保留前囊膜的晶状体摘出术后前囊膜下纤维增生膜的剥除及组织病理学分析

Management and pathology of the optical area fibrotic membrane underlying preserved anterior capsule after lensectomy

背景保留前囊膜的晶状体摘出术在特殊情况下的玻璃体切割术中仍有其应用价值。尽管术中对晶状体上皮进行抛光处理，但术后仍有不同程度的前囊膜下纤维增生膜样混浊，了解这些增生膜中的细胞成分对于术后前囊膜下纤维增生膜样混浊的预防和治疗具有重要的临床意义。目的研究增生性糖尿病视网膜病变（PDR）合并白内障患者行保留前囊膜的晶状体玻璃体切割联合硅油充填手术后晶状体光学区前囊膜下纤维增生膜的处理方法及其组织病理学特点。方法于2013年1—12月在中日友好医院眼科纳入保留前囊膜的晶状体玻璃体切割联合硅油充填治疗且术后发生前囊膜下纤维增生性混浊的PDR合并白内障患者21例23眼，参照文献中描述的前囊膜混浊分级标准，收集取出硅油后前囊膜下纤维增生膜中剥除的C级和D级混浊标本，若难以剥除或剥除过程中出现部分前囊膜撕裂，则给予光学区切开。将收集的前囊膜混浊标本行苏木精－伊红染色、Van Gieson染色及Masson染色，光学显微镜下观察标本中纤维组织和胶原组织的形态；采用苦味酸－天狼星红染色，在偏振光显微镜下观察胶原纤维的分型情况。结果共15眼成功剥除光学区前囊膜下纤维增生膜，占65.2%（15/23），包括C级混浊14眼，其中9眼成功剥除光学区前囊膜下纤维增生膜，占64.3%（9/14），5眼给予光学区直径约3～4 mm的前囊膜切开，3眼获得可利用标本；D级混浊9眼，其中6眼剥除纤维增生膜，占66.7%（6/9），3眼给予前囊膜光学区切开，7眼获得可利用标本。术后20眼最佳矫正视力（BCVA）较术前提高，3眼视力无变化。苏木精－伊红染色提示膜组织主要成分为成纤维细胞和纤维组织，间有色素颗粒和细胞内、外空泡；Van Gieson法染色可见有粉红色染色的纤维成分；Masson法胶原染色显示呈绿色染色的胶原组织；苦味酸－天狼星红染色后偏振光显微镜下可见Ⅰ型胶原纤维以折光性较强的红黄色为主，Ⅲ型胶原纤维间有少量折光性较弱的绿色。结论硅油取出术联合前囊膜下增生膜剥除并保持其完整性或光学区切开是恢复晶状体前囊膜光学区透明性的有效方法；晶状体前囊膜下增生膜由纤维组织、色素颗粒和硅油滴的多种成分组成，以纤维组织居多，胶原纤维以Ⅰ型为主。

Background Lensectomy with anterior capsule preserving is still advisable under specific conditions during vitrectomy.Although lens epithelial cells were polished off during surgery, opacification in varying degrees could be observed.Understanding the composition of proliferative anterior capsule membrane is of an important clinical significance for the prevention and manegement.ObjectiveThis study was to investigate the management and pathology of the pupillary area membranous opacity underling preserved anterior capsule after lensectomy in diabetic eyes with silicone oil tamponade.MethodsTwenty-three eyes of 21 patients with proliferative diabetic retinopathy （PDR） and cataract received vitrectomy combined with lensectomy preserved anterior capsule in China-Japan Friendship Hospital from January to December 2013, and the proliferative anterior capsular membrane specimens with the opacification grade C or D were obtained.The fibrotic membrane underlying anterior capsules were removed in order to make a clear optical area during the operation of silicone oil removal.The proliferative membrane at pupillary area was cut off by cutter probe for the eyes with the membrane attaching tightly or partial capsule laceration occurred.The available specimens were examined under the optical microscope and polarized microscope respectively after hemotoxylin and eosin staining, Van Gieson collagen staining, Masson collagen staining and Picrosirius staining.ResultsThe proliferative fibrosis membranes were pilled to get a clear pupillary area in 15 eyes, with the successfully rate 65.2% （15/23）. In 14 eyes with degree C opacity, the proliferative fibrosis membranes were pilled in 9 eyes, with the successfully rate 64.3% （9/14）, and 5 eyes received anterior capsule cut-through by cutter in pupillary area, with a diameter of 3-4 mm, and available specimens were obtained in 3 eyes.In 9 eyes with degree D opacity, the proliferative membranes were pilled in 6 eyes, with the successfully rate of 66.7% （6/9）, and 3 eyes underwent cut-through by cutter, and available specimens were obtained in 7 eyes.The best corrected visual acuity was obviously improved in 20 eyes and unchanged in 3 eyes after surgery.The histopathological examination showed fibroblasts, pigment particles and intracellular and extracellular vacuolus formation by hemotoxylin and eosin staining, fibril tissue with the pinke staining by Van Gieson, collage formation with green color by Masson staining in the specimens.Picrosirius staining plus polarization microscopy observation revealed that the collagen consisted of abundant type I collagen with stronger reddish yellow color and small amount of type Ⅲ collagen with green color.ConclusionsA combination of silicon oil removal with proliferative mambrane pelling is a available way to restore pupillary transparency in the eyes of PDR with cataract and silicone oil tamponade eyes.Proliferative residual lens epithelial cells, pigment epithelial cells and silicon oil granules are the main composition of opacity mambrane.The type I collagen is dominant in proliferative collagen tissue.