探查和处理巩膜穿刺内口在玻璃体术中的意义

Clinical significance of intraoperative observation and treatment of inner sclerotomy sites during vitrectomy surgery

目的探讨玻璃体手术中探查及处理巩膜穿刺孔内口的必要性及手术效果。方法分析2009年1月至2011年12月行标准20G玻璃体切割手术113只眼作为研究对象，其中53只眼为观察组，手术结束时检查巩膜穿刺孑L内口情况，根据术中探查，将巩膜穿刺孔内口玻璃体嵌顿分为5级，以Ⅱ级以上玻璃体嵌顿为有临床意义，发现异常进行相应处理和常规巩膜外冷冻。60只眼为对照组，对照组复发性视网膜脱离再手术患者术中亦进行巩膜穿刺口探查和处理。结果观察组1次手术成功48例（90．5％）；对照组45例（75％），15例再次手术，观察组手术成功率明显高于对照组（X2=4．68，P〈0．05），对比有统计学意义。观察组巩膜穿刺孔并发症发生率45％，而对照再手术为70％。玻璃体嵌顿主要发生在上方的巩膜切口，颞下方少。观察组发生周边医源性视网膜裂孔7．5％，而对照再手术组为67％。全部裂孔位于上方两个巩膜穿刺孔内口所在的象限，且10点位多于2点位。结论玻璃体手术中，巩膜穿刺孔玻璃体嵌顿并发症十分常见，是玻璃体手术失败的主要原因。应重视手术中巩膜穿刺孔内口的探查，预防和处理巩膜穿刺孔玻璃体嵌顿引起的并发症可明显提高手术的成功率。

Objective To investigate the importance and outcome of exploring and treating inner aspects of sclerotomies during vitreous surgery. Methods Record of patients＇ undergone 20G pars plana vitrectomy （PPV） between January 2009 and December 2011 were enrolled. Data was available for 113 eyes, which classified to observation group （53 eyes） and control group （60 eyes）. Intraopertive observation at the end of the surgery, Based on the intraoperative observation, the vitreous incarceration at inner aspects of Sclerotomies （IAS） was classified into five grades. More than Grade Ⅱ had clinical significance, once found abnormal treated immediately and frozen commonly around the inner aspects of sclerotomies. The eyes at control group had retina redetachment were explored and treated the inner aspects of sclerotomies during reoperation as well. Results Forty-eight eyes at observation group （90.5%） and 45 eyes at control group （75%） achieved anatomical retina re- attachment with one vitreous surgery. Compared to the control group, the observation group in the eyes with anatomical success was significantly improved （X2=4.68, P 〈0.05）. The sclerotomy-related complications at observation group were 45%, and the rate of needing second surgery was 70%. The vitreous incarceration occurred mainly at superior sclerotomy site, less at bitamporal below site. The rate of sclerotomy-related retinal breaks at observation group was 7.5%, and need to second surgery was 67%. All sclerotomy-related retinal breaks occurred at the quadrants with superior sclerotomy sites, and breaks found at 10 o＇clock site were more than 2 o＇clock site. Conclusions The vitreous incarceration at inner aspects of sclerotomies is very common clinical complications during pars plana vitrectomy, which has the chief cause of vitreous surgery failure. More attentions shall be paid to intraoperative observation and treatment of inner aspects of sclerotomies during vitrectomy surgery, which can prevent the complications from the vitreous incarceration, and improve the successful rate of operation.