不同类型近视牵引性黄斑病变的发病机制和手术疗效研究

Pathogenesis and surgical outcomes of different types of myopic traction maculopathy

摘要:

目的：应用光学相干断层扫描(OCT)探讨不同类型近视牵引性黄斑病变(MTM)的发病机制及手术疗效。

方法：回顾性纳入MTM患者193例(210眼)，其中74眼(35.2%)行玻璃体切除联合内界膜(ILM)剥离术。将患者分为三组：中央凹脱离组(FD)、中心凹劈裂(FS)、板层黄斑裂孔(LMH)。根据基线(M0)的中央视网膜厚度(CFT)，将FD组分为两个亚组：广泛性FD和局限性FD。观察指标包括最佳矫正视力(BCVA)、CFT、后巩膜葡萄肿高度(PSH)、黄斑前膜(ERM)和ILM脱离。采用线性回归分析玻璃体切除术后6mo(M6)的BCVA相关因素。

结果：M0时，LMH组的ERM发生率更高(r_s=0.28，P<0.001)，FD组和FS组的ILM脱离发生率更高(r_s=-0.25，P<0.001)。玻璃体切除术后，所有眼的CFT和BCVA均明显改善(P<0.001)。与局限性FD相比，广泛性FD组CFT更厚(r_s=0.56， P<0.001)、ILM脱离发生率更低(r_s=-0.25，P=0.034)，鼻侧PSH更高(r_s =0.27，P=0.024)。与局限性FD相比，广泛性FD组在M0(P=0.013)和M6(P=0.030)时BCVA更差。M6时BCVA较差的相关因素包括广泛性FD(β=-0.295，P=0.042)和M0时BCVA(β=0.669，P<0.001)。

结论：MTM有多种发病机制，其中ILM脱离可能在FD和FS的发展中占主导，ERM可能在LMH的发展中占主导。玻璃体切除联合ILM剥离手术可改善MTM患者的功能和解剖疗效。广泛性FD的预后可能较差。

Abstract:

AIM: To explore the pathogenesis and surgical outcomes of different types of myopic traction maculopathy(MTM)using optical coherence tomography(OCT).

METHODS: A total of 193 patients(210 eyes)with MTM were retrospectively included, of which 74 eyes(35.2%)underwent vitrectomy combined with internal limiting membrane(ILM)peeling. The patients were categorized into three groups: foveal detachment(FD), foveoschisis(FS)and lamellar macular hole(LMH). Based on the central foveal thickness(CFT)at baseline(M0), eyes with FD were classified into two subgroups: extensive FD and limited FD. Outcomes included best-corrected visual acuity(BCVA), CFT, posterior staphyloma height(PSH), the presence of epiretinal membrane(ERM)and ILM detachment. Risk factors for BCVA at 6mo after vitrectomy(M6)were analyzed using linear regression.

RESULTS: At M0, ERM was highly present in eyes with LMH(r_s=0.28, P<0.001). Eyes with FD and FS were characterized by higher incidence of ILM detachment(r_s=-0.25, P<0.001). After vitrectomy, CFT and BCVA significantly improved in all eyes(P<0.001). Eyes with extensive FD were characterized by a thicker CFT(r_s=0.56, P<0.001), a lower incidence of ILM detachment(r_s=-0.25, P=0.034)and a thicker nasal PSH(r_s=0.27, P=0.024)than eyes with limited FD. Eyes with extensive FD were associated with a worse BCVA at M0(P=0.013)and M6(P=0.030)than eyes with limited FD. Extensive FD(β=-0.295, P=0.042)and BCVA at M0(β=0.669, P<0.001)were risk factors for a worse BCVA at M6.

CONCLUSION: There are several pathogenetic mechanisms in MTM. ILM detachment may exert a dominant role in the development of FD and FS, while ERM may have a role in LMH. Vitrectomy combined with ILM peeling improved functional and anatomical outcomes in MTM patients. Eyes with extensive FD may carry a poor prognosis.