Vol 15, No 2 (2024)
- Year: 2024
- Published: 15.07.2024
- Articles: 13
- URL: https://journals.eco-vector.com/clinpractice/issue/view/8779
Full Issue
Original Study Articles
Dynamics of indicators of the vascular membrane of the ciliary body in predicting the risk of diabetic retinopathy in pregnant women with diabetes mellitus
Abstract
BACKGROUND: According to statistics, microvascular complications of diabetes mellitus are registered in a third of patients during their lifetime, and diabetic retinopathy is the main cause of irreversible blindness in people of reproductive age. Changes in the vascular membrane of the eye in patients with diabetes mellitus are currently being studied as predictors of the progression of diabetic retinopathy. Further study of changes in the vascular membrane in pregnant women with type 1 and type 2 diabetes may help in identifying criteria for the manifestation and progression of diabetic microangiopathy.
AIM: To develop a methodology for predicting the risk of diabetic retinopathy progression by analyzing the dynamics of the state of the vascular membrane of the ciliary body.
METHODS: The study was conducted in each trimester of pregnancy. A pregnant patient with confirmed diabetes mellitus 1 or diabetes mellitus 2 underwent a comprehensive ophthalmological examination, including visometry with maximally corrected visual acuity, tonometry, biomicroscopy of the anterior segment of the eye, ophthalmoscopy under conditions of drug-induced mydriasis (phenylephrine) with a high-diopter lens (78–90 D), and optical coherence tomography of the anterior and posterior eye segments.
RESULTS: With an increase in the thickness of the vascular layer of the ciliary body by ≥10% at one or more points compared with the study conducted in the first trimester of pregnancy, the patients exhibited diabetic retinopathy progression during subsequent routine examinations. Quantitative analysis of the vascular layer of ciliary body revealed the transition of diabetic retinopathy to its next stage; however, photoregistration of the fundus did not show obvious signs of transformation into another stage of the disease.
CONCLUSION: Dynamic examination of the thickness of the vascular layer of the ciliary body during gestation and its increase by 10% from the initial one enables prediction of progression of diabetic retinopathy to the next stage.
7-19
The effect of intravitreal antiangiogenic diabetic macular edema treatment on the corneal endothelium cell count
Abstract
BACKGROUND: Antiangiogenic treatment of diabetic macular edema is a first-line therapy in modern ophthalmology. Novel antiangiogenic drugs are increasingly being developed to improve treatment results and solve certain issues. However, owing to the advent of new drugs, more questions arise about their effect on the patient’s retina and other structures of the eye, such as the cornea.
AIM: The study aimed to investigate the effect of intravitreal administration of the anti-VEGF drug brolucizumab on the corneal endothelium in patients with diabetic macular edema.
METHODS: 106 patients (106 eyes) were included in the prospective study: 31 men and 75 women. The main group consisted of 56 patients (56 eyes) were included in the prospective study: 14 men and 42 women with different stages of diabetic retinopathy with diabetic macular edema, the average age of patients was 62.2±8.4 years. The average number of endothelial cells per 1 mm2 in these patients before the loading dose of brolucizumab was 2378.9±393.3 cl/mm2. The control group included 50 patients (50 eyes) without diabetes who did not receive intravitreal injections or any other surgical interventions on the examined eye for 1 year. All patients underwent endothelial microscopy using the Tomey EM-4000 endothelial microscope (REN 2017/6294), estimated: CD (the number of endothelial cells per 1 mm2); CCT (the central thickness of the cornea, microns); CV (the coefficient of variation, %); 6A (the proportion of hexagonal cells, %). All study participants received intravitreal injections of brolucizumab in a volume of 0.05 ml (5 injections with an interval of 6 weeks).
RESULTS: In the main group before intravitreal injections, the indices of the central corneal thickness and the number of endothelial cells per 1 mm2 were 549.7±30.1 microns and 2378.9±393.3 cells/mm2, respectively. After a course of antiangiogenic diabetic macular edema therapy, the central thickness of the cornea was 548.2±30.6 microns, and the number of endothelial cells per 1 mm2 was 2382.3±424.9 cells/mm2. The indicators CV (coefficient of variability, %) and 6A (proportion of hexagonal cells, %) before the start of intravitreal injections were 36.9±5% and 46.8±6.3%, respectively, after the introduction of the loading dose drugs, the average values were 37.9±4.3% and 45.8±6.3%. Changes in all indicators were not static significant.
CONCLUSION: The use of brolucizumab as therapy in patients with diabetic macular edema did not cause a negative effect on the cornea, there were no statistically significant changes in the central thickness of the cornea, the number of endothelial cells per 1 mm2, the coefficient of variation and the proportion of hexagonal cells.
20-28
Secondary silicone-induced glaucoma after vitrectomy for regmatogenic retinal detachment
Abstract
BACKGROUND: Retinal detachment is a leading cause of impaired vision and blindness, affecting 2–9% of individuals. Research has shown that local immune-inflammatory processes contribute significantly to the development of this condition. Polymethylsiloxane has long been used as a tamponade substance in the treatment of retinal detachment. It is currently utilized in various forms of retinal detachment as well as in the management of complications such as retinal edge folding and vitreous opacity. However, the use of silicone oil in the vitreous cavity can lead to the development of secondary ocular hypertension and glaucoma, with prevalence rates ranging from 2.2% to 64.2% according to studies.
AIM: Conduct a comparative analysis of biochemical and morphometric indicators and justify the expediency of conducting immune therapy for patients with secondary silicone-induced glaucoma.
METHODS: A prospective study included 22 patients (22 eyes) in the main group and 22 patients in the comparison group (22 eyes). The average age of the patients was 55±5.3 years (46–68 years), with 28 females and 16 males. Patients in the main group received anti-cytokine therapy (aminopropyldithioethylene-diamine sodium and anakinra). The primary endpoint of the study was the assessment of retinal nerve fiber layer thickness and perimetric indices.
RESULTS: The results revealed an inverse relationship between cytokine levels and retinal nerve fiber layer thickness in patients who underwent vitrectomy with silicone tamponade. Additionally, a direct relationship was observed between the diameter of emulsified silicone in the anterior chamber and cytokine levels. The impact of mechanical fragmentation of polymethylsiloxane during nystagmus and direct toxic effects on optic nerve fibers requires further investigation. The study also highlighted the need for more accurate methods of selecting anterior chamber fluid for evaluating the effectiveness of immune therapy. Determining the appropriate dosage, duration, and administration method of anti-cytokine drugs also requires further research. Evaluation of ophthalmotonometric indicators, retinal nerve fiber layer thickness, and mean deviation revealed significantly better outcomes in patients receiving anti-cytokine therapy compared to the control group.
CONCLUSION: The findings of this study support the use of anti-cytokine therapy to normalize biochemical parameters in the anterior chamber and reduce clinical manifestations of secondary silicone-induced glaucoma.
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Solitary cutaneous neoplasms: analysing the uncertain behaviour with the aid of histopathology
Abstract
BACKGROUND: Skin tumours can be classified as either benign or malignant, resulting due to the proliferation of one or more components of the skin. Reportedly, there has been a rise in the prevalence of skin cancer in recent decades, which has led to rely on histological evidence to distinguish between various types of skin cancer.
AIM: This study aims to provide a comprehensive description of the occurrence, symptoms, unpredictable nature, and range of histopathological spectrum in different types of skin tumours.
METHODS: This prospective research was conducted in the outpatient department of the Department of Dermatology at the Government General Hospital in Anantapur from July 2019 to July 2023. Patients who did not provide informed consent, those with infectious or cystic swellings, or those with multiple lesions were excluded from this study. Histopathological confirmation is obtained from all excisional biopsies of single cutaneous swellings, and tumours are classified based on the criteria established by the World Health Organization (WHO).
RESULTS: The study included a total of 123 individual cutaneous tumours, with 98 cases (79.67%) being classified as benign and 25 cases (20.32%) classified as malignant. The age group most affected is adults between the ages of 26 and 44, with a prevalence rate of 31.7%. Following closely behind are middle-aged individuals, with a prevalence rate of 30.08%. The males constitute 46.34% (57 cases) and the females constitutes 53.65% (66 cases). The extremities were the most frequently affected site, accounting for 53 cases (43.08%), followed by the head and neck region (29.26%). Based on the WHO classification of skin tumours, there were 42 cases (34.14%) of subcutaneous tissue tumours and 31 cases (25.20%) of soft tissue tumours. The prevalence of keratinocyte tumours is 26 (21.13%), whereas appendageal tumours account for 16 (13%) of cases. Melanocytic and neural tumours are the least prevalent, each representing 4 (3.25%) of cases. The majority of benign tumours arise from the subcutaneous tissues, whereas malignant tumours grow from keratinocytic differentiation.
CONCLUSION: Our study revealed that the majority of tumours displayed ambiguous clinical behaviour, which resulted in erroneous diagnoses. Hence confirmation by histopathology is crucial for accurate diagnosis and prompt management.
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Reviews
Post-COVID asthenia, sarcopenia and muscle weakness among geriatric patients
Abstract
Sarcopenia, asthenia, and motor activity restriction are common among geriatric patients in the post-COVID period. The SARS-CoV-2 virus triggers a cytokine storm in the human body and induces a direct viral effect on skeletal muscles. Manifestations of post-acute sequelae of COVID-19 (PASC) can include organ and system dysfunction, asthenia, muscle weakness, dyspnea, chest pain, cognitive impairment, depression, anxiety, and sleep disorders. Hypoxemia, comorbidity, and prolonged inactivity contribute to changes in the structure and functionality of the muscular fibers. One of the recent studies is ALMI-index, which indicates that a decrease in muscle mass of the upper and lower extremities may cause functional limitations in patients with long-COVID conditions. Rehabilitation of patients with post-COVID syndrome involves daily exercise with weights, considering load tolerance; mandatory medication; and nutritional and psychological support.
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Сontribution of circadian rhythms to the development of neurological disorders after prolonged anesthesia
Abstract
Despite the improvement of pre-, intra- and postoperative care methods, the problem of the development of postoperative neurological complications following prolonged anesthesia remains. A mechanism of occurrence of these complications may be circadian rhythm disorders. This article presents a review of the literature data on the prevalence, pathophysiological mechanisms, and risk factors of postoperative autonomic and circadian disorders. Notably, circadian rhythm disorders in surgical patients are observed at several levels: disruption of the sleep and wakefulness cycle, decreased melatonin secretion, instability of cortisol levels and body temperature, and changes in the vegetative balance towards sympathetic regulation. These disorders contribute to the development of postoperative pain and cognitive and anxiety-depressive disorders, hinder effective rehabilitation, and may be associated with postoperative mortality.
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Case reports
Clinical examples of correct orientation of a toric intraocular lens in patients with postkeratotomic corneal ectasia
Abstract
BACKGROUND: Surgical treatment of cataract in patients with postkeratotomic corneal ectasia has various features. First, difficulties arise when calculating the optical strength of an intraocular lens and its cylindrical component and determining the location of the main axes of astigmatism for toric intraocular lens implantation. Additionally, not all modern keratotopography installations are able to accurately determine the refractive power of the cornea in such patients owing to pronounced irregular astigmatism and a large difference in keratometric parameters in the main meridians.
CLINICAL CASES DESCRIPTION: Two clinical cases of surgical treatment of cataract in combination with postkeratotomic keratectasia are presented. Patients underwent a standard preoperative ophthalmological examination. TMS-4 Tomey keratotopograph was used to accurately determine the refractive power of the cornea. The optical power of toric intraocular lens were calculated using the Holladay 2 formula with amendments for radial keratotomy and the Johnson & Johnson VISIC online calculator. SN6AT9 intraocular lens (Alcon) and a Tecnis ZCT800 toric intraocular lens (Johnson & Johnson) were implanted in patients. The orientation of the position of the cylinder axis of toric intraocular lens was performed perpendicular to the most flattened meridian, corresponding to the position of the keratectasia zone, determined by the most expanded keratotomy scar. Before surgery, the best corrected visual acuity of patient M was OD=0.2, OS=0.4 and that of patient K was OD=0.4, OS=0.2. After surgery, the best corrected visual acuity of patient M was OD=0.8, OS=0.8 and that of patient K was OD=0.8, OS=0.7.
CONCLUSION: This study aimed to familiarize practicing ophthalmologists, clinical residents, and postgraduates with a possible treatment option for cataracts by phacoemulsification with implantation of a toric intraocular lens in patients with postkeratotomic keratectasia. The resulting high visual acuity and subjective satisfaction of patients indicate the accuracy of chosen treatment tactics. A reliable visual guide for choosing the cylinder axis is the meridian of the greatest degree of keratectasia (cornea flattening), which is determined by the maximally expanded keratotomy scar position. The intraocular lens cylinder axis is oriented perpendicular to the keratectasia meridian. Ultrasound phacoemulsification of cataract with implantation of a toric intraocular lens is an effective method for correcting induced ametropia after radial keratotomy against the background of postkeratotomy keratectasia with high astigmatism.
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Surgical treatment of secondary refractory glaucoma in chronic uveitis with corneal dystrophy (clinical case)
Abstract
BACKGROUND: Uveitis is the inflammation of the iris, ciliary body, vitreous, retina, or vascular membrane, in which the most common complication is a secondary increase in intraocular pressure that is difficult to compensate with antihypertensive drugs. Ahmed valve implantation in uveal glaucoma is an effective surgical method to reduce intraocular pressure.
CLINICAL CASE DESCRIPTION: In the Department of Surgical Treatment of Glaucoma of the S. Fyodorov Eye Microsurgery Federal State Institution, Ahmed valve implantation was performed in two patients with refractory, repeatedly operated uveal glaucoma. As a result of valve implantation, in both cases, compensation of intraocular pressure within up to 15 months after surgery was possible.
CONCLUSION: Ahmed valve implantation in secondary uveal repeatedly operated glaucoma in patients with chronic uveitis and corneal dystrophy achieved compensation of intraocular pressure and preserved visual functions.
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Treatment of a patient with massive osteochondral exostosis of the radial neck: clinical case
Abstract
BACKGROUND: Osteochondroma (osteochondral exostosis) is the most common benign neoplasm of bone tissue, accounting for up to 9% of all bone tumors. Possible manifestations of a single osteochondral exostosis are pain, a limited range of motion, compression of vascular or neural structures, and crepitus. The literature describes several clinical cases of the treatment of patients with osteochondral exostosis of the proximal radius. A distinguishing feature of the proximal radius’s anatomy is the close location of such anatomical structures as the posterior interosseous nerve, the enthesis of the distal biceps tendon, and the proximal radioulnar joint.
CLINICAL CASE DESCRIPTION: This clinical case for the first time describes osteochondroma of the radial neck, which causes supination deficiency.
CONCLUSION: The surgical treatment allowed us to achieve excellent treatment results with the complete restoration of the function and range of motion in the elbow joint. The key aspect is the knowledge of this segment’s anatomy.
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Features of clinical manifestations, diagnosis and treatment of Bertolotti syndrome: а clinical case
Abstract
BACKGROUND: One of the causes of pain in the lumbar spine may be congenital spinal column malformations. Bertolotti syndrome is a clinical and radiological symptom complex associated with sacralization of the LV vertebra, leading to disruption of the biomechanics of the lumbosacral spine and accelerated degeneration of facet joints and intervertebral discs, followed by foraminal and central stenosis of the spinal canal. The clinical manifestations of the disease can be polymorphic, and their cause is multifactorial. Thus, along with pain in the lumbar spine, patients with sacralization of the LV vertebra suffer from numbness and paresthesia in the lower extremities. The incidence of pathology ranges from 4% to 8%, mainly affecting elderly and mature people.
СLINICAL CASE DESCRIPTION: Patient S was born in 1982 with long-term nonspecific pain in the back and lower limb; she presented to the Neurosurgical Department of the Irkutsk Scientific Center for Surgery and Traumatology. During a clinical neurological examination and additional introscopic studies of the lumbar spine, dorsopathy diagnosed. Degenerative spondyloarthrosis LIV–LV grade III according to D. Weishaupt. Sacralization of the LV vertebra type IIa according to Castellvi A.E. Syndrome of lumbar ischialgia on the right. Persistent pain and muscle-tonic syndrome. Minimally invasive interventional treatment was performed: pulsed radiofrequency ablation of the dorsal ganglion and radicular nerve at the level of the foraminal openings LIV–LV on the right and thermal radiofrequency ablation of the recurrent nerve of Luschka at the level of LIV–LV and LV–SI on the right. In the postoperative period, the intensity of the pain syndrome decreased, and the patient was discharged to work.
CONCLUSION: A promising method of minimally invasive surgery is radiofrequency ablation in the area of neoarthrosis for denervation and relief of pathological pain impulses. Assessing the patient’s complaints, carefully collecting anamnesis, interpreting data from a clinical and neurological examination, and introscopic methods of examining the lumbar spine enables establishing an accurate diagnosis and selecting the most effective treatment method.
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Pyruvate dehydrogenase deficiency in a young boy: a clinical case
Abstract
BACKGROUND: Pyruvate dehydrogenase deficit is a severe hereditary mitochondrial metabolic disease characterized by impaired energy metabolism and manifested by a wide range of neurological symptoms. The difficulty in selecting therapy is due to insufficient data on the management of children with this pathology owing to death at an early age and insufficient diagnosis during life. The accurate prevalence of the disease is unknown, presumably <1 in 1,000,000, which makes it attributable to orphan diseases.
CLINICAL CASE DESCRIPTION: This article presents a case of a child with a rare neurometabolic disease pyruvate dehydrogenase complex E1 deficiency. The diagnosis was suspected after his birth based on neurological symptoms, neonatal hyperammonemia, and hyperlactatemia and confirmed after exome sequencing, where a homozygous variant of the nucleotide sequence in the PDNA1 gene (X-19359612-C-E) was determined. At the age of 2 months, he began to receive a ketogenic diet — a high-fat, low-carbohydrate dry mixture for enteral nutrition, metabolic therapy, and Vit B1 (300 mg/day). The article presents indicators of biochemical blood testing, acid-base state of blood, and dynamics of the neurological picture during the period of observation of the patient.
CONCLUSION: Early diagnosis and initiation of therapy is crucial for the physical and neuropsychiatric development of children with this pathology. Despite the lack of highly effective etiotropic treatment, in some cases, an improvement in the clinical course is observed with the use of thiamine preparations and adherence to a ketogenic diet.
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A clinical case of acute polyneuropathy, with the onset of bilateral facial nerve palsy in an early childhood
Abstract
BACKGROUND: The differential diagnosis of peripheral nervous system damage depends on a thorough collection of history, comprehensive assessment of clinical manifestations, and dynamic examination of the patient. This article describes a clinical case of acute polyneuropathy in a young child, which began with gastrointestinal symptoms and bilateral facial neuropathy.
CLINICAL CASE DESCRIPTION: The article presents a case of a child with an atypical course of acute polyneuropathy, which began with bilateral facial neuropathy combined with gastrointestinal complaints and pain syndrome. Features of the clinical presentation of the disease required extended laboratory and instrumental testing. Protocols for instrumental verification of diagnosis included nerve conduction studies examining neural conduction and axonal excitability of the affected facial nerve and the healthy side. Additionally, the functional status of the peripheral nerves in the upper and lower limbs was assessed. Polyneuropathic alterations revealed through nerve conduction studies confirmed diagnostic lumbar puncture to determine the presence of neuroinfectious processes. Magnetic resonance imaging of the brain, brachial, and lumbosacral plexuses using intravenous contrast showed the nature and prevalence of a lesion. Based on the overall clinical, laboratory, and instrumental examination data of the patient, “acute inflammatory demyelinating polyneuropathy” was diagnosed; timely etiopathogenetic treatment was initiated.
CONCLUSION: In children, the course of a neuroinfection may be atypical. Sometimes, when dissociating the clinical manifestations of the disease from the results of a standard laboratory and instrumental test, expert diagnostic techniques should be used for differential diagnosis purposes.
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Outpatient regenerative therapy of a chronic diabetic foot ulcer with exposed bone surface
Abstract
BACKGROUND: Treatment of deep chronic wounds with the bone tissue involvement against the background of lower limb atherosclerosis and diabetic foot syndrome does not fit any reasonable hospital stay duration and at the same time has no effective outpatient methods. Therapy with conditioned medium derived from human mesenchymal stem cells (CM-MSC) may be a solution for this problem.
CLINICAL CASE DESCRIPTION: Patient F., 77-year-old, arrived for an outpatient treatment of local necrosis in the area of the 1st toe of the left foot in April, 2022. The main diagnosis: Peripheral arterial disease of the lower extremities. Multifocal atherosclerosis. Occlusion of the superficial femoral and popliteal arteries, diffuse lesions of the lower leg arteries on the left. Chronic arterial insufficiency of the 4th degree. Attempts of revascularisation of the left lower limb. Limited gangrene (Wagner IV) of the 1st toe of the left foot. Associated diseases: insulin-dependent type 2 diabetes mellitus (for more than 30 years). Diabetic polyneuropathy. Diabetic foot syndrome, neurotrophic form. Local treatment was performed by the microsurgical debridement of the affected surface in combination with the method of multilayered dressings, according to the previously patented technology. The microsurgical treatment of the bone surface in the wound area was carried out with the use of CM-MSC. Positive dynamics in the form of a partial closure of the bone fragment with soft tissue was observed on the sixth month of therapy. The complete closure of the open bone fragment was observed in 12 months from the beginning of the outpatient treatment.
CONCLUSION: The developed method of treatment using CM-MSC can be effective for chronic wounds with open bone surfaces.
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