23G和20G玻璃体切割手术治疗糖尿病视网膜病变的有效性和安全性比较

Comparison of 23G and 20G vitrectomy for diabetic retinopathy

目的对比观察23G、20G玻璃体切割手术治疗糖尿病视网膜病变（DR）的有效性和安全性。方法接受玻璃体切割手术治疗的DR患者33例38只眼纳入研究。按其所接受的手术方式分为23G微创玻璃体切割手术组（23G组）和20G玻璃体切割手术组（20G组），分别为18例20只眼和15例18只眼。手术后随访6～12个月，对比分析两组患眼的玻璃体手术时间，手术中发生的医源性裂孔数目，手术中出血需电凝的次数，手术中需更换显微器械的情况，手术后连续1～3d的眼压，手术后并发症的情况，手术成功率和最佳矫正视力（BCVA）等指标。结果23G组手术时间为35～110min，平均手术时间为（63．5±21．7）min；20G组手术时间为40～150min，平均手术时间为（83．9±27．5）min，两组比较，差异有统计学意义（t=2．55，P=0．02）。23G组和20G组手术中发生医源性视网膜裂孔数平均分别为6、14个。23G组和20G组手术中视网膜或增生膜表面出血影响继续操作需电凝止血的次数平均分别为71、102次。23G组和20G组手术中进行反复显微器械更换操作的患眼分别为3、12只眼，两组比较，差异有统计学意义（y2=10．58，P=0．001）。23G组和20G组手术后第1、2、3天的平均眼压分别为（10．2±2．0）、（13．4±2．5）、（14．9±2．3）mmHg（1mmHg=0．133kPa）和（16．5±2．9）、（19．3±2．4）、（20．1±2．9）mmHg，两组比较，差异有统计学意义（t= 7．71，7．41，6．18；P〈0．01）。23G组手术后出现多量的眼内出血1只眼，牵引性视网膜脱离硅油填充眼出现新生血管性青光眼（NVG）1只眼，再次发生视网膜脱离未再次接受手术1只眼。20G组手术后出现多量的眼内出血2只眼，其中1只眼为玻璃体积血未予眼内填充的患眼，1只眼为牵引性视网膜脱离硅油填充眼，手术后2只眼硅油填充眼出现NVG，1只眼再次发生视网膜脱离未再次接受手术，两组比较，差异无统计学意义（x2=0．49，0．49，0．01；P〉0．05）。23G组和20G组最终手术分别成功19、17只眼，成功率为95．0％、94．4％，两组比较，差异无统计学意义（x2=0．01，P=0．94）。两组患眼均未发生眼内炎、明显脉络膜脱离等并发症。23G组BcVA〈O．05者1只眼；0．05～0．09者5只眼；0．1～0．2者10只眼；≥0．3者4只眼；20G组BCVA〈0．05者1只眼；0．05～0．09者9只眼；0．1～0．2者6只眼；≥0．3者2只眼，两组比较，差异无统计学意义（x2=2．70，P〉0．05）。结论23G微创玻璃体手术较20G手术减少了器械更换，缩短了手术时间，并减少了手术中出血、医源性裂孔等并发症发生。

Objective To compare the efficacy of 23G and 20G vitrectomy for diabetic retinopathy. Methods Thirty-eight eyes of 33 patients with diabetic retinopathy who underwent primary vitreetomy were enrolled in this study. Twenty eyes of 18 patients underwent 23G microincision vitrectomy （23G group）. Eighteen eyes of 15 patients underwent 20G vitrectomy （20G group）. The follow-up ranged from 6 to 12 months. The surgical time, number of iatrogenie retinal tears, times of coagulation for hemorrhage, instrumental change for fibromembrane removal, intraocular pressure （IOP） at 1st, 2nd and 3rd days after surgery, postoperative complications, anatomic success rate, and best corrected visual acuity （BCVA） were observed. Results The mean surgical times were （63.5±21.7） and （83.9±27.5） minutes in 23G and 20G group which was a significant difference （t= 2.55, P=0.02）. The numbers of iatrogenic retinal tears were six and 14, while the mean times of coagulation were 71 and 104 in 23G and 20G group respectively. There were three and 12 eyes needing instrumental change for fibromembrane removal in 23G and 20G group with significant difference （x2= 10.58, P= 0. 001）. At the 1st, 2nd and 3rd days after surgery, IOP were （10.2±2.0）, （13.4±2.5）, and （14.9±2.3） mm Hg （1 mm Hg=0. 133 kPa） in 23G group, （16.5± 2.9）, （19.3±2.4）, and （20.1 ± 2.9） mm Hg in 20G group. Compared with each other, the differences were statistically significant （t = 7.71, 7.41, 6.18, P〈 0.01）. There was one eye with intraocular hemorrhage, one eye with neovascular glaucoma （NVG）, and one eye with retinal detachment （RD） in 23G group. There were two eyes with intraocular hemorrhage, two eyes with NVG, and one eye with RD in 20G group. Compared with each other, the differences were not statistically significant （2：2 =0.49, 0.49, 0.01, P〉0.05）. The anatomic success rates were 95.0% and 94.4% in 23G and Z0G group without significant difference （x2= 0.01, P = 0.94）. There were no complications such as endophthalmitis or choroidal detachment. In 23G group, BCVA was 〈0.05 in one eye, 0.05 - 0.09 in five eyes, 0.1 - 0.2 in 10 eyes, 0.3 in two eyes. In20Ggroup, BCVA was 〈0.05 in one eye, 0.05- 0.09 in nine eyes, 0.1 - 0.2 in six eyes, ≥0.3 in two eyes. Compared with each other, the differences were not statistically significant x2= 2.70, P〉0.05）. Conclusion 23G microincision vitrectomy is beneficial to shorten the operation time, reduce instrumental changes, decrease intraoperative complications, and enhance visual rehabilitation.