玻璃体视网膜手术联合玻璃体腔注射康柏西普或雷珠单抗治疗严重PDR的临床观察

背景 玻璃体视网膜手术(VRS)是治疗严重增生性糖尿病视网膜病变(PDR)的重要手段,术前行玻璃体腔注射抗血管内皮生长因子(VEGF)药物辅助VRS治疗PDR已在临床上广泛应用,但不同抗VEGF药物对VRS辅助作用的差异尚不清楚. 目的 观察术前玻璃体腔注射抗VEGF药物对严重PDR患眼行VRS治疗效果的影响,并比较康柏西普和雷珠单抗2种不同抗VEGF药物对VRS辅助作用的差异.方法 采用回顾性病例对照研究.收集2014年10月至2016年1月就诊于天津市眼科医院并确诊为严重PDR行微创玻璃体切割术治疗的患者96例98眼的临床资料.根据VRS术前3d是否注射抗VEGF药物将患者分为术前玻璃体腔注射康柏西普(IVC)治疗组31例32眼、术前玻璃体腔注射雷珠单抗(IVR)治疗组30例31眼和单纯VRS治疗组35例35眼,3个组患者基线特征比较,差异均无统计学意义(均P＞0.05).所有手术均由同一名医生完成,观察并记录3个组患眼玻璃体切割手术时间、术中电凝使用、严重出血及医源性裂孔发生情况.手术后随访3～6个月,平均随访(3.51±0.59)个月,对比分析3个组患眼最佳矫正视力(BCVA)变化及术后并发症发生情况.结果 术前IVC治疗组、术前IVR治疗组和单纯VRS治疗组患眼平均手术时间分别为(84.84±11.03)、(83.45±14.24)、(104.57±13.42) min,术前IVC治疗组、术前IVR治疗组平均手术时间较单纯VRS治疗组明显缩短,差异均有统计学意义(t=6.622、6.604,均P＜0.01).术前IVC治疗组和术前IVR治疗组患眼术中电凝使用率分别为31.25％和29.03％,均显著低于单纯VRS治疗组的60.00％,差异均有统计学意义(x2=5.558,P=0.018;x2 =6.359,P=0.012).术前IVC治疗组、术前IVR治疗组和单纯VRS治疗组术中严重出血发生率分别为15.63％、12.90％和42.86％,术前IVC治疗组和术前IVR治疗组术中严重出血发生率较单纯VRS治疗组明显降低,差异均有统计学意义(x2=5.920,P=0.015;x2=7.195,P=0.007).术前IVC治疗组和术前IVR治疗组术中医源性裂孔发生率及术后玻璃体腔再出血、一过性高眼压、视网膜再脱离及新生血管性青光眼发生率比较,差异均无统计学意义(均P＞0.05).3个组患眼术前及术后3个月BCVA总体比较,差异均有统计学意义(F分组=4.077,P=0.020;F时间=100.937,P=0.000).术前IVC治疗组、术前IVR治疗组和单纯VRS治疗组患眼术后3个月BCVA分别为0.80±0.37、0.82±0.32和1.03±0.52,均较术前显著提高,差异均有统计学意义(均P＜0.01).术前IVC治疗组和术前IVR治疗组术后平均BCVA均较单纯VRS治疗组提高,差异均有统计学意义(均P＜0.05). 结论 严重PDR患眼VRS前行玻璃体腔注射抗VEGF药物可缩短平均手术时间,减少术中出血和电凝使用率,并提高患眼BCVA.玻璃体腔注射康柏西普和雷珠单抗对VRS治疗严重PDR的辅助效果相似.

Clinical effect of vitreoretinal surgery combined with intravitreal injection of conbercept or ranibizumab on severe proliferative diabetic retinopathy

Background Vitreoretinal surgery (VRS) is the main treatment of severe proliferative diabetic retinopathy (PDR),intravitreal injection of anti-VEGF drugs before VRS on severe PDR has been widely used in clinic,but the auxiliary effect of different anti-VEGF drugs on VRS is unclear.Objective This study was to observe the efficacy of preoperative intravitreal injection of anti-VEGF drugs for the treatment of severe PDR,and to compare the efficacy of intravitreal conbercept (IVC) versus intravitreal ranibizumab (IVR) before VRS.Methods A retrospective,comparative study was performed.Niety-six severe PDR patients (98 eyes) who experienced VRS were collected in Tianjin Eye Institute from October 2014.to January 2016.There were 32 eyes in the preoperative IVC group,31 eyes in the preoperative IVR group and 35 eyes in the simple VRS group.The intravitreal injection was performed 3 days prior to VRS in the preoperative IVC group and preoperative IVR group.All operations were conducted by the same physician.The duration of VRS,number of endodiathermy,incidence of severe hemorrhage and iatrogenic retinal breaks were recorded.The follow-up visit ranged from 3 to 6 months with an average of (3.51 ± 0.59) months,the changes of best corrected visual acuity (BCVA) and incidence of postoperative complications were compared among the three groups.Results The average operation duration was (84.84± 11.03) minutes and (83.45 ± 14.24) minutes in the preoperative IVC group and preoperative IVR group respectively,which were significantly shorter than (104.57 ± 13.42) minutes in the simple VRS group,with significant differences between them (t =6.622,6.604,both at P＜0.01).The incidences of endodiathermy were lower in the preoperative IVC group (31.25％) and preoperative IVR group (29.03％) than that in the simple VRS group (60.00％),with significant differences between them (x2 =5.558,P =0.018;x2 =6.359,P =0.012).The incidence of severe hemorrhage in the simple VRS group was 42.86％,which was significantly higher than that in the preoperative IVC group (15.63％) and preoperative IVR group (12.90％),with significant differences between them (x2 =5.920,P =0.015;x2=7.195,P =0.007).There were no statistical differences in the incidence of iatrogenic retinal breaks and postoperative vitreous hemorrhage,temporary increase of intraocular pressure,recurrent retinal detachment,glaucoma among the three groups (all at P＞0.05).The mean BCVAs were significantly different among the 3 groups of different timepoints (Fgroup =4.077,P =0.020;Ftime =100.937,P =0.000).The postoperative mean BCVA at 3 months after surgery was (0.80±0.37),(0.82±0.32) and (1.03±0.52) in the preoperative IVC group,preoperative IVR group and simple VRS group respectively,which was significantly improved compared with preoperative results (all at P＜0.01).The postoperative BCVAs were improved in preoperative IVC group and preoperative IVR group compared with the simple VRS group,with significant differences between them (both at P ＜ 0.05).Conclusions The preoperative intravitreal injection of anti-VEGF drugs combined with VRS is conductive to shorten the average operation time,reduce the rate of intraoperative hemorrhage,endodiathermy as well as improve the BCVA.Conbercept and ranibizumab had the similar auxiliary effect for VRS for the treatment of severe PDR.