糖尿病视网膜病变大片硬性渗出的手术治疗

Surgical management for massive subretinal hard exudates secondary to diabetic retinopathy

目的研究手术治疗糖尿病视网膜病变（DR）大片硬性渗出（HE）后的结果及对术后视力恢复的影响因素。设计回顾性病例系列。研究对象解放军总医院38～67岁合并大片HE的DR患者25例28眼。方法实施包括后界膜的玻璃体切除、视网膜前膜剥除及视网膜激光光凝治疗。手术前后行眼压、眼底、相干光断层扫描（OCT）和荧光素眼底血管造影（FFA）检查。分析对术后视力恢复的影响因素。主要指标最佳矫正视力（BCVA），术后HE的吸收、荧光素渗漏情况及黄斑区视网膜厚度。结果随访4-48个月（平均10．3个月）。最后随访时，23眼（82．15％）BCVA较术前不同程度提高。HE完全吸收者22眼（78．6％）。术后13眼BCVA〈0．1，原因包括黄斑部HE未全吸收、HE吸收后黄斑部视网膜下瘢痕形成、进行性光凝斑增大致黄斑部视网膜变薄及黄斑视网膜前膜形成。术后4-36个月，7眼BCVA下降，原因包括慢性前部缺血性视神经病变和黄斑水肿复发。结论包括后界膜的玻璃体切除、视网膜前膜剥除及视网膜激光光凝治疗DR大片HE患者对HE吸收有效，多数术眼视力不同程度提高。黄斑部HE未完全吸收和黄斑部视网膜的继发性病损、前部缺血性视神经病变和黄斑水肿复发是影响术后视力恢复及导致视力下降的主要因素。

Objective To report the outcomes of surgical treatment for massive subretinal hard exudates （HE） secondary to diabetic retinopathy （DR） and to analyze the influential factors of postoperative visual acuity recovery. Design retrospective case series. Par- ticipants Twenty eight eyes of 25 patients with diabetic retinopathy from Department of Ophthalmology, The General Hospital of PLA were included. Methods Pars plana vitreetomy included posterior hyaloid removal and preretinal proliferate fibrovascular membrane peeling, endolaser retinal photocoagulation were performed. Intraocular pressure measuring, color founds photography, founds fluorescein angiography （FFA）, optic coherence tomography （OCT） were performed preoperatively and postoperatively. The influential factors of the postoperative visual recovery were analyzed. Main Outcome Measures The postoperative best corrected visual acuity （BCVA）, ab- sorption of the hard exudates, leakage of the fluorescein and macular retinal thickness. Results The follow up period was 4 to 48 months （mean 10.3 months）. 23 eyes（82.15% ） had a improvement of BCVA , postoperatively. 22 eyes（78.6%） had a complete absorp- tion of HE. Postoperative BCVA〈0.1 was in 13 eyes, which causes included incomplete absorption of HE, submacular scar formation following complete absorption of HE, retinal thinning secondary to progressive enlargement of laser spots and premacular membrane. Visual decreasing was noted in 7 eyes from 4 to 36 months after operation, which causes were chronic anterior ischemic optic neuropa- thy and macular edema recurrence. Conclusion Vitrectomy, posterior hyaloid removal and endolaser retinal photoeoagulation may offer the relative satisfied effects in the treatment for massive subretinal HE. Most eyes had a visual improvement postoperatively. Incomplete absorption of HE, secondary maclaropathy, chronic anterior ischemic optic neuropathy and recurrence of macular edema were the causes of low vision in patients with massive HE.