玻璃體切割手術(shù)聯(lián)合或不聯(lián)合內(nèi)界膜剝除治療嚴重增殖型糖尿病視網(wǎng)膜病變黃斑水腫的對比研究
發(fā)布時間：2018-10-14 17:25
【摘要】：目的對比研究微創(chuàng)玻璃體切割手術(shù)(minimally invasive vitrectomy,MIV)聯(lián)合或不聯(lián)合內(nèi)界膜(internal limiting membrane,ILM)剝除治療嚴重增殖型糖尿病視網(wǎng)膜病變(proliferative diabetic retinopathy,PDR)黃斑水腫(macular edema,ME)的臨床療效,探索ILM剝除術(shù)在糖尿病黃斑水腫(diabetic macular edema,DME)手術(shù)治療中的應用價值及預后影響因素。方法2015年6月至2016年9月在天津市眼科醫(yī)院,經(jīng)臨床檢查確診為伴DME的PDR患者69例69只眼納入研究。入院眼部檢查有:最佳矯正視力(best-corrected visual acuity,BCVA)、光學相干斷層掃描(optical coherence tomography,OCT)、熒光素眼底血管造影(fluorescein fundus angiography,FFA)、眼底照相、眼部B型超聲、眼壓(intraocular pressure,IOP)、裂隙燈顯微鏡及雙目間接眼底鏡等。根據(jù)手術(shù)方式的不同將入選病例分為:MIV治療組36只眼(未剝ILM組)和MIV聯(lián)合ILM剝除治療組33只眼(剝ILM組)。兩組患者術(shù)中均接受全視網(wǎng)膜激光光凝(panretinal photocoagulation,PRP)、術(shù)畢玻璃體腔填充硅油,術(shù)后3個月眼底情況穩(wěn)定者常規(guī)行硅油取出術(shù)。未剝ILM組與剝ILM組患者術(shù)后隨訪6~12個月,平均隨訪時間為(10.47±2.17)月,記錄兩組患者術(shù)后1月、3月、6月及末次隨訪時的BCVA、黃斑中心視網(wǎng)膜厚度(central retinal thickness,CRT)、黃斑總體積(total macular volume,TMV)、ME嚴重程度、IOP及并發(fā)癥等觀察指標的變化情況并分析ILM剝除術(shù)視力預后相關因素。結(jié)果1.BCVA:未剝ILM組與剝ILM組術(shù)后1月、3月、6月及末次隨訪時的BCVA均較術(shù)前提高,除術(shù)后1月外,兩組患眼術(shù)后其它各時間點的平均logMAR BCVA與術(shù)前比較,差異均有統(tǒng)計學意義(P0.05);術(shù)后6月和末次隨訪時,剝ILM組平均logMAR BCVA明顯優(yōu)于未剝ILM組,差異均有統(tǒng)計學意義(P0.05),術(shù)后其它各時間點兩組間平均logMAR BCVA比較,差異均無統(tǒng)計學意義(P0.05);末次隨訪時,剝ILM組視力提高23只眼(69.70%)明顯優(yōu)于未剝ILM組17只眼(44.44%),差異有統(tǒng)計學意義(P0.05)。2.CRT:未剝ILM組與剝ILM組術(shù)后1月、3月、6月及末次隨訪時平均CRT值均較術(shù)前顯著降低,差異均有統(tǒng)計學意義(P0.05);術(shù)后3月、6月及末次隨訪時剝ILM組CRT值均顯著低于未剝ILM組,差異均有統(tǒng)計學意義(P0.05),術(shù)后1月兩組間平均CRT比較,差異無統(tǒng)計學意義(P0.05)。3.TMV:未剝ILM組與剝ILM組術(shù)后1月、3月、6月及末次隨訪時平均TMV較術(shù)前縮小,除術(shù)后1月外,兩組患眼術(shù)后其它各時間點的平均TMV與術(shù)前比較,差異均有統(tǒng)計學意義(P0.05);手術(shù)后1月、3月、6月及末次隨訪時兩組間平均TMV比較,差異均無有統(tǒng)計學意義(P0.05)。4.ME程度:末次隨訪時,未剝ILM組與剝ILM組中度及重度水腫患眼的比例均較術(shù)前顯著降低(P0.05);剝ILM組中度及重度水腫8只眼(24.24%)明顯低于未剝ILM組18只眼(50.00%),差異有統(tǒng)計學意義(P0.05)。5.并發(fā)癥及不良反應:未剝ILM組術(shù)后發(fā)生黃斑前膜3只眼、ME復發(fā)2只眼、一過性眼壓增高5只眼、玻璃體再出血1只眼、牽拉性視網(wǎng)膜脫離1只眼;剝ILM組術(shù)后發(fā)生一過性眼壓增高3只眼、玻璃體再出血2只眼,未發(fā)現(xiàn)黃斑前膜、ME復發(fā)及牽拉性視網(wǎng)膜脫離患眼,但兩組間術(shù)后黃斑前膜、ME復發(fā)、一過性眼壓增高、玻璃體再出血、牽拉性視網(wǎng)膜脫離發(fā)生率比較,差異均無統(tǒng)計學意義(P0.05)。6.ILM剝除術(shù)視力預后相關因素:ILM剝除術(shù)后logMAR BCVA與糖尿病病程、術(shù)前ME程度、手術(shù)前后CRT呈明顯正相關(P0.05)。提示DME患者病程越長,ME程度越重,CRT越厚,視力預后越差。結(jié)論1、MIV可去除玻璃體積血、視網(wǎng)膜前增殖膜并減輕ME,同時聯(lián)合ILM剝除能加快ME的吸收,對術(shù)前發(fā)現(xiàn)合并玻璃體積血、大量視網(wǎng)膜前增殖膜的DME患者,可選擇MIV聯(lián)合ILM剝除術(shù)治療。2、MIV術(shù)中聯(lián)合或不聯(lián)合ILM剝除均能改善嚴重PDR黃斑水腫患眼的視功能,但MIV與ILM剝除聯(lián)合應用在提高患者視力方面明顯優(yōu)于單純MIV,是治療嚴重PDR黃斑水腫的有效方法。3、MIV術(shù)中聯(lián)合ILM剝除較單純MIV能更顯著降低患眼術(shù)后CRT和TMV,有助于黃斑區(qū)解剖結(jié)構(gòu)及功能的進一步恢復。4、ILM的剝除使色素細胞及纖維細胞的移行增生失去支架,能有效抑制黃斑前膜的形成,降低術(shù)后ME的復發(fā)率。5、ILM剝除術(shù)后視功能與DME患者病程、術(shù)前ME嚴重程度、手術(shù)前后CRT有一定相關性。DME患者病程越長,術(shù)前ME程度越重,CRT越厚,視力預后越差。手術(shù)前后充分評估患者病情、合理選擇病例及恰當?shù)氖中g(shù)時間可以使手術(shù)治療DME獲得更好的療效。
[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.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R779.6
本文編號：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.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R779.6
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