增殖性糖尿病视网膜病变玻璃体切除术后残留膜的转归分析

Analysis of residual membranes after vitrectomy for proliferative diabetic retinopathy

目的分析增殖性糖尿病视网膜病变（PDR）玻璃体切除术后残留膜的预后及转归。方法回顾性系列病例研究。收集北京协和医院眼科2000年1月至2009年6月由同一医生进行玻璃体切除联合增殖膜剥离手术的Ⅴ或Ⅵ期PDR患者资料，共550眼，其中明确有残留增殖膜并且随诊半年以上的患者43例（50眼）。总结有残留增殖膜患者术前、术中及术后情况，采用Wilcoxon符号秩检验和Mann-Whitney检验对残留膜的转归及预后进行分析。结果残留膜位置：血管弓附近29处（33％）．颞侧血管弓内4处（5％），视乳头及其附近7处（8％），其他位置48处（54％）。术后随诊（27．7±26．2）个月，末次随诊视力提高42眼（84％），不变1眼（2％），下降7眼（14％），与术前比较差异有统计学意义（Z=-5．353，P〈0．01）。术后玻璃体出血和牵拉性视网膜脱离的发生率分别为14％（7／50）和8％（4／50），共有14眼再次发生程度不同的视网膜增殖膜，其中有5处（6％，5／88）增殖膜位置与残留膜相同，其余均与残留膜无关，多数残留膜（94％，83／88）表现为稳定或者萎缩。结论玻璃体切除联合增殖膜剥离治疗PDR的目的在于充分解除增殖膜对视网膜的牵拉，对于黏连紧密的局部增殖膜不需强行剥离．残留膜并不增加术后玻璃体出血和视网膜脱离的风险，多数残留膜能保持稳定或萎缩，与再次增殖无显著关系。

Objective To analyze the prognosis and results of residual membranes after vitrectomy for proliferative diabetic retinopathy （PDR）. Methods It was a retrospective case series study. Five hundred and fifty eyes were diagnosed with phase V or VI diabetic retinopathy and received vitrectomy and proliferative membrane peeling from Jan 2000 to June 2009. Among these patients, 50 eyes of 43 patients had definite residual membranes, and were followed up for more than half a year. Their condition was summarized before, during, and after surgery, and the prognosis and results of the residual membranes were analyzed. Data were analyzed by Wilcoxon signed rank test and Mann-Whitney test. Results Location of the residual membrane： along the arterial arc-29 pieces （33%）, inside the temporal arterial arc-4 pieces （5%）, near the optic disk-7 pieces （8%）, other locations-48 pieces （54%）. Mean follow-up time was 27.7.＋_26.2 months （6-102 months）. Visual acuity improved in 42 eyes （84%）, was unchanged in 1 eye （2%）, and decreased in 7 eyes （14%）. There were significant differences between preoperative and postoperative visual acuity （Z=-5.353, P〈0.01）. The incidences of postoperative vitreous hemorrhage and retinal detachment were 14%（7/50） and 8%（4/50）, respectively. There were recurrent proliferative membranes in 14 eyes, including 5 （6%, 5/88） at the same location as the residual membranes. Most residual membranes （94%, 83/88） manifested stability or atrophy. Conclusion Vitrectomy and membrane peeling for PDR is used to isolate the membrane and relieve retinal traction. Forced peeling is not suggested for focal membranes that adhere firmly to the retina. Residual membranes are not related to postoperative vitreous hemorrhage and retinal detachment. Most residual membranes can remain stable or become atrophied, and there is no significant relationship between residual membranes and recurrent proliferative membranes.