目的观察玻璃体切割术(PPV)联合视网膜下注射组织型纤溶酶原激活剂(t-PA)治疗黄斑下出血(SMH)的疗效。
方法采用系列病例观察研究方法，纳入2022年2—11月于天津医科大学眼科医院确诊的SMH患者12例12眼，其中息肉样脉络膜血管病变(PCV)11例11眼，视网膜大动脉瘤1例1眼；男5例，女7例；年龄为56～78岁，平均(65.67±8.09)岁；人工晶状体眼2眼，合并白内障10眼；高血压9例，糖尿病2例。SMH持续时间为2～25 d，平均(14.67±8.03)d。患眼均行PPV联合视网膜下注射t-PA。术前和术后1、3、6个月，患眼均行最佳矫正视力(BCVA)、眼压、裂隙灯显微镜、间接检眼镜、光学相干断层扫描(OCT)以及超广角眼底成像检查。采用OCT测量中央视网膜厚度(CRT)。观察患者手术后眼部情况以及不良反应发生情况。
结果患眼术前及术后1、3、6个月平均BCVA(LogMAR)分别为1.58±0.63、1.12±0.49、1.07±0.44和0.59±0.19，不同时间点患眼BCVA总体比较，差异有统计学意义( F＝14.435， P<0.001)，其中术后6个月患眼BCVA较术前明显提高，差异有统计学意义( P<0.001)。患眼术前及术后1、3、6个月平均CRT分别为(606.25±204.67)、(379.83±92.05)、(313.75±60.87)和(267.75±73.07)μm，不同时间点患眼CRT总体比较，差异有统计学意义( F＝27.720， P<0.001)，其中术后1、3、6个月患眼CRT较术前均明显变薄，差异均有统计学意义(均 P<0.001)。1眼于术后3个月出现脉络膜上腔出血；随访期间6眼因PCV复发行玻璃体腔注射抗血管内皮生长因子(VEGF)药物，共注射给药16次。术后1、3、6个月内平均抗VEGF注射次数分别为(0.3±0.5)、(1.3±1.4)和(2.7±2.0)次。
结论在SMH的治疗中，PPV联合视网膜下注射t-PA可提高患眼BCVA，降低CRT，减轻血凝块对视网膜的损伤，促进患眼术后早期视力恢复，是一种安全、有效的手术方式。
ObjectiveTo observe the efficacy of vitrectomy combined with subretinal injection of tissue plasminogen activator (t-PA) in the treatment of macular hemorrhage (SMH).
MethodAn observational case series study was performed.Twelve eyes of 12 SMH patients diagnosed in Tianjin Medical University Eye Hospital were included from February 2022 to November 2022, including 11 eyes of polypoid choroidal vascular disease (PCV) and 1 eye of retinal artery aneurysm.There were 5 males and 7 females, aged 56 to 78 years old, with an average age of (65.67±8.09) years.Two eyes had intraocular lenses and 10 eyes were with cataracts.Nine cases had hypertension and 2 cases had diabetes.The duration of SMH was 2 to 25 days, with an average of (14.67±8.03) days.Vitrectomy combined with subretinal injection of t-PA was performed in the 12 eyes.All affected eyes underwent best corrected visual acuity (BCVA), intraocular pressure, slit lamp microscopy, indirect ophthalmoscopy, optical coherence tomography (OCT), and ultra-wide-filed imaging examinations before and 1, 3, 6 months after surgery.The central retinal thickness (CRT) was examined using an OCT instrument.The postoperative ocular conditions and the occurrence of adverse effects were observed.This study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of Tianjin Medical University Eye Hospital (No.2022JS-05).Written informed consent was obtained from each patient before surgery.
ResultsThe preoperative, 1-, 3-, and 6-month postoperative average BCVA (LogMAR) of the affected eye was 1.58±0.63, 1.12±0.49, 1.07±0.44, and 0.59±0.19, respectively, showing a statistically significant overall difference ( F=14.435, P<0.001).The BCVA at 6 months after surgery was significantly better than that before surgery ( P<0.001).The preoperative, 1-, 3-, and 6-month postoperative average CRT of the affected eye was (606.25±204.67), (379.83±92.05), (313.75±60.87), and (267.75±73.07)μm, respectively, showing a statistically significant overall difference ( F=27.720, P<0.001).The CRT at 1, 3, 6 months after surgery were significantly thinner than that before surgery (all at P<0.001).One eye had suprachoroidal hemorrhage 3 months after surgery, and 6 eyes received intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs due to recurrent PCV during follow-up, with a total of 16 injections.The average number of anti-VEGF injections at 1, 3, and 6 months after surgery was (0.3±0.5), (1.3±1.4), and (2.7±2.0) times, respectively.
ConclusionsIn the treatment of SMH, vitrectomy combined with subretinal injection of t-PA can improve BCVA, reduce CRT, reduce retinal damage from blood clots, and promote early postoperative visual recovery.It is a safe and effective surgical procedure.
薛晓阳,刘勃实,李筱荣. 玻璃体切割术联合视网膜下注射组织型纤溶酶原激活剂对黄斑下出血的疗效观察[J]. 中华实验眼科杂志,2024,42(05)：448-452.
DOI:10.3760/cma.j.cn115989-20231012-00125版权归中华医学会所有。
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薛晓阳：实施研究、采集/分析数据、文章撰写及修改；刘勃实：参与设计试验、实施研究、采集数据；李筱荣：参与设计试验、实施研究、文章定稿
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