【摘要】目的 探讨显微镜直视下外路视网膜脱离手术的可行性。方法 孔源性视网膜脱离14例（14眼）在手术显微镜直视下行裂孔及变性区定位，在裂孔及裂孔周围行视网膜冷凝，放出视网膜下液，做硅胶填压及环扎带。最后顶起硅胶填压块，证实裂孔位于巩膜嵴前坡上，如眼压过低，则玻璃体腔内注入空气或C3F8，术后定期观察视力、玻璃体及视网膜复位情况。结果 随访1～6个月，术后视网膜裂孔均闭，完全复位14眼，视力提高14眼，矫正视力＜0.3者6眼，≥0.3者8眼，视网膜下液延缓吸收2眼，6天后完全吸收。冷凝反应：0级1眼，Ⅰ级4眼，Ⅱ级8眼，Ⅲ级1眼。结论 显微镜直视下外路视网膜脱离手术具有手术野清晰，操作简便、易掌握，手术效果良好等优点，值得临床推广应用。
Evaluation of the scleral buckling surgery of retinal detachment under surgical microscope
Jin Mei,Zhai Dongsheng,Li Congmei
Department of Ophthalmology,Yan’an Hospital of Kunming ,Yunnan 650051.
【Abstract】ObjectiveTo evaluate the possibility of the scleral buckling surgerty of retinal detachment under surgical microscope.Methods14 cases were the rhegmatogenous retinal detachment.14 eyes were performed the loation of retinal breaks and mutational areas under surgical microscope. The retinal cryotheropy was involved at or around the retinal breaks,drainage of subretinal fluid was involved then silicone buckling or circling were performed.At last the silicone buckling was stuck to prove that retinal breaks were located on the front part of scleral ridge.Filtered air or perfluropropane(C3F8 gas) eye pressure was too low.Visual acuity,vitreum and the condition of retinal redetachment were observed periodly after the surgeon.ResultsFollow up was one to six months. Retinal breaks were closed after operation.14 cases got complete redtachment.The visual acuity was improved in 14 eyes.The correct visual acuity was lower than 0.3 in 6 eyes but better than 0.3 in 8 eyes.Postponed absorption of subretinal fluid in 2 eyes and got complete absorption in 6 days.Cryotheropy reaction:0 level in 1 eye, 1 level in 4 eyes ,Ⅱ level and Ⅲ level in 8 eyes and 1 eye respectively.ConclusionEvaluation of the scleral buckling surgery of retinal detachment under surgical microsope has the merits that the scene of surgeon is clear,operation can be mastered easily and good surgical effort.Further more,it is easy to be spreaded and practised.
Key wordsretinal detachmentmicrosurgery
视网膜脱离是因为视网膜裂孔引起的急性致盲性疾病。常规的视网膜脱离裂孔定位及冷凝术、放液术均在双目间接检眼镜下完成，间接检眼镜具有倒像、放大倍数低、术中需反复取戴、不易掌握等缺点。2003年2月～2004年6月笔者采用同轴照明显微镜直视下外路视网膜脱离手术治疗，具有手术野清晰、放大倍数高、操作简便等优点，现将其报告如下。
1资料与方法
1.1一般资料本组病例为2003年2月～2004年6月孔源性视网膜脱离住院病人，共14例(14眼)，其中男9眼，女5眼，年龄21～68岁，病程1周～3个月。裂孔位于赤道部前后10眼，锯齿缘离断4眼，视网膜脱离范围1～3个象限，裂孔大小1/5PD～3PD，PVR分级B级12眼，C1级2眼。术前视力为手动～0.3，近视度数为-3.50～-16DS。复发性视网膜脱离1眼，有外伤史3眼。
1.2术前处理患眼常规进行远、近视力检查，1%阿托品+美多丽散瞳，间接检眼镜、三面镜检查定位裂孔，视网膜变性区，视网膜脱离范围，玻璃体混浊分级，绘制眼底图，非接触眼压计测量眼压，术前常规海伦滴眼液点眼，每日4次，共3天。
1.3手术方法1%阿托品+美多丽散瞳，行球后神经阻滞麻醉及球结膜下浸润麻醉，360°剪开球结膜，在内、外、上、下直肌做牵引线。显微镜放大8～10倍，在显微镜直视下用冷冻头顶起视网膜，寻找定位裂孔，在裂孔处用0-5非吸收缝线做硅胶块预置缝线，在裂孔及裂孔周围冷冻至视网膜发白立即停止冷冻，解冻后只见冷冻区灰白色，变性区用同样方法进行冷冻。如视网膜下液多影响裂孔观察，则先用5号尖刀片成45°角在视网膜脱离部位最高处穿刺切开巩膜，放出视网膜下液，待视网膜大部分复位后再行冷冻。随后，做硅胶填压及环扎带。用镊子顶起硅胶填压块，如裂孔未位于巩膜嵴前坡，则调整硅压块位置至裂孔位于巩膜脊前坡上，如眼压过低，则玻璃体腔内注入空气4.5ml或C3F8 0.5～0.6ml，眼压至20～25mmHg。术毕，1%阿托品+点必舒眼膏包封。
1.4术后检查检查视力、玻璃体、视网膜复位情况并仔细记录，随访时间3～6个月。
1.5评定标准冷冻区反应分为5级：0级：无任何反应；Ⅰ级：色素沉着；Ⅱ级：冷凝区混杂色素沉着和脱失；Ⅲ级：冷凝区色素完全脱失呈瓷白色；Ⅳ级：冷凝区视网膜前膜形成。0级为冷凝不足；Ⅰ、Ⅱ级为冷凝良好；Ⅲ级为冷凝过度；Ⅳ为冷凝并发症。
2结果
2.1手术效果随访1～6个月，术后视网膜裂孔均闭合，完全复位14眼，视力提高14眼，矫正视力＜0.3者6眼，≥0.3者8眼，视网膜下液延缓吸收2眼，6天后完全吸收。13眼术后裂孔闭合，术后7～10天冷凝区可见色素斑，20～30天后冷凝区可见粗大色素，裂孔边界不能分辨。1眼冷凝区7天后未见色素形成，行视网膜裂孔补充氩离子激光，6天后色素沉着显著，1眼术后4天再次发生视网膜脱离，采用同法手术治疗，术后视网膜复位，视力提高至0.2。冷凝区反应：0级1眼，Ⅰ级4眼，Ⅱ级8眼，Ⅲ级1眼。
2.2手术并发症(1)术中角膜上皮剥脱2眼，因角膜上皮混浊影响观察刮除中央角膜上皮，术后2天上皮愈合；(2)视网膜下液延缓吸收2眼，6天后吸收；(3)术后第1天眼压升高至36mmHg 1眼，为玻璃体注入C3F8 0.6ml，降眼压治疗后第2天眼压降至21mmHg；(4)裂孔区冷凝反应0级1例，术后7天补充氩离子激光治疗6天后色素形成，视网膜平伏。
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