Лечение синдрома «сухого глаза» при первичной глаукоме

PURPOSE: To develop the methods of treatment and prevention of secondary «dry eye» in patients with primary open-angle glaucoma. METHODS: The study involved 50 patients (100 eyes): 20 men, 30 women aged 46 to 85 years (mean age 65.5±9.6 years) with primary glaucoma. Glaucoma duration varied from 1.5 to 17 years. The patients administered the following hypotensive drops: Betoptik, Azopt, Arutimol, Xalatan, Travotan, Alfagan, Taflotan, Dorzopt as monotherapy or a combination of two or three of them. All patients underwent a clinical examination, Schirmer test, Norn test, vital staining with lissamine green and fluorescein, impression cytology, osmolarimetry (Tearlab Corp, USA) tearscopy, confocal microscopy («Confoscan-4», Nidek (Japan). The functional state of the meibomian glands and passability of its canaliculi were determined by the presence of lipids in the imprints of the palpebral intermarginal space on Millipore® filter after its OsO4-vapor staining (RF patent number 2.373.832). The digital image of the interference pattern of the lipid layer was analyzed by computer software «Lacrima». Follow-up period was 3 years. RESULTS: The signs of the «dry eye» syndrome were detected in 70.6% (76 eyes). Of these, 23.6% of patients (18 eyes) had meibomian gland dysfunction confirmed by Norn tests - 9.7±0.1. The most common complaint was the ocular pain sensation. The result of Schirmer test (20.7±0.8 mm) allows us to conclude the presence of hypersecretion as the initial manifestation of «dry eye». No increased tear osmolarity (average was 290.2±13.1 mOsm/l) was shown. The main changes pertained to the condition of the lipid layer of the tear film: an irregular thickness with normal thickness limited only to some small areas. Conjunctiva impression cytology showed a significant (from single to total absence of the field of view) reduction in the number of goblet cells and revealed pronounced degenerative changes in the epithelium. Confocal microscopy revealed a cytotoxic effect on the cornea (the front of desquamated epithelial corneal edema, stroke and intermittent crimp in subbasal neural plexus. When prescribing treatment for the «dry eye» associated with primary glaucoma, it is important to correct the defects of the lipid layer of the tear film using Systanebalance instillations. Adjuvant reparative agents may be presented by Korneregel, Sisteyn gel or Vit A Pos administered overnight. According to our data, these drugs should be used for a long time, depending on results of confocal microscopy of the cornea. For inflammatory process management we used the spectacle frame «Blephasteam» in combination with the drug Restasis. CONCLUSION: We have developed an algorithm of dry eye treatment in glaucoma patients, which allowed to optimize the state of the ocular surface and ensure the stability of the functional parameters for the entire period of observation.ЦЕЛЬ. Разработка лечения и профилактики развития вторичного синдрома «сухого глаза» у пациентов с первичной открытоугольной глаукомой. МЕТОДЫ. Обследовано 50 пациентов (100 глаз) - 20 мужчин, 30 женщин в возрасте от 46 до 85 лет (средний возраст 65,5±9,6 года) с первичной глаукомой. Продолжительность заболевания глаукомой от 1,5 до 17 лет. Алгоритм обследования включал: клинический осмотр, тест Ширмера, пробу Норна, тесты с витальными красителями: лиссаминовым зеленым и флюоресцеином, импрессионно-цитологическое исследование, осмолярометрию, тиаскопию, конфокальную микроскопию, определение функционального состояния мейбомиевых желез. Срок наблюдения составил 3 года. РЕЗУЛЬТАТЫ. Признаки синдрома «сухого глаза» (ССГ) были выявлены в 70,6% (76 глаз). В 23,6% случаев (18 глаз) имела место дисфункция мейбомиевых желез. Спектр жалоб был представлен: чувством жжения (89%), резью (71%), ощущением инородного тела (56%), болезненными ощущениями при инстилляциях (43%). Средние значения общего объема слезопродукции по данным теста Ширмера составили 20,7±0,8 мм, показатели пробы Норна - 9,7±0,1, осмолярности - 290,2±13,1 мОсм/л. Интерференционная картина слезной пленки выявила изменения ее липидного слоя в виде неравномерного истончения с сохранением нормальной толщины лишь на незначительных по площади участках, отсутствие цветов высокого порядка. С помощью конфокальной микроскопии показали наличие десквамированного переднего эпителия роговицы, отечность, извитость и прерывистость хода нервов суббазального сплетения. Результаты импрессионно-цитологического исследования продемонстрировали наличие дистрофических изменений эпителия конъюнктивы и снижение числа бокаловидных клеток. Степень этих изменений коррелировала с длительностью заболевания и количеством используемых антиглаукомных средств. При изменении гипотензивного режима в 5 (6,5%) случаях зафиксировано увеличение показателей осмолярности - в среднем до 330,0±11,2 мОсм/л, сопровождавшееся снижением показателей пробы Норна до 7,3±0,2 с и истончением липидного слоя. Нормализацию показателей осмолярности достигали назначением оптива в течение 3 недель, коррекцию липидного слоя - с помощью препарата систейн-баланс, восстановление эпителия роговицы - репаративными средствами (корнерегель, систейн-гель или витА-Пос). Для купирования воспалительного процесса применяли физиотерапевтический метод - очковую оправу «Блефастим» в комбинации с рестасисом. ЗАКЛЮЧЕНИЕ. Предложенная схема медикаментозного сопровождения пациентов с первичной глаукомой позволила снизить количество и степень проявления субъективных жалоб, сохранить стабильность объема слезопродукции в течение всего периода наблюдения, восстановить функциональное состояние мейбомиевых желез, эпителия роговицы и конъюнктивы, повысить стабильность слезной пленки за счет увеличения толщины липидного слоя

Optical Correction of Keratoconus with a Scleral Gas-Permeable Lenses

The optical properties of the cornea are determined by its ability to refract and transmit light. Keratoconus changes cornea’s shape, the surface of the cornea becomes irregular, which leads to a violation of light refraction and the occurrence of optical aberrations. The progressing course of the disease and its late detection lead to a delayed start of therapeutic measures, which affects the prognosis of the disease progression and reduces the patient’s quality of life. The quality of visual functions depends on the stage of the process. There are 4 stages of keratoconus (according to M. Asler), each of which corresponds to certain changes in refraction and degree of deformation of the cornea. Early biomicroscopic signs are: “dilution” of the stroma (inhomogeneity of the cornea and a grayish tint in the zone of the developing apex), change in the shape of endothelial cells and clearly visible nerve endings due to longitudinal thickening. In the second stage of keratoconus, the biomicroscopic picture is complemented by the appearance of keratoconus lines (Vogt’s striae). The opacities of the Bowman’s membrane indicate the beginning of the scarring process and the transition of the disease to its third stage. The fourth stage of the disease is characterized by further development of stromal opacities and the occurrence of gross changes of the Descemet’s membrane. Advanced medical equipment for topographic mapping and measuring the cornea makes it much easier for ophthalmologists to diagnose keratoconus and choose more effective treatment methods: crosslinking or surgical treatment. Later it allows to stabilize keratoconus, but does not provide high visual acuity due to the induction of optical aberrations, including high order optical aberrations. Contact lens vision correction is the main way to correct the refractive error resulting from keratoconus. However, the use of corneal gas permeable or soft contact lenses cannot provide high quality vision, additionally causing discomfort associated with their excessive mobility. The use of scleral gas permeable contact lenses is the most effective method of optical correction of all stages of keratoconus and after keratoplasty

Early cystic bleb needling revision after glaucoma filtering surgery with toxic keratopathy

<p>Clinical case of high thin-wall cystic limited filtering bleb needling revision in the early post-op period after trabeculectomy with sinusotomy accompanied by toxic keratopathy is presented. Optical coherence tomography (OCT) demonstrated that filtering bleb height was 2700 μm and bleb wall thickness was 70 μm. Bleb needling revision with its lateralwall dissection and subconjunctival injection of dexamethasone, fluorouracil, and ranibizumab near to the bleb site was performed. In 1.5 hours after the procedure, bleb height decreased to 550 μm (by 5 times) while bleb wall thickness increased up to 100 μm. Topical antibacterial, steroid, and non-steroid anti-inflammatory therapy was recommended. The next day IOP level reduced from 11 mm Hg to 4.5 mm Hg. It was accompanied by choroidal effusion that was managed conservatively with cycloplegic agents (drops and injections) for 3 days. On day 6, central corneal edema affecting all layers, Descemet’s membrane folds, and ocular hypertension were revealed. Metabolic therapy resolved corneal edema within 3 days. Re-needling bleb revision decreased IOP level to 6.2 mm Hg. This resulted in transient Descemet’s membrane folds. This paper describes filtering bleb needling revision with its lateral wall dissection and anti-inflammatory, cytostatic, and anti-VEGF agents use to prolong glaucoma filtering surgery effect in excessive scarring. The procedure was accompanied by toxic corneal endothelium decompensation with corneal edema and Descemet’s membrane folds treated with active metabolic therapy.</p

CLINICAL FEATURES, DIAGNOSIS, THE RESULTS OF THERAPEUTIC AND SURGICAL TREATMENT OF ACANTHAMOEBIC KERATITIS

Purpose: to describe our experience in Acanthamoeba keratitis diagnostics and treatment in the FGBNU Research Institute of eye diseases, Moscow.Patients and Methods. We observed 24 patients (25 eyes) with the Acanthamoeba keratitis (AK). The age ranged from 18 to 47 years. All patients, except one, were contact lenses wearers. Clinical signs included superficial epithelial-stromal lesions in 8 patients (8 eyes), stromal forms of AK- in 16 patients (17 eyes), and mixed keratitis in 9 (9 eyes). We used confocal microscopy, conjunctival smearing and blood immunofluorescent analysis for HSV types I and II. 8 patients (8 eyes) underwent penetrating keratoplasty (PKP) and their corneal buttons were morphologically examined. AK treatment included 2 biguanid antiseptics — a PHMB ("Comfort-drops" — solution for contact lenses care) and 0.025% solution of a chlorhexidini bigluconati, or "Vitabact" in frequent instillations. We also used Diflucan solution 0.2% instillations — 6–8 times a day in, and Orungal or Diflucan per os (200 mg once a day). Eye drops of aminoglycozide or fluorhinolon groups were added to the treatment as well. In the cases of mixed Acanthamoeba and HSV keratitis we used anti-herpetic medications (Poludan, Acyclovir).Results. Cysts were found with confocal microscopy in 66% examined patients, and in 75% of the corneal buttons after keratoplasty. 15 cases (60%) healed with various intensity opacities. We removed corneal epithelium in 2 patients with poor effect of the medication treatment. 8 patients (8 eyes) underwent PKP with transparent (2 patients) and a semi-transparent engraftment (2 patients), in 4 cases (4 eyes) AK recurrences had occurred, what required repeated surgery. Long persistence of Acanthamoeba cysts in the cornea after clinical recovery caused the admission of 2 antiseptic biguanids eye drops for 6–20 months in all patients. There were no recurrences in the group of patients during the observation period (range 1 to 6 years).Conclusion. AK is an extremely dangerous cornea disease , in most cases developing with contact lenses. Effective instrumental diagnostics methods of AK are confocal microscopy and morphological examination of distant corneal discs. Often, AK combined with a herpetic and bacterial infection (mixed keratitis). AK treatment requires the active use of several antiseptic agents with amoebicidal action, mycostatic drugs, antibiotics and other drugs. Therapeutic keratoplasty, often necessary in AK, accompanied by a high risk of complications and relapses of the disease, but in 50% cases, good results were achieved