| Macular hole(MH)refers to the organization of macular retinal internal limiting membrane to the photoreceptor cell layer defect occurs, serious inroads to the patient’s central vision. Among them, idiopathic macular hole(IMH)is the most common, accounting for about 83%. The disease is insidious onset, slow progression, early no obvious symptoms, often in the other eye is covered to be found, as the disease progresses seriously affect central vision acuity and quality of life of patients, severe vision loss in the elderly one. In recent years, as people become more aware of the pathogenesis of IMH, vitreoretinal surgical skills more and more skilled, and more perfect facilities, making 23 G pars plana vitrectomy and indocyanine green assisted internal limiting membrane peel off, combined with the eye filled with an inert gas to become routine surgical treatment of IMH, after surgery IMH closing rates are better. But for patients with IMH larger diameter hole, after routine surgery the closure rates tend to be lower, increasing the chances of a second surgery, and some scholars have reported reoperation closure rate is far lower than the first surgery, so not only adds the patient’s pain, but also adds the economic and social burden. Therefore how to increase the success rate of surgery in patients with a large macular hole, become the problem of attention.Objective:1 To compared the different closure rate of macular hole between vitrectomy combined with internal limiting membrane transplantation and the 23 G routine pars plana vitrectomy with indocyanine green assisted ILM peel off in patients with large macular hole wich minimum diameter greater than 500μm.2 To observe the different changes of macular retinal microstructure and the vision acuity by using of spectral-domain optical coherence tomography(SD-OCT)in different time postoperatively in patients with large IMH of two groups.3 To provide a theoretical basis for the treatment of large macular hole through improving surgical methods.Methods:The study included 40 eyes in 40 consecutive patients with idiopathic macular holes who underwent treatment at the Second Hospital of Hebei Medical University in the department of ophthalmology and examined by spectral-domain optical coherence tomography( SD-OCT) from 2013.1-2014.12. These patients in Gass stage Ⅲ or above, and exclusion of high myopia and other eye diseases. Preoperative and postoperative examined on patients, including best-corrected visual acuity( BCVA), slit lamp microscope, binocular indirect ophthalmoscope, SD-OCT, fundus autofluorescence in macular( FAF), etc. All eyes with a minimum diameter of the hole is larger than 500μm in IMH patients(which we call the large macular hole). Among them, 20 eyes implemented vitrectomy with internal limiting membrane transplantation and 12% C3F8( perfluoropropane)tamponade in experimental group, 20 eyes with the implementation of traditional vitrectomy with ILM peel off and 12% C3F8(perfluoropropane)tamponade in control group. After surgery one month, three months, six months, twelve months, respectively, were observed in the hole closure rate, BCVA, photoreceptor inner and outer segment junction(IS/OS) defect diameter, external limiting membrane(ELM) healing, foveal retinal thickness and fundus autofluorescence in macular(FAF) changes in. To analyzed comparing two surgical treatment of large macular hole differences in morphology and function.Results:All patients before surgery about hole diameter,BCVA,the average defect diameter of IS/OS and ELM,after statistics analysis,the difference was not statistically significant.Experimental group in 1,3,6,12 months postoperation with log MAR BCVA were:1.019±0.049,0.800±0.044,0.671±0.040,0.500±0.062,the control group were1.100±0.044,0.924±0.041,0.853±0.049,0.793±0.053.Postoperative 3,6,12 months compared to two groups,there were significant differences(t3=2.059,P3=0.046;t6=2.871,P6=0.007;t12=2.415,P12=0.027).Visual acuity in experimental group was better than the control group.In the experimental group,each time log MAR BCVA compared with the previous period,were statistically significant(t1月比术前=4.917,P1月比术前=0.0001;t3月比1月=3.335,P3月比1月=0.002;t6月比3月=2.141,P6月比3月=0.039;t12月比6月=2.209,P12月比6月=0.038).In the control group,only 3months after surgery compared with the previous period had significant difference(t1月比术前=3.662,P1月比术前=0.0007;t3月比1月=2.911,P3月比1月=0.006).Experimental group in 1,3,6,12 months postoperation with the average defect diameter of IS/OS were:849±83.53μm,646±53.47μm,492±45.78μm,317±41.03μm.The control group were:1045±108.31μm,888±104.30μm,804±144.02μm,690±120.70μm.Postoperative 3,6,12 months compared to two groups,after statistics analysis,there were significant differences(t3=2.070,P3=0.045;t6=2.110,P6=0.043;t12=2.121,P12=0.041).Experimental group IS/OS recovery better than the control group.In the experimental group,each time the average defect diameter of IS/OS compared with the previous period,were statistically significant(t1月比术前=2.681,P1月比术前=0.011;t3月比1月=2.048,P3月比1月=0.047;t6月比3月=2.117,P6月比3月=0.041;t12月比6月=2.145,P12月比6月=0.044).In the control group,except for 1 month postoperation the rest of the months compared with the preoperative,were statistically significant(t3月比术前=2.582,P3月比术前=0.014;t6月比术前=2.698,P6月比术前=0.011;t12月比术前=3.609,P12月比术前=0.001).Postoperative 1 month compared with the postoperative 3 months,there were statistically significant difference(t=2.048,P=0.047).Experimental group in 1,3,6,12 months postoperation with the average defect diameter of ELM were:739±63.02μm,573±48.78μm,434±42.54μm, 261±26.97μm. The control group were:869±113.80μm,811±106.51μm, 773±92.20μm,654±92.66μm. Postoperative 3,6,12 months compared to two groups, the differences were statistically( t3=2.034,P3=0.049; t6=3.647, P6=0.001;t12=3.556,P12=0.004).Experimental group in 1,3,6,12 months postoperation with the foveal retinal thickness were:219±29.58μm,170±13.03μm,166±13.84μm, 170±29.99μm. The control group were:184±13.92μm,180±19.39μm, 186±19.99μm,190±16.06μm. Compared two groups of postoperative 1 month, after statistics analysis, the difference was statistically significant(t=2.113,P=0.041). Postoperative 3,6,12 months compared to two groups, there were no statistically significant difference( t3=0.428,P3=0.671;t6=0.847,P6=0.404;t12=0.849,P12=0.409).Postoperative 3 months, fundus autofluorescence in macular the experimental group and the control group 9 patients were 6 cases presented strong fluorescence.Twelve months postoperatively in closing rate of experimental group was 100%, control group was 85%, compared two groups, through the analysis of the difference was statistically significant(χ2=4.079,P=0.043).Conclusions:1 Vitrectomy with internal limiting membrane transplantation is a safe and effective treatment of large macular hole.2 Transplantation of the free internal limiting membrane only as a temporary hyperplasia of the frame, and do not form permanent scarring.3 Transplantation of the free internal limiting membrane can promote the recovery of postoperative macular hole retinal microstructure. |
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