充分硅油填充术治疗复发性视网膜脱离的有效性和安全性研究

Adequate silicone oil tamponade technique for recurrent retinal detachment:An effectiveness and safety study

目的探讨应用前后段联合手术,后囊切开联合下方周边虹膜造孔、充分硅油填充治疗复发性视网膜脱离的解剖复位率、视力恢复、手术相关并发症情况等临床疗效。方法前瞻性系列病例研究。研究纳入2018年6月至2022年6月,在汕头国际眼科中心诊治的,既往有明确的孔源性视网膜脱离病史并曾行1次或多次视网膜脱离复位术,术后视网膜仍有脱离的患者25例(25只眼)。其中男性14例,女性11例,平均年龄(52.92±13.94)岁,既往平均行(1.44±0.71)次手术(范围1~3次)。本次术前增生性玻璃体视网膜病变(PVR)C_(1)级3只眼,C_(2)级9只眼,C_(3)级11只眼,D_(1)级2只眼;上方裂孔5只眼,下方裂孔18只眼,上下方均有裂孔2只眼;合并脉络膜脱离2只眼。应用晶状体后囊膜切开、下方周边虹膜造孔,充分硅油填充治疗。收集并分析术前、术后3个月、已取油患者取油后2个月及末次随访的最佳矫正视力、眼压、视网膜情况、眼内硅油状态、手术并发症及其处理等。结果所有患者出院时视网膜平伏,硅油完全退回玻璃体腔。术后3个月,所有患者视网膜平伏,平均眼压(14.24±6.28)mmHg。平均随访时长(20.64±12.20)个月,期间所有研究眼玻璃体腔裂隙灯前置镜下及欧堡眼底照相均未观察到油水界面,提示硅油充填相对充分。其中17只眼已取出眼内硅油,平均硅油填充时间(7.26±2.02)个月,在取出眼内硅油前行角膜内皮镜检查,角膜内皮丢失率18.57%。8只眼未取出眼内硅油,平均随访时长(24.38±12.07)个月,其中高度近视黄斑萎缩明显、视力较差3只眼;广泛视网膜及脉络膜疤痕、眼压≤8mmHg3只眼;拒绝再次手术取油2只眼,至末次随访,17只眼已取出眼内硅油均保持视网膜完全贴附,8只眼未取出硅油均保持视网膜复位,未发现硅油乳化迹象。末次随访最佳矫正视力logMAR(1.21±0.60)较术前logMAR(1.66±0.66)提高,差异有统计学意义(P<0.05)。主要并发症为术后早期高眼压(15只眼,60%),10只眼经过单纯降眼压药物处理控制良好,5只眼用药下眼压控制不良,行前房穿刺放出少量房水(2只眼)或硅油(3只眼),所有患者出院时眼压均控制在21 mmHg以下。结论对于复发性视网膜脱离,行玻璃体切除、后囊膜切开联合下方周边虹膜造孔、充分硅油填充的治疗安全有效,操作简单,可以实现硅油在眼内的相对充分填充,对裂孔处于后极部及下方的患者尤为重要。尽管术后早期高眼压发生率较高,但均可控制。该手术方式是复发视网膜脱离复位手术的一种有效的改良和补充。

Objective To assess the surgical outcomes of phaco-vitrectomy following posterior capsulotomy,inferior peripheral iridotomy,and adequate silicone oil tamponade in a series of patients with recurrent retinal detachment,including the anatomical surgery successful rate,visual function,and surgical complications.Methods In this prospective case series study,25 eyes of 25 patients diagnosed with recurrent retinal detachment between June 2018 and June 2022 in Joint Shantou International Eye Center were included.All patients had a history of one or more rhegmatogenous retinal detachment surgeries.Fourteen patients were male and 11 patients were female.The mean age was(52.92±13.94)years old with an average of 1.44±0.71 times of retinal detachment surgery.The proliferative vitreoretinopathy(PVR)grade at first presentation was C_(1)(n=3),C_(2)(n=9),C_(3)(n=11),and D_(1)(n=2).Five eyes showed superior retinal breaks,18 eyes showed inferior breaks,and 2 eyes presented with both.Two patients presented with combined choroidal detachment.Adequate silicone oil tamponade followed by posterior capsulotomy and inferior peripheral iridotomy was performed.Preoperative and follow-up data including best corrected visual acuity,intraocular pressure,the retina and silicone oil status,and surgical complications and management,were collected and analyzed.Results On the day of discharge,all eyes demonstrated an attached retina and complete migration of the anterior chamber silicone oil into the vitreous cavity.At the 3-month followup,all retinas were attached with a mean intraocular pressure of(14.24±6.28)mmHg.The mean follow-up time was(20.64±12.20)months,and all the eyes presented relatively adequate silicone oil tamponade with no signs of oil-fluid interface in the vitreous cavity.Seventeen eyes had the silicone oil removal at(7.26±2.02)months after the primary procedures.18.57%of corneal endothelial loss was found at the time of silicone oil removal in these patients.Eight eyes,with a follow-up period of(24.38±12.07)months,did not perform the silicone oil removal procedure due to myopic macular atrophy-associated poor vision(n=3),diffused chorioretinal scarring with intraocular pressure less than 8 mmHg(n=3),and treatment refusals by the patients(n=2).No sign of silicone oil emulsion was found.At the final visit,all 25 eyes demonstrated a completely attached retina,including 17 eyes with silicone oil removal and 8 eyes with silicone oil not removed.The overall logMAR best corrected visual acuity significantly improved from(1.62±0.66)before operation to(1.21±0.60)in the final follow-up(P<0.05).The main complications included acute intraocular pressure elevation(n=15,60%)in the early period of post-operation,among which 10 eyes had medical treatments,and 5 eyes received an extraction of a small amount of aqueous humor(n=2)or silicone oil(n=3)through anterior chamber paracentesis.All eyes had well-controlled intraocular pressure(<21 mmHg)at discharge.Conclusions Adequate silicone oil tamponade followed by posterior capsulotomy and inferior peripheral iridotomy is effective and safe for the treatment of recurrent retinal detachment.This surgical technique is responsible for a more complete tamponade of silicone oil in the vitreous cavity,especially in the eyes presenting with inferior retinal breaks.Although intraocular pressure often increases in the early stage of post-operation,it can be well controlled without the need for anti-glaucoma surgery.This technique can be considered as a modified and supplementary procedure for the treatment of recurrent retinal detachment.