保留黄斑中心凹的内界膜剥除术联合空气填充治疗中等直径特发性黄斑裂孔
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摘要
目的观察保留黄斑中心凹内界膜剥除术联合空气填充治疗直径为250～400μm的特发性黄斑裂孔(idiopathic macular hole,IMH)临床疗效。方法收集2014年1月至2016年1月确诊为Ⅳ期IMH经光学相干断层扫描(optical coherence tomography,OCT)测量裂孔最小直径为250～400μm的患者45例45眼,随机分为常规内界膜剥除组(常规组)22眼及保留中心凹内界膜剥除组(保留组)23眼。所有患者均行23G玻璃体切割术,常规组剥除后极部包括黄斑区内界膜至血管弓,保留组则保留以黄斑中心凹为圆心300～400μm直径的内界膜,全气-液交换后无菌空气填充。手术后随访时间为(21.52±5.68)个月,观察术后两组黄斑裂孔闭合及最佳矫正视力(best corrected visual acuity,BCVA)情况。结果常规组与保留组患者术前黄斑裂孔直径分别为(337.77±34.54)μm和(324.87±31.95)μm;黄斑裂孔指数分别为0.53±0.09和0.51±0.08,BCVA LogMAR分别为0.95±0.20、1.30±0.26,两组间比较,差异均无统计学意义(均为P>0.05)。末次随访时,常规组与保留组黄斑裂孔闭合率分别为95.45%和100.00%,差异无统计学意义(P=0.489)。常规组、保留组患眼BCVA LogMAR分别为0.72±0.15、0.49±0.11,均低于术前,差异均有统计学意义(均为P<0.05);保留组患眼BCVA LogMAR低于常规组,差异有统计学意义(t=-5.849,P<0.001)。结论常规内界膜剥除术与保留黄斑中心凹的内界膜剥除联合空气填充对于治疗直径为250～400μmⅣ期IMH成功率较高,行保留黄斑中心凹内界膜的剥除术患者术后视力改善情况要好于常规内界膜剥除术。
Objective To observe the outcome of foveola nonpeeling internal limiting membrane surgery combined with air tamponade for the treatment of idiopathic macular hole(IMH) with a diameter of 250-400 μm.Methods 45 eyes in 45 patients from January 2014 to January 2016 were included in this study.All these eyes with stage IV IMH diagnosed by optical coherence tomography(OCT) with a minimum diameter of 250-400 μm were randomly divided into two groups:total peeling of foveal ILM group(group A,22 eyes),and foveolar ILM nonpeeling group(group B,23 eyes).All patients underwent 23-gauge pars plana vitrectomy.Peeling of the internal limiting membrane was assisted with ICG.The ILM was removed with preservation of the central 300-400 μm diameter ILM in group B and was totally removed in group A.Air tamponade was performed after a fluid-air exchange.The mean follow up was(21.52±5.68)months.The macular hole closure and best corrected visual acuity(BCVA) were observed in the two groups.Results The preoperative macular hole diameters of the group A and B were(337.77±34.54)μm and(324.87±31.95)μm,respectively,MHI were 0.53±0.09 and 0.51±0.08,respectively,and BCVA(LogMAR) were 0.95±0.20 and 1.30±0.26,respectively.There was no significant difference between the two groups(all P>0.05).At the last follow-up,the macular hole closure rate was 95.45% and 100.00% in the group A and group B,and the difference was not statistically significant(P>0.05).The postoperative BCVA(LogMAR) of the group A and the group B were 0.72±0.15 and 0.49±0.11,respectively,which were both lower than those before surgery,and the difference was statistically significant(both P<0.05).The BCVA in the group A was lower than that of group B,and the difference was statistically significant(t=-5.849,P<0.001).Conclusion Nonpeeling of the foveolar ILM and total peeling of foveal ILM combined with air tamponade leads to high closure rates for the treatment of IMH with a diameter of 250-400 μm.However,nonpeeling of the foveolar ILM leads to a better final visual acuity.
Objective To observe the outcome of foveola nonpeeling internal limiting membrane surgery combined with air tamponade for the treatment of idiopathic macular hole(IMH) with a diameter of 250-400 μm.Methods 45 eyes in 45 patients from January 2014 to January 2016 were included in this study.All these eyes with stage IV IMH diagnosed by optical coherence tomography(OCT) with a minimum diameter of 250-400 μm were randomly divided into two groups:total peeling of foveal ILM group(group A,22 eyes),and foveolar ILM nonpeeling group(group B,23 eyes).All patients underwent 23-gauge pars plana vitrectomy.Peeling of the internal limiting membrane was assisted with ICG.The ILM was removed with preservation of the central 300-400 μm diameter ILM in group B and was totally removed in group A.Air tamponade was performed after a fluid-air exchange.The mean follow up was(21.52±5.68)months.The macular hole closure and best corrected visual acuity(BCVA) were observed in the two groups.Results The preoperative macular hole diameters of the group A and B were(337.77±34.54)μm and(324.87±31.95)μm,respectively,MHI were 0.53±0.09 and 0.51±0.08,respectively,and BCVA(LogMAR) were 0.95±0.20 and 1.30±0.26,respectively.There was no significant difference between the two groups(all P>0.05).At the last follow-up,the macular hole closure rate was 95.45% and 100.00% in the group A and group B,and the difference was not statistically significant(P>0.05).The postoperative BCVA(LogMAR) of the group A and the group B were 0.72±0.15 and 0.49±0.11,respectively,which were both lower than those before surgery,and the difference was statistically significant(both P<0.05).The BCVA in the group A was lower than that of group B,and the difference was statistically significant(t=-5.849,P<0.001).Conclusion Nonpeeling of the foveolar ILM and total peeling of foveal ILM combined with air tamponade leads to high closure rates for the treatment of IMH with a diameter of 250-400 μm.However,nonpeeling of the foveolar ILM leads to a better final visual acuity.
引文
[1] GASS C A,HARITOGLOU C,SCHAUMBERGER M,KAMPIK A.Functional outcome of macular hole surgery with and without indocyanine grene-assisted peeling of the internal limiting membrane[J].Graefes Arch Clin Exp Ophthalmol,2003,241(9):716-720.
[2] NAKAJIMA T,ROGGIA M F,NODA Y,UETA T.Effect of internal limiting membrane peeling during vitrectomy for diabetic macular edema:Systematic Review and Meta-analysis[J].Retina,2015,35(9):1719-1725.
[3] HO T C,YANG C M,HUANG J S,SHIH Y F,HO H,HUANG Y H.Foveola nonpeeling internal limiting membrane surgery to prevent inner retinal damages in early stage 2 idiopathic macula hole[J].Graefes Arch Clin Exp Ophthalmol,2014,252(10):1553-1560.
[4] DUKER J S,KAISER P K,BINDER S,DE SMET M D,GAUDRIC A,REICHEL E,et al.The International Vitreomacular Traction Study Group classification of vitreomacular adhesion,traction,and macular hole[J].Ophthalmology,2013,120(12):2611-2619.
[5] MORRIS R,KUHN F,WITHERSPOON C D.Hemorrhagic macular cysts[J].Ophthalmology,1994,101(1):1.
[6] CORNISH K S,LOIS N,SCOTT N W,BURR J,COOK J,BOACHIE C,et al.Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole[J].Ophthalmology,2014,121(3):649-655.
[7] HISATOMI T,NOTOMI S,TACHIBANA T,SASSA Y,IKEDA Y,NAKAMURA T,et al.Ultrastructural changes of the vitreoretinal interface during long-term follow-up after removal of the internal limiting membrane[J].Am J Ophthalmol,2014,158(3):550-556.
[8] BABA T,YAMAMOTO S,KIMOTO R,OSHITARI T,SATO E.Reduction of thickness of ganglion cell complex after internal limiting membrane peeling during vitrectomy for idiopathic macular hole[J].Eye,2012,26(9):1173.
[9] KIM J H,KANG S W,PARK D Y,KIM S J,HA H S.Asymmetric elongation of foveal tissue after macular hole surgery and its impact on metamorphopsia[J].Ophthalmology,2012,119(10):2133-2140.
[10] CHANG S.Controversies regarding internal limiting membrane peeling in idiopathic epiretinal membrane and macular hole[J].Retina,2012,32(Suppl 2):S200-204.
[11] HARITOGLOU C,GASS C A,SCHAUMBERGER M,EHRT O,GANDORFER A,KAMPIK A,et al.Macular changes after peeling of the internal limiting membrane in macular hole surgery[J].Am J Ophthalmol,2001,132(3):363-368.
[12] YOSHIKAWA M,MURAKAMI T.Author response:macular migration toward the optic disc after inner limiting membrane peeling for diabetic macular edema[J].Invest Ophthalmol Vis Sci,2013,54(1):629-635.
[13] MICHALEWSKA Z,MICHALEWSKI J,ADELMAN R A,NAWROCKI J.Inverted internal limiting membrane flap technique for large macular holes[J].Ophthalmology,2010,117(10):2018.
[14] SHIN M K,PARK K H,PARK S W,BYON I S,LEE J E.Perfluoronoctane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery[J].Retina,2014,34(9):1905-1910.
[15] KURIYAMA S,HAYASHI H,JINGAMI Y,KURAMOTO N,AKITA J,MATSUMOTO M,et al.Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia[J].Am J Ophthalmol,2013,156(1):125-131.
[16] IMAI H,AZUMI A.The expansion of RPE atrophy after the inverted ILM flap technique for a chronic large macular hole[J].Case Rep Ophthalmol,2014,5(1):83-86.
[17] LEE C L,WU W C,CHEN K J,CHIU L Y,WU,K Y,CHANG Y C,et al.Modified internal limiting membrane peeling technique (maculorrhexis) for myopic foveoschisis surgery[J].Acta Ophthalmol,2017,95(2):e128-131.
[2] NAKAJIMA T,ROGGIA M F,NODA Y,UETA T.Effect of internal limiting membrane peeling during vitrectomy for diabetic macular edema:Systematic Review and Meta-analysis[J].Retina,2015,35(9):1719-1725.
[3] HO T C,YANG C M,HUANG J S,SHIH Y F,HO H,HUANG Y H.Foveola nonpeeling internal limiting membrane surgery to prevent inner retinal damages in early stage 2 idiopathic macula hole[J].Graefes Arch Clin Exp Ophthalmol,2014,252(10):1553-1560.
[4] DUKER J S,KAISER P K,BINDER S,DE SMET M D,GAUDRIC A,REICHEL E,et al.The International Vitreomacular Traction Study Group classification of vitreomacular adhesion,traction,and macular hole[J].Ophthalmology,2013,120(12):2611-2619.
[5] MORRIS R,KUHN F,WITHERSPOON C D.Hemorrhagic macular cysts[J].Ophthalmology,1994,101(1):1.
[6] CORNISH K S,LOIS N,SCOTT N W,BURR J,COOK J,BOACHIE C,et al.Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole[J].Ophthalmology,2014,121(3):649-655.
[7] HISATOMI T,NOTOMI S,TACHIBANA T,SASSA Y,IKEDA Y,NAKAMURA T,et al.Ultrastructural changes of the vitreoretinal interface during long-term follow-up after removal of the internal limiting membrane[J].Am J Ophthalmol,2014,158(3):550-556.
[8] BABA T,YAMAMOTO S,KIMOTO R,OSHITARI T,SATO E.Reduction of thickness of ganglion cell complex after internal limiting membrane peeling during vitrectomy for idiopathic macular hole[J].Eye,2012,26(9):1173.
[9] KIM J H,KANG S W,PARK D Y,KIM S J,HA H S.Asymmetric elongation of foveal tissue after macular hole surgery and its impact on metamorphopsia[J].Ophthalmology,2012,119(10):2133-2140.
[10] CHANG S.Controversies regarding internal limiting membrane peeling in idiopathic epiretinal membrane and macular hole[J].Retina,2012,32(Suppl 2):S200-204.
[11] HARITOGLOU C,GASS C A,SCHAUMBERGER M,EHRT O,GANDORFER A,KAMPIK A,et al.Macular changes after peeling of the internal limiting membrane in macular hole surgery[J].Am J Ophthalmol,2001,132(3):363-368.
[12] YOSHIKAWA M,MURAKAMI T.Author response:macular migration toward the optic disc after inner limiting membrane peeling for diabetic macular edema[J].Invest Ophthalmol Vis Sci,2013,54(1):629-635.
[13] MICHALEWSKA Z,MICHALEWSKI J,ADELMAN R A,NAWROCKI J.Inverted internal limiting membrane flap technique for large macular holes[J].Ophthalmology,2010,117(10):2018.
[14] SHIN M K,PARK K H,PARK S W,BYON I S,LEE J E.Perfluoronoctane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery[J].Retina,2014,34(9):1905-1910.
[15] KURIYAMA S,HAYASHI H,JINGAMI Y,KURAMOTO N,AKITA J,MATSUMOTO M,et al.Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia[J].Am J Ophthalmol,2013,156(1):125-131.
[16] IMAI H,AZUMI A.The expansion of RPE atrophy after the inverted ILM flap technique for a chronic large macular hole[J].Case Rep Ophthalmol,2014,5(1):83-86.
[17] LEE C L,WU W C,CHEN K J,CHIU L Y,WU,K Y,CHANG Y C,et al.Modified internal limiting membrane peeling technique (maculorrhexis) for myopic foveoschisis surgery[J].Acta Ophthalmol,2017,95(2):e128-131.