Research progress of internal limiting membrane dissection for idiopathic macular hole
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摘要:
玻璃体切除联合内界膜(ILM)剥离是特发性黄斑裂孔(IMH)的有效治疗方法。IMH的预后与裂孔大小及病程长短密切相关。直径 < 400 μm的裂孔有自发闭合的可能, >400 μm的裂孔很少能够自行闭合, 需要玻璃体切除联合ILM剥离解除玻璃体黄斑牵引，才能达到理想的裂孔闭合率。部分直径>400 μm、病程长(6~12个月)的IMH, 单纯ILM剥除效果欠佳，常在ILM剥离的基础上联合应用气体填充、孔周按摩、自体血填充等手术方式优化治疗效果。但是，有研究者认为ILM剥离会造成视网膜显微结构及视功能损害。近些年ILM剥离技术不断改进，衍生出保留中心凹ILM剥离、向心牵引ILM剥离、根据黄斑裂孔(MH)形状定制ILM剥离、各种类型的ILM瓣等技术，以及ILM磨损、奥克纤溶酶药物治疗等其他方法，在保证治疗效果的基础上尽可能降低对视网膜的损害。本文基于国内外学者的临床经验，对ILM剥离治疗IMH最新进展进行综述，明确不同治疗和手术方式的特点和适用性，为临床上IMH的治疗提供参考。
Abstract:Vitrectomy combined with internal limiting membrane (ILM) dissection is an effective therapeutic method for idiopathic macular hole (IMH). The prognosis of IMH is closely related to size of hole and course of disease. The hole with a diameter < 400 μm may close spontaneously, while MH with a diameter >400 μm can rarely close spontaneously, and vitrectomy combined with ILM dissection is required to relieve the vitreous fovea traction, so as to achieve the ideal closure rate of macular hole. For some IMH patients with diameter >400 μm and a long course of disease (6 to 12 months), the ILM dissection alone is not well, and often requires to combined with gas filling, massage around macular hole and autologous blood filling to optimize surgery effect. However, some researchers believe that ILM dissection can cause damage to retinal microstructure and visual function. In recent years, the ILM dissection technology has been continuously improving, technologies are derived such as ILM dissection retaining fovea, centripetal traction ILM dissection, customized ILM dissection according to macular hole (MH) shape, various types of ILM flaps, and other methods such as ILM abrasion and ocriplasmin treatment, so as to reduce retinal damage as far as possible on the basis of ensuring the therapeutic effect. This paper reviewed the latest progresses of ILM dissection in the treatment of IMH based on the clinical experience of domestic and foreign scholars, in order to clarify the characteristics and applicability of different treatment and surgical methods, and provide reference for the clinical treatment of IMH.
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图 1 ILM剥离面积研究示意图
A: 视频终端实时显示以黄斑中心凹为中心的3个同心圆，直径分别1、2、3 PD; B: AIP小于3 PD; C: AIP大于3 PD。整体为ILM剥除术中眼底示意图，红色和蓝色曲线分别代表视网膜动静脉，左侧红色圆圈代表视盘，血管弓中间红色圆圈代表MH, 蓝色圆圈代表已染色的ILM, 蓝色圆圈中间的粉色区域代表剥除的ILM范围(本文所有示意图中均相同)。
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图 2 保留中心凹ILM剥离示意图
绕MH 1周分别重叠剥离数个圆形ILM, 保留MH边缘约500 μm的ILM。必要时可将ILM剥离区域扩展到孔周约2个PD范围(黑虚线)。
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图 3 向心牵引ILM剥离示意图
A: 分别在裂孔上下象限近血管弓处剥离2条水平ILM带; B: 沿ILM带从下至上剥离下方矩形ILM瓣，向心性牵拉MH的下边缘; C: 以相同的方式从相反方向剥离上方的矩形ILM瓣牵拉MH的上边缘(B和C无先后顺序区分); D: 最后将MH周围进行圆形ILM剥除。
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图 4 大型上半圆形ILM翻转覆盖术示意图
A: 先在下方血管弓至MH处完全剥除一个半圆形ILM; B: 在上方血管弓处不完全剥离一半圆形ILM瓣，剥离至距MH边缘100 μm处; C: 将半圆形ILM瓣翻转覆盖至MH上。
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图 5 舌状ILM翻转覆盖术示意图
A: 先将MH周围的ILM环形剥离，宽度200~300 μm; B: 在MH上方视网膜不完全剥离制成舌状的ILM瓣; C: 再将舌状ILM瓣翻转覆盖在MH和无ILM的区域。
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