78
1SSN2181-7812
www.tma-journals.uz
УДК 617.7
-007.691
ESTIMATION OF EFFICIENCY OF COMPLEX THERAPY OF PROGRESSING GLAUCOMA
NEUROPATHY
Mirbabaeva F.A., Yangieva N.R.
ОЦЕНКА ЭФФЕКТИВНОСТИ КОМПЛЕКСНОЙ ТЕРАПИИ ПРОГРЕССИРУЮЩЕЙ ГЛАУКОМНОЙ
НЕЙРОПАТИИ
Мирбабаева Ф.А., Янгиева Н.Р.
РИВОЖЛАНУВЧИ ГЛАУКОМАТОЗ НЕЙРОПАТИЯНИ КОМПЕЛЕКС ДАВОЛАШНИНГ
САМАРАДОРЛИГИНИ БАХОЛАШ
Мирбабаева Ф.А., Янгиева Н.Р.
Tashkent State Dental Institute
Оценка терапевтической эффективности глиатилина для стабилизации зрительных функций после комплексного
лечения больных прогрессирующей глаукомно оптической нейропатии с «нормализованным» давлением.
Глиатилин
-
ноотропный препарат, холиномиметик центрального действия с преимущественным влиянием на ЦНС. Включение
глиатилина в комплекс лечебных мероприятий, направленных на поддержание зрительных функций у больных
нестабилизированной глаукомой, направленных на различные звенья патогенеза глаукомной оптической нейропатии
позволяют добиться стабилизации процесса у 89% больных далеко зашедшей нестабилизированной глаукомой в
течение 6 месяцев.
Ключевые слова
-,
первичная глаукома, глаукомно оптическая нейропатия, глиатилин, ноотороп.
«Нормаллаштирилган» босимли, риволанувчи глаукоматоз оптик нейропатияли беморларни комплекс даволашдан
кейин, кўрув фаолиятларини барқарорлаштиришучун, глиатилиннинг терапевтик самарадор- лигини баҳолаш.
Глиатилин ноотроп дори воситаси бўлиб, марказий асабтизимига бирламчи таъсир кўрса- тадиган
марказийхолиномиметик воситадир.
Глиатилиннинг барцарорлашмаган глаукома билан огриган беморларда кўрув фаолиятларини сацлаб туришга
қаратилган, глаукоматоз оптик нейропатия патогенезида, турли хил таъсир этувчи, терапевтик чора-тадбир- лар
мажмуига киритилиши, олти ой давомида узок, муддатли барқарор бўлмаган глаукомали беморларнинг 89 фоизида,
жараённи баркарорлаштиришга имкон беради.
Калит сўзлар
-.
бирламчи глокома, глаукома-оптик нейропатия, глиатилин, ноотроп.
rimary glaucoma, despite advances in ophthalmology
still occupies one of the first places among the causes of
blindness throughout the world. Ophthalmologists are well
aware that even with the achievement of persistent I0P
compensation by medication or surgery, every 5th patient
continues to decompose visual functions [1- 3,5]. In this
regard, the problem of treating glaucoma optic neuropathy
is very relevant.
Glaucoma optical neuropathy fGONJ is usually con-
sidered from the standpoint of mechanical, vascular and
metabolic theories, including numerous risk factors that
increase the likelihood of progression of glaucoma lesions.
Determining the primacy of a factor is always debatable.
Only one thing is obvious: in the case of achieving an
individual level of intraocular pressure (10P) and at the
same time marked progression of GON, it is necessary to
identify other, most likely factors of influence.
Given the multifactorial progression of GON progression,
ophthalmologists usually recommend complex therapy,
prescribing drugs of various pharmacological groups [6-8].
This is often done when they plan to study the effectiveness
and safety of one of the drugs included in complex therapy.
Considering metabolic disorders, among which the
leading place is occupied by excitotoxic damage to the third
retinal neuron and activation of free radical processes in the
retina and optic nerve [1,4], we considered it expedient to
include drugs and treatment meth- ods that improve, on the
one hand, metabolism, on the other hand, neutralize the
negative influence of a number of factors and, on the third
hand, stimulate the activity of retinal neurons and restore
the conductivity of nerve fibers.
Gliatilin is a nootropic drug, a central cholinomimetic
with a primary effect on the central nervous system. Choline
is released from the active substance in the brain; choline is
involved in the biosynthesis of acetylcholine (one of the main
mediators of nervous excitation). Alfoscerate is
biotransformed to glycerophosphate, which is a precursor of
phospholipids.
Acetylcholine improves transmission of nerve impulses,
and glycerophosphate is involved in the synthesis of
phosphatidylcholine (membrane phospholipid), resulting in
improved membrane elasticity and receptor function.
Gliatilin increases cerebral blood flow, enhances metabolic
processes and activates the structure of the reticular
formation of the brain, restores consciousness in traumatic
brain damage. It has a preventive and corrective effect on
factors of involutional psycho-organic syndrome, such as a
change in the phospholipid composition of neuronal
membranes and a decrease in cholinergic activity. Thus,
pharmacodynamic studies have shown that gliatilin acts on
synaptic, including cholinergic, transmission of a nerve
impulse (neurotransmission), plasticity of a neural
membrane, and receptor function.
Despite the existing difficulties in evaluating the effec-
tiveness of neuroprotective therapy due to the lack of abso
P
ISSN2181-7812
www.tma-journals.uz
79
lutely reliable
criteria for a
number of structural
and func-
tional
indicators, such an assessment is still possible.
The aim of this work
is to evaluate the therapeutic ef-
ficacy
of gliatilin for stabilizing
visual
functions after the
complex treatment of patients with progressive GON with
“normalized” pressure.
Material and methods
We studied the
effectiveness of
treatment in two groups,
the proposed method
in
52 patients (61 eyes] with primary
open-angle glaucoma in the advanced stage with
compensated intraocular
pressure.
Patients of both groups
were comparable in age, concomitant somatic pathology, the
severity of the glaucoma process, their average age was
71.3±1.6 years.
In all
patients, therapists diagnosed systemic
atherosclerosis
with
a predominant damage to the vessels of
the brain
and
cerebrovascular insufficiency.
The analysis of ophthalmostatus indices showed that in
both groups the majority were patients with advanced stages
of glaucoma: 71.3% and 73.6%, respectively. In the 2nd
group, patients
prevailed
in which IOP normalization was
achieved surgically:
79.3%
versus 51.7% in the 1st group.
Therefore, in the latter there were more patients who
needed local antihypertensive therapy to maintain
ophthalmotonus within the target pressure. Nevertheless,
despite a steady level of IOP in the range of 15-17 mm Hg,
negative dynamics of visual functions was noted in all cases,
which served as the basis for the course of stabilizing
therapy.
When conducting complex treatment of patients, their
general somatic state was also taken into account. The
course of neuroprotective therapy included drugs of various
pharmacological groups acting on different pathogenetic
links. All patients received Mexidol 100 mg intramuscularly
1 time per day for 14 days, and patients of the 1st group, in
addition, were injected with gliatilin 1000 mg/4 ml
intravenously in an amount of 10 injections, then continued
the course of taking this drug by mouth 1 capsule 2 times a
day for 3 months.
A comprehensive ophthalmological examination was
carried out before, after treatment, after 3 and 6 months. The
following methods were used to assess visual functions:
visometry, perimetry, determination of the critical-
frequency of flicker fusion, eye rheography. Along with this,
a study was made of the electrosensitivity and electrolability
of the optic nerve and retina, and the registration of visually
evoked cortical potentials (VECP).
The state of the visual fields was evaluated in several
ways. Static perimetry was performed using a Humphrey
Visual Field Analyzer II (HFA II] 750i (Germany]. Depending
on the initial visual acuity and the degree of visual
impairment, a screening or threshold study program was
used. When assessing the central field of view (CTO], all
patients underwent correction of visual acuity near.
Screening was performed using the FF- 120 Screening
program using a three-zone strategy. The threshold program
for the study of the visual field included the application of
tests Central 30-2 in the study of the central lens (within
30
°
from the point of fixation of the gaze] and Peripheral 60-2
in the assessment of the peripheral field of vision - the
primary brain (from 30° to
60°].
At
the same time, we
analyzed the threshold foveo
lar photosensitivity,
the sum of
decibel threshold values
in each quadrant
over the entire
field of view, mean devi
ation (MD]
and standard deviation
(PSD] deviations cal
culated
automatically by the device
taking into account
its own
database.
The criteria for
evaluating
the
effectiveness of neu-
roprotective
therapy are not sufficiently
informative, and
from the
point of view of
practical ophthalmology, the study
of
visual functions
- perimetry - remains the most accessible.
Results and discussion
During the
observation
period in a hospital, during
which patients
received drugs,
in no case were adverse
events recorded.
The IOP level
was also normalized during
the entire
observation
period and was at a level not
exceeding 15 mm Hg
(p>0.05
compared with the initial data].
One of the criteria for evaluating functionality is central
visual acuity. Neuroprotective therapy, as a rule, does not
affect this indicator, however, mention of it is important as
indirect evidence of the dynamics of the process.
In our case, central visual acuity remained stable. Some
improvement in vision was noted in some patients in both
groups. Visual acuity indicators increased from 0.32±0.06 to
0.47±0.07 [p<0.05].
One of the objective criteria for assessing the effec-
tiveness of neuroprotective therapy, to a certain extent, can
be considered a study of the visual field. The indicators taken
into account when assessing changes in visual functions, we
considered CPL, foveolar and total photosensitivity, PPZ,
indicators MD and PSD.
The study was conducted before the start of a course of
drug therapy and 3, 6 months after it. All average indicators
tended to improve, especially for the central and peripheral
fields of vision. Moreover, in the group of patients receiving
gliatilin, this trend was more significant. This is all the more
important since the initial data of both groups were
comparable. The boundaries of peripheral vision (the sum of
degrees along 8 meridians] from 307±31° to 365±44
(p<0.05), CFSM from 23±6.0 to 29±7.0 (p<
0
.05] after
treatment. This amounted to 47%, 19%, 26%
of the
initial
level, respectively.
The
study was
conducted before the start of a course of
drug therapy and
3, 6
months after it. All average indicators
tended
to
improve, especially for the central and peripheral
fields of vision. Moreover, in the group of patients receiving
gliatilin, this trend was more significant. This is all the more
important since the initial data of both groups were
comparable. The boundaries of peripheral vision (the sum of
degrees
along 8
meridians] from 307±31° to 365±44
(p<0.05), CFSM from 23±6.0 to 29±7.0 (p 0.05] after
treatment. This relative to 47%, 19%, 26% of the initial level,
respectively.
Against the background of an increase in visual func-
tions, we noted an improvement in hemodynamic
and
electrophysiological parameters.
The
reographic coefficient
increased from 1.52±0.07 to
2.07±0.14% (p<0.05],
which amounted to
36% of the
initial
indicator.
The decrease
in the threshold of electric
80
1SSN2181-7812
www.tma-journals.uz
phosphene was 21.1 pA after treatment and 24.2 pA after 6
months of follow-up.
A significant increase in the index of electrolability of the
optic nerve was established by an average of 2.3 Hz after
treatment After half a year of dynamic observation, the
indicator is 3.5 Hz, which is 13% of the initial level, but this
difference is not statistically significant.
As a result of the treatment, a positive dynamics of the
state of visual functions was revealed according to the VECP
study. The amplitude of the P 100 component increased from
11.7 ± 4.7 to 14.3 + 5.1 pV.
We are inclined to believe that a more pronounced
therapeutic effect in patients of the 1st group is due to the
action of gliatilin. This assumption is confirmed by the
observation of a large number of patients who periodically
receive similar therapy at the institute.
Conclusion
Thus, the inclusion of gliatilin in the complex of ther-
apeutic measures aimed at maintaining visual functions in
patients with unstabilized glaucoma, aimed at various links
in the pathogenesis of glaucoma optical neuropathy, makes
it possible to achieve stabilization of the process in 89% of
patients with far-reaching unstabilized glaucoma for 6
months.
Thus, the inclusion of gliatilin in the complex of ther-
apeutic measures aimed at maintaining visual functions in
patients with unstabilized glaucoma, aimed at various links
in the pathogenesis of glaucoma optical neuropathy, makes
it possible to achieve stabilization of the process in 89% of
patients with far-reaching unstabilized glaucoma for 6
months.
The frequency of the course of stabilizing therapy
depends on the effectiveness of the previous therapy and the
clinical manifestation of the glaucoma process.
List of sources used
1.
Егоров
E.A.,
Алексеев
B.H.,
Мартынова Е.Б., Харьков
-
ский А.О. Патогенетические аспекты лечения первичной
открытоугольной глаукомы.
-
М., 2001.
-
118 с.
2.
Ермакова В.Н. О воздействии инстилляций эмокси
-
пина на циркуляцию водянистой влаги и состояние поля
зрения больных первичной открытоугольной глаукомой
//
Глаукома: проблемы
и решения: Материалы Всерос. на
-
уч.
-
практ. конф.
-
М., 2004.
-
С. 197
-201.
3.
Курышева Н.И. Механизмы
снижения зрительных
функций при первичной
открытоугольной
глаукоме и
пути
их предупреждения: Автореф.
дис. ... д
-
ра мед. наук.
-
М„
2001. -
47 с.
4.
Flammer J. Glaucomatous optic
neuropathy: a reperfusion
injury
//
Klin. Monatsbl. Augenbeilkd. -
2001.
-
Bd. 218, №5.
-S.
290-291.
5.
Hasler P.W., Orgul S., Gugleta K. et al.
Vascular
dysregulation in the choroid of subjects with
acral vasospasm
//
Arch. Ophthalmol. - 2002.
-
Vol. 120.
-
P. 302-307.
6.
Pache M., Krauchi K., Cajochen C. et al. Cold feet
and
prolonged sleep-onset latency in vasospastic syndrome
//
Lancet. - 2001. - Vol. 358. - P. 125-126.
7.
Satilmis M.,
Orgul
S., Doubler B., Flammer
J.
Rate
of
progression ofglaucoma correlates with retrobulbar circulation
and intraocular pressure
//
Amer. ]. Ophthalmol. - 2003.
-
Vol.
135. - P. 664-669.
8.
Schwartz M., Yoles E. Optic nerve degeneration and
potential neuroprotection: implications for glaucoma.
Department of Neurobiology, Weizmann Institute of Science,
Rehovot, Israel // Europ. J. Ophthalmol. - 1999. - Vol. 9. - P. 9-11.
ESTIMATION OF EFFICIENCY OF COMPLEX THERAPY
OF PROGRESSING GLAUCOMA NEUROPATHY
Mirbabaeva F.A., Yangieva N.R.
To evaluate the therapeutic efficacy of gliatilin for stabilizing
visual functions after complex treatment of patients with
progressive glaucoma-optical neuropathy with "normalized"
pressure. Gliatilin is a nootropic drug, a central cholinomimetic
with a primary effect on the central nervous system. The inclusion
of gliatilin in the complex of therapeutic measures aimed at
maintaining visual functions in patients with unstabilized
glaucoma, aimed at various
links in
the pathogenesis ofglaucoma
optical neuropathy, makes it possible to achieve stabilization of
the process in 89% of patients with far-reaching unstabilized
glaucoma for 6 months.
Key words:
primary glaucoma, glaucoma-optical neuropathy,
gliatilin, nootrope.
