术中光相干断层扫描在玻璃体视网膜手术中的应用价值评估

Application value assessment of intraoperative optical coherence tomography in vitreoretinal surgery

目的评估术中光相干断层扫描(iOCT)在玻璃体视网膜手术中的应用价值。方法采用病例系列观察研究方法,纳入2015年1月至2017年12月在温州医科大学附属眼视光医院杭州院区行玻璃体视网膜手术且行iOCT检查的患者316例316眼。记录iOCT扫描时间和结果、与术者显微镜下观察判断的一致性及其对手术治疗策略的影响,并观察术后不良反应及并发症。结果316眼中有271眼成功完成iOCT检测,占85.8%,平均扫描时间为(3.54±2.30)min;在271眼扫描成功患眼中,特发性黄斑裂孔51眼,黄斑前膜95眼,致密玻璃体积血50眼,黄斑板层裂孔30眼,玻璃体黄斑牵拉综合征12眼,高度近视黄斑病变33眼;iOCT检查结果与术者手术显微镜下观察判断不一致的有45眼,占16.6%,其中有27眼术中改变手术策略,占10.0%。特发性黄斑裂孔患眼iOCT检查结果显示,2眼内界膜剥除后内层视网膜桥状连接,改为空气填充玻璃体腔;15眼内界膜剥除后出现裂孔边缘纤细的条状高反射,称为Hole-door现象,占32.6%;裂孔直径>400μm的黄斑裂孔中出现Hole-door现象患眼术后最佳矫正视力和外界膜连续性均优于未出现Hole-door现象患眼。黄斑前膜患眼iOCT检查结果显示,8眼黄斑前膜残留,占8.4%,其中3眼增加黄斑前膜剥除操作,56眼出现黄斑前膜剥除后继发改变,占58.9%。致密玻璃体出血患眼iOCT检查结果显示,17眼黄斑结构正常,占34.0%,33眼黄斑结构异常,占66.0%;14眼iOCT检查黄斑结构与术中显微镜下判断结果不一致,占28.0%,其中11眼增加了黄斑前膜剥除操作。结论iOCT在玻璃体视网膜手术中应用可指导术中选择更合理的手术方式,预测术后恢复情况,提高术后疗效。

Objective To evaluate the application of intraoperative optical coherence tomography(iOCT)in vitreoretinal surgery.Methods An observational case series study was conducted.A total of 316 patients(316 eyes)who received vitreoretinal surgery and iOCT from January 2015 to December 2017 in Hangzhou Branch of Eye Hospital,Wenzhou Medical University were enrolled.The iOCT scanning time and result,the consistency between iOCT result and observation under the operating microscope as well as the influence of iOCT on surgical strategy were recorded.The postoperative adverse reactions and complications were observed.The study protocol was approved by an Ethics Committee of Eye Hospital,Wenzhou Medical University(No.2019-168-K-160).Written informed consent was obtained from all patients prior to any medical examination.Results There were 85.8%(271/316)of patients who successfully completed iOCT scanning,with an average scanning time of(3.54±2.30)minutes.Among the 271 successful eyes,there were 51 with idiopathic macular hole(IMH),95 with epiretinal membrane,50 with dense vitreous hemorrhage(VH),30 with macular lamellar hole,12 with vitreous macular traction syndrome,33 with myopic maculopathy.There were 45 eyes,accounting for 16.6%,the iOCT results of which were inconsistent with the observation of operator under the operating microscope.There were 27 eyes,accounting for 10.0%,the surgical strategy of which was changed.The iOCT results of IMH showed that intra-retinal bridge connection appeared in 2 eyes after ILM peeling,then air tamponade was used.High-reflection strips on the edge of the MH after ILM peeling,called the Hole-door phenomenon,were found in 15 eyes,accounting for 32.6%.In MH with a diameter>400μm,the postoperative best corrected visual acuity and continuity of outer limiting membrane were better in eyes with Hole-door phenomenon than eyes without Hole-door phenomenon.There were 8 eyes,accounting for 8.4%,showing residual membrane,3 eyes of which received extra ERM peeling.There were 56 eyes,accounting for 58.9%,showing the secondary changes after membrane peeling.For 50 eyes with dense VH,there were 17 eyes showing the normal macular structure,accounting for 34%,and 33 eyes showing the abnormal macular structure,accounting for 66.0%.In addition,the macular structures of 14 eyes,accounting for 28.0%,observed in iOCT image were inconsistent with the intraocular microscope finding,and 11 of them received extra ERM peeling.Conclusions The application of iOCT in vitreoretinal surgery can guide the selection of reasonable surgical methods during operation,predict postoperative recovery as well as improve postoperative outcomes.