【摘要】 目的：描述视网膜内界膜剥离在继发性黄斑前膜手术中的应用、临床特点及效果。方法：回顾我院2000/2006年因继发性黄斑前膜需行玻璃体视网膜手术患者32例32眼，其中男24例，女8例;年龄13～69(平均41±28)岁;病程3～69(平均21±19)mo，有6眼病程在1a以上。术前视力:CF～0.4。原发病:常规视网膜脱离复位术后13眼(男/女:13/0)、玻璃体切除术后8眼(男/女:7/1)、视网膜血管病变6眼(男/女:4/2)、平坦部炎5眼(男/女:0/5)，其中经平坦部后部玻璃体手术中发现黄斑部有铁锈和炎性物质附着共5眼5例。所有患者行标准的经睫状体平坦部的三通道玻璃体切除，术中先剥除前膜后再剥除视网膜内界膜，部分患者结合TA标记，眼内空气充填1wk左右。追踪观察6～38mo。结果：术后视力0.05～0.7，其术前与术后差视力差异有显著性(采用fisher确切概率法P<0.05)。术后黄斑中心凹厚度与术前相比差异具有显著性(采用Friedman test，P<0.05)。尚未发现由视网膜内界膜剥离所致的严重并发症。结论：视网膜内界膜剥离在继发行黄斑前膜手术中的应用不但可以达到整理松解黄斑区处视网膜皱褶,解除对黄斑中心凹的牵引，还可以清除紧密附着在黄斑前视网膜表面的炎性物质，改善黄斑区局部的代谢，有利于黄斑功能的恢复。
【关键词】 视网膜内界膜剥离;玻璃体视网膜手术;继发性黄斑前膜
Application of divesting retinal inner limiting membrane in secondary epiretinal membrane in macular
YiQin Duan1, XiaoHua Zhu2
1Changsha Aier Eye Hospital, Changsha 410015,Hunan Province,China;2Department of Ophthalmology, Xiangya Second Hospital of Zhongnan University, Changsha 410011, Hunan Province, China
Correspondence to: XiaoHua Zhu.Department of Ophthalmology, Xiangya Second Hospital of Zhongnan University, Changsha 410011, Hunan Province, [email protected]
Received:20100705 Accepted:20100809
Abstract
AIM:To describe the applications, clinical features and effect of the divesting of retinal inner limiting membrane in secondary epiretinal membrane in macular.
METHODS: Retrospective series of consecutive but noncomparative cases from 2000 to 2006 was reviewed. There were 32 patients 32 eyes underwent vitreoretinal surgery(par plana vitrectomy)for secondary macular epiretinal membrane.26 cases were male and 6 case were female;age ranged from 13 to 69 yeas old ,and the average was 41.5 years old. Course of illness was from 3 to 69 months,and the average was 21.6 months.6 cases lasted for more than one year. The records of 5 cases 5 eyes were diagnosed as intraocular foreign body associated with siderosis bulbi in macular.During the operation, divesting of retinal inner limiting membrane was performed after peeling epiretinal membrane. A part of patient were targeted with TA. Air intraocular tamponaded for about a week. The followup was 638 months.
RESULTS:Postoperative visual acuity of suffering eyes ranged from 0.05 to 0.7. There was significant difference between the preoperative vision and the postoperative vision(fishers exact test,P<0.05)，and there was also significant difference between the foveal thickness of preoperative and postoperative (Friedman test，P<0.05).Serious complication of tearing retinal inner limiting membrane was not discovered.
CONCLUSION:The application of tearing retinal inner limiting membrane is used in vitreoretinal surgery more and more. It not only could relieve the traction of retinal inner limiting membrane to retina and clivus of fovea but also could get rid of the virose substance adhered firmly to the surface of macular, improve the maculars metabolization, accelerate the furbish of the function of macular.
KEYWORDS:divesting of retinal inner limiting membrane;vitreoretinal surgery;secondary macular epiretinal membrane
Duan YQ, Zhu XH. Application of divesting retinal inner limiting membrane in secondary epiretinal membrane in macular. Int J Ophthalmol
(Guoji Yanke Zazhi) 2010;10(9):16951698
视网膜内界膜剥离在黄斑裂孔手术中有着广泛的应用[1]，可以解除内界膜对黄斑中心凹视网膜的牵引，有利于黄斑裂孔的封闭,但要求手术者有较高的内眼手术操作技巧。随着眼科手术医生对此操作技术的提高和经验的积累，内界膜手术被玻璃体视网膜手术医师更为广泛的应用于内眼手术的其他方面，现将我院内界膜剥除手术在继发性黄斑前膜眼中的应用报告如下。
1对象和方法
1.1对象
回顾我院2000/2006年因继发性黄斑前膜需行玻璃体视网膜手术患者32例32眼，其中男24例，女8例，均为单眼发病;年龄13～69(平均41±28)岁;病程3～69(平均21±19)mo，其中6眼病程在1a以上。所有患者都有不同程度的视物变形，术前视力：CF～0.4。经过细致的检眼镜及光学相关断层扫描(Stratus OCT)的检查，均发现黄斑区皱褶样膜状物形成，确诊为黄斑前膜。原发病:常规视网膜脱离复位术后13眼(男/女:13/0)、玻璃体切除术后8眼(男/女:7/1)、视网膜血管病变6眼(男/女:4/2)、平坦部炎5眼(男/女:0/5),其中经平坦部后部玻璃体手术中发现黄斑部有铁锈和炎性物质附着共5眼5例。32例继发性黄斑前膜患者均在术前术后作了眼底彩色照相及OCT等检查。术后追踪观察6～38(平均22)mo，术后随诊时间为0.5，2，4，6mo以此推类。每次随访，检查视力、眼前节，OCT及眼底彩色照相。以视力、OCT、眼底彩色照相的检查资料作为判断黄斑区水肿改善以及是否存在黄斑前膜的标准。
1.2方法
所有患者行标准的经睫状体平坦部的三通道玻璃体切除。剥离前膜时，寻找黄斑前膜与视网膜的分离位置是手术的较关键的步骤。薄而透明、没有明显边界的黄斑前膜，可以用巩膜穿刺刀轻轻挑起前膜以寻找前膜边界;边界清晰的黄斑前膜，用视网膜铲钩沿膜的边缘来回分离，使之与视网膜分开，然后用视网膜镊夹住分开的膜边缘，沿网膜切线方向剥离膜组织。剥离内界膜时，临床上一般多采用由Morris提出的黄斑表面ILM撕除术,在颞侧视网膜血管弓内、远离中心凹(至少1.5mm)处选择一开始点，用一尖端预先精确弯好的显微玻璃体视网膜刀(MVR)在该点的ILM上造一小口,掀起一小片膜瓣，再用末端开放的膜镊抓住，随后以中心凹为圆心，朝向切线方向，缓慢地行环绕黄斑区的连续曲线撕开。操作过程应谨慎耐心，尽量减少对下方视网膜血管和神经层的损伤。术中可以通过TCG染色技术或观察ILM剥离后的视网膜反光及点从状出血状况，确定剥膜效果。部分患者结合TA标记，以消毒空气或/和惰性气体作眼内填压。手术不能1次完整撕下黄斑区视网膜内界膜者，可重复数次完成。视网膜内界膜剥除后，局部视网膜略呈灰白色，有时可见细点状出血，但出血多可自行停止。 统计学分析：应用SPSS 13.0统计学软件对数据进行统计学处理，采用χ2检验fisher确切概率法，Friedman test，P<0.05为差异有统计学意义。
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