Nghiên cứu phẫu thuật cắt dịch kính điều trị bong võng mạc do lỗ hoàng điểm TT TIENG ANH

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY NGUYỄN KIẾM HIỆP RESEARCH OF VITRECTOMY IN THE TREATMENT OF RETINAL DETACHMENT DUE TO MACULAR HOLE Speciality: Ophthalmology Code: 62.72.01.57 SUMMARY OF DOCTORAL THESIS HÀ NỘI - 2021 THIS RESEARCH WAS CONDUCTED IN HANOI MEDICAL UNIVERSITY Research supervior: Ass Prof PhD Cung Hồng Sơn Reviewer 1: Reviewer 2: Reviewer 3: This thesis will be defended before a Thesis committee in Hanoi Medical University At ……………………, …………./………/ 2021 This thesis may be found at - National library - Library of Hanoi Medical University LIST OF PUBLISHED PAPERS RELATED TO THE THESIS Nguyễn Kiếm Hiệp, Nguyễn Thị Phương Thảo Phacoemulsification on patients with severe myopia with cataracts combined with retinal detachment and macular hole Vietnam medial journal, No 01 April 2020, p.184 - 188 Nguyễn Kiếm Hiệp, Cung Hồng Sơn Evaluation of vitrectomy and removal of internal limiting membrane with inverted flap to treat retinal detachment due to primary macular hole Journal of medical research, Vol 137, No 2021, p.229 -235 Nguyễn Kiếm Hiệp, Cung Hồng Sơn, Nguyễn Thị Phương Thảo OCT results on patients after surgery for retinal detachment due to macular hole Journal of medical research, Vol 137, No 2021, p 236 - 242 Nguyễn Kiếm Hiệp Factors related to the outcomes of vitrectomy for retinal detachment due to macular hole Vietnam medial journal, No 01, p.63 – 68 INTRODUCTION Necessity of the thesis Retinal detachment associated with macular hole (MHRD) accounts for 0.5% of retinal detachment, the rate is higher in some ethnic groups, reported in the Japanese and Chinese literature at 9% and 21% respectively MHRD occurs predominantly in highly myopic eyes but has also been noted to occur after blunt ocular trauma The difficulty in determining whether a full or partial retinal macular hole is the cause of retinal detachment has been emphasized by many authors Sometimes retinal detachment causing macular hole or vice versa is difficult to determine because the patient presented with extensive retinal detachment and macular hole The MHRD occurs in one of two cases: firstly, high myopia and staphyloma account for 67.7% - 96.7% with myopia from -8.25D to 3.25D In these cases, the macular hole is the tear leading to the retinal detachment Retinal detachment is predominantly at posterior pole or extend anteriorly without other tears In the second case, retinal detachment was progressive, starting from periphery and then spreading posteriorly The stretching of the retinal tissue on the thin film during detachment leads to the formation of a macular hole Although its pathophysiology is not fully understood, it is thought that MHRD in highly myopic occurs due to reasons: Anteroposterior vitreous traction on the posterior pole due to a posterior staphyloma Tangential traction on the macula from contraction of the cortical vitreous and epiretinal membranes Reduced retinal adherence to the choroid due to retinal pigment epithelial (RPE) atrophy Surgery is the unique way to treat MHRD Different surgical methods have been described by many authors In the past, macular infusion combined with macular hole treatment by cryotherapy, electrocoagulation or laser photocoagulation were the methods of early treatment of choice for these eyes Today, a better understanding of retinal traction and advances in vitrectomy have increased the success rate from about 50% to more than 90% The choice of the surgical technique is based on vitreous status, with or without staphyloma, and degree of macular changes such as neovascularization or central choroidal atrophy, axial length, and disease peripheral retinal disease However, the anatomical successes but the functional failures are challenging for surgeons The reports in the literature are largely retrospective, making direct comparisons of surgical approaches difficult Therefore, the optimal treatment of macular hole retinal detachment remains controversial In the world as well as in Vietnam, failure of closure the macular hole and recurrent retinal detachment, especially the visual results are often disappointing, which is a challenge for ophthalmologists in general as well as for retina specialist in particular Therefore, there should be studies on this issue to help ophthalmologists choose the appropriate method in each case That is why we carry out this research Objectives of the thesis - Evaluate the surgical outcomes of retinal detachment due to macular hole - Analyze some factors related to surgical outcomes Scientific and practical significance of the thesis - This is the first study on vitrectomy and removal of the inner limiting membrane (ILM) in the treatment of RDMH in Vietnam with a sufficient number of patients and relatively long follow-up - This study showed that the peeling of the ILM creating a reversible flap without tissue loss provides a higher rate of macular hole closure and better vision after surgery, explaining why previous surgeries were anatomically successful but had little or no improvement in vision - The study reported highly successful outcomes on anatomy, retinal reapposition and macular hole closure Improved vision is an important factor in helping patients improve their quality of life - The study also analyzed the relationship between the success rate of surgery with some factors: disease duration, preoperative visual acuity, macular hole size, ocular axis length In addition, a number of factors that are not related to anatomical surgical results are also analyzed: age of the patient, degree of retinal detachment before surgery, intraocular tamponade Structure of the thesis: The thesis is presented in 126 pages (excluding references and appendices) It includes introduction (2 pages), overview (39 pages), objects and methods (19 pages), results (31 pages), discussion (33 pages), conclusions (2 pages),118 references Chapter 1: INTRODUCTION 1.1 PATHOLOGICAL MECHANISM RDMH 1.1.1 Definition of RDMH Retinal detachment is a condition in which the nerve layer of the retina is separated from the pigment epithelium due to accumulation of fluid in the subretinal space RDMH accounts for a relatively low rate of 0,5 of all retinal detachments and is mainly seen in patients with highly myopia Figure 1.1 Retinal detachment associated with macular hole13 1.1.2 Mechanism of RDMH 1.1.2.1 Factors that stablize the retinal The outer part of the photoreceptors (cones and rods) is surrounded by villi of the pigment epithelium, the cell adhesion between these two layers is not tight, the normal virtual cavity exists and is maintained by many factors The first element is the hydrostatic gradient related to intraocular pressure The next and most important factor is the impermeability of the retinal pigment epithelium and the continuous and active pumping of water from the subretinal space back to the choroid Lastly, the pigment epithelium and the photoreceptor layer are bound together by a glycoprotein complex present in the subretinal space.14 1.1.2.2 Risque factors of retinal detachment Retinal tears and fluid movements in the vitreous cavity are necessary conditions for retinal detachment Retinal holes or tears deprive the retina of its water-resistance and provide a pathway for fluid to pass directly into the subretinal space However, retinal detachment occurs only when there is prior liquefaction of the vitreous and enough fluid went through the tears to exceed the pump capacity of the pigment epithelium 1.1.2.3 Mechanism of macular hole formation The primary macular hole is formed by traction in front of the central fossa of the vitreous cortex with tangential combined with antero-posterior traction leading to the formation of the primary partial and total macular hole Primary macular holes occur mainly in elderly patients and have an incidence of 0,03 to 0,05% The incidence in women is three times higher than in men Chronic macular edema associated with venous occlusion or diabetic macular edema can also lead to a total macular hole Relatively rare cases of macular holes have been reported following electric welding and bright light injuries There have also been some case reports of macular holes in both eyes after posterior capsule opening by YAG 1.1.3 Etiology of retinal detachment due to macular hole 1.1.3.1 Staphyloma Staphyloma is a clinical feature of pathological myopic eyes It is a focal dilatation of the sclera, choroid and pigment epithelium 1.1.3.2 Atrophy of the choroid and retinal As a result of elongation of the ocular axis and internal structures, peripapillary crescent formation and choroidal atrophy are fairly common features in highly myopic eyes Areas of atrophy may be localized or diffuse, with clear or irregular margins, appearing as isolated pale white multifocal areas or fused together 1.1.3.3 Macular retinoschisis This is a separation of the retinal layers in the macula, resulting in blurred vision and distortion This macular retinoschisis can then lead to the formation of a macular hole due to myopia and possibly retinal detachment 1.1.3.4 Macular hole Macular hole is one of the complications of high myopia, accompanied by staphyloma and choroidal atrophy The occurrence of macular holes in myopic patients also increases with age 1.1.3.5 Retinal detachment associated with macular hole This is considered to be the final stage of macular disease on high myopia, of which the primary stage is retinoschisis According to Siam A (1969) there were no cases of RDMH without staphyloma except patients with another peripheral tear Retinal detachment is usually initially localized to the posterior pole in the staphyloma area, then gradually spreads to the peripheral retina According to Akiba et al (1999) in 37 eyes with retinal detachment, 36 eyes had staphyloma and the retinal detachment was localized in this area Only one eye had retinal detachment without staphyloma.1 Thus, in cases of RDMH in patients with high myopia, staphyloma plays a more important role than antero-posterior traction of the macular vitreous 1.1.4 Clinical and imaging features of RDMH 1.1.4.1 Clinical features of RDMH * Age and gender Retinal detachment due to macular hole is common in elderly patients A study of Ripandeli et al (2004) including 120 patients with retinal detachment due to myopic macular hole had the mean age of 53.6 ± 6.4 years, the lowest was 42, the highest was 68 years old Most of the studies showed that retinal detachment due to macular hole occurs predominately in female patients A research by Lim et al (2014) included 114 patients with 79 female patients (69.3%) * Visual acuity Retinal detachment due to myopic macular hole directly affects the macula, so most cases have very poor vision Feng's research (2012) showed that only 10,3% patients with retinal detachment due to myopic macular hole had visual acuity above 20/200, 58,6% had finger counting vision, 10,3% had hand movement and 3,4% had light perception * Degree of myopia Primary retinal detachment due to macular hole occurs mostly in myopic patients The rate of macular hole patients with retinal detachment is 0,6%, but this rate increases to 10% if the patient has high myopia Severe myopia or pathological myopia is defined when the myopia is greater than -6.0D or ocular axis is above 26mm * Symptoms Patients with RDMH often have a variety of previous macular symptoms At first, symptoms appear mild and vague, such as blurred or distorted central vision and appear only when reading or driving Typical functional symptoms of macular hole are macular syndrom: blurred vision, central scotoma, visual distortion and chromatic disturbance Accompanying signs include floaters and light flashes * Signs - Posterior staphyloma - Posterior hyaloid detachment Posterior vitreous detachment often occurs in patients with high myopia The typical sign of vitreous detachment on ophthalmoscopy is the appearance of a Weiss' ring A research by Soheilian et al showed that 100% of eyes with RDMH had liquefied vitreous and posterior vitreous detachment - Retinal detachment Ligou Feng et al (2012) also showed a low rate of total retinal detachment (6,9%), but nearly total retinal detachment accounted for the majority (55,2%), the remaining 37,9% had localized posterior retinal detachment - Macular hole According to Koybayashi et al (2001), a study on patients with macular holes stages III and IV showed high myopia patients with ocular axis over 26 mm 1.1.4.2 Imaging of macular retinal detachment due to macular hole On ultrasound and OCT studies, Li et al (2009) reported 231 eyes with myopic macular hole retinal detachment showing 38,8-43,6% localized posterior retinal detachment, 14,9-22,8% posterior retinal detachment with quadrant, 17,8-25,6% posterior retinal detachment with quadrants, 12,9-14,9% near-total retinal detachment (posterior detachment with quadrants) and the remaining of about 3-5,8 % total retinal detachment 1.2 VITRECTOMY IN THE TREATMENT OF RDMH 1.2.1 The evolution of vitrectomy Since the appearance of the first vitrectomy system in the 1970s until now, the general principles have remained unchanged The vitrectomy system must ensure an efficient cutting-aspiration cycle and not compromise the retina and vitreous On the other hand, the system must compensate for the amount of fluid removed and inserted into the globe to maintain the balance of intraocular pressure 1.2.2 General principles of vitrectomy in RDMH Vitrectomy in the treatment of RDMH has the following objectives: − Create a space in the vitreous chamber for endotamponade during surgery (air, perfluorocarbon solution) and postoperatively (silicone oil, expanding gas) − Allow the instrument to come into direct contact with the retina to peel off the proliferative membrane, the inner limiting membrane and aspirate the subretinal fluid − Separate the posterior vitreous cortex and the posterior hyaloid membrane if adhesion is present − Separate the vitreous base, releases the vitreous body of anterior structures (ciliary body, vitreous capsule ) and detaches the anterior hyaloid membrane if possible − Release vitreous’ pull on the edge of the tear − Remove the cataract to enhance the view of the fundus − Peel off the inner limiting membrane and preretinal membrane 1.2.3 Complications related to surgery - Retinal tearing in surgery - Changes in pigment epithelium - Recurrent retinal detachment - Cystic macular edema, choroidal neovascularization, endophthalmitis - Recurrent macular hole - Increased intraocular pressure - Visual field loss - Cataracts 1.3 SOME FACTORS RELATED TO SURGICAL RESULTS 1.3.1 General characteristics of the study group 1.3.1.1 Age and gender According to Chen et al (2015), the ratio female/male patients was 3/1 with the mean age of the group of patients being 61,25 years old Lam (2006) and Nishimura (2011) also showed that age is not a factor related to the outcomes of surgery 1.3.1.2 Duration of disease Time from ignition of symptoms to diagnosis and surgery is an important factor affecting the outcomes because retinal detachment is an emergency According to another study by Lim et al, the duration was 5,2 ± 10,6 months 1.3.1.3 Visual acuity According to Nishimura (2011) initial visual acuity is related to the anatomical outcomes of surgery Lim (2014) showed that the lower the visual acuity, the lower the possibility of retinal reapposition and macular hole closure after surgery Poorer baseline visual acuity represents more severe ocular damage, so recovery from surgery is more limited than in eyes with less damage 1.3.1.4 Ocular axial length According to Ikuno Y (2003), the rate of macular hole closure after surgery in the long axial group is lower It has been hypothesized that the retina surface is insufficient to cover the staphyloma, even after retinal reapposition in high myopia On OCT, they also reported that eyes with retinal reapposition around the border of the hole after surgery still have very flat retinal detachment at the posterior pole Thus, the axial length of the globe is an important factor in the prognosis of vitrectomy for retinal detachment due to macular hole 11 2.2.3 Study conduction 2.2.4 Study equipment - Clinical examination instruments and imaging equipment - Surgical equipment 2.2.5 Study protocol Each patient was included in the study according to the following procedure: Patient with suspected retinal detachment comes to the clinic Imaging Clinical examintion Confirm diagnosis, indication for surgery Vitrectomy and removal of internal limiting membrane Combine Phacoemulsification and IOL placement when indicated Follow-up immediately after surgery, month, months and every month for at least months Data collection, processing and analysis Objective Evaluate the surgical outcomes of retinal detachment due to macular hole Objective Analyze some factors related to surgical outcomes 12 Chapter RESULTS 3.1 Characteristics of patients 3.1.1 Age and gender Among the study group, 75% of the patients were female, 25% were male, the difference was statistically significant with p < 0,001 The mean age of the study group was 62,60 ± 7,66 years old The number of patients in the age group over 50 to under 70 accounted for the highest rate of 80,8%, the group of patients aged 70 years and older accounted for 17,3%, patients aged 50 and under accounted for only 1,9% 3.1.2 Preoperative visual acuity The mean preoperative patient's visual acuity was 1,98 ± 0,31 logMAR (Counting finger at 0,3m), ranging from 1,3 logMAR (20/400) to 2,4 logMAR (hand movement at 0.1m) Most of the patients with preoperative visual acuity ≤ Counting fingers at 1m accounted for 73,1%, the group with Counting fingers at 1m 20/400 accounted for 19,2%, the group with the best acuity 20/400 20/100 accounted for 7,7%, no patient had visual acuity ≥ 20/100 The difference was statistically significant with p < 0,0005 3.1.3 Degree of retinal detachment Table 3.1 Degree of retinal detachment Number of Degree of retinal detachment % p eyes Localized posterior detachment 39 75,0 Posterior detachment with quadrant 15,4 < 0,0005 Posterior detachment with quadrants 9,6 Total 52 100 Localized retinal detachment around the macula accounted for 75,0% cases had larger detachment in lower temporal quadrant (15,4%), cases of extensive detachment in lower quadrants (9,6%) The difference was statistically significant with p < 0,0005 3.1.4 Axial length Table 3.2 Axial length Axial length Number of eyes % p < 24mm 3,8 ≥ 24 - < 26mm 9,6 < 0,0005 ≥ 26mm 45 86,5 Total 52 100 The average axial length of the study group was 28 ± mm, in which the smallest was 23mm and the highest was 32,5mm 13 3.1.5 Preoperative characteristics of macular hole 3.1.5.1 Size of macular hole Table 3.3 Size of macular hole Preoperative visual Mean size of macular Number of eyes acuity hole (µm) (%) ≥ 20/400 - < 20/100 648 (7,7) ≥ ĐNT 1m - 0,05 3.3 Functional outcomes 3.3.1 Visual acuity outcomes Table 3.5 Mean visual acuity in the last follow-up Time Preoperative Postoperative p Mean visual acuity 1,99 1,35 < 0,0001 (logMAR) Visual acuity on admission to the hospital before surgery had an average value of 1,99 ± 0,31 logMAR (Hand movement 0,3m), ranging from 1,3 logMAR (20/400) to 2,4 logMAR (Hand movement 0,1m) ) The mean postoperative visual acuity at the last visit was 1,35 ± 0,26 logMAR (≈20/400), ranging from 0,6 logMAR (20/100) to 2,1 logMAR (Counting fingers 0,5m) Postoperative visual acuity was significantly higher than before surgery with p < 0,0001 After surgery, the group of patients with visual acuity at 20/400 20/100 accounted for the highest rate of 51,9%, followed by the group of patients with visual acuity at 1m - 20/400, accounting for 44,2% There was case of high visual acuity above 20/100 and case less than Counting fingers at 1m (1,9%) 3.4 Factors related to surgical outcomes 3.4.1 Factors related to anatomic outcomes 3.4.1.1 Duration of disease The difference in retinal anatomy after surgery between groups of patients with different disease onset time was statistically significant with p = 0,04 Thus, with a shorter duration of disease, the rate of retinal reattachment after surgery is higher than in the group with a long duration of disease The difference in macular hole anatomy after surgery between the two groups of patients with different disease onset time was statistically significant with p = 0,045 With a short duration of disease, the rate of complete macular hole closure is higher than that of those who has long duration 3.4.1.2 Preoperative visual acuity Retinal anatomy after surgery in different groups of vision at time of admission had a statistically significant difference with P = 0,047 The lower the visual acuity, the higher the rate of recurrent retinal detachment was 15 The difference in macular hole anatomy in different groups of visual acuity when admitted to the hospital was statistically significant with p = 0,0084 The lower the visual acuity on admission, the less likely it is to close the macular hole completely 3.4.1.3 Degree of retinal detachment Retinal anatomy after surgery in groups with different degree of retinal detachment had no difference with p = 0,351 The rate of retinal reattachment after surgery was independent of the degree of retinal detachment before admission 3.4.1.4 Axial length Retinal anatomy after surgery in different groups of axial length was statistically significant with p = 0,038 < 0.05 The longer the axis, the higher the risk of recurrent retinal detachment after surgery 3.4.1.5 Preoperative size of macular hole Retinal anatomy after surgery in different preoperative macular hole size groups had a statistically significant difference with p < 0,05 All eyes with macular hole size < 600 µm have retinal reposition after the first surgery Up to 10/34 eyes with macular hole ≥ 600 µm have recurrent retinal detachment after the first surgery Thus, the larger the macular hole size the higher the risk of recurrent retinal detachment The difference of macular hole anatomy after surgery in the different preoperative macular hole size groups was statistically significant with p = 0,013 The smaller the macular hole before surgery, the easier it is to close completely after surgery 3.4.1.6 Technique of internal limiting membrane peeling For the method of removing the internal limiting membrane, the main technique used was inverted flap in 51 eyes (98,1%) Only case didn’t use invert flap (1,9%) and in this case the macular hole only reduced in size The difference was statistically significant with p = 0,202 (phi cramer's test) 3.4.1.7 Condition of internal limiting membrane during surgery In surgery, the percentage of eyes of which the inner limit membrane was completely removed accounted for 80,8%, the remaining 19,2% of the patients only had the inner limit membrane removed partially The more the inner limiting membrane is peeled off to the correct size, the better the chance of complete closure of the macular hole 16 3.4.2 Factors related to functional outcomes 3.4.2.1 Duration of disease Table 3.6 Relationship between duration of disease and vision outcomes Visual acuity after surgery and the degree of visual improvement between groups of different duration of disease less than months and over months did not have a statistically significant difference, with p = 0,456 3.3.2.3 Preoperative size of macular hole Table 3.7 Relationship between preoperative size of macular hole and visual outcomes Mean size Number Visual outcomes of macular of eyes p hole (µm) (%) ≥ 20/100 468 (1,9) ≥ 20/400 -