飞秒激光白内障超声乳化手术临床研究

发布时间：2018-06-08 19:09

本文选题：飞秒激光白内障 + 超声乳化手术飞秒激光穿透性角膜松解切口联合白内障　；参考：《天津医科大学》2016年博士论文

【摘要】：目的:观察飞秒激光白内障超声乳化手术对角膜内皮细胞、超声能量的使用、术中眼压及房水中炎性因子(IL-1β,IL-6及PGE2)浓度的影响,并观察术中术后并发症、系统性评价该新技术临床应用的安全性及有效性。观察飞秒激光穿透性角膜松解切口联合白内障超声乳化手术矫正角膜散光的临床效果,并利用Holladay-Cravy-Koch formula修正用于术前计算角膜松解切口弧长及轴位的参考表(nomogram)。方法:前瞻性研究。在山西省眼科医院行白内障超声乳化吸除联合人工晶体植入术的老年性白内障患者87例(114眼)分为2组,飞秒激光超声乳化手术组(FLACS组)44例(60眼),2.2mm同轴微切口白内障超声乳化手术组(传统组)43例(54眼)。对比两种手术方式对术后早期远视力,中央角膜厚度,角膜内皮细胞计数,超声能量的使用情况及术中术后并发症。收集42名老年性白内障患者前房水100微升,其中27例(27只眼)患者进行飞秒激光白内障手术,在飞秒激光操作之后,打开侧切口,抽取100微升前房水。15例(15只眼)患者在进行传统白内障超声乳化手术之前,抽取100微升前房水。用酶联免疫吸附实验对比观察两组前房水中IL-1β、IL-6、及PGE2的浓度。收集2014年2月至2014年6月在山西省眼科医院白内障科就诊的32例预行飞秒激光白内障超声乳化手术的老年性白内障患者(39眼),在手术开始前使用手持回弹式眼压计iCare测量基线眼压并记录解除负压吸引环及角膜接触镜后30秒、1分钟、2分钟、3分钟、5分钟及10分钟的眼压。每个时间点测量三次,取平均值用于数据分析。飞秒激光穿透性角膜松解切口联合白内障超声乳化手术矫正角膜散光的临床观察,收集2014年12月至2015年7月在山西省眼科医院白内障科就诊,预行飞秒激光穿透性角膜松解切口联合白内障超声乳化手术,角膜散光为0.7 D~3D之间的老年性白内障患者38例(48眼),记录裸眼视力,矫正视力。进行前节oct、iolmaster及角膜地形图orbscanⅡ检查。术后1天、1周、1个月、3个月进行随访,检查裸眼远视力,最佳矫正视力,屈光度。术后1个月及3个月复查角膜地形图orbscanⅡ查角膜曲率,前节oct查穿透性角膜松解切口深度。术前应用amolridonnenfeld参考表(nomogram)在线计算角膜松解切口位置及弧长。利用飞秒激光制作一对直径为8mm穿透性角膜松解切口在白内障手术的同时矫正角膜散光。散光的评估采用alpins向量分析法,计算目标矫正散光向量、手术矫正散光向量、误差向量、误差率、矫正率、误差值、误差角及方向偏移,并绘制double-angleplots散点图显示术前及术后角膜散光的分布。同时应用holladay-cravy-kochformula计算wtw-atw,显示松解切口对角膜散光造成的总体变化(neteffect),修正参考表。结果:飞秒激光白内障超声乳化手术(lensx设备)使超声能量的使用显著减少,超声时间较传统组减少29.69%,累计释放能量较传统组减少48.89%。flacs组术后早期中央角膜厚度的恢复早于传统组。前囊膜切开过程中,4眼(6.67%)前囊膜片未完全游离,需要用撕囊镊辅助撕开,其中3眼(5%)手工完整撕开前囊膜,1眼(1.67%)发生小的撕裂,但未累及赤道部,所有病例未发生后囊膜破裂并发症。4例(6.67%)在激光后出现瞳孔缩小。飞秒激光白内障超声乳化手术的飞秒激光操作,会导致房水中il-1β、il-6及pge2浓度显著升高(p0.01),但三种因子的浓度与患者年龄、白内障核硬度、负压吸引时间和飞秒激光发射时长无关。飞秒激光白内障超声乳化手术在移除负压吸引环后30秒、1分钟、2分钟、3分钟、5分钟及10分钟,眼压分别为21.61mmhg、17.34mmhg、16.80mmhg、17.20mmhg、17.13mmhg及17.86mmhg。与基线相比,2分钟的眼压值低于基线水平,差异有统计学意义(p0.05)。各个观察时间点的眼压与负压吸引时间及飞秒激光发射时长均无相关性(p0.05)。飞秒激光穿透性角膜松解切口联合白内障超声乳化手术术后1个月及3个月角膜散光由术前1.42±0.43d下降至0.79±0.39d及0.78±0.38d。术后3个月,角膜散光≤1.0D的比例由术前16%升高至87%,≤0.5D的患者由术前2%上升至50%,术后1至3个月散光值稳定。术后1个月及3个月平均手术矫正散光向量(SIA)为1.14±0.63 D及1.05±0.56 D。SIA与目标校正散光向量(TIA)呈正相关,但SIA小于TIA,表现为欠矫。术后1个月及3个月误差值(EM)分别为0.30±0.50 D及0.42±0.46 D;矫正率(CI)为0.78±0.38及0.72±0.32,小于理想值1,两指标均表示欠矫。误差向量(DV)表示术后散光,较术前有明显下降。术后1个月及3个月误差率(ER)的结果为0.60±0.34及0.57±0.32。术后1个月,AE的平均值为1.67±29.84°(-80.78°~89.77°);术后3个月时,AE的平均值为2.14±18.24°(-41.80°~47.73°)。术后逆规散光(ATR)组SIA值为1.25±0.58D大于顺规散光(WTR)组0.86±0.50 D,ATR组的DV、ER及ME值均小于WTR组,显示ATR组术后散光误差率及误差值更小。ATR组的CI为0.83±0.25高于WTR组的0.57±0.30,显示ATR的矫正率接近80%,而WTR组的矫正率接近60%,ATR组的矫正率更高。LenSx飞秒激光平台制作深度达90%的穿透性角膜松解切口,术后1个月及3个月时,深度为78.6%及78.9%,切口深度并未达到理想的90%。结论:飞秒激光白内障超声乳化手术与传统2.2mm同轴微切口白内障超声乳化手术相比,其使用的超声能量显著减少,术后早期角膜组织恢复更快。该手术飞秒激光操作可使房水中IL-1β、IL-6及PGE2浓度升高。负压吸引导致眼压波动。飞秒激光穿透性角膜松解切口联合白内障超声乳化手术矫正角膜中低度散光安全有效。
[Abstract]:Objective: To observe the effects of femtosecond laser cataract phacoemulsification on the corneal endothelial cells, the use of ultrasonic energy, intraoperative intraocular pressure and the concentration of inflammatory factors (IL-1, IL-6 and PGE2) in aqueous humor, and observe the postoperative complications, and systematically evaluate the safety and effectiveness of the new technique in the clinical application of this new technique. The clinical effect of incision combined with cataract phacoemulsification to correct corneal astigmatism and the reference table (nomogram) modified by Holladay-Cravy-Koch formula for preoperative calculation of the arc length and axis of corneal loosening incision. Method: prospective study in Shanxi ophthalmic hospital with phacoemulsification and intraocular lens implantation 87 cases (114 eyes) of senile cataract were divided into 2 groups, 44 cases (60 eyes) with femtosecond laser phacoemulsification group (group FLACS), 43 cases (54 eyes) with 2.2mm coaxial micro incision phacoemulsification group (traditional group). Comparison of two surgical methods for early postoperative far vision, central corneal thickness, corneal endothelial cell count, and ultrasonic energy use 42 patients with senile cataract were collected by 100 micro elevation of anterior chamber water, of which 27 cases (27 eyes) underwent femtosecond laser cataract surgery. After the femtosecond laser operation, the side incision was opened, and 100 micro elevation anterior chamber water (15 eyes) was extracted.15 (15 eyes) before the traditional cataract phacoemulsification, and before the traditional cataract phacoemulsification, 100 l l l l was extracted. Aqueous enzyme linked immunosorbent assay (ELISA) was used to compare the concentration of IL-1 beta, IL-6, and PGE2 in two groups of anterior chamber water. 32 cases of senile cataract (39 eyes) were collected from February 2014 to June 2014 at the cataract Department of Shanxi ophthalmology hospital, which was treated with femtosecond laser cataract phacoemulsification, and the handheld rebound type of intraocular pressure was used before the operation. ICare measured baseline intraocular pressure and recorded 30 seconds, 1 minutes, 2 minutes, 3 minutes, 5 minutes and 10 minutes of intraocular pressure after negative pressure suction ring and corneal contact lens. Measure three times at each time point for data analysis. Clinical observation of corneal astigmatism corrected by femtosecond laser penetrating keratoplasty incision combined with white obstacle phacoemulsification From December 2014 to July 2015, the treatment of cataract in the Shanxi ophthalmological hospital was collected. Femtosecond laser penetrating keratoplasty combined with cataract phacoemulsification and 38 cases of senile cataract (48 eyes) with corneal astigmatism between 0.7 D~3D were collected. The naked eye vision and corrected visual acuity were recorded. The anterior segment OCT, IOLMaster and corneal topographic map were performed. Orbscan II examination. Follow up 1 days, 1 weeks, 1 months, 3 months, examination of naked eye vision, best corrected visual acuity, diopter. Corneal topography of corneal topography was examined by Orbscan II in 1 months and 3 months after operation. The depth of penetrating keratoplasty in anterior segment was examined by OCT, and corneal loosening was calculated online by amolridonnenfeld reference table (nomogram) before operation. The position of the incision and the arc length. Using the femtosecond laser to make a pair of 8mm penetrating keratoplasty incision to correct corneal astigmatism at the same time in cataract surgery. The evaluation of astigmatism by alpins vector analysis is used to correct astigmatism vector, correct astigmatism vector, error rate, correction rate, error value, error angle and direction. The distribution of corneal astigmatism before and after double-angleplots was plotted and the distribution of corneal astigmatism before and after the operation was plotted. At the same time, the holladay-cravy-kochformula calculation of wtw-atw was used to show the overall changes in corneal astigmatism (NetEffect) and corrected reference table. Results: the ultrasonic energy of femtosecond laser phacoemulsification (lensx equipment) was made. With significant reduction, the time of ultrasound was reduced by 29.69% than that in the traditional group. The cumulative release of energy was earlier than that in the traditional group. The early recovery of central corneal thickness in the 48.89%.flacs group was earlier than that in the traditional group. In the process of anterior capsule incision, 4 eyes (6.67%) were not completely free, and tearing tweezers were needed to tear open the anterior capsule, and 3 eyes (5%) were manually tearing the anterior capsule, 1 The eyes (1.67%) had small tear, but did not involve the equator, all cases did not have posterior capsule rupture..4 cases (6.67%) appeared to decrease the pupil after laser. Femtosecond laser cataract operation of femtosecond laser phacoemulsification could lead to a significant increase in the concentration of IL-1 beta, IL-6 and PGE2 in aqueous humor (P0.01), but the concentration of three factors and the year of the patient Age, cataract nuclear hardness, negative pressure attraction time and duration of femtosecond laser emission. Femtosecond laser cataract phacoemulsification, 30 seconds, 1 minutes, 2 minutes, 3 minutes, 5 minutes and 10 minutes after the removal of negative pressure suction ring, and intraocular pressure of 21.61mmhg, 17.34mmhg, 16.80mmhg, 17.20mmhg, 17.13mmhg and 17.86mmhg. respectively to the baseline, 2 minutes of intraocular pressure The difference was statistically significant below the baseline level (P0.05). There was no correlation between the intraocular pressure of the observation time and the duration of the negative pressure and the duration of the femtosecond laser emission (P0.05). The corneal astigmatism of the femtosecond laser penetrating keratoplasty combined with cataract phacoemulsification decreased from 1.42 + 0.43d to 0.79 + 0. in the 1 and 3 months after the cataract phacoemulsification. At 3 months after 39d and 0.78 + 0.38d., the proportion of corneal astigmatism less than 1.0D increased from 16% to 87% before operation, and the patients with less than 0.5D increased from 2% to 50% before operation and 1 to 3 months after operation. The average corrected astigmatism vector (SIA) was 1.14 + 0.63 D and 1.05 + D.SIA with target correction astigmatism vector (TIA) in 1 and 3 months postoperatively. IA was less than TIA and was under correction. The 1 month and 3 month error values (EM) were 0.30 + 0.50 D and 0.42 + 0.46 D, respectively, the correction rate (CI) was 0.78 + and 0.72 + 0.32, less than 1 of the ideal value, and two index were all under correction. The error vector (DV) indicated the postoperative astigmatism. The average value of AE was 1.67 + 29.84 degrees (-80.78 [~89.77]) at 1 months after 34 and 0.57 + 0.32.. The average value of AE was 2.14 + 18.24 degrees (-41.80 / ~47.73) at 3 months after operation. The SIA value of the reverse optical astigmatism (ATR) group after operation was 1.25 + 0.58D greater than 0.86 + 0.50 D. The CI of.ATR group was 0.83 + 0.25 higher than that of group WTR, 0.57 + 0.30, which showed that the correction rate of ATR was close to 80%, and the correction rate of WTR group was close to 60%. The correction rate of group ATR was higher than that of.LenSx femtosecond laser platform making penetrating keratoplasty with 90% depth of 90%. The depth was 78.6% and 78.9% at 1 and 3 months postoperatively, and the depth of incision was not in depth. The ideal 90%. conclusion: femtosecond laser cataract phacoemulsification, compared with the traditional 2.2mm coaxial micro incision phacoemulsification, has a significant reduction in ultrasonic energy and faster corneal tissue recovery. The operation of femtosecond laser operation can increase the concentration of IL-1 beta, IL-6 and PGE2 in aqueous humor. Negative pressure attraction leads to intraocular pressure. Conclusion: femtosecond laser penetrating keratoplasty combined with phacoemulsification for corneal astigmatism is safe and effective.
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R779.6

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