Ponomarchuk V. The effectiveness of a modified staged method of treatment of patients with proliferative diabetic retinopathy

The dissertation is devoted to the actual problem of clinical ophthalmology - to increase the effectiveness of the modified step - by - step method of treatment of patients with proliferative diabetic retinopathy. To solve these problems, experimental studies were conducted on 89 eyes of 79 patients with proliferative PDR. At the first stage, the study of the dependence of the level of total VEGF in 41 patients (45 eyes) aged 19 to 81 years with proliferative DRP without prior antiangiogenic therapy depending on the general clinical condition of the patient (type, history of diabetes, hypertension) and features of ophthalmic hypertension status. It was found that the level of VEGF in the vitreous in patients with proliferative PDR averages 757.69±117 pg/ml. There was no significant difference between the level of VEGF in patients with PDR depending on the general clinical condition of the patient (type and experience of diabetes, hypertension), the presence of IOL and history of panretinal lasercoagulation. There was a significant increase in the concentration of VEGF in the vitreous in patients with fibrovascular epiretinal membranes (ERM) in the presence of a pronounced proliferative component which averaged 997.0 ± 151.8 pg/ml, while in patients with fibrovascular ERM with a moderate proliferative component - 244.9±53,7 pg/ml (p = 0.002). In the second stage, we determined the level of VEGF in the vitreous and studied the features of vitrectomy (VE) in patients with proliferative PDR after previous intravitreal injection of various doses of aflibercept. 75 patients (75 eyes) were monitored during this fragment of the study. The concentration of VEGF in vitreous in patients with PDR after intravitreal injection of aflibercept is significantly reduced regardless of the dose (1 or 2 mg) and the time after administration (3 or 5 days) almost twice. Preoperative administration of 1.0 mg or 2.0 mg of aflibercept is equally effective by reducing the concentration of VEGF in vitreous, reducing the risk of intraoperative hemorrhagic complications, the need for silicone endotamponade and, accordingly, reducing the duration of vitrectomy by 14 minutes. To determine the morphological and ophthalmoscopic features of ERM after intravitreal administration of different doses of aflibercept in patients with proliferative PDR, 75 people (75 eyes) were also studied. According to our studies, the use of aflibercept before vitrectomy in patients with proliferative diabetic retinopathy leads to fibrotization of epiretinal ERM with a pronounced proliferative component, which is detected ophthalmoscopically and by microscopic studies. The degree of ERM fibrotization and obliteration of newly formed vessels depend on the dose of aflibercept administered intravitreal. Thus, complete obliteration of newly formed vessels of ERM was observed for 3 days with intravitreal administration of 2.0 mg of aflibercept, while with the use of 1.0 mg of the drug - for 5 days. Preoperative intravitreal administration of 1.0 mg of aflibercept in patients with proliferative diabetic retinopathy reduces the likelihood of complications associated with sealing of the ERM, increased traction component and retinal detachment. The aim of the further study was to study the features of the ultrastructure of ERM in patients with PDR after intravitreal injection of different doses of aflibercept. To determine the features of the ultrastructure of epiretinal membranes in patients with proliferative PDR after intravitreal injection of different doses of aflibercept, 5 patients (5 eyes) were studied. Thus, we found that intravitreal injections of aflibercept lead to narrowing and obliteration of newly formed microvessels, depending on the dose administered and the length of stay in the vitreous. Reducing the number of fenestres in the endothelial cells of newly formed capillaries in the dynamics of the study prevents the infiltration of plasma substances around the vascular space. In general, the development of destructive processes in the ERM and obliteration of newly formed vessels after intravitreal injection of aflibercept prevents hemorrhage and easier removal. To assess the effectiveness of the method of combined surgical treatment of patients with neovascular-glial form of proliferative PDR under our supervision were 75 patients (75 eyes). The results of our study show that intravitreal injection of aflibercept (1.0 mg and 2.0 mg) before vitrectomy in patients with PDR statistically significantly increases visual acuity 2 months after surgery, reduces the incidence of hemorrhagic complications in the early postoperative period, 2 months after the intervention, and reduces the risk of developing iris rubeosis in the remote period (6 months). Key words: proliferative diabetic retinopathy, aflibercept, epiretinal membrane, vitrectomy, intravitreal injection, surgery, diabetes mellitus type 2, vitreoretinal surgery, hyperglycemia.