This study evaluated the treatment outcomes of retinal vein occlusion (RVO). In a study that lasted for 6 months. 38 patients with low vision due to MC with RCVO (9 patients) or RCVO (29 patients) participated in one eye. The age of the patients was 46-72 years, and the average age was 52 years. Immature cataracts were diagnosed at old age in 14 patients with concomitant eye diseases. The maximum corrected visual acuity (MCVA) was 0.06-0.4, the retinal thickness in the central region was ≥430 μm, and the duration of macular edema was from 4 weeks to 9 months. All patients underwent ophthalmological examination prior to implantation, after 1 and 7 days, 1, 4, and 6 months. After the injection. At each follow-up examination, visual acuity was determined according to the Sivtsev-Golovin table, ocular tension measurement, and ophthalmoscopy microscopy using a 78 dioptric aspherical lens or Goldman contact lenses. Retinal thickness was estimated using OCT "SPECTRALIS" OCT Heidelberg Engineering, initially in microns, size - in mm3, as well as retinal structure - thickness and cystic changes, subepithelial detachment, after 1, 4, 6 months. With a decrease in OZ observed after the treatment effect in the form of an increase in BCVA was achieved in the first months. Fundus imaging was performed using a seven-field computer suture of the retina (Visucam 500 ZEISS) before implantation and 6 months later; At a period of 10-14 weeks, PAH was performed in the retina according to the standard technique. Statistical Analysis: The data were processed using the Statistical program using the paired Student's t-test for related samples. Results with an error of less than 5% (p <0.05) were considered significant.
Treatment of the occlusion of retinal veins focuses on two main goals. The first is the identification of risk factors and their drug therapy, and the second is the detection and treatment of complications of retinal vein occlusion. Treatment should be aimed at diagnosing and treating systemic risk factors (in particular hypertension, cardiovascular disease, diabetes, hyperlipidemia of thrombophilia) and therapy of comorbidities. This is necessary both to prevent extraoglact vascular disorders, such as myocardial infarction or stroke, and to reduce the risk of venous occlusion on the paredus eye.
The use of anticoagulants, fibrinolithians and antithrombocytic drugs is a pathogenetic, seemingly logical method of conservative therapy, and their use should be highly effective. But the results of clinical studies of the effectiveness of heparin, streptokinase and warfarin in retinal vein occlusion were disappointing. The positive effect has not been proven, and at the same time adverse effects of these drugs on the retina and high risk of hemophthalm have been identified. The role of aspirin in the treatment and prevention of retinal vein occlusion also remains questionable.
Hemodilyucia
Some studies have shown a positive effect of hemodylucia as a therapy in the early phase of occlusion. Hemodylus is used to prevent the blood flow from slowing down by significantly reducing its viscosity. As a result of prospective multicenter studies using the new technique of hemodylation and erythropoiesis, the effectiveness of this treatment method has been proved. Hemodylumium is recommended for patients with occlusion of the central vein of the retina and its branches in the absence of contraindications (ischemic form of occlusion of the central vein of the retina, requiring panretinal laser coagulation, diabetes, uncontrolled systemic hypertension, acute cardiac or renal failure, anemia and serpentine cell disease).
To date, the following algorithm for the treatment of non-ischemic occlusion of the central vein of the retina has been developed and recommended for clinical practice.
Patients with non-ischemic occlusion and visual acuity of more than 0.5 (prognosis favorable) are shown dynamic observation and treatment of comorbidities such as hypertension, dyslipidemia and diabetes. Dynamic observation is aimed at detecting macular edema or the transition of non-ischemic occlusion into ischemic. The presence of concomitant eye pathology, predisposing or associated with occlusion, such as glaucoma, requires a comprehensive examination and treatment of eye hypertension, which can reduce the risk of transition of non-ischemic form of CVS occlusion to ischemic.
Biomicroscopy, gonoscopy and optical coherent tomography are key moments in the clinical examination of patients. Fluorescent angiography should be performed whenever there are doubts about the progression of the process or to assess the degree of ischemia. Patients should be monitored monthly for the first3 months, then every 2 months for the first year. Patients should be informed about clinical manifestations of the disease, possible complications and the need for emergency examination by an ophthalmologist while reducing visual acuity.
In the non-ischemic type of occlusion and reduction of visual acuity to 0.5 and below due to macular edema, treatment of macular edema is shown. Modern treatments for macular edema are the use of corticosteroids, endothelial growth factor blockers (anti-VEGF) and laser photocoagulation by grid laser photocoagulation.
Central vein thrombosis retinal (PCV), causing the development of complications such as hemophthalmos, cystic macular edema, neovascular glaucoma, leads to a persistent and irreversible decrease in visual acuity, complicating the medical and social rehabilitation of patients [1,2,3]. Currently, there is an increase in the incidence of retinal vein thrombosis, especially in younger patients, which is associated with an increase in the number of cardiovascular and endocrine disorders, which are predictors of the development of retinal vascular occlusion [4].
Conservative therapy, involving the appointment of fibrinolytics, fibrinolysis activators and anticoagulants, does not always provide complete resorption of the thrombus, which ultimately worsens the clinical and functional results treatment [5,6,7,8].
For the treatment of PCV obturation, laser coagulation of the retina is actively used, which promotes the resorption of hemorrhages and plasmorrhages in the fundus [9,10]. However, this procedure is not always feasible in the presence of extensive intra- and preretinal hemorrhages, hemophthalmos [10].
Surgical treatments retinal vein occlusions are currently one of the most promising, since they allow you to achieve a quick therapeutic effect due to direct or indirect effects on the thrombus [11-17]. However, surgical interventions can cause the development of complications such as hemophthalmos, retinal detachment, endophthalmitis [14,3].
Treatment of retinal vein occlusion focuses on two main goals: the first is to identify risk factors and treat them with drugs, and the second is to identify and treat complications of retinal vein occlusion.
According to the literature [16], a relationship between OZ and a decrease in retinal thickness has been revealed, so the direct effect on the decrease in retinal thickness is a pathologically oriented treatment, and the effect in this case is the result of providing pressure relief, which leads to increased drainage of residual fluid outside Cell and blood. ...
Presumably, the vitreous (ST) plays an important role in the pathogenesis of angiogenesis and macular edema (MO) in CVV and CVV. With embolism of the retinal veins (ARV) due to the formation of acute retinal ischemia, the half-permeability function of the posterior hyaloid membrane of CT is disrupted, and metabolic stress occurs, which is manifested in the accumulation of toxic metabolic products, blood derivatives in the retina and in computed tomography. A healthy CT scan accumulates angiogenic factors and is the basis for the formation of new blood vessels [13]. Given that the CT fibrils are anatomically closely related to Müller cells and the internal border membrane, and are also involved in the formation of the superposition due to the development of vitreoretinal traction, there is a risk of development in refractory cyst cells.
Despite the fact that MO is explained by fluid accumulation in the retina due to a defect in the internal blood-retinal barrier, the expression and release of inflammatory mediators (cytokines) due to retinal tissue damage remains a major link in the pathogenesis of retinitis. RVOs [18]. Chronic macular edema is the primary cause of prolonged OH deficiency and leads to secondary changes in retinal pigment epithelium (RPE). For the treatment of MO, intravitreal administration of corticosteroids, angiogenesis inhibitors, laser coagulation of the retina, trans-pupillary laser induction of a chorionic venous anastomosis, vitrectomy with removal of the posterior hyaloid membrane, resection of the optic radial nerve, and cell resection at the site of the AV junction Have been achieved.
Although the use of surgical techniques is currently widely discussed, there is no large, randomized controlled trial to support their use in the treatment of MO after ORVO.
There is an opinion that their mechanism of action is related to influencing the inflammatory chain reaction that plays an important role in the pathogenesis of MO. Corticosteroids reduce the production of inflammatory mediators and, to some extent, vascular endothelial growth factor (VEGF), activate leukocyte apoptosis, and increase production of intracellular tight linkage proteins, resulting in decreased vascular permeability [14]. In vitro studies have shown that corticosteroids suppress the function of the gene responsible for VEGF [14]. For many years, triamcinolone acetonide, not officially approved for use in ophthalmology, has been "off-label" (i.e.).
Several studies have shown a significant decrease in MO and an increase in visual function after intravitreal administration of triamcinolone acetonide - "Kenalog", even with pronounced cystic changes in the retina [10]. According to different authors, after the drug is injected, the thickness of the retina decreases on average 2 times, and the visual acuity increases by 2 lines [5,16]. The duration of action of triamcinolone acetonide is approximately 3-6 weeks, and a large proportion of patients require frequent injections, which increases the risk of side effects[7,15]
The research conducted to create prolonged formulations to reduce repeated injections resulted in the synthesis of slow-release implants inside the vitreous and one of the first was created and officially registered in the USA in 2007 for the treatment of non-infectious uveitis, which is a synthetic corticosteroid Retisert, which is effective for 3 years, A decrease in MR was recorded in 51% of patients, and an increase in OZ - in 27% [15,2]. On its basis, the drug "Medidur" (Alimera Sciences) was created, which was already implanted with a special piston syringe through the flat part of the ciliary body [17]. To date, it has been registered in the Russian Federation since 2012 and uses an intravitreal implant - "Ozurdex", the active ingredient is dexamethasone 0,7 mg (Allergan Inc.). The implant is a co-polymer of lactic and glycolic acids (SMGA polymer matrix), which gradually hydrolyses to H2O and CO2 and provides a gradual release of dexamethasone for up to 6 months. The implant is progressively degradable, hydrolysed and dissolved in the vitreous [15].
Treatment
For macular edema: intraocular administration of anti-VEGF drugs, an implant with dexamethasone and / or triamcinolone acetonide (not registered in the Russian Federation).
In some cases of macular edema with occlusion of the branches of the central retinal vein, focal laser coagulation is performed.
With the development of neovascularization, pan retinal laser photocoagulation is indicated.
Focal laser coagulation can also be used for central retinal vein occlusion with macular edema, but this method is less effective than intraocular administration of an anti-VEGF drug or implant with dexamethasone. Focal laser coagulation is usually not effective in treating macular edema due to central retinal vein occlusion.
If neovascularization of the retina or anterior segment develops after occlusion of the central vein or its branches, pan retinal laser coagulation should be done as soon as possible to reduce vitreous hemorrhage and prevent the development of neovascular glaucoma.
Retinal vein thrombosis, which provides a rapid and stable clinical effect, is an urgent task of modern ophthalmology. And purpose Increasing the efficacy of treating PCV thrombosis with a new combined method of surgical intervention, "massaging" the affected vein and postoperative laser thrombosis of the retina in the postoperative period.
Most of the patients included in the study had long-term macular edema. The proportion of patients with macular edema lasting more than 3 months. was 68% (26 patients).
In the study of changes in BCVA, its increase was observed from the 7th day of using the drug in 24% (9 patients); after 1 month the proportion of patients with an improvement in BCVA by 0.2-0.4 from the initial was 47% (18 patients); in 16% (6 patients) - did not change; in 37% (14 patients) it increased by 0.05-0.1.
The proportion of patients who achieved an increase in BCVA after 4 months. after the injection of the implant by 0.2-0.4 from the initial, it was 52% (20 patients); by 0.1 - in 37% (14 patients); in 10% (4 patients) it did not change.
When compared after 1 month. the number of patients with deterioration of BCVA by 0.1 or more after 4 months. after implantation was 16% (6 patients).
After 6 months. after implantation, BCVA improved by 0.2-0.4 from baseline in 47% (18 patients); by 0.1 - in 16% (6 patients), did not change - in 10% (4 patients); worsened - in 26% (10 patients).
According to FAG data, 16% (6 patients) had good macular perfusion in combination with an increase in BCVA from the initial level by 0.4 on average or more; in 50% (19 patients) macular edema with moderate perfusion was detected, the size of the non-perfused area was 4-9 dDHN, an increase in MCVA - by 0.1 or more; 34% (13 patients) showed the absence of macular perfusion and the size of the non-perfused area was 9-13 dDHN, no changes in BCVA from the initial one were found.
A decrease in retinal thickness was observed in all 38 patients after 1 month. after IVI at 85-360 microns from the original; after 4 months a decrease in the thickness of the retina after implantation was observed in 89% (34 patients) and amounted to 115-275 microns; in 10% (4 patients) - returned to the initial level; examination of the thickness of the retina after 6 months. after implantation of the drug, Ozurdex showed a decrease in the thickness of the retina in 66% (25 patients) by 110-270 microns, of which 60% (15 patients) was within the normal range; recurrence of edema occurred in 34% (10 patients).
During the study, two adverse events were recorded: the progression of cataracts - in 21% (8 patients, of which 6 eyes had a clouding of the lens before treatment), where surgical treatment was required in 2.6% of cases (1 patient), and ophthalmic hypertension - in 21 % of cases (8 patients, of which: 1 - OCVS, 7 - OCVS), IOP increased by more than 8 mm Hg. The resulting ophthalmic hypertension was detected mainly by the first month of observation after injection, followed by a gradual decrease to the initial level by 4 months. observation, no patient required surgical treatment, hypertension was arrested on an antihypertensive regimen (mono-drug). It was not possible to determine the relationship between the progression of cataract and the use of IVI at this stage of the study.
Thus, it can be concluded that Ozurdex provides a long-term and significant improvement in visual acuity in patients with macular edema due to retinal vein occlusion. One injection increases BCVA and decreases retinal thickness according to OCT for a period of up to 6 months. in 66% (25 patients), but a relapse of edema with a decrease in BCVA is also recorded - in 34% (13 patients), which requires further research. Ozurdex is effective for both PCV occlusions and PCV branches. Ozurdex has shown a favorable safety profile. It is necessary to continue research of this implant in clinical practice to develop appropriate criteria for re-injection and combination therapy.
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