增生型糖尿病视网膜病变微创玻璃体切割手术后新生血管性青光眼的危险因素分析

Risk factors of neovascular glaucoma after pars plana vitrectomy for proliferative diabetic retinopathy

目的分析增生型糖尿病视网膜病变(PDR)25G玻璃体切割手术(PPV)后发生新生血管性青光眼(NVG)的危险因素。方法回顾性病例研究。2017年1月至2018年12月在天津医科大学眼科医院首次行PPV治疗的PDR合并玻璃体积血(VH)患者340例340只眼纳入研究。其中,男性185例,女性155例;平均年龄(55.79±10.82)岁。患者平均糖尿病病程(13.01±7.70)年;平均空腹血糖(7.55±2.15)mmol/L。合并冠心病19例,合并脑梗死20例。所有患眼均行最佳矫正视力(BCVA)、眼压、间接检眼镜、彩色眼底照相等检查。BCVA检查采用国际标准Snellen视力表进行,并将结果换算为最小分辨角对数(logMAR)视力记录。患眼平均logMARBCVA2.04±0.73,平均眼压(15.45±2.93)mmHg(1 mmHg=0.133kPa)。VH持续时间3周〜6个月,平均时间(2.98±1.46)个月。340只眼中,Ⅳ期93只眼(27.35%),Ⅴ期107只眼(31.47%),Ⅵ期116只眼(34.12%);伴牵引性视网膜脱离(TRD)83只眼。所有患眼均行25G标准经睫状体平坦部三通道PPV。57只眼手术前3d行玻璃体腔注射抗血管内皮生长因子(VEGF)药物治疗,234只眼手术中剥除内界膜,262只眼同时行白内障超声乳化手术,141只眼手术完毕时行玻璃体腔注射抗VEGF药物治疗。手术后随访至少12个月,平均随访时间(10.80±5.79)个月。以裂隙灯显微镜或房角镜检查发现虹膜和(或)房角存在新生血管且眼压〉21mmHg者诊断为NVG。采用Kaplan-Meier法和Cox单因素、多因素回归分析手术前基线因素、眼部因素、手术因素与手术后NVG发生的关系。结果340只眼中,PPV后发生NVG者66只眼(19.41%);发生NVG的时间为手术后6〜335 d,平均时间为(98.00±5.79)d。PPV后第3、6、12个月,NVG发生风险比分别为11.50%、15.29%、20.75%。单因素Cox分析结果表明,年龄、合并冠心病或脑梗死疾病等手术前基线因素对手术后发生NVG有影响(P<0.05);PDR分期、合并TRD、手术前logMAR BCVA、手术前眼压等眼部因素对手术后发生NVG无影响(P>0.05);联合白内障超声乳化手术、手术中剥除内界膜、手术前3d玻璃体腔注射抗VEGF药物等手术因素对手术后发生NVG有影响(P<0.05)。将Cox单因素分析有意义的变量纳入多因素Cox比例风险模型进行分析,逐步回归探索手术后NVG的影响因素。结果显示,年龄、合并冠心病或脑梗死、联合白内障超声乳化和手术中内界膜剥除是手术后发生NVG的独立风险预测因素(P<0.05)。结论低龄、合并冠心病或脑梗死、联合白内障超声乳化手术是PDR患者PPV后发生NVG的危险因素,手术中剥除内界膜可减少NVG的发生。

Objective To analyze the risk factors of neovascular glaucoma(NVG)after 25G pars plana vitrectomy(PPV)in proliferative diabetic retinopathy(PDR).Methods A retrospective study.From January 2017 to December 2018,340 PDR patients(340 eyes)with vitreous hemorrhage(VH)who were first treated with PPV in Tianjin Medical University Eye Hospital were included in the study.Among them,185 were male Ocul Fundus Dis,January 2021,Vol.37,No.1 and 155 were female,with an average age of 55.79±10.82 years.The duration of diabetes was 13.01±7.70 years,the fasting blood glucose was 7.55±2.15 mmol/L.Nineteen patients combined coronary heart disease,and 20 patients combined cerebral infarction.All patients underwent best-corrected visual acuity(BCVA),intraocular pressure(IOP),non-contact fundus examination,and fundus color photographs.BCVA was measured using an international standard Snellen visual acuity chart,and the values were converted to logarithm of the minimum angle of resolution(logMAR)scores for data analysis.The baseline logMAR BCVA was 2.04±0.73,The baseline IOP was 15.45±2.93 mmHg(1 mmHg=0.133 kPa).The duration of VH was 2.98±1.46 months,ranged from 3 weeks to 6 months.Three hundred and forty eyes included 93 eyes of PDRⅣstage(27.35%),107 eyes ofⅤstage(31.47%),and 116 eyes ofⅥstage(34.12%),combined tractional retinal detachment(TRD)83 eyes.All patients underwent 25G standard three channel vitrectomy through the pars plana of the ciliary body.Preoperative anti-VEGF injection was performed in 57 eyes,internal limiting membrane(ILM)peeling in 234 eyes,combined phacoemulsification cataract surgery in 262 eyes and 141 eyes intravitreal anti-VEGF injection at the end of surgery.The patients were followed up for at least 12 months,with an average follow-up time of 10.80±5.79 months.NVG was defined as the presence of neovascularization in the anterior chamber angle or iris with an IOP higher than 21 mmHg after vitrectomy.Kaplan-Meier method and Cox univariate and multivariate regression were used to analyze the relationship between baseline factors,ocular factors,surgical factors and the occurrence of NVG after surgery.Results Among 340 eyes,66 eyes(19.41%)developed NVG after vitrectomy during 12 months of observation,NVG occurred from 6 to 335 days after surgery,and the mean period between vitrectomy and developing NVG was 98.00±5.79 days.The incidence of NVG was 11.50%,15.29%and 20.75%,respectively in the 3rd,6th and 12th month after PPV.The result of univariate analysis with the Cox regression analysis showed that the development of NVG at 12 months after surgery and age,combined coronary heart disease or cerebral infarction,combined with cataract phacoemulsification,ILM peeling,preoperative anti-VEGF injection had effect on postoperative NVG(P<0.05).Ocular factors such as PDR staging,combined TRD,preoperative logMAR BCVA,preoperative intraocular pressure,etc.had no effect on the occurrence of NVG after surgery(P>0.05).Combined cataract phacoemulsification surgery,internal limiting membrane peeling,surgical factors such as intracavity injection of anti-VEGF drugs 3 days before surgery,had an impact on the occurrence of NVG after surgery(P<0.05).The meaningful variables of the Cox univariate analysis were incorporated into the multivariate Cox proportional hazard model for analysis,and the influencing factors of NVG after surgery were gradually regressed.The results showed that age,coronary heart disease or cerebral infarction,combined with phacoemulsification of cataract,and internal limiting membrane removal during surgery were independent risk predictors of NVG after surgery(P<0.05).Conclusions Younger,coronary heart disease or cerebral infarction,combined with cataract phacoemulsification are the risk factors of NVG in PDR patients after PPV.The removal of internal limiting membrane can reduce the incidence of NVG.