部分患者被醫囑需要做光凝術加固,常見有這么幾種情況：

①無裂孔，有閃光

②裂孔，無閃光察覺

③萎縮區，萎縮孔，體檢時發現

文本的目的是：

解釋②③會在報告單上一律被寫成“裂孔”的原因，

以及①②③都會被醫生建議激光光凝術是否應該聽從。

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一些醫學術語概念

英文術語	精準中文含義	對應的國內醫院 慣用術語
operculated retinal hole【24】	牽引孔	裂孔
atrophic hole	萎縮孔	裂孔
retinal degeneration	視網膜退化	視網膜變性
retina denaturation	視網膜變性	視網膜變性

兩種孔的區別可以參見【24】

根據【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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激光光凝術術原理

那么上面第二個圖就是激光光凝術加固后的效果， 也就是說，雖然自己感覺不到，但是其實會造成視野缺失，也就是看東西的范圍變窄了。如果運氣再差一點，那么手術后的效果會是這樣的，會留下終生的黑塊和黑線，一輩子都無法恢復。

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可否避免激光光凝術？

對于①中的患者而言，根據【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.

如果覺得不能接受視野損失，可以采取局部波切的方式來解決拉扯的問題。

需要找醫生問清楚，闡明自己不能接受視野缺失，能接受白內障提前【1】

還有種辦法就是只要沒有裂孔就繼續觀察，代價是閃光一定風險拉扯出裂孔。

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激光光凝術打死視網膜的哪些結構？

激光光凝是必定會出現視野損失，視網膜結構如下：

視網膜激光光凝術是不是把10層都打死呢？我們來看下面的依據：
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膜色素上皮（RPE），使視網膜內層細胞完好無損。幾天后，RPE覆蓋恢復，幾周后，感光層恢復其連續性【3】

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

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。【24】

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

（破壞脈絡膜意味著視網膜里面的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。【22】

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流入液體的情況下，必須進行光凝手術)

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】

（萎縮孔出現脫離的只有6.7%）

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黃斑水腫時為何需要激光治療？

上面這個圖的邏輯相當于腳底起了一個水泡，用針刺破。

視網膜10層結構如下：

其中感光層視錐細胞和視桿細胞

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結論：

對于醫生診斷報告中的“孔”，

首先分清楚自己是那種孔，裂孔還是萎縮孔（必須免散瞳相機拍照，留下報告案底），萎縮孔不做光凝加固的話，網脫概率是6.7%，光凝手術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造成拉扯，理由見【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該放棄使用，此時可以不做激光光凝（光凝會打死視網膜全部10層，終生不可逆）

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

③如果是單純的萎縮孔，可以不做光凝手術

所以國內的孔（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慣都有關。

激光光凝后，出現閃光和視野缺失，如果實在不能忍受，可以考慮嘗試偏光鏡來弱化影響。

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激光光明導致的視野缺失，如果激光位置是在上方，那么會在視野下方出現視野損失，往下看會有明顯的閃光（說明導致拉扯）

因為晶狀體是凸透鏡，有反圖像的效果

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視網膜色素上皮脫離就是視網膜脫落（漿液性）脫離【27】

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另外需要注意：

皮質假性裂孔和孔源性視網膜脫離 區分開來【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】選擇性視網膜光凝療法研究進展--《中國激光醫學雜志》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】免除視網膜損傷的選擇性視網膜色素上皮光凝 - 百度學術

【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頻繁閃光的原因_微電子學與固體電子學-CSDN博客?

【27】視網膜色素上皮脫落_周琳琳醫生的語音科普_妙手醫生?

【28】Retinal hole: Is it serious?

【29】玻璃體后皮質假性裂孔誤診為孔源性視網膜脫離一例

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