增生型糖尿病视网膜病变患眼玻璃体切割手术后持续性角膜上皮缺损的危险因素分析

Risk factor analysis of persistent corneal epithelial defects after vitrectomy in patients with proliferative diabetic retinopathy

目的 观察分析增生型糖尿病视网膜病变（PDR）患眼玻璃体切割手术（PPV）后持续性角膜上皮缺损（PCED）的危险因素。 方法 回顾性临床分析。临床确诊为PDR并行PPV治疗的201例201只眼纳入研究。其中，男性86例86只眼，女性115例115只眼。年龄30～81岁，平均年龄（57.94±9.65）岁；其中，≥50岁159例，＜50岁42例。糖化血红蛋白＜7.0% 36例，≥7.0% 165例。右眼93只，左眼108只。PPV前糖尿病视网膜病变（DR）分期Ⅳ期24只眼，Ⅴ期78只眼，Ⅵ期99只眼。患眼手术时间1～4 h，平均手术时间 2 h。201只眼中，手术中刮除角膜上皮25只眼；联合白内障手术70只眼；激光光凝点数＜1000者78只眼，≥1000者123只眼；硅油填充61只眼，C3F8填充18只眼，未行眼内填充122只眼。以PPV后眼压≥21 mmHg（1 mmHg=0.133 kPa）且应用降眼压药物维持眼压时间≥2周为持续性高眼压。采用我国2016专家共识角膜上皮缺损的诊断标准确立角膜上皮缺损的判定标准。以泪液替代物或角膜接触镜等常规方法治疗角膜上皮缺损无效，连续2周以上不可愈合即可诊断为PCED。观察患眼手术后PCED的发生率，统计分析其相关危险因素。应用多因素logistic回归分析PCED的危险因素。以比值比（OR）及95%可信区间（CI）表示。 结果 201只眼中，手术后发生PCED 16只眼，发生率为7.96%；未发生PCED 185只眼，占92.04%。发生PCED者与未发生PCED者年龄、性别及眼别比较，差异均无统计学意义（χ^2=6.548、0.927、0.044，P=0.011、0.336、0.833）。多因素logistic回归分析结果显示，手术中刮除角膜上皮（OR=13.239，95%CI 2.999～58.442，P=0.001）、联合白内障手术（OR=7.448，95%CI 1.975～28.091，P=0.003）、手术中C3F8填充（OR=11.344，95%CI 2.169～59.324，P=0.004）、手术后持续性高眼压（OR=10.462，95%CI 2.464～44.414，P=0.001）是手术后发生PCED的危险因素。 结论 手术中刮除角膜上皮、联合白内障手术、手术中C3F8填充、手术后持续性高眼压是PDR患眼PPV后发生PCED的危险因素。

Objective To analyze the risk factors for persistent corneal epithelial defects （PCED） after pars plana vitrectomy （PPV） in patients with proliferative diabetic retinopathy （PDR）. Methods A total of 201 PDR patients （201 eyes） who received PPV were enrolled in this retrospective study. There were 86 males （86 eyes） and 115 females （115 eyes）. The patients aged from 30 to 81 years, with the mean age of （57.94±9.65） years. Among them, 159 patients were ≥50 years of age, and 42 patients were 〈50 years of age. There were 36 patients with HbA1c 〈7.0%, 165 patients with HbA1c ≥7.0%. There were 93 right eyes and 108 left eyes. There were 93 right eyes and 108 left eyes. The diabetic retinopathy stages were as follows： stage Ⅳ in 24 eyes, stage Ⅴ in 78 eyes and stage Ⅵ in 99 eyes. The operation time was ranged from 1 to 4 hours, with an average of 2 hours. Among the 201 eyes, corneal epidermis were scraped on 25 eyes; 70 eyes were combined with cataract surgery; a laser photocoagulation count 〈1000 points was performed in 78 eyes, and 〉1000 points were performed in 123 eyes. Sixty-one eyes involved intravitreal silicone oil tamponade, 18 eyes involved intravitreal tamponade with C3F8, and 122 eyes were not involved with intraocular tamponade. Postoperative persistent intraocular hypertension was defined as an intraocular pressure （IOP） ≥21 mmHg （1 mmHg=0.133 kPa） after PPV with necessary treatment using IOP-lowering medications for ≥2 weeks. The diagnostic criteria for corneal epithelial defects were taken from the Expert Consensus on Clinical Diagnosis and Treatment of Corneal Epithelial Defect in China （2016）. The corneal epithelial defect was diagnosed as PCED if it was treated with common methods such as a lacrimal substitute or corneal contact lens, but showed no improvement and no signs of healing for ≥2 weeks. The incidence of PCED after eye surgery was recorded and its related risk factors were analyzed. A multivariate logistic regression was used to analyze the risk factors for PCED, which were expressed as a odds ratio （OR） and a 95% confidence interval （CI）. Results Of 201 eyes, 16 eyes （7.96%） presented with PCED after surgery and 185 eyes （92.04%） with no PCED. There was no significant difference in the age, sex, and eyes between the patients with or without PCED （χ^2=6.548, 0.927, 0.044; P=0.011, 0.336, 0.833）. A multivariate logistic regression showed that intraoperative epithelial debridement （OR=13.239, 95%CI 2.999？58.442, P=0.001）, intraoperative treatment in combination with cataract surgery （OR=7.448, 95%CI 1.975？28.091, P=0.003）, intravitreal tamponade with C3F8 （OR=11.344, 95%CI 2.169-59.324, P=0.004）, and postoperative persistent intraocular hypertension （OR=10.462, 95%CI 2.464-44.414, P=0.001） were risk factors for PCED after PPV. Conclusion Intraoperative epithelial debridement, intraoperative treatment in combination with cataract surgery, intravitreal tamponade with C3F8, and postoperative persistent intraocular hypertension are risk factors for PCED in patients with PDR after PPV.