Hemophthalmus

Hemorrhages in the vitreous humor usually occur with changes in the walls of the vessels of the retina and the vascular tract.

They burst during injuries and during intraocular operations, as well as as a result of inflammatory or degenerative processes (hypertension, atherosclerosis, diabetes mellitus).

[1], [2], [3], [4]

Causes of the hemophilia

Among the causes of hemorrhage in the vitreous humor, traumatic injuries of the organ of vision, accompanied by hemorrhages in more than 75% of cases, take the leading position.

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Symptoms of the hemophilia

The first signs of hemorrhage in the vitreous humor are the weakening or absence of reflex from the fundus, a decrease in vision of various degrees, up to its complete loss. In these cases, the vitreous humor seems reddish, and blood is often visible behind the lens.

The diffuse and massive hemorrhage in the vitreous body is denoted by the term "hemophthalmus". To establish the degree of filling the eye cavity with blood, diascleral translucence is performed with a diaphanoscope. Glow of sclera testifies to local hemorrhages in the vitreous body. The absence of luminescence at the maximum intensity of the light beam indicates a massive hemorrhage, or hemophthalmia.

The outcome of hemorrhages, as well as the formation of vitreal opacities of one type or another depend on the nature and severity of the trauma, the volume of blood flow, its localization, the reactivity of the organism, the duration of the pathological process and the fibrinolytic activity of the vitreous. However, regardless of the factors influencing the outcome of the hemophthalmus, this pathological condition is characterized by interrelated processes, the main ones of which are hemolysis, blood diffusion, fibroblast proliferation and phagocytosis.

Hemolysis and blood diffusion in terms correspond to the middle of the 1st - the end of the 2nd week after the hemorrhage. The blood is in the form of strands and ribbons along the course of the fibrous structures of the vitreous. In the course of hemolysis whole red blood cells become smaller, only their "shadows" and fibrin are determined. By the 7th-14th day, cell-free film formations consisting of fibrin and lysed erythrocytes oriented along the fibrous structures of the vitreous body are formed in the injured eye. A feature of this stage of hemophthalmic flow is acoustic noninformativity, since the length of an acoustic wave is commensurate with the value of lysed blood cells, so the vitreous on sonograms looks acoustically homogeneous. Later, within 2-3 weeks, more coarse opacities are formed due to fibroblast proliferation.

[6], [7], [8]

Treatment of the hemophilia

Conservative treatment, which usually takes place in the early stages, should be aimed at resolving the hemorrhage and preventing its recurrence. For this purpose, it is advisable to use angioprotectors and vikasol.

After 1-2 days after hemorrhage complex treatment is shown, the main component of which is resorption therapy. In these cases, heparin is used (0.1-0.2 ml - up to 750 ED) in combination with dexazone (0.3 ml) as subconjunctival injections.

The main pathogenetically oriented method of treatment in the early period is fibrinolytic therapy to increase the fibrinolytic activity of the vitreous and resorption of hemorrhage. For this purpose, streptode- case (immobilized streptokinase) is used, which transfers inactive plasminogen to an active enzyme capable of cleaving fibrin. The drug has a prolonged action, it is administered retrobulbarno or subconjunctivally in a dose of 0.1-0.3 ml (15 000-45 000 FE), as a rule, once a day for 2-5 days. Taking into account the fact that streptodecase is an antigenic preparation, 0.3 ml of a 0.1% solution of dexazone is injected into the conjunctiva prior to its administration. Subconjunctival administration of fibrinolytic agents is recommended in the presence of hyphema and hemorrhages in the anterior third of the vitreous humor.

When localized vitreal hemorrhages in the middle and / or posterior third of the vitreous humor, it is advisable to inject streptode- case retrobulbarno.

With hemophthalmia processes of lipid peroxidation are significantly activated, as a result of which hydroperoxides and hydroperoxide radicals accumulate, which have a damaging effect on the lipid layer of cellular and membrane formations. To reduce the activity of peroxidation processes, it is recommended to use antioxidants (emoxipine and taufon).

Hemorrhages in the vitreous can be accompanied by an increase in intraocular pressure to 35-40 mm Hg. As a result of a temporary blockade of the outflow pathways by products of blood decay. Increase in intraocular pressure is stopped with the help of hypotensive therapy.

Surgical treatment of traumatic hemophthalmia

The results of numerous studies suggest that the pathological changes in the vitreous humor in traumatic hemophthalms are due to profound disturbances in the cycle of metabolic processes in the vitreous humor and surrounding tissues, which are accompanied by a violation of the acid-base state, the accumulation of intermediate metabolic products, which in turn renders adverse effect on the further course of metabolic reactions. The so-called vicious circle is formed, in connection with which the removal of the vitreous body - vitrectomy - acquires a pathogenetic orientation. During vitrectomy, the vitreous body is dissected into small parts, removed. From the cavity of the eyeball and simultaneously mix with a balanced saline solution.

Vitrectomy can be performed with the opening of the eyeball (open vitrectomy) and with the help of special instruments (fiber illuminators, tips of irrigation and aspiration and cutting systems) that are injected into the eye through one or two punctures (closed vitrectomy).

The process of vitrectomy consists in capturing a small portion of the vitreous body with a vacuum needle of vitreotome with the help of vacuum (suction) and then cutting off this portion. Then the next portion is sucked and cut off and thus the tissue of the pathologically altered vitreous body is removed ("pinch off") step by step. The rate of excision and aspiration depends on the strength of the vacuum, the frequency of motion of the vitreotome knife and the state of the vitreous.

After removal of the front part of the vitreous body vitreotom is directed to the posterior pole of the eye. As the viscous vitreous body is removed, the pink reflex from the fundus becomes more vivid. After the removal of the vitreous body in the optical zone is completed and the posterior pole of the eye becomes visible, the peripheral part of it begins to be removed. If necessary, remove almost all the vitreous body. It is difficult to remove the base because of its strong fixation in the zone of the dentate line and the flat part of the ciliary body. In these cases, there is a real threat of lens damage. Presence of residual turbidity in the periphery usually does not cause visual disturbances after surgery.

Of the complications that may occur during surgery, it should be noted intravitreal bleeding, which is stopped by artificial increase in intraocular pressure with increased supply of replacement fluid.

To prevent the recurrence of hemorrhage in the vitreous cavity, patients in the pre-operative period are prescribed antihemorrhagic drugs (prodektin, dicinone, ascorutin, calcium chloride, etc.).

Numerous clinical observations and analysis of functional results show that with the use of modern vitreotomas and vitrectomy techniques, it is practically safe, and the risk of complications is much lower than with prolonged exposure to large amounts of blood in the vitreous. In addition, the early restoration of vitreous transparency allows early detection of changes in the retina, in case of necessity, coagulation of these pathological foci with the help of laser radiation energy and thereby prevent the appearance of new portions of blood.