曲安奈德在玻璃体切除手术治疗增生性糖尿病视网膜病变中止血作用机制研究

发布时间：2018-04-21 03:28

本文选题：增生性糖尿病视网膜病变 + 曲安奈德　；参考：《天津医科大学》2017年硕士论文

【摘要】：目的:探讨玻璃体切除手术治疗增生性糖尿病视网膜病变(proliferative diabetic retinopathy,PDR)过程中,眼内应用曲安奈德(Triamcinolone acetonide,TA)对于术中止血的作用及其可能作用机制。方法:第一部分:玻璃体切除手术治疗严重PDR患者25人29只眼,术中首先尽可能切除干净玻璃体及容易剥除的增生膜。在剥除增生膜时发生视网膜出血或小血管出血,此时向眼内注入TA(4mg/0.1ml),然后继续切除残存的玻璃体和增生膜。记录患者视网膜术中、术后出血情况,术后最佳矫正视力、眼压及并发症。第二部分:因PDR接受玻璃体切除手术并且术中眼内应用TA治疗的患者共12例12只眼,为TA组;因黄斑前膜或裂孔接受玻璃体切除手术32例32只眼,为对照组。TA组术中眼内应用TA与第一部分方法相同。在玻璃体切除手术开始时对所有患眼均采集玻璃体样本,采用双抗体夹心法酶联免疫吸附实验法(enzyme linked immunosorbent assay-sandwich technique,ELISA)分别测定TA组和对照组患者玻璃体中尿激酶纤溶酶原激活物(urokinase plasminogen activator,u-PA)、组织纤溶酶原激活物(tissue plasminogen activator,t-PA)及纤溶酶原激活物抑制剂(plasminogen activator inhibitors 1,PAI-1)含量,同时比较TA组和对照组之间上述指标含量差异。结果:第一部分:术中所有眼于TA注射后,视网膜颜色稍微变浅,视网膜渗血及小血管出血减轻或停止。术后1周及1个月分别观察到9只眼(31.03%)及4只眼(13.79%)有少量残存视网膜出血。术后3个月,所有视网膜出血吸收(100%)。末次随访,视力提高25只眼(86.21%),视力不变4只眼(13.79%),未观察到视力下降者。术后早期眼压升高8只眼(27.59%),其中7只眼经抗青光眼药物治疗,2周内眼压恢复正常;1只眼于术后1个月行小梁切除术,术后眼压得到控制。白内障进展加重3只眼(21.43%)。随访期间未观察到视网膜再出血、眼内炎及其他并发症。第二部分TA组u-PA中位数为25.45ng/m L,t-PA中位数为127.44ng/m L,PAI-1中位数为0.42ng/m L。对照组u-PA中位数为22.94ng/m L,t-PA中位数为142.37ng/m L,PAI-1中位数为0.27ng/m L。TA组玻璃体u-PA含量显著高于对照组,差异有统计学意义(Z=-2.268,P0.05),而玻璃体t-PA和PAI-1含量在TA组和对照组之间无显著性差异(Z=-0.092、-1.847,P值均0.05)。结论:玻璃体切除治疗PDR于术中适当时机向眼内注射TA可有效控制术中视网膜出血,使手术时间缩短,手术安全性提高。PDR患者玻璃体u-PA含量高,导致眼内容易引起出血。玻璃体切除手术中眼内应用TA可能通过降低t-PA和u-PA水平而降低出血倾向,而通过增加PAI-1水平来达到止血作用。
[Abstract]:Objective: to investigate the effect of triamcinolone acetonide during vitrectomy in the treatment of proliferative diabetic retinopathy (PDR) and its possible mechanism. Methods: the first part: vitrectomy was performed on 29 eyes of 25 patients with severe PDR. Retinal haemorrhage or small vessel hemorrhage occurred during the exfoliation of the proliferative membrane, and then the residual vitreous and proliferative membranes were continued to be removed by injecting TAA 4 mg / 0.1 ml into the eye. Postoperative bleeding, postoperative best corrected visual acuity, intraocular pressure and complications were recorded. The second part: 12 cases (12 eyes) received vitrectomy for PDR and 12 eyes for intraocular TA, 32 cases (32 eyes) received vitrectomy because of macular membrane or hole, 32 cases (32 eyes) received vitrectomy because of macular membrane or hole, and 32 eyes (32 eyes) received vitrectomy because of macular membrane or hole. The intraocular application of TA in the control group was the same as that in the first part. Vitreous samples were collected from all affected eyes at the beginning of vitrectomy. Determination of urokinase plasminogen activator u-PA-PAA, tissue plasminogen activator tissue plasminogen activator t-PAA and plasminogen activation in vitreous of TA group and control group by enzyme-linked immunosorbent assay (Elisa) with double antibody sandwich enzyme-linked immunosorbent assay (Elisa) The content of plasminogen activator inhibitors 1 (PAI-1), At the same time, the contents of above indexes were compared between TA group and control group. Results: in the first part, all eyes were injected with TA, the retinal color was slightly lighter, retinal blood leakage and small vessel hemorrhage were alleviated or stopped. Retinal hemorrhage was observed in 9 eyes (31. 03%) and 4 eyes (13. 79%) at 1 week and 1 month after operation. After 3 months, all retinal hemorrhage absorbed 100 times. At the last follow-up, the visual acuity was improved in 25 eyes (86.21 eyes), and the visual acuity was unchanged in 4 eyes (13.79%). Early postoperative intraocular pressure was increased in 8 eyes (27.59%), of which 7 eyes were treated with antiglaucoma drugs and the intraocular pressure returned to normal within 2 weeks. One eye underwent trabeculectomy 1 month after operation, and the intraocular pressure was controlled. The progression of cataract was aggravated in 3 eyes. No retinal rebleeding, endophthalmitis and other complications were observed during follow-up. In the second part, the median of u-PA in TA group was 25.45ng/m Lnt-PA, the median of 127.44ng/m Ln PAI-1 was 0.42ng/m L. The content of vitreous u-PA in the group of 0.27ng/m L.TA was significantly higher than that in the group of 0.27ng/m L.TA, the difference was statistically significant (P < 0.05), but there was no significant difference in the contents of t-PA and PAI-1 in vitreous between TA group and control group (P < 0.05). Conclusion: intraocular injection of TA in vitrectomy can effectively control intraoperative retinal hemorrhage, shorten the operative time, and improve the safety of vitreous u-PA in patients with PDR, which may lead to intraocular hemorrhage. Intraocular application of TA in vitrectomy may reduce bleeding tendency by decreasing t-PA and u-PA levels, and achieve hemostatic effect by increasing PAI-1 level.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R779.6;R587.2

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