孔源性视网膜脱离术后持续性黄斑下积液的相干光断层扫描观察与分析

Clinical survey and analysis of persistent submacular fluid on optical coherence tomography after surgery for rhegmatogenous retinal detachment

目的探讨孔源性视网膜脱离术后持续性黄斑下积液的发生、转归情况及其与手术方式等因素的关系和对视功能的影响。方法回顾性系列病例研究。选择2008年6月至2010年12月在河南省眼科研究所河南省立眼科医院行玻璃体切除术或巩膜扣带术的90例（92只眼）连续病例纳入研究，其中男性52例（54只眼），女性38例（38只眼），患者年龄15—76岁，平均（45．8±15．3）岁。病例人选标准：孔源性视网膜脱离波及黄斑区，无黄斑裂孔，无明显眼底增生病变；术后1个月经检眼镜和眼部超声检查证实视网膜完全解剖复位，至末次随访无复发；术后随访时间至少1年，且黄斑下积液完全消失后半年以上。患者术前行全面眼科检查，术后第1、3、6、12个月随诊时除常规检查外均行相干光断层扫描（OCT）检查，以后每半年复查一次，至末次随诊，观察黄斑下积液的发生、发展、吸收及视力恢复情况。对视网膜裂孔数目及视网膜脱离范围（波及的钟点数）的比较采用秩和检验，视网膜裂孔不同位置及类型的构成比、黄斑下积液的发生率采用X。检验或Fisher精确检验。结果玻璃体切除术组和巩膜扣带术组患者术后1、6个月时持续性黄斑下积液的发生率分别为13．9％（5／36）、2．8％（1／36）和48．2％（27／56）、23．2％（13／56）。上方裂孔和下方裂孔者术后1个月持续性黄斑下积液发生率分别为13．9％（5／36）和64．3％（18／28），差异有统计学意义（）f。=17．38，P〈0．01）。术后6、12个月时，持续性黄斑下积液阳性和阴性者视力差异均有统计学意义（t=2．525、2．254，P值均〈0．05），其他时间点差异均无统计学意义（P〉0．05）。按术后6个月时黄斑下积液是否吸收将所有黄斑下积液患者分为36个月组和〈6个月组，术后1、3个月两组平均视力分别为0．70±0．33、0．63±0．37和0．50±0．25、0．45±0．22，差异均无统计学意义（P〉0．05），术后6、12个月及末次随诊时，两组患者平均视力分别为0．47±0．29、0．44±0．28、0．42±0．22和0．30±0．16、0．27±0．15、0．27±0．19，差异均有统计学意义（t=2．114、2．207、2．068，P值均〈0．05）。结论巩膜扣带术和玻璃体切除术后均可发生持续性黄斑下积液，但巩膜扣带术的发生率较高，病例的选择、裂孔的位置及发病时间是可能的影响因素；持续性黄斑下积液延缓视网膜脱离患者视功能的恢复进程并可能影响术后最终视力，持续时间越长，视力受损的可能性越大。

Objective To investigate the incidence, duration and consequences of persistent submacular fluid after pars plana vitrectomy （PPV） and scleral buckling surgery （SB） in rhegmatogenous retinal detachment, thus to explore the clinical association between persistent SMF and different surgical methods, and simultaneously, to study the effect of persistent submacular fluid on visual outcome. Methods It was a retrospective case-series study. Ninety-two qualified eyes including 54 eyes of males and 38 eyes of females with rhegmatogenous retinal detachment which had been performed PPV or SB were recruited. The average age of the patients was （45.8 ＋ 15.3 ） years with a age-range from 15 to 76 years. The inclusion criteria was as follows, the macula-off rhegmatogenous retinal detachments without macular hole and obvious proliferative vitreoretinopathy, the retina was completely reattaehed 1 month after operation and no redetachment was found by ophthalmoscope and B scan till the last follow-up, the minimal follow-up time was 1 year and the submacular fluid must have been dissolved for at least 6 months. All patients underwent thorough ophthalmologic examinations before and after operation, Those patients in whom a persistent submacular fluid was seen on optical coherence tomography （OCT） at 1 month after operation performed follow-up with repeat of the investigations at 3,6 and 12 months after surgery, If the abnormality resolved, further observations were continued to undertake for 6 months or more till the last follow-up. Rank-sum test, X2-test and Fisher exact test were applied respectively to analyze for statistical analysis. Results The incidence of persistent submacular fluid at 1 month after surgery in the PPV and SB group was 13.9% （5/36） and 48.2% （27/56）. Six months later however, the figure expressed as percentage was 2. 8% （1/36） and 23.2% （18/28） correspondingly. Persistent submacular fluid was more frequent in eyes with inferior breaks （ 64. 3% ） than that with superior ones （ 13.9% ） , making a significant differences （ ~2 -= 17.38 ,P 〈 0. 0! ）. The persistent submacular fluid group showed worse best-corrected visual acuity than no persistent submacular fluid group 6 and 12 months after surgery （ t = 2. 525, t = 2. 254, both P 〈 0. 05 ）. Comparing the visual acuity（VA） between the eyes with or without persistent submacular fluid 6,12 months after surgery and the lastest followed-up among the ever suffered eyes, a statistically significant differences presented in late stages （ average VA ： 0.47 _ 0. 29,0. 30 ＋ 0. 16 ; 0.44 ＋- 0. 28,0. 27 ＋ 0. 15 ; 0.42 ＋- 0. 22, 0.27 ＋ 0. 19;t = 2. 114,2. 207,2. 068 ;all P 〈 0.05）, though there were no significant differences in the first three months （ average VA ： 0. 70 _＋ 0. 33,0. 63 -＋ O. 37 ;0. 50 -＋ 0. 25,0. 45 _＋ O. 22 ; t = O. 556, O. 601 ; both P 〉 0.05 ）. Conclusions Persistent submacular fluid presents in both surgical procedures but it is more frequent after buckling surgery than vitrectomy, the selection of patients, the location of retinal breaks and the duration of detachment may be the potential influencing factors. Persistent submacular fluid after retinal detachment surgery is responsible for delayed recovery, and may affect the final visual outcome. The longer it lasts, the more harm may it do.