RU2784954C1 - Method for surgical treatment of secondary macular retinal breaks with epiretinal proliferative structures (options) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: inventions group relates to medicine, namely to ophthalmology. According to the first variant, transconjunctival subtotal three-port 27G vitrectomy is performed, epiretinal proliferative structures (EPS) and internal limiting membrane (ILM) are stained, and ILM peeling is performed. At the same time, peeling of the ILM is started from the side of the lower temporal vascular arcade, for which, in the place of clear staining, the ILM is torn at a distance of 2 mm from the edge of the gap, the ILM is separated from the retina and lifted as a single block with EPS, not reaching the edge of the macular hole 0.5 mm. In the same way, the separation of the "ILM-EPS" complex is performed in all quadrants concentric to the macular hole (MH), with the exception of a retinal area 2 MH diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact. The separated complex "ILM-EPS" is removed with a vitreotomy so that the zone of the intact retina is preserved concentrically to the MH with a width of 0.5 mm and from the side of the superior temporal vascular arcade at 12 o'clock with a width of 2 MH diameters. Then the intact area "ILM-EPS" at 12 o'clock with a width of 2 MH diameters is separated from the underlying retina in a single block in the direction of the MH center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the side of the epiretinal membrane (ERM) is placed on the macular hole . According to the second option, if it is impossible to visualize the ILM due to a continuous layer of the EPS and to determine the boundary between the EPS and the ILM, the ERM is separated from the side of the inferior temporal vascular arcade towards the center of the macular hole, not reaching its edge by 0.5 mm and not crossing the horizontal line, passing tangentially to the lower edge of the ONH. Then the EPS is cut off with a vireotome; perform re-staining of the EPS of the macular zone of the retina. After that, the EPS freed from EPS is removed in local areas, not reaching the edge of MH 0.5 mm. The rest of the EPS of the macular zone is concentric to the MH, with the exception of a retinal area 2 MH diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact, is removed as a single block with the ILM. Then, the intact area of ​​"ILM-EPS" at 12 o'clock, 2 MH diameters wide, is separated from the underlying retina as a single block in the direction of the MH center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the ERM side is placed on the macular hole.

EFFECT: inventions group provides reduction of surgical intervention trauma, no need to use PFOS, permanent closure of the macular hole, restoration of the normal structure of the retina, high postoperative visual functions, no recurrence of the disease and no need for repeated treatment.

2 cl, 2 ex

Description

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of secondary lamellar and penetrating macular retinal breaks with epiretinal proliferative structures (EPS): epiretinal proliferative tissue (EPT) and epiretinal membranes (ERM).

Epiretinal proliferation (EP) is a pathological anatomical structure on the surface of the retina, which became known not so long ago due to the wide capabilities of modern ophthalmic diagnostic equipment [Pang SE, Spaide RF, Freund KV. Comparing functional and morphologic characteristics of lamellar macular holes with and without lamellar hole-associated epiretinal proliferation. Retina 2015;35:720-6.; Compera D, Entchev E, Haritoglou C, et al. Lamellar hole-associated epiretinal proliferation in comparison to epiretinal membranes of macular pseudoholes. Am J Opthalmol 2015; 160:373-84].

The natural course of EP can lead to the formation of macular retinal tears (through or lamellar) [Bottoni F, Deiro AP, Giani A, et al. The natural history of lamellar macular holes: a spectral domain optical coherence tomography study. Graefes Arch Clin Exp Ophthalmol 2013; 251:467-75]. These cases require surgical intervention, but among specialists there are disagreements about the methods of surgical treatment, the scope of intervention and postoperative prognosis [Lai TT, Chen SN, Yang CM. Epiretinal proliferation in lamellar macular holes and full-thickness macular holes: clinical and surgical findings. Graefes Arch Clin Exp Ophthalmol 2016; 254:629-38. Ko J, Kim GA, Lee SC, et al. Surgical outcomes of lamellar macular holes with and without lamellar hole-associated epiretinal proliferation. Acta Ophthalmol 2017; 95:e221-6].

It has been proven that the epiretinal proliferative tissue (EPT) around the retinal MP has a special structure that differs from classical epiretinal membranes (ERMs). In the literature, this tissue has various names: "thick ERM", "dense ERM", "yellow tissue" or tissue associated with lamellar macular hole" [Witkin AJ, Co. TH, Fujimoto JG, et al. Redefining lamellar holes and the vitreomacular interface: an ultrahigh-resolution optical coherence tomography study. Ophthalmology 2006;113:388-97. ParoliniB, Schumann RG, CeredaMG, et al. Lamellar macular hole: a clinicopathologic correlation of surgically excised epiretinal membranes. Invest Ophthalmol Vis Sci 2011; 52:9074-83. Pang CE, Spaide RF, Freund KB. Epiretinal proliferation seen in association with lamellar macular holes: a distinct clinical entity. Retina 2014;34:1513-23].

There is still no consensus on the origin of EP: Muller cells, retinal pigment epithelial cells or vitreous body [Parolini B, Schumann RG, Cereda MG, et al. Lamellar macular hole: a clinicopathologic correlation of surgically excised epiretinal membranes. Invest Ophthalmol Vis Sci 2011;52:9074-83. Pang CE, Maberley DA, Freund KB, et al. Lamellar hole-associated epiretinal proliferation: a clinicopathologic correlation. Retina 2016;36:1408-12; Compera D, Entchev E, Haritoglou C, et al. Correlative microscopy of lamellar hole-associated epiretinal proliferation. J Ophthalmol 2015;2015:450212. Ko J, Kim GA, Lee SC, et al. Surgical outcomes of lamellar macular holes with and without lamellar hole-associated epiretinal proliferation. Acta Ophthalmol 2017; 95:e221-6].

As a generalizing term, foreign scientists have proposed the term "epiretinal proliferation associated with macular defect", which includes EP accompanying lamellar and penetrating secondary retinal MPs [Lai TT, Chen SN, Yang CM. Epiretinal proliferation in lamellar macular holes and full-thickness macular holes: clinical and surgical findings. Graefes Arch Clin Exp Ophthalmol 2016; 254:629-38.; Son G, Lee JS, Lee S, Sohn J. Epiretinal proliferation associated with macular hole and intraoperative perifoveal crown phenomenon. Korean J Ophthalmol 2016; 30:399-409].

Recent scientific studies in the field of retinal MP surgery with epiretinal membranes indicate the need, in addition to the removal of ERM in the macular zone of the retina, to remove the ILM in order to obtain better anatomical and functional results of surgical treatment: a significantly higher frequency of closure of through MP with epiretinal membranes and a higher postoperative correctable visual acuity. However, according to Lyskin P.V. et al., ILM peeling leads to irreversible changes in the microarchitecture of the retina and, therefore, to a decrease in the functional result of treatment [Lyskin P.V., Makarenko I.R. Additional aspects of peeling the inner limiting membrane of the retina // Russian Children's Ophthalmology. - 2020. - No. 1. - S. 40-41].

Perforating macular holes with EP are more difficult to surgically treat, and the functional result is usually lower than with penetrating MPs without epiretinal structures [Characterization of Epiretinal Proliferation in Full-Thickness Macular Holes and Effects on Surgical Outcomes Ophthalmology Retina Volume 3, Issue 8, August 2019, Pages 694-702]. In addition, according to scientists, the preservation of "thick ERM with yellow macular pigment" (EP or "yellow tissue") at the edge of the gap gives better clinical results than its removal [Shiraga F, Takasu I, Fukuda K, et al. Modified vitreous surgery for symptomatic lamellar macular hole with epiretinal membrane containing macular pigment. Retina 2013; 33:1263-9].

It is believed that EPT rich in yellowish pigment is associated with the outer and middle layers of the retina [Son G, Lee JS, Lee S, Sohn J. Epiretinal proliferation as-sociated with macular hole and intraoperative perifoveal crown phenomenon. Korean J Ophthalmol 2016; 30:399-409].

Therefore, the removal of EP can turn the lamellar MP into a through one, similar to pulling out the “central plug” from the structurally connected macula, or additionally damage the edges of the through macular hole [Pang SE, Spaide RF, Freund KV. Epiretinal proliferation seen in association with lamellar macular holes: a distinct clinical entity. Retina 2014; 34:1513-23]. Therefore, it is undesirable to remove the EPT along the edge of the tear, but it should be carefully excised with care, working outside the gap and not reaching the edge of the macular hole. Careful handling of this fabric is very important.

Retinal MP surgery is developing along the path of minimizing the volume and duration of surgery, thereby reducing the trauma of the intervention and improving the functional outcome of the treatment.

Techniques based on the use of an inverted ILM flap to close the MP are being actively developed and modified. Their effectiveness is confirmed by many years of surgical practice [Michalewski Z, Michalewski J, Adelman RA, Nowrocki J. Inverted internal limiting membrane flap technique for large macular holes // Ophthalmology. -2010. - Vol.117 (10). - P. 2018-2025; Bely Yu.A., Tereshchenko A.V., Shkvorchenko D.R., Erokhina E.V., Shilov N.M. A new technique for the formation of a fragment of the internal limiting membrane in the surgical treatment of large idiopathic macular holes // Ophthalmology. - 2015. - Issue 12 (4). - S. 27-31].

However, surgical techniques with the formation of an inverted ILM flap, as a rule, are not technically feasible or difficult to perform in the presence of epiretinal membranes on the retina. This is due to the peculiarities of the anatomical structure and physical properties of epiretinal structures, namely: the ability to tear, extensibility and staining with standard dyes. ERM, as a rule, are less elastic and more extensible than ILM, which makes it difficult or even impossible to tear off the ERM in a strictly necessary place or to give it the desired shape while removing and maintaining intact areas of the retina. It is practically impossible to separate the ERM from the underlying surface of the ELM, without damaging the latter, due to the tight adhesion.

In addition, epiretinal membrane structures are less amenable to staining with standard dyes, which complicates their visualization and manipulation during surgery, and increases the risk of iatrogenic retinal damage. Recently, dyes Membrane blue-Dual ™ (DORC International, the Netherlands) and "Staining solution" (OPTIMED, Russia), which have a similar composition, have been actively used to stain epiretinal membranes and ILMs of the retina. Although the Trypan Blue and Brilliant Blue dyes included in their composition have a selective affinity for ERM and ELM, visualization of membrane structures intraoperatively often causes difficulties and inconvenience. Staining of epiretinal structures with this dye has an "island" (fragmentary) character and does not give a full-fledged homogeneous staining, as when staining a "clean" surface of the ELM. This complicates the course of the operation and increases the risk of iatrogenic damage to retinal structures. Also, there is a need for repeated application of the dye to the surface of the vitreomacular interface and the need to increase the exposure time of the dye on the retina to achieve the required staining and visualization, which increases the duration of surgery.

The “temporal inverted flap” technique with partial removal of the ILM only from the temporal side of the macular zone and inversion of the obtained flap on the MP with air tamponade of the vitreal cavity was proposed by Michalewska Z. et al. in 2015 [Michalewska Z., Michalewski J., Nawrocki J. et al. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study. retina. - 2015. - Vol. 35. - P. 1844-1850]. A similar technique with incomplete removal of the ILM was described by Fayzrakhmanov P.P., which consists in partial removal of the ILM from the temporal side of the macular zone and subsequent inversion of the resulting ILM flap to close the MP, not reaching the edge of the gap, thereby maintaining the point of visual fixation, followed by air tamponade vitreal cavity [Faizrakhmanov P.P., Pavlovsky O.A., Larina E.A. A method for closing macular holes with partial preservation of the inner limiting membrane. Bulletin of ophthalmology. 2020; 136(1):73-79]. These methods of surgical treatment are not applicable in case of ruptures with epiretinal membrane structures. Preservation of ERMs on the surface of the retina can lead to their progression, constriction, increased tangential traction to the edges of the tear and non-closure/recurrence of MP or the development of interstitial retinal edema in the macular zone, decreased visual function, increased metamorphopsia, and, as a result, repeated surgical intervention.

Foreign sources describe a technique for lamellar macular rupture surgery using EP (“yellow tissue”) for plugging a defect in the inner layers of the retina, followed by its additional blockade with an inverted fragment of the ILM. After a standard three-port vitrectomy, epiretinal membranes were removed using retinal forceps. "Yellow tissue", which corresponds to epiretinal proliferation (EP), was carefully separated from the underlying retina using ILM forceps to the edge of the MP. Thus, a crown-like structure (“tissue perifoveal crown”) was formed around the rupture. IPM peeling was performed. Excess perifoveal tissue was removed, leaving a portion at the edge of the tear. The operation was completed with gas-air tamponade of the vitreal cavity [Shiode Y, Morizane Y, Takahashi K, Kimura S, Hosokawa M, Hirano M, Doi S, Toshima S, Hosogi M, Fujiwara A, Shiraga F. Embedding of lamellar hole-associated epiretinal proliferation combined with internal limiting membrane inversion for the treatment of lamellar macular hole: a case report. BMC Ophthalmol. 2018 Sep 24; 18(1):257. doi: 10.1186/sl2886-018-0926-8. Yang YS, Lee JS, Son G, Sohn J. Epiretinal Proliferation Associated with Lamellar Hole or Macular Hole: Origin and Surgical Prognosis. Korean J Ophthalmol. 2019 Apr; 33(2): 142-149. doi: 10.3341/kjo.2018.0070]. As a rule, the epiretinal membrane is tightly soldered to the underlying SLM, and when trying to separate these structures, inevitable damage and partial/complete removal of the SLM occurs as a single block with epiretinal membrane structures. Therefore, it is technically difficult to form the necessary inverted flap, sufficient for the subsequent blockade of the macular hole. In addition, there is an increased risk of spontaneous detachment of the ILM and epiretinal membrane structures from the edge of the tear, damage to the point of visual fixation along the edge of the tear, as well as detachment of the “yellow tissue” along the edge of the tear, causing additional trauma to the structures of the retinal neuroepithelium. Manipulations with tweezers when separating the “yellow tissue” along the edge of the gap can be dangerous for iatrogenic damage to the retinal neuroepithelium in the area of the fixation point along the edge of the gap.

Thus, in surgery of secondary MPs with EPS (ERM+EP), it becomes necessary to remove all EPS that create tangential traction to the edges of the tear and perform peeling of the ILM of the retina, which is a substrate for the development of epiretinal fibrosis in the future, but one should not forget about the delicate attitude to EP (“epiretinal proliferation associated with a macular defect”) along the edge of the rupture and retinal structures that determine the long-term functional result of surgical treatment.

The objective of the invention is to create an effective, rational, high-tech and safe method of surgical treatment of secondary lamellar and penetrating macular retinal breaks with EPS.

The technical result is a reduction in the trauma of surgical intervention, no need to use PFOS, persistent closure of the macular hole, restoration of the normal structure of the retina, obtaining high postoperative visual functions, no recurrence of the disease and the need for repeated treatment.

The technical result is achieved by the fact that in a method involving transconjunctival subtotal three-port 27G vitrectomy, EPS and ILM staining, ILM peeling, according to the invention, ILM peeling starts from the side of the lower temporal vascular arcade, for which, in the place of the most clear staining, an ILM tear is performed on at a distance of 2 mm from the edge of the gap, the ILM is separated from the retina and lifted as a single block with EPS, not reaching the edge of the macular hole 0.5 mm; in the same way, the department of the "VPM-EPS" complex is performed in all quadrants concentrically to the MP, with the exception of a retinal area 2 MP diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact; the separated complex "VPM-EPS" is removed with a vitreotomy so that the zone of the intact retina is preserved concentrically to the MP with a width of 0.5 mm and from the side of the superior temporal vascular arcade at 12 o'clock with a width of 2 MP diameters; then, the intact area "VPM-EPS" at 12 o'clock, 2 MP diameters wide, is separated from the underlying retina as a single block in the direction of the MP center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the ERM side is placed on the macular hole.

If it is impossible to visualize the ILM due to a continuous layer of the EPS and to determine the boundary between the EPS and the ILM, separate the ERM from the side of the lower temporal vascular arcade towards the center of the macular hole, not reaching its edge 0.5 mm and not crossing the horizontal line, passing tangentially to the lower edge of the OD; then the EPS is cut off with a vireotome; perform re-staining of the EPS of the macular zone of the retina; after which the EPS freed from EPS is given in local areas not reaching the edge of MP 0.5 mm; the rest of the EPS of the macular zone is concentric to the MP, with the exception of a retinal area 2 MP diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact, is removed as a single block with the ILM; then, the intact area "VPM-EPS" at 12 o'clock, 2 MP diameters wide, is separated from the underlying retina as a single block in the direction of the MP center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the ERM side is placed on the macular hole. The technical result is achieved due to the fact that:

1) leaving an intact area of the retina (without removing the ER) 0.5 mm wide concentric to the MP, keep the ILM in this area, thereby maintaining the point of visual fixation;

2) preservation of the intact zone of the retina 0.5 mm concentric to the macular hole allows you to save the EPS ("yellow tissue") along the edge of the macular hole;

3) removing the EPS as a single block with the ILM reduces the traction effects on the surface of the retina and reduces the duration of the operation;

4) separation of EPS with a monolayer, if necessary, from the side of the inferior temporal vascular arcade, not reaching the horizontal line passing tangentially to the lower edge of the optic disk, allows you to keep the area of the foveolar fragment of the SLM intact (0.5 mm along the edge of the gap), thereby maintaining the point of visual fixation. In addition, this allows not to create unnecessary traction effects on the area of the papillomacular bundle of nerve fibers;

5) the creation of a flap from the VPM-EPS complex to close the MP makes it possible to “weight” it, which ensures its more stable position on the retina in the projection of the MP. This is especially true when replacing fluid/air at the final stages of surgery and allows not to use PFOS for intraoperative compression of the flap to the retina;

6) EPS has other physical properties, in contrast to HPM, in particular, it is less elastic and rigid. Therefore, the complex "VPM-EPS" is not prone to twisting on the surface of the retina, which greatly facilitates the work with the flap and reduces the risk of its unintentional detachment from the retina and facilitates its correct positioning in the MP projection. Therefore, EPS, which complicates the course of the operation in the initial stages, helps in the final stages, contributing to a high anatomical and functional result of the treatment;

7) "yellow tissue" along the edge of the gap, together with the overturned ILM flap, is wrapped into the macular hole, additionally plugging it;

8) keeping the EPS intact in the area of the inverted ILM flap being formed to close the MP reduces the risk of damage (tearing or removal of a local area) of the ILM in this area, which is necessary to create a flap of the right size, which can hermetically close the macular hole;

9) separation of the inverted "heavy" flap "VPM-EPS" from the retina at the moment when the rest of the membranes have already been separated from the retina and cut off by a vitreotome, eliminates the risks of involuntary removal of the inverted flap necessary to block the macular hole.

The method is carried out as follows.

Perform transconjunctival 27G subtotal three-port vitrectomy. To exclude a direct directed flow of liquid or air into the fovea, the supply for infusion into the vitreal cavity is set at an angle of 45 degrees to the surface of the eyeball. The posterior hyaloid membrane and the posterior cortical layers of the vitreous body are exfoliated from the optic disc (OD) and retina by aspiration. Vacuum - from 0 to 650 mm. Hg Frequency - 5 000-10 LLC cuts / min. The EPS and the inner limiting membrane (ILM) are stained with the MembranBlue dye, exposure time is 20-25 seconds. As a rule, the ILM stains brighter and more homogeneously than epiretinal structures, which stain "fragmentally" and less clearly.

In the presence of visualization of the ILM, its peeling is started from the side of the inferior temporal vascular arcade (at 5-7 hours). In the place of the most clear staining, the ILM is torn at a distance of 2 mm from the edge of the gap. The ILM is separated from the retina and lifted as a single block with EPS, not reaching the edge of the macular hole 0.5 mm. In the same way, the department of the VPM-EPS complex is performed in all quadrants concentrically with MP. At the same time, a section of the retina with a width of 2 MP diameters from the side of the superior temporal vascular arcade (at 12 o'clock) is left intact.

If it is impossible to visualize the ILM due to a continuous layer of the EPS and it is impossible to determine the border between the EPS and the ILM, the EPS is separated from the side of the lower temporal vascular arcade towards the center of the macular hole, not reaching its edge 0.5 mm and not crossing the horizontal line passing tangentially to the lower edge of the optic disc. The separated ER is cut off with a vitreotome with a minimum vacuum (100-150 mm Hg) and a maximum cutting frequency (8000-10000/min) to avoid unnecessary traction on the retina. The naked EPS of the macular zone of the retina is stained after removal of the EPS with the dye "MembranBlue", exposure - 10 seconds. At the same time, the ILM, exposed after the removal of EPS, is stained homogeneously. Visualization of the border of the intact part of the retina with the intact ER is improved. The IPM is removed in local areas, like the petals of a flower, while not reaching the edge of MP 0.5 mm. The rest of the EPS of the macular zone concentrically to the MP is removed with a single block "VPM-EPS", with the exception of the area of the retina with a width of 2 MP diameters from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact.

The separated EPS-EPS complex is removed with a vitreotome at a minimum vacuum (100-150 mm Hg) with a maximum cutting frequency (8000-10000 / min) so as not to create traction on the edges of the retinal MP and not cause involuntary detachment of the intact part of the EPS and EPS ("yellow tissue"). In this case, the retinal band 0.5 mm wide along the edge of the gap is left untouched.

Having captured the ILM with tweezers, the intact area of the ILM-EPS from above relative to the MP is separated from the underlying retina as a single block in the direction of the MP center (from top to bottom, towards the lower temporal vascular arcade). The resulting "heavy" flap (HPM-EPS) is turned over and the inner side (the side with the EPS) is placed on the macular hole, blocking it.

The operation is completed by replacing the liquid with an air mixture. Sclerotomies are self-sealing. The patient is recommended the “face down” position and the prohibition of being in the “on the back” position during the first day to achieve tight adhesion of the “VPM-EPS” flap with the retina.

Clinical example 1. Patient K. Diagnosis: OD - secondary penetrating macular hole of the retina of large diameter, epiretinal fibrosis.

Complaints about the distortion of the boundaries of objects, low visual acuity. Visual acuity 0.1 n/k. Light sensitivity (MF) central - 15.8 dB according to the microperimeter. Absolute scotoma in the fovea projection. The point of visual fixation is located in the lower nasal quadrant along the edge of the gap.

According to spectral optical coherence tomography (SOCT), the minimum diameter of the macular hole is 640 µm, the maximum diameter is 1320 µm, and the height of the rupture is 415 µm.

The patient was operated on according to the proposed method in the presence of visualization of the ILM.

Positive dynamics was observed 2 weeks after the operation. According to SOCT, the MP is closed and blocked by the ILM flap with the formation of a duplication, the small cystic edema along the edge of the gap was resorbed. The defect remained at the level of the outer layers of the retina (width 254 μm, height 87 μm). There was an increase in BCVA up to 0.2, an increase in central photosensitivity - up to 20.0 dB, according to microperimetry. The scotoma in the center of the fovea has disappeared. The patient subjectively noted a decrease in the severity of distortions and an improvement in vision.

During surgery, no intraoperative complications were observed, the invasiveness of the intervention was minimal, there were no iatrogenic retinal injuries, and PFOS was not used.

Positive dynamics was observed 1 month after the operation. According to SOCT data, the MP is closed, the defect at the level of the photoreceptor layer has decreased (width 170 µm, height 55 µm). The MP is blocked by the ILM flap. BCVA 0.4. Increase in central photosensitivity up to 21.4 dB, according to microperimetry.

After 3 months, according to SOCT data, the defect remained at the level of the ellipsoidal zone of photoreceptors (width 87 μm), MP was blocked by the ILM flap. BCVA increased to 0.5. Increasing the central photosensitivity - up to 22.9 dB. Shift of the point of visual fixation to the center of the fovea. Subjectively - improvement in the quality of vision.

After 6 months - a state without significant dynamics. According to SOCT data, the defect remained at the level of the ellipsoidal zone of photoreceptors (width 80 μm), MP was blocked by the ILM flap. BCVA 0.5. An increase in central photosensitivity - up to 23.2 dB, according to microperimetry. Subjectively - mild distortion.

Follow-up period - 2 years: no recurrence of the disease, no need for re-treatment.

Clinical example 2. Patient N. Diagnosis: OD - secondary end-to-end macular retinal hole of medium diameter, epiretinal fibrosis.

Complaints about the distortion of the boundaries of objects, low vision. Visual acuity 0.2 n/a. MF central - 17.1 dB. Absolute scotoma in the center of the fovea. The point of visual fixation is located in the lower temporal quadrant along the edge of the gap. SOCT: the minimum diameter of the macular hole - 380 microns, the maximum diameter - 1120 microns, the height of the gap -415 microns.

The patient was operated on according to the proposed method in the absence of visualization of the ILM due to dense ERM.

During surgery, no intraoperative complications were observed, the invasiveness of the intervention was minimal, there was no iatrogenic damage to the retina, and PFOS was not used.

Positive dynamics was observed 2 weeks after the operation. According to SOCT, the MP is closed and blocked by the ILM flap with the formation of a duplication, the small cystic edema along the edge of the gap was resorbed. The defect remained at the level of the outer layers of the retina (width - 96 microns, height - 43 microns). Increase in BCVA up to 0.5. Increase in central photosensitivity up to 22.3 dB, according to microperimetry. The scotoma in the center of the fovea has disappeared. The patient subjectively noted an improvement in vision, a decrease in the intensity of distortions.

Positive dynamics was observed 1 month after the operation. According to SOCT, MP is closed, the defect is at the level of the ellipsoidal zone of photoreceptors (width 78 μm). The MP is blocked by the ILM flap. BCVA 0.6. Increase in central photosensitivity up to 23.1 dB, according to microperimetry.

After 3 months, according to SOCT data, the defect remains at the level of the ellipsoidal zone of photoreceptors (width 44 μm), MP is blocked by the ILM flap. BCVA increased to 0.7. Increase in central photosensitivity up to 27.9 dB according to microperimetry. Shift of the point of visual fixation to the center of the fovea. Subjectively - improving the quality of visual functions.

After 6 months, the state without significant dynamics. According to SOCT data, the defect at the level of the ellipsoidal zone of photoreceptors was not detected, MP was blocked by the ILM flap. BCVA 0.7. Increase in central photosensitivity - up to 28.5 dB, according to microperimetry. Subjectively, the distortions have disappeared.

Follow-up period - 2.5 years: no recurrence of the disease, no need for re-treatment.

Thus, the proposed method provides a reduction in the trauma of surgical intervention, no need to use PFOS, persistent closure of the macular hole, restoration of the normal structure of the retina, obtaining high postoperative visual functions, no recurrence of the disease and the need for repeated treatment.

Claims (2)

1. A method for the surgical treatment of secondary macular retinal breaks with epiretinal proliferative structures, including transconjunctival subtotal three-port 27G vitrectomy, staining of epiretinal proliferative structures (EPS) and the internal limiting membrane (ILM), peeling of the ILM, characterized in that the peeling of the ILM is started from the inferior temporal vascular arcade, for which, in the place of clear staining, the ILM is torn at a distance of 2 mm from the edge of the gap, the ILM is separated from the retina and lifted as a single block with EPS, not reaching the edge of the macular hole 0.5 mm; in the same way, the department of the "VPM-EPS" complex is performed in all quadrants concentric to the macular hole (MP), with the exception of a retinal area 2 MP diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact; the separated complex "VPM-EPS" is removed with a vitreotomy so that the zone of the intact retina is preserved concentrically to the MP, 0.5 mm wide and from the side of the upper temporal vascular arcade at 12 o'clock, 2 MP diameters wide; then the intact area "VPM-EPS" at 12 o'clock with a width of 2 MP diameters is separated from the underlying retina as a single block in the direction of the MP center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the side of the epiretinal membrane (ERM) is placed on the macular hole . 2. A method for the surgical treatment of secondary macular retinal tears with epiretinal proliferative structures, including transconjunctival subtotal three-port 27G vitrectomy, staining of the EPS and ILM, peeling of the ILM, characterized in that if it is impossible to visualize the ILM due to the continuous layer of the EPS and determine the border between the EPS and ILM separate the ERM from the side of the inferior temporal vascular arcade towards the center of the macular hole, not reaching its edge by 0.5 mm and not crossing the horizontal line tangentially to the lower edge of the optic disc; then the EPS is cut off with a vireotome; perform re-staining of the EPS of the macular zone of the retina; after which the EPS freed from EPS is removed in local areas, not reaching the edge of MP 0.5 mm; the rest of the EPS of the macular zone is concentric to the MP, with the exception of a retinal area 2 MP diameters wide from the side of the upper temporal vascular arcade at 12 o'clock, which is left intact, is removed as a single block with the ILM; then, the intact area "VPM-EPS" at 12 o'clock, 2 MP diameters wide, is separated from the underlying retina as a single block in the direction of the MP center, not reaching the edge of the macular hole 0.5 mm, it is turned over and the ERM side is placed on the macular hole.