| Objective:To compare the efficacy of sodium hyaluronate-assisted inverted internal limiting membrane flap from superior to the inferior side,sodium hyaluronate-assisted inverted internal limiting membrane flap from temporal to the nasal side and internal limiting membrane peeling in the treatment of large idiopathic macular hole(IMH).Method:The clinical data of 84 patients(85 eyes)with large IMH who underwent vitrectomy in the ophthalmology department of our hospital from March 2017 to August2022 were analyzed retrospectively.The diameter of the hole ranges from 415 μm to1186 μm and the age ranges from 43 to 82 years old.These patients were divided into two groups according to the hole diameter measured by OCT before operation: the large hole group with the hole diameter of 400～800 μm and the super large hole group with the hole diameter >800 μm.According to the different surgical methods of the patients,the two groups were subdivided into three groups: group A was treated with vitrectomy combined with internal limiting membrane peeling,group B was treated with vitrectomy combined with sodium hyaluronate-assisted inverted internal limiting membrane flap from temporal to the nasal side and group C was treated with vitrectomy combined with sodium hyaluronate-assisted inverted internal limiting membrane flap from superior to the inferior side.Sterilized air was filled during the operation and prone position was maintained after operation.The large hole group included 19 persons(20 eyes)in group A,17 persons(17 eyes)in group B and 15persons(15 eyes)in group C;the super large hole group included 12 patients(12 eyes)in group A,11 patients(11 eyes)in group B and 10 patients(10 eyes)in group C.All patients underwent binocular intraocular pressure(IOP)examination,best corrected visual acuity(BCVA)examination,fundus examination under slit lamp,fundus photography,axial measurement and macular optical coherence tomography(OCT)before operation.The patients were followed up for 6 months.IOP,BCVA,hole closure,diameter of internal limiting membrane(ELM)defect,diameter of ellipsoid zone(EZ)defect and postoperative complications were recorded at 1 month,3 months and 6months after operation.Result:1.Clinical data and complications: there was no significant difference in age,sex,hole diameter,ocular axis,preoperative intraocular pressure and preoperative BCVA among the three groups(all P>0.05).Patients in all groups were followed up for 6months.There were no cases of elevated or decreased intraocular pressure,no serious complications such as endophthalmitis,vitreous hemorrhage,retinal detachment and so on.2.Postoperative BCVA: in the large hole group,there was no significant difference in BCVA at 1 month,3 months and 6 months after operation among the three groups(P>0.05).There was significant difference in the improvement of visual acuity among the three groups(the difference between BCVA before operation and BCVA 6months after operation).By pairwise comparison,it was found that the improvement of visual acuity in group B was better than that in group C,and that in group C was better than that in group A,but no significant difference was found among the three groups.There were significant differences among the three groups at each adjacent time point before and after operation(all P<0.05).In the super large hole group,there was no significant difference in BCVA at 1 month,3 months and 6 months after operation among the three groups,but there was significant difference in the improvement of visual acuity among the three groups.No significant difference was found between 1 month before operation and 1 month after operation in group A(P>0.05),but there was significant difference at each adjacent time point after operation(all P<0.05).There were significant differences between group B and group C at each adjacent time point before and after operation(all P<0.05).3.Hole closure rate and shape: in large hole group,the hole closure rates of group A,B and C were 75.0%,94.4% and 100% respectively,the difference was statistically significant.(P<0.05).After comparison,it was found that there was no significant difference between group An and group B,group B and group C(P<0.05).There was significant difference between group An and group C(P>0.05).In terms of closure morphology,V-shaped closure was dominant in the three groups,and there was no significant difference in U-shaped closure rate among the three groups(P<0.05).In the super large hole group,the hole closure rate was 42.7% in group A,90.9% in group B,90% in group C,and there was significant difference among the three groups(P<0.05).After pairwise comparison,it was found that there was significant difference between group An and group B,group An and group C(P>0.05),but there was no significant difference between group B and group C(P<0.05).In terms of closure morphology,V-shaped closure was dominant in the three groups,while U-shaped closure was rare,and there was no significant difference in U-shaped closure rate among the three groups(P<0.05).4.The diameter of ELM defect before and after operation: in the large hole group,there was no significant difference in the diameter of ELM defect(μm)between the three groups before and 6 months after operation.Six months after operation,the diameter of ELM defect in the three groups was significantly smaller than that before operation,and the difference was statistically significant(all P<0.001).In the super large hole group,there was no significant difference in the preoperative ELM defect diameter among the three groups,but there was significant difference in the ELM defect diameter among the three groups 6 months after operation.The pairwise comparison showed that the defect diameter in group B was smaller than that in group C and that in group C was smaller than that in group A,but the difference was not statistically significant.Six months after operation,the diameter of ELM defect in the three groups decreased compared with that before operation,and the difference was statistically significant(P<0.05).5.The diameter of EZ defect before and after operation: in the large hole group,there was no significant difference in the diameter of EZ defect(μm)among the three groups,and there was no significant difference in the diameter of EZ defect 6 months after operation among the three groups.Six months after operation,the diameter of EZ defect in the three groups was significantly smaller than that before operation,and the difference was statistically significant(all P<0.05).In the super large hole group,there was no significant difference in the diameter of EZ defect before operation among the three groups,but there was significant difference in the diameter of EZ defect 6 months after operation among the three groups.The results of pairwise comparison showed that the diameter of EZ defect in group B and C was smaller than that in group C,and there was no significant difference between group B and group C.Six months after operation,the diameter of EZ defect in the three groups was significantly smaller than that before operation,and the difference was statistically significant(all P<0.05).Conclusion:1.Sodium hyaluronate-assisted inverted internal limiting membrane flap from superior to the inferior side,from temporal to the nasal side and internal limiting membrane peeling have definite therapeutic effects on idiopathic macular hole with large aperture.2.The effect of sodium hyaluronate-assisted inverted internal limiting membrane in the treatment of large idiopathic macular hole was better than that of internal limiting membrane peeling,and the difference became more obvious with the increase of hole diameter.3.The inversion of the internal limiting membrane from superior to the inferior side and from temporal to the nasal side can effectively improve the postoperative visual acuity,promote the closure of the hole and the recovery of the microstructure of the outer layer of the retina,but there is no significant difference between them. |
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