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0THE ADVANTAGE OF LYMPHATERAPY IN THE TREATMENT OF DIABETIC RETINOPATHY
IkramovA.F.1, Mamajanov X.X.2
1DSc, Professor, Department of Ophthalmology, Andijan State Medical Institute 2Doctoral student of the Department of Ophthalmology, Andijan State Medical Institute
https://doi.org/10.5281/zenodo.13332355
Abstract. Diabetic retinopathy(DR) is one of the most common complications in patients with diabetes(DB), leading to a decrease in visual acuity(VA). Insufficient attention to the disease can lead to disability in the early stages ofpatient's life[5]. Proper treatment and use of modern methods of treatment of DR are necessary. The main goal of our research is to study the influence of regional lymphotherapy(RLT) on DR. To achieve this goal, we divided patients with diagnosed DR into two groups. In the first group, only traditional conservative methods of treatment were used, and in the second group - a combination of RLT and traditional conservative methods of treatment. We appreciated the effectiveness of treatment in both groups. The results showed that in patients who received RLT in combination with traditional treatment methods, positive changes in VA were observed. Thus, RLT was effective in improving VA with DR. The inclusion of RLT in the basic methods for the treatment of DR can be effective for improving VA.
Keywords: diabetic retinopathy, diabetes mellitus, diabetes, visual acuity, regional lymphotherapy, nonproliferative diabetic retinopathy, preproliferative diabetic retinopathy, proliferative diabetic retinopathy.
Introduction. Diabetes mellitus (DM) is one of the most common noninfectious diseases in the world, affecting about 10.5% of the adult population. In developed countries, medical care and preventive measures for patients with DB are limited[7]. DR is a specific damage to the retina in patients with DB, which can lead from a decrease in VA to complete blindness. According to studies conducted in 2016, DR affects from 21.9% to 33.6% of patients with DB around the world[10]. Pathogenesis of this condition is associated with an increase in the level of free glycogen in the blood, which leads to structural changes and damage to small blood vessels . As a result, various destructive changes occur in pericites and endothelia of arterioles and capillaries, which negatively affects the metabolism and accelerates the filtration of blood elements in the fabric of the retina. Acceleration of blood flow, chronic ischemia and an increase in the amount of aneurysm of blood vessels lead to the formation of hemorrhagic foci, an increase in the number of solid and soft exudates, which in turn causes pathological changes in the retina, such as the formation of edema and organic changes in vision and require immediate treatment. The acceleration of blood flow and chronic ischemia contribute to an increase in the amount of aneurysm of blood vessels, which leads to their rupture and formation of hemorrhagic foci. An increase in the number of solid and soft exudates, as well as the accumulation of toxic substances and liquids in the tissues of the retina, causes pathological changes, such as the formation of cones and organic changes. These processes negatively affect VA and require immediate medical intervention to prevent further damage to vision and possible blindness. As a result of a decrease in VA in patients, there is a limitation of active life, a deterioration in physical and mental disability, which leads to disability. DR plays a key role in limiting the disability of patients at an early age and in the development of disability. Currently, ophthalmologists around the world use
several methods of treating DR. Modern medicine offers such methods for the treatment of DR as controlling the level of glucose and lipids in the blood, blood pressure, laser photocoagulation, intravitreal and parabulbaric administration of steroids or anti-VEGF, as well as surgical methods[1]. However, these treatment methods are not completely effective and require constant updating and introducing new modern approaches. In some cases, after treatment, a further decrease in VA is observed. The main goal of the prevention of diabetic damage to the retina is to maximize compensation for carbohydrate metabolism in the body, normalization of systolic and diastolic blood pressure, and dyslipidemia correction using phenofibrates[9]. However, even after treatment, VA is not always completely restored, and repeated cases of damage to vision may be observed. In order to limit the pathological process caused by DM and preventing its progression in the world, various studies are conducted aimed at studying and developing new treatment methods. One of these methods that attract special attention is lymphaterapy. The lymphatic system plays an important role in the regulation of inflammatory and immune processes that participate in the pathogenesis of DR. Lymphaterapy can be useful to prevent the formation of edema, which are a key element in pathogenesis of DR. The lymphatic system performs a critical function in the control of inflammatory and immune reactions involved in the development of DR[4]. RLT is a method in which drugs are introduced directly into the lymph trains and lymph nodes, which contributes to their activation and improve the local metabolism. This, in turn, helps to restore the lymphatic function and normalize metabolic processes in pathologically altered tissues. As a result, it becomes possible to actively remove toxic substances and blood elements that have emerged from the blood vessels. RLT allows you to effectively affect key factors that contribute to the development of edema in DR. These factors include the accumulation of toxic metabolism products that cannot be removed from the retina, as well as hemorrhagic and exudative changes that occur as a result of destructive processes in the walls of small blood vessels. Thus, RLT allows you to achieve high efficiency in the treatment of DR due to the purposeful and accurate administration of drugs[2]. RLT helps to improve the condition of the retina and restore VA in DR[8]. The advantages of this method include the possibility of accurate and targeted administration of drugs into the affected body, the procedure once every 24-48 hours, the preservation of therapeutic effectiveness of the drug within 24 hours, as well as the savings of drugs by reducing the need for drugs compared to traditional methods treatment[6]. The use of regional lymphaterapy in patients with DB and myopia allows you to maintain VA at a possible level, prevent blindness and help restore the active life of patients[3]. This method not only promotes the treatment of DR, but also allows to understand deeperly the pathogenesis of this disease.
Modern medicine classifies DR as follows:
Nonproliferative diabetic retinopathy (NPDR).
Preproliferative diabetic retinopathy (PreDR).
Proliferative diabetic retinopathy (PDR).
Thus, RLT is a promising method of treating DR, which helps to improve the state of retina and restore VA in patients. Each stage of DR has its own unique significance and differs in its development, clinical manifestations and methods of treatment. In the early stages of DR, minimal changes in the retina can be observed, such as microanevrisms and small hemorrhages that may not cause significant symptoms. However, as the disease progresses, more serious changes can develop, including macular edema and neovascularization, which can lead to a significant
reduction in vision. Treatment at different stages also differs: from controlling the level of glucose in the blood and laser coagulation in the early stages to intravitreal injections and vitrectomy in the later stages. Thus, each stage of DR requires an individual approach and specific treatment methods to prevent the progression of the disease and preservation of vision. Currently, the exact mechanism of action of RLT at various stages of DR has not been established, and studies in this area continue. The introduction of new methods of treatment in order to use them for the treatment of DR is important for preventing and improving vision in patients. In Andijan branch of the Republican Specialized Scientific and Practical Center for Endocrinology, we applied traditional and RLT methods in patients with a diagnosis of DR. Based on the results obtained, we tried to determine how effective the additional use of RLT in the treatment of DR.
Purpose of the study: To study the effect of the method of RLT on VA in patients with DR against the background of DB.
Materials and Methods. For the study, 44 patients (87 eyes) with DR against the background of DB were selected. Of the 44 patients, 18 (41%) were men and 26 (59%) - women. Patients were divided into two groups: the 1st group included 21 (48%) patients, the 2nd group-23 (52%) patients. The patients selected for the study were distributed in groups as follows: in the 1st group of 21 (48%) patients 10 (23%) were men and 11 (25%)-women. Type 1 DB was diagnosed in 3 (7%) patients, type 2 DM - in 18 (41%) patients. In patients, the following stages of DR were identified: 16 (36%) cases of NPDR, 3 (7%) cases of prepropoliferative DR and 2 (4.5%) cases of PDR. The duration of the disease with DB was 11.5 ± 4.88 years. In the 2nd group of 23 (52%) patients, 8 (18%) were men and 15 (34%)-women. Type 1 DB was diagnosed in 5 (11%) patients, type 2 DM - in 18 (41%) patients. In patients, the following stages of DR were identified: 17 (39%) cases of NPDR, 4 (9%) cases of prepropolifective DR and 2 (4.5%) cases of PDR. The duration of the disease with DB was 12.8±5.54 years. All patients underwent an endocrinological and ophthalmological examination, after which they were prescribed appropriate methods of treatment. Patients of the 1st group were prescribed standard treatment methods, including parabulbar administration of the following drugs: SOL. Emoxipini 1% - 0.5 ml, SOL. Dexamethaconi 0.4% - 0.5 ml, SOL. Dicynoni 2.5% - 0.5 ml. Patients of the 2nd control group, in addition to treatment methods used in the 1st group, were prescribed additional use of RLT. In this case, the drugs were introduced into the submandibular lymph nodes. To do this, in the area of submandibular lymph nodes closely located to the pathological focus, the lymphatic drainage of the stimulant was first introduced (Sol. Novocaini 0.5% - 1.0 ml).
The purpose of the introduction of the lymphastimulator was a temporary change in the regional microcirculatory state, which contributed to an increase in the sensitivity of the lymphatic system to subsequent drugs. After 3-5 minutes, a therapeutic mixture of drugs was administered in a volume of 2.0 ml (Sol. Acidi ascorbinici 2% - 1,0 ml + Sol. Cyanocobalamini 0,05% - 1,0 ml + Sol.Actovegin 4% - 1,0 ml + Sol.Taurini 4% - 2,0 ml). After that, a semi-spire compress was imposed on the area of administration for 6-8 hours[3]. The procedures were carried out daily. The course of treatment for each patient lasted 8-10 days depending on the clinical condition. During this period, the general endocrine state and daily state of the organ of vision were controlled: the total body temperature, blood pressure, blood glucose, VA, intraocular pressure, biomicroscopic studies, field of view and the state of the fundus.
Table 1. Distribution of patients by groups(M ±m)
№ Indicators 1st group. n=21 2nd group. n=23 Total
1 Women 11 15 26
2 Men 10 8 18
3 diabetes type 1 3 5 8
4 diabetes type 2 18 18 36
5 Duration of diabetes 11,5 ±4,88 12,8 ±5,54
6 NPDR 16 17 33
7 PreDR 3 4 7
8 PDR 2 2 4
Results and Their Discussions. During the 10-day course of treatment, patients were thoroughly observed by ophthalmologists and endocrinologists. After the treatment, the following results were identified (Table 2). In the 1st group: out of 21 (48%) patients in 12 (27%) patients, VA was 60-80%. The effectiveness of treatment in these patients was 10%. All these patients suffered from unprofitive DR. In patients with PreDR (7%) and PDR (4.5%), no significant changes in VA were observed. The field of view improved in 9 (20%) patients. In the 2nd control group: at the beginning of the study, 3 (7%) patients had an increase in blood pressure. In addition, in 1 (2%) the patient, a body temperature of 37.9 ° C was recorded. The condition of these patients improved after 24 hours, and the treatment was continued. In 19 (43%) out of 23 (52%) patients, VA was 80-100%. The effectiveness of treatment in these patients was 20%. These patients suffered from unprofitive DR (17 (39%)) and PreDR (2 (4.5%)). The field of view also expanded by 20 degrees. In the remaining patients with PreDR (4.5%) and PDR (4.5%) of significant changes in VA were not observed. This is due to the fact that in these patients, DR was in severe stages, and before the start of treatment, numerous hemorrhagic foci, extensive exudates, multiple microanemks, neovascularization and fibrous tissues were observed. As a result, the average VA in these patients was significantly reduced. After treatment, VA improved. In these patients, VA was 0.05-0.07%, after treatment it increased to 0.07-0.1%, the effectiveness of treatment was 3%. In all patients with NPDR, a significant improvement in VA was observed.
Table 2. Obtained results(M ±m)
№ Indicators 1st grou p. n=21 2nd group. n=23
before treatment after treatment before treatment after treatment
1 Visual acuity.V 0,6±0,485 0,7±0,302 0,6±0,562 0,8±0,453
2 field of vision." 407,1±172,3 445,3±134,7 423,4±132,6 465,6±101,2
3 intraocular pressure mmHg. 22,3±2,69 21,4±2,34 21,3±3,01 23,4±1,43
4 body temperature. 37,0°C< 1
5 high blood pressure 1 3
6 blood glucose. mmol/L 8,2±3,24 7,2±1,65 8,8±1,87 6,8±2,87
Conclusion. Studies show that the use of RLT in combination with traditional methods of treatment in patients with DR has a positive effect on VA and helps to improve treatment results. This method also helps to expand the field of view. High efficiency was noted in the treatment of NPDR. However, with preproliferative and PDR, effectiveness was lower. Conducting additional studies on this method can help prevent the transition of DR into severe stages in the future, which is important to prevent a significant reduction in VA and blindness. In addition, this can contribute to saving material costs for treating patients with severe stages of DR. The use of regional lymphaterapy in patients with DB allows to maintain VA at a possible level and prevent blindness, which in turn helps to prevent disability and preserve active work.
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