1、高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離治療的臨床研究        【摘要】     目的:研究高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離的臨床治療效果及不同手術方式的有效性方法：回顧性分析2003 05/2008 05診斷治療的高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離91眼，分析視網(wǎng)膜復位情況及最佳矯正視力。結果：在這些視網(wǎng)膜脫離的治療中，有6種手術方式：單純黃斑區(qū)鞏膜外墊壓12眼，5眼(42%)首次術后視網(wǎng)膜回貼；單純玻璃體腔氣體充填15眼，6眼(4

2、0%)首次術后視網(wǎng)膜回貼；平坦部玻璃體切除聯(lián)合球內氣體充填20眼，14眼(70%)首次術后視網(wǎng)膜回貼；平坦部玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填16眼，11眼(69%)首次術后視網(wǎng)膜回貼；鞏膜環(huán)扎、玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填25眼，18眼(72%)首次術后視網(wǎng)膜回貼；鞏膜環(huán)扎、玻璃體切除聯(lián)合硅油填充13眼，10眼(77%)首次術后視網(wǎng)膜回貼。64眼(70%)首次手術治療后視網(wǎng)膜回貼，85眼(93%)視網(wǎng)膜回貼。結論：玻璃體切除聯(lián)合球內惰性氣體或硅油填充是治療高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離的最有效方法。     【關鍵詞

3、】  高度近視眼；鞏膜葡萄腫黃斑裂孔性；視網(wǎng)膜脫離    Clinical research of the treatment of retinal detachment resulting from a posterior staphylomaassociated macular hole in high myopiaJianBin Hu, YuFeng Yu, ChunTao Lei, Hui ChenDepartment of Ophthalmology, Peoples Hospital of Sichuan Medical Scien

4、ce College, Chengdu 610072, Sichuan Province, China; Nursing College, Chengdu University of Traditional Chinese Medicine, Chengdu 610072, Sichuan Province, ChinaAbstractAIM: To evaluate the surgical outcome of retinal detachment resulting from a posterior staphylomaassociated macular hole in high my

5、opia. METHODS: Ninetyone high myopia with retinal detachment resulting from a posterior staphylomaassociated macular hole diagnosed between May 2003 and May 2008 were retrospectively studied. Anatomical reattachment of the retinal and best corrected visual acuity were measured. RESULTS: Six differen

6、t operative methods were used to treat these eyes: 12 eyes were undergone scleral buckle only, in which 5 eyes (42%) retina attached after the first surgery; 15 eyes were performed longacting gas tamponade only, of them, 6 eyes (40%) retina attached after the first surgery; 20 eyes received pars pla

7、na vitrectomy (PPV) with longacting gas tamponate, 14 eyes (70%) retina attached after the first surgery; 16 eyes were performed PPV with epiretinal membrane(ERM) peeling and longacting gas tamponate, 11 eyes (69%) retina attached after the first surgery; 25 eyes were undergone encircling scleral bu

8、ckling combined with PPV, ERM peeling and longacting gas tamponate, 18 eyes (72%) retina attached after the first surgery; 13 eyes were practiced encircling scleral buckling combined with PPV and silicone oil tamponate, 10 eyes (77%) retina attached after the first surgery. Overall, successful retin

9、al reattachment was achieved in 64 of 91 eyes (70%) after the first surgery. The ultimate successful retinal reattachment was 85 of 91 eyes (93%) after subsequent surgery. The mean preoperative vision was 4.00±0.15, and mean postoperative vision was 4.40±0.15.  CONCLUSION: Pars plana

10、vitrectomy combined with longacting gas or silicone oil tamponade is the best treatment choice for the retinal detachment resulting from a posterior staphylomaassociated macular hole in highly myopic eyes. KEYWORDS: high myopia; posterior staphylomaassociated macular hole; retinal detachment視網(wǎng)膜脫離是常見

11、的致盲性眼底疾病，多發(fā)生于近視眼人群，尤其是高度近視者。對于視網(wǎng)膜脫離的治療，有多種的手術治療方式，但其治療效果不一。自20世紀70年代以來，隨著玻璃體切除技術的完善及廣泛應用，視網(wǎng)膜脫離的治療進入了新的里程碑，挽救了很多患者的視功能1。高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離是一種特殊類型的視網(wǎng)膜脫離,由于其眼軸較長,術后視網(wǎng)膜不易回貼2。本研究回顧性分析2003 05/2008 05 91例高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離患者，對其手術方式及治療效果進行分析研究。1對象和方法1.1對象  2003 05/2008 05四川省人民醫(yī)院眼科診斷治療的高度近視眼伴后鞏膜

12、葡萄腫黃斑裂孔性視網(wǎng)膜脫離91例（91眼），左眼42眼，右眼49眼；男32例，女59例；年齡3278歲；治療前視網(wǎng)膜脫離時間130wk。所有患者皆于術前散瞳行間接眼底鏡、三面鏡檢查、A/B型超聲波檢查以確診黃斑裂孔、視網(wǎng)膜脫離范圍、后鞏膜葡萄腫及玻璃體視網(wǎng)膜增殖情況。其他裂孔性視網(wǎng)膜脫離、糖尿病性視網(wǎng)膜病變及其他原因所致視網(wǎng)膜脫離等不納入本研究。1.2方法  91例中包括6種手術方式：單純黃斑區(qū)鞏膜外墊壓；單純玻璃體腔氣體充填；平坦部玻璃體切除聯(lián)合球內氣體充填；平坦部玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填；鞏膜環(huán)扎、玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填；鞏膜環(huán)扎、玻璃體切除

13、聯(lián)合硅油填充。術后病例隨訪312mo。    統(tǒng)計學分析：采用SPSS 12.0統(tǒng)計軟件包進行統(tǒng)計學分析,統(tǒng)計方法包括2檢驗、t檢驗，檢驗水準為0.05。2結果    91例患者,平均年齡53.8±9.0(3278)歲,治療前視網(wǎng)膜脫離時間平均6.0±6.5(130)wk,所有患者近視屈光度>10.00D,平均14.57±6.15(10.0023.00)D,眼軸平均27.13±1.65(26.1733.15)mm,平均隨訪時間28.25±26.12(398)mo。所有患者皆有后鞏

14、膜葡萄腫及脈絡膜萎縮斑，82例患者有完全性玻璃體后脫離，9例患者沒有玻璃體后脫離。91例91眼，有6種手術方式：單純黃斑區(qū)鞏膜外墊壓12眼，5眼(42%)首次術后視網(wǎng)膜回貼；單純玻璃體腔氣體充填15眼，6眼(40%)首次術后視網(wǎng)膜回貼；平坦部玻璃體切除聯(lián)合球內氣體充填20眼，14眼(70%)首次術后視網(wǎng)膜回貼；平坦部玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填16眼，11眼(69%)首次術后視網(wǎng)膜回貼；鞏膜環(huán)扎、玻璃體切除、視網(wǎng)膜前膜剝離聯(lián)合球內氣體充填25眼，18眼(72%)首次術后視網(wǎng)膜回貼；鞏膜環(huán)扎、玻璃體切除聯(lián)合硅油填充13眼，10眼(77%)首次術后視網(wǎng)膜回貼。64眼(70%)首次手術

15、治療后視網(wǎng)膜回貼，85眼(93%)視網(wǎng)膜回貼。術前最佳矯正視力平均4.00±0.15,術后隨訪最佳矯正視力平均4.40±0.15,統(tǒng)計學分析差異有顯著性(P=0.032)。術后并發(fā)白內障35例(38%)，20例行白內障超聲乳化術未植入人工晶狀體，15例行白內障超聲乳化人工晶狀體植入術；繼發(fā)青光眼5例（5%）。3討論    高度近視眼者是視網(wǎng)膜脫離的高發(fā)人群。高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離是一種特殊類型的視網(wǎng)膜脫離，由于其眼軸長，眼球畸形，視網(wǎng)膜較薄，黃斑裂孔不易封閉，視網(wǎng)膜回貼率較低35。本研究常規(guī)的鞏膜外墊壓及單純的球內注氣術視

16、網(wǎng)膜回貼率為40%左右。隨著玻璃體切除技術及玻璃體腔填充物的廣泛應用，使復雜性視網(wǎng)膜脫離的治療方式不斷改進，手術的成功率及視網(wǎng)膜回貼率得到較大提高。本研究玻璃體切除聯(lián)合球內惰性氣體填充者首次視網(wǎng)膜回貼率都在70%左右，而玻璃體切除聯(lián)合硅油填充者首次術后視網(wǎng)膜回貼率達77%，所有患者最終視網(wǎng)膜回貼率93%，所以玻璃體切除聯(lián)合球內惰性氣體或硅油填充是治療高度近視眼伴后鞏膜葡萄腫黃斑裂孔性視網(wǎng)膜脫離的有效方法。近年關于黃斑裂孔玻璃體切除聯(lián)合剝離視網(wǎng)膜內界膜治療方式的研究認為剝離視網(wǎng)膜內界膜有助于黃斑裂孔的封閉611，本研究部分患者剝離內界膜，但視網(wǎng)膜回貼率沒有明顯差異。對于高度近視眼伴后鞏膜葡萄腫黃

17、斑裂孔性視網(wǎng)膜脫離者，由于其眼軸較長，視網(wǎng)膜較薄，術中視網(wǎng)膜內界膜的剝離較為困難且剝離不全，因此對于此類患者不必強調視網(wǎng)膜內界膜的剝離。本研究組中,視網(wǎng)膜再次脫離的主要原因是黃斑裂孔的不封閉及前部增殖性玻璃體視網(wǎng)膜病變（proliferative vitreoretinopathy,PVR)的形成。黃斑裂孔不封閉多發(fā)生于眼軸較長（29mm）的后鞏膜葡萄腫患者，這與眼軸較長，視網(wǎng)膜薄，裂孔不易封閉有關，部分患者通過再次手術及硅油填充而使視網(wǎng)膜回貼，但仍有4例患者因黃斑裂孔不封閉而視網(wǎng)膜未回貼。前部PVR的形成多發(fā)生于年輕、無玻璃體后脫離患者，由于前部PVR的形成致視網(wǎng)膜漏斗狀脫離，再次手術的難度

18、較大，需行鞏膜環(huán)扎聯(lián)合硅油填充。    對于手術方式的選擇，雖然玻璃體切除聯(lián)合球內惰性氣體或硅油填充是最有效的方法，但單純球內注氣、鞏膜外墊壓仍有40%左右的回貼率，因此對于部分僅黃斑區(qū)周圍視網(wǎng)膜脫離、有玻璃體后脫離、經(jīng)濟條件有限的患者，仍可選擇這兩種手術方式或兩者聯(lián)合治療。    【參考文獻】  1 Wolfensberger TJ, Gonvers M, Bovey E. Very longterm followup of retinal detachment due to macular hole treat

19、ed with vitrectomy and air injection. Retina2001;21(6):678 6812 Phillips CI, Dobbie JG. Posterior staphyloma and detachment. Am J Ophthalmol1963;45:3323353 Stripe M, Michels RG. Retinal detachment in highly myopic eyes due to macular holes and epiretinal traction. Retina1990;126:669 6764 Seike C, Ku

20、saka S, Sakagami K, et al. Reopening of macular holes in highly myopic eyes with retinal detachments. Retina1997;17:2 65 Akiba J, Konno S, Yoshida A. Retinal detachment associated with a macular hole in severely myopic eyes. Am J Ophthalmol1999;128:654 6556 Nishimura A, Kita K, Segama Y, et al. Perfluorocarbon liquid assists in stripping the ILM to treat detached retina caused by macular hole. Ophthalmic Surg Lasers2002;33(1):77787 Kadonosono K, Yaza