23G玻璃体切割手术联合与不联合内界膜剥除治疗特发性黄斑前膜的疗效对比观察

Clinical outcomes of idiopathic macular epiretinal membrane removal by 23G vitrectomy with or without internal limiting membrane peeling

目的 对比分析23G玻璃体切割手术联合与不联合内界膜（ILM）剥除治疗特发性黄斑前膜（IMEM）的临床效果.方法 临床确诊为IMEM并行23G经睫状体平坦部三切口闭合式玻璃体切割手术治疗的40例患者40只眼纳入研究.其中,联合ILM剥除20只眼（ILM剥除组）,不联合ILM剥除20只眼（ILM未剥除组）.ILM剥除组患眼在曲安奈德染色辅助下剥除视网膜前膜,然后在吲哚青绿染色辅助下剥除黄斑血管弓区域内ILM;ILM未剥除组患眼只在曲安奈德染色辅助下剥除视网膜前膜.ILM剥除组、ILM未剥除组手术后平均随访时间分别为（15.85±3.79）、（16.45±3.72）个月.两组患者间性别、年龄、眼别、最小分辨角对数（logMAR）矫正视力（BCVA）、黄斑中心凹厚度（CMT）、黄斑体积（TMV）及随访时间比较,差异均无统计学意义（P＞0.05）.观察两组患眼手术中及手术后并发症的发生情况.对比分析末次随访时两组患眼BCVA、CMT及TMV的差异.同时对手术后BCVA与CMT、TMV的关系进行相关性分析.结果 ILM剥除组与ILM未剥除组手术中及手术后均未发生视网膜脱离、眼内炎等严重并发症,亦未见IMEM复发.末次随访时,ILM剥除组、ILM未剥除组平均logMAR BCVA分别为0.53±0.27、0.54±0.26,均较手术前明显提高.ILM剥除组、ILM未剥除组手术前后logMAR BCVA比较,差异均有统计学意义（t=5.035、4.964,P＜0.05）.两组间手术后logMAR BCVA比较,差异无统计学意义（t=0.176,P＞0.05）.ILM剥除组、ILM未剥除组平均CMT分别为（343.55±48.74）、（311.70±42.48） μm,均较手术前明显变薄.ILM剥除组、ILM未剥除组手术前后CMT比较,差异均有统计学意义（t=9.508、8.549,P＜0.05）.ILM剥除组手术后CMT较ILM未剥除组更厚,差异有统计学意义（t=-2.203,P＜0.05）.ILM剥除组、ILM未剥除组平均TMV分别为（7.78±0.40）、（7.88±0.43） mm3,均较手术前明显缩小.ILM剥除组、ILM未剥除组手术前后TMV比较,差异均有统计学意义（t=11.098、15.372,P＜0.05）.两组间手术后TMV比较,差异无统计学意义（t=0.755,P＞0.05）.相关性分析发现,ILM剥除组、ILM未剥除组手术后logMAR BCVA与CMT（r=0.244、0.266）、TMV（r=-0.096、0.157）之间均无相关性（P＞0.05）.结论 23G玻璃体切割手术联合与不联合ILM剥除均能安全有效地治疗IMEM.联合ILM剥除较不联合ILM剥除在改善视力方面并未显示出更大优势,且其手术后CMT更厚.

Objective To evaluate the clinical outcomes of idiopathic macular epiretinal membrane （IMEM） by 23G vitrectomy with or without internal limiting membrane peeling.Methods A total of 40 eyes in 40 patients diagnosed as IMEM underwent 23G pars plana thre-port vitrectomy （23G PPV）.The macular ERM alone was removed in 20 eyes （non-ILM peeling group）.Both ERM and ILM peeling were performed in another 20 eyes （ILM peeling group）.All patients underwent removal of ERM with assistance of triamcinolone acetonide.For patients who underwent ILM peeling,indocyanine green dye was used to stain the ILM.ILM was peeled off up to the marginal of macular vessels arch.The patients in ILM peeling group and non-ILM peeling group had postsurgical follow-up for （15.85±3.79） months and （16.45±3.72） months respectively.There were no significant differences in gender,age,OD/OS,preoperative bestcorrected visual acuity （BCVA）,preoperative central macular thickness （CMT）,preoperative total macular volume （TMV） and follow-up time between the two groups （P＞0.05）.Intraoperative or postoperative complication was recorded during the follow-up period.At the final visit,the differences in BCVA,CMT and TMV between the two groups were analyzed,so did the correlations between BCVA and CMT or TMV in each group at the same time.Results There was no recurrence of an ERM or severe complications,such as retinal detachment and endophthalmitis in either group.The mean BCVA of ILM peeling group and nonILM peeling group was 0.53 ± 0.27 and 0.54 ± 0.26 respectively at the final visit.Postoperative BCVA improved significantly in both groups with significant difference （t=5.035,4.964; P＜0.05）.The was no difference of postoperative BCVA between two groups （t =0.176,P＞ 0.05）.The mean CMT was （343.55 ± 48.74） μm and （311.70±42.48） μm,and the mean TMV was （7.78±0.40） mm3 and （7.88±0.43） mm3.CMT （t=9.508,8.549） and TMV （t =11.098、15.372） revealed a significant decrease in both groups with significant difference （P ＜ 0.05）.The postoperative CMT in the ILM peeling group was significantly higher than that in the non-ILM peeling group （t=-2.203,P＜0.05）.No difference was found between the two groups in terms of TMV （t =0.755,P＞0.05）.Furthermore,no correlation was observed between postoperative BCVA and CMT （r =0.244,0.266 ; P ＞ 0.05） or TMV （r =-0.096,0.157; P＞0.05）.Conclusions 23G PPV combined with or without ILM peeling is an efficient and safe treatment for IMEM.ILM peeling appears to have similar effect on the long-term visual outcomes comparing with non-ILM peeling,combined with much thicker postoperative CMT.