增生性糖尿病视网膜病变玻璃体切割术后玻璃体再出血危险因素分析

Risk factors of postoperative vitreous hemorrhage after pars plana vitrectomy for proliferative diabetic retinopathy

目的分析增生性糖尿病视网膜病变(PDR)患者玻璃体切割手术(PPV)后玻璃体再出血(PVH)的危险因素。方法采用病例对照研究方法,选择2012年6月至2019年5月于天津医科大学眼科医院收治的首次行PPV治疗的PDR伴玻璃体积血(VH)患者1848例1848眼,其中男979眼,女869眼;平均年龄(55.72±10.39)岁。所有患眼均行经睫状体平坦部标准三通道PPV。术后随访6~24个月,平均(379.34±231.28)d。按PPV术后是否发生PVH分为PVH组和无PVH组,再根据PVH发生时间分为早期PVH组和晚期PVH组。1848例1848眼中PPV后发生PVH 170眼,占9.19%,其中早期PVH 30眼,晚期PVH 140眼,发生时间为术后6~450 d。纳入统计分析的基线因素包括性别、年龄、糖尿病病程、手术前糖化血红蛋白(HbA1c)等;眼部因素包括术前是否完成全视网膜激光光凝、术前3 d是否抗血管内皮生长因子(VEGF)药物治疗、晶状体状态、是否合并虹膜新生血管(NVI)等;手术因素包括术中是否发现视盘新生血管(NVD)伴出血、是否联合白内障超声乳化、手术结束时是否行玻璃体腔内注射抗VEGF药物治疗等。采用二元多因素Logistic回归分析PDR伴VH患者PPV术后PVH的危险因素。结果多因素Logistic回归分析显示,年龄(OR=0.940,P<0.01)、术前高HbA1c水平(OR=1.878,P<0.01)、合并视网膜静脉阻塞(RVO)(OR=8.310,P<0.01)、糖尿病饮食控制血糖(OR=3.030,P=0.019)、糖尿病病程(OR=1.044,P<0.01)、高血压病史(OR=1.802,P<0.01)、合并肾脏或心脑血管疾病(OR=18.377,P<0.01)、术前合并NVI(OR=7.488,P<0.01)、未联合白内障超声乳化手术(OR=1.628,P=0.023)、NVD伴出血(OR=2.691,P<0.01)、术毕玻璃体腔内注射抗VEGF药物治疗(OR=0.181,P<0.01)、术毕玻璃体腔无菌空气填充(OR=1.901,P=0.024)与PVH相关。早期PVH组和晚期PVH组术前基线、眼部和手术因素等指标比较差异均无统计学意义(均P>0.05)。结论低龄、术前高HbA1c、合并RVO、糖尿病饮食控制治疗、糖尿病病程、高血压病史、合并肾脏或心脑血管疾病、术前合并NVI、未联合白内障超声乳化手术、NVD伴出血、术毕未行玻璃体腔内注射抗VEGF药物治疗、术毕玻璃体腔无菌空气填充是PDR伴VH患者PPV术后发生PVH的危险因素。

Objective To investigate the risk factors of postoperative vitreous hemorrhage(PVH)after vitrectomy for proliferative diabetic retinopathy(PDR).Methods A case-control study was conducted.A total of 1848 consecutive PDR patients(1848 eyes)with vitreous hemorrhage receiving first pars plana vitrectomy(PPV)in Tianjin Medical University Eye Hospital from June 2012 to May 2019 were enrolled.There were 979 males and 869 females,with the average age of(55.72±10.39)years.All of the enrolled eyes underwent standard three-channel PPV.The subjects were followed up for 6 to 24 months,with the mean follow-up of(379.34±231.28)days.The eyes were divided into PVH group and non-PVH group according to whether the PVH occurred or not.The PVH group were further divided into early PVH group and late PVH group according to the occurrence time of PVH.There were 170(9.19%)of 1848 eyes developed PVH after surgery,including 17.64%(30/170)of eyes with early PVH and 82.36%(140/170)of eyes with late PVH.The PVH occurred at 6 to 450 days after surgery.Baseline systemic parameters including sex,age,diabetes duration,preoperative glycosylated hemoglobin(HbA1c)level,and ocular parameters including whether or not performing panretinal photocoagnlation,whether or not receiving treatment of anti-vascular endothelial growth factor(VEGF)three days before operation,lens status,whether or not being combined with neovascularization of iris(NVI),as well as intraoperative ocular parameters including whether or not having neovascularization of disc(NVD)bleeding,whether or not being combined with cataract phacoemulsification,whether or not receiving postoperative anti-VEGF,were analyzed by multivariate logistic regression analysis to identify the risk factors of PVH after PPV in PDR patients with VH.This study adhered to the Declaration of Helsinki,and the study protocol was approved by an Ethics Committee of Tianjin Medical University Eye Hospital(No.2019KY[L]-09).Results Multivariate logistic regression analysis revealed that age(OR=0.940,P<0.01),preoperative high HbA1c level(OR=1.878,P<0.01),combined with retinal vein occlusion(RVO)(OR=8.310,P<0.01),diabetes diet to control blood glucose(OR=3.030,P<0.01),diabetes duration(OR=1.044,P<0.01),history of hypertension(OR=1.802,P<0.01),nephropathy or cardiovascular or cerebrovascular diseases(OR=18.377,P<0.01),preoperative NVI(OR=7.488,P<0.01),not combined with phacoemulsification surgery(OR=1.628,P=0.023),NVD bleeding(OR=2.691,P<0.01),postoperative anti-VEGF treatment(OR=0.181,P<0.01),postoperative air tamponade(OR=1.901,P=0.024)were associated with PVH.There were no significant differences in baseline,ocular and intraoperative ocular parameters between early PVH and late PVH groups(all at P>0.05).Conclusions Younger age,preoperative high HbA1c level,combined with RVO,diabetes diet to control diabetes,diabetes duration,history of hypertension,nephropathy or cardiovascular or cerebrovascular diseases,preoperative NVI,uncombined with cataract surgery,NVD bleeding,without postoperative intravitreal anti-VEGF injection,postoperative air tamponade are the potential risk factors of PVH after PPV for PDR patients with VH.