联合电凝改良青光眼手术动物实验及临床研究

发布时间：2018-04-13 11:07

本文选题：青光眼 + ECT　；参考：《天津医科大学》2012年硕士论文

【摘要】：目的 1.探讨兔眼小梁切除术联合巩膜床电凝术(改良术式ECT)的降眼压作用,探讨巩膜床电凝是否存在抗瘢痕化作用。 2.联合电凝术的改良前三联手术治疗青光眼白内障的临床研究,与传统MMC的前三联手术对照,探讨小梁切除术联合巩膜床电凝术的临床效果。方法 1.新西兰白兔12只(12眼),体重2.0-2.5kg,随机分为两组分别行小梁切除+ECT(ECT组)、小梁切除+MMC (0.2mg/ml,2min)(MMC组),另取新西兰白兔3只(3眼)行单纯小梁切除术(Trab组)。ECT组、MMC组两组术后定期观察眼压、眼前节变化、并发症发生情况；三组定期各随机处死1只实验兔,制作术区滤过道病理切片。 2.选择2010年6月至2011年7月在天津医科大学眼科中心住院的青光眼合并白内障患者,随机行超声乳化白内障吸除+IOL植入+小梁切除+ECT (ECT组)、超声乳化白内障吸除+IOL植入+小梁切除+MMC (MMC组)。比较术前术后视力、眼压、眼前节形态、眼底、UBM、视野及并发症发生情况等指标。分析与传统术式相比,改良前三联手术的实用性及安全性。采用SPSS16.0统计软件对相关数据进行统计学分析。结果 1.动物实验中,ECT组与传统MMC组兔眼术后3d内,所有术眼均有不同程度的结膜充血,7d内充血全部消退,1d、7d各组结膜充血差异无显著性(x2=0.556,0.78,P值均0.05)。手术后第1、2天两组前房反应较重,所有兔术眼前房水混浊程度(++),7d后两组前房反应均消失。术后早期大多为功能性滤过泡,随着时间的推移,滤过泡均有不同程度瘢痕化,术后第14天,两组功能性滤过泡所占比例均为66.7%(4／6),差异无统计学意义。ECT组及MMC组在做周边虹膜切除术时各有1例前房出血,均于术后第3天吸收。MMC组术后1天有2例前房纤维素渗出,于术后7天内吸收。 2.动物实验中,ECT组与传统MMC组术后1d、3d、7d眼压均较术前下降,下降程度有统计学差异(tECT=0.000、0.000、0.001,tMMc=0.000、0.000、0.011,P均0.05),而第14d、28d两组眼压与术前比较无统计学差别(tECT=0.39、0.728,tMMC=0.084、0.908,P均0.05)；ECT组与传统MMC组之间各时间点眼压水平均无统计学意义(P0.05)。 3.动物实验中,术后7天所有兔术眼结膜下组织疏松且轻度水肿,巩膜瘘道间隙可见,滤过道内较多成纤维细胞及少数炎症细胞浸润,除单纯Trab组有较薄纤维结缔组织阻塞滤过道外,ECT组和MMC组滤过道均开放。术后14天三组滤过通道不同程度关闭。术后28天,周围大量胶原纤维沉积,三组均呈现瘢痕样改变。 4.临床研究中,术后1年随访时ECT组功能性滤过泡占89.7%(26／29),MMC组功能性滤过泡占93.3%(28／30),差异无统计学意义(x2=0.056,P=0.813)。两组均各有7眼BCVA20／30,无统计学差异(Mann-Whitney U检验t,Z=-1.000,P=0.710)。ECT组5眼轻度角膜水肿,1眼术后早期前房有渗出；MMC组6眼角膜轻度水肿,1眼前房少量积血,1眼伤口渗漏,均在1周内自愈。 5.临床研究中,ECT组术后眼压14.6±2.2mmHg,较术前27.0±6.2mmHg有统计学差异(t=13.675,P=0.000)；MMC组术后眼压14.2±3.7mmHg,较术前28.6±7.1mmHg,差别有统计学差异(t=0.655,P=0.000)。各组术后眼压较术前均有明显下降(P=0.000),但两组眼压下降程度无明显统计学差异(t=0.655,P=0.109)。随访12个月,两组术前、术后MD值与PSD值差异无统计学意义(ECT组tMD=1.417,PMD=0.171,tPSD=0.553,PPSD=0.586；MMC组tMD=1.665,PMD=0.110,tPSD=-1.390,PPSD=0.178),表明术后视野保持稳定。 6.临床研究中两组内所有患者术后3,6,12月均能通过UBM观察到滤过道。结论 1.动物实验研究电凝联合小梁切除术与传统MMC小梁切除切除术术后眼压变化无统计学差异、术后并发症少且14d内病理切片显示两组均尚存滤过间隙,较单纯小梁切除术明显延缓了滤过道瘢痕化进程。 2.临床研究联合电凝的改良前三联手术与传统MMC前三联手术术后1年内降眼压效果相当,且术后并发症少、操作简单易于基层医院推广。其长期的治疗效果仍有待于多中心、大样本的临床研究考察。 3.本研究的结果是令人鼓舞的,但也存在不足,仍需深一步细胞或基因水平的研究证实电凝抗瘢痕化的机理。并且,本研究的随访时间还需延长,以验证改良术式是否存在长期保持滤过通路的效果。
[Abstract]:objective
1. to explore the anti cicatricial effect of scleral bed electrocoagulation on rabbit eye trabeculectomy combined with scleral bed electrocoagulation (modified ECT).
2. clinical study of combined triple electrocoagulation for glaucoma and cataract. Compared with the traditional triple operation of MMC, we explored the clinical effect of trabeculectomy combined with scleral bed electrocoagulation.
Method
1. 12 New Zealand white rabbits (12 eyes), weighing 2.0-2.5kg, were randomly divided into two groups respectively underwent trabeculectomy with +ECT (group ECT), trabeculectomy +MMC (0.2mg/ml, 2min) (MMC group), another 3 New Zealand white rabbits (3 eyes) underwent trabeculectomy (group Trab).ECT group MMC, two groups of regular postoperative intraocular pressure, anterior segment changes, the occurrence of complications; three groups of the regular 1 experimental rabbits were making area filtration road sections.
2. June 2010 to July 2011 in patients with glaucoma complicated with cataract hospitalized in Ophthalmological Center of Tianjin Medical University, were underwent phacoemulsification and +IOL implantation and trabeculectomy with +ECT (group ECT), phacoemulsification and +IOL implantation and trabeculectomy with +MMC (group MMC). Compared with visual acuity before and after surgery, intraocular pressure, anterior segment morphology, fundus, UBM, vision and complications were measured. Compared with the traditional technique, practicability and safety of the modified triple operation. Before the relevant data were statistically analyzed by SPSS16.0 statistical software.
Result
1. animal experiment, the ECT group and the traditional group MMC rabbits in 3D after the surgery, all patients had different degrees of eye conjunctival hyperemia, congestion in 7d 1D, 7d were all faded, conjunctival congestion had no significant difference (x2=0.556,0.78, P 0.05). The 1,2 day after operation in two groups was higher than the anterior chamber all the rabbits, anterior chamber water turbidity, 7d (+ +) two groups after anterior chamber reaction disappeared. Early postoperative mostly functional blebs, with the passage of time, the bleb had different degree of scarring, fourteenth days after operation, two groups of functional bleb proportion was 66.7% (4 / 6), there was no significant difference between.ECT group and MMC group in peripheral iridectomy when each had 1 cases of hyphema, were absorbed in third days after operation in.MMC group after 1 days there were 2 cases of anterior chamber fibrin exudation, 7 days after the operation and absorption.
2. animal experiment, the ECT group and the traditional group MMC after 1D, 3D, 7d, intraocular pressure decreased, there were significant differences in degree of decline (tECT=0.000,0.000,0.001, tMMc=0.000,0.000,0.011, P 0.05), and the 14d, 28d two group compared with the preoperative IOP had no statistical difference (tECT= 0.39,0.728, tMMC=0.084,0.908, P 0.05); between the ECT group and the traditional group MMC intraocular pressure level at each time point were not statistically significant (P0.05).
3. animal experiment, 7 days after operation all postoperative subconjunctival tissue loose and mild edema, scleral fistula clearance visible, filtering channel in more fibroblasts and few inflammatory cell infiltration, in addition to the pure Trab group had thinner fibrous connective tissue blocking filtration outside, ECT group and MMC group were filtering are open to the public. 14 days after the three groups of filtering channels different degree closed. After 28 days, around a large number of collagen deposition, three groups showed a scar like changes.
4. clinical studies, 1 years of follow-up after operation group ECT functional bleb accounted for 89.7% (26 / 29), MMC group of functional bleb accounted for 93.3% (28 / 30), the difference was not statistically significant (x2=0.056, P=0.813). The two groups each have 7 eyes BCVA20 / 30, no significant difference (Mann-Whitney U test T, Z=-1.000, P=0.710).ECT group of 5 eyes with mild corneal edema, 1 eyes of early postoperative anterior chamber exudative MMC group; 6 slight corneal edema in 1 eyes, 1 eyes a few real blood, wound leakage, all in 1 weeks to heal.
5. clinical studies, ECT group of postoperative IOP was 14.6 + 2.2mmHg, 27 + 6.2mmHg compared with preoperative had statistically significant difference (t=13.675, P=0.000); group MMC IOP was 14.2 + 3.7mmHg, 28.6 + 7.1mmHg compared with preoperative, the difference was statistically significant (t=0.655, P=0.000). The postoperative intraocular pressure before surgery were significantly decreased (P=0.000), but the two groups of intraocular pressure decreased with no statistical difference (t=0.655, P=0.109). After 12 months of follow-up, the two groups before surgery, postoperative MD and PSD values had no significant difference (ECT group tMD=1.417, PMD=0.171, tPSD=0.553, PPSD=0.586; group MMC tMD= 1.665, PMD=0.110, tPSD=-1.390, PPSD=0.178) that, to maintain the stability of vision after surgery.
In 6. clinical studies, all patients in two groups were able to observe the filter through UBM 3,6,12 months after operation.
conclusion
1. animal experimental study on electrocoagulation combined with trabeculectomy and traditional MMC trabeculectomy resection after intraocular pressure had no statistical difference, less postoperative complications and 14d pathological examination showed that two groups were still filtration gap, compared with simple trabeculectomy significantly delayed the scarring process.
2. the improved triple surgery combined with electrocoagulation in the clinical research is equivalent to the intraocular pressure reduction in 1 years after the traditional MMC triple surgery. There are fewer postoperative complications and easy operation. It is easy to promote in primary hospitals. Its long-term therapeutic effect needs to be investigated in a multicenter, large sample clinical study.
3., the results of this study are encouraging, but there are still some shortcomings. Further research on cell or gene level is needed to confirm the mechanism of electric coagulation against scarring. Moreover, the follow-up time of this study needs to be extended to verify whether there is a long-term maintenance effect of filtration pathway.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R779.6

【参考文献】