INTRODUCTION

Secondary epiretinal membrane (ERM) is not a rare complication after vitrectomy. About 8.97% to 47.7%patients occurred secondary ERM after vitrectomy without internal limiting membrane (ILM) peeling for rhegmatogenous retinal detachment (RRD)

. The location of retinal breaks at the equator is a significant risk factor [odds ratio (OR),3.9; 95% confidence interval (CI), 1.3-11.2]

. It might cause visual impairment or metamorphopsia

, thus requiring further membrane peeling surgery. A series of clinical studies found ILM peeling prevent the development of secondary ERM for RRD, although better best-corrected visual acuity (BCVA)among ILM peeling patients was not found

. There were also some studies found ILM peeling can be as a prophylactic treatment to prevent macular pucker formation in patients who underwent retinectomy

.

2.2.2.1 危害癥狀。葉片先出現(xiàn)水漬狀青灰色斑點，沿葉脈向兩端擴展，形成邊緣暗褐色、中央淡褐色或青灰色的大斑。后期病斑?？v裂，嚴重時融合，葉片變黃枯死(圖2)。

However, in practice, there are no uniform criteria for the surgical removal of the secondary ERM after vitrectomy for PDR. We encountered rapid and apparent development of secondary ERM in some cases with a mild postoperative reaction. We investigated the original ILM peeling for the prevention of secondary ERM and postoperative visual acuity(VA) and risk factors for secondary ERM development.

治療結(jié)果：試驗組28例，一次治愈2例，6-12月后二次治愈13例，6-12月后行第三次131-I治療者13例；第一次治愈（以下均含甲低）2例，第二次治愈13例，第三次治愈（含甲低）13例，1年后甲低11例。對照組29例，一次治愈（含甲低）25例，二次治愈（含甲低）4例，1年后甲低26例。血管雜音：試驗組與對照組血管雜音消失治愈后基本相同，甲低發(fā)生率對照組高于實驗組，有統(tǒng)計學意義。結(jié)果見表1。

農(nóng)業(yè)經(jīng)濟管理是指在市場環(huán)境和社會經(jīng)濟條件的實際情況下，根據(jù)國家相關(guān)的經(jīng)濟政策方針而對農(nóng)村經(jīng)濟施行的一種管理活動。具體到不同的地區(qū)，農(nóng)業(yè)經(jīng)濟管理就要充分考慮到各地不同的市場環(huán)境和經(jīng)濟條件，并要在國家相關(guān)經(jīng)濟政策方針的框架內(nèi)實現(xiàn)對農(nóng)業(yè)經(jīng)濟發(fā)展的指導，制定相關(guān)的發(fā)展目標。而其中核心的部分就是將規(guī)劃、決定、調(diào)控及組織協(xié)調(diào)的過程實施于生產(chǎn)資料再生產(chǎn)過程中的生產(chǎn)、分配、交換、消費等環(huán)節(jié)，或與農(nóng)業(yè)、金融、銷售、物流等資源進行跨行業(yè)整合，打通現(xiàn)代農(nóng)業(yè)發(fā)展的產(chǎn)業(yè)鏈條，實現(xiàn)對農(nóng)村經(jīng)濟發(fā)展的法制化、規(guī)范化、科學化，以促進農(nóng)村經(jīng)濟發(fā)展水平、社會穩(wěn)定和人們整體生活水平的提高。

SUBJECTS AND METHODS

ERMs were assessed by two experienced ophthalmologists(Wen H and Lin Z) using the OCT (Heidelberg Spectralis OCT, Heidelberg, Germany) photographs. In the OCT scan,postoperative ERM was defined as hyper-reflective line internal to the ILM. If there were inconsistencies on the ERMs, the photographs were sent to the 3

senior vitreoretinal surgeon with equal or more experience for consultation (Wu RH). To reduce subjective bias, the blind method was applied during assessment.

Although the occurrence of secondary ERM after diabetic vitrectomy is common, its mechanism remains unclear. Several factors are likely contributed to the high incidence of ERMs.First, residual native vitreous collagen and ILM in the macular area may act as a scaffold for cellular proliferation. Second,VH, postoperative inflammation, and the damaged retinal surface may provide an ideal environment for the growth of secondary ERMs. ILM peeling may therefore decrease the incidence of secondary ERM because it removes the scaffold that proliferates astrocytes, myofibroblasts, and retinal pigment epithelium cells

. Our results confirm that ILM peeling could effectively reduce the formation of secondary ERM. This result is consistent with previous studies that ILM peeling significantly reduced postoperative ERM after PPV for PDR

. In the current study, we observed that the overall incidence of secondary ERM was 26.9%. Furthermore, from the Cox proportional curve, we observed that the incidence of secondary ERM was lower in ILM peeling group that in ILM non-peeling group at any follow-up point. The incidence of ERM was 37.0% in ILM non-peeling group and 14.0% in ILM peeling group. Several previous studies have reported similar incidences of secondary ERM in ILM non-peeling groups, ranging from 20% to 52.8%, depending on the case mix and the methods of detection

. In fact, more factors associated with ERM formation were presented in ILM peeling group. In ILM peeling group, the patients had a higher rate of preoperative ERM, fibrovascular membrane, retinal attachment, PRP, and air tamponade. PDR eyes with more severe preoperative vitreoretinal changes may be more prone to secondary ERM

. Under diabetic conditions, a local proinflammatory and proangiogenic environment in eyes provides a strong stimulation for tissue proliferation, which is associated with the frequent incidence of ERM

. As well as head-down tilt after gas injection in the postoperative period,a higher number of cells on the macular surface would also result in an increased risk of ERM. In the current study, when considering the comprehensive risk factors, ILM peeling was the only independent risk factor for postoperative secondary ERM, which strongly emphasized the importance of ILM peeling during vitrectomy for patients with PDR.

The 23- or 25-gauge PPVs were performed under retrobulbar(50% mixture of 2% lidocaine and 0.75% bupivacaine) or general anesthesia using three different vitrectomy machines(Accurus Surgical System, Alcon Laboratories, Fort Worth,TX; Stellaris PC, Bausch & Lomb, Bridgewater Township,NJ; Constellation Vision System, Alcon Laboratories) by 5 surgeons. The ERM will be peeled off if there was already ERM at the time of first vitreous surgery. But the removal of ILM was depended on the doctor’s judgment. The ILM was stained with indocyanine green (Dandong Yi Chuang Pharmaceutical Co., Ltd, Liaoning Province, China) and then removed by ILM peeling forceps. ILM was peeled in the entire macular area (at least 2 disc diameters around the fovea). A combined surgery (PPV + phacoemulsification or intraocular lens implantation), pan retinal photocoagulation (PRP), and intraocular tamponade with air were performed, if necessary,depending on the surgeons’ experience.

The research protocol complies with the ethical guidelines of the Declaration of Helsinki and was approved by the Ethics Committee of Wenzhou Medical Eye Hospital. The informed consent was waived. Patients’ clinical information was obtained from archived electronic medical records.

The VA in decimal fraction was converted into logarithm of the minimum angle of resolution (logMAR)values. A BCVA of ＜0.02 was recorded as a logMAR value of 1.7. The normally distributed parameters were presented as mean±standard deviation, whereas median and quartile range was used for non-normally distributed parameters. The Chisquare or Fisher’s exact test, as appropriate, was performed to compare discrete categorized data. Univariate logistic regressions were used to assess the relationship between postoperative ERM development and risk factors, including age, sex, history of retinal laser treatment, and ILM peeling.Next, multivariate logistic regression was performed for postoperative ERM, adjusted age and sex, and factors with a

value of ＜0.1 in the univariate analysis. The OR, hazard ratio, and 95%CIs were presented. A Cox proportional hazard regression was conducted for postoperative ERMs with adjustment of covariates. Statistical analysis was performed using SAS for Windows (Statistical Analysis System, version 9.1.3, SAS Inc., Cary, NC, USA).

RESULTS

As showed in Figure 2, after adjusting for the factors screened from the univariate model, a Cox proportional hazard regression for the incidence of secondary ERM was performed.which showed only ILM peeling remained significant (hazard ratio, 0.47; 95%CI, 0.23-0.98;

=0.04).

We evaluated perioperative factors to identify their potential effect on the postoperative development of secondary ERM(Table 3). Univariate logistical regression showed that the incidence of secondary ERM significantly increased in cases without ILM peeling, preoperative intravitreal injection of anti-VEGF, preoperative VH, and history of retinal laser treatment.Multivariate analysis revealed that ILM peeling was highly associated with the prevention of secondary ERM development(OR, 0.38; 95%CI, 0.17-0.86,

＜0.05).

The intra- and postoperative details for both groups are presented in Table 2. More patients in ILM peeling group underwent combined surgery with phacoemulsification (89.2%

73.1% ;

=0.006), fibrovascular membrane peeling (57.0%

33.6%;

＜0.001), retinal attachment (22.6%

11.8%;

=0.04), PRP(76.3%

61.3%;

=0.02), and air tamponade (57.0%

33.6%;

＜0.001). The follow-up duration was 9.3±5.4mo in ILM non-peeling group and 8.0±4.1mo in ILM peeling group(

=0.06). During the follow-up period, supplemental PRP treatment was more common in ILM non-peeling group thanin ILM peeling group (12.6%

4.3%;

=0.04). At the final follow-up, in ILM non-peeling group, the median logMAR VA was statistically better than in ILM peeling group (0.40

0.52;

=0.04). The median logMAR VA improvement was 0.90 in ILM non-peeling group and 0.49 in ILM peeling group with significant difference (

=0.03). Compared with patients in ILM peeling group, patients in ILM non-peeling group had higher incidence of secondary ERM (37.0%

14.0%;

＜0.001; Table 2). There was no difference between ILM nonpeeling group [3.63mo (interquartile range, 1.45-5.88mo)]and ILM peeling group [3.39mo (interquartile range, 3.21-4.64mo)] in the timing of secondary ERM development during the follow-up (

=0.80). Figure 1 shows a typical example of ERM development in ILM non-peeling group.

Total 212 eyes of 197 patients (average age, 55.8±11.6y;49.8% men) were enrolled in our study. The overall duration of follow-up was 8.7±4.9mo. There were 93 eyes in ILM peeling group and 119 in ILM non-peeling group. The baseline clinical characteristics of all patients are shown in Table 1.There were no differences in patient age, sex, status of lens,BCVA, and intraocular pressure between the groups. Patients in ILM peeling group had a higher proportion of preoperative ERM (39.8%

16.0%;

＜0.001) and preoperative intravitreal anti-VEGF injection (61.3%

17.6%;

＜0.001), a lower proportion of VH (19.4%

63.9%;

＜0.001) and retinal laser treatment history (3.2%

15.1%;

=0.004) compared with those in ILM non-peeling group.

DISCUSSION

Secondary ERM development causes visual deterioration and macular disorders such as macular cysts or macular thickening after successful surgical treatment of PDRs

. Recently, it has been reported that ILM peeling might decrease the ERM formation and diabetic macular edema

. Although a previous randomized clinical trial that enrolled 207 patients with PDR reported a beneficial role of ILM peeling in patients with PDR for improvement in VA

, ILM peeling was evaluated in patients with PDR undergoing PPV for the primary indication of VH as the primary objective. Most of these patients had VH, making the cohort different from our patient population. This study examined the effectiveness of ILM peeling during vitrectomy for PDR in reducing secondary ERM as well as identifying risk factors.

廣墾旅游集團主營酒店、旅游和出租車三大業(yè)務板塊。作為墾區(qū)十大產(chǎn)業(yè)集團之一的旅游集團，近年來在省農(nóng)墾集團“走出去”發(fā)展經(jīng)營理念的指導下，大力整合墾區(qū)酒店、旅游、出租車資源，目前已將業(yè)務領域由廣州輻射到茂名、湛江、汕頭、揭陽等廣東地市以及北京地區(qū)。集團旗下?lián)碛袕V東農(nóng)墾燕嶺大廈有限公司、廣東綠色國際旅行社、北京賽達福出租汽車有限公司、茂名燕嶺綠湖灣酒店、湛江燕嶺翠園飯店、廣墾（茂名）國家熱帶農(nóng)業(yè)公園、北京國信達福汽車租賃公司等十多家法人單位，經(jīng)營規(guī)模不斷壯大。

We retrospectively reviewed patients’ information who underwent pars plana vitrectomy (PPV) for PDR at the Eye Hospital of Wenzhou Medical University between January 2018 and December 2019. PDR was defined by the presence of neovascularization of the disc (NVD) or elsewhere (NVE) or vitreous hemorrhage (VH) or preretinal hemorrhage

. Patients who underwent PPV for PDR and had readable postoperative(≥3mo after operation) OCT photographs were included. The exclusion criteria were as follows: 1) history of PPV surgery;2) history of ocular penetrating trauma; 3) history of retinal vein occlusion, uveitis, age-related macular degeneration,or other fundus disease that may influence the macula; 4)traction retinal detachment involving the posterior pole; 5)silicone oil tamponade; 6) postoperative endophthalmitis. Preand postoperative retinal photocoagulation and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF)or triamcinolone acetonide were considered risk factors for postoperative ERM development but were not exclusion criteria.

2011年，中央安排41億元支持中西部地區(qū)新建、改擴建特殊教育學校1001所。為重視和支持民族教育事業(yè)，中央安排近210億元改善民族教育辦學條件、資助困難學生，穩(wěn)步推進雙語教育，舉辦西藏、新疆內(nèi)地中職班，培養(yǎng)技能人才近萬人。目前，內(nèi)地各級各類教育民族班在校生達9.6萬人。

Regarding secondary ERM after vitrectomy for proliferative diabetic retinopathy (PDR), two pilot studies have reported the incidence to be 38.5% and 49%

, respectively. ILM peeling can significantly minimize this frequency. Recently,Mehta

reported that ILM cleaning without ILM peeling can reduce the incidence of ERM formation after vitrectomy for PDR compared with that after standard procedure (4%

20%;

=0.01). Lin

had reported that ILM peeling can treat diabetic macular edema, although this has been refuted by some studies

.

For this study, we have also analyzed the time of secondary ERM. The median timing of secondary ERM development was similar at approximately 3mo for both groups. Most of the cases developed secondary ERM between 3 and 6mo postoperatively, similar to that observed in a study with a mean interval of 2.3mo (range, 1-4mo)

.

According to our study, history of retinal laser treatment and preoperative VH was associated with an increased risk of secondary ERM. Chehaibou

found that the eyes with laser treatment developed proliferative tissue along the border of the laser scar, which may induce a gliotic reaction.Furthermore, intravitreal anti-VEGF injection prior to surgery decreased the risk of secondary ERM. Preoperative intravitreal anti-VEGF injection may enhance the absorption of VH by reducing the dissemination of blood cells, thereby decreasing the formation of ERM. However, these three factors were no longer significant in the multivariate analysis, after adjusting for ILM peeling. This may be because of the higher proportion of preoperative VH and laser treatment in ILM non-peeling group and the higher proportion of preoperative intravitreal anti-VEGF injection in ILM peeling group. Additionally, both preoperative retinal laser treatment and PRP were performed away from the retinal vessel arch/posterior polar area (no macular grid pattern laser treatment was performed), rather than adjacent to the macular area.

Considering the visual prognosis after surgery to treat postoperative ERMs, there might be a case for not peeling the ILM

. Meanwhile, several studies have demonstrated that the ILM peeling group had a better BCVA than the ILM nonpeeling group

. In our study, although the improvement in VA was significant in both groups, the final median VA in ILM non-peeling group was better than that in ILM peeling group, and the most significant reason was an apparent higher proportion of VH in the former than that in latter (63.9%

19.4%); therefore, a more apparent VA improvement was gained in ILM non-peeling group.

沒有人是永動機，忙碌如他，我一直很好奇他何以如此目標清晰，極度專注地朝前進？他說：“當時最重要的一個機緣是覺得我不年輕了。我24歲，一事無成，大學都沒畢業(yè)，浪費了很多錢，真的是不能再浪費時間了。其實我從小學習還是可以的，就是大學時有段時間比較迷茫，但沒有那段時間也就沒有現(xiàn)在的我?！被貞浧甬敵鯊奶祗w物理轉(zhuǎn)到葡萄酒專業(yè)，我在他身上感受到了一直伴隨著我的危機感。

Postoperative complications were similar between the two groups. Compared to previous studies, we found that the incidence of postoperative VH and neovascular glaucoma(NVG) was relatively lower at 5.6% and 2.8%, respectively(VH: 8%-25%

; NVG: 1%-9%

). In our study, PRP was extensively applied during PPV, and anti-VEGF was injected preoperatively, which may explain the relatively low rate of VH and NVG

.

Although the current study had a relatively large sample size, there are some limitations. First, because the study was retrospective in nature, there was certain to be some degree of subject heterogeneity. Second, pre- and postoperative intervention and operative procedures varied among different surgeons. Third, the length of follow-up was relatively short.Nonetheless, this is the first study to examine the prevention of secondary ERM for patients with PDR after ILM peeling.It would be beneficial to conduct further randomized clinical trials to support the efficacy of initial ILM peeling for PDR.In conclusion, ILM peeling might prevent secondary ERM development during PPV for PDRs and should be considered by sophisticated vitreoretinal surgeons.

The study was designed by Wu RH,Xu MN and Lin Z; Xu MN, Feng KM and Zhou HJ did data analysis; Wu RH, Xu MN, and Lin Z drafted the manuscript;all authors conducted the acquisition of data; the final manuscript has been read and approved by all authors.

1.基層矛盾預防化解機制的建構(gòu)必須貫徹法治的原則。黨的十八大報告提出“運用法治思維和法治方式化解矛盾、維護穩(wěn)定”的要求。新時期，讓法治思維融入社會的血脈，提高執(zhí)法者的制度執(zhí)行力，進而破解社會管理難題，維護社會的穩(wěn)定，讓法律銘刻在公民的心里，應作為基層社會矛盾預防化解機制中長期部署的任務和應當遵循的一個原則。如何讓基層社會矛盾解決的過程變成公眾真正理解法律、服從法律的行動是要探索的問題。提高公職人員的法律思維，引導群眾按法定途徑解決糾紛則是法治原則的應有之義。只有回到法治的軌道，才能重樹政府和法律的權(quán)威。我們期待基層社會矛盾能夠在法治的框架內(nèi)有效得到解決，在全社會重塑法治的信仰。

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