【作者】 张晓鹏；

【导师】 叶存喜；

【作者基本信息】 河北医科大学 ， 眼科学， 2008， 硕士

【摘要】 目的:探讨撕除视网膜内界膜分别对III期和IV期特发性黄斑裂孔患者术后裂孔愈合及视功能改善的影响。方法:对符合纳入标准的2005年12月-2007年9月43例(43只眼) ,其中III期20例IV期23例特发性黄斑裂孔患者进行手术治疗。标准三切口玻璃体切割术联合20%SF6气体填充治疗特发性黄斑裂孔23例,其中III期11眼,IV期12眼。标准三切口玻璃体切割术联合0.05%吲哚青绿染色内界膜撕除加20%SF6气体填充治疗特发性黄斑裂孔20例,其中III期9眼,IV期11眼。0.05%吲哚青绿染色为4分钟。内界膜撕除范围以黄斑中心凹为中心约2-3 PD大小。对手术治疗前后的数据进行分析,比较两手术组手术前后黄斑裂孔闭合率及视功能。比较内界膜撕除术式对III期及IV期特发性黄斑裂孔的黄斑裂孔闭合率及视功能的影响。手术中撕除的膜组织用透射电镜观察超微结构。结果:1解剖闭合率:III期撕除内界膜组9眼,有8眼黄斑裂孔达到解剖闭合,解剖闭合率88.9%;IV期撕除内界膜组l1眼,有10眼裂孔达到解剖闭合,解剖闭合率90.9%。III期与IV期撕除内界膜组黄斑裂孔解剖闭合率比较无统计学显著性差异(P>0.05)。撕除内界膜组(III期加IV期)20例,黄斑裂孔解剖闭合18例,解剖闭合率90.0%,不撕除内界膜组(III期加IV期)23例,黄斑裂孔解剖闭合13例,解剖闭合率56.5%。经统计学分析,撕除内界膜组与不撕除撕除内界膜组比较具有统计学显著性差异(P<0 .05)。随访期间黄斑裂孔成功愈合者没有再次复发。2视功能:2.1手术后6个月时ILM撕除组(III期加IV期)视力提高者16眼(80.0%),不撕除ILM组(III期加IV期)视力提高者13眼(56.5%),两者相比较具有统计学显著性差异(P<0.05)。III期和IV期内界膜撕除组手术后黄斑裂孔成功愈合者术后l、3、6个月组间视力提高率比较无统计学显著性差异(P>0.05)。III期和IV期撕除ILM组各1例术后黄斑裂孔闭合但视力无提高。两手术组术后黄斑裂孔未闭者视力无提高。2.2 III期IV期手术前两组患者的多焦视网膜电图(mfERG)一阶函数的1环和2环P1波反应密度与正常眼对照组相比均明显降低,有显著性差异(P<0.05),III期IV期两组间比较无统计学显著性差异(P>0.05)。手术后黄斑裂孔愈合眼6个月的mfERG一阶函数的1环和2环P1波反应密度逐渐增加,并且表现为三维地形图的中央峰逐渐恢复,与术前相比较均具有统计学显著性差异(P<0.05);III期IV期两组间l、3、6个月mfERG一阶函数的1环和2环P1波反应密度比较无统计学显著性差异(P>0.05),但仍然低于正常眼,差异有显著性意义(P<0.05)。3透射电镜观察结果:标本中17例为典型的内界膜形态,可见一层连续均质的纤维状结构交织成致密的网状,面向玻璃体一侧较平坦光滑,面向视网膜一侧起伏不平。3例不同程度地在平坦面附着纤维条索结构,未见到细胞结构。1例撕除为视网膜前膜,杂乱的胶原纤维及中间类基质层中可见巨噬样细胞结构。结论:1 III期和IV期特发性黄斑裂孔行ICG染色内界膜撕除均能够提高黄斑裂孔解剖闭合率,有助于早期视力恢复。2临床确诊的完全玻璃体后脱离患眼中,部分仍有玻璃体纤维粘附于视网膜内界膜上。3 mfERG可以客观、精确地观察和评价术前术后特发性黄斑裂孔眼的黄斑部视功能变化。更多还原

【Abstract】 Object : To investigate macular hole’s healing and effects of visual fuction improvement in the patients who had an operation for idiopathic macular hole(IMH), stageIII,IV by internal limiting membrane (ILM) peeling.Methods: Forty-three eyes (from the cases of Dec. 2005-Sep. 2007)with IMHs ,including 20 eyes in stage III and 23 eyes in stage IV,had an operation . Twenty-three eyes with IMHs ,including 11 eyes in stage III and 12 eyes in stage IV ,underwent standard subtotal three-port pars plana vitrectomy along with 20% SF6 intraocular tamponade. Twenty eyes with IMHs ,including 9 eyes in stage III and 11 eyes in stage IV ,underwent standard subtotal three-port pars plana vitrectomy along with 0.05% ICG assisted ILM peeling and 20% SF6 intraocular tamponade.Analyze the data before and after operation .Compare the closure rate, visual fuction before and after the surgery of IMH. Compare the closure rate, the effects of visual fuction after the surgery of IMH in stage III,IV by using standard subtotal three-port pars plana vitrectomy ,0.05% ICG assisted ILM peeling and 20% SF6 intraocular tamponade .Observe ultramicrostructure of tissue by transmission electron microscope (TEM).Result:1 anatomic close rate:After operation, 8 eyes with ILM peeling in stage III go to anatomic close, anatomic close rate(88.9%). 10 eyes with ILM peeling in stage IV go to anatomic close, anatomic close rate(90.9%). The anatomic close rate in these two groups was not statistically significan (P>0.05).ICG assisted ILM peeling group 18 eyes anatomic close , anatomic close rate(90.0%),without ICG assisted ILM peeling group 13 eyes anatomic close , anatomic close rate(56.5%) . ICG assisted ILM peeling group (including stage III and stage IV) 20 eyes ; without ICG assisted ILM peeling group (including stage III and stage IV) 23 eyes . The anatomic close rate in these two groups was statistically significan (P<0.05). During follow-up macular hole successful healing did not relapse again.2 visual function: 2.1 Six months after the operation, ICG assisted ILM peeling group corrected vision was improved 16 eyes (80.0%)(including stage III and stage IV) . without ICG assisted ILM peeling group 13 eyes (56.5%) (including stage III and stage IV). There was statistically significan (P<0.05).After the surgery of ILM peeling in stage IIIand IV,visual improvement rate was not statistically significan in 1、3、6 months postoperatively(P>0.05).2 eyes with ILM peeling has no improvement in vision,but macular hole is close,one in the stage III ,another in the stage IV .The vision of the patients whose macular hole is not close was not improved. 2.2 Before operation, the response densities of wave P1 of mfERG ring 1 and ring 2 decline significantly in the patients of stage IIIand IV.There is statistically significan (P<0.05). It is no statistically significance in stage III and stage IV groups(P>0.05).After operation, the response densities of wave P1 of mfERG ring 1 and ring 2 increase gradually in 6 months postoperatively.It presents that center peaks of mfERG topographies of mfERG topographies reappeared little by little .There have statistically significant differences with preoperative ones(P<0 .05).In the two groups of stageIII and IV, the response densities of wave P1 of mfERG ring 1 and ring 2 have no statistically significant differences in 1、3、6 months(P>0.05).But it is still lower than the normal eyes and the differences has significant(P<0.05).3 The result of TEM view : There are 17 samples of ILM, are homogeneous ibriform membrane,one side to face vitreous body is flat and slick,another side to face retina is gravamen .3 samples of ILM have fibro-trab structure.There is no cell structure. 1 sample of peeling epiretinal membrane (ERM), in disordered collagen fibrils can be seen macrophage like cell.Conclusion:1 After the surgery of IMH in stage III and IV, ICG—assisted ILM peeling can improve anatomic close rate and can be helpful for inchoate vision renewal.2 The clinical diagnosis of complete posterior vitreous detachment from the eyes, and some are still vitreous fibers in the retina adhesion.3 mfERG can observe and evaluate visual fuction’s changes of preoperative and postoperative IMH objectively and accurately.更多还原