Pathogenesis. The pathogenesis of the pump of the optic nerve disk is unclear. Some authors suggest that the yam of the disk of the optic nerve; It is a light shape of a spokesmage of optic nerve, i.e. Also due to the incomplete closure of the eye slit. The arguments confirming this point of view, its supporters call rather rare cases of combinations of colobroms and pumps of the optic nerve disk.
There are facts that are not consistent with this hypothesis: firstly, the disk pits are often located in places relating to the embryonic gap; secondly, disk pits are usually one-sided, sporadic and do not combine with other developmental anomalies; Thirdly, the disk pits are not combined with the colobomas of iris or retina. Despite the fact that the cooboma of the optic nerve can sometimes be a crater about the figurative deformation that resembles a hole of the optic nerve disk, and it is difficult to distinguish the fume localized in the lower segment from a small colobum, the above facts seem sufficient to prove the obvious pathogenesis difference with a spool nerve. The presence of one or more cylinder vessels coming from most of the spawning nerve vessels makes it possible to assume that this fact is also somehow connected with the pathogenesis of anomaly.
Histological studies. In the area of \u200b\u200bthe fossa there is a lattice plate defect. Retinal fibers are lowered inside the fifth, then returned and exit in front of an incoming visual nerve. Some pits are communicated with the subarachnoid space.
Clinical manifestations.
With an ophthalmoscopy, the pumping nerve disk appears looks like a root or oval-shaped deepening, having a white, gray or yellow color (Fig. 13.27).
The diameter of the disk of the optic nerve varies from 1/3 before 1/8 RD. Usually, the hole is localized in the temporal half of the disk, but can also be located in other sectors. The disease is more often unilateral. Bilateral dyski-nerve disk bilateral 15 % Cases. With one-sided defeat, an abnormal disk seems slightly increased compared to normal.
With a significant sizes of the disk, it is possible to obtain its sagittal slice using in-echography; For small sizes - optical coherent tomography.
Approximately B. 45-75 % Eye with a congenital disk of the optic nerve disk is developing a serous penetration of macula. Lineoff et al. (1988) examined the development of macular complications:
The path of intretinal liquid to the present moment is not exactly installed. Possible moanners are indicated in the literature:
- vitreal cavity through a hole;
- blood vessels at the base of the fossa;
- subarachnovdal space;
- allen vessels.
Conducted disk pump Macular retinosisis and retinal detachment develop in age 10- 40 years. The risk of macular complications is higher in cases where the pump of the optic nerve disk has big sizes and localizes in the temporal half of the disk. In cases where a macular detachment exists for a long time (within 6 Years and more), on the edge of the disk and / or along the border of the detachment, a pigment is postponed. Pigment deposits are due to impairment of a retinal pigment epithelium layer, in which extensive ending of defects are formed over time. G.Theodossiadis et al. (1992) found that in the existence of a macular detachment for 10 Years and more increases the size of the disk fifth, and its color becomes gray, which is probably due to loss or restructuring of glial tissue within the fifth.
Fluorescent angiography. In the arterial and arteriovenomic phases, the gradually increasing seeping of fluorescein in the neuroepithelium detachment zone towards the Maculeus is determined. In the early phases of the phage or indocyanic angiography of the disk, it usually does not pass a contrast agent. In the late phase phage or indocyanic angiography, there is a hyperflyluorescence of the disk beams and the area of \u200b\u200bthe macular detachment.
Psychophysical studies. The acuity of vision in patients with a hole of a disk of the optic nerve is maintained normal until the appearance of macular complications. TO 16 -years old because of the development of a macular detachment of neuroepitheli visual sharpness 0,1 and below are celebrated 80 % patients. Impact impacts are diversified and often do not correlate with the localization of the pog. With persistent macular changes, defects are progressing in the field of view. Cottrices detected in non-oolement correspond to the defects of the retina pigment epithelium detectors or phage.
Electrophysiological studies. ERG is maintained normal in most patients even in the case of macular complications. The SVP is not changed until the creation of a macular detachment. With the advent of macular complications in all cases, a decrease in the amplitude of the P100 component is noted. Less frequently, its latency.
Treatment. Conservative treatment, including dehydration therapy and local application of corticosteroids, inefficiently. Earlier, laser coagulation of the retina was used to block the fluid flow from the disk fox to the macule, but the effectiveness of this technique was rather low and difficult to be projected due to the impossibility of adequate overlapping of the retinocisis cavity using alone laser coagulation. Currently enjoy a combined method that includes vitrectomy, followed by intravitreal tamponade expanding perfluorocarbonane gas and barrier laser coagulation. Combined treatment makes it possible to achieve an increase in visual acuity in all patients, anatomical success - 87 % .
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A sprinkling nerve is quite rare congenital development anomaly, occurs in 1 per 11 thousand ophthalmological patients. Approximately 85% of cases, the disease is one-sided character, men and women are sick equally often. It is manifested between the ages of 20 and 40 years of reducing vision due to macular disorders.
Although the pathogenesis of the disease is not fully known, as a rule, it is associated with incomplete closure of the embryonic eye slit. No connection to the venge of the optic nerve with systemic diseases was not detected. Histologically detect the expansion and offset of the gluable channel, the introduction of the retina to the stem of the optic nerve, the rudimentary tissue of the retina in the disk area, the nerve fibers of the retina on the walls of the columma. It is inherited by autosomal-recessive type.
Ophthalmoscopically, the optic nerve is a rounded or oval recess in a sulfur dzn with clear boundaries of 1/8 to 1/2 diameter of the disk (Fig. 1). Usually, the fossa is localized in the temporal half of the DZN. Two pits are very rarely; The second in these cases is localized in the nasal half of the disk. The pits have a different depth, sometimes at the bottom of the vessels are visible. In most cases, the affected disc is increased in size.
The most frequent complication of the spawning nerve pits is a stratification (schist) of the retina in Macula. One of the probable reasons for the formation of retinocyssism in the macular region is the current of the cerebripinal liquid from the subarachnoidal into the subretal space. The penetration of intravitreal fluid through the yamper of the optic nerve, which, with a long existence, leads to the development of anti-macular edema and even through macular rupture. The treatment of the venge nerve pits is carried out with a decrease in visual acuity due to retinosisis and is currently a transciliary vitrectomy, a gas-air tamponade, possibly in combination with laser adoption on the edge of the pumm.
Optical chereten tomography Clearly illustrates the defects of the DZN and the stratification of the retina, the changes occurring in the Fovaa (Fig. 2, 3).
Fig. 1. Biomicroscopy of the eye bottom of the patient with a spatial nerve straw and retinocyisis, which captures the maculus. Himony is 0.1.
Fig. 2. Tomogram through maculus and optic patient's nerve with a spawning nerve. On the horizontal scan is determined by the stratification of the retina for several layers. The connection of intretinal and vitreal space was not revealed, while the channel is visible to the subarachnoid space.
Pathology of optic nerve in most cases is a consequence of common diseases, especially brain diseases. There are congenital anomalies for the development of optic nerve, inflammation (neuritis), stagnant nipples, atrophy, damage. Vascular violations in children are extremely rare. The pathology of the optic nerve, as a rule, leads to a violation of visual functions, which is the main symptom that patients notice. In the children's age! E diagnosis of diseases of the optic nerve is difficult and often late "discover, as children, especially preschoolers, usually do not notice violations of vision, especially with a unilateral process.
Anomalies of the optic nerve
Aplasia and hypoplasia disk optic nerve. Aplasy disk optic nerve - its innate absence, is a rare single or bilateral anomaly. It is often combined with other vices for the development of the eye and the central nervous system. In cases of true aplasia, there is no disk and fibers of the optic nerve, retinal ganglion cells and retinal vessels. Abnifications are absent (Francois J., 1961].
One of the embodiments of the anomaly is an aplasia of nervous structures in the normal development of mesodermal elements in the stem of the visual nerve and central vessels. This anomaly is called an aplasia of a disk or third neuron, retina.
The hypoplasia of the optic nerve disk is more common than its aplasia, but also quite rare. In the hypoplasia, the dispersion nerve disk on one or both eyes is reduced in size to 1/3-1 / 2 of its normal value. Often it is surrounded by a pigmentation zone. Vascular disk system is normally developed, the vessels are less often noted. With a x-ray study, it is sometimes revealed to decrease the size of the optic opening, which indicates the propagation of hypoplasia of the V. ProKoximal direction. The hypoplasia of the optic nerve disk is often combined with microftralm, aniridia, underdevelopment of the orbit. At the same time, the delay in psychophysical development, the hemiatrophy of the face on the side of the defeat may be observed. Spectating functions are sharply violated and depend on the degree of hypoplasia. With a combination of the hypoplasia of the disk of the optic nerve, "with nastagm and squint, as well as its weak severity, it is necessary to carry out differential diagnosis with amblyopy.
The anatomical essence of aplasia and hypoplasia disk of the optic nerve is the absence of all or part of the visual fibers. Anomaly arises as a result of a delay of rustling of fibers into the visual nerve channel, as a result of which they do not reach the disk.
Yameki. (deepening) in the disk of the optic nerve - often meeting congenital anomaly, the pathogenesis of which is not entirely clear. V.N. Arkhangelsky (1960) considers it as an option of the disk hypoplasia with a partial delay of rotation of nerve fibers, other authors associate the formation of the pits with the introduction of rudimentary retina folds into the interdavatic space of the optic nerve.
The pits are easily detected with an ophthalmoscopic study in the form of dark stains (since the bottom is not illuminated by an ophthalmoscope) with clear edges, oval, rounded and sliding form. More often, the holes are located in the temporal part of the disk, closer to its edge. Their size ranges from 1/2 to 1/8 of the disk diameter, the depth varies from a little noticeable up to 25 DPTR, sometimes the bottom is not visible at all. Often it is covered with a grayish vouales-different cloth; On the bottom can be visible vessels. Anomaly is more often one-sided. Pile can be single (more often) and multiple (up to 2-4). The central vessels, as a rule, are not changed and bypassing the pocket. More than half of the cases, with this anomaly, the eye detects cylineoretical artery.
The functions of the eye are often not changed. However, defects of the field of view can be detected: an increase in the blind spot, sectoral fallouts, less often central and paraventional cattle. The decline in view is usually associated with a variety of macular changes - from the picture of the central serous retinopathy, edema of varying degrees of severity, macular cyst, hemorrhages, various pigment disorders to coarse degenerative foci. The pathogenesis of changes in the macular zone is not entirely clear. Due to the location of the fossa in the temporal part of the disk, the meal of the Macula can be disturbed. The results of fluorescent angiography indicate the presence of a sub-tying current of the fluid from the hole to the yellow spot, which is obviously due to the violation of the permeability of the vessels in the pummage area.
Increased disk of the optic nerve (Megalopapilla) - rarely encountered anomaly, one- or bilateral. Discs can be increased to varying degrees, sometimes there is almost doubling their area. Anomaly is most likely due to an increase in the amount of mesodermal or supporting tissue under the invasion of the visual stem. The visual acuity can be reduced to varying degrees.
Inversion of the optic nerve disk - Its reverse, inverted location. It differs from the usual state of only an ophthalmoscopic pattern: there is a rotation of the disk 180 ° or, less often, 90 ° and less. The disk inversion can be combined with a congenital cone, often accompanied by refractive anomalies, as a result of which visual acuity is reduced.
Relevance.
The pump of the optic nerve disk (DZN) is quite rare congenital development anomaly, occurs in the 1st to 11 thousand ophthalmic patients. Approximately 85% of cases, the disease is one-sided character, men and women are sick equally often. It is manifested between the ages of 20 and 40 years of reducing vision due to macular disorders.
The most frequent complication of the yam of the DZN is a stratification (schist) of the retina in Makula. One of the probable reasons for the formation of retinocyssism in the macular region is the current of the cerebripinal liquid from the subarachnoidal into the subretal space. The penetration of intravitreal fluid through the DZN was not excluded, which, with a long existence, leads to the development of cystal macular edema and even through a macular gap.
Surgical treatment of the yammers of the DZN is to carry out vitrectomy, endolaseroagulation and gas-high tamponade of the vitreal cavity. Efficiency this method Low, which requires repeat interventions.
One of their approaches to the treatment of the yammers of the DZN is the creation of a fluid flow barrier into a macular zone by filling the yams on autologous scler. This technique is quite effective, but does not exclude the recurrence of the macular detachment and rather trauma.
Recently, the technology of using an autologous internal borderline membrane (VPM) was distributed to close the defects of the central retinal field.
Purpose.
Development of a new method of surgical treatment of a pump of the optic nerve disk using VPM.
Material and methods.
True 2 patients with a yam of ZN at the age of 25 and 37 years. The acuity of view before the operation was 0.01 and 0.25, respectively.
Technique surgery: Pre-perform transconductive 3-port 25G vitrectomy according to the standard technique, frequency - from 2500 to 5000 cuts per minute, vacuum - from 5 to 400 mm Hg. Standard dyes use standard dyes to detail the structure of the rear cortical layers of the vitreous body and VPS. The separation of the rear hyaloid membrane is carried out with aspiration technology, ranging from DZN, gradually lifting it to the periphery.
Then remove VPM in the macular zone, performing circular maculorexis. Next, begged to form the VPM flap, which is carried out in several consecutive actions. At the border of the Maculorexis on 6 hours using a micropintsta, the tip of the VPM from the retina is separated (Action 1). Then, capturing the tip of the HPM tip, carry out the membrane to the movement directed to the lower temporal arcade, without reaching it 0.5 mm (action 2). Next, they intercept the edge of the VPM and carry out its separation along the lower temporal arcade in the direction of the DZN for 2-3 hours of meridians (Action 3). After that, they intercept the edge of VPM and perform a movement similar to action 2, but in reverse direction And up to the border of circular maculorexis, thus separating the PRM site from the retina (action 4).
After the formation and removal of the first part, the VPS is proceeded to the formation of the second part of the VPM. To do this, return to the point, from where they started to perform 4, the plug is separated by the tip of the VPM from the retina, then, capturing the tip of the VPM, is carried out, the membrane is separated by the movement directed along the lower temporal arcade towards the DZN for 2-3 hour meridians (Action 5) , after which they intercept the edge of VPM and the action 4 (action 6) is repeated from this point, as a result of which the second part of the VPM is separated from the retina.
After the formation and removal of the second part of the VPM from the point, from where the action was started from, performing a circular movement towards the lower temporal arcade as much as it allows to separate the membrane (action 7).
As a result of the above-described actions between the VPM peeling zones, VPM flap is preserved. This flap turns over and laid on the DZN.
The next step is carried out by replacing the fluid into air, then 1.5-2.0 ml of PFOS is administered and in the MFOS medium using a tweezers, there is a slight compression effect on the flap above the yamm of the DMN. After that, they perform the replacement of PFOS into air on vacuum 30-40 mm Hg, not allowing a sharp jump jump during the aspiration of the PFOS, trying to remove the liquid as much as possible and exclude the flap offset.
The operation is completed by the introduction of 1 mm³ of 20% SF6 gas to the cavity until the light hypertonus is achieved.
Results.
In both cases, the intervention was fulfilled in full, intraoperative complications, including nuclear damage, not marked.
Observation period - up to 12 months. In both patients, according to optical coherent tomography, the reduction of a macular detachment, the sealing of the yam of the DZN was observed. Visual acuity by the end of the observation period was 0.1 and 0.5, respectively.
The key step of the proposed technique that promotes the achievement of favorable anatomical results is the formation of the VPM flap and the closing of the DZN fumes, which allows it to be placed and create a fluid barrier in a macular zone.
Conclusion.
The developed method of surgical treatment of the pump of the optic nerve disk is promising and requires further research on a larger clinical material for a reliable assessment of its effectiveness.
Abstract
The Study Purpose Was To Evaluate The Effectiveness of the Central Serous ChoroidOdopathy Prevention Method in Patients with Optic Nerve Pit. Material and Methods: 19 Patients (38 Eyes) with Optic Nerve Pit Associated with Refractive Anomalies and Retinal Dystrophy Which Had Been Treated in Republican Eye Hospital in 2010-2012. According to Obtained Results The Effectiveness of Prophylactic Neuroprotective Therapy in Patients with Optic Disc Pit Has Been Proven, Which Allows Reducing The Risk of Central Serous Choroidopathy and Avoiding The Loss of Visual Function.
The relevance of the detected congenital pathology of the organ of vision is 2-4%. Of these, the anomalies of the optic nerve disk (DZN) - 15%, accompanied by a decrease in visual functions - 7%. Many congenital anomalies may cause pathological conditions in an adolescent or adult period, for example: a fossa, oblique entry, DzN Druz, Leber Amavroz, etc., which are up to 3%. It is assumed that the development of the yam of the DZN is associated with the introduction of the folds of rudimentary retinal tissue into the space of the optic nerve. There are changes in the edge of the disk with the formation of the pocket, sometimes filled with glial cloth. Between Makula and the disk in the retina, the number of nerve fibers, neuroepithelia and the outer granular layer are reduced. At the location of the fossa in the temporal department in patients, the development of central serous choriopathy is often observed. Development of measures for the prevention of the development of central serous choriopathy in patients with a NCN hole remains one of the important directions in ophthalmology and requires the search for new more effective methods. The purpose of this work was to assess the effectiveness of the method of prevention of central serous choriopathy in patients with a yamm of the DZN. The material and methods of the study material served as a comprehensive examination of 19 patients (38 eyes) with yamms of DZN, accompanied by the abnormalities of refraction and retinal dystrophy, which were in the Republican Clinical Ophthalmological Hospital of the Ministry of Health of the Republic of Uzbekistan from 2010 to 2012. Standard ophthalmic examination methods were conducted with all patients: collection of anamnesis, visometry, tonometry, refractometry, perimetry on white, red, green, blue, ophthalmoscopy with eyeball photoregation, optical coherent tomography, study of the critical frequency of merging flashes, electrophysiological research methods (ERG, ZVP). If necessary, the examination was supplemented with magnetic resonant tomography (MRI) of the brain, advisory inspections of the therapist, neuropathologist or neurosurgeon. In order to assess the effectiveness of the proposed preventive measures, patients were divided into 2 groups. The first group (9 patients; 18 eyes) amounted to patients who were prescribed by traditional therapy for the treatment of yammets of DZN and anomalies of refraction (vitaminotherapy, angioprotectors, antioxidants, barrier laser buds). Patients of the second group (10 patients; 20 eyes), along with traditional methodsThe neuroprotective therapy was obtained (cerebrolysin - 0.5 ml of parabulbarno No. 10 and nucleo CMF forte 2.0 intramuscularly No. 6). Dates of the re-examination: 3, 6, 10, 30, 180 days. For the results of the treatment, data was taken on 180 hours of examination. The groups were randomized by sex, age, the main disease and visual functions. The results of the study in assessing the effectiveness of comprehensive therapy, we found that if, before the treatment of visual acuity, in the 1st group was 0.09 ± 0.02, and in the 2nd group - 0.07 ± 0.02, then after the treatment of the magnitude These indicators were increased in the 1st group to 0.13 ± 0.02, and in the 2nd group - to 0.29 ± 0.01 (Fig. 1). As a result of traditional treatment in the 1st group of visual acuity, it was increased by 0.048 ± 0.01, and in the 2nd group with the inclusion of neuroprotectors and laser coagulation - by 0.19 ± 0.05. The acuity of view in the second group had a reliable difference with the initial indicators (P< 0,05), в отличие от первой группы. При изучении данных электрофизиологического исследования нами также была отмечена тенденция к улучшению показателей зрительно вызванных потенциалов (ЗВП), электроретинограмм (ЭРГ) и критической частоты слияния мельканий (КЧСМ). Полученные данные представлены в виде диаграммы на рисунке 2. При использовании нейропротекторной терапии в комплексном лечении ямки ДЗН отмечалось более существенное улучшение электрофизиологических показателей, особенно ЗВП и КЧСМ, в отличие от показателей 1 группы больных. Центральная серозная хориопатия развилась на 3-х глазах в 1 группе наблюдения и ни в одном случае во 2 группе. При далеко зашедших стадиях заболевания проводились повторные курсы лечения с целью снижения риска развития отслойки сетчатки и потери зрительных функций. Заключение На основании полученных результатов считаем целесообразным назначение нейропротекторной терапии с целью профилактики развития центральной серозной хориопатии у больных с ямкой зрительного нерва. Использование нейропротекторов, наряду с традиционной терапией, у больных с ямкой диска зрительного нерва положительно влияет на динамику показателей остроты зрения, ускоряя восстановление зрительных функций.
Rustam Asralovich Zakirhodjaev
Tashkent Institute Of Postgraduate Medical Education, Ministry of Health, UzbekistanEmail: [Email Protected]
MD, PhD, Associate Ophthalmology Department
