玻璃体切割手术联合或不联合内界膜剥除治疗严重增殖型糖尿病视网膜病变黄斑水肿的对比研究
发布时间：2018-10-14 17:25
【摘要】：目的对比研究微创玻璃体切割手术(minimally invasive vitrectomy,MIV)联合或不联合内界膜(internal limiting membrane,ILM)剥除治疗严重增殖型糖尿病视网膜病变(proliferative diabetic retinopathy,PDR)黄斑水肿(macular edema,ME)的临床疗效,探索ILM剥除术在糖尿病黄斑水肿(diabetic macular edema,DME)手术治疗中的应用价值及预后影响因素。方法2015年6月至2016年9月在天津市眼科医院,经临床检查确诊为伴DME的PDR患者69例69只眼纳入研究。入院眼部检查有:最佳矫正视力(best-corrected visual acuity,BCVA)、光学相干断层扫描(optical coherence tomography,OCT)、荧光素眼底血管造影(fluorescein fundus angiography,FFA)、眼底照相、眼部B型超声、眼压(intraocular pressure,IOP)、裂隙灯显微镜及双目间接眼底镜等。根据手术方式的不同将入选病例分为:MIV治疗组36只眼(未剥ILM组)和MIV联合ILM剥除治疗组33只眼(剥ILM组)。两组患者术中均接受全视网膜激光光凝(panretinal photocoagulation,PRP)、术毕玻璃体腔填充硅油,术后3个月眼底情况稳定者常规行硅油取出术。未剥ILM组与剥ILM组患者术后随访6~12个月,平均随访时间为(10.47±2.17)月,记录两组患者术后1月、3月、6月及末次随访时的BCVA、黄斑中心视网膜厚度(central retinal thickness,CRT)、黄斑总体积(total macular volume,TMV)、ME严重程度、IOP及并发症等观察指标的变化情况并分析ILM剥除术视力预后相关因素。结果1.BCVA:未剥ILM组与剥ILM组术后1月、3月、6月及末次随访时的BCVA均较术前提高,除术后1月外,两组患眼术后其它各时间点的平均logMAR BCVA与术前比较,差异均有统计学意义(P0.05);术后6月和末次随访时,剥ILM组平均logMAR BCVA明显优于未剥ILM组,差异均有统计学意义(P0.05),术后其它各时间点两组间平均logMAR BCVA比较,差异均无统计学意义(P0.05);末次随访时,剥ILM组视力提高23只眼(69.70%)明显优于未剥ILM组17只眼(44.44%),差异有统计学意义(P0.05)。2.CRT:未剥ILM组与剥ILM组术后1月、3月、6月及末次随访时平均CRT值均较术前显著降低,差异均有统计学意义(P0.05);术后3月、6月及末次随访时剥ILM组CRT值均显著低于未剥ILM组,差异均有统计学意义(P0.05),术后1月两组间平均CRT比较,差异无统计学意义(P0.05)。3.TMV:未剥ILM组与剥ILM组术后1月、3月、6月及末次随访时平均TMV较术前缩小,除术后1月外,两组患眼术后其它各时间点的平均TMV与术前比较,差异均有统计学意义(P0.05);手术后1月、3月、6月及末次随访时两组间平均TMV比较,差异均无有统计学意义(P0.05)。4.ME程度:末次随访时,未剥ILM组与剥ILM组中度及重度水肿患眼的比例均较术前显著降低(P0.05);剥ILM组中度及重度水肿8只眼(24.24%)明显低于未剥ILM组18只眼(50.00%),差异有统计学意义(P0.05)。5.并发症及不良反应:未剥ILM组术后发生黄斑前膜3只眼、ME复发2只眼、一过性眼压增高5只眼、玻璃体再出血1只眼、牵拉性视网膜脱离1只眼;剥ILM组术后发生一过性眼压增高3只眼、玻璃体再出血2只眼,未发现黄斑前膜、ME复发及牵拉性视网膜脱离患眼,但两组间术后黄斑前膜、ME复发、一过性眼压增高、玻璃体再出血、牵拉性视网膜脱离发生率比较,差异均无统计学意义(P0.05)。6.ILM剥除术视力预后相关因素:ILM剥除术后logMAR BCVA与糖尿病病程、术前ME程度、手术前后CRT呈明显正相关(P0.05)。提示DME患者病程越长,ME程度越重,CRT越厚,视力预后越差。结论1、MIV可去除玻璃体积血、视网膜前增殖膜并减轻ME,同时联合ILM剥除能加快ME的吸收,对术前发现合并玻璃体积血、大量视网膜前增殖膜的DME患者,可选择MIV联合ILM剥除术治疗。2、MIV术中联合或不联合ILM剥除均能改善严重PDR黄斑水肿患眼的视功能,但MIV与ILM剥除联合应用在提高患者视力方面明显优于单纯MIV,是治疗严重PDR黄斑水肿的有效方法。3、MIV术中联合ILM剥除较单纯MIV能更显著降低患眼术后CRT和TMV,有助于黄斑区解剖结构及功能的进一步恢复。4、ILM的剥除使色素细胞及纤维细胞的移行增生失去支架,能有效抑制黄斑前膜的形成,降低术后ME的复发率。5、ILM剥除术后视功能与DME患者病程、术前ME严重程度、手术前后CRT有一定相关性。DME患者病程越长,术前ME程度越重,CRT越厚,视力预后越差。手术前后充分评估患者病情、合理选择病例及恰当的手术时间可以使手术治疗DME获得更好的疗效。
[Abstract]:Objective To compare the clinical efficacy of minimally invasive vitrectomy (MIV) combined with or without intra-border membrane (ILM) stripping in the treatment of severe proliferative diabetic retinopathy (PDR) macular edema (ME). Objective To explore the application value and prognostic factors of ILM stripping in diabetic macular edema (DME) surgery. Methods 69 eyes of 69 patients with PDR with DME were studied by clinical examination from June 2015 to September 2016. Admission eye examinations include best-corrected visual acuity (BCVA), optical coherence tomography (OCT), fundus fluorescein angiography (OCT), fundus photography, eye-type ultrasound, intraocular pressure (IOP), Slit lamp microscope and binocular indirect ophthalmoscope. The selected cases were divided into three groups according to the surgical method: 36 eyes of the MIV treatment group (the unpeeled ILM group) and the MIV combined ILM stripping treatment group 33 eyes (skin peeling group). In both groups, total retinal laser photocoagulation (PRP) was received, silicone oil was filled in vitreous cavity after operation, and silicone oil was removed for 3 months after surgery. After 6-12 months follow-up, the mean follow-up time was (10.47-2.17) months, and BCVA, central retinal thickness (CRT) and total macular volume in the two groups were recorded for the first month, March, June and last follow-up. The changes of ME severity, IOP and complications were analyzed and the factors related to the visual prognosis of ILM were analyzed. Results 1. BCVA: The BCVA between the unpeeled ILM group and the peeling ILM group was improved before the operation, and the mean logMAR BCVA of the other two groups was statistically significant (P <0.05) except for 1 month after operation (P <0.05). The mean logMAR BCVA of peeling ILM group was significantly better than that of unpeeled ILM group (P0.05). The visual acuity of peeling ILM group increased by 23 eyes (69. 70%) obviously superior to 17 eyes (44. 44%) in the unpeeled ILM group, and the difference was statistically significant (P0.05). The values of CRT were significantly lower than those in the unpeeled ILM group at the follow-up of March, June and the end of the surgery (P <0.05). There was a statistically significant difference in the mean difference between the two groups (P0.05). In January, March, June and last follow-up, there was no statistically significant difference between the two groups (P0.05). 8 eyes (24.24%) of moderate and severe edema in ILM group were significantly lower than those in 18 eyes (50. 00%) without ILM group, and the difference was statistically significant (P0.05). Complications and adverse reactions: 3 eyes were found in 3 eyes, 2 eyes of ME, 5 eyes with intraocular pressure increase, 1 eye for vitreous hemorrhage and 1 eye for traction retina, 3 eyes were increased after the operation of peeling ILM group. There were 2 eyes in vitreous hemorrhage, no premacular membrane, ME recurrence and traction retinal detachment were found. However, there was a comparison between the two groups of postoperative macular membrane, ME recurrence, increased intraocular pressure, vitreoretinal hemorrhage, and traction retinal detachment. There was no statistically significant difference (P <0.05). 6. There was a significant positive correlation between logMAR BCVA and diabetes course, pre-operative ME and CRT before and after ILM stripping (P0.05). It was suggested that the longer the disease course of DME, the heavier the ME, the thicker the CRT and the worse the prognosis. Conclusion 1. MIV can remove vitreous humor, preretinal membrane and relieve ME, meanwhile, combined with ILM stripping can accelerate ME absorption. The combined or non-combined ILM stripping in MIV can improve the visual function of severe PDR macular edema, but the combination of MIV and ILM is superior to simple MIV in improving vision of patients, and is an effective method for treating severe PDR macular edema. Combined ILM stripping in MIV can significantly lower CRT and IIEF after eye operation, contribute to further recovery of the anatomical structure and function of the macular region. 4. The peeling of ILM causes the migration of pigment cells and fibroblasts to lose the scaffold, and can effectively inhibit the formation of premacular membrane. The recurrence rate of ME after operation was decreased. 5. The postoperative visual function of ILM was related to the course of DME, the severity of ME, and CRT before and after operation. The longer the duration of the DME patient, the heavier the ME before operation, the thicker the CRT, and the worse the prognosis. Before and after the operation, the patient's condition, reasonable selection of cases and proper operation time can be used to treat DME with better curative effect.
【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
本文编号：2271118
[Abstract]:Objective To compare the clinical efficacy of minimally invasive vitrectomy (MIV) combined with or without intra-border membrane (ILM) stripping in the treatment of severe proliferative diabetic retinopathy (PDR) macular edema (ME). Objective To explore the application value and prognostic factors of ILM stripping in diabetic macular edema (DME) surgery. Methods 69 eyes of 69 patients with PDR with DME were studied by clinical examination from June 2015 to September 2016. Admission eye examinations include best-corrected visual acuity (BCVA), optical coherence tomography (OCT), fundus fluorescein angiography (OCT), fundus photography, eye-type ultrasound, intraocular pressure (IOP), Slit lamp microscope and binocular indirect ophthalmoscope. The selected cases were divided into three groups according to the surgical method: 36 eyes of the MIV treatment group (the unpeeled ILM group) and the MIV combined ILM stripping treatment group 33 eyes (skin peeling group). In both groups, total retinal laser photocoagulation (PRP) was received, silicone oil was filled in vitreous cavity after operation, and silicone oil was removed for 3 months after surgery. After 6-12 months follow-up, the mean follow-up time was (10.47-2.17) months, and BCVA, central retinal thickness (CRT) and total macular volume in the two groups were recorded for the first month, March, June and last follow-up. The changes of ME severity, IOP and complications were analyzed and the factors related to the visual prognosis of ILM were analyzed. Results 1. BCVA: The BCVA between the unpeeled ILM group and the peeling ILM group was improved before the operation, and the mean logMAR BCVA of the other two groups was statistically significant (P <0.05) except for 1 month after operation (P <0.05). The mean logMAR BCVA of peeling ILM group was significantly better than that of unpeeled ILM group (P0.05). The visual acuity of peeling ILM group increased by 23 eyes (69. 70%) obviously superior to 17 eyes (44. 44%) in the unpeeled ILM group, and the difference was statistically significant (P0.05). The values of CRT were significantly lower than those in the unpeeled ILM group at the follow-up of March, June and the end of the surgery (P <0.05). There was a statistically significant difference in the mean difference between the two groups (P0.05). In January, March, June and last follow-up, there was no statistically significant difference between the two groups (P0.05). 8 eyes (24.24%) of moderate and severe edema in ILM group were significantly lower than those in 18 eyes (50. 00%) without ILM group, and the difference was statistically significant (P0.05). Complications and adverse reactions: 3 eyes were found in 3 eyes, 2 eyes of ME, 5 eyes with intraocular pressure increase, 1 eye for vitreous hemorrhage and 1 eye for traction retina, 3 eyes were increased after the operation of peeling ILM group. There were 2 eyes in vitreous hemorrhage, no premacular membrane, ME recurrence and traction retinal detachment were found. However, there was a comparison between the two groups of postoperative macular membrane, ME recurrence, increased intraocular pressure, vitreoretinal hemorrhage, and traction retinal detachment. There was no statistically significant difference (P <0.05). 6. There was a significant positive correlation between logMAR BCVA and diabetes course, pre-operative ME and CRT before and after ILM stripping (P0.05). It was suggested that the longer the disease course of DME, the heavier the ME, the thicker the CRT and the worse the prognosis. Conclusion 1. MIV can remove vitreous humor, preretinal membrane and relieve ME, meanwhile, combined with ILM stripping can accelerate ME absorption. The combined or non-combined ILM stripping in MIV can improve the visual function of severe PDR macular edema, but the combination of MIV and ILM is superior to simple MIV in improving vision of patients, and is an effective method for treating severe PDR macular edema. Combined ILM stripping in MIV can significantly lower CRT and IIEF after eye operation, contribute to further recovery of the anatomical structure and function of the macular region. 4. The peeling of ILM causes the migration of pigment cells and fibroblasts to lose the scaffold, and can effectively inhibit the formation of premacular membrane. The recurrence rate of ME after operation was decreased. 5. The postoperative visual function of ILM was related to the course of DME, the severity of ME, and CRT before and after operation. The longer the duration of the DME patient, the heavier the ME before operation, the thicker the CRT, and the worse the prognosis. Before and after the operation, the patient's condition, reasonable selection of cases and proper operation time can be used to treat DME with better curative effect.
【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
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