部分患者被医嘱需要做光凝术加固,常见有这么几种情况：
①无裂孔，有闪光
②裂孔，无闪光察觉
③萎缩区，萎缩孔，体检时发现
文本的目的是：
解释②③会在报告单上一律被写成“裂孔”的原因，
以及①②③都会被医生建议激光光凝术是否应该听从。
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一些医学术语概念
两种孔的区别可以参见【24】
根据【28】
Atrophic retinal holesare 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 holesare 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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激光光凝术术原理
那么上面第二个图就是激光光凝术加固后的效果， 也就是说，虽然自己感觉不到，但是其实会造成视野缺失，也就是看东西的范围变窄了。如果运气再差一点，那么手术后的效果会是这样的，会留下终生的黑块和黑线，一辈子都无法恢复。
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可否避免激光光凝术？
对于①中的患者而言，根据【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.
如果觉得不能接受视野损失，可以采取局部波切的方式来解决拉扯的问题。
需要找医生问清楚，阐明自己不能接受视野缺失，能接受白内障提前【1】
还有种办法就是只要没有裂孔就继续观察，代价是闪光一定风险拉扯出裂孔。
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激光光凝术打死视网膜的哪些结构？
激光光凝是必定会出现视野损失，视网膜结构如下：
视网膜激光光凝术是不是把10层都打死呢？我们来看下面的依据：
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年提出的激光光凝术是靶向RPE，不损坏光感受器
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., ; Belokopytov et al., ). 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., ). The most likely origin of the photoreceptors filling the lesion is a shift of healthy photoreceptors from the adjacent untreated areas (Zwick et al., ). Although these results indicate that migrating photoreceptors can fill in the lesion, little is known about the extent of the functional restoration.
选择性光凝只破坏光感受器和视网膜色素上皮（RPE），使视网膜内层细胞完好无损。几天后，RPE覆盖恢复，几周后，感光层恢复其连续性【3】
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RRD（rhegmatogenous retinal detachment）孔源性视网膜脱离
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
（破坏脉络膜意味着视网膜里面的10层都被破坏了）【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】(在一些边缘下面已经流入液体的情况下，必须进行光凝手术)
Subclinical RD was seen in 10 (6.7%) of 150 eyes with atrophicholes, involving 9 (7.5%) of 120 patients, and had a much less serious prognosis than clinicaldetachment.【25】
（萎缩孔出现脱离的只有6.7%）
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黄斑水肿时为何需要激光治疗？
上面这个图的逻辑相当于脚底起了一个水泡，用针刺破。
视网膜10层结构如下：
其中感光层视锥细胞和视杆细胞
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结论：
对于医生诊断报告中的“孔”，
首先分清楚自己是那种孔，裂孔还是萎缩孔（必须免散瞳相机拍照，留下报告案底），萎缩孔不做光凝加固的话，网脱概率是6.7%，光凝手术做还是不做可以自己决定。
牵引孔的话激光的必要性比较大。
另外注意，激光光凝+玻璃体后脱离本身会造成拉扯，理由见【26】
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所以总共有3种情况：
①如果是萎缩孔+伴有拉扯（俗称“vr牵引”）
那么拉扯处的视角应该放弃使用，此时可以不做激光光凝（光凝会打死视网膜全部10层，终生不可逆）
②如果拉扯处的视角在平时的用眼习惯中不能自我纠正，那么此时需要做激光光凝（否则会扯下来）
③如果是单纯的萎缩孔，可以不做光凝手术
所以国内的孔（包括萎缩孔、裂孔）要不要做激光和孔的类型以及患者用眼习惯都有关。
激光光凝后，出现闪光和视野缺失，如果实在不能忍受，可以考虑尝试偏光镜来弱化影响。
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激光光明导致的视野缺失，如果激光位置是在上方，那么会在视野下方出现视野损失，往下看会有明显的闪光（说明导致拉扯）
因为晶状体是凸透镜，有反图像的效果
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视网膜色素上皮脱离就是视网膜脱落（浆液性）脱离【27】
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另外需要注意：
皮质假性裂孔和孔源性视网膜脱离 区分开来【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】选择性视网膜光凝疗法研究进展--《中国激光医学杂志》05期
【6】Safety and efficacy of selective retina therapy (SRT) for the treatment of diabetic macular edema in Korean patients | SpringerLink
【7】免除视网膜损伤的选择性视网膜色素上皮光凝 - 百度学术
【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? –
【23】Retinal holes - All About Vision
【24】Managing Retinal Breaks
【25】Lattice Degeneration & Retinal Detachment Risk - Preventative Treatment? - Endmyopia®
【26】激光光凝后容易出现频繁闪光的原因_微电子学与固体电子学-CSDN博客
【27】视网膜色素上皮脱落_周琳琳医生的语音科普_妙手医生
【28】Retinal hole: Is it serious?
【29】玻璃体后皮质假性裂孔误诊为孔源性视网膜脱离一例
