晶状体前囊膜在二切口青光眼白内障联合手术中的应用研究

发布时间：2018-05-06 14:40

  本文选题：青光眼白内障联合手术 + 晶状体前囊膜　； 参考：《天津医科大学》2012年硕士论文

【摘要】：目的 1.观察自体晶状体前囊膜作为植入物应用于兔眼超声乳化联合小梁切除术中抗滤过道瘢痕化的效果。 2.比较自体晶状体前囊膜与丝裂霉素C应用于青光眼白内障联合手术的临床效果,评价晶状体前囊膜的安全性和有效性。 方法 1.动物实验：对20只新西兰白兔实施超声乳化联合小梁切除术。随机分为两组,每组各10只兔(20只眼),第1组：随机选取1只眼做超声乳化+小梁切除术(简称Trab组),另1只眼做超声乳化小梁切除术并辅助应用晶状体前囊膜(简称ALC组)；第2组：随机选取1只眼做超声乳化小梁切除术联合应用丝裂霉素C(简称MMC组)；另1只眼做超声乳化小梁切除术并辅助应用晶状体前囊膜。第3、7、14、21、28天观察并比较三种不同术式手术后眼前节反应、滤过泡形态及功能、眼压情况,并于上述5个时间点两组中各随机处死1只兔制作病理切片,光学显微镜下观察各组滤过道情况。 2.临床研究：选择2010年5月至2011年3月在天津医科大学眼科中心确诊的青光眼合并白内障的住院患者共60例(60只眼),行二切口白内障超声乳化吸出、后房型折叠式人工晶状体植入及小梁切除术,采用随机的方法,分为ALC组和MMC组,术中ALC组29例(29只眼)巩膜瓣下植入自体晶状体前囊膜,MMC组31例(31只眼)应用丝裂霉素。术后1、3、6、12月随访,观察两组患者的眼压、最佳矫正视力、滤过泡形态、术后并发症等情况,并定期行超声生物显微镜及视野检查,对观察结果进行分析比较。采用SPSS16.0统计学软件进行数据处理,以P0.05作为差异有统计学意义。 结果 1.动物实验：(1)眼前节反应：3种术式术后第1、5天,结膜充血差异无统计学意义(χ2=0.784,0.232,P值均0.05)；角膜混浊差异无统计学意义(χ2=1.200,3.442,P值均0.05)；术后第1、3、7、14天前房炎性反应差异无统计学意义(χ2=3.599,3.200,3.388,2.133,P值均0.05),所有眼均未发现囊膜对兔眼的刺激体征；(2)滤过泡情况：术后第21天,3种术式术后功能性滤过泡所占比例分别为14.3%(1/7)、92.9%(12/14)、85.7%(6/7),差异有统计学意义(χ2=13.077,P0.05),结合所占比例值,可以认为ALC组和MMC组的功能性滤过泡数多于Trab组,其他观察时间3组之间差异无统计学意义；(3)眼压：3种术式术后眼压早期下降,后逐渐升高,术后第14、21天眼压差异有统计学意义(χ2=14.377,10.279,P值均0.05),其他观察时间3组之间差异无统计学意义；(4)组织病理学：术后7天除Trab组有1眼近端部分滤过道关闭外,ALC组和MMC组滤过道均开放,ALC组可见囊膜组织结构完整,边缘清楚,与周围组织分界明显,未见炎症细胞侵入；术后28天Trab组滤过道完全被瘢痕组织阻塞,MMC组滤过道远端闭合,近端小部分开放,ALC组滤过道完全开放,囊膜边缘变钝,未见淋巴细胞浸润。 2.临床研究：(1)眼压：术后1年时,ALC组眼压从术前(22.28±10.81mmHg)下降至(12.24±2.91mmHg),差异有统计学意义(t=4.851,P0.05); MMC组眼压从术前(26.50±12.69mmHg)下降至(11.15±2.87mmHg),差异有统计学意义(t=6.701,P0.05)。组间各时间点眼压下降程度无统计学差异；(2)最佳矫正视力：术后1年时,两组患者视力较术前提高,差异均有统计学意义(tALc=-5.294, P0.05; tMMc=-4.027, P0.05),两组之间视力差异无统计学意义(t=-0.022,P0.05)；(3)滤过泡形态：术后1年时,ALC组Ⅰ、Ⅱ型滤过泡分别有4眼、21眼,即功能性滤过泡占86.2%(25/29),Ⅲ型滤过泡4眼；MMC组Ⅰ、Ⅱ型滤过泡分别有5眼、24眼,即功能性滤过泡占93.5%(29/31),Ⅲ型滤过泡2眼,两组均未出现Ⅳ型滤过泡,两组滤过泡差异无统计学意义(χ2=0.912,P0.05)；(4)手术成功率与抗青光眼药物使用情况：术后1年时,ALC组手术成功率为86.2%(25/29),MMC组为93.5%(29/31),两组间差异无统计学意义(χ2=0.897,P0.05)。术前ALC组患者平均使2.45种抗青光眼药物,MMC组为2.61种；术后1年时,ALC组减少至0.14种,MMC组为0.06种,术前术后比较差异有统计学意义(tALc=13.970, tMMC=14.772, P0.05);(5)并发症：两组患者术后并发症在术后2周内消退或缓解,ALC组未出现严重排斥反应；(6)视野：术后1年时,两组患者的平均视野缺损值、平均模式标准差的变化与术前相比均无统计学差异,即术后视野均保持稳定；(7)超声生物显微镜检查：两组患者术后3个月均可见清晰的滤过间隙,滤过道内外口通畅,而ALC组部分患者可见巩膜瓣下晶状体前囊膜的强回声,为晶状体前囊膜。 结论 1.动物实验：超声乳化小梁切除术中应用晶状体前囊膜与丝裂霉素相比,两者在眼前节反应及降眼压效果方面无明显差异,但组织病理学结果表明植入晶状体前囊膜维持滤过道开放的时间长于应用丝裂霉素,两者均明显优于单纯小梁切除术后的降眼压效果及滤过道瘢痕化程度。 2.临床研究：晶状体前囊膜应用于青光眼白内障联合术中能有效防止滤过泡瘢痕化,控制眼压、提高视力、稳定视野,与传统应用丝裂霉素C的疗效相当,方法安全有效。
[Abstract]:objective
1. to observe the effect of autologous lens anterior capsule as an implant in the treatment of rabbit eye phacoemulsification combined with trabeculectomy.
2. compare the clinical effect of the anterior capsule of autologous lens and mitomycin C in the combined operation of glaucoma and cataract, and evaluate the safety and effectiveness of the anterior lens capsule.
Method
1. animal experiments: 20 New Zealand white rabbits were treated with phacoemulsification combined with trabeculectomy. They were randomly divided into two groups, 10 rabbits in each group (20 eyes) and first groups: 1 eyes were randomly selected to do phacoemulsification and trabeculectomy (Trab group), the other 1 eyes were excised by phacoemulsification and assisted with the anterior capsule (ALC group); second Group: 1 eyes were randomly selected to do phacoemulsification and trabeculectomy combined with mitomycin C (MMC group); the other 1 eyes were treated with phacoemulsification and assisted with the anterior capsule membrane. On day 3,7,14,21,28, the anterior segment reaction, the morphology and function of filter bubble, the intraocular pressure, and the 5 of the three different surgical procedures were compared. At each time point, 1 rabbits were randomly executed in two groups to make pathological sections, and the filter passages were observed under light microscope.
2. clinical study: 60 cases (60 eyes) of hospitalized patients with glaucoma diagnosed in Ophthalmological Center of Tianjin Medical University from May 2010 to March 2011 were selected with two incision phacoemulsification, posterior chamber foldable intraocular lens implantation and trabeculectomy, and were randomly divided into group ALC and group MMC, ALC The anterior capsule of autologous lens was implanted under the scleral flap in 29 cases (29 eyes), and 31 cases (31 eyes) in group MMC were treated with mitomycin. The intraocular pressure of the two groups, the best corrected visual acuity, the form of filtering bleb and the postoperative complications were observed in the group of 31 (31 eyes), and the observation results were analyzed and compared. Data was processed with SPSS16.0 statistical software, and P0.05 as the difference was statistically significant.
Result
1. animal experiments: (1) anterior segment reaction: there was no significant difference in conjunctival hyperemia (x 2=0.784,0.232, P value 0.05) on day 1,5 after 3 surgical operations, and there was no statistically significant difference in corneal opacity (x 2=1.200,3.442, P value 0.05), and there was no statistical significance (x 2=3.599,3.200,3.388,2.133, P value 0) before the operation (0). .05), all eyes did not find the stimulation of the capsule to the rabbit eye; (2) the filter bubble situation: twenty-first days after the operation, the proportion of the 3 functional filtration blebs was 14.3% (1/7), 92.9% (12/14), 85.7% (6/7), the difference was statistically significant (x 2=13.077, P0.05), combined with the proportional value, the functional filter bubbles of the ALC group and MMC group could be considered. Number more than Trab group, other observation time between the 3 groups had no statistical significance; (3) intraocular pressure: 3 kinds of postoperative intraocular pressure decreased early, then gradually increased, postoperative 14,21 day intraocular pressure difference was statistically significant (x 2=14.377,10.279, P value is 0.05), the other observation time between the 3 groups had no statistical significance; (4) histopathology: 7 after the operation 7 In group Trab, 1 eyes were close to the proximal part of the filter, ALC and MMC were open, and the ALC group showed that the membrane structure was complete, the edge was clear, and the boundary was clear, and no inflammatory cells were intruded. The Trab group was completely blocked by scar tissue on the 28 day after the operation, and the distal end of the MMC group was closed, the proximal part of the filter was open, ALC The filtering passages were completely open, and the edges of the membranes were blunt and there was no lymphocytic infiltration.
2. clinical study: (1) intraocular pressure: at 1 years after operation, intraocular pressure in group ALC decreased from (22.28 + 10.81mmHg) to (12.24 + 2.91mmHg), and the difference was statistically significant (t=4.851, P0.05), and in group MMC, intraocular pressure dropped from (26.50 + 12.69mmHg) to (11.15 + 2.87mmHg), and the difference was statistically significant (t=6.701, P0.05). The degree of IOP decline at each time point between groups was not unified. Study difference; (2) best corrected visual acuity: 1 years after operation, the visual acuity of the two groups was higher than before the operation, the difference was statistically significant (tALc=-5.294, P0.05; tMMc=-4.027, P0.05), and there was no statistical difference between the two groups (t=-0.022, P0.05); (3) the form of filtering bleb: 1 years after the operation, ALC group I, type II filter bubbles were 4 eyes and 21 eyes respectively, that is, Functional filtration blebs accounted for 86.2% (25/29) and type III filter bubbles in 4 eyes; group I and type II filter bubbles were 5 eyes, 24 eyes, 93.5% (29/31), 2 eyes of type III filter bubbles, two groups without type IV filter bubbles, and two groups of filter bubbles in two groups (x 2=0.912, P0.05), and (4) the success rate of operation and the use of anti glaucoma drugs (4). 1 years after operation, the success rate of group ALC was 86.2% (25/29) and 93.5% (29/31) in group MMC. There was no statistical difference between the two groups (2=0.897, P0.05). Before operation, there were 2.45 kinds of anti glaucoma drugs in group ALC and 2.61 in MMC group; 1 years after the operation, the ALC group decreased to 0.14, and the MMC group was 0.06. The difference was statistically significant before and after the operation. TALc=13.970, tMMC=14.772, P0.05); (5) complications: two groups of postoperative complications were subsided or remission within 2 weeks after operation, and group ALC had no serious rejection; (6) the average visual field defect value of the patients in the 1 year after operation, and the average pattern standard deviation was not statistically different from that before the operation, that is, the postoperative visual field was maintained. Stability; (7) ultrasound biomicroscopy: two groups of patients showed clear filtration space at 3 months after 3 months of operation, and the inside and outside of the filter were unobstructed, while the anterior capsule of the scleral flap was strongly echoed by the scleral flap, which was the anterior capsule of the lens.
conclusion
1. animal experiments: there was no significant difference between the anterior capsule and mitomycin in the anterior capsule reaction and the effect of the intraocular pressure in the phacoemulsification of the trabeculectomy, but the histopathological results showed that the time of the implantation of the anterior capsule to maintain the filter was longer than that of mitomycin. Both of them were obviously superior to the simple trabeculae. The effect of lowering intraocular pressure and scar degree of filtering passage after resection were observed.
2. clinical study: the application of the anterior capsule of the lens to the combined operation of glaucoma and cataract can effectively prevent the scarring of filter bubbles, control the intraocular pressure, improve the vision and stabilize the field of vision, which is quite effective with the traditional application of mitomycin C, and the method is safe and effective.

【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
，

本文编号：1852707