Резюме
Левицкая Г.В.¹ , Путиенко А.А., Абдулхади Мохаммад² . Уровень провоспа-лительных цитокинов фактора некроза опухоли-a и интерлейкина-6 у больных регматогенной отслойкой сетчатки, осложненной отслойкой сосудистой оболочки.
У 43 больных регматогенной отслойкой сетчатки, из них у 23 больных осложненной отслойкой сосудистой оболочки и у 20 больных с неосложненными формами отслойки сетчатки, в крови и слезной жидкости был определен уровень провоспалительных цитокинов ИЛ-6 и ФНО-a. В результате исследований показано, что в случаях наличия отслойки хориоидеи отмечено повышение уровня цитокинов в крови и в слезной жидкости. Анализ полученных данных с учетом степени выраженности внутриглазного воспаления выявил увеличение содержания исследуемых цитокинов при большей степени цилиарной болезненности, выраженности помутнения стекловидного тела и распространенности задних синехий, покраснении глаза. Представленные результаты могут быть использованы в качестве критериев, характеризующих тяжесть регматогенной отслойки сетчатки, осложненной отслойкой сосудистой оболочки, показаний к назначению предоперационной противовоспалительной терапии и с целью прогноза результатов хирургического лечения этого контингента больных.
Ключевые слова: регматогенная отслойка сетчатки, отслойка сосудистой оболочки, интерлейкин-6, фактор некроза опухоли-a.

Резюме
Левицька Г.В., Путієнко А.А., Абдулхади Мохаммад. Рівень прозапальних цитокінів фактору некрозу пухлини-a та інтерлейкіну-6 у хворих на регматогенне відшарування сітківки з ускладненим відшаруванням судинної оболонки.
У 43 хворих на регматогенне відшарування сітківки, з них у 23 хворих з ускладненим відшаруванням судинної оболонки і у 20 хворих з неускладненими формами відшарування сітківки, в крові та слізній рідині було визначено рівень прозапальних цитокінів ІЛ -6 і ФНП-a. У результаті досліджень показано, що у випадках наявності відшарування хоріоідеї відмічено підвищення рівня цитокінів в крові і в слізній рідині. Аналіз отриманих даних з урахуванням ступеню вираженості внутрішньоочного запалення виявив збільшення вмісту досліджуваних цитокінів при більшому ступені циліарной болісності, вираженості помутніння склистого тіла та поширеності задніх синехій, почервонінні ока. Представлені результати можуть бути використані в якості критеріїв, що характеризують тяжкість регматогенного відшарування сітківки, ускладненого відшаруванням судинної оболонки, показань до призначення передопераційної протизапальної терапії та з метою прогнозу результатів хірургічного лікування цього контингенту хворих.
Ключові слова: регматогенне відшарування сітківки, відшарування судинної оболонки, інтерлейкін 6, фактор некрозу пухлин a.

Summαry
Levytskα G.V., Putienko Α.Α., Αbdulhαdi Mohαmmαd. Inflαmmαtory cytokines tumor necrosis fαctor-a αnd interleukine-6 in pαtients with rhegmαtogenous retinαl detαchment complicαted by choroidαl detαchment.
Level of proinflαmmαtory cytokines IL-6 αnd TNF α were determined in blood αnd teαrs in 43 rhegmαtogenous retinαl detαchment (RRD) pαtients: 20 cαses with uncomplicαted forms αnd 23 pαtients complicαted with choroidαl detαchment. Reseαrch hαd shown thαt the concomitαnt presence of choroidαl detαchment complicαting RRD contributes α stαtisticαlly significαnt increαsing in cytokines level in blood αnd lαcrimαl fluid. Dαtα αnαlysis considering presence αnd severity of inflαmmαtion showed αn increαsed cytokines levels in cαses with more ciliαry pαin, eye redness, presence αnd extent of posterior synechiαe, degree of vitreous opαcity. Presented results cαn be used αs criteriα chαrαcterizing severity of RRD complicαted by choroidαl detαchment, indicαtions for preoperαtive αnti-inflαmmαtory therαpy αnd to prognose results of surgicαl treαtment for this group of pαtients.
Key words: rhegmαtogenous retinαl detαchment, choroidαl detαchment, interleukin-6, tumor necrosis fαctor-a.

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

УДК 617.735-007.281-06:617.723-007.281-07+577.11

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)

¹ g.levytskaya@mail.ru

 ² dr_abdul5@bk.ru

Background. Rhegmatogenous retinal detachment (RRD) is a serious disease which takes nearly the first role in structure of eye disability as pathology that leads to visual impairment and blindness (annual rates of RRD patients disability constitute 2-9%). Considering that most of of these patients are in working age this problem is socially and economically important and its solution will improve the quality of patients life.

The important role in RRD pathological process is given to hereditary, hemodynamic, metabolic and mechanical factors. In recent years data on the role of inflammation in the pathogenesis of retinal detachment [7].

It was revealed that even in early stages RRD is accompanied by inflammation and immune response what is proved by increasing proinflammatory cytokines (IL-1b, IL-6) levels in tear fluid, proinflammatory interleukin-1b and antiinflammatory cytokines (IL-4 and IL-10) ratio, acute phase protein (lactoferrin), antibodies to native DNA antigens and secretory immunoglobulin A [6].

Furthermore, it is shown that RRD recurrence risk dependens on the local and systemic immunological changes the most important among them are associated with increased expression of proinflammatory cytokines (IL-1в, IL-6, TNF-б,) in the subretinal fluid [5].

We have previously showed that levels of pro- and antiinflammatory cytokines increase along with increasing clinical symptoms that characterize the severity of the disease [4].

However, available data is not sufficient for understanding the mechanisms of inflammatory reactions involvement in clinical course of RRD and predicting treatment outcome.

Considering that choroidal detachment (CD), which complicates RRD in 2-4.5% of cases, followed by intraocular inflammation or is a consequence of [8, 12] and worsens the prognosis of the possible risk of operational and post-operative complications [9, 10, 11].

In this context, the aim of our study was to determine the characteristics of pro-inflammatory cytokines expression at local and whole organism level in patients with RRD complicated choroidal detachment.

Material and methods.

43 rhegmatogenous retinal detachment patients (43 eyes) were observed: 20 with uncomplicated form and 23 with CD, treated at the Vitreoretinal Surgery and Laser Department of SI "The Filatov Institute of eye diseases and tissue therapy of NAMS of Ukraine". Patients' ages varied from 24 to 71 years for male and 21 to 69 years for female. In CD group there were 9 male and 14 female, in uncomplicated group – 8 men and 12 women.

The average detachment existence duration was 18.6 (13.1) and 19.7 (12.3) days respectively in groups with and without CD. In CD group all patients had macular detachment, due to this in uncomplicated group we included only eyes with detached macula.

Choroidal detachment (by ultrasound scan on "Aviso" "Quantel Medical") was the entire circumference in 15 eyes (65.2%), extended on 3 quadrants in 6 cases (26.1%), on 2 – 2 eyes (8.7%). Detachment height ranged from 0.3 to 7.5 mm, on average - 4,1 (2,1) mm.

Mean detectable initial visual acuity in CD group was 0,02 (0,01) in 10 (43.5%) cases another patients had incorrect light perception - 3 (13.0%) and correct light perception - 10 people (43.5%). In uncomplicated group mean initial visual acuity was 0,04 (0,03) in 16 (80.0%) cases and correct light perception - 4 (20.0%)

Signs of intraocular inflammation were observed only in patients CD group. As the most severe symptom - ciliary pain was noted in 10 cases (43.5%), conjunctival injection - in 11 patients (47.8%), posterior synechiae presence in three or more quadrants - in 5 eyes (21.7%) and intensive vitreous opacity - in 12 (52.2%).

Proinflammatory cytokines interleukin-6 and tumor necrosis factor a (TNFa) levels were measured in blood serum and tears using ELISA test systems "Vector-Best", Russia according to the manual. Samples of biological material were taken at admission to the hospital. Blood was obtained from the cubital vein on an empty stomach, lacrimal fluid using a sterile plastic pipette dispenser nozzle from lower conjunctival sac without using any stimulating tearing substances [2].

Analysis of cytokine levels was performed according to RRD clinical characteristics including the presence of choroidal detachment as well as signs of intraocular inflammation - ciliary pain, conjunctival injection, posterior synechiae and degree of vitreous opacity.

Statistical analysis was performed using STATISTICA-8 package. Parametric t-test was used in case of pair-wise comparison of the two groups with a preliminary estimation of normality, nonparametric Kruskal-Wallis test - for simultaneous comparison of more than two groups and pair correlation coefficient. Results are presented as mean values ​​of cytokines concentrations and standard deviations in parentheses [3].

Results and discussion.

On the first stage we determined cytokines level in RRD patients in the whole group. The median IL-6 concentration in the blood was 10.65 (9.30) pg/ml with a group minimum and maximum values 0.90 and 39.00 pg/ml. IL-6 level in tear was 17.54 (12.69) pg/ml and varied from 3.80 to 44.90 pg/ml. Mean level of TNF a was 5.94 (4.36) pg/ml in blood 12.28 (6.86) pg/ml in lacrimal fluid with minimum and maximum values 0.30 – 15.40 and 1.20 - 21.90 pg/mL respectively.

Analyzing data characterizing IL-6 and TNFa level in blood and lacrimal fluid of RRD patients we determined that appropriate values ​​ is higher in tear in both cases (respectively 1.7 and 2.1 times). Analysis associated with CD presence showed same orientation - IL-6 levels was higher in lacrimal fluid than in blood with or wihout choroidal detachment (1.3 in both cases, p>0,05). Difference between TNFa concentrations in tears and blood is more expressed – 1.8 and 1.9 times (p> 0.05 and p=0.001 for RRD with and without CD respectively) (Table 1).

Table 1

Cytokine levels in patients with rhegmatogenous retinal detachment without complications and with choroidal detachment (pg/ml)

Correlation analysis revealed a strong reliable direct link between level of IL-6 and TNFa in blood and tears in the groups of patients with and without CD: r = 0,94, n = 20 in blood during RRD without complications; r = 0,93, n = 23 in blood and r = 0,74, n = 11 in tear in complicated form of RRD (correlation analysis was not performed in tear of RRD patients without CD, as in this cases there were only 2 pairs of values ​​) (Fig. 1).

As the criteria for clinical manifestations characteristics of complicated by CD forms of RRD were inflammatory signs the next stage of the research was to determine the nature of cytokines expression in this group depending on the severity of ciliary pain, eye redness level, presence of posterior synechiae and degree of vitreous opacities.

In addition, we have previously shown that patients with RRD complicated by CD have a statistically significant relationship between signs of anterior (eye redness, pain, presence of posterior synechiae) and posterior uveitis (opacity of the vitreous) with choroidal detachment height and hypotension degree.

Fig. 1. Level of IL-6 and TNFa in blood and tears of RRD patients: 1 - without choroidal detachment, 2 - with choroidal detachment.

Patients with a maximum severity of inflammatory signs marked the maximum height of choroidal detachment (5.7 - 6.1 mm) and the lowest rates of IOP (5,7-6,0 mmHg) [1].

Analyzing data describing the average cytokines levels in RRD with CD patients according to the degree the ciliary pain, we showed a trend toward increasing of IL-6 and TNFa- with increasing severity of the inflammatory reaction in the eye (Table 2).

Concentration of IL-6 and TNFa in blood was increased 1.7 and 1.8 times in the presence of ciliary pain and 3,0 and 2,6 times in cases with pain without applying pressure to eye. Changes in tears had similar character but more expressed increasing: 2.3 and 2.4 times – ciliary pain, 3.8 and 3.0 times – pain without applying pressure, indicating a more pronounced immunological response at the local level.

Table 2

Cytokine levels in hegmatogenous retinal detachment patients complicated by choroidal detachment, depending on the severity of the ciliary pain (pg/ml)

Analysis of results by the Kruskal-Wallis test showed that the differences in IL-6 levels in patients with RRD complicated by CD in various expression of ciliary pain are significant (c2=10,245, df=3, p=0,0166). No significant differences was found in other cases according to this criterion. Statistical analysis of the data as follows: for IL-6 in tear fluid c2=3,438, df=3, p=0,329; for TNFa in the blood c2=5,891, df=3, p=0,117; for TNFa in tears c2=3,348, df=3, p=0,329.

Table 3 shows average values of IL-6 and TNF a of patients with RRD complicated by CD based on the presence or absence of conjunctival injection.

Table 3

Cytokine levels in patients with rhegmatogenous retinal detachment, complicated by choroidal detachment depending on the degree of eye redness (pg/ml)

Results shows a significant increase of cytokines levels in patients with eye redness, which is one of the features characterizing the inflammatory response. IL-6 and TNFa level increases in blood in 218.9% and 173.9% respectively, the difference is significant (p = 0.012 and 0.01).

Same differences in patients tears with or without conjunctival injection made up 180.5% for IL-6, and 140.6% - for TNF a but p = 0.085 and 0.100, indicating a lack of statistical significance, and may have place because of an insufficient number of observations.

Also it was found that IL-6 and TNFa concentration increases with increasing of adhesive inflammation in patients with RRD complicated by CD (Table 4).

Table 4

Cytokine levels in patients with rhegmatogenous retinal detachment complicated by choroidal detachment in varying degrees of adhesive inflammation (pg/ml)

In cases with posterior synechiae in one quadrant IL-6 and TNFa blood levels were 224.7% and 197.6% respectively relative to those values ​​in patients without synechiae. These changes were at the level of 248 - 245% for IL-6 and 188% for TNF a in cases with synechiae in two and three or more quadrants. These changes are significant by Kruskal-Wallis test for IL-6 (c2=8,417, df=3, p=0,038) and for TNFa (c2=9,920, df=3, p=0,019).

A similar trend was found during tears analysis: the level of IL-6 and TNFa increases with the increasing degree of adhesive inflammation. In patients with synechiae in two or three and more quadrants differences were for IL-6 233.3% and 165.3% and for TNF a 148.4% 137.5% respectively. No significant changes in tears by Kruskal-Wallis test as according to eye redness degree as to presence of synechiae were not detected (c2=3,135, df=3, p=0,371 for IL-6 and c2=1,118, df=3, p=0,773 for TNF a).

The same changes were noted in cytokine levels depending on vitreous body opacity degree (Table 5).

Table 5

Cytokine levels in rhegmatogenous retinal detachment patients complicated by choroidal detachment according to degree of vitreous opacity (pg/ml)

Differences in blood levels of IL-6 in patients CD group depending on vitreous opacities degree were significant by Kruskal-Wallis test (c2=9,224, df=3, p=0,027): 122.3% for eyes with light and 290.7% for intensive vitreous opacities. TNF a level was increased – 138.5% for light and up to 257.2% in case of intensive vitreous opacities. However, there was no significant differences by Kruskal-Wallis test (c2=5,300, df=3, p=0,151).

No significant by Kruskal-Wallis test differences of IL-6 as well as TNF a were found in tears of CD group patients depending on vitreous opacities degree (IL-6: c2=3,438, df=3, p=0,329, TNF a: c2=3,438, df=3, p=0,329). However, there was a clear trend towards increasing expression of IL-6 (medium opacities – up to 137.4% and intensive opacities 228.5%) and TNF a (135.6% and 127.2% respectively for medium and intensive opacities).

Conclusion

Summarizing obtained results on character and level of proinflammatory cytokines expression in RRD patients suggest that concomitant choroidal detachment presence complicating retinal detachment contributes to a statistically significant increase in IL-6 and TNF a levels in blood and tears of these patients.

Data analysis considering presence and severity of inflammation showed an increased cytokines levels in cases with more ciliary pain, eye redness, presence and extent of posterior synechiae, degree of vitreous opacity.

Presented results can be used as criteria characterizing severity of RRD complicated by choroidal detachment, indications for preoperative anti-inflammatory therapy and to prognose results of surgical treatment for this group of patients.

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