白内障手术前后全视网膜光凝对糖尿病视网膜病变的疗效比较

Effects of pan-retinal photocoagulation (PRP) before or after cataract surgery in patients with diabetic retinopathy

目的比较增生前期(PPDR)和增生期(PDR)糖尿病视网膜病变患者合并中、重度白内障在不同时期行全视网膜光凝术(PRP)的疗效。设计回顾性病例系列。研究对象62例(95眼)经荧光素眼底血管造影(FFA)诊断PPDR和PDR且伴有中、重度白内障的患者。方法所有患者均能模糊看到眼底,取得知情同意后根据病情将PPDR期和PDR期分配置A、B二组中。A组30例47眼,先行视网膜周边光凝2次,再行人工晶状体植入术,术后1个月再行2次视网膜光凝,补充术前未光凝部分;B组32例48眼,先行人工晶状体植入术,术后1个月分3次行全视网膜光凝(PRP)治疗,每次间隔1周。治疗前及治疗后1个月,所有患者行眼科常规检查及FFA和OCT检查。FFA检查结果为判定糖尿病视网膜病变的疗效标准。显效:原有新生血管完全萎缩和无灌注区消失;有效:原新生血管部分萎缩和无灌注区大部分消失;无效:新生血管无明显变化、发生玻璃体积血和新生血管青光眼。主要指标最佳矫正视力、视网膜新生血管及无灌注区消失状况、黄斑中心视网膜厚度。结果 A组和B组PPDR期患者激光术前、后视力提高和视力稳定率分别为90.5%(19/21眼)和86.4%(19/22眼),两组比较差异无统计学意义(P=0.12);在PDR期,两组分别为76.9%(20/26眼)和65.4%(17/26眼),两组比较差异有统计学意义(P=0.02)。PPDR期患者FFA检查无灌注区消失A组显效和有效占85.7%(18/21眼),B组显效和有效占81.8%(18/22眼),两组比较无明显差异(P=0.1);PDR期两组FFA检查新生血管和无灌注区消失状况:A组显效和有效占61.5%(16/26眼),B组显效和有效占42.3%(11/26眼),两组比较差异显著(P=0.03)。PPDR期患者A组黄斑中心凹厚度(213±11.8)μm,与B组(189±10.4)μm比较,差异无统计学意义(P=0.1);PDR期A组黄斑中心凹视网膜厚度(286±16.7)μm,明显低于B组(425±20.7)μm(P=0.01)。结论对于PDR合并白内障患者,在人工晶状体植入术前、后分期行全视网膜光凝对PDR的效果优于人工晶状体植入术后光凝治疗。

Objective To investigate the effects of pan-retinal photocoagulation （PRP） in patients with preproliferative（PPDR）and proliferative（PDR）diabetic retinopathy （DR） that underwent cataract surgery. Design Retrospective case series. Participants Sixty five patients （95 eyes） diagnosed with FFA as having proliferative and preproliferative DR with moderate or severe cataract. Methods In all patients we were able to see the fundus, patients with PPDR and PDR were divided into two groups according to patient＇s condition after obtaining informed consent. Group A was treated with IOL implantation following peripheral laser for 2 times, then photocoagulation was carried out for 2 times during 1 month. Group B was treated with IOL implantation and then PRP treatment were given for 3 times （each time interval for one week） after 1 month. The results of FFA were used to grade DR. Obvious effects： The original neovascularization was completely atrophied and non-perfusion areas disappeared. Effectiveness： neovascularization and non-perfusion areas mostly disap- peared. Ineffectiveness： no change in neovascularization, presence of vitreous hemorrhage or neovascular glaucoma. Main Outcome Measures Best corrected visual acuity, new blood vessels and areas of no perfusion evaluated with FFA, macular center thickness eval- uated by OCT. Results The proportion of patients with improved visual acuity and stable visual acuity in PPDR patients before and after laser surgery was 90.5% （19/21） in group A and 86.4% （19/22） in group B, with no significant difference between the two groups （P=0.12）. In PDR patients, the proportion of patients with improved visual acuity and stable visual acuity was 76.9% （20/26） in group A and 65.4% （17/26） in group B, with a statistically significant difference （P=0.02）. In PPDR patients, as shown by FFA, non-perfusion areas largely disappeared in Group A （85.7% （18/21））, and in Group B （81.8% （18/22））, without significant difference between the two groups （P=0.1）. In PDR patients, non-perfusion areas largely disappeared in group A （61.5% （16/26）） and in group B （42.3% （11/26））, with a significant difference between the two groups （P=0.03）. There was no significant change in the thickness of the macular center in the two treatment groups of PPDR patients （Group A： 213±11.8 μm; Group B： 189±10.4 μm, P=0.1）. The macular foveal thickness of PDR treatment Group A was significantly lower in treatment Group B （group A： 286±16.7 μm; group B： 425±20.7 μm; P=0.01）. Conclusion Pan-retinal photocoagnlation treatment in PDR patients with cataract is more effective for PDR when given before IOL implantation than after.