特发性黄斑前膜异常中心凹内层的临床意义评估

Evaluation of the clinical significance of the ectopic inner foveal layers of idiopathic epiretinal membranes

目的观察特发性黄斑前膜(IMEM)合并或不合并异常中心凹内层(EIFL)患眼手术前后视网膜内层结构变化和视功能改善情况,初步探讨影响IMEM患眼手术后视功能恢复的影响因素。方法回顾性临床研究。2015年3月至2019年6月于河北医科大学第二医院眼科中心检查确诊的IMEM患者90例90只眼纳入研究。均行最佳矫正视力(BCVA)、频域光相干断层扫描检查。BCVA采用Snellen视力表进行,记录时换算为最小分辨角对数(logMAR)视力。90只眼中,黄斑前膜(MEM)分级为2~4级者分别为68(75.6%,68/90)、18(20.0%,18/90)、4(4.4%,4/90)只眼。据此将2级设为A组,3、4级合并设为B组。两组患者年龄(t=0.015)、性别构成比(χ^(2)=0.060)、平均黄斑中心凹视网膜厚度(CMT)(F=2.277)比较,差异均无统计学意义(P=0.904、0.809、0.141);平均logMAR BCVA比较,差异有统计学意义(F=35.913,P=0.000)。所有患眼均行25G经睫状体平坦部三切口闭合式玻璃体切割手术,同时剥除MEM及内界膜。观察手术后1、3、6、12个月BCVA、CMT变化以及MEM分级改善情况。手术前后BCVA、EIFL厚度、CMT比较采用单因素重复方差分析;手术后12个月时两组患眼解剖结构的改变情况比较采用Fisher确切概率法。结果手术后1、3、6、12个月,A组患眼平均logMAR BCVA分别为0.50±0.13、0.38±0.12、0.27±0.12、0.19±0.10,平均CMT分别为(364.82±81.29)、(281.65±72.45)、(228.55±55.34)、(182.84±56.13)μm;B组患眼平均logMAR BCVA分别为0.66±0.14、0.60±0.13、0.54±0.14、0.52±0.14,平均CMT分别为分别为(455.88±69.60)、(440.18±68.65)、(383.76±65.38)、(371.39±66.60)μm。两组患眼手术后不同时间平均logMAR BCVA、CMT比较,差异均有统计学意义(BCVA:F=37.913、11.479、24.250、39.013,P=0.000、0.002、0.000、0.000;CMT:F=10.987、39.610、55.789、79.987,P=0.002、0.000、0.000、0.000)。手术后12个月,A组68只眼中,MEM改善至1级57只眼;B组3级18只眼中,MEM改善至1、2级分别为1、3只眼,4级4只眼均无改善。两组患眼MEM分级改善眼数比较,差异有统计学意义(P=0.000)。结论不合并EIFL的IMEM患眼具有较好的视力预后和解剖改变的可逆性;EIFL是影响手术后视功能和解剖结构恢复的重要因素。

Objective To observe the changes of the structure and visual function of the retina in patients with or without the ectopic inner foveal layers(EIFL)and to explore the factors influencing the recovery of visual function in patients with idiopathic epimacular membrane(IMEM).Methods A retrospective clinical study.From March 2015 to June 2019,90 patients with MEM who were diagnosed by Ophthalmic Center of the Second Hospital of Hebei Medical University were enrolled in the study.All patients were examined by best corrected visual acuity(BCVA)and frequency domain optical coherence scan.BCVA was recorded by Snellen vision table,and it was converted into the minimum resolution angle logarithm(logMAR)vision.Among 90 eyes,IMEM grade 2-4 was 68(75.6%,68/90),18(20.0%,18/90),4(4.4%,4/90),respectively.According to this,the grade 2 was set as group A,and the grade 3 and grade 4 were combined to group B.There was no significant difference in age(t=0.015),sex composition ratio of patients between two groups(χ^(2)=0.060)and the average of central macular thickness(CMT)(F=2.277)(P=0.904,0.809,0.141).The difference of average logMAR and BCVA was statistically significant(F=35.913,P=0.000).All patients underwent 25G pars plana three channel vitrectomy with simultaneous removal of epiretinal membrane and internal limiting membrane.BCVA,CMT and improvement of IMEM grading were observed at 1,3,6 and 12 months after operation.BCVA,EIFL thickness and CMT were compared before and after operation by single factor repeated variance analysis;Fisher exact probability method was used to compare the changes of the anatomical structure of the eyes in the two groups at 12 months after operation.Results 1,3,6,12 months after operation,the average eyes of logMAR BCVA in group A were 0.50±0.13,0.38±0.12,0.27±0.12,0.19±0.10.The patients in group B were 0.66±0.14,0.60±0.13,0.54±0.14,0.52±0.14.CMT in group A were 364.82±81.29,281.65±72.45,228.55±55.34,182.84±56.13μm.The patients in group B were 455.88±69.60,440.18±68.65,383.76±65.38,371.39±66.60μm.The difference was statistically significant in the two groups(BCVA:F=37.913,11.479,24.250,39.013;P=0.000,0.002,0.000,0.000.CMT:F=10.987,39.610,55.789,79.987;P=0.002,0.000,0.000,0.000).In group A,IMEM was improved to 57 eyes of grade 1 on 12 months after operation.Among the 18 eyes in group B,IMEM was improved to 1 and 3 eyes in level 1 and level 2,respectively,and no improvement was found in 4 eyes in grade 4.The difference was statistically significant(P=0.000)in the improvement of the number of eyes in the two groups.Conclusions The patients with IMEM without EIFL have better visual prognosis and reversible anatomical changes.EIFL is an important factor affecting the visual function and anatomical structure recovery after operation.