儿童孔源性视网膜脱离发病特点、病因及手术方式的临床研究

目的探讨儿童孔源性视网膜脱离(RRD)的发病特点、病因及手术方式。方法收集首都医科大学附属北京同仁医院2004年1月至2018年12月的儿童RRD患者668例(737只眼)的病历资料进行研究。其中,男性532例(589只眼),女性136例(148只眼)。年龄3~14岁,平均年龄(11.14±2.74)岁。检索并记录患者的年龄、性别、眼别、病史、发病时间、术前最佳矫正视力、屈光状态、视网膜脱离范围、裂孔的类型、增生性玻璃体视网膜病变(PVR)等级、手术方式及对侧眼情况。将患者的年龄、性别、眼别及手术方式等以文字形式描述;将眼外伤史、屈光状态、晶状体情况、眼部及全身系统性疾病情况、是否双眼发病、视网膜裂孔的类型、视网膜脱离的范围、PVR等级及百分比,以列表形式描述。结果在纳入的668例(737只眼)儿童RRD患者中,伴有外伤史者72例(72只眼),占9.8%男性58例(58只眼),女性14例(14只眼),男女比例为4.14:1,平均年龄(11.14±3.12)岁。外伤的原因,拳击伤者34例,鞭炮炸伤者6例,钝器击伤者17例,弹弓子弹伤者15例];伴屈光不正者256例(270只眼),占33.6%中度近视者177例(193只眼),高度近视者53例(55只眼)及远视者22例(22只眼)];伴白内障手术史者61例(61只眼),占8.3%人工晶状体眼者28例(28只眼),无晶状体者33例(33只眼),伴并发性白内障者70例(72只眼)及伴晶状体脱位者17例(17只眼)及伴先天性白内障者17例(17只眼)];伴有家族性渗出性玻璃体视网膜病变者49例(54只眼),占7.3%;伴有马凡综合征者11例(13只眼),占1.8%;伴有遗传性视网膜劈裂者11例(11只眼),占1.5%;伴有先天性青光眼者10例(10只眼),占1.4%;伴有永存原始玻璃体增生症者7例(9只眼),占1.2%;伴有先天性虹膜及脉络膜缺损者5例(5只眼),占0.7%;伴有早产儿视网膜病变者3例(3只眼),占0.4%;伴有视网膜色素变性者3例(3只眼),占0.4%;伴有Coats病、牵牛花综合征、视网膜血管炎及眼弓蛔虫病各2例(2只眼),各占0.3%;伴有Leber病及急性视网膜坏死各1例(1只眼),各占0.1%;双眼发病者有69例(138只眼),占10.3%;有视网膜裂孔者668例(701只眼),眼占95.1%圆孔438只眼,锯齿缘离断91只眼,巨大裂孔61只眼,马蹄形孔53只眼,撕裂孔41只眼及黄斑孔17只眼]。视网膜脱离的特点,视网膜全脱离384例(384只眼),占57.4%;视网膜脱离累及黄斑部523例(523只眼),占78.3%;视网膜脱离达1个象限39例(39只眼),占5.8%;视网膜脱离达2个象限206例(206只眼),占30.8%;视网膜脱离达3个象限108例(108只眼),占16.2%;出现PVR者596例(621只眼),占89.2%(A级14只眼,B级144只眼,C级245只眼、D级218只眼及C级以上463只眼)。伴陈旧性视网膜脱离者190例(196只眼),占28.4%;伴脉络膜脱离13例(13只眼),占1.9%。采取的手术方式,实施巩膜扣带术者504例(569只眼),占75.4%;玻璃体视网膜手术者136例(140只眼),占20.3%;玻璃体视网膜手术联合巩膜扣带术者28例(28只眼),占4.1%。结论男性儿童较女性更易发生RRD,近视眼、眼部发育不良、眼部钝挫伤及内眼手术史等是儿童RRD的主要原因。儿童RRD具有发现晚、严重PVR和陈旧性视网膜脱离并累及黄斑等特点,提示对于存在眼部高风险因素的患者,应该加强眼底视网膜的检查和随访。

Rhegmatogenous retinal detachments in children:clinical characteristics,etiology and surgical methods

Objective To describe the spectrum of clinical features,etiology and surgical methods in children with rhegmatogenous retinal detachments(RRD).Methods 668 children with RRD(737 eyes)from January 2004 to December 2018 in Beijing Tongren Hospital,Capital Medical University were enrolled.Among of them,there were 532 males(589 eyes)and 136 females(148 eyes),with an average age of(11.14±2.74)years-old.Age,gender,ocular and systemic diseases,onset time,best corrected visual acuity(BCVA),refractive status,retinal detachment range,type of retinal hole,grade of proliferative vitreoretinopathy(PVR),operation method and contralateral eye were collected and recorded.The patients’age,gender,eye type and operation method were described in the form of words.The history of ocular trauma,refractive status,lens condition,ocular and systemic diseases,bilateral incidence,the type of retinal hole,the range of retinal detachment and the percentage of PVR grade were described in the form of words and tables.Results Among of668 children(731 eyes)with RRD,72 cases(72 eyes)had a history of trauma,accounting for 9.8%(58 males and 14 females).The ratio of male to female was 4.14∶1,and the average age was(11.14±3.12)years-old.Among of them,34 cases were injured by boxing,6 cases by firecrackers,17 cases by stumbling and 15 cases by slingshot and bullet.There were 256 cases(270 eyes)with ametropia,accounting for 33.6%,which had177 cases(193 eyes)with moderate myopia,53 cases(55 eyes)with high myopia and 22 cases(22 eyes)with hyperopia;61 cases(61 eyes)had a history of cataract surgery,including 28 cases(28 eyes)with intraocular lens and 33 cases(33 eyes)with out lens.There were 70 cases(72 eyes)with complicated cataract,17 cases(17 eyes)with lens dislocation and 17 cases(17 eyes)with congenital cataract.There were 49 cases(54 eyes)with familial exudative vitreoretinopathy,accounting for 7.3%;11 cases(13 eyes)with Marfan syndrome,accounting for 1.8%;11 cases(11 eyes)with hereditary retinoschisis,accounting for 1.5%;10 cases(10 eyes)with congenital glaucoma,accounting for 1.4%;7 cases(9 eyes)with persistent primary vitreous hyperplasia,accounting for 1.2%;and 7 cases(9 eyes)with congenital glaucoma.There were 5 cases(5 eyes)with congenital coloboma of choroids,accounting for 0.7%;3 cases(3 eyes)with retinopathy of prematurity,accounting for 0.4%;3 cases(3 eyes)with retinitis pigmentosa,accounting for 0.4%;2 cases(2 eyes)with Coats disease,accounting for 0.3%;2 cases(2 eyes)with morning glory syndrome,accounting for 0.3%;2 cases(2 eyes)with retinal vasculitis,accounting for 0.3%;2 cases(2 eyes)with ocular ascariasis,accounting for 0.3%;1 case(1 eye)with Leber disease,accounting for 0.1%and 1 case(1 eye)acute retinal necrosis,accounting for 0.1%.There were 69 cases(138 eyes)with bilateral disease,accounting for 10.3%.668 cases(701 eyes)with retinal holes were recorded,accounting for 95.1%(438 eyes with round hole,91 eyes with retinal dialysis,61 eyes with giant hole,53 eyes with horseshoe hole,41 eyes with tear hole,17 eyes with macular hole).There were 384 cases(384 eyes)with total retinal detachment(57.4%),523 cases(523 eyes)with macular detachment(78.3%),39 cases(39 eyes)with retinal detachment in one quadrant(5.8%),206 cases(206 eyes)with retinal detachment in two quadrants(30.8%),and 108 cases(108 eyes)with retinal detachment in three quadrants(16.2%).There were 596 cases(621 eyes)with PVR,accounting for 89.2%(14 eyes of grade A,144 eyes of grade B,245 eyes of grade C,218 eyes of grade D and above).There were190 cases(196 eyes)with long-standing retinal detachment,accounting for 28.4%.Choroidal detachment in13 cases(13 eyes),accounting for 1.9%.There were 504 cases(569 eyes)with scleral buckling,accounting for 75.4%;136 cases(140 eyes)with vitreoretinal surgery,accounting for 20.3%;28 cases(28 eyes)with vitreoretinal surgery combined with scleral buckling,accounting for 4.1%.Conclusions Boys were affected more than girls.Ocular trauma,myopia,history of intraocular surgery and developmental or ophthalmic/systemic associations with RRD were major predisposing risk factors in pediatric rhegmatogenous retinal detachment patients,suggesting that the examination and follow-up of fundus and retina should be strengthened in patients with high risk factors.