扩大内界膜剥除范围联合黄斑孔缘笛针按摩治疗初次手术失败的特发性黄斑裂孔疗效分析

Extended internal limiting membrane peeling combined with releasing the edge for primary failed idiopathic macular hole surgery

目的观察扩大内界膜剥除范围联合黄斑孔缘笛针按摩治疗初次手术失败的特发性黄斑裂孔(IMH)的临床疗效。方法回顾性临床研究。2013年8月至2019年6月在北京大学人民医院眼科经初次手术失败并接受再次手术治疗的18例IMH患者18只眼纳入研究。其中,男性5例,女性13例;平均年龄(66.2±6.4)岁。所有患眼采用早期糖尿病视网膜病变治疗研究视力表行BCVA检查,并采用OCT测量黄斑裂孔孔径。初次手术时,患眼平均BCVA为(32.6±13.1)个字母,平均孔径为(621.0±161.8)μm;再次手术时,患眼平均BCVA为(34.4±12.3)个字母,平均孔径为(499.0±148.6)μm。初次及再次手术平均间隔(3.4±1.3)周。再次手术术式为扩大内界膜剥除范围联合黄斑孔缘按摩。ILM剥除范围扩大至直径为4 DD至上下血管弓。黄斑孔缘按摩采用软硅胶头笛针利用负压吸引或轻触孔缘向心方向活动。手术后平均随访时间(9.3±5.2)个月。对比观察再次手术前后患眼BCVA变化;同时,根据手术后OCT图像判断黄斑裂孔是否闭合。以手术后首次获得清晰的黄斑裂孔闭合的OCT图像时间作为裂孔闭合时间。手术前后视力比较均采用配对t检验。结果18只眼中,再次手术后裂孔闭合17只眼,裂孔闭合率为94.4%,裂孔平均闭合时间为(2.1±1.0)周;再次手术失败1只眼,接受第3次手术后裂孔闭合。末次随访时,患眼平均BCVA为(51.5±13.0)个字母,较初次手术时平均提高18.9个字母(>3行),差异有统计学意义(t=5.412,P<0.001)。末次随访时患眼BCVA较初次手术前提高大于3行者11只眼(61.1%),提高>1行者15只眼(83.3%),无变化或下降者3只眼(16.7%)。与再次手术前BCVA比较,末次随访时患眼BCVA平均提高(17.1±9.5)个字母,差异有统计学意义(t=7.595,P<0.001)。结论扩大内界膜剥除范围联合黄斑孔缘笛针按摩治疗初次手术失败的ILM患眼,可提高黄斑裂孔闭合率,改善患眼视力。

Objective To explore the outcome of extended internal limiting membrane(ILM)peeling combined with releasing the edge technique for primary failed idiopathic macular hole(IMH)surgery.Methods A retrospective analysis was performed.The data of 18 eyes of 18 IMH patients who were failed in primary surgery from August 2013 to June 2019 in Peking University People’s Hospital were enrolled in the study.Among them,5 patients were males and 13 patients were females.The average age was 66.2±6.4 years.The BCVA were measured by ETDRS charts.The minimum macular hole size was measured on OCT B-scan image.The average preoperative BCVA and minimum macular hole size of primary surgery was 32.6±13.1 letters and 621.1±161.8μm.The average preoperative BCVA and minimum macular hole size of second surgery was 34.4±12.3 letters and 499.0±148.6μm.Average interval period of first and second surgery was 3.4±1.3 weeks.The surgical technique used in the reoperation included the extended ILM peeling combined with releasing the MH edges.The extended ILM peeling area ranged from 4 DD diameter to vascular arcades.The technique of releasing the macular hole edges was performed by using a silicone soft-tip extrusion cannula,with which tapping the edges softly or aspirated vacuum the edges concentricly.The average follow-up was 9.3±5.2 months.The clear OCT image can be obtained for confirming MH closure which was considered as the closure time in the first time.The comparison of preoperative and postoperative was performed by paired t-test.Results The closure rate of second surgery was 94.4%(17/18),and average closure time was 2.1±1.0 weeks.Only 1 eye experienced the second surgical failure and received the third surgery to achieved macular hole closure.Average final follow-up BCVA was 51.5±13.0 ETDRS letters,with average improvement of 18.9 ETDRS letters(>3 lines)compared with preoperative BCVA of primary surgery.There was significantly statistical difference between the final BCVA and preoperative BCVA(t=5.412,P<0.001).Eleven patients(61.1%)had 3 lines BCVA improvement,15 patients(83.3%)had more than 1 line improvement,and 3 patients(16.7%)had on improvement.The final BCVA of patients significantly improved compared with preoperative BCVA of the second surgery(t=7.595,P<0.001),with average improvement of 17.1±9.5 letters.Conclusion The extended ILM peeling combined with releasing macular hole edges technique is effective to improve the closure rate and BCVA of primary failed IMH eyes.