特发性黄斑前膜与手术相关的预后影响因素

摘要

目的 评估特发性黄斑前膜(IERM)剥离术后与手术相关的视功能影响因素.方法回顾性系列病例研究.根据研究入组标准,收集2014年1月至2015年1月于同济大学附属上海第十人民医院进行23G玻璃体切除联合IERM剥离术的IERM患者37例(37只眼),对其术后6个月临床资料进行回顾.根据术后6个月视力被分为高视力组[最佳矫正视力(BCVA≥0.5)]和低视力组(BCVA<0.5).主要术中观察指标是患者术中IERM剥离难易度、剥离前膜时黄斑中心凹视网膜表面出血和吲哚菁绿染色剂(ICG)着色状态.主要临床检查项目包括手术前后BCVA、OCT、多焦视网膜电图(mfERG),部分患者进行FFA检查.最佳矫正视力转换成logMAR视力进行数据统计.应用独立样本t检验分析两组间的差异,术中指标之间的关系采用Spearman相关分析,术中指标与视力预后的关系采用单因素及多因素Logistic回归分析.结果37例患者平均随访时间(14.41±2.33)个月.术后高视力组有28例(75.7%);低视力组9例(24.3%).37只眼中,记录IERM剥离困难14只眼(37.8%);黄斑中心凹视网膜表面出血10只眼(27.0%);IERM剥离后ICG染色阳性13只眼(35.1%).剥离后黄斑中心凹表面出血(OR,7.221;95%CI,1.775~29.372;P=0.006)与术后低视力有关;IERM剥离困难与剥离后中心凹出血(γ=0.336,P=0.042)和ICG阳性着色(γ=0.593,P=0.000)有相关性.10只眼剥离前膜时伴有黄斑中心凹表面出血,其术后6个月的mfERG 1环N1波潜伏期是(16.88±1.27)ms[无出血眼(12.80±4.21)ms,t=-2.187,P=0.042],其中8只眼(8/10)的FFA显示黄斑区片状荧光素渗漏.结论在IERM剥离术中,黄斑中心凹视网膜表面出血是患者术后视功能预后不良的危险因素;IERM剥膜困难易造成前膜剥除后黄斑中心凹出血和内界膜残留.%Objective To evaluate intraoperative risk factors related to the postoperative visual acuity in idiopathic epiretinal membrane (IERM). Methods According to the well-established study criterion, a retrospective observational study was carried out on 37 eyes of 37 patients with epiretinal membrane peeling surgery for IERM between January 2014 and January 2015. Intraoperative situations during membrane peeling were documented, including complexity of operation, superficial hemorrhage and the state of indocyanine green(ICG)staining. Best-corrected visual acuity (BCVA) measurement and optical coherence tomography were performed before and 1, 3, 6 and 12 months after surgery. Multifocal electroretinography and fundus fluorescein angiography were conducted at 6 months postoperatively. The patients were divided into two groups based on the BCVA (≥0.5 and<0.5) at 6 months after surgery. The BCVA was converted to logarithm of the minimum angle of resolution (logMAR) equivalents for statistical analysis. The relationship between intraoperative factors and postoperative visual acuity was analyzed by multiple logistic regression analysis. Results All patients completed follow-ups in an average duration of (14.41 ± 2.33) months. Among the 37 patients, 28 patients(75.7%)were in the BCVA ≥0.5 group. and 9patients (24.3%)were in the BCVA<0.5 group. Statistical analysis revealed that superficial hemorrhage during membrane peeling was associated with poor visual acuity after surgery (OR: 7.221, 95%CI:1.775-29.372, P=0.006). The peeling complexity was positively increased with presence of superficial hemorrhage(γ=0.336, P=0.042)and ICG staining(γ=0.593, P=0.000). The electroretinography revealed that the average latency of N1 wave at ring 1 in eyes with superficial hemorrhage (16.88±1.27)ms was longer than that in eyes without superficial hemorrhage (12.80±4.21)ms at 6 months postoperatively (t=-2.187, P=0.042). The fluorescein angiography showed 8 in 10 eyes with superficial hemorrhage had leakage on the macular fovea. Conclusions Superficial hemorrhage in IERM peeling is a risk factor for the poor postoperative visual function. Complex peeling contributes to superficial hemorrhage and the positive staining of ICG.