摘要
[目的]探讨玻璃体切割手术治疗黄斑裂孔性视网膜脱离的临床疗效。[方法]观察在我院行玻璃体切割手术治疗的53例53只眼MHRD患者,均为初次手术患者。术前行常规眼部检查,记录患者临床资料,采用不同方式玻璃体切割手术治疗,术后随访6～12个月。从不同角度比较黄斑裂孔及视网膜的解剖复位情况,术后视力改善情况,评价玻璃体切割手术治疗黄斑裂孔性视网膜脱离的手术效果,数据采用SPSS14.0 for windows统计分析软件包进行分析。[结果](1)53例MHRD患者中,一次手术后解剖治愈47只眼,黄斑裂孔及视网膜总解剖复位率88.68%。应用内界膜剥除组的解剖复位率高于未应用组(P<0.05):是否存在后巩膜葡萄肿术后解剖复位率无显著统计学差异(P>0.05);是否合并视网膜周边裂孔术后解剖复位率无显著统计学差异(P>0.05);硅油填充组的解剖复位率高于气体填充组(P<0.05)。(2)53例MHRD患者解剖复位的47只眼中,视力改善35只眼,占74.5%,脱盲率42.6%(视力≥0.05)。根据OCT检查分为一类愈合和二类愈合,且一类愈合患者术后视力改善率高于二类愈合患者(P<0.05)。[结论]1.应用玻璃体切割术治疗黄斑裂孔性视网膜脱离术后解剖复位率高,并发症少,视力得到一定程度的改善。2.玻璃体切除手术术中应用吲哚青绿染色、剥除视网膜内界膜可有效地提高黄斑孔视网膜脱离的解剖复位率。3.根据是否存在后巩膜葡萄肿、是否合并周边裂孔等眼部具体情况合理选择黄斑裂孔性视网膜脱离的术式及眼内填充物,均能达到较好的解剖复位及功能改善。4.根据术后黄斑区OCT检查结果,将裂孔愈合方式分为一类愈合和二类愈合两类,一类愈合患者术后视力改善好于二类愈合患者。
Macular hole retinal detachment(MHRD) is a special type of retinal detachment which is also one of the serious eye-blinding diseases.It prevails in middle-aged female patients with high myopia.With the high occurrence of MHRD in our country,it has great significance to explore the treatment options and clinical efficacy.The surgery of MHRD is very important to the preservation of visual acuity.However,we cannot neglect the high rate of postoperative recurrence and the restoration of visual function is not so ideal.At present,there are many ways of surgery:scleral buckling and pressure pad,liquid-releasing and gas tamponade,pars plana vitrectomy(PPV),gas- liquid exchange operation,inert gas or silicone oil tamponade surgery,indocyanine green dye,retinal or macular frontal membrane and internal limiting membrane peeling(ILMP) surgery,the macular hole sealing with autologous platelet concentrate or serum,and so on.Optical coherence tomography(OCT) is the optical analog product of ultrasound,is a new tool for morphological examination which is similar with in vivo eye on histopathological changes in the image,provides non-invasive,non-contact technique.It also can be implemented in the cross-sectional retinal scan for high resolution.In order to observe the evolution of macular hole,the development of surgical programs,as well as the improvement of surgical methods of observation of in the pathogenesis of the study provides a reliable basis for preventing permanent ablepsia.
Observed from September of 2006 to October of 2008,the 53 cases of MHRD eyes PPV carried out in our hospital are all initial surgery.Oculer examinations as follows are better to do before the surgery,such as visual-correcting acuity(vision of international standards), intra- ocular pressure,slit-lamp microscope,direct ophthalmoscopy,78D mirror front lamp, three-mirror contact lens examination;B-mode echography,axial length,and OUT.Here is the clinical data of patients:9 males cases & 44 females(83%);24 cases of the right eye & 29 cases of the left eye;age:40～78 years old,averaging:60.92±9.45 years old;duration:10 days～2 years,averaging 4.03±6.54 months;Diopter:0～-23.00D,averaging:-12.82± 6.45D;ocular axial length:22.50～33.30mm,averaging:28.59±2.54mm.There are 45 cases of patients with high myopia,accounting for 84.91%.The best preoperative visual acuity covers as followings:light perception～0.05;with posterior scleral staphyloma:29 eyes;with serious chorioretinal atrophy(white hole):6 eyes;with peripheral retinal holes:11 eyes(the number of peripheral holes 1～2);with choroidal detachment:3 eyes.Most of macular hole is round or elliptic,macular hole sized from 1/6PD to 1/2PD,except for the patients as followings:1.patients with shallow retinal detachment caused by idiopathic macular hole;2. patients with MHRD caused by ocular trauma;3.patients with significant cataract and combined cataract surgery;4.patients with corneal disease and vitreous hemorrhage;5. patients who ever experienced intraocular surgery.
We used different modes of PPV.They were PPV with gas(C_3F_8) tamponade(17eyes), PPV with silicone oil tamponade(10eyes),PPV combined internal limiting membrane peeling with gas(C_3F_8) tamponade(11eyes),PPV combined internal limiting membrane peeling with silicone oil tarnponade(15eyes).Post- operative patients were followed up for 6 to 12 months. We compared the anatomical reattachment of macular hole and retina from different angles, postoperative visual acuity improvement,and evaluated the surgery results of treating MHRD by PPV.Data use SPSS14.0 for windows for analysis.
The result of this study shows that:(1) Among 53 cases of patients with MHRD, successful retinal reattachment was achieved in 47 eyes after the first surgery,and the macular hole and retinal anatomic reattachment rate can be totalized to 88.68%.The anatomic reattachment which applied ILMP is higher than which didn't apply that(P＜0.05); postoperative anatomic reattachment has no significant statistical difference with or without posterior scleral staphyloma(P＞0.05);postoperative anatomic reattachment has no significant statistical difference with or without peripheral retinal holes(P＞0.05);the anatomic reattachment of eyes of silicone oil tamponade group is higher than eyes of gas tamponade group(P＜0.05).(2) Among the 47 eyes with anatomic reattachment of 53 patients with MHDR,the number of eyes which improved visual acuity is 35,accounting for 74.5%and eyes which escaped from blindness account for 42.6%(vision≥0.05).According to postoperative macular OCT findings,the types of holes healing of 47 eyes of anatomic reattachment are divided into type one and type two.The number of eyes with type one is 17, accounting for 36.2%and the number of eyes with type two is 30,accounting for 63.8%.We compared the visual acuity improvement rate of two types of healing mode by continuity correction chi-square test,χ~2=3.911,P＜0.05.There is significant difference between these two types:the visual acuity improvement rate of type one is higher than type two.
In conclusion:the application of PPV for the treatment of MHRD has a higher rate of anatomical reattachment and less complication.The visual acuity has also been improved to some extent.If we perform PPV with indocyanine green staining and ILMP,the rate of anatomical reattachment of MHRD will effectively improve.We can reasonablely choose the surgery modes of MHRD and intraocular tamponade according to whether there are posterior scleral staphyloma and periphery hole or not,in order to achieve better anatomic reattachment and functional improvement.According to postoperative macular OCT findings,the types of holes healing are divided into type one and type two.The postoperative visual acuity of type one improved more than that of type two.
In this study,because the samples are fewer and follow-up duration is short,even the follow-up duration of some patients was shorter than one year,there are some limitations and the conclusions are for references only and it still demands forward-looking and multi-center clinical study of large samples to evaluate the effect of different surgical types.In the future, we should continue to improve the closure rate of holes and visual function,meanwhile reduce complications.We should be more devoted to the further improvement of the technology and equipment as well as the prevention from the formation of macular hole on the perspective of etiology.
引文
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