The bullous keratopatiya is the pathology of a cornea which is characterized by cover hypostasis, defeat of an epitelialny layer with formation of specific "bulls". The clinical symptomatology is presented by decrease in visual acuity, a pain syndrome, feeling of a foreign matter in an eye, photophobia raised by lachrymation. For diagnostics the biomicroscopy, a keratopakhimetriya, an oftalmoskopiya, BRIDLES, a vizometriya, a tonometriya, a gonioskopiya is carried out. On the I-II Art. conservative therapy is shown. Application of contact lenses, phototherapeutic keratectomy, a krosslinking is possible. To patients at the III-V stage carry out a layer-by-layer or through keratoplasty.
The bullous keratopatiya (secondary endotelialno-epitelialny dystrophy) in 80% of cases is caused by performing surgeries on forward department of an eyeball. After treatment on the IV-V Art. it is possible to restore visual acuity no more than for 30%. According to statistical data, reactions of rejection of a transplant are observed at 6% of patients. It is possible to stop a pain syndrome in 91% of cases. The recidivous course of pathology is characteristic of 8% of patients that is shown by formation of single bulls and erosive defects on a cornea surface. The disease is widespread everywhere. Men and women are ill with an identical frequency.
Reasons of a bullous keratopatiya
Pathology has the acquired character, however often it is possible to establish hereditary predisposition to this disease. Genetic mutations and type of inheritance of a keratopatiya it is not studied. Main reasons for development:
- Endotelialny dystrophy of Fuchs. Genetically determined apoptosis of cages of a back epithelium is observed that leads to increase in its permeability and developing of pathology.
- Infections of eyes. The disease develops at damage of a cornea of the herpetic or syphilitic nature. Identification of specific pomutneniye at newborn children allows to assume pre-natal infection.
- Traumatizing cornea. Damage owing to a mechanical trauma or a burn provokes the raised ekssudation that becomes the reason of formation of typical "bulls".
- Yatrogenny influence. Pathology can arise in the early postoperative period after a fakoemulsifikation of a cataract or implantation of intraocular lenses.
Malfunction of endotelialny and epitelialny layers of a cornea is the cornerstone of the mechanism of development of a disease. The endoteliya leads increase in permeability to treatment of fabrics intraocular liquid from the forward camera. Because of a congestion of a transsudat on a blanket specific bubbles or "bulls" are formed. Chronic hypostasis significantly breaks trophic processes. At accession of an inflammatory component the organization of exudate leads to formation of permanent turbidity. The thickening of a cornea involves secondary defeat of nervous fibers, there is a pain syndrome. Decrease in visual acuity is caused, on the one hand, by violation of permeability of optical environments of an eye, with another – narrowing and deformation of a pupil.
Distinguish the congenital and acquired forms. Persons at whom the transparent cornea of normal thickness decides on density of endoteliotsit of 320-510 C/mm2 enter into risk group of development of pathology. In clinical ophthalmology classification according to which allocate the following stages of a disease is used:
- I – small sites with the reduced transparency of a cornea and an uneven arrangement of endotelialny cages are visualized. Thickness of a cover does not exceed 0,7 mm.
- II – transparency is reduced moderately at a thickness of 0,7-0,79 mm. The cornea is evenly covered with an endotelialny layer thanks to the expressed hypertrophy of cages. The quantity of endoteliotsit is reduced.
- III – considerable violation of transparency. Average thickness exceeds 0,8 millimeters. Endotelialny cages connect among themselves only thanks to shoots.
- IV – thickness averages 0,97 mm. Separate groups of endoteliotsit come to light. Transparency is sharply reduced.
- V – the expressed turbidity of a cornea which thickness exceeds 1,15 mm is visualized. Single cages are defined.
Symptoms of a bullous keratopatiya
At the first stage patients occasionally note at themselves the feeling of discomfort in an eye-socket which is followed by lachrymation. Visual dysfunction does not arise. External changes of an iris are absent. The second stage is characterized by feeling of a foreign matter, periodic reddening of an orbital conjunctiva. Insignificant decrease in visual functions is noted. At 3 Art. patients show complaints to the raised dacryagogue, photophobia. The discomfort reminding feeling of gripes, a foreign matter or "sand" in eyes and under centuries is observed. Stretching of nervous fibers leads to the expressed pain syndrome of the pricking character. Visual acuity is sharply reduced.
On 4 stages the severe headache which irradiates in nadbrovny arches, temporal and frontal lobes joins. Progressing of visual dysfunction leads to emergence of "fog" or "veil" before eyes. The terminal stage is followed by sharply expressed pain syndrome, decrease in visual functions up to a svetooshchushcheniye. Patients note that application of contact methods of correction of violation of sight does not give the chance to achieve desirable results. Besides the general symptomatology at the expense of the expressed hypostasis, hyperaemia of a conjunctiva and deformation of a pupil cosmetic defect is formed.
At 1 stage development of complications is not characteristic. On 2 stages recidivous Irit is often diagnosed. The 3rd stage becomes complicated iridotsiklity, 4 – a cataract, a retrokornealny film. The widespread phenomenon at a bullous keratopatiya – superficial keratit. At defeat of a back segment of an eye multiple sinekhiya are formed, there is an otsloyka of a mesh cover. At a terminal stage secondary glaucoma develops. Most a disease failure – a total blindness which on condition of the expressed pain syndrome demands carrying out an enukleation.
Inspection of the patient with a bullous form of a keratopatiya assumes carrying out external examination and use of special methods of diagnostics. Visually the ophthalmologist defines permanent turbidity of forward department of eyes, is frequent in combination with hyperaemia of an orbital conjunctiva. The complex of ophthalmologic researches includes:
- Eye biomicroscopy. At an initial stage local hypostasis of an endotelialny layer, single folds on a destsementovy membrane comes to light. 2 Art. are characterized by resistant limited puffiness, diffusion dispersion of a pigment, multiple folds. At the following stage in addition to the above described manifestations there is an injection of vessels of a conjunctiva, signs of a superficial keratit, erosive defects, the strengthened neovaskulyarization. On 4 Art. hypostasis extends to all layers. Are characteristic of a final stage vascular turbidity of different density. The cornea is replaced with dense cicatricial fabric with focal ulcerations.
- To Keratopakhimetry. Symptoms of local or diffusion hypostasis are defined. Cornea thickness in the central part varies from 600 to 1500 .
- To Gonioskopy. At the fifth stage the obliteration of a corner of the forward camera comes to light that is caused by the organization of exudate and adjournment of granules of a pigment. Iridokornealny unions are visualized. Watery moisture transparent, contains fibrilla of a vitreous body.
- To Vizometry. Visual acuity often is ranging from 0,1-0,3 . At severe defeat only the svetooshchushcheniye remains.
- To Oftalmoskopy. Oftalmoskopichesky survey is possible only at 1-3 stages of a disease. The reflex received from an eye bottom, pink is more rare than gray color. Signs of an otsloyka of a retina are characteristic.
- Ultrasonography of an eye. Back sinekhiya and a pupillary ekssudativny film on 3 stages are visualized. It is applied at all patients on 5 Art. because of a zarashcheniye of a pupillary opening. Turbidity or destruction of a vitreous body can come to light.
- Contactless tonometriya. At total defeat increase in VGD is noted that is caused by violation of outflow of intraocular liquid.
Differential diagnostics is carried out with primary keratopatiya of Fuchs and keratity. At Fuchs's disease process bilateral, surgeries in the anamnesis are absent, genetic predisposition is noted. When performing ultrasonography signs of damage of eyeballs are not found. Unlike a bullous keratopatiya at a keratita hypostasis local, comes to light inflammatory infiltrate. The epithelium is absent only in the field of infiltrate. According to a keratopakhimetriya thickness of a cornea does not exceed 800-1000 , signs of its thinning are defined less often. Patients often note interrelation between development of a keratit and the postponed inflammatory diseases, microdamages, non-compliance with rules of hygiene.
Treatment of a bullous keratopatiya
Therapeutic tactics is defined by a stage of pathology and expressiveness of secondary changes of an eyeball. Keratoprotektorny therapy which is based on purpose of medicines of an artificial tear, sodium of a gialuronat, dekspantenol is shown to all patients with a bullous keratopatiya. The important part is assigned to infection prevention. Are included in a complex of treatment:
- Medicamentous therapy. Antibacterial and hypotensive medicines are applied. Instillations of antibiotics are carried out throughout the entire period of a disease for the prevention of a keratit. Local hypotensive therapy is shown at increase in VGD, development of a clinical picture of eye hypertensia and secondary glaucoma. Instillations of glucocorticosteroids allow to stop inflammation symptoms. Conservative therapy is used at 1-2 stages.
- Contact methods of correction. Soft contact lenses promote regeneration of an epitelialny layer. Patients should give preference to lenses with hydrophilic or silicone - hydrogel structure. Thanks to their change 1 time in 2 weeks can be stopped slightly a pain syndrome. This type of lenses is used when forming erosive defects on a cornea and resistance to drug treatment.
- Phototherapeutic keratectomy. It is applied in the absence of effect of conservative therapy at patients with a resistant pain syndrome. At a thickness of cover less than 450 , infectious complications, dekompensirovanny glaucoma keratectomy is contraindicated. An alternative to this intervention is the corneal collagenic krosslinking with Riboflavinum.
- Keratoplasty. Indications to carrying out through or layer-by-layer plasticity of a cornea: lack of sight, the expressed pain syndrome on 3-5 St. Operation is contraindicated at high risk of rejection of a transplant or otsloyka of a retina, an eyeball subatrophy.
- Physical therapy. Appointment helium - the neon laser is recommended. The technique possesses antiedematous and anti-inflammatory action.
Along with the main treatment when narrowing a pupillary opening apply M-holinolitiki the prolonged action. At development of inflammatory complications use of antimicrobic medicines from groups of ftorkhinolon is shown. If the disease is followed by the expressed morbidity, appoint local anesthetics and opioid narcotic analgetics. Preparation for surgery includes purpose of antibacterial means, glucocorticosteroids and carrying out a premedikation.
Forecast and prevention
The forecast at a bullous retinopathy is defined by weight of a current. At the I-II stage of a disease timely treatment provides a complete recovery of functions of a cornea. The III stage is characterized by rather favorable forecast. At the IV-V Art. it is possible to eliminate dysfunction only by a keratoplasty or a keratoprotezirovaniye. Specific preventive measures are absent. Nonspecific prevention comes down to treatment of infectious and inflammatory pathologies of a forward segment of an eye, observance of rules of an asepsis and antiseptics when performing surgery on a cornea.