玻璃体后脱离及其并发症的发病机制

在衰老过程中,玻璃体液化和玻璃体视网膜界面改变可诱发玻璃体后脱离(posterior vitreous detachment,PVD).不完全PVD及异常PVD通过玻璃体视网膜牵拉作用以及容量和化学转移可引起视网膜裂孔、孔源性视网膜脱离、视网膜前膜、黄斑水肿、年龄相关性黄斑变性、黄斑裂孔、玻璃体黄斑牵拉综合征等一系列并发症.为防止这些并发症进一步加重,减轻疾病恶化的风险,可以提前诱导完全性PVD或者采用玻璃体切除手术.目前药物性玻璃体融解术已进入临床前期研究,非酶试剂等非侵入性的治疗方法也在探索阶段.     

药物玻璃体溶解术治疗玻璃体黄斑黏着

OCT的兴起揭示了玻璃体黄斑黏着(vitreomacular adhesion,VMA)在很多疾病起病理基础的作用,包括黄斑裂孔 (macular hole,MH)、玻璃体黄斑牵拉综合征(vitreomacular traction syndrome,VMT)、囊样黄斑水肿(cystoid macular edema,CME)、糖尿病性黄斑水肿(diabetic macular edema,DME)、糖尿病性视网膜病变(diabetic retinopathy,DR)、视网膜静脉阻塞(retinal vein occlusion,RVO)、年龄相关性黄斑病变(age-related macular degeneration,AMD)和近视导致的牵拉性黄斑病变.玻璃体切割手术是通常选用的治疗方法,但具有复杂、并发症多及费用较高的局限性.针对这些,研究人员将注意力集中在非手术方法治疗病理性VMA.研究最多的是通过玻璃体腔药物注射引起玻璃体液化和/或玻璃体后脱离(posterior vitreous detachment,PVD).文中回顾了药物治疗VMA相关疾病的研究进展,讨论了玻璃体分子组成和生理性PVD的原理,详述了几种在实验中获得卓越效果的药物.     

玻璃体酶溶术的研究进展

玻璃体视网膜界面异常与许多玻璃体视网膜病变密切相关。玻璃体内注射酶剂水解玻璃体与视网膜粘连,诱导完全性玻璃体后脱离、解除玻璃体的牵拉治疗玻璃体视网膜界面疾病,是近年来发展的一项新技术。一些酶剂包括纤溶酶、微小纤溶酶、透明质酸酶、中性蛋白酶、软骨素酶及枯草杆菌蛋白酶,已被用于辅助或代替玻璃体切割术来诱导玻璃体后脱离。本文对有关玻璃体酶溶术相关进展进行综述。     

药物性玻璃体后脱离的临床与实验研究

药物性玻璃体后脱离是近年来许多学者关注的问题，玻璃体后脱离（posterior virteous detachment,PVD)可以改善增殖性糖尿病性视网膜病变，非增殖性糖尿病性视网膜病变。黄斑裂孔等眼底疾病的预后，缩短玻璃体切割手术的时间，减少手术并发症。目前，药物性PVD的临床与实验研究已取得了一定进展。本文对药物性PVD的组织结构基础。药物的作用机制。临床及实验研究方面的进展作一综述。     

视网膜脱离环扎术后黄斑裂孔的相关原因分析及处理

目的：研究视网膜脱离术后黄斑裂孔产生的相关原因及处理。方法：分析在我院采用环扎加压手术后不同时期产生黄斑裂孔患者23例23眼，对其术前PVD情况、裂孔大小位置、黄斑部情况、术中冷凝量、环扎带长度、放液及术后玻璃体与黄斑区视网膜粘连、PVR情况，与对照组42眼进行卡方统计分析比较。结果：术前黄斑情况、上方大裂孔、PVD、术中冷凝量、环扎带长、术后黄斑区PVD及PVR情况均与视网膜脱离术后黄斑裂孔的形成有密切关系，两组比较P＜0．01，差异有显著性，而术中是否放液与术后黄斑孔的形成关系两组比较差异无显著性。术后60．87％患者视力≥0．1，发生MH后视力均＜0．1，积极治疗后视力≥0．1者39．13％，与术后60．87％相比差异无显著性。结论：视网膜脱离术后MH的形成与术前上方象限大裂孔、黄斑脱离囊变及PVD有关，与术中冷凝过量、环扎过紧，术后黄斑区PVD及PVR情况密切相关。术中应控制冷凝量、环扎松紧度，术后密切观察黄斑区、玻璃体及PVR的变化，一旦发生术后MH，应综合考虑患眼情况，进行玻璃体切割术或激光等治疗，一般均能挽回一定的视功能。     

玻璃体切割术治疗飞蚊症的疗效及安全性

飞蚊症是眼科的常见病,玻璃体液化和玻璃体后脱离(PVD)是飞蚊症的主要原因.临床上,飞蚊症一直被认为不属于严重的病理性改变而建议患者采取保守治疗方法,但部分患者因飞蚊症严重影响视力而迫切需要解除症状.国外已有利用玻璃体切割术治疗飞蚊症的报道,但手术治疗的利弊尚存在争议,近年来关于玻璃体切割术治疗飞蚊症的安全性也日益引起学者们的关注.目前飞蚊症尚不是玻璃体切割术的手术适应证,因此对玻璃体切割术治疗飞蚊症的病例选择、手术方式、手术并发症及安全性、患者满意度等方面的研究进展进行综述,对于临床工作有其重要意义.     

辅助性药物诱导玻璃体后脱离的研究进展

玻璃体视网膜交界面的状态与许多玻璃体视网膜疾病的发生发展密切相关.近年来研究表明,玻璃体切割术前应用药物可使玻璃体液化或使许多增生性玻璃体视网膜疾病玻璃体内的纤维增生膜溶解,解除玻璃体后皮质与视网膜内界膜之间的粘连,形成完全性玻璃体后脱离,不但有利于手术的进行而且有利于玻璃体视网膜疾病的治疗和视力的恢复.本文对目前药物诱导玻璃体后脱离的组织结构、药物的作用机制及其在临床和实验研究方面的进展作简要综述.     

重新认识玻璃体的功能

随着对玻璃体越来越深入的研究,临床上需要重新认识一下玻璃体的功能,异常的玻璃体后脱离(posterior vitreous detachment,PVD)可以导致视网膜脱离、玻璃体黄斑牵拉综合征、黄斑裂孔等疾病,而在玻璃体液化或者缺失状态下,却容易罹患核性白内障及原发性开角型青光眼(primary open angle glaucoma,POAG).此外,研究还发现玻璃体可以调节氧含量及分布,从而使玻璃体液化对缺血性视网膜疾病可能有益.     

纤溶酶和透明质酸酶在诱导猪玻璃体后脱离中对眼前部组织的安全性研究

近年来产生的酶辅助的玻璃体切割术，即应用酶化学作用液化玻璃体并分离玻璃体视网膜交界面，诱导产生完全性玻璃体后脱离（PVD），可用于辅助玻璃体切割术，简化手术，减少并发症，也为微创玻璃体切割术的发展创造了条件，甚至可以替代玻璃体切割术，用于预防和治疗一些玻璃体视网膜疾病，     

玻璃体与湿性年龄相关性黄斑变性间关系研究进展

明确玻璃体是否参与湿性年龄相关性黄斑变性(Wet-AMD)的发生、发展.很多研究表明玻璃体黄斑粘连、牵引确实在湿性AMD的发生、发展中具有重要的作用,通过手术或药物治疗解除二者间的粘连牵引可以达到对其预防和治疗的目的.玻璃体与湿性AMD间有密切的联系,但这种联系是受多种因素影响的,未来还需要进行设计合理的大样本对照研究.相信最终的研究结果会给湿性AMD的治疗带来一场革命.     

Ocriplasmin for pharmacologic vitreolysis

ABSTRACT:: The vitreous may play an important role in the pathogenesis of various retinal disorders. Pharmacologic vitreolysis uses intravitreal pharmacologic agents to provide liquefaction of the vitreous and complete vitreoretinal separation. Ocriplasmin, a genetically engineered version of plasmin, has been shown in clinical trials to be able to safely release vitreomacular adhesion and close Stage 2 macular holes in a significant number of patients. Advancements in the development of this safe and effective method of vitreolysis have provided an alternative, nonsurgical treatment option to physicians who manage these patients. A roundtable of clinical investigators convened to discuss and summarize recent progress in pharmacologic vitreolysis. Preclinical studies, and efficacy and safety data from controlled clinical trials of ocriplasmin were presented and discussed. Case studies were then presented to provide an opportunity for experts to reveal their specific thoughts regarding ocriplasmin for the treatment of vitreomacular adhesion and resulting vitreomacular traction and macular holes, based on their own interpretation of current clinical data and experience.     

Early vitreomacular separation with delayed macular hole closure after ocriplasmin treatment

Based on the indications, one-third to one-half of patients can achieve full-thickness macular hole (FTMH) closure with or without the separation of vitreomacular adhesion (VMA) within 28 days of ocriplasmin treatment. The authors report the case of a 63-year-old man with early VMA separation and delayed FTMH closure after ocriplasmin treatment. Four weeks posttreatment, the posterior vitreous detachment occurred at the optic disk, and the macular hole (MH) started decreasing thereafter. MH closure was finally achieved at 10 weeks posttreatment, leaving minimal subretinal fluid. The patient''s vision improved from 0.8 LogMAR (pretreatment) to 0.3 LogMAR (12 weeks posttreatment). This case suggests that FTMH closure can be achieved within 28 days of ocriplasmin treatment.     

Ocriplasmin for treatment of vitreomacular traction and macular hole: A systematic literature review and individual participant data meta-analysis of randomized,controlled, double-masked trials

Ocriplasmin is used to treat vitreomacular traction (VMT), with or without full-thickness macular hole (MH). We systematically reviewed the evidence on ocriplasmin's effect on vitreomacular adhesion resolution (VMAR), MH closure, vitrectomy, and best-corrected visual acuity (BCVA) and investigated the effect of baseline covariates on outcome. We applied individual participant data meta-analyses to the entire population and to subgroups defined by MH or epiretinal membrane (ERM) presence. Safety data were pooled and tabulated. Five randomized controlled trials (1,067 participants) were included. Six months after treatment, ocriplasmin achieved higher rates of VMAR and MH closure versus control, lowered vitrectomy odds, and increased the likelihood of a ≥10-letter BCVA increase. VMAR rates were lower when ERM, broad VMA (> 1500 µm), diabetic retinopathy, or pseudophakia were present and higher in younger participants, women, and eyes with MHs. Ocriplasmin-treated participants experienced more short-term visual impairment that was not predictive of final BCVA, as well as vitreous floaters, photopsia, photophobia, eye pain, blurred vision, and dyschromatopsia. The most common serious adverse events for ocriplasmin and control, respectively, were MH progression (22.5%, 17.3%), new MH (1.5%, 3.4%) and retinal detachment (0.8%, 1.2%). Ocriplasmin promotes VMAR and MH closure. Transient visual phenomena are not uncommon.     

The Efficacy and Safety Profile of Ocriplasmin in Vitreomacular Interface Disorders

ABSTRACT

Vitreomacular adhesion (VMA) describes the adhesion of the posterior hyaloid face to the inner retina in any part of the macula. This can arise after incomplete separation of the posterior vitreous cortex from the macula during vitreous liquefaction. While the VMA may resolve spontaneously, a strong and persistent adhesion can lead to a variety of anatomical changes, including vitreomacular traction (VMT) and macular hole (MH). Both conditions can present with metamorphopsia and decreased vision. In cases of symptomatic VMT and full-thickness macular hole, pars plana vitrectomy has long been the standard of care. However, due to the possible surgical complications and need for postoperative care, many have searched for non-surgical options via pharmacologic vitreolysis. Ocriplasmin (Jetrea, Thrombogenics USA, Alcon/Novartis EU) is a recombinant protease approved in October 2012 for the treatment of symptomatic vitreomacular adhesion (VMA). There have been conflicting views on the safety of Ocriplasmin with changes in the ellipsoid zone seen on OCT and changes seen on ERG indicating photoreceptor damage. This publication reviews the efficacy and safety of ocriplasmin injection for VMA based on previously published data.     

Release of vitreomacular traction following retinal photocoagulation in an eye with branch retinal vein occlusion

Infrequently, vitreomacular traction is released through the spontaneous development of complete posterior vitreous detachment (PVD). PVD caused by laser photocoagulation has also been reported. A 62-year-old woman with ischemic branch retinal vein occlusion showed decreased vision in the affected eye due to vitreomacular traction. We performed laser photocoagulation in the ischemic retinal area in the hope of eliminating vitreomacular traction through laser-induced PVD. Forty days later, her vision improved and the release of vitreomacular traction was observed, associated with PVD. Optical coherence tomography demonstrates clearly the change of vitreomacular interface before and after photocoagulation.     

A retrospective study of a single practice use of ocriplasmin in the treatment of vitreomacular traction

Purpose: To evaluate success with intravitreal injection of ocriplasmin in releasing symptomatic vitreomacular traction (VMT).Methods: A retrospective review of consecutive series of patients in a single vitreoretinal practice. Patients with symptomatic distortion and loss of vision secondary to VMT were included in the study. Patients received a single injection of ocriplasmin (JETREA®) and were followed-up after 1 month with optical coherence tomography.Results: Eight patients (8 eyes) were included (2 males and 6 females) in the study. Five of 8 eyes (62.5%) experienced complete release of the VMT; one of 8 eyes (12.5%) had partial release of VMT and two of 8 eyes (25%) did not have release of VMT. The two patients with no release of their VMT had the same vision. Of the 5 patients with complete release of VMT, 3 patients had a one line worsening of their vision, 1 had a 4 line improvement of vision, and 1 stayed the same. The patient with only partial release of their VMT had a 1 line worsening of vision.Conclusions: Intravitreal ocriplasmin is a promising treatment option for vitreomacular traction syndrome in symptomatic patients.     

Vitreomacular adhesion and the defect in posterior vitreous cortex visualized by triamcinolone-assisted vitrectomy

PURPOSE: To study the vitreomacular adhesion and the contractile force of posterior hyaloid, which are shown in triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV). DESIGN: Interventional case series. METHODS: Twenty-eight eyes with diabetic macular edema (DME) without posterior vitreous detachment (PVD) received TA-assisted PPV. Surgical PVD was performed by an aspiration of vitrectomy probe, and the dynamic changes of posterior vitreous cortex and residual vitreous cortex were evaluated. RESULTS: A premacular defect was formed in the detached posterior vitreous cortex during surgical PVD in 27 of 28 eyes. Immediately thereafter, the small defect expanded into a large hole in the detached posterior vitreous cortex in all cases. A residual vitreous cortex was left on the macula in 22 eyes. CONCLUSIONS: These observations demonstrate a firm vitreoretinal adhesion in the central macula and suggest that the enlargement of the defect of posterior vitreous cortex may be extrusion of vitreous out through the premacular dehiscence into the preretinal space, or a tangentially contractile force may exist in the posterior vitreous cortex. Both macular adhesion and the traction of vitreous cortex might contribute to the pathogenesis of DME and other vitreomacular disease.     

Detecting vitreomacular adhesions in eyes with asteroid hyalosis with triamcinolone acetonide

Background To report the incidence of posterior vitreous detachments (PVDs) and the surgical results of vitrectomy with intravitreal triamcinolone acetonide (TA) to detect vitreomacular adhesions in eyes with asteroid hyalosis (AH). Methods Ten eyes of nine patients with AH underwent vitrectomy, six eyes with TA and four without TA. The presence of a PVD was determined preoperatively by ultrasound echography (USE) and intraoperatively by microscopic observations. The postoperative best-corrected visual acuities (BCVA) were evaluated. Results The BCVA was improved by >2 Snellen lines in nine eyes and maintained at 20/20 with symptomatic improvements in the other eye. A vitreomacular adhesion was clearly seen during TA-assisted vitrectomy, and none was seen when TA was not used, even though preoperative USE showed an incomplete PVD in all eyes. The BCVA was not significantly better in eyes with TA-assisted vitrectomy than without TA-assisted vitrectomy. In one eye with vitrectomy without TA, a second surgery was required for a persistent cystoid macular edema and an epiretinal membrane. The BCVA and the edema in this eye improved after removing the epiretinal membrane. Conclusions All (ten) of the eyes with AH were found to have a vitreomacular adhesion by preoperative USE and intraoperative microscopic observations. The residual vitreous over the macula is more easily detected and removed after intravitreally injected TA, but the visual acuities were not significantly different from eyes without TA.     

Spontaneous resolution of vitreomacular traction: a case series

Three patients had unilateral vitreomacular traction (VMT) syndrome and the diagnosis was confirmed by spectral domain‐type optical coherence tomography (OCT). All patients were female aged 51, 55 and 62 years. All denied surgical intervention. In one patient, rapid spontaneous resolution of the vitreomacular traction with a complete posterior vitreous detachment (PVD) and a normal foveal contour was achieved within 15 days. In the remaining two cases a complete PVD could be detected as late as seven months after the initial presentation. In one, though the vitreomacular adhesion released spontaneously, there was a minimal residual epiretinal membrane. In all three eyes, visual acuity was considerably improved. Spontaneous, uneventful resolution has been rarely reported in the natural course of VMT but several recent studies with the aid of OCT have shown that spontaneous resolution might be more common than previously known. In light of our cases, we believe that there is still room to search for OCT clues in eyes with VMT to predict eyes with higher likelihood of spontaneous resolution, thereby avoiding unnecessary pharmacologic and/or surgical intervention.     

Vitreomacular interface diseases: Diagnosis and management

This article discusses the diagnosis and management of abnormal vitreomacular interfaces disorders including vitreomacular adhesion, vitreomacular traction, epiretinal membrane, full thickness macular holes, lamellar holes and pseudoholes. Optical coherence tomography has better enabled our ability to diagnose abnormalities of the vitreoretinal interface by providing clinical information that cannot be obtained by other ophthalmic diagnostic techniques. While vitrectomy remains the most commonly performed treatment for these disorders, the recent introduction of pharmacologic vitreolysis represents the development of non-surgical treatment options of certain diseases of the vitreoretinal interface.