摘要目的 分析内界膜剥除联合空气填充治疗大特发性黄斑裂孔(IMH)的手术效果,探讨裂孔直径与一次手术裂孔闭合率的关系.方法 回顾性研究.纳入2015年7月至2019年1月就诊于北京同仁医院、黄斑裂孔最小径>400μm、行玻璃体切除联合内界膜剥除术的IMH患者282例(300只眼),其中男性56例(61只眼),女性226例(239只眼),年龄65(62,68)岁.2016年7月以前接受手术的患者,玻璃体腔内采用惰性气体填充,此后采用消毒空气填充.测量所有患眼的黄斑裂孔最小径,按裂孔最小径每50μm为一区间进行分组,以卡方检验比较各组裂孔不同填充物的一次手术裂孔闭合率.以受试者工作特征(ROC)曲线分析消毒空气填充者裂孔最小径与IMH一次闭合率关系.结果 黄斑裂孔最小径为(615.7±126.0)μm,总体一次手术裂孔闭合率为91.7％(275/300),术后BCVA为0.5(0.3,0.7),较术前的0.1(0.05,0.2)提高,差异有统计学意义(P<0.001).消毒空气填充者187例,一次手术裂孔闭合率(88.2％,165/187)总体显著低于惰性气体填充者(97.3％,110/113),差异有统计学意义(P=0.005).消毒空气填充者各区间一次手术裂孔闭合率最高为100％,650μm以上各区间闭合率渐降,与最高闭合率相比差异均具有统计学意义(P<0.05);ROC曲线显示裂孔最小径大于664.5μm者一次闭合率显著降低(P<0.001).以消毒空气填充,650μm以下裂孔一次闭合率(96.1％,123/128)与惰性气体填充(100.0％,67/67)相当(P=0.17),大于650μm裂孔一次闭合率(71.2％,42/59)较惰性气体填充(93.5％,43/46)显著降低,差异有统计学意义(P=0.002).无论何种气体填充,小于650μm IMH术后BCVA均较大于650μm者显著为优,差异有统计学意义(P<0.01).小于650μm的IMH,两种气体填充视力预后水平相当,大于650μm者亦然.结论 对于消毒空气填充者,IMH裂孔最小径与手术闭合率及视力预后密切相关,大于650μm的IMH解剖和功能预后均较小于650μm者显著降低,提示对于此类大IMH,可以考虑联合其他内界膜处理技术以期改善手术预后.

abstractsObjective To analyze surgical outcomes by internal limiting membrane peeling and air tamponade in large idiopathic macular holes (IMHs) and the correlation between the minimal diameter and the primary closure rate. Methods Retrospective study. A total of 282 patients (300 eyes) with IMHs larger than 400 μm who underwent vitrectomy and internal limiting membrane peeling in Beijing Tongren Hospital from July 2015 to January 2019 were enrolled, including 56 males (61 eyes) and 226 females (239 eyes) with an medium age of 65(62, 68) years. Before July 2016, gas tamponade was applied while after that, air tamponade was used. The minimal diameter of the IMH was measured. IMHs were divided into intervals every 50μm by minimal diameter, and the primary closure rate of the two tamponades were compared&nbsp;between intervals by Chi-square test. The receiver operating characteristic (ROC) curve was drawn to show the correlation between the minimal diameter and the primary closure rate by air tamponde. Results The mean minimal diameter of all the IMHs was (615.7 ± 126.0)μm. In general, the primary closure rate was 91.7％(275/300), and the BCVA at last visit(0.5(0.3, 0.7)) improved significantly (P<0.001) comparing to the preoperative one(0.1(0.05, 0.2)). A total of 187 eyes with air tamponade exhibited a primary closure rate of 88.2％, which was significantly lower (P=0.005) than that with gas tamponade (97.3％). For IMHs with air tamponade ,the optimal closure rate was 100％among all intervals;from the interval of (650, 700)μm on, the primary closure rates of every interval gradually decreased and were significantly lower than the optimal one (P<0.05) respectively;the ROC curve revealed that IMHs larger than 664.5μm tended to exhibit a smaller chance of primary closure. For IMHs ≤650μm, the two tamponades exhibited comparable primary closure rate (96.1％ for air, 100.0％ for gas, P=0.17), while for IMHs>650μm, air tamponade (71.2％) presented significantly lower rate (93.5％ for gas, P=0.002). IMHs ≤650μm exhibited significantly better BCVA compared to those larger (P<0.01), no matter which tamponade was applied. In IMHs ≤650μm, BCVA exhibited no significant difference between the two tamponades, so as in IMHs>650μm. Conclusions For IMHs with air tamponade, the minimal diameter is closely related to both the primary closure rate and the postoperative BCVA. IMHs>650μm exhibited evidently poorer anatomical and functional outcomes compared with those ≤650μm, which suggested that maybe other techniques for the internal limiting membrane could be applied to improve surgical outcomes for these large IMHs.