本视频为2025年10月于山西省眼科医院所开展的玻璃体视网膜相关院基培训的手术范例之二。
在本视频中，Hendrick医生与学员为一名左眼糖尿病性牵拉性视网膜脱离，且有糖尿病史的45岁女性患者，施行了经平坦部玻璃体切除术。
手术地点：山西省眼科医院，太原，山西省，中国
手术医生：Andrew M. Hendrick医生，埃默里大学 (Emory University)，美国
Transcript
0:00 This is a combined RRD TRD from advanced PDR. You can see heavy hemorrhagic membranes detaching the retina and no prior laser. This patient had an anti-vegf injection performed a few days prior to surgery. I always start these cases incising the equatorial vitreous cone. It typically has a bit of separation in middle aged patients and people with prior anti-VEGF, but can be quite adherent in very young patients without much PVD. Gentle lifting maneuvers help visualize and separate the vitreous planes.
该病例为晚期增殖性糖尿病视网膜病变所致的孔源性合并牵拉性视网膜脱离。可见大量出血性增殖膜导致视网膜脱离，且未行既往激光治疗。该患者于手术前数日接受了抗VEGF药物的玻璃体腔注射。在处理此类病例时，我通常首先切开赤道部的玻璃体锥。在中年患者以及既往接受过抗VEGF治疗者中，玻璃体通常存在一定程度的分离；而在无明显玻璃体后脱离的年轻患者中，玻璃体则可能高度黏附。通过轻柔的提拉操作能够更好地显露并分离玻璃体各层平面。
0:40 Once the cone is incised, I start the posterior dissection to find an entry point under the hyaloid into the macula or adjacent the disc. The vitreous cutter can incise the fibrous elements and hook the membranes for gentle blunt dissection. These cases often bleed and will benefit from bursts of supraphysiologic infusion pressures to enhance hemostasis.
切开玻璃体锥后，我即开始进行后部剥离，寻找进入玻璃体后界膜下、通向黄斑或视盘旁的切入点。玻切头可有效切开纤维性成分，并勾取增殖膜，便于实施轻柔的钝性分离。此类病例常伴有出血，因此可通过短暂升高灌注压以增强止血效果。
1:40 Areas of vitreous traction are identified and gradually resected from posterior to anterior until connected to the previously resected area. If I see points too adherent, I will often try another route and see if safe access to the pre-macular hyaloid is available. We try to avoid breaks in these cases, especially early which could greatly destabilize the retina and increase the difficulty of the case.
应识别出存在玻璃体牵拉的区域，并自后向前逐步切除，直至与既往已切除区域连通。如发现某些部位黏附过于紧密，我会尝试其他途径，评估是否能够安全进入黄斑前的玻璃体后界膜。我们尽量避免在此类病例中发生裂孔，尤其是在手术早期出现裂孔会显著降低视网膜的稳定性并增加手术难度。
2:29 You can see we do not have good hemostasis at this point during the case. My assistant is depressing the sclera to visualize the peripheral retina and shave the anterior gel. No tears are seen during this process, which leaves a lot of subretinal fluid that will require drainage to deliver adequate PRP laser.
可以看到，在病例的这一阶段，止血效果尚不理想。助手正按压巩膜，以便更好地观察周边视网膜并修整前部玻璃体。操作过程中未发现裂孔，但因此遗留了大量视网膜下液，需进行引流以便后续充分实施PRP激光。
3:12 I have used the diathermy tool to cauterize bleeding foci in the retina, residual fronds of neovascularization that could not be safely resected, and here – to fashion a posterior retinotomy and drain the subretinal fluid with a cannula under an air fluid exchange. I try to make a retinotomy posterior to enhance drainage and superior to provide better support from the bubble.
我使用电凝工具对视网膜中的出血灶及无法安全切除的新生血管化残余组织进行凝固，并在此处实施后部视网膜切开术，通过套管在特定气液交换下引流视网膜下液。我尽量选择后部进行视网膜切开，以增强引流效果，同时选择上方位置，这样气泡能提供更好的支撑。
4:01 After the first drainage, I apply anterior laser as the often accumulating posterior residual subretinal fluid will degrade the effectiveness of photocoagulation and retinopexy that are both needed. We save the posterior laser for after a second drain maneuver later. I want this laser to be white and try to be ½ to 1 burn width apart.
首次引流后，先行前部激光治疗，因为后部残余视网膜下液常常会影响光凝和视网膜复位术的疗效，而这两者均为必要步骤。后部激光则留待第二次引流操作完成后再行施行。我希望此次激光为白色，并尽量保持每个光斑之间的间距为1/2至1个光斑。
4:26 Here is the additional drainage to allow better delivery of the posterior laser.
此处进行了额外引流，以便更顺利地完成后极部激光治疗。
5:12 The view posteriorly is limited and requires corneal epithelial debridement. Now we can see very little residual subretinal fluid and vitreous hemorrhage. We will fill the vitreous with oil and close the sclerotomies using 7-0 Vicryl.
由于后部视野受限，因此需要进行角膜上皮去除以改善术野。目前可以见到仅有极少量残留的视网膜下液及玻璃体出血。我们将以油填充玻璃体腔，并使用7-0 vicryl缝合巩膜切口。