous. However they did not leaded to retina detachment recurrence.

In 3 months after vitrectomy in the group with intravitreal anti-inflammatory preparation cumulative incidence of complications, including peripheral preretinal proliferation, development of epimacular membranes, presence of hypotension, recurrent of retina detachment or the presence of peripheral retinal detachment was significantly lower and was 12.8% versus 70.8% in patients who performed the traditional preparation (χ2 = 23,7, p = 0.0025) (see Table. 3).

Table 3

The type and frequency of postoperative complications in patients of main and control group in 3 months term

Type of postoperative complication

Main group

n = 39 eyes (%)

Control group,

n = 24 eyes (%)

Significant differences

peripheral preretinal proliferation

2 (5,1)

4 (16,7)

 

 

 

 

 

 

 

χ2 = 23,7

р = 0,0025

Epimacular membrane

1 (2,6)

3 (12,5)

Hypotony with reattached retina

1 (2,6)

2 (8,3)

peripheral retinal detachment

-----

3 (20,8)

retinal detachment recurrence

1 (2,6)

5 (25,0)

Total

5 (12,8)

17 (70,8)

 

 

According to the most unfavorable long-term prognosis in abutment against the retina and a possible degree of visual acuity recovery proliferative processes are manifested as vitrectomy after development of scar tissue on the inner most surface of the retina in the vitreous base. Analysis of the sum frequency of vitreoretinal proliferation manifestations, such as the development of epimacular membranes, PVR area of laser lesions, recurrent retinal detachment is informative. The overall incidence of proliferative complications was significantly lower in the main group 10.3% (4 patients) versus 50.0% (12 people) in the control group, χ2 = 22,1, p = 0.002.

In all patients with retina reattachment a statistically significant positive changes in visual acuity were noted.

The number of patients with undetectable visual acuity decreased from 27 people (69.2%) to 1 (2.7%) in the main group and from 10 people (41.7%) to 5 people (16.7%) in control group. These is due to the large number of recurrences and consequently extremely low visual acuity in these cases of control group.

Average detectable visual acuity in the main group increased from 0,023 ± 0,014 to 0,17 ± 0,1 (Minimum = 0,01, Maximum = 0,40, Median = 0,12, N = 37).

In the control group the average visual acuity increased from 0,029 ± 0,013 to 0,09 ± 0,04 (Minimum = 0,01, Maximum = 0,17, Median = 0,10, N = 19) the difference is statistically significant, Fig 1.

Fig. 1. Average visual acuity in patients in main and control groups at 3 months after vitrectomy.

 

On the 6 month examination retina was attached in 38 patients (97.4%) in the main group and in 21 patients (87.5%) in the control group (difference of frequency of positive result is significant, χ2 = 8,03, p = 0.018 ). Recurrence of retinal detachment in a period of 3 to 6 months occurred in one patient main group and two patients in control group. All patients underwent a successful surgery with implantation of silicone oil.

In total to achieve retina reattachment in all cases in 6 months term were performed 2 repeated vitrectomy in the main group and 6 in the control group. More frequent recurrence of retinal detachment in the control group could be due to greater expression of proliferative complications compared to main group, which was observed in period 3 months after vitrectomy (10.3% vs. 50.0% and control group, respectively, p = 0.002).

Efficacy of a single vitrectomy in the main group was significantly higher at 94.8% (37/39), compared with 70.8% (17/24 patients) in the control group, χ2 = 8,02, p = 0,018.

A significant increase in the incidence of retina reattachment in the control group (from 70.8% to 87.5%) achieved by reoperation in 6 patients over a period of 6 months.

In the main group there was a little changes - from 94.8% to 97.4%, after re-vitrectomy was performed in 2 patients.

Frequency of repeated interventions to achieve full retina reattachment in the main group was 5.1% (2 patients) and 25% (6 people) in the control group (p = 0.05).

Analysis of the frequency and types of complications showed that the cumulative incidence of most adverse prognostic proliferative complications (epimacular membranes, PVR in area of laser coagulation,  recurrence of retinal detachment) in the main group was 12.8% (5 patients) and 58.3% (at 12 people) in the control group, χ2 = 25,4, p = 0.00001.

In all patients with retinal reattachment the positive dynamics of IOP normalization was noted (Table. 4).

Table 4

IOP changes after treatment in patients in main and control groups

IOP

Main group,

n = 39 eyes,

M (SD)

Control group,

n = 24 eyes,

M (SD)

preoperative

6,4 (1,5)

7,5 (1,1)

3 months

16,9 (0,4)

15,5 (0,4)

6 months

17,5 (0,4)

15,6 (0,4)

 

IOP increased in the main group from baseline of 6.4 to 16.9 at 3 months and to 17.5 mm Hg. after 6 months of treatment (p = 0.0001 compared to baseline IOP).

In the control group IOP increased from baseline of 7.5 to 15.5 at 3 months and to 15.6 mm Hg. after 6 months of treatment (p = 0.0001 compared to baseline IOP).

In all patients with retinal reattachment reached in 6 months term was statistically significant positive changes in visual acuity compared with to preoperative visual acuity. In the main group average visual acuity increased from 0,023 ± 0,014 to 0,24 ± 0,09, in the control group – from 0,029 ± 0,013 to 0,13 ± 0,06 (p = 0.0001 compared to the original value of each group).

Conclusion. The proposed method of the complex treatment of patients with RRD complicated by CD comprising intravitreal injection of triamcinolone acetonide or in combination with perfluoropropane allows to increase the frequency of full retina reattachment after single vitrectomy to 94.8% compared with 70.8% in the control group, to reduce the number of reoperations in 4.9 times, to decrease level of postoperative complications in the early term in 2.6 times and late postoperative complications in 4.6 times, to increase visual acuity in 1.9 times.

Литература

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  2. Левицкая Г.В. Показания и схема проведения предоперационной подготовки, в комбинированном лечении больных рос, осложненной отслойкой сосудистой оболочки / Г.В. Левицкая, Мохаммад Абдулхади // Oftalmologiya: Elmi – Practik jurnal. – 2013. - № 2 (12). – С.58-64.
  3. Патент № 81704 Украины (51) МПК A61F 9/00. Cпосіб лікування регматогенного відшарування сітківки, ускладненого відшаруванням судинної оболонки / Левицька Г.В., Путієнко О.О., Абдулхаді Мохаммад(UA). - № u20130026; заявл. 08.01.2013; опубл. 10.07.2013, Бюл. № 13.
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