玻璃体切除术中白内障的不同处理方式及远期疗效观察

目的:通过观察玻璃体切除手术中白内障的不同处理方式及远期疗效,寻找玻璃体切除手术中最适宜的白内障的手术方式。方法:选取2006-06/2009-08于我院行玻璃体视网膜手术联合晶状体摘除手术的糖尿病视网膜病变患者50例50眼。采用标准三通道玻璃体切除手术方式。对术前晶状体混浊影响术中玻璃体手术操作或术中晶状体混浊加重无法进行玻璃体手术的患眼同时行晶状体手术。患者随机分为两组,晶状体超声乳化组(A组)和晶状体超声粉碎组(B组),各25例25眼。晶状体手术完成后,建立标准的巩膜三通道切口,进行前后段的玻璃体切除术,完全切除周边前段玻璃体和玻璃体后皮质。部分病例同时行剥膜,部分患者同时行硅油填充术。手术结束后,根据视网膜情况决定是否囊袋内或睫状沟内植入折叠人工晶状体。观察术后1,3,6mo的视力、前房反应程度、虹膜表面新生血管情况、囊膜混浊情况和人工晶状体的位置。术后均按常规局部应用抗生素、激素眼药水和短效散瞳剂,检测眼压和进行裂隙灯散瞳检查。结果:两组手术经过顺利,术中晶状体囊膜完整。两组同时行硅油充填15眼。A组术后囊袋内植入AcrysofNatural人工晶状体15例15眼。B组术后睫状沟内植入AcrysofNatural人工晶状体18例18眼。术后最佳矫正视力:随诊3～22mo,乳化组手术后视力为光感3眼,眼前手动者10眼,0.1～0.3者12眼,粉碎组手术后视力为光感者4眼,眼前手动者10眼,0.1～0.3者11眼,差别无显著性(P>0.05);乳化组术后1,3,6mo后囊膜混浊逐渐增加,以后囊周边部及前囊膜为主,术后3～6mo,取硅油时后囊膜混浊不妨碍手术前后对眼底的检查,粉碎组术后2～4wk晶状体前囊膜混浊逐渐加重,术后3～6mo取硅油时14例均有严重的囊膜混浊,16例同时进行前囊膜切开术,差别有显著性(P<0.05);人工晶状体偏移程度:乳化组有4眼发生轻度偏移,粉碎组有10眼发生轻、中度偏移,差别有显著性(P<0.05)。结论:本组观察表明,玻璃体切除手术中,对混浊的晶状体采取超声乳化手术方式的远期疗效优于晶状体超声粉碎术。由于现有人工晶状体的设计多适用于囊袋内植入,符合生理解剖结构,其后表面的方边设计有利于减少后发性白内障的发生。囊袋内的稳定植入,有利于减少术后的炎症反应。

Different surgical methods on treatment of cataracts and observation of their long-term effects during the process of vitrectomy

·AIM:To find the best surgical way to treat patients who had proliferative retinopathy combined with cataract by different surgical methods and observe the long-term effect during the process of vitrectomy.·METHODS:Fifty PDR cases 50 eyes coexisted with cataracts who underwent two different combined surgeries from Jun.2006 to Aug.2009 were reviewed.These cases were randomly divided into two groups.Group A included 25 cases 25 eyes who were treated with phacoemulsification combined with vitrectomy,IOLs were implanted into the capsular bag via the clear corneal incision at the end of the surgeries.While group B included another 25 cases 25 eyes who were treated with the technique of lensectomy via the pars plana combined with vitrectomy,the anterior capsule was preserved and the cortex and nucleus were aspirated,IOL was implanted via the cornea-scleral incision on the anterior capsule at the end of the surgeries.Standard pars plana vitrectomy was performed,many relative key technologies such as membrane dissections and membranectomy were adopted.Implantations of silicon oil were adapted to some eyes at the end of the surgeries.The clinical data,such as vision,anterior chamber reaction,iris neovascularization,IOP,capsular opacification and the location of IOL were observed postoperatively.·RESULTS:All posterior or anterior capsular membranes were preserved without damage.Implantations of silicon oil were adapted to 15 cases 15 eyes in both groups respectively.IOL implantations were performed in 15 eyes in group A,while 18 eyes in group B.The average follow-up time was from 3 months to 22 months.There was no significant difference in postoperative best-corrected vision between the 2 groups(P>0.05),while there were more capsular opacification and more dislocation of IOL in group B than in group A(P<0.05).·CONCLUSION:Phacoemulsification and intracapsular IOL implantation combined with vitrectomy in the treatment of proliferative retinopathy and cataract is safer and more effective than pars plana lensectomy combined with vitrectomy.The design of IOL is in accordance with the physiological and anatomical structure of the eyeball which can lower the incidence of capsular opacification,dislocation of IOL and postoperative inflammation.·