Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China,
Hong Kong Eye Hospital, Hong Kong, Hong Kong, China,
Ophthalmologica. 2024;247(2):118-132. doi: 10.1159/000537953. Epub 2024 Feb 26.
The objective of this study was to compare the outcome of submacular hemorrhage (SMH) displacement using pneumatic displacement with intravitreal expansile gas versus pars plana vitrectomy (PPV) with subretinal injection of tissue plasminogen activator (tPA), anti-vascular endothelial growth factor (VEGF) agent, and air as primary surgery.
Retrospective interventional case series of 63 patients who underwent surgical displacement of SMH secondary to neovascular age-related macular degeneration (nAMD) or polypoidal choroidal vasculopathy (PCV) from May 1, 2015, to October 31, 2022. Medical records were reviewed for diagnosis, logMAR visual acuity (VA), central subfield thickness (CST), and postoperative displacement rates and complications up to 12 months after operation.
The diagnosis was nAMD in 24 (38.1%) and PCV in 39 (61.9%) eyes. There were 40 (63.5%) eyes in the pneumatic displacement group (38 received C3F8, 2 received SF6) and 23 (36.5%) eyes in the subretinal cocktail injection. Mean baseline VA was 1.46 and 1.62, respectively (p = 0.404). The subretinal injection group had more extensive SMH (p = 0.005), thicker CST (1,006.6 μm vs. 780.2 μm, p = 0.012), and longer interval between symptom and operation (10.65 vs. 5.53 days, p < 0.001). The mean postoperative VA at 6 months was 0.67 and 0.91 (p = 0.180) for pneumatic displacement and subretinal injection groups, respectively, though VA was significantly better in the pneumatic group at 12-month visit (0.64 vs. 1.03, p = 0.040). At least 10 mean change in VA were >10 letters gain in both groups up to 12 months. Postoperative CST reduction was greater (625.1 μm vs. 326.5 μm, p = 0.008) and complete foveal displacement (87.0% vs. 37.5%), p < 0.001, odds ratio [OR] = 11.1) and displacement to arcade or beyond (52.5% vs. 17.5%, p = 0.009, OR = 5.15) were more frequent in the subretinal injection group. Two patients with failed pneumatic displacement were successfully treated with subretinal cocktail injection as a second operation.
Surgical displacement of SMH leads to clinically meaningful improvement in VA. PPV with subretinal cocktail injection is more effective than pneumatic displacement in displacing SMH with similar safety profile despite longer interval before operation, higher CST, and more extensive SMH at baseline. Retinal surgeons could consider this novel technique in cases with thick and extensive SMH or as a rescue secondary operation in selected cases.
本研究的目的是比较使用气压移位与玻璃体内膨胀气体和经睫状体平坦部玻璃体切除术（PPV）联合视网膜下注射组织纤溶酶原激活剂（tPA）、抗血管内皮生长因子（VEGF）药物和空气作为主要手术治疗脉络膜新生血管性年龄相关性黄斑变性（nAMD）或息肉样脉络膜血管病变（PCV）继发的黄斑下出血（SMH）的结果。
回顾性干预性病例系列研究，纳入了 2015 年 5 月 1 日至 2022 年 10 月 31 日期间因 nAMD 或 PCV 而接受手术治疗的 63 例继发于 SMH 的患者。回顾性分析诊断、最佳矫正视力（BCVA）、中央视网膜下厚度（CST）以及术后 12 个月内的移位率和并发症。
诊断为 nAMD 的有 24 只眼（38.1%），PCV 的有 39 只眼（61.9%）。40 只眼（63.5%）接受了气压移位治疗（38 只眼接受了 C3F8，2 只眼接受了 SF6），23 只眼（36.5%）接受了视网膜下鸡尾酒注射。基线 BCVA 分别为 1.46 和 1.62（p = 0.404）。视网膜下注射组的 SMH 更广泛（p = 0.005），CST 更厚（1006.6 μm 比 780.2 μm，p = 0.012），症状与手术的间隔时间更长（10.65 天比 5.53 天，p < 0.001）。6 个月时的平均术后 BCVA 分别为 0.67 和 0.91（p = 0.180），但在 12 个月时气压组的视力更好（0.64 比 1.03，p = 0.040）。两组均有至少 10 例患者的视力改善大于 10 个字母。术后 CST 减少更多（625.1 μm 比 326.5 μm，p = 0.008），完全黄斑中心凹移位（87.0%比 37.5%，p < 0.001，优势比[OR] = 11.1）和移位到弓状或更远（52.5%比 17.5%，p = 0.009，OR = 5.15）在视网膜下注射组更常见。2 例气压移位失败的患者成功接受了视网膜下鸡尾酒注射作为二次手术。
SMH 的手术移位可显著改善视力。尽管手术间隔时间较长、CST 较高、基线 SMH 更广泛，但与气压移位相比，PPV 联合视网膜下鸡尾酒注射在移位 SMH 方面更有效，且安全性相当。视网膜外科医生可以考虑在存在厚且广泛的 SMH 或作为选定病例的挽救性二次手术时使用这种新的技术。
