摘要：
目的 观察玻璃体切割手术中视网膜下液(SRF)完全引流(CSFD)与部分引流(PSFD)对视网膜脱离累及黄斑区并伴周边视网膜裂孔患眼视网膜复位及最佳矫正视力(BCVA)恢复的影响.方法 前瞻性非随机对照临床研究.临床检查确诊的视网膜脱离累及黄斑区并伴周边视网膜裂孔的孔源性视网膜脱离(RRD)患者72例72只眼纳入研究.患者均行BCVA、眼压、裂隙灯显微镜、间接检眼镜检查.BCVA记录时转换为最小分辨角对数(logMAR)视力.采用随机数字表法将72例72只眼随机分为CSFD组及PSFD组,均为36例36只眼.两组患者性别构成比、平均年龄、平均视网膜脱离时间、平均logMARBCVA、晶状体状态、视网膜裂孔数目及位置、视网膜脱离累及象限比较,差异均无统计学意义(P＞0.05).所有患眼行25G玻璃体切割手术.CSFD组患眼玻璃体腔注入重水,患眼偏向视网膜裂孔侧,尽可能吸出重水及SRF;PSFD组患眼不使用重水,患眼无需刻意偏向视网膜裂孔侧,允许部分SRF残留.记录从25G巩膜刀穿刺至拔出巩膜穿刺套管的手术时间;行白内障手术者,不包括白内障手术时间.手术后患者保持仰卧位24 h,之后根据视网膜裂孔位置采用相应适宜体位6～10 d.手术后1、3、6个月随访,其中1、3个月行黄斑区光相干断层扫描检查.观察两组患眼视网膜复位以及BCVA变化情况;手术后3个月黄斑区SRF吸收情况.记录并观察手术中及手术后并发症发生情况.结果 CSFD组、PSFD组患眼平均手术时间分别为(62.25±4.32)、(47.90±5.00) min;两组患眼平均手术时间比较,差异有统计学意义(t=2.99,P＜0.01).手术后3个月,CSFD组、PSFD组患眼一次手术后视网膜复位率分别为88.9％、91.6％;两组患眼一次手术后视网膜复位率比较,差异无统计学意义(x2 =0.158,P＞0.05).手术后6个月,两组患眼视网膜复位率均为100.0％.CSFD组、PSFD组患眼平均logMAR BCVA分别为0.99±0.52、1.07±0.34;两组患眼平均logMAR BCVA比较,差异无统计学意义(t=0.580,P=0.564).手术后1、3个月,一次手术后视网膜复位眼均未见黄斑区SRF残留.CSFD组29只有晶状体眼中,手术中发生晶状体损伤7只眼,占本组有晶状体眼的24.1％;PSFD组31只有晶状体眼手术中未发生晶状体损伤.手术后CSFD组患眼中存在重水残留6只眼,占16.7％.结论 玻璃体切割手术中CSFD与PSFD对视网膜脱离累及黄斑区并伴周边视网膜裂孔的RRD患眼视网膜复位及BCVA改善的影响无差异;但PSFD可简化手术步骤、缩短手术时间,减少并发症发生.%Objective To compare clinical outcomes in eyes with macula-off rhegmatogenous retinal detachments (RRD) with peripheral breaks managed by surgical protocols that result in either complete (CSFD) or partial subretinal fluid drainage (PSFD).Methods Following the clinical detection of a maculaoff RRD with peripheral retinal breaks,patients were offered the opportunity to enroll in the study,and those patients who signed the consent were evaluated for eligibility based upon the inclusion and exclusion criteria for this clinical study,and if fully eligible they were assigned prospectively to one of the two surgical designs (PSFD or CSFD,1∶ 1) using a random number table.Seventy-two eyes of 72 patients were enrolled and studied.Patients were treated with 25G plus vitrectomy,endolaser or transscleral cryopexy,either complete (n=36),or partial (n=36) subretinal fluid drainage,and 14％C3F8 (PFO) was used for intraocular tamponade.After surgery,all patients were kept in a supine position for 24 hours,and then in a clinically optimal position for 6-10 days.The study patients were examined at 1,3 and 6 months after surgery with thorough ophthalmic examinations.Macular optical coherence tomography (OCT) imaging was acquired in 1 month.Anatomical and visual outcomes as well as intra-operative and postoperative complications of the two groups were compared.Furthermore,the persistence of subfoveal fluid in OCT images and the symptoms of distortion at 3 months were measured and recorded.The primary study endpoint of anatomic retinal reattachment for each group was based upon the 6-month time-point.Results The preoperative baseline characteristics between the two groups were not significantly different.The single-operation success rates were 88.9％ and 91.6％ respectively for the CSFD and the PSFD groups (x2 =0.158,P＞0.05).The mean best corrected visual acuity (BCVA) at 6 month endpoint were 0.99± 0.52 minimum resoluation angle in logarithmic (logMAR) for the CSFD group and 1.07±0.34 logMAR for the PSFD group(t=0.580,P=0.564).The mean operative time was longer in the CSFD group (62.25± 4.32) minutes than that in the PSFD group (47.9 ± 5.0) minutes (t =0.580,P=0.564).seven of 29 (24.1％) phakic eyes in the CSFD group had lens injury during SRF drainage,and none of the 31-phakic eyes in the PSFD group sustained lens damage.Residual PFO was present in 6 of 36 CSFD cases (16.7％).Successful retinal reattachment after primary surgery was achieved in 33) PSFD eyes and in 32 CSFD eyes based upon OCT imaging at 1 month demonstrated reattached foveae with no residual subfoveal fluid.Among these patients,22 patients (62.5％) in the CSFD group and 23(69.7％) patients in the PSFD group reported distortion in the operated eye or/and a difference in image size between the two eyes at the 6 month visit (P=1.00).Conclusions Partial subretinal fluid drainage during pars plana vitrectomy for the repair of macula-off RRD with peripheral breaks is effective.The success rates are not statistically different.Additionally,PSFD procedures can simplify the surgery procedure,shorten operative time and,and to some extent,reduce the incidence of complications relevant to the CSFD approach.
