A Clinical Research Of Intravitreal Ranibizumab Combined With Posterior Scleral Reinforcement For The Treatment Of Choroidal Neovascularization Secondary To Pathological Myopia

Pathological myopia is one main cause of the permanent blindness which generally refers to the refractive diopter higher than-6.00 D,the axial length greater than 26.5mm accompany with fundus lesions.The axial length of the eyeball is the basis of its pathological anatomy,which resulting in a series of complications such as posterior staphyloma,chorioretinal atrophy,choroidal neovascularization(CNV),retinal detachment and vitreous opacity and so on,leading permanent irreversible damage to vision.CNV is one of the most dangerous complications of pathological myopia which suggesting poor visual outcome,especially for subfoveal choroidal neovascularization which easily lead to macular hemorrhage,the risk of visual loss is very high if without timely treatment.Posterior scleral reinforcement surgery can not only treat pathological myopia,but also control axial extension,prevent the progression of fundus lesions,the effect is clear and reliable.The surgical effect has been accepted by most scholars nowadays,improved and simplified according to different needs,but to patients with CNV the effect is not good.Lucentis is a new anti angiogenesis drug that have good benifits to neovascular diseases and wet macular degeneration.However,CNV secondary to pathological myopic is different from idiopathic CNV or pathological myopia itself,single PSR or intravitreal anti angiogenesis drugs have the deficiency that can’t control vision decreased further and thr CNV recurrence rate is high.PSR combined with intravitreal ranibizumab can treat pathological myopia under the control of CNV,and reduce the hemorrhage caused by stimulation CNV.Presently this combined approach is rarely reported,therefore,this research through the comparison and analysis of visual acuity,diopter,axial length and intravitreal ranibizumab times of preoperative and postoperative to evaluate the effect of ranibizumab combined with posterior scleral reinforcement for choroidal neovascularization secondary to pathological myopia.ObjectiveThis research through the comparison and analysis of visual acuity,diopter,axial length and intravitreal ranibizumab times of preoperative and postoperative to evaluate the effect of ranibizumab combined with posterior scleral reinforcement for choroidal neovascularization secondary to pathological myopia.MethodsChoose 40 eyes(40 cases)diagnosed mCNV in our hospital from December 2013 to February 2015,of which 20 eyes underwent intravitreal ranibizumab combined with PSR,denoted as PL group,8 male and 12 female,aged 18-62 years old(39.350±10.302);the other 20 eyes simply intravitreal ranibizumab,labeled as l group,9 male and 11 female,aged 19-59 years old(40.500±10.822),the difference was’ t statistically significant(t=-0.344,P=0.733﹥0.05),and also sex(χ2=0.102,P=0.749﹥0.05).The preoperative uncorrected visual acuity(UCVA),best corrected visual acuity(BCVA),axial length(AL),diopter(D)of PL group are(1.510±0.310)LogMAR,(0.710±0.261)LogMAR,(30.537±2.269)mm,(-15.780±5.038)D,while the L group are(1.550±0.248)LogMAR,(0.760±0.209)LogMAR,(29.792±1.600)mm,(-14.200±2890)D,the difference of the same observation index between the two groups was’ t statistically significant(t=-0.451,P=0.654﹥0.05、Z=-0.835,P=0.429、t=1.200,P=0.238﹥0.05、Z=-1.098,P=0.277).Group PL underwent PSR 5-7 days later after intravitreal ranibizumab 0.05ml(0.5mg),group L only intravitreal ranibizumab(0.05 ml 0.5mg).The follow up period was treated on demand which for 2 years.The visual have been converted to LogMAR standard.Statistical analysisSPSS 21.0 statistical software was used for data statistics analysis and take alpha 0.05 as inspection level,with P < 0.05 difference was statistically significant.The inner comparation of the UCVA,BCVA,Al and D values of the two groups preoperative and postoperative use paired sample t test or rank test — Wilcoxon test.The comparation of the age,UCVA,BCVA,Al and D values preoperative and the change of the UCVA,BCVA,Al,D values between the two groups and the injection times of intravitreal ranibizumab independent sample t test or rank test — Mann-Whitney U test.As to other nonspecific complications such as postoperative high intraocular pressure,corneal epithelial injury and anterior chamber flare,descriptive analysis was used.The comparation of sex use Chi-Square test and macular hemorrhage occurrence postoperative of the two groups use Fisher’s exact test.Results 1 The innergroup compare of preoperative UCVA,BCVA,AL and D with 2 years postoperativeThe UCVA,BCVA and AL of 2 years postoperative of PL group were(1.165±0.237)LogMAR,(0.303±0.180)LogMAR,(30.639±2.210)mm,the differences were statistically significant compared with preoperated(t=6.830,P﹤0.05、Z=-3.729,P﹤0.05、t=-2.855,P﹤0.05).The D values of 2 years postoperative of PL group is(-15.913±4.596)D,the difference was’ t statistically significant compared with preoperative(t=0.616,P=0.545﹥0.05).The UCVA,BCVA AL and D values of 2 years postoperative of L group were(1.235±0.280)LogMAR,(0.458±0.300)LogMAR,(30.749±1.539)mm,(-16.100±2.799)D,the differences were statistically significant compared with preoperated(Z=-3.566,P﹤0.05、Z=-3.470,P﹤0.05、t=-5.560,P﹤0.05、t=5.763,P﹤0.05)。 2 The change of UCVA,BCVA,AL and D of postoperative.The UCVA improved of group PL and group L were(0.345±0.226)LogMAR,(0.315±0.220)LogMAR,the difference was not statistically significant(t=0.425,P=0.673﹥0.05);the BCVA improved were(0.408±0.248)LogMAR,(0.303±0.266)LogMAR,the difference was not statistically significant(t=1.290,P=0.205﹥0.05),but the p=0.205 to 0.05,although the two groups in BCVA improved was not statistically significant,but the combined surgery group had the better tendency of improve the BCVA of mCNV;the AL growth were(0.102±0.159)mm,(0.957±0.769)mm,and the deepening of D were(-0.138±0.998)D,(-1.950±1.495)D,the difference were statistically significant(Z=-3.815,P﹤0.05、Z=-3.667,P﹤0.05).3 Injection times of intravitreal ranibizumabDuring the follow-up period of 2 years,the injections times of PLgroup was 32,with an average of(1.600±0.598)times;while the Lgroup was 44,with an average of(2.200±0.951)times,the difference was statistically significant(Z=-2.096,P=0.036﹤0.05),which showed that the combined surgey can decrease the injection times of intravitreal ranibizumab.4 Other complicationsThere were one case of corneal epithelial edema and corneal epithelial injury,five cases high intraocular pressure,three cases nonspecific inflammatory reaction in the PLgroup within the next one weeks,the incidence was 35%.One case of macular hemorrhage occurred within 2 years,the incidence was 5%.There were 2 cases of anterior chamber flash in the Lgroup,and the incidence rate was 10%.There were two cases macular hemorrhage in the 2 years,with an incidence of 10%.The macular hemorrhage occurrence was not statistically significant between the two groups(P=1.000 ﹥ 0.05).There was no lens injury,retinal detachment and other complications in the two groups.Conclusion1 For the treatment of choroidal neovascularization secondary to pathological myopia,ranibizumab combined with posterior scleral reinforcement can decrease the injections times of ranibizumab.2 Ranibizumab combined with posterior scleral reinforcement is a safe and effective operation for choroidal neovascularization secondary to pathological myopia that can decrease the progression of pathological myopia and without obvious complications.