Офтальмохирургия. 2015; : 32-37
ОДНОМОМЕНТНАЯ КОМБИНИРОВАННАЯ ТЕХНОЛОГИЯ ЛЕЧЕНИЯ РЕТИНОВАСКУЛЯРНОГО МАКУЛЯРНОГО ОТЕКА «MACULAR DOUBLE BLOCK»
https://doi.org/undefinedАннотация
РЕФЕРАТ
Цель. Повысить эффективность лечения отека макулы при неишемической окклюзии ветви ЦВС путем комбинированной технологии, включающей субпороговую микроимпульсную лазеркоагуляцию и интравитреальное введения ингибиторов VEGF.
Материал и методы. В исследование вошли 79 пациентов (80 глаз) с макулярным отеком, соответствующим критериям клинически значимого макулярного отека (Early Treatment Diabetic Retinopathy Study), вторичным по отношению к неишемическому тромбозу ветви ЦВС. Пациенты находились под наблюдением в течение 1 года. Все пациенты были разделены на две группы: основная группа – 40 чел. (40 глаз) и группа сравнения – 39 чел. (40 глаз). Всем пациентам основной группы проводилось лечение по запатентованной методике «Macular double block». Данная комбинированная методика лечения состоит из двух последовательных этапов лечения. Сначала вводят интравитреально ингибитор вазоэндотелиального фактора роста (0,5 мг), затем через 30 минут проводят микроимпульсную субпороговую лазеркоагуляцию сетчатки. Пациентам группы сравнения вводили интравитреально ингибитор вазоэндотелиального фактора роста ранибизумаб (Луцентис) в количестве 0,5 мг ежемесячно в течение 3 мес. В исследовании, помимо стандартного офтальмологического обследования, применялась компьютерная периметрия согласно протоколу Macula threshold 10° (Oculus Twinfield), флуоресцентная ангиография сетчатки (немидриатическая цифровая фундус-камера Kowa VX-10), спектральная оптическая когерентная томография сетчатки (Optovue RTVue-100).
Результаты. По результатам лечения МКОЗ у пациентов основной группы повысилась на 1 и более строк в 90% случаев (36 глаз) против 77,5% (31 глаз) у пациентов группы сравнения. Толщина макулы по данным спектральной оптической когерентной томографии сетчатки в глазах исследуемой группы составила к концу исследования в среднем 196 мкм, в глазах группы сравнения – 219 мкм. Повышение центральной световой чувствительности было отмечено в обеих группах начиная с 10 дня после начала исследования. Причем в основной группе увеличение центральной световой чувствительности было более выражено с самого начала и кривая прироста была в первые 2 мес. более крутой. За все время исследования у пациентов основной группы не было выявлено относительных или абсолютных скотом в зоне лазерного воздействия в режиме импульсной модуляции по авторской методике.
Выводы. Разработанная технология лечения позволяет достигнуть более полного восстановления анатомии макулы в ранние сроки и большего повышения остроты зрения в сравнении с монотерапией ингибиторами VEGF (ранибизумаб), при равном профиле безопасности и атравматичности. Данная комбинированная технология лечения ретиноваскулярного макулярного отека позволяет сократить число интравитреальных инъекций по сравнению с монотерапией интравитреальным ранибизумабом.
Список литературы
1. Шадричев Ф.Е., Шкляров Е.Б., Григорьева Н.Н. Использование анти-VEGF-терапии в лечении диабетического макулярного отека // Офтальмологические ведомости. – 2011. – Т. 4, № 1. – С. 83-93.
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3. Bughi S., Shaw S., Bessman A. Laser damage to retinal ganglion cells. The effect on circadian rhythm // J. Diabetes Complicat. – 2006. – Vol. 20. – P. 184-187.
4. Campochiaro P.A., Hafiz G., Shah S.M. et al. Ranibizumab for macular edema due to retinal vein occlusions: implication of VEGF as a critical stimulator // Mol. Ther. – 2008. – Vol. 16. – P. 791-799.
5. Denton R., McCцrmie J. Calcium ions, hormones and mitochondrial metabolism // Clin. Seien. – 1981. – Vol. 61, № 2. – P. 35-40.
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7. Elman M.J., Aiello L.P. et al. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema // Ophthalmology. – 2010. – Vol. 117. – P. 1064-1077.
8. Elsner H., Porksen E., Klatt C. et al. Selective retina therapy in patients with central serous chorioretinopathy // Graefes Arch. Clin. Exp. Ophthalmol. – 2006. – Vol. 244. – P. 1638-1645.
9. Figueira J., Khan J., Nunes S. et al. Prospective randomised controlled trial comparing sub-threshold micropulse diode laser photocoagulation and conventional green laser for clinically significant diabetic macular oedema // Br. J. Ophthalmol. – 2009. – Vol. 93, № 10. – P. 1341-1344.
10. Figueroa M.S., Ruiz Moreno J.M. BRAVO and CRUISE: ranibizumab for the treatment of macular edema secondary to retinal vein occlusion // Arch. Soc. Esp. Oftalmol. – 2012. – Vol. 87, № 1. – P. 46-53.
11. Framme C., Brinkmann R., Birngruber R., Roider J. Autofluorescence imaging after selective RPE laser treatment in macular diseases and clinical outcome: a pilot study // Br. J. Ophthalmol. – 2002. – Vol. 86. – P. 1099-1106.
12. Framme C., Walter A., Prahs P. et al. Structural changes of the retina after conventional laser photocoagulation and selective retina treatment (SRT) in spectral domain OCT // Curr. Eye Res. – 2009. – Vol. 34. – P. 568-579.
13. Friberg T. Infrared micropulsed laser treatment for diabetic macular edema – Subthreshold versus threshold lesions // Semin. in Ophthalmol. – 2001. – Vol. 16, № 1. – P. 19-24.
14. Gupta N., Mansoor S., Sharma A. et al. Diabetic retinopathy and VEGF // Open Ophthalmol. J. – 2013. – Vol. 7. – P. 4-10.
15. Kaufman S.C., Ferris F.L., Seigel D.G. et al. Factors associated with visual outcome after photocoagulation for diabetic retinopathy. DRS Report Number 13 // Invest. Ophthalmol. Vis. Sci. – 1989. – Vol. 30. – P. 23-28.
16. Koss M.J., Beger I., Koch F.H. Subthreshold diode laser micropulse photocoagulation versus intravitreal injections of bevacizumab in the treatment of central serous chorioretinopathy // Eye (Lond). – 2012. – Vol. 26, № 2. – P. 307-314.
17. Laursen M., Moeller F. Subthreshold micropulse diode laser treatment in diabetic macular oedema // Br. J. Ophthalmol. – 2004. – Vol. 88, № 9. – P. 1173-1179.
18. Lavinsky D., Cardillo J.A., Melo L.A. et al. Randomized clinical trial evaluating mETDRS versus normal or high-density micropulse photocoagulation for diabetic macular edema // Invest. Ophthalmol. Vis. Sci. – 2011. – Vol. 52, № 3. – P. 4314-4323.
19. Luttrull J.K., Spink C.J. Serial optical coherence tomography of subthreshold diode laser micropulse photocoagulation for diabetic macular edema // Ophthalmic Surg. Lasers Imaging. – 2006. – Vol. 37, № 5. – P. 370-377.
20. Nakamura Y., Mitamura Y., Ogata K. et al. Functional and morphological changes of macula after subthreshold micropulse diode laser photocoagulation for diabetic macular edema // Eye (Lond). – 2010. – Vol. 24, № 5. – P. 784-788.
21. Olk R.J., Akuduman L. Minimal intensity diode laser (810 nm) photocoagulation (MIP) for diffuse diabetic macular edema (DDME) // Semin. Ophthalmol. – 2001. – Vol. 16. – P. 25-30.
22. Paulus Y., Jain A., Nomoto H. et al. Selective retinal therapy with microsecond exposures using a continuous line scanning laser // Retina. – 2011. – Vol. 31. – P. 380-388.
23. Pece A., Isola V., Piermarocchi S., Calori G. Efficacy and safety of anti-vascular endothelial growth factor (VEGF) therapy with intravitreal ranibizumab (Lucentis) for naive retinal vein occlusion: 1-year follow-up // Brit. J. Ophthalmol. – 2011. – Vol. 95. – P. 56-68.
24. Roider J., Brinkmann R., Wirbelauer C. et al. Retinal sparing by selective retinal pigment epithelial photocoagulation // Arch. Ophthalmol. – 1999. – Vol. 117. – P. 1028-1034.
25. Roider J., Michaud N.A., Flotte T.J. et al. Response of the retinal pigment epithelium to selective photocoagulation // Arch. Ophthalmol. – 1992. – Vol. 110. – P. 1786-1792.
26. Scott I.U., Ip M.S., VanVeldhuisen P.C. et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6 // Arch. Ophthalmol. – 2009. – Vol. 127. – P. 1115-1128.
27. Stewart M.W., Rosenfeld P.J. Predicted biological activity of intravitreal VEGF Trap // Br. J. Ophthalmol. – 2008. – Vol. 92, № 5. – P. 667-668.
28. Zhang X., Bao S, Lai D et al. Intravitreal triamcinolone acetonide inhibits breakdown of the blood-retinal barrier through differential regulation of VEGF-A and its receptors in early diabetic rat retinas // Diabetes. – 2008. – Vol. 57, № 4. – P. 1026-1033.
Fyodorov Journal of Ophthalmic Surgery. 2015; : 32-37
THE ONE-STAGE COMBINED TECHNOLOGY OF TREATMENT RETINOVASCULAR MACULAR EDEMA «MACULAR DOUBLE BLOCK»
https://doi.org/undefinedAbstract
Purpose. To increase the effectiveness of the macular edema treatment in non-ischemic occlusion of central retinal vein (CRV) branches in the early stages by means of a combined technology including micro-pulse sub-threshold laser photocoagulation and intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors.
Material and methods. The study included 79 patients (80 eyes) with macular edema that met the criteria of clinically significant macular edema (Early Treatment Diabetic Retinopathy Study), secondary to non-ischemic BRVO thrombosis. Patients were followed up within 1 year. All patients were divided into two groups: the main group – 40 individuals (40 eyes) and a comparative group – 39 individuals (40 eyes). All patients of the main group were treated according to a patented technique «macular double block». This combined method of treatment consisted of two consecutive stages of treatment. Initially the VEGF inhibitor (0.5mg) was injected intravitreally and then 30 minutes later the micro-pulse sub-threshold photocoagulation of the retina was carried out. In patients of the comparative group the VEGF inhibitor ranibizumab (Lucentis) was injected intravitreally in an amount of 0.5mg monthly within 3 months. In the study besides the standard ophthalmic examination there were used the computer perimetry according to the Macula threshold of 10° protocol (Oculus Twinfield), the fluorescent angiography of the retina (non-mydriatic digital fundus camera Kowa VX-10), the spectral optical coherence tomography (OCT) of the retina (Optovue RTVue-100).
Results. At the end of treatment, the BCVA in patients of the main group increased by one or more lines in 90% (36 eyes) versus 77.5% (31 eyes) in patients of the comparative group. Macular thickness according to the data of the spectral OCT of the retina in eyes of the main group averaged 196 microns at the end of the study, in eyes of the comparative group – 219 microns. An increase of the light sensitivity of the central visual field was observed in both groups, starting from the 10th day after the beginning of the study. Moreover, in the main group the increase of light sensitivity of the central visual field was more pronounced from the outset and its curve of growth was in the first 2 months steeper. During the entire period of the study no relative or absolute scotoma was revealed in the area of laser exposure in the mode of the micro-pulse modulation by the author’s method in patients of the main group.
Conclusions. The developed technology of treatment allows to achieve a more complete recovery of the macula anatomy, in the early periods, and a greater visual acuity in comparison with the monotherapy by VEGF inhibitors (ranibizumab), with an equal safety and an atraumatic profile. This combined technology of treatment for retinovascular macular edema allows to reduce a quantity of intravitreal injections, compared with the intravitreal ranibizumab monotherapy.
References
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2. Patent RF № 2527360. Sposob kombinirovannogo lecheniya retinovaskulyarnogo makulyarnogo oteka / Ismailov M.I., Agmadov A.M.; Zayavitel' i patentoobladatel' GBOU «Dagestanskaya gosudarstvennaya meditsinskaya akademiya» Minzdrava Rossii; Zayavl. 23.04.2013 g.; Opubl. 27.08.2014 g. // Byul. – 2014. – № 24. – 9 s.
3. Bughi S., Shaw S., Bessman A. Laser damage to retinal ganglion cells. The effect on circadian rhythm // J. Diabetes Complicat. – 2006. – Vol. 20. – P. 184-187.
4. Campochiaro P.A., Hafiz G., Shah S.M. et al. Ranibizumab for macular edema due to retinal vein occlusions: implication of VEGF as a critical stimulator // Mol. Ther. – 2008. – Vol. 16. – P. 791-799.
5. Denton R., McCtsrmie J. Calcium ions, hormones and mitochondrial metabolism // Clin. Seien. – 1981. – Vol. 61, № 2. – P. 35-40.
6. Desmettre T., Maurage C. Transpupillary thermotherapy (TTT) with short, duration, laser exposures induce; heat shock protein; hyperexpression on choroidoretinal layers // Lasers Surg. Med. – 2003. – Vol. 33. – P. 102-107.
7. Elman M.J., Aiello L.P. et al. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema // Ophthalmology. – 2010. – Vol. 117. – P. 1064-1077.
8. Elsner H., Porksen E., Klatt C. et al. Selective retina therapy in patients with central serous chorioretinopathy // Graefes Arch. Clin. Exp. Ophthalmol. – 2006. – Vol. 244. – P. 1638-1645.
9. Figueira J., Khan J., Nunes S. et al. Prospective randomised controlled trial comparing sub-threshold micropulse diode laser photocoagulation and conventional green laser for clinically significant diabetic macular oedema // Br. J. Ophthalmol. – 2009. – Vol. 93, № 10. – P. 1341-1344.
10. Figueroa M.S., Ruiz Moreno J.M. BRAVO and CRUISE: ranibizumab for the treatment of macular edema secondary to retinal vein occlusion // Arch. Soc. Esp. Oftalmol. – 2012. – Vol. 87, № 1. – P. 46-53.
11. Framme C., Brinkmann R., Birngruber R., Roider J. Autofluorescence imaging after selective RPE laser treatment in macular diseases and clinical outcome: a pilot study // Br. J. Ophthalmol. – 2002. – Vol. 86. – P. 1099-1106.
12. Framme C., Walter A., Prahs P. et al. Structural changes of the retina after conventional laser photocoagulation and selective retina treatment (SRT) in spectral domain OCT // Curr. Eye Res. – 2009. – Vol. 34. – P. 568-579.
13. Friberg T. Infrared micropulsed laser treatment for diabetic macular edema – Subthreshold versus threshold lesions // Semin. in Ophthalmol. – 2001. – Vol. 16, № 1. – P. 19-24.
14. Gupta N., Mansoor S., Sharma A. et al. Diabetic retinopathy and VEGF // Open Ophthalmol. J. – 2013. – Vol. 7. – P. 4-10.
15. Kaufman S.C., Ferris F.L., Seigel D.G. et al. Factors associated with visual outcome after photocoagulation for diabetic retinopathy. DRS Report Number 13 // Invest. Ophthalmol. Vis. Sci. – 1989. – Vol. 30. – P. 23-28.
16. Koss M.J., Beger I., Koch F.H. Subthreshold diode laser micropulse photocoagulation versus intravitreal injections of bevacizumab in the treatment of central serous chorioretinopathy // Eye (Lond). – 2012. – Vol. 26, № 2. – P. 307-314.
17. Laursen M., Moeller F. Subthreshold micropulse diode laser treatment in diabetic macular oedema // Br. J. Ophthalmol. – 2004. – Vol. 88, № 9. – P. 1173-1179.
18. Lavinsky D., Cardillo J.A., Melo L.A. et al. Randomized clinical trial evaluating mETDRS versus normal or high-density micropulse photocoagulation for diabetic macular edema // Invest. Ophthalmol. Vis. Sci. – 2011. – Vol. 52, № 3. – P. 4314-4323.
19. Luttrull J.K., Spink C.J. Serial optical coherence tomography of subthreshold diode laser micropulse photocoagulation for diabetic macular edema // Ophthalmic Surg. Lasers Imaging. – 2006. – Vol. 37, № 5. – P. 370-377.
20. Nakamura Y., Mitamura Y., Ogata K. et al. Functional and morphological changes of macula after subthreshold micropulse diode laser photocoagulation for diabetic macular edema // Eye (Lond). – 2010. – Vol. 24, № 5. – P. 784-788.
21. Olk R.J., Akuduman L. Minimal intensity diode laser (810 nm) photocoagulation (MIP) for diffuse diabetic macular edema (DDME) // Semin. Ophthalmol. – 2001. – Vol. 16. – P. 25-30.
22. Paulus Y., Jain A., Nomoto H. et al. Selective retinal therapy with microsecond exposures using a continuous line scanning laser // Retina. – 2011. – Vol. 31. – P. 380-388.
23. Pece A., Isola V., Piermarocchi S., Calori G. Efficacy and safety of anti-vascular endothelial growth factor (VEGF) therapy with intravitreal ranibizumab (Lucentis) for naive retinal vein occlusion: 1-year follow-up // Brit. J. Ophthalmol. – 2011. – Vol. 95. – P. 56-68.
24. Roider J., Brinkmann R., Wirbelauer C. et al. Retinal sparing by selective retinal pigment epithelial photocoagulation // Arch. Ophthalmol. – 1999. – Vol. 117. – P. 1028-1034.
25. Roider J., Michaud N.A., Flotte T.J. et al. Response of the retinal pigment epithelium to selective photocoagulation // Arch. Ophthalmol. – 1992. – Vol. 110. – P. 1786-1792.
26. Scott I.U., Ip M.S., VanVeldhuisen P.C. et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss associated with macular Edema secondary to branch retinal vein occlusion: the Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) study report 6 // Arch. Ophthalmol. – 2009. – Vol. 127. – P. 1115-1128.
27. Stewart M.W., Rosenfeld P.J. Predicted biological activity of intravitreal VEGF Trap // Br. J. Ophthalmol. – 2008. – Vol. 92, № 5. – P. 667-668.
28. Zhang X., Bao S, Lai D et al. Intravitreal triamcinolone acetonide inhibits breakdown of the blood-retinal barrier through differential regulation of VEGF-A and its receptors in early diabetic rat retinas // Diabetes. – 2008. – Vol. 57, № 4. – P. 1026-1033.
