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目的 观察玻璃体切割手术(PPV)联合内界膜剥除消毒空气填充治疗特发性黄斑裂孔(IMH)疗效,初步探讨黄斑区微结构参数与IMH预后的相关性.方法 前瞻性、非随机对照病例队列研究.2016年9月至2017年1月于吉林大学第二医院眼科中心确诊的IMH患者20例20只眼纳入研究.其中,男性4例4只眼,女性16例16只眼;平均年龄(60.60±9.50)岁;平均病程(9.55±15.5)个月.裂孔分期为Ⅱ～Ⅳ期.均行BCVA、眼压、OCT、多焦ERG(mf-ERG)检查.采用国际标准视力表行BCVA检查,统计分析时换算为logMAR视力.采用德国Heidelberg公司Spectralis OCT仪测量黄斑裂孔最小直径(MIN)、裂孔底径、裂孔高度、椭圆体带缺损直径、外界膜(ELM)缺损直径,并计算黄斑裂孔指数(MHI)、裂孔直径指数、裂孔牵拉指数(THI).mf-ERG测量一阶函数1～5环P1波反应密度.患眼logMAR BCVA 1.18±0.54.MIN＜400、400～700、＞700 μm分别为5、13、2只眼.所有患眼均行PPV联合内界膜剥除消毒空气填充治疗.根据患眼手术后OCT图像特征,将IMH闭合分为Ⅰ型闭合、Ⅱ型闭合及未闭合.手术后随访时间≥3个月.观察手术后裂孔闭合情况,以及BCVA、黄斑区微结构参数变化.手术前BCVA以及mf-ERG各环P1波反应密度与IMH手术后疗效的相关性行Spearman相关性分析.结果 末次随访时,20只眼中,IMH Ⅰ型闭合18只眼(90.0％).其中,MIN＜400 μm者5只眼均闭合(100.0％);400～700 μm者闭合12只眼(92.3％);＞ 700 μm者闭合1只眼(50.0％).未闭合2只眼(10.0％).手术后1周,1、3个月时,患眼logMARBCVA分别为0.83±0.54、0.65±0.41、0.48±0.34;与手术前比较,差异均有统计学意义(t=3.382、4.459、5.250,P=0.003、0.007、0.004).手术后3个月,20只眼中,ELM恢复完整性18只眼(90.0％).平均椭圆体带缺损直径为(260.34±272.08)μm;与手术前比较,差异有统计学意义(t=13.545,P=0.002).mg-ERG检测结果显示,患眼1、2环P1波反应密度较手术前明显提高,差异有统计学意义(t=-16.748、-6.151,P＜0.01、＜0.01).Spearman相关性分析结果显示,手术后3个月,BCVA与手术前MIN、椭圆体带缺损直径、ELM缺损直径、手术后3个月椭圆体带缺损直径呈正相关(r=0.56、0.59、0.68、0.52,P=0.010、0.006、0.001、0.019);与1、2环P1波反应密度呈负相关(r=-0.34、-0.16,P=0.006、0.020).MIN、ELM缺损直径与裂孔闭合呈负相关(r=-0.449、-0.449,P=0.047、0.047),MHI、THI与裂孔闭合呈正相关(r=0.474、0.546,P=0.035、0.013).随访期间出现眼压升高2只眼,给予降眼压药物干预后1周内恢复正常;其余患眼手术中及手术后均未出现相关并发症.结论 PPV联合内界膜剥除消毒空气填充治疗IMH安全、有效.MIN、MHI、THI与IMH手术后疗效有明显相关性,可作为IMH手术前预测评估疗效的指标;1、2环P1波反应密度较手术前明显提高,且与BCVA呈负相关.

Objective To observe the clinical effect ofvitrectomy with internal limiting membrane peeling and air tamponade in the treatment of idiopathic macular hole (IMH).Methods A prospective,nonrandomized controlled case cohort study.Twenty eyes of 20 patients with IMH in Ophthamology Department of The Second Hospital of Jilin University from September 2016 to January 2017 were included in this study.There were 4 males (4 eyes) and 16 females (16 eyes),with the mean age of 60.60 ± 9.50 years and the mean disease course of 9.55 ± 15.5 months.The stage of macular hole ranged from Ⅱ to Ⅳ.All patients underwent BCVA,intraocular pressure,spectral-domain OCT (SD-OCT) and multifocal ERG examinations.The BCVA examination was performed using the international standard visual acuity chart,which was converted into logMAR visual acuity.The minimum diameter (MIN),bottom diameter (BD),height (H),the defective diameter of ellipsoid zone,the defective diameter of external limiting membrane (ELM) of the macular hole were measured by SD-OCT (German Heidelberg).Then the macular hole index (MHI=H/BD),hole traction index (THI=MD/BD) and hole diameter index (DHI=H/MD) were calculated.The response density in P1 wave was detected by mf-ERG.The logMAR BCVA was 1.18 ± 0.54.There were 5 eyes with less than 400 μm MIN,13 eyes with 400-700 μm MIN and 2 eyes with over than 700 μm MIN.All the patients were underwent vitrectomy with internal limiting membrane peeling and air tamponade.According to the SD-OCT image features after surgery,IMH closure was divided into type Ⅰ closed,type Ⅱ closed and unclosed.The follow-up was equal or greater than 3 months.The closure rate of IMH,BCVA and the changes of microstructure parameters of macular area were observed.Spearman correlation analysis was used to analyze the correlation between BCVA and the wave response density in P 1 before surgery and the efficacy after IMH surgery.Results Closure rate of IMH:18 eyes (90.0％) were completely closed (all type Ⅰ closed).The closure rate of macular hole with the MIN less than 400 μm was 100.0％ (5/5),400-700 μm was 92.3％ (12/13),and over than 700 μm was 50％ (1/2).BCVA:the mean logMAR BCVA at 1 week,1 month,3 months after surgery were 0.83± 0.54,0.65 ± 0.41,0.48± 0.34,and there was statistically significant difference between preoperative and postoperative BCVA (t=3.382,4.459,5.250;P=0.003,0.007,0.004).The outcomes of SD-OCT at 3 months after surgery:18 eyes (90.0％) with intact ELM.The defective diameter of ellipsoid zone was 260.34±272.08 μm,there was statistically significant difference between before and after surgery (t=13.545,P=0.002).The outcomes of mf-ERG:the P 1 wave response density of the ring 1 and ring 2 after surgery were increased compared with before surgery (t=-16.748,-6.151;P＜ 0.01,＜ 0.01).The results of Spearman correlation analysis:there was a positive correlation between postoperative BCVA and preoperative MIN,the defective diameter of ellipsoid zone and ELM,and postoperative the defective diameter of ellipsoid zone (r=0.56,0.59,0.68,0.52;P=0.010,0.006,0.001,0.019).The postoperative BCVA was negatively correlated with the P 1 wave response density of ring 1 and ring 2 of mfERG (r=-0.34,-0.16;P=0.006,0.020).The IMH closure had a significant negative correlation with MIN and the defective diameter of ELM (r=-0.449,-0.449;P=0.047,0.047).MHI and THI were positively correlated with the closure of the hole (r=0.474,0.546;P=0.035,0.013).Intraocular pressure increased in 2 eyes during the follow-up period,and returned to normal within 1 week after the administration of antihypertensive drugs.There were no complications during or after the operation.Conclusions Vitrectomy with internal limiting membrane peeling and air tamponade in the treatment of IMH is safe and effective.The MIN,MHI THI are significantly correlated with the curative effect after IMH surgery,which could be used as the index to predict and evaluate the curative effect.The response density of ring 1 and ring 2 in P1 wave of mf-ERG is signifi-cantly improved compared with before surgery,and which is negatively correlated with BCVA.