Clinical Analysis Of Postoperative Vitreous Hemorrhage After Vitrectomy With Silicon Oil Tamponade For Proliferative Diabetic Retinopathy

PurposeTo explore the relevant factors and treatment measures of postoperative vitreous hemorrhage(PVH)after 23G vitrectomy with silicon oil tamponade for proliferative diabetic retinopathy(PDR).MethodA retrospective cohort study method was used.246 eyes of 215 patients who were diagnosed as PDR and underwent vitrectomy with silicon oil tamponade in Tianjin Eye Hospital during September 2017 to August 2019 were enrolled.All patients were treated with intravitreal anti-vascular endothelial growth factor(VEGF)drugs,and then 23G PPV after 3-7 days.The fibrovascular membrane(FVM)peeling,pan retinal photocoagulation(PRP)and gas-liquid exchange were performed during vitrectomy.Then,the vitreous cavity was filled with silicone oil.Regular reviews were needed after the operation.Patients with complications should be reviewed at any time.Visual acuity,intraocular pressure,anterior segment and fundus examination should be performed during the reviews.The best-corrected visual acuity(BCVA)should be regularly checked.The time and severity of PVH were observe and the treatment measures were recorded in detail.The baseline data(gender,age,fasting blood glucose,postprandial blood glucose,whether had hypertension,platelet count),ocular conditions(intraocular pressure,BCVA,whether received preoperative retinal photocoagulation,whether had FVM,whether had neovascular of the dise(NVD),whether had tractional retinal detachment(TRD)involved the macular area),and the operation time between the patients with and without PVH were analyzed to find out the cause and prognosis of PVH.ResultPVH occurred in 21 of 246 eyes of 215 patients,which occurred from 3 days to8 months after vitrectomy,the incidence rate was 8.54%.They can be divided into early PVH(10 eyes,47.62%)and late PVH(11 eyes,52.38%),including 8 eyes with mild PVH,9 eyes with moderate PVH and 4 eyes with severe PVH.Thirteen eyes were bleeding under silicone oil,and 8 eyes were bleeding after removal of silicone oil.The 10 of 21 eyes needed to be re-operated:3 early PVH eyes and 7 late PVH eyes;5 eyes required intravitreous drug injection,3 eyes underwent supplemental retinal photocoagulation treatment,and three eyes self-absorbed blood after conservative treatment.The time from the initial vitrectomy to the second vitrectomy was from 2 weeks to 6 months.After careful examinations and the re-operation,TRD involved macular occurred in 4 eyes,TRD occurred in 1 eye,FVM occurred in 4 eyes,neovascularization of iris(NVI)occurred in 2 eyes and neovascular glaucoma(NVG)in 1 eye.At the last follow-up,the postoperative Log MAR BCVA of patients in the PVH group was 0.1-2.3(average 0.98).There were 17 eyes improved,3 eyes remained unchanged,and 1 eyes decreased.Postoperative vision was improved by 0.88(P=0.000)compared with preoperative Log MAR BCVA(0.4-2.3,average 1.86).Log MAR BCVA was 0.4-2.3(average 1.68)before the second vitrectomy,Log MAR BCVA was 0.2-1.85(average 0.99)after the second vitrectomy,and vision was improved by 0.69(P=0.015),However,there was no significant change in vision(P=0.979)compared with those who did not undergo vitrectomy again.Risk factors for PVH:PVH occurred in 6 of the 130 eyes with preoperative retinal photocoagulation,and PVH occurred in 15 of 116 eyes without preoperative retinal photocoagulation(~2=5.429,P=0.020).The PVH eyes were divided into two groups according to whether preoperative retinal photocoagulation was performed.It was not found that the preoperative retinal photocoagulation affected the number of operations(P=0.080).The average age of the patients with and without PVH were 46.52±9.79 years old and 52.71±13.32 years old by single factor analysis(t=2.076,P=0.039).There was a significant difference in fasting blood glucose(t=-2.391,P=0.018).The average fasting blood glucose in the PVH group was 7.60±2.46 mmol/L,and the average fasting blood glucose in the non-PVH group was 6.47±2.02 mmol/L.The proportion of eyes with FVM(38.1%)in the PVH group was higher than that in the group without PVH(18.7%)(~2=4.477,P=0.034).The operation time in the PVH group 82.00±14.38 min was significantly longer than that in the non-PVH group74.80±20.95 min(t=-2.094,P=0.045).There were no significant difference in gender(P=0.602),history of hypertension(P=0.306),postprandial blood glucose(P=0.053),number of platelets(P=0.163),whether or not combined with NVD(P=0.588).There was no statistically significant difference in whether TRD involved the macula(P=0.236).The age,fasting blood glucose,whether received preoperative retinal photocoagulation,whether combined FVM and operation time were included in the multivariate logistic regression analysis.High fasting blood glucose and non-preoperative retinal photocoagulation were independent risk factors for PVH.Other complications:Secondary glaucoma occurred in 2 eyes of PVH patients,and optic atrophy occurred in 1 eye and then transscleral diode ciliary body laser photocoagulation was performed.Three eyes were observed with residual neovascularization during the second vitrectomy,and no vascular ingrowth was found with the careful examination in the scleral incision,but the PVH patients did not undergo ultrasound biomicroscopy(ultrasound biomicroscope,UBM).Conclusion1.The results of this study showed that young patients,high fasting blood glucose,non-preoperative retinal photocoagulation and combined FVM were associated with the occurrence of PVH,and PDR patients with PVH require longer operation time.However,multivariate logistic regression analysis showed that high fasting blood glucose and non-preoperative retinal photocoagulation were independent risk factors for PVH.2.PDR patients should control blood glucose,blood pressure and other indicators strictly before vitrectomy.The pre-operative PRP and anti-vascular endothelial growth factor(VEGF)treatment should be performed if the ocular and systemic conditions allow.The vitreous cortex,FVM and neovascularization stumps should be stripped cleanly,and the retinal traction should be fully loosened to completely reset the retina during vitrectomy.In addition,sufficient retinal photocoagulation should be performed to seal off all non-perfused areas and neovascularization during the vitrectomy.3.Once PVH occurs,treatment measures should be taken depending on the severity of the disease and the cause of bleeding,such as conservative treatments,supplemental retinal photocoagulation and intravitreal VEGF drugs.Vitrectomy can be performed again,if these treatments are failed.