晚期早产儿视网膜病变巩膜外加压手术及玻璃体切割手术疗效观察

Therapeutic effect of segmental scleral buckling and vitreoretinal surgery for stage 4 and 5 retinopathy of prematurity

目的观察巩膜外加压手术及玻璃体切割手术（PPV）治疗晚期早产儿视网膜病变（ROP）的临床效果。方法回顾性病例分析。临床确诊为4、5期ROP的134例患儿181只眼纳入研究。患眼中，4a期40只眼，4b期51只眼，5期90只眼。根据造成牵拉视网膜脱离的纤维膜部位及范围制定不同的手术方法。181只眼中，行巩膜外加压手术37只眼，包括4a期23只眼、4b期14只眼；行PPV50只眼，包括4a期14只眼、4b期29只眼、5期7只眼；行晶状体切割联合PPV94只眼，包括4a期3只眼、4b期8只眼、5期83只眼。手术后4a、4b、5期患眼平均随访时间分别为34、31、29个月。根据患眼视网膜解剖复位情况以成功、好转、失败对手术效果进行评价。结果行巩膜外加压手术37只眼中，成功23只眼，占62．16％；好转11只眼，占29．73％；失败3只眼，占8．11％。行PPV50只眼中，成功20只眼，占40．00％；好转22只眼，占44．00％；失败8只眼，占16．00％。行晶状体切割联合PPV94只眼中，成功20只眼，占21．28％；好转17只眼，占18．08％；失败57只眼，占60．64％。4a期40只眼中，成功33只眼，占82．50％；好转6只眼，占15．00％；失败1只眼，占2．50％。4b期51只眼中，成功11只眼，占21．57％；好转30只眼，占58．82％；失败10只眼，占19．61％。5期90只眼中，成功14只眼，占17．50％；好转19只眼，占23．75％；失败57只眼，占71．25％。行巩膜外加压手术的不同分期患眼手术效果比较，4a期手术效果优于4b期，差异有统计学意义（x2=6．707，P=0．035）。行PPV的不同分期患眼手术效果比较，差异有统计学意义（x2=21．010，P=0．000）；其中，4a期手术效果最好，其次是4b期，5期手术效果最差。行晶状体切割联合PPV的不同分期患眼手术效果比较，5期手术效果明显较4a、4b期差，差异有统计学意义（x2=16．066，P=0．003）。结论根据病变位置及严重程度有针对性的选择巩膜外加压手术或PPV治疗晚期ROP可取得一定治疗效果；与4期患眼比较，5期患眼无论采取何种手术方式，预后均较差。

Objective To observe the therapeutic effect of segmental scleral buckling and vitrectomy with/without lensectomy on the retinopathy of prematurity （ROP） stage 4a, 4b and 5. Methods One hundred and thirty-four ROP infants （181 eyes） diagnosed as stage 4a, 4b and 5, and performed with segmental scleral buckling or vitreous with/without lensectomy were retrospectively analyzed. The operated 4a-, 4b- and 5- stage eyes were 40, 51 and 90 eyes. The operational method depended on the location and severity of fibrovascular membrane. Of 181 eyes, segmental seleral buckling was referred for 37 eyes which include 23 eyes with 4a stage and 14 eyes with 4b stage; vitrectomy was referred for 50 eyes which include 14 eyes with 4a stage, 29 eyes with 4b stage and 7 eyes with 5 stage; vitrectomy with lensectomy was referred for 94 eyes which include 3 eyes with 4a stage, 8 eyes with 4b stage and 83 eyes with 5 stage. The effect was classified as success, improved and failure. Failure includes lost eye. Follow-up for 4a, 4b and 5 stage patients are 34, 31 and 29 months respectively. Results Segmental scleral buckling was referred for a7 eyes, success in 23 eyes （62.16%）, improved in 11 eyes （29. 73%）, failure in 3 eyes （8. 11%）. Vitrectomy was referred for 50 eyes, and success in 20 eyes （40.00%）, improved in 22 eyes （44.00%）, and failure in 8 eyes （16.00%）. In the total of 94 eyes underwcnt vitrcctomy with lensectomy, 20 eyes was success （21.28%）, improved in 17 eyes （18.08%）, failure in 57 cycs （60.64%）. In 40 stage 4a eyes, 33 successes （82.50%）, 6 improved （15.00%） and ] failure （2.50%）. In 51 stage 4b eyes, 11 successes （21.57%）, 30 improved （58.82%） and 10 failures （19.61%）. For.90 stage 5 eyes, 14 successes （17.50%）, 19 improved （233.75%） and 57 failures （71.25%）. The therapeutic effect of segmental scleral buckling for stage 4a was better than that for stage 5 （X2= 6.707,P= 0.035）. The difference of therapeutic effect of vitrectomy for different stage was significant （x2= 21.010,P =0.000）; stage 4a was the best; stage 4b was the second, stage 5 was lhe worst. The therapeutic effect of vitrectomy with lensectomy for stage 5 was worse than that for stage 4a and 4h （x2 = 16. （366,P =0.003）. Conclusion The surgery patterns of ROP was determined based on the disease severity, the surgery effects of stage 4a and 4b were hotter than stage 5, which had nothing to do with the surgical procedures.