全植床深板层角膜移植术治疗不同时期圆锥角膜的临床疗效分析

发布时间：2017-12-28 06:13

本文关键词：全植床深板层角膜移植术治疗不同时期圆锥角膜的临床疗效分析　出处：《浙江大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:评估全植床深板层角膜移植术(Full-bed deep lamellar keratoplasty,简FB-DLKP)治疗不同时期圆锥角膜的疗效,分析不同时期圆锥角膜患者FB-DLKP术前术后各项指标的差异,包术前术后裸眼视力、最佳矫正视力、角膜厚度、散光、内皮细胞密度、术中情况、术后并发症等,并对其临床疗效进行评估。方法:回顾性研究数据分析2013年1月至2015年12月于我院行FBDLK的圆锥角膜患者共53人、56眼,并完整随访12个月的患者,根据Amsler-Krumeich的圆锥角膜分期标准将病例进行分期,将Ⅱ期及Ⅲ期分为A组,Ⅳ期为B组。观察每一期病例的手术过程,比较各期之内以及各期之间术前、术后1月、6月、12月随访时视力(裸眼视力及最佳矫正视力,对视力进行统计学分析时转换为LogMAR视力)、内皮细胞密度、角膜厚度的变化情况、术前及术后6月、12月散光变化、植片存活情况、术中情况、术后并发症等。非正态分布的数据用中位数[四分位距]表示,各时期组内的各随访使用配对非参数检验,如Wilcoxon符号秩检验、符号检验,各时期组间使用独立样本的非参数检验,如秩和检验。对于正态分布或近正态分布的数据用均数±标准差表示,用配对t检验进行统计学分析。结果:纳入标准的共53人,56眼,左眼26例,右眼30例,其中男性35人,女性18人,患者年龄分布为14-41岁,平均年龄为22.68±7.17岁。满足II期及III期的共有18眼,满足IV期的有38眼。分析统计以上随访数据结果如下:术前B组有3眼(5.4%)为急性水肿后疤痕累及后弹力膜,但术中未发现疤痕重新裂开,术中2例(3.6%,A组B组各1例)发现厚弹力膜面微穿孔,并有少量房水涌出,予前房注气。A组(II期及III期)术后1、6、12的裸眼视力分别为:0.75[0.54,0.90]、0.56[0.34,0.82]、0.52[0.40,0.67],有显著性差异(Wilcoxon符号秩检验,P0.05)。B组(IV期)术后1、6、12的裸眼视力分别为:0.56[0.40,0.90]、0.52[0.40,0.60]、0.40[0.22,0.60],有显著性差异(Wilcoxon符号秩检验,P0.05)。A组与B组之间比较术后各个随访时间点的裸眼视力统计学上无显著性差异(秩和检验,P0.05)。A组术后1、6、12的BCVA分别为:0.34[0.24,0.40]、0.26[0.22,0.40]、0.26[0.11,0.35],有显著性差异(Wilcoxon符号秩检验,P0.05),B组术后1、6、12的BCVA分别为:0.26[0.22,0.40]、0.22[0.15,0.30]、0.22[0.11,0.28],有显著性差异(Wilcoxon符号秩检验,P0.05)。B组与A组之间比较术后各个随访时间点的BCVA,二者无显著性差异(秩和检验,P0.05)。术前A组和B组角膜厚度分别为:411[360,436]μm、357[319.75,371],有显著性差异(秩和检验,P0.05)。术后A组各个随访时间点角膜厚度分别为 515[498.25,531.25]μm、467[458.5,493.25]μm、464[445.75、471]μm,有显著性差异(Wilcoxon符号秩检验,P0.05)。术后B组期各个随访时间点角膜厚度分别为539.5[515.5,566.5]μm、479.5[458.25,503.75]μm、467[449,504.75]μm,有显著性差异(Wilcoxon符号秩检验,P0.05)。术后各个随访时间点A组和B组角膜厚度相互比较均无显著性差异(秩和检验,P0.05)。术前各组内皮细胞数分别为:2322[2287,2587]cells/mm~2、2516.5[2326.50,2612.25]cells/mm~2,二者无显著性差异(秩和检验,P0.05)。术后A组各个随访时间点内皮细胞数分别为:2224.5[2013,2314.5]cells/mm~2、2253.5[2070.25,2311.5]cells/mm~2、2210[1850.5,2288.5]cells/mm~2,术后6月与术后1月比较无显著性差异(Wilcoxon符号秩检验,P0.05),术后6月与术后12月比较有显著性差异(Wilcoxon符号秩检验,P0.05)。术后B组各个随访时间点内皮细胞数分别为2217[2013.5,2374]cells/mm~2、2166,5[1990,2311.5]cells/mm~2、2084.5[1870,2259]cells/mm~2,有显著性差异(Wilcoxon符号秩检验,P0.05)。术后A组与B组各个随访时间点内皮细胞数相互比较无显著性差异(秩和检验,P0.05)。术前A组与B组散光分别为:4.33[3.12,5.87]D、8.21[4.50,12.01]D,有显著性差异(秩和检验,P0.05)。术后A组6月、12月的散光分别为:5.16[2.76,9.67]D、3.67[3.06,6.13]D,有显著性差异(Wilcoxon符号秩检验,P0.05)。术后B组6月、12月的散光分别为:5.21[3.61,7.44]D、3.71[1.99,5.21]D,有显著性差异(Wilcoxon符号秩检验,P0.05)。A组与B组术后散光各个随访时间点之间相互比较无显著性差异(秩和检验,P0.05)。不同时期的圆锥角膜术后植片存活率100%,植片排斥率0%,术后一过性高眼压、继发性青光眼、并发性白内障等并发症发生率为0,仅有1眼(1.8%B组)于术后第1天1针缝线脱开,予及时缝合。结论:综上所述全植床深板层角膜移植术在治疗不同时期圆锥角膜术后各个随访时间的裸眼视力以及矫正视力都较术前明显提高。不同时期患者术后内皮细胞数较FB-DLKP术后内皮细胞较术前有所减少,但是术后长期随访内皮细胞数丢失逐渐减少并趋于相对稳定,且残留的内皮细胞数保持在可以维持角膜透明的数量范围内。不同时期患者FB-DLKP术后角膜植片厚度均较术前明显增加。不同时期患者术后角膜散光均较术前有明显减少。不同时期患者术后一过性高眼压、继发性青光眼、并发性白内障等并发症发生率低。不同时期圆锥角膜患者之间相互比较可以发现Ⅳ期的患者术后裸眼视力、角膜厚度、内皮细胞数、散光与Ⅱ期及Ⅲ期相比无明显差异。尽管术前Ⅳ期的角膜厚度均较Ⅱ期及Ⅲ期薄、曲率、散光大,但是FB-DLKP术后Ⅳ期患者各项随访指标均较Ⅱ期及Ⅲ期无明显差异,说明FB-DLKP治疗圆锥角膜Ⅳ期的预后与Ⅱ期及Ⅲ期无显著性差异,Ⅳ期术后的各项指标均可以达到Ⅱ期及Ⅲ期水平。并且FB-DLKP最大的优点是无排斥反应,术后无需终生使用抗排斥药物,因手术无需新鲜角膜,大大增加了角膜供体来源。所以FB-DLKP手术是目前治疗圆锥角膜最有效也是最优化的方案之一。
[Abstract]:Objective: To evaluate the graft bed deep lamellar keratoplasty (Full-bed deep lamellar keratoplasty, FB-DLKP) curative effect in the treatment of keratoconus in different periods, the differences of different period of keratoconus FB-DLKP preoperative and postoperative indexes, package of preoperative and postoperative uncorrected visual acuity, best corrected visual acuity, astigmatism, corneal thickness, endothelial cell density, intraoperative and postoperative complications, and to evaluate its clinical curative effect. Methods: a retrospective study on the data analysis of January 2013 to December 2015 in our hospital FBDLK patients with keratoconus were 53 people, 56 eyes, and 12 months of follow-up of patients with keratoconus, according to the Amsler-Krumeich criteria were stage II and III will be divided into A group, B group IV. To observe the operation process of each phase of the case, the comparison between the period and the period before and after surgery in January, June, December (follow-up vision uncorrected and best corrected visual acuity, the statistical analysis on the visual conversion for LogMAR vision), endothelial cell density, corneal thickness changes, preoperative in June December, and postoperative astigmatism, graft survival, intraoperative and postoperative complications. The data of non normal distribution were expressed by median [four minute distance]. Each group was followed by paired nonparametric tests, such as Wilcoxon signed rank test and symbol test. Each group used independent sample nonparametric tests, such as rank sum test. The data of normal distribution or near normal distribution were expressed with mean standard deviation, and the statistical analysis was carried out by paired t test. Results: a total of 53 patients, 56 eyes, 26 left eyes and 30 right eyes were included in the study, including 35 males and 18 females. The age of the patients was 14-41 years, with an average age of 22.68 + 7.17 years. A total of 18 eyes were met in phase II and III, and 38 eyes were met in IV phase. Statistical analysis of follow-up data above results are as follows: preoperative B group have 3 eyes (5.4%) for acute edema after scar involving Descemet's membrane, but were not found to scar dehiscence, 2 cases during operation (3.6% A group, B group with 1 cases in each group) found thick elastic membrane surface micro perforation, and a small amount of real water gushed out, to the anterior chamber gas injection. In group A (stage II and III), 1, 6 and 12 of uncorrected visual acuity were 0.75[0.54,0.90], 0.56[0.34,0.82] and 0.52[0.40,0.67], respectively, with significant difference (Wilcoxon signed rank test, P0.05). Group B (stage IV) had 1, 6, 12 naked eyes after operation: 0.56[0.40,0.90], 0.52[0.40,0.60] and 0.40[0.22,0.60], respectively, with significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in the visual acuity between the A group and the B group at each follow-up time point (rank sum test, P0.05). Group A after 1, 6 and 12 BCVA respectively: 0.34[0.24,0.40], 0.26[0.22,0.40], 0.26[0.11,0.35], there was significant difference (Wilcoxon signed rank test, P0.05), group B after 1, 6 and 12 BCVA respectively: 0.26[0.22,0.40], 0.22[0.15,0.30], 0.22[0.11,0.28], there was significant difference (Wilcoxon signed rank test, P0.05). Between group B and group A, there was no significant difference between the two groups (rank sum test, P0.05) at each follow-up time point of BCVA. The corneal thickness of group A and group B before operation were 411[360436] mu m and 357[319.75371], and there were significant differences (rank and test, P0.05). The corneal thickness at each follow-up time in group A was 515[498.25531.25] mu m, 467[458.5493.25] m, 464[445.75 and 471] m respectively, showing significant difference (Wilcoxon signed rank test, P0.05). The corneal thickness at each follow-up time in group B was 539.5[515.5566.5] m, 479.5[458.25503.75] m and 467[449504.75] m, respectively. There was significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in corneal thickness between the A group and the B group after the operation (rank sum test, P0.05). The number of endothelial cells in each group was 2322[22872587]cells/mm~2 and 2516.5[2326.502612.25]cells/mm~2 before operation, and there was no significant difference between the two groups (rank and test, P0.05). The postoperative A group each follow-up time point, the number of endothelial cells were 2224.5[20132314.5]cells/mm~2, 2253.5[2070.252311.5]cells/mm~2, 2210[1850.52288.5]cells/mm~2, after June and January after the operation showed no significant difference (Wilcoxon signed rank test, P0.05), after June and December after the operation had significant difference (Wilcoxon signed rank test, P0.05). The number of endothelial cells at each follow-up time in group B was 2217[2013.52374]cells/mm~2, 2166,5[19902311.5]cells/mm~2 and 2084.5[18702259]cells/mm~2, respectively, with significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in the number of endothelial cells between the A group and the B group after the operation (rank sum test, P0.05). Before operation, the astigmatism in group A and group B were respectively 4.33[3.12,5.87]D and 8.21[4.50,12.01]D, and there were significant differences (rank and test, P0.05). After the operation, the astigmatism of group A in June and December were 5.16[2.76,9.67]D and 3.67[3.06,6.13]D, and there were significant differences (Wilcoxon sign rank test, P0.05). After the operation, the astigmatism of group B in June and December were 5.21[3.61,7.44]D and 3.71[1.99,5.21]D, and there were significant differences (Wilcoxon sign rank test, P0.05). There was no significant difference between group A and group B after the follow-up time points of astigmatism (rank sum test, P0.05). The survival rate of keratoconus at different stages was 100%, the graft rejection rate was 0%. The incidence of postoperative complications such as transient intraocular hypertension, secondary glaucoma and complicated cataract was 0. Only 1 eyes (group 1.8%B) were removed from the 1 needle stitch on the first day after operation, and then sutured in time. Conclusion: In conclusion, the whole bed deep lamellar keratoplasty is effective in the treatment of keratoconus. Endothelial cells in different periods decreased compared with those after FB-DLKP, but the number of endothelial cells decreased gradually and tended to be relative after long-term follow-up.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R779.65

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