白内障手术切口及缝线的改进

白内障手术切口及缝线的改进湖南江华瑶族自治县二医院眼科李金生１９９０年以来，笔者采用以穹窿部为基底的结膜瓣，在角巩缘切口作１－１．５ｍｍ的巩膜瓣及切口内缝线打结的方法，共作２０例２４只眼白内障手术，效果满意，现报告如下。方法：沿上方角膜缘（３～９点）...     

无缝线隧道切口可折叠人工晶体植入术后房角镜观察

了解无缝线隧道切口白内障手术内切口及周边虹膜的变化。方法用Ｇｏｌｄｍａｎｎ房角镜，术前、术后观察３．５ｍｍ无缝线巩膜隧道切口超声乳化白内障摘除及可折叠人工晶体植入术５６例（５８只眼）的前房角改变。结果５６只眼可见内切口位于ｓｃｈｗａｌｂｅ线前的透明角膜上，２只眼内切口在Ｓｃｈｗａｌｂｅ线上。４２只眼（７２．４１％）内切口平整，１４只眼（２４．１４％）内切口后唇轻微卷曲，５只眼（８．６２％）角膜后弹力层脱离，２只眼（３．４５％）发生虹膜周边前粘连。结论通过无缝线隧道切口进行可折叠人工晶体植入术，周边虹膜前粘连发生率较低，但容易发生角膜后弹力层脱离。     

三种巩膜隧道外切口超声乳化白内障吸除术后手术源性散光的动态研究

目的 比较３种不同长度巩膜隧道外切口超声乳化白内障吸除术后产生手术源性散光（ｓｕｒｇｉｃａｌｌｙ ｉｎｄｕｃｅｄ ａｓｔｉｇｍａｔｉｓｍ,ＳＩＡ）度数及方向的变化规律,并评价手术效果。方法 将１０４例（１０４只眼）白内障患者分为Ａ、Ｂ、Ｃ３组,分别以３．２、５．５及７．０ｍｍ巩膜隧道外切口施地超声乳化白内障吸除术,测定术前、术后１周、１、３和６个月的角膜曲率,运用Ｃｒａｖｙ向量分析法计算ＳＩＡ度数     

无缝线切口人工晶体植入术

报告弦长５．５ｍｍ无缝线切口植入直径６．０ｍｍＰＭＭＡ人工晶体５０只眼的切口建造方法、自身关闭程度及术后手术性角膜散光的结果。患者年龄范围为８￣７２岁。对其中１３只眼行一期植入，３７只眼为二期植入术。该组患者中１９只眼无晶体眼既往有穿通伤和１￣３次手术史，１５只眼无晶体眼为老年性白内障摘除术后，１４只眼为先天性白内障，其他２只眼。手术切口包括巩膜外切口，弦长５．５ｍｍ；巩膜隧道分离；辨状角膜内切口     

角巩膜缘小切口不缝合超声乳化术

超声乳化术,切口是保证手术操作顺利与成功的关键一步,常规的巩膜隧道切口和透明角膜切口对于初学者来说不易掌握,我们采用角巩缘小切口不缝合超声乳化技术对１００只眼白内障患者进行手术,现将结果与体会报告如下。一、资料和方法１．一般资料：老年性白内障８２例,外伤性白内障１８例,男性５４例,女性４６例。２．操作技术要点：（１）作以穹窿为基底结膜瓣,不必过大。（２）于角膜缘后界后１ｍｍ,做垂直于巩膜与角膜平行的切口,深达巩膜厚度的１／２,切口长度根据所植人人工晶体的类型而定。（３）沿切口在同一巩膜板层平行向…     

小切口非超声乳化人工晶状体植入术临床分析

目的 探讨小切口非超声乳化白内障摘出联合人工晶状体植入术的效果。方法 采用５．５～６．５ｍｍ反弧形巩膜隧道切口摘出白内障植入后房型人工晶状体。并与常规大切口手术进行对比。结果 术后１周及３月，小切口组矫正视力均优于常规大切口组（Ｐ〈０．０５），散光绝对值，亦均优于常规大切口组（Ｐ〈０．０５）。结论 小切口手术组织损伤轻、术后散光少、视力恢复快，不需要昂贵设备，便于在基层医院推广应用．     

4mm巩膜隧道自闭切口白内障超声乳化吸出术

为评价小切口技术中，巩膜隧道自闭切口的自闭性能，和对角膜散光的影响。采用４ｍｍ带角膜瓣的巩膜隧道切口，对２７眼行白内障超声乳化吸出术，其中２０眼未缝合，７眼子午线方向缝１针。结果：术后３～５天，角膜手术性散光（Ｊａｆｅ法计算）缝线组离散程度大于无缝线组。术后３～５天到１月，两组中角膜散光（Ｎａｅｓｅｒ法计算）都存在逆规向的漂移。术后眼压变化幅度两组间无差别。房角镜观察内切口整体或部分靠后者有渗漏迹象。结论：巩膜隧道自闭切口具有一定优点，但当角膜瓣构造不正确时，应当缝合以防止渗漏     

高度近视白内障超声乳化摘出术

目的 评价高度近视合并白内障超声乳化摘出术的临床疗效。方法 ３６例（４４眼）眼轴长≥２６ｍｍ的高度近视合并白内障,其中Ⅱ级核１０眼,Ⅲ级核３１眼,Ⅳ级核３眼。采用巩膜隧道式切口及囊袋内超声乳化,并植入人工晶状体。结果 术后１月最佳矫正视力≥０．５者２３眼（５２．３％）;手术主要并发症为后囊破裂４眼（９．０９％）,角膜水肿３眼（６．８２％）。视网膜脱离１眼（２．２７％）。结论 超声乳化联合人工晶状体     

巩膜瓣联合巩膜隧道切口行青光眼白内障三联手术的临床疗效观察

目的观察巩膜瓣联合巩膜隧道切口行青光眼白内障三联手术的临床疗效。方法对21例(23只眼)青光眼合并白内障患者采用巩膜瓣联合巩膜隧道切口行三联手术治疗,观察视力、眼压、滤过泡、术后并发症。结果术后眼压均满意控制,视力较术前均提高。结论该手术方式治疗青光眼合并白内障疗效满意,能够较好的控制眼压,术后视力恢复快,并发症少。     

葡萄膜炎并发白内障超声乳化摘除及人工晶体植入术

目的 探讨葡萄膜炎并发白内障超声乳化摘除及人工晶体植入术的疗效。方法 对２６例２６只眼患者行５．５ｍｍ的巩膜隧道切口,超声乳化白内障摘除,植入后房型人工晶体。结果 ２６只眼中有２只眼轻度炎症反应,全部瞳孔恢复圆瞳孔,术后１个月裸眼视力≥０．５者２２只眼（８４．６％）;≥０．３者３只眼（１１．５％）;〈０．０５者１只眼（３．９％）。结论 超声乳化白内障摘除术治疗葡萄膜炎并发白内障,术后炎症反应轻,视     

青光眼白内障联合手术治疗青光眼合并白内障

目的　探讨3种不同切口三联手术治疗青光眼合并白内障的效果。方法　将2 4例(2 6眼)青光眼合并白内障分为3组:11眼采用常规巩膜瓣下小梁切除联合白内障囊外摘出人工晶状体植入术;9眼采用小切口隧道式巩膜瓣小梁切除联合超声乳化吸出及后房人工晶状体植入术;6眼采用透明角膜切口超声乳化联合后房人工晶状体植入术及房角分离术。观察术后视力、眼压及并发症。结果　随访3月,术后平均眼压(15 . 12±3 . 42 )mmHg(1mmHg =0 .13 3kPa) ,与术前平均眼压(2 6 .5 0±4 .92 )mmHg比较有了明显下降,差异有显著性意义(t =0 . 897,P <0 .0 0 1) ;视力明显提高;并发症有角膜水肿(19. 2 3 % )及后囊浑浊(11. 5 3 % )。结论　青光眼白内障联合手术(三联手术)是治疗白内障合并青光眼的一种有效的方法。     

小切口小梁切除联合超声乳化白内障吸除术治疗青光眼合并白内障

目的　探讨 3 5mm小切口小梁切除联合超声乳化白内障吸除后房型人工晶状体植入术 (三联手术 )治疗青光眼合并白内障患者的效果。方法　应用小切口三联手术对 2 0例 (2 6只眼 )青光眼合并白内障患者进行手术治疗。术后随访 3～ 41个月 ,平均 16 1个月。结果　术前平均眼压(2 3 0 1± 2 6 3)mmHg(1mmHg =0 133kPa) ,术后随访最终平均眼压降至 (13 93± 1 85 )mmHg(P <0 0 0 1)。术后随访最终矫正视力范围 0 0 5～ 1 0 ,其中≥ 0 6者 17只眼 (6 5 % ) ,术后平均散光度0 81D ,其中 4只眼无散光度。术后早期 2只眼使用降眼压药物 ,随访后期无使用者。术后早期并发症角膜水肿 5只眼 (19% ) ,浅前房 3只眼 (12 % ) ;晚期并发症后发性白内障 6只眼 (2 3% )。结论　小切口三联手术治疗青光眼合并白内障患者 ,具有恢复有用视力、稳定眼压、减少术后用药、并发症少等理想效果。     

Glaucoma triple procedure comprising trabeculotomy with a fornix-based scleral flap

A new triple surgery procedure was applied to 20 primary open-angle glaucomatous (POAG) eyes. This technique comprises trabeculotomy with narrow (2–3 mm) fornix-based scleral flap, combined with extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC-IOL) implantation. As to surgical results, at two years postsurgery 53% (9/17) of the eyes were controlled under 21 mm Hg without medication, 35% (6/17) with topical medication alone. Eighteen (90%) eyes showed improved visual acuity of two or more Snellen lines. No serious postoperative complications occurred. There was no significant difference in postoperative astigmatism as compared with ordinary ECCE and PC-IOL surgery. Trabeculotomy with fornix-based scleral flap offers the advantage of simple and safe surgery when combined with ECCE and PC-IOL implantation.Abbreviations POAG primary open-angle glaucomatous - ECCE extracapsular cataract extraction - PC-IOL posterior chamber intraocular lens - IOP intraocular pressure     

小梁切除联合羊膜植入和巩膜瓣松解缝线术治疗难治性青光眼

目的　探讨小梁切除联合羊膜植入和巩膜瓣松解缝线术治疗难治性青光眼的疗效。方法　对完成追踪观察的 5 8例 (6 7只眼 )难治性青光眼患者施行小梁切除术 ,术中巩膜瓣下及结膜瓣下植入新鲜或贮存羊膜 ,联合应用巩膜瓣松解缝线术控制房水渗漏量。结果　术后随访 5～ 38个月 ,平均 19 5个月 ,其中≥ 12个月者占 79 1%。术后 12个月时 ,新生血管性青光眼的眼压由术前 (43 86± 7 12 )mmHg(1mmHg=0 133kPa)降至 (19 6 3± 2 5 7)mmHg(t=4 96 ,P <0 0 0 1) ,人工晶状体植入术后青光眼的眼压由术前 (40 31± 4 79)mmHg降至 (18 0 9± 2 2 1)mmHg(t=3 5 4 ,P <0 0 5 ) ,无晶状体性青光眼的眼压由术前 (37 94± 5 6 3)mmHg降至 (2 0 14± 3 15 )mmHg (t=5 12 ,P <0 0 5 ) ,青少年型青光眼的眼压由术前 (32 4 8± 3 98)mmHg降至 (16 5 4± 1 84 )mmHg(t=4 2 3,P <0 0 1) ,葡萄膜炎性青光眼的眼压由术前 (36 0 1± 4 13)mmHg降至 (18 11± 3 4 0 )mmHg(t=4 4 7,P <0 0 1) ,滤过性手术失败的青光眼眼压由术前 (34 4 3± 5 2 8)mmHg降至 (18 31± 1 5 2 )mmHg(t=2 0 5 ,P <0 0 5 ) ;患者手术前、后眼压比较 ,差异均有显著意义。功能性滤过泡形成率为 80 6 %。无排斥反应和严重并发症。结论     

Results of phacoemulsification in eyes with preexisting glaucoma filters

PURPOSE: To evaluate the intraocular pressure (IOP), best corrected visual acuity (BCVA), and glaucoma medication requirements in patients having phacoemulsification after preexisting glaucoma filters. SETTING: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. METHODS: A retrospective analysis of 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or a scleral tunnel (26 eyes) approach after filtration surgery was performed with a minimum follow-up of 12 months. Two-tailed homoscedastic t tests were used for statistical analysis. RESULTS: The mean preoperative IOP in all eyes was 11.8 mm Hg +/- 4.2 (SD), and the mean final postoperative IOP was 13.7 +/- 4.6 mm Hg (P<.022). The mean preoperative logMAR equivalent BCVA was 0.8 +/- 0.4, which improved to a mean of 0.4 +/- 0.4 postoperatively (P<.0000002). There was no statistically significant change in glaucoma medication requirements postoperatively. The differences in IOP, BCVA, and postoperative glaucoma medication requirements were not statistically significant between the clear corneal group and the scleral tunnel group or between patients who received mitomycin at the time of filtration surgery and those who did not. There were no intraoperative complications; 1 patient required additional glaucoma surgery. CONCLUSION: Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medicines required for IOP control over a minimum follow-up of 1 year.     

Mini-trabeculectomy in eyes with high risk of scarring: midterm follow-up

PURPOSE: To report on the surgical outcome after at least 1 year of follow-up of mini-trabeculectomy (without scleral radial incisions), which took place in eyes at high risk of postoperative filtering bleb scarring. METHODS: In a prospective, institutional study, mini-trabeculectomy was performed on 26 eyes of 26 consecutive patients aged 40 years and older who had undergone a previous intraocular surgery or had had a post-traumatic recessed anterior chamber angle. The surgical procedure, a modification of the standard trabeculectomy, involved a 3-mm fornix-based conjunctival flap, sclerostomy at 1 mm from the limbus, and a sclerocorneal tunnel without radial incisions. During surgery, 0.4 mg per ml of mitomycin C was applied in the scleral pocket of each eye for 3 minutes. Of the 26 eyes, each of two eyes underwent an intraocular intervention during the first postoperative year and therefore was evaluated only for surgical complications. Another eye underwent inferior mini-trabeculectomy, and three other eyes did not complete 12 months of follow-up. Twenty eyes have completed 12 months or more of follow-up and were included in the midterm calculations of intraocular pressure control. RESULTS: Mean preoperative intraocular pressure (n = 20) was 32.2 +/- 9.5 mm Hg with 3.3 +/- 0.9 hypotensive medications. After 12 to 37 months (mean, 22.1 +/- 6.6) of follow-up, intraocular pressure was 20 mm Hg or less in 18 of 20 eyes (90%) and the mean intraocular pressure was 17.4 +/- 2.9 mm Hg (range, 12 to 23) with 1.1 +/- 1.2 hypotensive medications (range, 0 to 4). At that time, the filtering bleb was low and fleshy in appearance in 15 eyes (75%). Postoperative complications of the 22 eyes included early postoperative aqueous leakage in one eye (4.5%); cataract extraction took place in one eye and vitrectomy was performed in another eye, 7 and 3 months postoperatively, respectively. The four eyes that were excluded from the study had controlled intraocular pressure at the last examination. CONCLUSION: Mini-trabeculectomy in eyes with high risk of scarring was found efficacious and relatively safe. The relatively small peritomy, the tunnel approach, and the avoidance of radial incisions seem to offer important advantages over the standard trabeculectomy.     

Milling trabeculoplasty for nonpenetrating glaucoma surgery

PURPOSE: To describe the use of a motorized milling drill to perform nonpenetrating glaucoma surgery and to assess its safety. SETTING: Instituto Oftalmológico de Alicante, Miguel Hernandez University, School of Medicine, Alicante, Spain. METHODS: This prospective noncomparative study included 16 eyes (13 patients) diagnosed with primary open-angle glaucoma. The eyes were divided into 2 groups. Group 1 (8 eyes) had a milling procedure, and Group 2 (8 eyes) had combined phacoemulsification and milling. A fornix-based conjunctival flap was created, and then the milling procedure was performed using a notched hemispherical metallic tip. Evolution of intraocular pressure (IOP), visual outcomes, and the development of intraoperative and postoperative complications were evaluated. RESULTS: The mean age of the patients was 67.9 years +/- 10.9 (SD) (range 50 to 80 years). In Group 1, the mean IOP preoperatively was 27.6 +/- 10.1 mm Hg (range 18 to 50 mm Hg) and after 6 months, 15.8 +/- 5.2 mm Hg (range 12 to 24 mm Hg). The mean IOP reduction 6 months postoperatively was 15.4 +/- 10.6 mm Hg, a 55.7% decrease from preoperatively. In Group 2, the mean IOP preoperatively was 21.7 +/- 4.6 mm Hg (range 13 to 30 mm Hg), and after 6 months, 16.2 +/- 3.4 mm Hg (range 13 to 23 mm Hg). The mean reduction in IOP at 6 months was 5.5 +/- 2.8 mm Hg, a decrease of 25.3% from the preoperative value. In Group 1 at 6 months, 5 eyes (62.5%) had a diffuse filtering bleb and 3 (37.5%), localized filtration. In Group 2, 7 eyes (87.5%) had a diffuse filtering bleb and 1 (12.5%) had fibrosis of the bleb and reduction of filtration. CONCLUSION: The motorized milling drill can be safely used to mill and refine the remaining scleral thickness, eliminating the rupture of trabeculo-Descemet's membrane.     

Circumferential viscodilation and tensioning of Schlemm canal (canaloplasty) with temporal clear corneal phacoemulsification cataract surgery for open-angle glaucoma and visually significant cataract: one-year results

PURPOSE: To evaluate the safety and efficacy of circumferential viscodilation and tensioning of the inner wall of Schlemm canal, a new nonpenetrating surgical procedure (canaloplasty) to treat open-angle glaucoma (OAG), combined with clear corneal phacoemulsification and posterior chamber intraocular lens (IOL) implantation. SETTING: Multicenter surgical sites. METHODS: This international multicenter prospective study comprised adult patients with OAG having combined glaucoma and cataract surgery. Patients with qualifying treated preoperative intraocular pressure (IOP) of at least 21 mm Hg or higher and open angles were eligible. Evaluation was performed at baseline and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. Intraoperative and postoperative high-resolution ultrasound imaging was used to assess Schlemm canal and anterior segment angle morphology, including distension of the trabecular meshwork due to the tensioning suture. RESULTS: Data from 54 eyes that had combined glaucoma and cataract surgery performed by 11 surgeons at 9 study sites were analyzed for this interim analysis. The mean baseline IOP was 24.4 mm Hg+/-6.1 (SD) with a mean of 1.5+/-1.0 medications per eye. In all eyes, the mean postoperative IOP was 13.6+/-3.8 mm Hg at 1 month, 14.2+/-3.6 mm Hg at 3 months, 13.0+/-2.9 mm Hg at 6 months, and 13.7+/-4.4 mm Hg at 12 months. Medication use dropped to a mean of 0.2+/-0.4 per patient at 12 months. Surgical complications were reported in 5 eyes (9.3%) and included hyphema (n=3, 5.6%), Descemet tear (n=1, 1.9%), and iris prolapse (n=1, 1.9%). Transient IOP elevation of more than 30 mm Hg was observed in 4 eyes (7.3%) 1 day postoperatively. CONCLUSION: Circumferential viscodilation and tensioning of Schlemm canal combined with clear corneal phacoemulsification and posterior chamber IOL implantation was a safe and effective procedure to reduce IOP in adult patients with OAG.     

Pars plana filtration with multiple laser perforation of the uvea for neovascular glaucoma following proliferative diabetic retinopathy

PURPOSE: To evaluate the effect of pars plana filtration with multiple laser perforation of the uvea in neovascular glaucoma patients following proliferative diabetic retinopathy. METHODS: In 18 eyes of 13 patients, after a fornix-based conjunctival incision, two 9 x 3 mm, thin, rectangular scleral flaps were created 3-6 mm posterior to the limbus. The remaining layers of sclera under each flap were removed. The exposed uvea was irradiated at a mean of 60.6 spots with an argon laser just to the point of perforation. After the posterior chamber fluid escaped, the flaps were sutured. RESULTS: The mean preoperative intraocular pressure (IOP) was 36.4 +/- 9.0 mm Hg. After an average follow-up of 16.6 +/- 5.9 months, the mean final postoperative IOP was 16.6 +/- 4.4 mm Hg. The postoperative IOP was below 21 mm Hg in 3 (16.7%) of the 18 eyes without medication, in 14 (77.8%) on anti-glaucoma eye drops, and in 16 (88. 9%) on anti-glaucoma eye drops and an oral carbonic anhydrase inhibitor. Snellen visual acuity improved by more than 2 lines in 7 of the 18 eyes, worsened by this amount in 3, and remained within baseline +/- 2 lines in 8. CONCLUSION: This procedure is an effective treatment for neovascular glaucoma patients following proliferative diabetic retinopathy.     

Early postoperative spikes of the intraocular pressure (IOP) following phacoemulsification in late-stage glaucoma

BACKGROUND: Modern cataract surgery with use of viscoelastics can induce remarkable early spikes of the intraocular pressure (IOP) in patients with glaucoma. PATIENTS AND METHODS: The purpose of this prospective study was to investigate risk factors for an early increase of the IOP following cataract surgery in eyes with end-stage glaucoma. Clear cornea phacoemulsification with implantation of a foldable acrylic lens was performed in 25 eyes with end-stage glaucoma (primary open-angle glaucoma including normal tension glaucoma or exfoliative glaucoma) either under topical anesthesia or under general anesthesia. In eyes with exfoliative glaucoma, trabecular aspiration was performed additionally. IOP measurements were conducted at the day before surgery, 4 hours following surgery and on the first morning following surgery. RESULTS: Cataract surgery was performed without complications. The mean IOP was 18.5 +/- 4.2 mm Hg with 2.1 +/- 1.0 topical medications. 4 hours postoperatively, mean IOP was 31.3 +/- 11.9 mm Hg. In eyes with exfoliative glaucoma (n = 12) the early postoperative IOP was 28.5 +/- 12.0 mm Hg, but without significant difference compared to eyes with POAG (n = 13). The early postoperative IOP showed significant correlation with the maximum IOP in patient's history (p = 0.014). CONCLUSIONS: Patients with late-stage glaucoma can experience considerable early IOP spikes following uneventful cataract surgery, although preoperatively IOP is controlled by topical medications. Postoperative IOP monitoring is recommended at the day of surgery, especially if high IOP values are reported in patient's history.