Clinical Study Of Ranibizumab Assisted Vitrectomy Combined With Ahmed Valve Implantation In The Treatment Of Neovascular Glaucoma With Vitreous Hemorrhage

Background and PurposeNeovascular glaucoma(NVG)causes complex,diverse,is a refractory,secondary glaucoma,the blinding rate is high,especially with vitreous hemorrhage(VH),often make ophthalmologists treatment is very difficult.Common causes of NVG include retinal central venous obstruction(CRVO),proliferative diabetic retinopathy(PDR)and ischemic syndrome.The NVG pathology is due to the growth of neovascularization(NV)caused by retinal ischemic disease.These NVs are scattered on the surface of the iris and trabecular meshwork,which will lead to external iris anterior adhesions,trabecular meshwork obstruction,and angle closure.Resulting in increased intraocular pressure,but high intraocular pressure and eye ischemia,hypoxia,will further damage the optic nerve and retina function,vicious cycle,and further lead to serious damage to patients with visual function.In the pathogenesis of NVG,vascular endothelial growth factor(VEGF)is the most critical cytokine that triggers the formation of neovascularization.VEGF as a vascular endothelial cell-specific mitogen,can bind to its receptor,induced vascular endothelial cell proliferation,promote neovascularization,enhance microvascular permeability and so on.In the past for the treatment of NV with NVG,whether it is simple anti-glaucoma drugs or anti-glaucoma surgery is not ideal,often need to use eye drops,the elimination of new blood vessels,the treatment of primary disease,anti-glaucoma surgery and other comprehensive treatment.Olmos and Lee(2008)[1] And other studies on the treatment of NVG,for different clinical manifestations,should choose a different treatment programs,see table below.At the same time,regardless of which treatment options,have emphasized the fundus laser and anti-VEGF in the treatment of NVG process has important value.Studies have shown that intravitreal injection of anti-VEGF drugs adjuvant treatment of NVG,can effectively inhibit the formation of NV,to promote NV regression or atrophy.In VEGF antibody inhibitors,Ranibizumab has the effect of inhibiting the binding of VEGF to its receptor,thereby inhibiting the growth of neovascularization.When the neovascularization regression or atrophy after 23 G vitrectomy(intraoperative retinal photocoagulation)combined with Ahmed drainage valve implantation treatment of NVG,improve the success rate of surgery.The aim of this study was to investigate the clinical efficacy and safety of intravitreal injection of Ranibizumab in 23 G vitrectomy(intraoperative retinal photocoagulation)combined with Ahmed valve implantation in the treatment of stage III NVG with VH in order to explore a system,A comprehensive treatment with VH phase III NVG method.1 Materials and Methods1.1 clinical informationCollected from our hospital in July 2014 to August 2015,the eye two eye fundus group with complete follow-up data of vitreous cavity injection Ranibizumab assisted 23 G vitrectomy(intraoperative retinal photocoagulation)combined with Ahmed valve implantation with glass A total of 25 patients(25 eyes)with stage Ⅲ neovascular glaucoma.Among them,15 were male(60.0% in 15 eyes)and 10 in female(40.0% in 10 eyes),aged between 40 and 75 years,mean age(58.3 ± 4.7)years.The best corrected visual acuity was 0.05 ~ 0.05,and the intraocular pressure was still between 30 ~ 69 mm Hg(1mm Hg = 0.133 k Pa)after the most severe anti-glaucoma treatment.The average intraocular pressure was(46.02 ± 5.9)mm Hg.Twenty-five patients(25 eyes)had a major cause of neovascular glaucoma,including 12 patients(12 eyes)with retinal central venous obstruction(CRVO,48.0%);diabetic retinopathy(8 eyes)(DR,32.0%);retina There were 3 cases(3 eyes)(BRVO,12.0%)of branch vein occlusion and 2 cases of eye ischemic syndrome(2 eyes)(8.0%).In this study,all patients with stage III NVG with VH were admitted to the informed consent form.1.2MethodsAll patients underwent best corrected visual acuity,intraocular pressure,slit lamp microscope,anterior chamber angle,eye B ultrasound and other eye routine examination,clear neovascular glaucoma diagnosis,staging,retina;all patients were All patients underwent vitreous cavity injection of Ranibizumab,7 days after injection of 23 G vitrectomy(intraoperative PRP)combined with Ahmed valve implantation.Statistical analysis was performed using spss19.0(Statistic package social science,SPSS)statistical software.The intraocular pressure at each time point was compared with the variance analysis of repeated measurement data.The postoperative time points were compared with the preoperative intraocular pressure(IOP)using the paired design t test,using the mean ± standard deviation(P)As a statistically significant difference.1.3 Follow-up and observeIntravitreal injection of Ranibizumab intraoperatively(within 1 week)observed intraocular pressure,iris neovascular regression.23 G vitrectomy(intraoperative retinal photocoagulation)combined with Ahmed valve implantation after observation of 1 week,1 month,3 months,6 months,12 months of intraocular pressure,the best corrected visual acuity,Iris neovascularization regression,the success rate of surgery and complications of the situation,followed up for 6 to 12 months,the average(8.53 ± 2.48).2 Results2.1 Intravitreal injection of Ranibizumab after surgeryTwenty-five patients(25 eyes)with VH stage III NVG underwent intravitreal injection of Ranibizumab,with an average intraocular pressure(40.58 ± 8.24)mm Hg at 1 week postoperatively.After surgery,7 eyes were injected 2-3 days after INV subsided,4 eyes 5-7 days after injection INV subsided.14 eyes after 7 days of INV was significantly atrophic,showing a small amount of small INV.2.2 23 G vitrectomy combined with Ahmed valve after implantationAt the end of the last follow-up,the best corrected visual acuity was light perception ~ 0.1,12 months after surgery compared with the best corrected visual acuity before 21 eyes(84.00%)visual acuity improved to varying degrees,13(16.00%)had no significant changes in visual acuity,no postoperative visual acuity decreased;The average IOP of 13 weeks,1 month,3 months,6 months and 12 months after implantation of 23 G vitrectomy combined with Ahmed valve was(13.85 ± 3.67),(14.69 ± 4.52(15.02 ± 4.97),(15.98 ± 4.52)and(17.86 ± 3.31)mm Hg,respectively.Compared with IOP(46.02 ± 5.9)mm Hg before operation,the difference was Statistically significant(t = 11.85,11.14,10.56,12.69,9.86,P <0.05).2.3 Surgical success rate and complicationsThe success rate was 96.0% and the complete success rate was 88.0%.There were 8(32.0%)complications during follow-up.Including shallow anterior chamber 4 eyes(16.0%),anterior chamber a small amount of blood 1 eye(4.0%),the drainage tube was blocked in 1 eye(4.0%),the drainage tube was exposed to 1 eye(4.0%),and the drainage plate was wrapped in 1 eye(4.0%).25 eyes did not appear retinal detachment,eye atrophy,endophthalmitis,choroidal hemorrhage and choroidal detachment and other serious eye complications.ConclusionIntravitreal injection of Ranibizumab assisted 23 G vitrectomy(intraoperative retinal photocoagulation)combined with Ahmed valve implantation is the use of a variety of methods combined and systematic treatment of vitreous hemorrhage associated with stage III neovascular glaucoma,this Comprehensive treatment of safe,effective and less postoperative complications,can make the intraocular pressure control in the normal range to protect patients with residual visual function as the goal,is the treatment of vitreous hemorrhage with stage III neovascular glaucoma patients more effective one Treatment of integrated systems.