Zamiast inwazyjnej transplantacji całej rogówki okuliści z Uniwersytetu Medycznego w Łodzi zaproponowali przeszczep tylko jej części. Operację wykonują manualnie mikro narzędziami. – Pacjenci miesiącami borykają się z problemem niegojących się owrzodzeń. Po operacji mogą funkcjonować normalnie – zapewniają specjaliści. Publikacja o nowatorskich zabiegach została nagrodzona w konkursie na najlepszą publikację o schorzeniach powierzchni oka.
Pacjenci z tym schorzeniem długo nie czują objawów choroby. Do okulisty zgłaszają się dopiero, gdy zaniepokoi ich wygląd oka, np. białawy naciek na rogówce albo gdy pogarsza się im ostrość wzroku lub widzą przez mgłę. To główne objawy keratopatii neurotroficznej. Czyli schorzenia oka, w którym rogówka ma obniżone albo zniesione czucie. W konsekwencji na jej obszarze powstają głębokie owrzodzenia, które uszkadzają wzrok bez objawów bólu.
Inwazyjne zabiegi i leczenie immunosupresyjne
Choroba najczęściej występuje u pacjentów z nawrotowym zapaleniem wirusowym rogówki, obniżoną odpornością, długo trwającą cukrzycą, po oparzeniach, czy po rogówkowej korekcji wad wzroku laserem. Wiek nie ma tu znaczenia. – Naszymi pacjentami są głównie osoby starsze, chociaż ostatnio zgłasza się do nas coraz większa grupa młodych ludzi stosujących przewlekle leki „wybielające” spojówkę. Chcąc mieć ładne oczy, miesiącami zakraplają krople do oczu, które obkurczają naczynia krwionośne – opowiada prof. Piotr Jurowski, kierownik Kliniki Okulistyki i Rehabilitacji Wzroku, Uniwersytetu Medycznego w Łodzi.
Metod leczenia keratopatii neurotroficznej jest kilka. Zaczyna się od stosowania substancji nawilżających w postaci kropli, żeli, maści oraz terapeutycznych soczewek. Druga opcja to metody chirurgiczne, np. częściowe zszycie brzegów powiek, naszycie błony owodniowej czy wreszcie przeszczepy rogówki. – Są to inwazyjne zabiegi, które wiążą się z koniecznością szerszego leczenia immunosupresyjnego. Nie u wszystkich pacjentów można je wykonać – zaznacza Diana Wyroślak-Bednarek z Kliniki Okulistyki i Rehabilitacji Wzroku Uniwersytetu Medycznego w Łodzi.
Jak pozyskać tylko jedną cienką warstwę?
Specjaliści z UMED-u zaproponowali więc przeszczep tylko drugiej części rogówki, warstwy Bowmana. Znajduje się ona pomiędzy nabłonkiem na wierzchu i zrębem rogówki poniżej. Jej pobranie podlega takim samym zasadom jak w przypadku innych przeszczepianych tkanek i narządów. Od zmarłych dawców zespół transplantacyjny pobiera całą rogówkę, z ogólnopolskiej listy transplantacyjnej wybierany jest pacjent, który może być biorcą. Takie przeszczepy są w zasadzie jedyną formą pozyskania materiału do przeszczepu rogówki. – Niestety, sztuczne rogówki nie są jeszcze dostępne, chociaż na świecie trwają badania w tym kierunku – mówi Wyroślak-Bednarek.
Podczas operacji pacjent jest znieczulany miejscowo i płytko usypiany. Cały zabieg okuliści wykonują manualnie, mikro narzędziami pod mikroskopem w bardzo dużym powiększeniu.
– Cała sztuka polega na tym, żeby od dawcy pozyskać drugą warstwę rogówki. Jej pozyskanie to najtrudniejszy etap operacji – mówi prof. Jurowki.
Specjaliści przygotowaną do przeszczepu rogówkę wprowadzają w sztuczną komorę, która symuluje oko pacjenta. Po usunięciu nabłonka rogówki pod mikroskopem warstwa Bowmana jest delikatnie nacinana i ściągana za pomocą pęsetek i noży chirurgicznych.
– Warstwa Bowmana pod wpływem odpowiedniej siły i techniki odrywa się od zrębu rogówki – tłumaczy prof. Jurowski.
Leczone owrzodzenie rogówki ma zazwyczaj ok. 5 milimetrów średnicy, rogówka – 12 mm. Warstwa Bowmana ma od 10 do 20 mikrometrów grubości. – To jedna z głównych przyczyn trudności w jej wypreparowaniu. Warstwa często przerywa się lub ulega przecięciu. Dlatego taka metoda transplantacyjna nie była wcześniej stosowana. Ale od kiedy zaczęliśmy rozumieć lepiej biomechanikę rogówki, dopracowaliśmy także zasady techniki pozyskania pojedynczej warstwy rogówki – wyjaśnia okulista.
Specjaliści opracowali również metodę bezszwowego przeszczepienia warstwy Bowmana do oka biorcy. Pod nabłonkiem wokół owrzodzenia tworzą specjalną kieszonkę rogówkową. Jej wielkość i kształt muszą być idealnie dopasowane do przeszczepianej warstwy. – Oznaczamy markerem rozmiary kieszonki i taką samą wielkość zaznaczamy w wypreparowanej warstwie Bowmana. Później warstwa rogówki wprowadzona jest śródrogówkowo. Dzięki temu nie musimy jej przyszywać – opowiada prof. Jurowski. Dodatkowo, żeby warstwa nie przemieściła się lub nie wypadła, okuliści zakładają na oko soczewkę kontaktową albo naszywają błonę owodniową (element struktury pęcherza płodowego człowieka po porodzie, który uzyskuje się z banku tkanek).
Poprawa funkcji oka w końcu możliwa
Badania nad selektywnymi przeszczepami warstwy Bowmana rogówki trwają niecałe dwa lata. Zabieg przeszło 10 pacjentów. Dotychczasowe wyniki są bardzo dobre.
– Taki zabieg jest bezpieczniejszy i mniej inwazyjny dla pacjenta. Warstwa Bowmana jest immunologicznie nieaktywna, praktycznie bezkomórkowa, więc nie generuje takiej odpowiedzi układu odpornościowego jak przy przeszczepie pełnościennym. Jest niskie ryzyko odrzutu – wyjaśnia Diana Wyroślak-Bednarek.
Po zabiegu okres rekonwalescencji trwa kilka tygodni. – Operowani pacjenci miesiącami borykają się z problemem niegojących się owrzodzeń. W wielu wypadkach nie chodzi nam o uzyskanie pełnej ostrości wzroku, ale o zagojenie się owrzodzenia i poprawę funkcji oka, która nie była możliwa wcześniej. Pacjenci po operacji mogą funkcjonować normalnie – podkreśla prof. Jurowski.
– Po przeszczepie rogówka jest bardziej wytrzymała na ewentualne urazy, patogeny. Zauważamy też procesy odbudowy dalszych uszkodzonych warstw rogówki – dodaje Wyroślak-Bednarek.
Jej publikacja o tych nowatorskich zabiegach i ich efektach pt. „Selektywne przeszczepy warstwy Bowmana rogówki – nowa nadzieja na odzyskanie prawidłowej powierzchni oka” została właśnie nagrodzona podczas X edycji konkursu Trophy na najlepszą publikację poświęconą schorzeniom powierzchni oka.
Konkurs jest corocznym wydarzeniem o światowym zasięgu kierowanym do młodych okulistów. W tym roku przystąpiło do niego ponad 200 osób. W finałowym etapie wybrano trzy najlepsze prace, w tym publikację Diany Wyroślak-Bednarek. Nagrodą za zwycięstwo w konkursie jest możliwość zaprezentowania wyników na międzynarodowej konferencji okulistycznej ARVO (The Association for Research in Vision & Ophthalmology) w Nowym Orleanie w USA, a także udział w Europejskiej konferencji EVER (European Association for Vision and Eye Research) w Hiszpanii w październiku 2023.
To nie koniec badań
Okuliści z Uniwersytetu Medycznego w Łodzi mają już opracowaną metodę, technikę, ale badania wciąż trwają. Teraz chcą zastosować tę formę przeszczepu w innych schorzeniach rogówki. Cały czas badają też strukturę rogówki przed wykonanym przeszczepem warstwy Bowmana i po nim. – Podstawą keratopatii neurotroficznej jest uszkodzenie unerwienia i obniżone czucie rogówki. Poszukujemy dowodów na to, że po przeszczepie unerwienie też się odbudowuje – wyjaśnia Wyroślak-Bednarek.
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