慢性肾衰竭患者增生型糖尿病视网膜病变玻璃体切割手术疗效观察及预后影响因素分析

Therapeutic effect and prognostic factors of vitrectomy for proliferative diabetic retinopathy in patients with chronic renal failure

目的观察并分析合并慢性肾功能衰竭(CRF)的增生型糖尿病视网膜病变(PDR)玻璃体切割手术(PPV)疗效及预后影响因素。方法回顾性病例研究。2016年1月至2021年6月于河北医科大学第二医院眼科确诊为合并CRF的PDR并行PPV治疗的58例患者82只眼纳入研究。其中,男性32例,女性26例;年龄(48.45±10.41)岁。肾功能衰竭病程(4.15±3.23)年;糖尿病病程(14.45±6.71)年。患眼均行最佳矫正视力(BCVA)检查。BCVA检查采用国际标准Snellen视力表进行,记录时换算为最小分辨角对数(logMAR)视力。患眼logMAR BCVA 2.04±0.82(0.7~2.8)。玻璃体积血持续时间(2.65±1.55)个月。伴牵拉性视网膜脱离38只眼(46.3%,38/82)。既往有全视网膜激光光凝治疗史32只眼(39.0%,32/82)。患眼均行25G PPV治疗。伴牵拉性视网膜脱离者手术前3 d行玻璃体腔注射抗血管内皮生长因子药物治疗。晶状体混浊影响手术操作者联合白内障超声乳化吸除手术。收集患者血糖、血红蛋白、血肌酐、血尿素氮等生化指标和替代治疗方式(无透析、血液透析、腹膜透析)。手术后随访时间≥6个月。组间比较采用χ^(2)检验或Fisher确切检验。采用logistic回归模型进行单因素及多因素分析;采用Spearman相关性分析判断两变量相关性。结果手术后6个月,患眼平均logMAR BCVA 1.16±0.57;与手术前logMAR BCVA比较,差异有统计学意义(t=-0.837,P<0.001)。BCVA≥0.1、<0.1者分别为44、38只眼。手术后玻璃体再积血(PVH)17只眼(20.7%,17/82)。无透析者、血液透析者、腹膜透析者发生PVH分别为15(46.9%,15/32)、1(2.3%,1/44)、1(16.7%,1/6)只眼。无透析者与血液透析者PVH发生率比较,差异有统计学意义(χ^(2)=26.506,P<0.05);腹膜透析者与无透析者、血液透析者PVH发生率比较,差异无统计学意义(χ^(2)=2.694、2.849,P>0.05)。玻璃体腔填充硅油、灌注液者发生PVH分别为3(10.0%,3/30)、14(27.0%,14/52)只眼;两者比较,差异有统计学意义(χ^(2)=3.315,P<0.05)。需再次PPV手术治疗者分别为1(33.3%,1/3)、10(71.4%,10/14)只眼,差异有统计学意义(P<0.05)。并发新生血管性青光眼(NVG)12只眼(14.6%,12/82)。Logistic回归分析结果显示,年龄[比值比(OR)=0.911,P<0.05]、糖尿病视网膜病变(DR)分期(OR=7.229,P<0.05)、肾功能衰竭病程(OR=0.850,P<0.05)、手术时间(OR=1.135,P<0.05)是视力预后不佳的独立危险因素;糖尿病病程(OR=1.158,P<0.05)、肾功能衰竭病程(OR=1.172,P<0.05)、替代治疗是发生PVH的独立影响因素;糖尿病病程(OR=1.138,P<0.05)、肾功能衰竭病程(OR=1.157,P<0.05)是手术后发生NVG的独立危险因素。Spearman相关性分析结果显示,PVH与手术后NVG呈强相关性(r=0.469,P<0.01)。血糖、血红蛋白、血肌酐、血尿素氮与手术后视力预后、PVH、NVG发生无显著相关性(P>0.05)。结论合并CRF的PDR患者,DR分期、年龄、肾功能衰竭病程及手术时长与视力预后相关;与未行替代治疗者比较,血液透析治疗可降低手术后PVH、NVG的发生。

Objective To investigate the efficacy and prognostic factors of pars plana vitrectomy(PPV)in the treatment of proliferative diabetic retinopathy(PDR)with chronic renal failure(CRF).Methods A retrospective study.From January 2016 to June 2021,a total of 82 eyes of 58 patients diagnosed with PDR combined with CRF and treated with PPV in Department of Ophthalmology,The Second Hospital of Hebei Medical University were included in the study.There were 32 cases in males and 26 cases in females.The mean age was(48.45±10.41)years.The course of renal failure was(4.15±3.23)years,and the course of diabetes was(14.45±6.71)years.All patients undergo best-corrected visual acuity(BCVA).The BCVA examination was performed using the international standard Snellen visual acuity chart,which was converted to logarithm of the minimum angle of resolution(logMAR)visual acuity for recording.The mean number of logMAR BCVA was 2.04±0.82(0.7-2.8).The duration of vitreous hemorrhage averaged(2.65±1.55)months.There were 38 eyes(46.3%,38/82)with traction retinal detachment;32 eyes had a history of panretinal photocoagulation(PRP)treatment(39.0%,32/82).All eyes were treated with 25G PPV.Patients with traction retinal detachment were treated with intravitreal injection of anti-vascular endothelial growth factor(VEGF)3 days before surgery.Opacification of the lens affected the operation operator combined with phacoemulsification.Biochemical indexes such as hemoglobin,glycosylated hemoglobin,albumin,creatinine,uric acid,and alternative treatment(non-dialysis/hemodialysis/peritoneal dialysis)were collected.Postoperative follow-up time was≥6 months.χ^(2) test or Fisher's exact test were used for comparison between groups.A logistic regression model was used for multivariate analysis,and Spearman correlation analysis was used to evaluate the correlations between variables.Results At 6 months after surgery,the mean logMAR BCVA was 1.16±0.57.Compared with logMAR BCVA before surgery,the difference was statistically significant(t=-0.837,P<0.001);44 eyes had BCVA≥0.1 and 38 eyes had BCVA<0.1.Postoperative vitreous hemorrhage(PVH)was observed in 17 eyes after surgery(20.7%,17/82).PVH occurred in 15(46.9%,15/32),1(2.3%,1/44),and 1(16.7%,1/6)eyes in patients without dialysis,hemodialysis and peritoneal dialysis,respectively.There was significant difference between those without dialysis and those on hemodialysis(χ^(2)=26.506,P<0.05).There was no significant difference between peritoneal dialysis patients and those without dialysis and hemodialysis patients(χ^(2)=2.694,2.849;P>0.05).PVH occurred in 3(10.0%,3/30)and 14(27.0%,14/52)eyes of vitreous cavity filled with silicone oil and perfusion fluid,respectively.The difference was statistically significant(χ^(2)=3.315,P<0.05);1(33.3%,1/3)and 10(71.4%,10/14)eyes were treated with PPV again,respectively,and the difference was statistically significant(P<0.05).Neovascular glaucoma(NVG)occurred in 12 eyes(14.6%,12/82).Logistic regression analysis showed that age[odds ratio(OR)=0.911,P<0.05],diabetic retinopathy(DR)stage(OR=7.229,P<0.05),renal failure duration(OR=0.850,P<0.05),operation time(OR=1.135,P<0.05)was an independent risk factor for poor vision prognosis.Diabetes duration(OR=1.158,P<0.05),renal failure duration(OR=1.172,P<0.05)and alternative therapy were independent factors affecting the occurrence of PVH.Diabetes duration(OR=1.138,P<0.05)and renal failure duration(OR=1.157,P<0.05)were independent risk factors for postoperative NVG.Spearman correlation analysis showed that PVH was strongly correlated with post-operative NVG(r=0.469,P<0.01).There was no significant correlation between blood glucose,hemoglobin,creatinine and blood urea nitrogen and prognosis of postoperative vision,PVH and NVG occurrence(P>0.05).Conclusions In PDR patients with CRF,DR Stage,age,renal failure course and operation duration are correlated with vision prognosis.Compared with those who do not receive alternative therapy,hemodialysis treatment can reduce the occurrence of PVH and NVG after surgery.