背景 玻璃体切割术(PPV)是治疗严重增生性糖尿病视网膜病变(PDR)的主要方法,但常因术中或术后出血而影响手术操作或影响术眼的预后.目前临床上已将抗血管内皮生长因子(VEGF)单克隆抗体ranibizumab用于PPV,对玻璃体腔注射ranibizumab联合PPV的疗效及安全性进行评价至关重要. 目的 探讨和分析术前玻璃体腔注射ranibizumab(IVR)辅助23G PPV治疗PDR的疗效及其并发症. 方法 对2012年8月至2013年12月在扬州大学临床医学院眼科确诊并行23G PPV治疗的严重PDR患者77例82眼的临床病历资料进行回顾性分析,其中接受IVR联合PPV者49眼(IVR辅助PPV组)和接受单纯PPV者33眼(单纯PPV组),2个组间患者基线特征匹配.IVR辅助PPV组于术前5～7d行IVR(0.5 mg/0.05 ml),然后行23G PPV,单纯PPV组患眼仅行23G PPV,比较2个组间术眼手术持续时间、术中使用电凝次数、医源性视网膜裂孔发生率、术后最佳矫正视力(BCVA) (LogMAR)、术后玻璃体再出血率、再行PPV率.结果 IVR辅助PPV组平均手术时间为(71.90±26.42) min,明显短于单纯PPV组的(96.76±25.15) min,差异有统计学意义(t=-4.300,P＜0.01);IVR辅助PPV组术中电凝平均使用(0.76±0.14)次,明显少于单纯PPV组的(2.18±1.64)次,差异有统计学意义(x2=-4.284,P＜0.05);IVR辅助PPV组和单纯PPV组术后3个月BCVA分别为0.70±0.50和0.74±0.50,与各自术前视力(1.73±0.50,1.70±0.47)相比均明显改善,差异均有统计学意义(t=-0.151、0.118,均P＜0.01),但术后组间BCVA的差异无统计学意义(t=-0.318,P=0.758).IVR辅助PPV组医源性视网膜裂孔发生率为6.12％,单纯PPV组为21.20％,差异有统计学意义(x2=4.193,P=0.041);IVR辅助PPV组术后早期玻璃体再出血率为2.04％,单纯PPV组为15.15％,差异有统计学意义(x2=6.580,P=0.010).2个组间再行PPV率、视网膜未Ⅰ期复位率、新生血管性青光眼发生率和一过性眼压升高发生率比较差异均无统计学意义(均P＞0.05). 结论 严重PDR患者PPV前玻璃体腔注射ranibizumab可降低术中和术后玻璃体出血的风险、缩短手术时间并减少医源性视网膜裂孔的发生率,其术后视力的改善情况与单纯PPV接近.%Background Pars plana vitrectomy (PPV) is a main method of treating severe proliferative diabetic retinopathy (PDR) , but intraoperative bleeding often occurs, which affects the intraoperative process and final prognosis.Intravitreal injection of ranibizumab (IVR), a vascular endothelial growth factor (VEGF) monoclonal antibody,has been used in PPV,so the evaluation of therapeutic effect and safety of PPV associated by IVR is very important.Objective This study was to evaluate the effect of IVR-assisted 23G PPV on patients with severe PDR.Methods The clinical data of 82 eyes of 77 patients with severe PDR who received 23G PPV from August 2012 to December 2013 were respectively analyzed,including 49 eyes undergone IV R-assisted 23G PPV (IVR combined with PPV group) and 33 eyes undergone 23G PPV only (simple PPV group).IVR (0.5 mg/0.05 ml) was performed on the eyes 5-7 days before PPV in the IVR combined with PPV group,and only PPV was carried out in the simple PPV group.Operative duration, endodiathermy times, incidence of iatrogenic retinal holes, best corrected visual acuity (BCVA) (LogMAR), postoperative bleeding, re-operation rate, Ⅰ phase attached rate of retinas, occurrence rate of neovascular glaucoma and temporary ocular hypertension rate were compared between the two groups.Results The average operation duration was (71.90-± 26.42) minutes in the IVR combined with PPV group, which was significantly shorter than (96.76±25.15) minutes in the simple PPV group (t =-4.300, P＜0.05).Endodiathermy time in the IVR combined with PPV group was significantly less than that in the simple PPV group (0.76±0.14 versus 2.18±1.64) (x2 =-4.284,P＜0.01).The BCVA at postoperative 3 months was (0.70±0.50) and (0.74±0.50) in the IVR combined with PPV group and simple PPV group,which was significantly improved in comparison with before operation (1.73±0.50,1.70±0.470) respectively (t=-0.151,0.118,both at P＜0.01),but no significant difference in the postoperative BCVA between the two groups (t =-0.318, P =0.758).The incidence of iatrogenic retinal holes was significantly lower in the IVR combined with PPV group than that in the simple PPV group (6.12％ versus 21.20％) (x2 =4.193 ,P=0.041).In addition,the postoperative bleeding rate was also significantly different between the IVR combined with PPV group and the simple PPV group (2.04％ versus 15.15％) (x2=6.580, P=0.010).No significant differences were seen in the incidence of re-operation rate, I phase attached rate of retinas,occurrence rate of neovascular glaucoma and temporary ocular hypertension rate between two groups (all at P＞O.05).Conclusions IVR before 23G PPV can reduce the risk of intravitreal bleeding during operation and after surgery,shorten operation duration and lessen the incidence of iatrogenic retinal break.The BCVA after IVR-assisted PPV improves as good as simple PPV.
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