部分患者被醫(yī)囑需要做光凝術(shù)加固,常見(jiàn)有這么幾種情況：

①無(wú)裂孔，有閃光

②裂孔，無(wú)閃光察覺(jué)

③萎縮區(qū)，萎縮孔，體檢時(shí)發(fā)現(xiàn)

文本的目的是：

解釋②③會(huì)在報(bào)告單上一律被寫(xiě)成“裂孔”的原因，

以及①②③都會(huì)被醫(yī)生建議激光光凝術(shù)是否應(yīng)該聽(tīng)從。

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一些醫(yī)學(xué)術(shù)語(yǔ)概念

英文術(shù)語(yǔ)	精準(zhǔn)中文含義	對(duì)應(yīng)的國(guó)內(nèi)醫(yī)院 慣用術(shù)語(yǔ)
operculated retinal hole【24】	牽引孔	裂孔
atrophic hole	萎縮孔	裂孔
retinal degeneration	視網(wǎng)膜退化	視網(wǎng)膜變性
retina denaturation	視網(wǎng)膜變性	視網(wǎng)膜變性

兩種孔的區(qū)別可以參見(jiàn)【24】

根據(jù)【28】

• Atrophic retinal holes are caused by a localized degeneration of a small spot in the retina. The underlying cause for this atrophy is usually unknown but is generally associated with aging.

• Operculated retinal holes are caused by traction on the retina by the vitreous humor (the gel-like fluid inside the eye) as it liquifies with age. This type of retinal hole is often associated with posterior vitreous detachment. Trauma to the head or eye also may cause an operculated retinal hole.

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激光光凝術(shù)術(shù)原理

那么上面第二個(gè)圖就是激光光凝術(shù)加固后的效果， 也就是說(shuō)，雖然自己感覺(jué)不到，但是其實(shí)會(huì)造成視野缺失，也就是看東西的范圍變窄了。如果運(yùn)氣再差一點(diǎn)，那么手術(shù)后的效果會(huì)是這樣的，會(huì)留下終生的黑塊和黑線，一輩子都無(wú)法恢復(fù)。

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可否避免激光光凝術(shù)？

對(duì)于①中的患者而言，根據(jù)【1】

In vitrectomy surgery, the vitreous gel (vitreous body) is removed to prevent it from pulling on the retina and replaced with a bubble containing a mixture of air and gas. The bubble acts as an internal, temporary bandage that holds the edge of the macular hole in place as it heals. Vitrectomy surgery is performed under local anesthesia and often on an out-patient basis.

如果覺(jué)得不能接受視野損失，可以采取局部波切的方式來(lái)解決拉扯的問(wèn)題。

需要找醫(yī)生問(wèn)清楚，闡明自己不能接受視野缺失，能接受白內(nèi)障提前【1】

還有種辦法就是只要沒(méi)有裂孔就繼續(xù)觀察，代價(jià)是閃光一定風(fēng)險(xiǎn)拉扯出裂孔。

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激光光凝術(shù)打死視網(wǎng)膜的哪些結(jié)構(gòu)？

激光光凝是必定會(huì)出現(xiàn)視野損失，視網(wǎng)膜結(jié)構(gòu)如下：

視網(wǎng)膜激光光凝術(shù)是不是把10層都打死呢？我們來(lái)看下面的依據(jù)：
In 1992 Reginald Birngruber and colleagues introduced application of even shorter microsecond continuous-wave laser pulses. These microsecond laser pulses also selectively target the retinal pigment epithelium (RPE) sparing the photoreceptors and other intraretinal cells.25,26 Such short-pulse continuous wave laser cause explosive vaporization of melanosomes and formation of cavitation bubbles resulting in cell death and subsequent proliferation and migration of RPE cells to restore the integrity of the defective RPE layer.25 The clinical term adopted for this approach has been “Selective Retina Therapy” or SRT.26【2】

92年提出的激光光凝術(shù)是靶向RPE，不損壞光感受器

It was discovered recently that continuity of the photoreceptor layer in rabbit and rodent retina can be restored after selective photocoagulation (Busch et al., 1999; Paulus et al., 2008; Belokopytov et al., 2010). Unlike more intense conventional burns, selective photocoagulation destroys only photoreceptors and retinal pigment epithelium (RPE), leaving cells in the inner retinal layers intact. After a few days, RPE coverage is restored and, after a few weeks, the photoreceptor layer regains its continuity (Paulus et al., 2008). The most likely origin of the photoreceptors filling the lesion is a shift of healthy photoreceptors from the adjacent untreated areas (Zwick et al., 2008). Although these results indicate that migrating photoreceptors can fill in the lesion, little is known about the extent of the functional restoration.

選擇性光凝只破壞光感受器和視網(wǎng)膜色素上皮（RPE），使視網(wǎng)膜內(nèi)層細(xì)胞完好無(wú)損。幾天后，RPE覆蓋恢復(fù)，幾周后，感光層恢復(fù)其連續(xù)性【3】

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RRD（rhegmatogenous retinal detachment）孔源性視網(wǎng)膜脫離

Atropic retinal holes. The underlying cause of these defects is a poorly functioning choriocapillaris that no longer gives adequate circulation to the retinal layers above the hole.

Fewer than 1% of cases of lattice degeneration with holes progress to RRD。

The operculated retinal hole results from increased focal vitreoretinal traction?！?4】

One year and later after treatment, CRL lesions were characterized by RPE atrophy combined with significant damage of the neurosensory tissue. SRT lesions aged one year and older revealed unaffected neurosensory structures and an intact RPE layer.【4】

SRT用于DME（diabetic macular edema）【6】

Theodore Maiman, PhD, designed the first ophthalmic laser in 1960 at the Hughes Research Laboratories emitting monochromatic energy. Systems using ruby laser (694-nm wavelength) were among the first to be studied in ophthalmology.3,4 They offered some variability in pulse durations and more precisely targeted treatments. They could be successfully applied therapeutically but intense chorioretinal destruction and frequent hemorrhaging soon showed to be an issue. The advent of argon laser marked a new milestone in retinal photocoagulation.5,6

（破壞脈絡(luò)膜意味著視網(wǎng)膜里面的10層都被破壞了）【2】

No conclusions could be reached about the effectiveness of surgical interventions to prevent retinal detachment in eyes with asymptomatic retinal breaks or lattice degeneration, or both. Current recommendations for treatment, based upon a consensus of expert opinion, should be assessed in a randomized controlled trial.【16】

An operculated hole occurs when vitreous traction amputates the flap of the tear from the retinal surface and the separated flap becomes suspended within the posterior hyaloid above the retinal surface?！?2】

Retinal hole surgery
In most cases, no treatment for retinal holes is required. Your eye doctor will usually just note the finding of a retinal hole and monitor it with routine comprehensive eye exams.

However, in some cases — for example, if vitreous fluid is seeping under the border of a retinal hole, which could increase the risk of a retinal detachment — retinal hole surgery may be performed.【23】(在一些邊緣下面已經(jīng)流入液體的情況下，必須進(jìn)行光凝手術(shù))

Subclinical RD was seen in 10 (6.7%) of 150 eyes with atrophic?holes, involving 9 (7.5%) of 120 patients, and had a much less serious prognosis than clinical?detachment.【25】

（萎縮孔出現(xiàn)脫離的只有6.7%）

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黃斑水腫時(shí)為何需要激光治療？

上面這個(gè)圖的邏輯相當(dāng)于腳底起了一個(gè)水泡，用針刺破。

視網(wǎng)膜10層結(jié)構(gòu)如下：

其中感光層視錐細(xì)胞和視桿細(xì)胞

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結(jié)論：

對(duì)于醫(yī)生診斷報(bào)告中的“孔”，

首先分清楚自己是那種孔，裂孔還是萎縮孔（必須免散瞳相機(jī)拍照，留下報(bào)告案底），萎縮孔不做光凝加固的話，網(wǎng)脫概率是6.7%，光凝手術(shù)做還是不做可以自己決定。

牽引孔的話激光的必要性比較大。

另外注意，激光光凝+玻璃體后脫離本身會(huì)造成拉扯，理由見(jiàn)【26】

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所以總共有3種情況：

①如果是萎縮孔+伴有拉扯（俗稱“vr牽引”）

那么拉扯處的視角應(yīng)該放棄使用，此時(shí)可以不做激光光凝（光凝會(huì)打死視網(wǎng)膜全部10層，終生不可逆）

②如果拉扯處的視角在平時(shí)的用眼習(xí)慣中不能自我糾正，那么此時(shí)需要做激光光凝（否則會(huì)扯下來(lái)）

③如果是單純的萎縮孔，可以不做光凝手術(shù)

所以國(guó)內(nèi)的孔（包括萎縮孔、裂孔）要不要做激光和孔的類型以及患者用眼習(xí)慣都有關(guān)。

激光光凝后，出現(xiàn)閃光和視野缺失，如果實(shí)在不能忍受，可以考慮嘗試偏光鏡來(lái)弱化影響。

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激光光明導(dǎo)致的視野缺失，如果激光位置是在上方，那么會(huì)在視野下方出現(xiàn)視野損失，往下看會(huì)有明顯的閃光（說(shuō)明導(dǎo)致拉扯）

因?yàn)榫铙w是凸透鏡，有反圖像的效果

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視網(wǎng)膜色素上皮脫離就是視網(wǎng)膜脫落（漿液性）脫離【27】

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另外需要注意：

皮質(zhì)假性裂孔和孔源性視網(wǎng)膜脫離 區(qū)分開(kāi)來(lái)【29】

Reference：

【1】Vitrectomy Surgery

【2】Modern retinal laser therapy?

【3】Restoration of Retinal Structure and Function after Selective Photocoagulation

【4】Structural changes of the retina after conventional laser photocoagulation and selective retina treatment (SRT) in spectral domain OCT - PubMed

【5】選擇性視網(wǎng)膜光凝療法研究進(jìn)展--《中國(guó)激光醫(yī)學(xué)雜志》2016年05期

【6】Safety and efficacy of selective retina therapy (SRT) for the treatment of diabetic macular edema in Korean patients | SpringerLink

【7】免除視網(wǎng)膜損傷的選擇性視網(wǎng)膜色素上皮光凝 - 百度學(xué)術(shù)

【8】Selective retina therapy (SRT) in patients with geographic atrophy due to age-related macular degeneration - PubMed

【9】Selective Retinal Pigment Epithelium Laser Therapy for Macular Disease of the Retina

【10】Laser Photocoagulation

【11】Selective retina therapy and thermal stimulation of the retina: different regenerative properties - implications for AMD therapy - PubMed

【12】How Do I Lower My Intraocular Pressure - Missouri Eye Institute

【13】Laser Photocoagulation: All you Need to Know | Norlase

【14】Retinal hole And Its Treatment Options

【15】Selective retina therapy (SRT) in patients with geographic atrophy due to age-related macular degeneration - PubMed

【16】Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment

【18】Selective Retina Therapy | SpringerLink

【19】TREATMENT OF VITREOMACULAR TRACTION WITH INTRAVITREAL PERFLUOROPROPANE (C3F8) INJECTION - PubMed【20】Structural changes of the retina after conventional laser photocoagulation and selective retina treatment (SRT) in spectral domain OCT - PubMed

【22】What is an Operculated retinal hole? – Easierwithpractice.com

【23】Retinal holes - All About Vision

【24】?Managing Retinal Breaks

【25】Lattice Degeneration & Retinal Detachment Risk - Preventative Treatment? - Endmyopia?

【26】激光光凝后容易出現(xiàn)頻繁閃光的原因_微電子學(xué)與固體電子學(xué)-CSDN博客?

【27】視網(wǎng)膜色素上皮脫落_周琳琳醫(yī)生的語(yǔ)音科普_妙手醫(yī)生?

【28】Retinal hole: Is it serious?

【29】玻璃體后皮質(zhì)假性裂孔誤診為孔源性視網(wǎng)膜脫離一例

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