玻璃体切除治疗增生性糖尿病视网膜病变保留晶状体前囊膜的临床观察

Clinical investigation on anterior capsule preservation in surgical management for severe proliferative diabetic retinopathy

目的探讨保留晶状体前囊膜技术在增生性糖尿病视网膜病变（PDR）手术治疗中的临床效果。方法系列病例研究。对伴有晶状体混浊和累及眼底后极部的牵拉性视网膜脱离或牵拉孔源性视网膜脱离的51例（58只眼）PDR患者，在行玻璃体切除手术中，采用经睫状体平坦部切除或超声粉碎吸出晶状体核及皮质并保留前囊膜的技术，处理混浊的晶状体，完成玻璃体手术后给予硅油充填。术后对晶状体前囊膜照相，并对其透明度进行分级评价，对与手术相关的并发症及其处理方法、患者视力和眼压、视网膜复位情况进行分析。结果玻璃体切除硅油充填并保留晶状体前囊膜的58只眼中，晶状体前囊膜透明度：A级26只眼（44．8％），B级20只眼（34．5％），C级7只眼（12．1％）；D级5只眼（8．6％）。46只眼（79．3％）术后最佳矫正视力≥0．05，21只眼接受二期人工晶状体植入术。最终7只眼因视网膜不能复位，黄斑裂孔未闭合，而未行硅油取出术。手术并发症：误切虹膜1只眼，硅油进入前房7只眼，虹膜新生血管形成及新生血管性青光眼各1只眼，术后高眼压4只眼，继发性黄斑和视网膜前膜11只眼，黄斑裂孔2只眼。结论保留晶状体前囊膜，酌情行二期人工晶状体植入术，是处理严重PVR眼的一种较好方法。晶状体上皮细胞残留和积血的长期存在是晶状体前囊膜混浊的主要原因，硅油进人前房是玻璃体切除术中应用保留晶状体前囊膜技术的主要并发症之一。

Objective To report the outcomes of patients treated with the anterior capsule preservation technique used in surgical management for severe proliferative diabetic retinopathy. Methods Anterior capsule was preserved following pars plana lensectomy or fragmentation during vitrectomy for cataract patients with proliferative diabetic retinopathy, all eyes presented tractional and tractional/ rhegmatogenous retinal detachment and involvement of posterior retina. Postoperatively, the transparency of anterior capsule was classified into A, B, C and D degrees according to the photographic record. The outcomes of visual acuity, retinal reattachment, intraocular pressure and the complications related to the operation as well as their managements were analyzed. Results Vitrectomy, silicone oil tamponade and anterior capsule preservation were performed in 58 eyes. The transparency of the anterior capsule in these eyes was degree A in 26 eyes（44. 8% ） ;degree B in 20 eyes（34. 5% ） ;degree C in 7 eyes （12. 1% ） and degree D in 5 eyes （8.6%）. Forty eyes （79. 3% ）had a postoperative best corrected visual acuity ≥0. 05, 21 eyes received secondary intraocular lens implantation. Finally, 7 eyes were classified to be silicone oil-depended eyes because of severe proliferative changes occurred and the presence of macular hole. Complications related to the operation included iris mal-cut in 1 eye, silicone oil escaped into anterior chamber in 7 eyes, iris neovascularization and new vascular glaucoma in 1 eye respectively, intraocular pressure elevation in 4 eyes, secondary pre-macular membrane formation in 11 eyes and macular hole in 2 eyes. Conclusions The anterior capsule preservation procedure and selective secondary intraocular lens implantation is an acceptable method in surgical management for severe proliferative diabetic retinopathy. The main causes of the opacification of anterior capsule are the proliferation of residual lens epithelial cells and blood deposit on the posterior surface. Silicone oil escaped into the anterior chamber is one of the most common complications related to this procedure.