CLINICAL AND STRUCTURAL IMPACT OF SUBMACULAR FLUID AFTER PNEUMATIC RETINOPEXY REPAIR FOR RHEGMATOGENOUS RETINAL DETACHMENT
(Retina 43(1):p 72-80, January 2023. ）
Purpose
To assess the impact of submacular fluid (SMF) after pneumatic retinopexy for primary rhegmatogenous retinal detachment repair.
探讨气压式视网膜固定术后黄斑下积液(SMF)对孔源性视网膜脱离修复的影响。
Methods
Retrospective review of consecutive patients treated with pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. 387 eyes (374 patients) were included, of which 166 underwent optical coherence tomography imaging after successful pneumatic retinopexy. Foveal-centered optical coherence tomography scans were reviewed.
回顾性分析了连续采用气压式视网膜固定术治疗原发性孔源性视网膜脱离的患者。共纳入387只眼(374例)，其中166例在成功的气压式视网膜固定术后进行了光学相干断层成像。对中央凹中心光学相干断层扫描进行了综述。
Results
SMF occurred in 59 eyes (35.5%) and was associated with macular detachment (P ≤ 0.001) and phakic lens status (P = 0.007). Submacular fluid resolved over an average of 9.39 months and was associated with worse preprocedure best-corrected visual acuity and delayed visual recovery. The mean final best-corrected visual acuity was 0.277 logarithm of the minimum angle of resolution (20/40) in eyes with SMF and 0.162 logarithm of the minimum angle of resolution (20/30) in those without SMF (P < 0.001). Submacular fluid was associated with discontinuity of the interdigitation zone (P = 0.003), ellipsoid zone (P = 0.005), and external limiting membrane (P ≤ 0.001) after SMF resolution. Ellipsoid zone discontinuity was associated with worse visual prognosis (P = 0.009).
59只眼(35.5%)发生SMF，与黄斑脱离(P≤0.001)和有晶状体状态(P = 0.007)相关。黄斑下积液的消退时间平均为9.39个月，与术前最佳矫正视力较差和视力恢复延迟有关。有SMF组的最终最佳矫正视力均值为最小分辨率角的0.277对数(20/40)，无SMF组的最小分辨率角的0.162对数(20/30)(P<0.001)。在SMF解决后，黄斑下积液与指状交错区(P =0.003)、椭球区(P =0.005)和外限制膜(P≤0.001)不连续有关。椭球带不连续与视力预后较差相关(P=0.009)。
Conclusion
Trace SMF detected by optical coherence tomography is common after successful pneumatic retinopexy and resulted in delayed visual recovery and increased rates of outer retinal discontinuity after SMF resorption, although the final difference in best-corrected visual acuity in those with and without SMF was minimal.
尽管有和没有SMF的患者最终最佳矫正视力的差异很小，但在成功的气压式视网膜固定术后，光学相干断层扫描检测到微量的SMF是常见的，并会导致延迟视力恢复和SMF吸收后视网膜外不连续率的增加。
该研究结果表明浅泡状或条状的SMF在PR术后很常见，并与有晶状体眼晶状体状态和晶状体连续性的增加显著相关，SMF的存在导致PR术后视力恢复延迟，但SMF吸收后的最终视力良好。考虑到SMF导致的最终视力差异极小，外科干预可能收效甚微。在大多数情况下，可以安全地观察到残留的黄斑SMF，除非担心复发性脱离。
该研究的创新之处在于使用Microsoft Excel和R Project for Statistical Computing (R Foundation for Statistical Computing)软件进行统计分析。对特征和结果之间的关联进行单变量检验，分类变量采用Fisher精确检验和卡方检验，连续变量采用不等方差t检验和Wilcoxon秩检验。采用logistic回归进行术前和术中特征与单次手术失败的多因素分析。
该研究的局限性在于是回顾性设计，导致在各种平台上获得OCT图像，而不是在预定的时间间隔获得。并且浅层SMF与特殊的解剖因素，如玻璃体后脱离、外层视网膜不连续和脉络膜微血管的关系需要前瞻性研究。
Deep Capillary Plexus Features in Acute Macular Neuroretinopathy: Novel Insights Based on the Anatomy of Henle Fiber Layer
(Investigative Ophthalmology & Visual Science December 2022, Vol.63, 4.）
Purpose
The purpose of this study was to identify a precise location of deep capillary plexus (DCP) injury in acute macular neuroretinopathy (AMN) lesions using multimodal imaging.
本研究的目的是使用多模态成像确定急性黄斑神经视网膜病变（AMN）中深毛细血管丛（DCP）损伤的精确位置。
Methods
En face structural optical coherence tomography (OCT) images were manually segmented to delineate outer retinal AMN lesions involving the ellipsoid zone and interdigitation zone. AMN lesion centroid was calculated, and image distortion was applied to correct for Henle fiber layer (HFL) length and orientation. The resulting image was registered with the corresponding en face OCT angiography (OCTA) image segmented at the DCP and structural OCT volume before grading for vascular and structural features, respectively.
手动分割人脸结构光学相干断层扫描（OCT）图像，描绘涉及椭球区和指间区的视网膜外AMN病变。计算AMN病变质心，并应用图像失真来校正Henle纤维层（HFL）的长度和方向。所得图像与相应的面部OCT血管造影（OCTA）图像一起记录，分别在DCP和结构OCT体积上分割，然后分别对血管和结构特征进行分级。
Results
Thirty-nine AMN lesions from 16 eyes (11 female patients, mean age 34 ± 4 years) were analyzed. After correcting for HFL anatomy, in 62% of AMN lesions, the centroid co-localized with a capillary vortex (pattern 1); flow defects were detected in 33% of lesions (pattern 2); and in 5% of lesions no specific pattern could be identified (pattern 3). The detection of a specific pattern increased after correcting the projection of AMN lesion for HFL anatomy (28% vs. 5%, P = 0.04). Outer nuclear layer thickness was lower in the centroid area in 10 (29%) AMN lesions from 6 patients, all corresponding to lesions fitting pattern 2 (r = 0.78, P < 0.001).
分析16只眼（11例女性患者，平均年龄34岁±4岁）的39例AMN病变。在纠正 HFL 解剖结构后，在 62% 的 AMN 病变中，质心与毛细血管涡旋共定位（模式1）;在 33% 的病变中检测到血流缺陷（模式 2）;在5%的病变中，无法确定特定的模式（模式3）。在纠正HFL解剖学的 AMN 病变投影后，特定模式的检测增加（28% vs 5%，P=0.04）。6例患者的10例（29%）AMN病变的质心区外核层厚度较低，均与病变拟合模式2（r=0.78，P<0.001）相对应。
Conclusion
AMN lesions might be a result of DCP impairment at the level of the capillary vortex or draining venule. In eyes with AMN, the location of outer retinal changes associated with DCP ischemia appears to be influenced by the length and orientation of HFL.
AMN病变可能是在毛细血管涡旋或引流小静脉水平的DCP损伤的结果。在AMN患者中，与DCP缺血相关的视网膜外变化的位置似乎受到HFL的长度和方向的影响。
该研究结果表明，在大约60%的病例中，小于一个椎间盘直径的AMN病变与毛细血管涡旋共定位（模式1）。这一观察结果可能对涉及DCP的疾病机制产生影响。DCP的解剖学特征最近已使用共聚焦显微镜进行了解决。作者表明，DCP毛细管的平均直径为6.9μm，层状排列，许多环会聚并形成中央引流小静脉，具有涡状外观。毛细血管丛中的血液流变学很复杂，由血浆之间的相互作用、网络的几何形状、血细胞的动力学和血管壁决定。实验研究表明，当血浆粘度增加时，流速、血细胞比容和氧气提取都会降低。
该研究的创新之处在于对于每个符合条件的患者，审查了完整的医疗记录。数据收集包括患者年龄、性别、伴随的全身和眼部疾病、药物和使用 Snellen 图表的基线 Snellen 视力（VA）。将Snellen VA转换为最小分辨率角（logMAR）的对数以进行统计分析。所有患者均接受了完整的眼科检查，包括裂隙灯生物显微镜检查、检眼镜检查和多模态视网膜成像。
该研究的局限性包括样本量小和缺乏统一的随访时间。影像学检查显示，AMN 患者在症状发作后的最初几周内视网膜外侧病变横向延伸，可能代表小的邻近病变融合成较大的病变。我们系列研究中某些病例的早期影像学检查可能会影响病变的数量和大小。此外，目前的研究排除了七个大于一个椎间盘直径的AMN病变，因此该研究结果对较大的AMN病变的普遍性尚不清楚。
Diabetic Macular Edema and Diode Subthreshold Micropulse Laser: A Randomized Double-Masked Noninferiority Clinical Trial
(Volume 130, Issue 1, January 2023, Pages 14-27.）
Purpose
To determine clinical effectiveness, safety, and cost-effectiveness of subthreshold micropulse laser (SML), compared with standard laser (SL), for diabetic macular edema (DME) with central retinal thickness (CRT) < 400 μm.
探讨阈下微脉冲激光(SML)与标准激光(SL)治疗视网膜中央厚度(CRT) < 400 μm的糖尿病性黄斑水肿(DME)的临床疗效、安全性和成本效益。
Design
Pragmatic, multicenter, allocation-concealed, double-masked, randomized, noninferiority trial.
实用、多中心、分配隐藏、双盲、随机，非劣效性试验。
Participants
Adults with center-involved DME < 400 μm and best-corrected visual acuity (BCVA) of > 24 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in one/both eyes.
中心DME < 400 μm且>最佳矫正视力(BCVA) 24单眼/双眼糖尿病视网膜病变早期治疗研究(ETDRS)评分的成人。
Methods
Randomization 1:1 to 577 nm SML or SL treatment. Retreatments were allowed. Rescue with intravitreal anti–vascular endothelial growth factor therapies or steroids was permitted if 10 or more ETDRS letter loss occurred, CRT increased > 400 μm, or both.
随机1:1到577 nm SML或SL处理。再治疗是允许的。如果ETDRS字母丢失10个或以上，CRT增加> 400 μm，或两者同时发生，则允许采用玻璃体内抗血管内皮生长因子治疗或类固醇治疗。
Main Outcome Measures
Primary outcome was mean change in BCVA in the study eye at 24 months (noninferiority margin 5 ETDRS letters). Secondary outcomes were mean change from baseline to month 24 in binocular BCVA; CRT and mean deviation of Humphrey 10-2 visual field in the study eye; percentage meeting driving standards; EuroQoL EQ-5D-5L, 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), and Vision and Quality of Life Index (VisQoL) scores; cost per quality-adjusted life-years (QALYs) gained; adverse effects; and number of laser and rescue treatments.
主要终点为研究眼24个月时BCVA的平均变化(非劣效性缘5个ETDRS字母)。次要结局为双眼BCVA患者基线至24个月的平均变化;研究眼的CRT和Humphrey 10-2视野平均偏差符合驾驶标准的比例;EuroQoL EQ-5D-5L、25项国家眼科研究所视功能问卷(NEI-VFQ-25)、视力和生活质量指数(VisQoL)评分;获得的每质量调整寿命年成本;不利影响;激光和抢救治疗的数量。
Results
The study recruited fully (n = 266); 87% of SML-treated and 86% of SL-treated patients had primary outcome data. Mean ± standard deviation BCVA change from baseline to month 24 was –2.43 ± 8.20 letters and –0.45 ± 6.72 letters in the SML and SL groups, respectively. Subthreshold micropulse laser therapy was deemed not only noninferior but also equivalent to SL therapy because the 95% confidence interval (CI; –3.9 to –0.04 letters) lay wholly within both upper and lower margins of the permitted maximum difference (5 ETDRS letters). No statistically significant difference was found in binocular BCVA (0.32 ETDRS letters; 95% CI, –0.99 to 1.64 ETDRS letters; P = 0.63); CRT (–0.64 μm; 95% CI, –14.25 to 12.98 μm; P = 0.93); mean deviation of the visual field (0.39 decibels (dB); 95% CI, –0.23 to 1.02 dB; P = 0.21); meeting driving standards (percentage point difference, 1.6%; 95% CI, –25.3% to 28.5%; P = 0.91); adverse effects (risk ratio, 0.28; 95% CI, 0.06–1.34; P = 0.11); rescue treatments (percentage point difference, –2.8%; 95% CI, –13.1% to 7.5%; P = 0.59); or EQ-5D, NEI-VFQ-25, or VisQoL scores. Number of laser treatments was higher in the SML group (0.48; 95% CI, 0.18–0.79; P = 0.002). Base-case analysis indicated no differences in costs or QALYs.
该研究招募了全部人员(n = 266);87%的sml治疗患者和86%的sl治疗患者有初步结果数据。从基线到第24个月，SML组和SL组BCVA变化的均值±标准差分别为-2.43±8.20个字母和-0.45±6.72个字母。阈下微脉冲激光治疗被认为不仅不差，而且与SL治疗相当，因为95%置信区间(CI;-3.9至-0.04个字母)完全位于允许的最大差值(5个ETDRS字母)的上下边界内。双眼BCVA差异无统计学意义(0.32个ETDRS字母;95% CI， -0.99 ~ 1.64 ETDRS字母;P = 0.63);CRT (-0.64 μm;95% CI， -14.25 ~ 12.98 μm;P = 0.93);视野平均偏差(0.39分贝(dB));95% CI， -0.23 ~ 1.02 dB;P = 0.21);符合驾驶标准(百分点差，1.6%;95% CI， -25.3% ~ 28.5%;P = 0.91);不良反应(危险比，0.28;95% ci, 0.06-1.34;P = 0.11);抢救治疗(百分比差，-2.8%;95% CI， -13.1% ~ 7.5%;P = 0.59);或EQ-5D、NEI-VFQ-25、VisQoL评分。SML组激光治疗次数较多(0.48;95% ci, 0.18-0.79;P = 0.002)。基本案例分析表明成本或质量aly没有差异。
Conclusions
Subthreshold micropulse laser therapy was equivalent to SL therapy, requiring slightly higher laser treatments.
阈下微脉冲激光治疗与SL治疗相当，需要较高的激光治疗。
该研究的主要结局是治疗组之间在研究眼中BCVA平均变化的差异，在第24个月。次要结局包括双眼BCVA、CRT从基线到第24个月的平均变化，以及研究眼中Humphrey10-2视野的平均偏差;达到驾驶标准的人数百分比;EuroQoL （EQ-5D-5L）、25 项国家眼科研究所视觉功能问卷（NEI-VFQ-25）以及视力和生活质量指数评分、每质量调整生命年获得的成本、不良反应、进行的激光治疗次数和抢救治疗。在每次就诊时通过注意激光手术期间或之后的任何并发症来评估治疗的安全性，包括自我报告的视力障碍，以及从就诊到就诊时发生的10个字母或以上和15个字母或更多评分的ETDRS视力丧失。
该研究的创新之处在于患者被具体询问关于色觉下降、是否存在副中央暗点。此外，在方案中还列出了以下激光治疗的潜在预期不良事件，并在试验期间对中央凹烧伤、视网膜前膜形成和脉络膜新生血管形成做了专门评估。
该研究的局限性在于在DIAMONDS试验中，没有观察到从基线到第24个月或激光组之间在健康相关或视力相关生活质量测量方面有统计学意义或临床上重要的差异。这表明在DIAMONDS试验中观察到的视力差异与受试者没有临床相关性。DIAMONDS试验并非旨在比较SL或SML疗法与抗VEGF疗法对CRT<400μm的DME患者。因此，关于黄斑激光治疗（SL或SML）与抗VEGF治疗对该患者群体的临床有效性和成本效益的结论无法得出，需要进一步研究。
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