玻璃体切割手术治疗难治性黄斑裂孔的手术策略

The surgical strategy of vitrectomy for refractory macular hole

难治性黄斑裂孔通常包括直径超过400μm的黄斑裂孔、病理性近视合并黄斑劈裂或病程大于6个月、经历多次手术,抑或是合并广泛视网膜脱离或增生性玻璃体视网膜病变的黄斑裂孔。相较于普通裂孔,难治性黄斑裂孔经常规玻璃体切割联合内界膜剥除手术后愈合率低,视功能恢复不理想,困扰玻璃体视网膜手术医生。通过回顾近年来新涌现的针对各类难治性黄斑裂孔的手术技术,我们总结了三大关键策略。(1)各类内界膜的剥除技术和黄斑裂孔区域的视网膜松解技术;(2)各类眼内组织或生物组织的填塞或覆盖,促进黄斑裂孔区神经上皮层的修复;(3)适当的眼内填充,降低裂孔边缘张力,促进填塞物与黄斑区域的贴附。总之,难治性黄斑裂孔的玻璃体切割手术策略应体现对各解剖因素的综合考虑和对不同患者的个体化设计。

Refractory macular holes typically represent macular holes larger than 400μm,macular holes in pathological myopic eyes or complicated with myopic schisis,chronic holes longer than 6 months,persistent macular holes after surgeries,and some subtypes of secondary macular holes.A routine pars plana vitrectomy combined with internal limiting membrane peeling yielded a lower closure rate and unsatisfying visual rehabilitation in patients with refractory macular holes,which raised concerns among vitreoretinal surgeons.This editorial reviewed the new upcoming surgical techniques which were reportedly to improve the anatomical and visual prognosis of major subtypes of refractory macular holes.Although with a great variability,these surgical techniques are based the following surgical strategies:firstly,to sufficiently unravel the epi-macular tractional force;secondly,to bridge the defect of neurosensory retina by tissue insertion or implantation and stimulate wound healing process;thirdly,proper tamponade of gas or silicone oil so that the surface tension can stabilize the inserted or implanted tissue and encourage closure of the holes.In conclusion,surgical strategies for refractory macular holes should be made after a comprehensive consideration and a customized design.