玻璃体切割联合内界膜剥除术对孔源性视网膜脱离疗效的Meta分析

Meta-analysis of the effect of combined internal limiting membrane peeling on the rhegmatogenous retinal detachment

目的系统评价玻璃体切割术(PPV)治疗孔源性视网膜脱离(RRD)时,术中是否联合内界膜(ILM)剥除。方法检索Pubmed、Embase、Cochrane Librara、Clinical Trials.gov及CNKI数据库,检索自建库之始至2020年11月,搜集所有PPV联合ILM剥除与未联合ILM剥除治疗RRD的临床对照实验。由两位研究员独立筛选文献并提取术后黄斑前膜(ERM)发生率、最佳矫正视力(BCVA)、RRD复发率、椭圆体带缺损发生率及视网膜神经纤维层分离(DONFL)发生率等指标。文献研究间的异质性采用Q和I^(2)检验。若I^(2)>50%,则认为异质性较大,采用随机效应模型进行比较;反之,采用固定效应模型。二分类变量采用相对危险度(RR)及其95%可信区间(CI)表示;连续性变量采用均数差(MD)及其95%CI表示。结果初步检索获得相关文献893篇,排除重复、与本研究无关及不符合本研究结局指标的文献,最终纳入文献11篇,共计987只眼。其中,PPV联合ILM剥除术者有514只眼,未联合者有473只眼。各原始研究间具有较高同质性,结果稳健。各研究间患者ERM发生率的组间异质性较小(I^(2)=26%)。PPV联合ILM剥除组患者术后的ERM发生率明显低于未联合组。经固定效应模型分析,两组比较的差异有统计学意义(RR=0.11,95%CI:0.07~0.18,P<0.05)。各研究间患者BCVA的组间异质性较大(I^(2)=86%)。经随机效应模型分析,两组比较的差异无统计学意义(MD=0.08,95%CI:-0.05~0.21,P>0.05)。4项研究间患者RRD复发率的组间异质性较大(I^(2)=73%)。PPV联合ILM剥除组患者术后RRD的复发率低于未联合组。经固定效应模型分析,两组比较的差异有统计学意义(RR=0.48,95%CI:0.30~0.76,P<0.05)。4项研究间患者椭圆体带缺损发生率的组间异质性较大(I^(2)=73%)。经固定效应模型分析,两组比较的差异无统计学意义(RR=0.99,95%CI:0.38~2.53,P>0.05)。5项研究间患者术后DONFL发生率的组间异质性较小(I^(2)=0)。联合ILM剥除组患者术后DONFL的发生率高于未联合组。经固定效应模型分析,两组比较的差异有统计学意义(RR=39.08,95%CI:11.35~134.60,P<0.05)。结论PPV联合ILM剥除可预防非复杂性RRD患者术后ERM的形成,降低术后RRD的复发率,但无显著视觉效果优势,且对黄斑有潜在危害。

Objective The aim of this study was to systematically evaluate the effect of intraoperative combined with internal limiting membrane(ILM)removal during the treatment of rhegmatogenous retinal detachment(RRD)with vitrectomy(PPV).Methods The Pubmed,Embase,Cochrane Librara,Clinical Trials.gov and CNKI databases were searched.The search time was from the self-built database to November 2020.All clinical controlled trials of PPV combined with ILM peeling and without ILM peeling were collected for the treatment of RRD.Two researchers independently screened the literatures and extracted postoperative macular membrane(ERM)incidence,best corrected visual acuity(BCVA),RRD recurrence rate,ellipsoid zone defect incidence,and retinal nerve fiber layer separation(DONFL)incidence.The Q test and I^(2) statistics were used to evaluate the heterogeneity of the data.When the heterogeneity was large(I^(2)>50%),the random effects model was used to analysis;otherwise,the fixed effects model.Binary variables was represented by risk ratio(RR)and its 95%confidence interval(CI);continuous variables was represented by difference(MD)and its 95%CI.Results 893 literatures were collected after a preliminary searching.After excluding duplicate documents,articles irrelevant to the study,and documents that did not meet the outcome indicators,and finally 11 literatures were included.Among of them,a total of 987 eyes were included,of which 514 eyes were combined with ILM removal and 473 eyes without ILM removal during the operation.The original studies had high homogeneity,and the results were robust.The heterogeneity of the incidence of ERM among patients in each study was relatively small(I^(2)=26%).The postoperative ERM rate of patients in PPV combined with ILM peeling group was significantly lower than that of the non-ILM peeling group.After the fixed effects model test,the difference between two groups was statistically significant(RR=0.11,95%CI:0.07~0.18,P<0.05).The heterogeneity of BCVA of patients in each study was big(I^(2)=86%).After the random effects model analysis,there was no significant difference in BCVA between two groups(MD=0.08,95%CI:-0.05~0.21,P>0.05).The heterogeneity of RRD recurrence rate among patients in four studies was big(I^(2)=73%).The postoperative RRD recurrence rate in the combined ILM peeling group was lower than that in the non-ILM peeling group.After the fixed effects model analysis,the difference between two groups was statistically significant(RR=0.48,95%CI:0.30~0.76,P<0.05).The incidence of ellipsoidal zone defects among patients in four studies was quite heterogeneous(I^(2)=73%).After the fixed effects model analysis,there was no significant difference in the incidence of postoperative ellipsoidal band defects between two groups(RR=0.99,95%CI:0.38~2.53,P>0.05).The incidence of postoperative DONFL among patients in five studies was relatively heterogeneous(I^(2)=0).The incidence of DONFL in the combined ILM peeling group was higher than that in the non-ILM peeling group.After the fixed effects model analysis,the difference between two groups was statistically significant(RR=39.08,95%CI:11.35~134.60,P<0.05).Conclusions ILM peeling during PPV operation could prevent the formation of ERM after RRD and reduce the recurrence rate of RRD after RRD;however,PPV combined with ILM removal had the disadvantage for vision and also has potential harm to the macula.