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陶继伟, 褚梦琪, 王奇骅, 陈亦棋, 赵士鑫, 林晶晶, 沈丽君. 术中OCT在致密玻璃体积血玻璃体切割手术中的应用[J]. 中华眼视光学与视觉科学杂志, 2017,19(11): 686-690.
Jiwei Tao, Mengqi Chu, Qihua Wang, Yiqi Chen, Shixin Zhao, Jingjing Lin, Lijun Shen. Intraoperative Optical Coherence Tomography during Vitreoretinal Surgery for Dense Vitreous Hemorrhage[J]. CHINESE JOURNAL OF OPTOMETRY OPHTHALMOLOGY AND VISUAL SCIENCE, 2017,19(11): 686-690.  
Doi:10.3760/cma.j.issn.1674-845X.2017.11.010
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术中OCT在致密玻璃体积血玻璃体切割手术中的应用
陶继伟, 褚梦琪, 王奇骅, 陈亦棋, 赵士鑫, 林晶晶, 沈丽君
325027 温州医科大学附属眼视光医院
通信作者：沈丽君,Email:slj@mail.eye.ac.cn
收稿日期: 2017-01-23
基金资助: 浙江省科技厅重大专项（2013C03048-3）; 浙江省康恩贝医院管理软件科学研究项目（2012ZHA-KEB320）
摘要

目的:评估术中光学相干断层扫描(iOCT）在致密玻璃体积血手术中的临床应用价值。方法:回顾性系列病例研究。收集2015年6月至2016年9月在温州医科大学附属眼视光医院采取玻璃体切割手术治疗的致密玻璃体积血患者共24例（24眼）,其中男14例,女10例,平均年龄（62.3±16.6）岁。所有患者术中清除致密出血后行iOCT检查,了解黄斑情况。记录iOCT检查时间及结果,对比iOCT结果与术者显微镜下观察判断是否一致,观察iOCT结果是否对手术治疗策略产生影响,以及与检查相关的并发症发生情况。结果:纳入的24例病例中,糖尿病视网膜病变15例,视网膜静脉阻塞4例,视网膜裂孔1例,息肉状脉络膜血管病变2例,大动脉瘤1例,不明原因新生血管1例。iOCT结果提示10例患者术中黄斑区结构正常,14例结构异常：其中黄斑水肿8例,黄斑前膜2例,黄斑前膜伴水肿1例,黄斑萎缩2例,黄斑板层裂孔1例。iOCT检查结果与手术者手术显微镜观察结果不一致为6例;因iOCT结果而改变手术策略的有4例。未见与检查相关的眼内炎等并发症发生。结论:iOCT在致密玻璃体积血患者玻璃体切割术中的应用可给手术者提供显微镜下无法察觉的黄斑区异常改变,指导术者选择更为合理的手术方式。

关键词: 光学相干断层扫描; 致密玻璃体积血; 手术指导
Intraoperative Optical Coherence Tomography during Vitreoretinal Surgery for Dense Vitreous Hemorrhage
Jiwei Tao, Mengqi Chu, Qihua Wang, Yiqi Chen, Shixin Zhao, Jingjing Lin, Lijun Shen
Eye Hospital , Wenzhou Medical University, Wenzhou 325027, China
Corresponding author: Lijun Shen, Eye Hospital , Wenzhou Medical University, Wenzhou 325027, China (Email: slj@mail.eye.ac.cn)
Fund:This study was funded by Zhejiang Province Department (2013C03048-3); The Kang Enbei Hospital Management Software Science Research of Zhejiang Province (2012ZHA-KEB320)
Abstract

Objective: To observe the preliminary application of intraoperative optical coherence tomography (iOCT) in vitreoretinal surgery for dense vitreous hemorrhage.Methods: In this retrospective case study, 24 subjects (14 males, 10 females, mean±standard deviation age 62.3±16.6 years) were recruited from June 2015 to September 2016 at Eye Hospital, Wenzhou Medical University. One eye of each patient received iOCT to evaluate macular architecture after removal of a dense hemorrhage.Results: The etiologies for the vitreous hemorrhages included proliferative diabetic retinopathy (15 eyes), horseshoe retinal tear (1 eye), retinal vein occlusion with neovascularization (4 eyes), polypoid choroidal vasculopathy (2 eyes), retinal arterial macro aneurysm (1 eye), and neovascularization due to unknown cause (1 eye). iOCT revealed macular edema (8 eyes), epiretinal membrane (2 eyes), macular edema and epiretinal membrane (1 eye), macular atrophy (2 eyes), and lamellar macular hole (1 eye). The iOCT macular findings were not consistent with examination under the operating microscope in six eyes. The differences resulted in intraoperative changes in the surgical management in four of these eyes. None of the patients experienced endophthalmitis associated with iOCT.Conclusions: Morphological changes of the macular area that are difficult to detect under the operating microscope can be observed by iOCT after removal of a dense vitreous hemorrhage. iOCT may help surgeons improve the management of vitreoretinal surgery.

Keyword: optical coherence tomography; dense vitreous hemorrhage; operation guide

玻璃体积血是糖尿病视网膜病变-视网膜静脉阻塞性疾病等导致视力丧失的常见原因之一。对于致密或长期不吸收的出血, 玻璃体视网膜手术是主要的治疗方法。光学相干断层扫描（OCT）是眼底病领域重要的辅助诊疗技术, 而致密玻璃体积血的患者术前由于OCT成像受限无法进行检查, 在清除积血的手术中, 部分患者可能存在手术显微镜下无法察觉的黄斑区病变, 若不能及时发现, 需再次手术治疗。术中光学相干断层成像技术（Intraoperative optical coherence tomography, iOCT）是解决这一难题的可行办法, 术者可在积血清除后进行黄斑区扫描检查, 根据检查结果指导进一步的手术治疗方案[1, 2, 3, 4, 5, 6, 7]。iOCT在黄斑疾病、视网膜脱离等眼底疾病方面的应用已有报道[8, 9, 10, 11, 12, 13, 14, 15, 16, 17], 但在玻璃体积血中的应用目前国内尚缺乏相关研究, 本研究主要介绍iOCT在致密性玻璃体积血患者手术中的应用价值。

1 对象与方法
1.1 对象

回顾性系列病例研究。收集2015年6月至2016年9月在温州医科大学附属眼视光医院因致密玻璃体积血行玻璃体视网膜手术且行iOCT的患者资料, 共24例（24眼）, 其中男14例, 女10例, 年龄25~88岁, 平均（62.3± 16.6）岁。

纳入标准：致密玻璃体积血（参考Ehlers等[16]研究, 定义为玻璃体切割术前2个月内因严重积血遮挡无法采集眼底OCT图像者）。

排除标准：①既往曾行玻璃体切割术者; ②角膜白瘢、晶状体后囊膜机化等屈光介质严重混浊者。

1.2 方法

术前均常规行最佳矫正视力（BCVA）、眼压、裂隙灯显微镜联合前置镜检查。术中清除眼内致密出血后行iOCT检查, 记录iOCT扫描时间与结果、与术者显微镜下观察判断的一致性、对手术治疗策略的影响。并观察术后不良反应及并发症。

24例均行23G平坦部三通道玻璃体切割术, 手术由同一医生主刀, 清除积血后行iOCT扫描。采用ivue OCT(美国Optovue 公司), 扫描速度26 000次/s, 轴向分辨率5 μ m, 横向分辨率11.4 μ m, 波长830 nm, 进行3D模式和Crossline 2种扫描模式扫描。iOCT检查均由具有丰富台式OCT操作经验的同一眼科医生进行操作, 检查时OCT镜头粘贴无菌手术贴膜, 患者保持手术体位（仰卧位）, 移动底部车轮对准瞳孔区, 自动调焦对准视网膜平面采集图像, 平衡盐溶液保持角膜湿润。

由同一位技术人员记录iOCT扫描耗时和结果, 并询问和记录术者手术显微镜对黄斑区的观察判断, 比较两者一致性; 记录iOCT结果对手术治疗策略的影响; 观察与检查相关的不良反应及并发症的发生情况。

2 结果

24例病例中糖尿病视网膜病变15例, 视网膜静脉阻塞4例, 视网膜裂孔1例, 息肉状脉络膜血管病变2例, 大动脉瘤1例, 不明原因新生血管1例。

扫描情况：所有病例均成功完成iOCT扫描, 所采集的图像均清晰, 可用于分析。扫描结果显示：10例患者术中黄斑区结构正常; 14例结构异常, 其中黄斑水肿8例, 黄斑前膜2例, 黄斑前膜伴水肿1例, 黄斑萎缩2例, 黄斑板层裂孔1例。平均扫描时间为 2.0（1.0~4.4）min。

iOCT检查结果与术者手术显微镜下观察判断不一致的有6例, 其中5例术者判断为黄斑区正常, 但扫描结果显示黄斑区异常, 2例为黄斑前膜, 3例为黄斑水肿; 另 1例术者判断黄斑区存在水肿, 但iOCT未见异常。

4例因iOCT检查结果而改变了手术治疗方案（即上述与主刀显微镜判断不一致6例中的4例, 均是主刀医生在显微镜下无法分辨, 通过iOCT扫描发现的异常, 增加了手术操作）, 其中2例为黄斑前膜, 1例为黄斑水肿伴前膜, 1例为黄斑板层裂孔。病例1：积血清除后显微镜下未见明显黄斑区异常, 但iOCT扫描显示存在黄斑前膜, 予增加剥膜操作（见图1）。病例2：积血清除后iOCT扫描显示黄斑板层裂孔伴玻璃体牵拉（和显微镜下判断不一致）, 术者增加剥内界膜操作, 再次扫描发现全层裂孔, 改为C3F8填充(见图2)。病例3：糖尿病视网膜病变患者, 积血清除后显微镜下未见明显黄斑区异常, iOCT扫描显示黄斑区轻度水肿伴前膜, 予增加剥膜操作(见图3A-B)。病例4：糖尿病视网膜病变患者, 积血清除后显微镜下未见明显黄斑区异常, iOCT扫描显示黄斑前膜, 予增加剥膜操作(见图4)。4例患者均取得较好的预后疗效。手术后未发生与检查相关的眼内炎等并发症。

图 1. 视网膜分支静脉阻塞继发玻璃体积血患者眼底图像
A：积血清除后, 手术显微镜下黄斑区未见异常; B：iOCT扫描提示黄斑前膜; C：术后末次随访, OCT扫描提示黄斑形态正常Figure 1. Fundus images of a vitreous hemorrhage secondary to branch retinal vein occlusion.
A: The macular appeared normal under the operating microscope after the vitreous hemorrhage was removed. B: The iOCT image showed an epiretinal membrane in the macular region after removal of the vitreous hemorrhage. C: OCT showed that the macular was normal at the last postoperative follow-up. iOCT, intraoperative optical coherence tomography.

图2. 视网膜分支静脉阻塞继发玻璃体积血伴发黄斑裂孔患者OCT图像
A：积血清除后, iOCT扫描提示黄斑板层裂孔; B：剥膜后, 再次iOCT扫描显示黄斑全层裂孔; C：术后末次随访, OCT扫描提示黄斑裂孔愈合Figure 2. Macular hole combined with vitreous hemorrhage secondary to brand retinal vein occlusion.
A: iOCT image showed lamellar macular hole after vitreous hemorrhage removed. B: iOCT image showed macular hole after vitreous hemorrhage removed. C: OCT scan revealed macular hole resolution at last follow-up postoperatively. iOCT, intraoperative optical coherence tomography.

图3. 糖尿病视网膜病变继发玻璃体积血患者眼底图像
A：积血清除后, iOCT扫描提示黄斑水肿伴前膜; B：术后末次随访, OCT扫描提示黄斑水肿吸收Figure 3. Fundus image of a vitreous hemorrhage secondary to diabetic retinopathy.
A: The iOCT image revealed an epiretinal membrane and macular edema after the vitreous hemorrhage was removed. B: The OCT image showed that the macular edema was resolved at the last postoperative follow-up. iOCT, intraoperative optical coherence tomography.

图4. 糖尿病视网膜病变继发玻璃体积血患者眼底图像
A：积血清除后, iOCT扫描提示黄斑前膜; B：术后末次随访, OCT扫描提示黄斑前膜消失Figure 4. Fundus image of a vitreous hemorrhage secondary to diabetic retinopathy.
A: The iOCT image showed an epiretinal membrane after the vitreous hemorrhage was removed. B: The OCT image showed that no epiretinal membrane at the last postoperative follow-up. iOCT, intraoperative optical coherence tomography.

3 讨论

玻璃体切割手术是治疗玻璃体积血的主要手段, 致密出血的患者由于术前OCT成像受限, 部分患者由于存在术中无法察觉的黄斑区病变, 以后仍可能需要再次手术治疗。iOCT可为术者提供术中黄斑区结构及玻璃体视网膜界面等的情况, 明确诊断, 便于术中做出合理的手术决策。iOCT已被用于观察黄斑疾病、孔源性视网膜脱离等的术中黄斑区形态改变并指导手术[7, 8, 9, 16]。Ehlers等[18]报道43%的眼后段手术中术者对黄斑的形态学判断因iOCT介入而改变。Ehlers 等[18]和Smith等[19]2个大样本研究结果显示, 13%~22%的玻璃体视网膜手术因iOCT而选择了更合适的手术方式。

本研究主要针对致密性玻璃体出血的iOCT应用情况进行具体分析。iOCT显示致密玻璃体积血清除后黄斑区异常的发现率为58%(14/24), 分别为8例黄斑水肿、2例黄斑前膜、1例黄斑前膜伴水肿、2例黄斑萎缩、1例黄斑板层裂孔。轻度的黄斑水肿和细微的黄斑前膜改变, 主刀医生很难在手术显微镜下观察到, 而iOCT可细致地观察黄斑区结构, 做出准确诊断。本研究中两者不一致率达25%（6/24）, 其中4例术者根据iOCT结果而选择更合理的手术方案, 如增加剥膜操作, 更改了填充物选择等, 使得治疗方案更合理。

致密玻璃体积血的最常见原因是糖尿病视网膜病变及视网膜静脉阻塞, 常伴有黄斑水肿、黄斑前膜, 部分程度较轻, 在清除积血的手术中, 因术者在手术显微镜下无法辨认而未予处理, 导致需要再次手术治疗, 从而影响视功能预后, 增加患者负担和医疗成本。iOCT可实时清晰提供黄斑区形态, 如存在异常可及时指导术中改变策略, 减少二次手术率及医疗成本。

本研究中iOCT平均扫描时间仅2 min, 比 Ehler等[18]的平均时间（4.4 min）短, 这是因为我们使用的是车载式的iOCT, 相比手持式及显微镜配置式iOCT, 操作更便捷。目前大部分文献报道iOCT均无法实时成像, 需暂停手术进行图像扫描操作, 本组病例无一例发生因术中扫描操作而导致眼内炎等相关并发症, 初步表明iOCT是安全的。随着技术的发展, 第三代iOCT即显微镜集成式已部分投入临床使用, 它将显微镜和OCT系统进行结合, 从而达到实时成像, 但由于与现有商用频域OCT兼容性的问题, 成像质量并不理想, 其临床应用效果还有待进一步验证[20, 21, 22]。

本研究结果表明, iOCT在致密玻璃体积血的玻璃体手术中可给术者提供手术显微镜下无法察觉的黄斑区异常改变, 指导术者选择更合理的手术方式, 且无明显的相关并发症。但本研究尚存在一定的局限性：由于致密性玻璃体积血患者相对较少, 故本研究样本量偏少; iOCT应用的安全性也有待于进一步验证; 本研究是回顾性研究, iOCT对手术方式的影响是否与预后相关需通过长期随访验证。

利益冲突申明 本研究无任何利益冲突

作者贡献声明 陶继伟：课题设计, 收集数据, 资料分析及解释, 撰写论文, 对编辑部的修改意见进行修改。褚梦琪、王奇骅、 赵士鑫、林晶晶：参与收集数据。陈亦棋：参与课题设计, 修改论文并参与编辑部修改意见的修改。沈丽君：指导课题设计, 修改论文, 进行关键性数据和结果的创作

The authors have declared that no competing interests exist.

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