眼球贯通伤合并后球壁出口异物存留的临床处理

Clinical treatment for perforating injuries with foreign bodies located at posterior global wall

目的探讨眼球贯通伤合并后球壁出口异物存留病例的临床表现及手术疗效。方法回顾性系列病例研究。分析2006至2010年天津市眼科医院收治的眼球贯通伤合并后球壁出口异物存留患者共17例（17只眼）的临床资料。贯通伤出口位于视乳头及黄斑部8例。伴玻璃体积血17只眼，外伤性白内障11只眼，视网膜脱离8只眼，眼内炎1只眼。根据治疗方案不同分为两组：A组（7例）急诊行玻璃体手术联合异物取出；B组（10例）急诊取出异物，术后1～2周二期行玻璃体手术。随访9～47个月，平均18个月。比较两组的视功能及解剖结果。采用Fisher精确概率检验对数据进行统计。结果所有患者的后球壁出口异物均被取出。贯通伤出口位于视乳头及黄斑部的8例患者视力均低于或等于0．1，而出口位于视乳头及黄斑部以外的9例中有4例患者视力低于或等于0．1，差异有统计学意义（P=0．029）。末次随访时12例患者视力提高，其中A组5例，B组7例（P=1．000）；7例患者视力等于或高于0．1，其中A组4例，B组3例（P=0．350），两组间比较差异均无统计学意义。术中后球壁伤口漏水：A组4例，B组0例，差异有统计学意义（P=0．015）；术中视网膜脱离、术后硅油漏出均为：A组2例，B组0例（P=0．154）；术后视网膜脱离：A组l例，B组3例（P=0．603）；硅油依赖眼：A组1例，B组2例（P=1．000）；两组间比较差异均无统计学意义。结论贯通伤出口位于视乳头及黄斑部的患者视力预后较差。两种手术方案均有效但各有优缺点，应根据病情选择合理的治疗方案。为避免后球壁伤口漏的发生，我们建议尽量采取B方案。

Objective To describe the clinical features and surgical outcomes in a series of patients with perforating injuries and foreign bodies located at the exit wound in posterior global wall. Methods Retrospective case series of 17 eyes of 17 patients were included in the study, each patient who received treatments between January 2006 and December 2010 had perforating injuries with foreign bodies located at posterior global wall. The exit wounds of perforating injuries were in the area of optic disc and macula in 8 eyes. Seventeen eyes had vitreous hemorrhage, 11 eyes had traumatic cataract, 8 eyes had retinal detachment and one eye had endophthalmitis. According to different therapeutic regimen, cases were divided into two groups . Group A （7 cases ） underwent vitrectomy combined with extraction of foreign body as an emergency operation. Group B （10 cases ） underwent extraction of foreign body as an emergency operation and secondary vitrectomy were performed 1 -2 weeks later. The mean follow-up time was 18 months （ranged from 9 -47 months ）. The functional and anatomical results were compared between Group A and B. Fisher＇s exact test were used to analyze the data. Results The foreign bodies were extracted in 17 cases. Poor final best corrected visual acuity （BCVA） （ worse than or equal to 0. 1 ） was presented in all 8 cases with the exit wound being in the area of optic disc and maeula, but only in 4 of 9 cases with the exit wound located in other sites, the difference between these two groups was statistically significant （P = 0. 029）. At final follow-up, vision was improved in 5 cases from Group A and 7 cases from Group B （ P = 1. 000 ） ; BCVA were better than or equal to 0. 1 in 4 cases from Group A and 3 cases from Group B （ P = 0. 350 ） the differences were statistically nonsignificant. Intraoperative leakage at the exit wound occurred in 4 eases from Group A and one from Group B, the difference was statistically significant （P = 0. 015 ）. Intraoperative retinal detachment and postoperative silicone oil leakage occurred in 2 cases from Group A and none from Group B （P =0. 154）. Postoperative retinal detachment occurred in 1 case from Group A and 3 eases from Group B （ P = 0. 603 ）. Silicone oil-dependent eye occurred in 1 case from Group A and 2 eases from Group B （P = 1. 000） ;the differences were statistically nonsignificant. Conclusions The visual prognosis is worse in cases with the exit wound being in the area of optic disc and macula. Both therapeutic regimens were effective, but each has their pros and cons. Appropriate therapeutic regimen should be selected in term of situations. To avoid leakage at the exit wound in vitrectomy, we recommend therapeutic regimen B be selected first.