中华眼底病杂志

中华眼底病杂志

增生型糖尿病视网膜病变患眼玻璃体切割手术后玻璃体再积血原因及预后观察分析

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目的 观察分析增生型糖尿病视网膜病变(PDR)患眼玻璃体切割手术(PPV)后玻璃体再积血(PVH)的原因及预后。 方法 回顾性研究。临床确诊为PDR的160例患者171只眼纳入研究。其中,男性85例92只眼,女性75例79只眼。年龄33~73岁,平均年龄(56.40±8.97)岁。所有患眼均由同一位医生行25G PPV,手术中充分剥除视网膜前纤维血管膜并行全视网膜激光光凝治疗。手术结束时行硅油填充43只眼,C3F8填充63只眼,灌注液或空气填充65只眼。105例患者同时联合行白内障超声乳化吸除手术。手术后平均随访时间(9.34±6.97)个月。观察PPV或硅油取出玻璃体腔廓清后PVH发生情况。对比分析是否发生PVH者之间年龄、糖化血红蛋白(HbA1c)、血肌酐水平、手术前眼底病变的严重程度、是否接受抗血管内皮生长因子(VEGF)药物治疗、是否联合白内障超声乳化吸除手术等基线资料。观察分析PVH的发生原因及预后。 结果 患眼首次PPV后矫正视力为眼前数指~1.0。171只眼中,发生PVH 15只眼,占8.77%;未发生PVH 156只眼,占91.23%。PVH发生时间为手术后2周~6个月,其中11只眼发生于手术后4~6周。发生与未发生PVH者年龄(t=2.551)以及手术前合并牵拉性视网膜脱离(χ2=7.431)、合并进行性纤维血管增生(χ2=4.987)、接受抗VEGF药物治疗(χ2=9.742)的眼数比较,差异均有统计学意义(P<0.05);HbA1c(t=0.501)、血肌酐水平(t=1.529)以及联合白内障超声乳化吸除手术的眼数(χ2=0.452)比较,差异无统计学意义(P>0.05)。15只PVH患眼中,发生虹膜新生血管(NVI)1只眼,新生血管性青光眼(NVG)4只眼。积血自行吸收7只眼,接受再次治疗7只眼,自愿放弃治疗1只眼。积血自行吸收7只眼中,可见视网膜前膜(ERM)5只眼。行再次治疗的7只眼中,可见ERM 2只眼,纤维血管膜2只眼。随访结束时,14只PVH患眼出血吸收;末次随访与首次手术后矫正视力相比,无变化12只眼,下降2只眼。合并NVI或NVG者矫正视力较未合并NVI或NVG者明显降低,差异有统计学意义(P=0.022)。 结论 PDR患眼PVH发生与眼底病变严重程度相关,残存或再生纤维血管膜是PDR患眼PPV后PVH发生的重要原因。NVG是影响PVH患眼视力预后的重要因素。

Objective To observe and analyze the causes and prognosis of postoperative vitreous hemorrhage (PVH) after vitrectomy for proliferative diabetic retinopathy (PDR). Methods A total of 160 PDR patients (171 eyes) were enrolled in this retrospective study. There were 85 males and 75 females. The patients aged from 33 to 73 years, with the mean age of (56.40±8.97) years. All the patients were performed 25G pars plana vitrectomy by the same doctor. Fibrovascular membrane peeling and panretinal photocoagulation were performed during the operation. Combined phacoemulsification was performed in one hundred and five patients. Vitreous tamponade was used at the end of surgery, including silicone oil (43 eyes), C3F8 (63 eyes), air or fluid (65 eyes). The follow-up ranged from 6 to 22 months, with the mean follow-up of (9.34±6.97) months. The features of PVH were observed. The difference of age, HbA1c, creatinine level, the severity of the fundus lesions, whether received treatment of anti-vascular endothelial growth factor (VEGF), whether received combined cataract phacoemulsification were analyzed to find out the cause and prognosis of PVH. Results The corrected vision of all the patients after the primary PPV at the latest follow up was finger counting/1 meter. PVH occurred in 15 eyes of 15 patients, the incidence was 8.77%. The PVH occurred 2 weeks to 6 months after surgery. There were significant difference in age (t=2.551), proportion with tractional retinal detachment (χ2=7.431), progressive fibrovascular proliferation (χ2=4.987) and using anti-VEGF (χ2=9.742) between the patients with and without PVH (P<0.05). There was no significant difference in HbA1c (t=0.501), creatinine level (t=1.529), and the proportion of cataract phacoemulsification (χ2=0.452) between the patients with and without PVH (P>0.05). During follow-up, neovascularization of iris (NVI) occurred in 1 eye and neovascular glaucoma (NVG) occurred in 4 eyes. Seven eyes underwent reoperation, 7 eyes were spontaneous recovered, 1 eye with NVG give up treatment. Fibrovascular membrane was the major cause of recurrent hemorrhage. At the end of follow-up, hemorrhage was absorbed in all the 14 eyes which were treated, 12 eyes had same visual acuity compared to that before postoperative hemorrhage, 2 eyes with NVG had decreased vision. There was significant difference in the corrected vision between the patients with and without NVI or NVG (P=0.022). Conclusions PVH after PPV for PDR is closely related to the severity of diabetic retinopathy, fibrovascular membrane is the major cause of recurrent hemorrhage. NVG is an important factor related to vision acuity prognosis.

关键词: 糖尿病视网膜病变/外科学; 玻璃体切除术/副作用; 玻璃体出血

Key words: Diabetic retinopathy/surgery; Vitrectomy/adverse effects; Vitreous hemorrhage

引用本文: 楚艳华, 刘玉燕, 王莹, 韩泉洪. 增生型糖尿病视网膜病变患眼玻璃体切割手术后玻璃体再积血原因及预后观察分析. 中华眼底病杂志, 2017, 33(4): 391-395. doi: 10.3760/cma.j.issn.1005-1015.2017.04.015 复制

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