玻璃体切割联合内界膜剥除治疗特发性黄斑裂孔的临床分析
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摘要
[目的]观察玻璃体切割(PPV)联合内界膜剥除(ILMP)治疗特发性黄斑裂孔(IMH)术后裂孔愈合类型及视功能变化,评价手术疗效并探讨影响视力预后的因素。[方法]连续性、自身对照病例研究。对22例IMH患者行玻璃体切割联合内界膜剥除术,记录患者临床资料,OCT记录术前黄斑裂孔形态(最小直径、基底直径、裂孔高度)并根据术后OCT检查将裂孔愈合方式分为二类;记录手术前后最佳矫正视力(BCVA),比较BCVA的变化,分析与视力预后相关的因素。应用Spss12.0统计软件行数据处理。[结果] (1)术后最佳矫正视力与术前各因素相关性:术后BCVA与患者病程、裂孔最小直径、基底直径负性相关(P<0.05),与术前BCVA、裂孔分期、黄斑裂孔指数(MHI)、黄斑裂孔预后因数(HPF)呈正性相关(P<0.05),其中术前BCVA是评价术后BCVA最佳指标;(2)术后BCVA高于术前BCVA(P<0.01);(3)所有患者均达到解剖复位,根据OCT检查分为一类愈合和二类愈合,一类愈合患者的术后BCVA高于二类愈合(P<0.05),且一类愈合患者术后视力提高程度大于二类愈合患者(P<0.01)。[结论] 1、应用玻璃体切割联合内界膜剥除治疗特发性黄斑裂孔可以达到良好的解剖复位,术后视力较术前提高。2、术后BCVA与患者年龄无相关性,与术前BCVA、病程、裂孔分期、MHI、HPF及裂孔形态相关。3、术前BCVA是评价术后BCVA最佳指标,MHI、HPF计算简便,可作为评价临床预后指标。4、一类愈合患者术后BCVA好于二类愈合患者,视力提高程度大于二类愈合。
Idiopathic macular hole (IMH) is one of the common blindness -threatening eyes disease of the senile population, which is referred to the full-thickness rupture of the macular retina, without other ocular problems or antecedent events. Macular is the most important part of the retina for vision and any macular diseases may cause severe loss of vision of the patients. In addition, IMH is also seen in some middle age people. Along with the coming of older population in the world and the increase of older people in our country, the investigation of the older stage disease is becoming a more and more important problem. But the real cause for IMH is not clear yet, the following factors may be considered: cystoid macular edema(CME),macular cyst rupture, systemic vascular disease, disorder of endocrine system, systemic estrogen usage. Based on the above factors, in the early trials, therapy of cardiovascular drugs, psychological treatment, nutrition, anti-inflammation agents were used, but none of them gave a good result. Then laser coagulation for macular hole to prevent retinal detachment (RD) was coined in. Because RD is rare caused by IMH and every photocoagulation of macular cause the damage of photoreceptor and pigment epithelium ,which harms the central vision of the patients. Laser is no longer recommended for IMH. Because some patients can be healed spontaneously, in a certain period time, the treatment of IMH is conservative observation.
1988, Gass proposed that the path physiological mechanism of IMH and classed it for 4 stages. In Gass theory, he thought the development of IMH is the result of tangential and anterior-posterior traction exerted on the fovea by the attached posterior pathologic vitreous hyaloids membrane. Vitrectomy for IMH achieved good results, and quickly be popularized. Some scholars found the rate of healing in vitrectomy with the internal limiting membrane peeling(ILMP)is large than vitrectomy alone, vitrectomy with ILMP has been widely accepted as the treatment of IMH . The healing rate and visual prognosis was much improved by ILMP.
In this study ,the clinical data of patients, preoperative form of macular hole ,hole healing methods and visual function of the patients was observed , to evaluate the curative effect of surgical treatment and investigate the related factors of postoperative best corrected visual acuity (BCVA). 22 eyes of IMH in 22 patients were performs pars plana vitrectomy with ILMP ,from December 2005 to August 2007 in the second of the Jilin University School of Medicine Eye Hospital. All subjects have comprehensive review of the records. Preoperative examinations: the best corrected visual acuity (international standard visual acuity), IOP, slit lamp, direct ophthalmoscope, the front-slit lamp, fundus photography, optical coherence tomography (OCT ) and fundus fluorescence angiography (FFA) . The stage and configuration were measured by OCT, the macular hole index (MHI) and the hole prognostic factor (HPF) were calculated. Measuring postoperative BCVA and hole healing methods. All statistics was analyzed by the SPSS12.0. Measurement data using t-test. Related test using Spearman rank correlation analysis, Pearson single factor correlation analysis, multivariate linear regression analysis.
The results of this study showed that: 22 patients were reached anatomic closure after operation, 18 cases type 1 close, 4cases type 2 close. Which 20 patients’(91%) postoperative visual acuity improved, 2 cases (9%) the preoperative visual acuity keep invariably ,no vision decrease. No patient has significant postoperative complications. And the postoperative BCVA better than preoperative BCVA (paired-samples T test, P <0.01). Therefore, vitrectomy with ILMP considered to be the effect method to cure the IMH. According to clinical stages, in this study, 5 cases of stage 2, 14 cases of stage3,3 cases of stage 4. Postoperative BCVA positively correlated with the stage of preoperative hole (P <0.05) by rank correlation analysis (Spearman), suggesting that IMH patients after stage 2 to do operation early can be achieved better postoperative BCVA.
The relevant research of preoperative factors and postoperative BCVA shows that: postoperative BCVA have no correlation with the age of the patients (P = 0.313) and the hole height (P = 0.679) ,have the negative correlation with the course of disease (P = 0.033)、the smallest hole diameter (P = 0.005) and basal diameter (P = 0.003),have the positive correlation with the preoperative BCVA (P = 0.036), MHI (P = 0.019) and HPF (P = 0.012) .So, the longer of the disease course , the bigger of the smallest diameter and basal diameter, the prognosis visual to be worse. The size of the hole increased gradually with the time change, and also show that the recovery of eyesight rely on the absence degree of retinal macular. While the bigger MHI and HPF, the better visual prognosis, and the calculation is simple, can be considered to be the indicators of postoperative BCVA .To use the multiple linear regression analysis the above mentioned factors shows that the postoperative BCVA only positive correlated with preoperative BCVA, no correlated with the patient's age, the course of disease ,all preoperative measurement indicators, show that the preoperative BCVA is the most important factor which affect the preoperative visual acuity.
With the vitrectomy with ILMP become mature, despite clinical hole closure rate has been greatly improved, but the improvement of visual function of postoperative is not obvious in many patients. Some scholars believe that the healing of postoperative hole morphology is closely related to post-operative visual acuity. In this study, the healing of postoperative hole morphology divided into 2 categories, 18 cases of type 1 close, about 81.82 percent, 4 cases type 2 close , about 18.18 percent. Postoperative BCVA of the patients of type 1 close better than type 2 close (P <0.01),and the visual acuity improvement is more in type 1 close than type 2 close (P <0.05).
In summary, the application of vitrectomy with ILMP treatment of IMH can be achieved good anatomical closure. The postoperative BCVA have the negative correlation with the course of disease ,the smallest diameter, basal diameter, have positive correlation with preoperative BCVA,MHI,HPF. Preoperative BCVA can be used as the best predictor to evaluate the postoperative BCVA. The postoperative BCVA of type 1 close higher than type 2 close, the visual acuity improvement is more in type 1 close than type 2 close .
Idiopathic macular hole (IMH) is one of the common blindness -threatening eyes disease of the senile population, which is referred to the full-thickness rupture of the macular retina, without other ocular problems or antecedent events. Macular is the most important part of the retina for vision and any macular diseases may cause severe loss of vision of the patients. In addition, IMH is also seen in some middle age people. Along with the coming of older population in the world and the increase of older people in our country, the investigation of the older stage disease is becoming a more and more important problem. But the real cause for IMH is not clear yet, the following factors may be considered: cystoid macular edema(CME),macular cyst rupture, systemic vascular disease, disorder of endocrine system, systemic estrogen usage. Based on the above factors, in the early trials, therapy of cardiovascular drugs, psychological treatment, nutrition, anti-inflammation agents were used, but none of them gave a good result. Then laser coagulation for macular hole to prevent retinal detachment (RD) was coined in. Because RD is rare caused by IMH and every photocoagulation of macular cause the damage of photoreceptor and pigment epithelium ,which harms the central vision of the patients. Laser is no longer recommended for IMH. Because some patients can be healed spontaneously, in a certain period time, the treatment of IMH is conservative observation.
1988, Gass proposed that the path physiological mechanism of IMH and classed it for 4 stages. In Gass theory, he thought the development of IMH is the result of tangential and anterior-posterior traction exerted on the fovea by the attached posterior pathologic vitreous hyaloids membrane. Vitrectomy for IMH achieved good results, and quickly be popularized. Some scholars found the rate of healing in vitrectomy with the internal limiting membrane peeling(ILMP)is large than vitrectomy alone, vitrectomy with ILMP has been widely accepted as the treatment of IMH . The healing rate and visual prognosis was much improved by ILMP.
In this study ,the clinical data of patients, preoperative form of macular hole ,hole healing methods and visual function of the patients was observed , to evaluate the curative effect of surgical treatment and investigate the related factors of postoperative best corrected visual acuity (BCVA). 22 eyes of IMH in 22 patients were performs pars plana vitrectomy with ILMP ,from December 2005 to August 2007 in the second of the Jilin University School of Medicine Eye Hospital. All subjects have comprehensive review of the records. Preoperative examinations: the best corrected visual acuity (international standard visual acuity), IOP, slit lamp, direct ophthalmoscope, the front-slit lamp, fundus photography, optical coherence tomography (OCT ) and fundus fluorescence angiography (FFA) . The stage and configuration were measured by OCT, the macular hole index (MHI) and the hole prognostic factor (HPF) were calculated. Measuring postoperative BCVA and hole healing methods. All statistics was analyzed by the SPSS12.0. Measurement data using t-test. Related test using Spearman rank correlation analysis, Pearson single factor correlation analysis, multivariate linear regression analysis.
The results of this study showed that: 22 patients were reached anatomic closure after operation, 18 cases type 1 close, 4cases type 2 close. Which 20 patients’(91%) postoperative visual acuity improved, 2 cases (9%) the preoperative visual acuity keep invariably ,no vision decrease. No patient has significant postoperative complications. And the postoperative BCVA better than preoperative BCVA (paired-samples T test, P <0.01). Therefore, vitrectomy with ILMP considered to be the effect method to cure the IMH. According to clinical stages, in this study, 5 cases of stage 2, 14 cases of stage3,3 cases of stage 4. Postoperative BCVA positively correlated with the stage of preoperative hole (P <0.05) by rank correlation analysis (Spearman), suggesting that IMH patients after stage 2 to do operation early can be achieved better postoperative BCVA.
The relevant research of preoperative factors and postoperative BCVA shows that: postoperative BCVA have no correlation with the age of the patients (P = 0.313) and the hole height (P = 0.679) ,have the negative correlation with the course of disease (P = 0.033)、the smallest hole diameter (P = 0.005) and basal diameter (P = 0.003),have the positive correlation with the preoperative BCVA (P = 0.036), MHI (P = 0.019) and HPF (P = 0.012) .So, the longer of the disease course , the bigger of the smallest diameter and basal diameter, the prognosis visual to be worse. The size of the hole increased gradually with the time change, and also show that the recovery of eyesight rely on the absence degree of retinal macular. While the bigger MHI and HPF, the better visual prognosis, and the calculation is simple, can be considered to be the indicators of postoperative BCVA .To use the multiple linear regression analysis the above mentioned factors shows that the postoperative BCVA only positive correlated with preoperative BCVA, no correlated with the patient's age, the course of disease ,all preoperative measurement indicators, show that the preoperative BCVA is the most important factor which affect the preoperative visual acuity.
With the vitrectomy with ILMP become mature, despite clinical hole closure rate has been greatly improved, but the improvement of visual function of postoperative is not obvious in many patients. Some scholars believe that the healing of postoperative hole morphology is closely related to post-operative visual acuity. In this study, the healing of postoperative hole morphology divided into 2 categories, 18 cases of type 1 close, about 81.82 percent, 4 cases type 2 close , about 18.18 percent. Postoperative BCVA of the patients of type 1 close better than type 2 close (P <0.01),and the visual acuity improvement is more in type 1 close than type 2 close (P <0.05).
In summary, the application of vitrectomy with ILMP treatment of IMH can be achieved good anatomical closure. The postoperative BCVA have the negative correlation with the course of disease ,the smallest diameter, basal diameter, have positive correlation with preoperative BCVA,MHI,HPF. Preoperative BCVA can be used as the best predictor to evaluate the postoperative BCVA. The postoperative BCVA of type 1 close higher than type 2 close, the visual acuity improvement is more in type 1 close than type 2 close .
引文
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