| Background And ObjectivesDiabetes mellitus(DM)is one of the most common chronic diseases in all countries.With the economic development and urbanization leading to lifestyle changes,decreased physical activity and increased obesity,the number of DM is increasing.From 1980 to 2010,the morbidity of DM in China increased from 0.67% to 9.7%.At present,the number of DM patients has exceeded 100 million in China,ranking first in the world.Diabetic retinopathy(DR),one of the most common microvascular complications of DM,is one of the major causes of blindness in patients with ophthalmopathy.Studies have shown that the morbidity of DR is 34.6% in DM patients.With the prolongation of the course of diabetes and lack of awareness of DR in the country,the majority will develop into proliferative diabetic retinopathy(PDR),and vision will be seriously impaired.Most of them have other systemic diseases such as hypertension,hyperlipidemia,proteinuria,and these factors interact with each other.PDR mainly manifests as fundus neovascularization,vitreous hemorrhage,a large number of fibroproliferative cords and retinal detachment.The final stage of PDR is tractional retinal detachment(TRD),and the patient's vision is severely degraded,even becomes blind.His daily life is severely affected,causing a heavy burden on family and society.At present,the main treatment for PDR and TRD is vitrectomy.However,complications of retinal anatomy,intraoperative bleeding and poor surgical field of vision resulted in the high incidence of complications in operation and postoperative.Studies have shown that anti-vascular endothelial growth factor(VEGF)can reduce systemic and intraocular VEGF levels in patients with PDR,promote neovascularization regression and significantly reduce vascular leakage,reduce intraoperative and postoperative complications,and improve prognosis.However,Zhang et al.eported that anti-VEGF drugs can shrink the fibrous membrane,exacerbate TRD and cause new hemorrhage.Therefore,this study collected a group of patients with PDR combined with TRD,respectively,using two methods of vitrectomy and vitreous intravitreal of ranibizumab(IVR)combined with vitrectomy,to evaluate whether IVR affected the results of vitrectomy for this type of patient and provide more evidence for the clinical application of ranibizumab.Materials and Methods From September 2014 to September 2016,46 patients(46 eyes)with PDR and TRD who underwent vitrectomy at the Second Affiliated Hospital of Zhengzhou University were selected.Inclusion criteria:1.Type 2 diabetes mellitus;2.The patients were diagnosed as PDR and TRD after fundus examination and B ultrasonography;3.All patients signed informed consent and agreed to be included in the study.Exclusion criteria: 1.Those who have received intraocular injections of anti-VEGF drugs or hormones;2.Person who has undergone panretinal photocoagulation(PRP)and vitrectomy;3.High myopia,retinal vascular disease other than PDR;4.The general condition can not tolerate surgery,such as uncontrolled blood pressure,uncontrolled blood sugar and coagulation dysfunction and so on.According to the treatment method selected by the patient,they were divided into two groups:observation group(24 eyes)and control group(22 eyes).In the observation group,IVR was performed 3 to 5 days before surgery,and then vitrectomy was performed.In the control group,only vitrectomy was performed.After follow-up of 6 months,contrast observation indicators:1.The duration of vitrectomy,intraoperative bleeding,fibrovascular membrane condition(Grade of intraoperative bleeding: ?.There was no need to stop bleeding during operation.?.Punctate haemorrhage and flake haemorrhage can stop by oneself or by raising the height of perfusion bottle to stop bleeding;?.Electric coagulation is required to stop bleeding.Classification of fibrovascular membrane: ?.No blood vessels were found on the proliferative membrane,which were easily torn off.?.A small number of blood vessels were seen in the proliferative membrane.The root of the vessel and the retina were close,and the other parts were loose and easy to tear.?.Vascular climbing can be seen on the proliferative membrane.The proliferative membrane adheres closely to the retina and is not easy to cut.);2.The macular foveal thickness after operation;3.Best corrected visual acuity(BCVA)after operation(International standard logarithmic visual acuity table is used and converted to minimum resolution angle logarithmic log MRA visual acuity is easy to count.);4.Postoperative complications such as bleeding,newborn vascular-related diseases and retinal detachment and so on.Results1.Comparison of basic data between the two groups:There was no significant difference in age,sex,course of diabetes,preoperative log MRA BCVA and IOP between the two groups(P > 0.05).2.Comparison of intraoperative conditions: The mean operation time of the observation group was(82.50±7.60)min,and the average operation time of the control group was(95.90±6.55)min,the difference was statistically significant(P<0.05);The intraoperative hemorrhage in the observation group was mostly Grade I and Grade II,while in the control group intraoperative hemorrhage was Grade III.There was a statistically significant difference in intraoperative bleeding grading between the two groups(P<0.05);The fibrovascular membranes were grade I and grade II in the observation group,while the control group was grade III.The difference was statistically significant(P<0.05).In the observation group,intraoperative hemorrhage was treated with electrocoagulation(1.22± 0.46)times,less than the control group(1.87 ± 0.58)times,the difference was statistically significant(P <0.05).3.Comparison of macular foveal thickness: 6 mnths after operation,the macular foveal thickness in the observation group was(248.32±21.76)?m,which was lower than the control group(286.13±14.92)?m,and the difference was obviously significant(P<0.05).4.Comparison of preoperative and postoperative visual acuity: Preoperative log MRA BCVA in the observation group and control group was(1.89±0.30)?(1.90±0.31),and the difference was no significant(P>0.05);At 6 months,log MRA BCVA was(0.84±0.24)and(0.99±0.25)in the observation group and control group respectively,which were significantly higher than before surgery(all P<0.05).And the observation group increased significantly compared with the control group,the difference was significant(P <0.05).5.Comparison of postoperative complications: 3 months after surgery,there were 4 eyes and 3 eyes with significantly increased opacity of the lens(complicated cataract)in the observation group and the control group,there was no statistically significant difference(P>0.05)(2 eyes in the observation group and 4 eyes in the control group were intraocular lens eyes before vitrectomy.).The number of eyes with vitreous hemorrhage(1 month after surgery)in both groups was 2 eyes and 7 eyes respectively.The difference was statistically significant(P<0.05).Patients with vitreous hemorrhage were treated with drugs.Blood samples were gradually absorbed and no secondary surgery was performed.The number of eyes with advanced vitreous hemorrhage in both groups was 2 eyes and 3 eyes respectively,and the difference was no statistically significant(P>0.05).One eye in the observation group underwent secondary surgery after vitreous hemorrhage,and the rest was gradually absorbed after drug treatment.Tthe retina was anatomically reset during the follow-up period in the observation group,and the retinal detachment was observed in the control group after silicone oil was removed(In the observation group and the control group,3 eyes and 2 eyes were not removed from the silicone oil at the end of the follow-up.),and the difference was no significant(P>0.05).Patients with retinal detachment underwent secondary surgery.Neovascular glaucoma occurred in 1 eye in the observation group and 2 eyes in the control group.The difference was not statistically significant(P>0.05).Silicone oil had been removed in all patients with neovascular glaucoma.Intraocular pressure could be controlled in 2 eyes and could not be controlled in 1 eye after anti-angiogenic drug therapy.Ciliary body cryotherapy was performed in 1 eye.Conclusions1.Vitrectomy is an effective method for the treatment of PDR with TRD.Combined with IVR can reduce the difficulty of operation and make the operation faster,more effective and safer.2.For PDR with TRD,IVR of 3 to 5 days prior of vitrectomy could reduce intraoperative bleeding,reduce the time of operation,reduce the incidence of vitreous hemorrhage and macular edema in the early stage of vitrectomy,and ultimately improve the visual acuity.3.The sample size,follow-up time and evaluation criteria of this study are still insufficient.The results of the study and the long-term efficacy still need to be confirmed by a large sample of clinical randomized controlled trials. |
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