全植床深板层角膜移植术后角膜透明性变化及其与基质细胞重构的关系

发布时间：2018-09-03 10:25

【摘要】：目的：全植床深板层角膜移植术(Cull-bed deep lamellar keratoplasty, FBDLK)是我们独创的一种深板层角膜移植技术,该技术通过基质钩取联合粘弹剂分离法可以成功地暴露全植床的受体角膜后弹力膜,术中我们采用-20℃冰冻保存的供体角膜作为移植材料。我们已证实了FBDLK手术的临床价值,但关于这种水肿无细胞的移植材料在FBDLK术后的透明性变化和细胞成分重构的问题则尚待解决。对此进行深入研究可以为这项新技术的推广应用提供更有力的理论依据。本研究拟观察FBDLK术后冰冻保存供体角膜的透明性变化以及基质细胞重构的过程,并评价两者间的关系。方法：研究对象为2002年2月至2009年10月期间在浙江大学附属邵逸夫医院眼科成功接受FBDLK手术的病例133人141眼。术前原发病包括圆锥角膜(n=56眼),单疱病毒性角膜炎后角膜白斑(n=41眼),外伤后角膜白斑(n=25眼)和角膜变性(n=19眼)。病人于术后2天、7天,0.5个月、1个月、3个月、6个月、12个月和24个月进行随访,每次随访观察角膜透明性变化并进行裂隙灯显微镜照片记录,并于术后0.5、1、3、6、12和24个月对患者进行超声角膜测厚和共焦显微镜检查。回顾分析病历资料,评估中央角膜厚度变化,通过裂隙灯显微镜照片观察分析角膜水肿混浊和角膜前(25%)、中(50%)、后(25%)基质Haze (非水肿性的基质混浊)以及植片植床交界面混浊度的变化。并通过共焦显微镜资料观察角膜各基质层紊乱无细胞反光物质和基质细胞的形态及数量的变化规律。最后通过裂隙灯显微镜和共焦显微镜对应观察和相关分析研究Haze与基质细胞重构的关系。结果：FBDLK术后冰冻保存供体角膜的平均上皮化完成时间为2.9±1.5天。中央角膜厚度在术后3个月时减少至正常水平,术后1年时趋于稳定,达到515.6±50.6μm。角膜水肿混浊于术后1个月内迅速消退。角膜基质Haze最早在术后1个月时出现,3个月时最明显,12个月时基本减退。术后3-6个月时,前基质Haze级别显著高于中、后基质(P=0.000, Mann-Witney U检验)。不同术眼的前基质Haze所达到的严重程度有所区别,通过二维逻辑回归分析证实年龄是影响明显前基质Haze形成的主要因素(危险因子,0.93；95%置信区间,0.87-0.99,P=0.015)。共焦显微镜下,部分冰冻保存供体角膜(33.1%)中可观察到残留细胞反光结构,均于术后1个月内消失,以后出现紊乱无细胞反光物质和基质细胞的聚集。紊乱无细胞反光物质的变化过程和Haze一致,且两者在术后3-24个月时存在显著正相关性(r=0.46-0.51,P=0.000-0.001)。裂隙灯显微镜下明显的Haze形成对应于共焦显微镜下角膜基质内大量紊乱无细胞反光物质的聚集,Haze减退对应于紊乱无细胞反光物质减少和基质细胞数量的增加。基质细胞密度从FBDLK术后3-24个月逐渐增加,前基质的基质细胞密度显著高于中、后基质(P0.001,One-Way ANOVA). FBDLK术后2年角膜前、中、后基质重构的基质细胞密度分别达到正常角膜的28%、19%和9%。低年龄,术后3个月时有明显前基质Haze形成的患者,术后1年时前基质重构的基质细胞密度越高。植片植床交界面混浊在术后1个月内较明显,术后3个月时开始减退,术后1年时基本减退。术后0.5-12个月植片植床交界面混浊与紊乱无细胞反光物质间存在显著正相关(r=0.23-0.44,P=0.000-0.02)。结论：FBDLK术后1个月时冰冻保存供体角膜的水肿混浊消退,3个月时恢复正常角膜厚度。角膜基质Haze可能是FBDLK术后基质细胞重构过程的一个重要现象,与紊乱无细胞反光物质的聚集有关,在术后3个月时最重,1年时消退。前基质重构的基质细胞显著高于中、后基质,基质细胞密度在术后2年时仍显著低于正常角膜水平。
[Abstract]:OBJECTIVE: Full-bed deep lamellar keratoplasty (FBDLK) is an innovative technique for deep lamellar keratoplasty. It can successfully expose the posterior elastic membrane of the recipient cornea by matrix hooking combined with viscoelastic separation. As transplantation materials, we have confirmed the clinical value of FBDLK surgery, but the problem of transparency change and cell component remodeling of this edematous acellular graft after FBDLK remains to be solved. Further study on this issue will provide a more powerful theoretical basis for the popularization and application of this new technique. The changes of corneal transparency and the process of stromal cell remodeling after FBDLK were evaluated.
Methods: From February 2002 to October 2009, 133 patients (141 eyes) underwent FBDLK surgery in the Ophthalmology Department of Shaoyou Hospital, Zhejiang University. Primary preoperative diseases included keratoconus (n = 56 eyes), keratoleukoplakia after herpes simplex keratitis (n = 41 eyes), corneal leukoplakia after trauma (n = 25 eyes) and corneal degeneration (n = 19 eyes). All patients were followed up 2 days, 7 days, 0.5 months, 1 month, 3 months, 6 months, 12 months and 24 months postoperatively. The changes of corneal transparency were observed and slit lamp photographs were recorded. Ultrasound corneal thickness and confocal microscopy were performed at 0.5, 1, 3, 6, 12 and 24 months postoperatively. Thickness changes were observed and analyzed by slit lamp microscopy, including corneal edema and opacity, anterior (25%), middle (50%) and posterior (25%) stroma Haze (non-edematous stroma opacity) and interface opacity of implant bed. Confocal microscopy was used to observe the morphology of corneal stroma with disordered acellular reflector and stromal cells. Finally, the relationship between Haze and the remodeling of stromal cells was studied by slit lamp microscopy and confocal microscopy.
Results: The average epithelialization time of frozen preserved donor cornea after FBDLK was 2.9 (+ 1.5) days. The central corneal thickness decreased to normal level at 3 months after FBDLK, and stabilized at 515.6 (+ 50.6) microns at 1 year after FBDLK. The corneal edema and turbidity subsided rapidly within 1 month after FBDLK. At 3-6 months after surgery, the Haze level in the anterior matrix was significantly higher than that in the middle and posterior matrix (P = 0.000, Mann-Witney U test). The severity of Haze in the anterior matrix was different in different eyes. Two-dimensional logistic regression analysis showed that age was the main factor affecting the formation of Haze in the anterior matrix. Factor, 0.93; 95% confidence interval, 0.87-0.99, P = 0.015). Reflective structure of residual cells was observed in some frozen corneas (33.1%) under confocal microscope, and disappeared within one month after operation. After that, disordered acellular reflector and matrix cell aggregation appeared. There was a significant positive correlation (r = 0.46-0.51, P = 0.000-0.001) between the two groups at 3-24 months postoperatively. Haze formation under slit lamp microscopy corresponded to a large number of disordered acellular reflectors in the corneal stroma under confocal microscopy. The decrease of Haze corresponded to a decrease in disordered acellular reflectors and an increase in the number of stromal cells. Cell density increased gradually from 3 to 24 months after FBDLK. The density of stromal cells in anterior stroma was significantly higher than that in middle and posterior stroma (P 0.001, One-Way ANOVA). The density of stromal cells reconstructed in anterior, middle and posterior stroma reached 28%, 19% and 9% of normal cornea 2 years after FBDLK. The density of stromal cells was higher before 1 year after operation. The turbidity of graft-bed interface was more obvious at 1 month after operation, began to decrease at 3 months after operation, and basically decreased at 1 year after operation. There was a significant positive correlation between the turbidity of graft-bed interface and the disordered acellular reflector at 0.5-12 months after operation (r = 0.23-0.44, P = 0.000-0.02).
Conclusion: The edema and turbidity of frozen preserved donor cornea subsided at 1 month after FBDLK and recovered to normal corneal thickness at 3 months after FBDLK. Corneal stromal Haze may be an important phenomenon in the process of stromal cell remodeling after FBDLK, which is related to the disordered accumulation of acellular reflective substances. It was the most severe at 3 months after FBDLK and subsided at 1 year after FBDLK. Stromal cells were significantly higher than those in the middle and posterior stroma, and the density of stromal cells was still significantly lower than that of normal cornea at 2 years after surgery.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R779.65

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