COVID-19爆发期武汉原发性急性闭角型青光眼的手术治疗

目的：总结新型冠状病毒肺炎(COVID-19)疫区原发性急性闭角型青光眼患者的特点和救治方法。

方法：回顾性分析2020-03-02/20疫情期间我院治疗的原发性急性闭角型青光眼患者5例9眼的病历资料,慢性进展期8眼施行白内障超声乳化人工晶状体植入联合房角分离术,临床前期1眼施行激光虹膜周切术。分析手术前后眼压、视力及并发症等情况,总结患者特点及诊治体会。

结果：原发性急性闭角型青光眼患者5例中3例为双眼发病,发病时间12～40(25.2±11.82)d; 白内障超声乳化人工晶状体植入联合房角分离术后眼压(12.63±1.68mmHg)较术前(48.38±3.22mmHg)明显下降(t=12.192,P<0.01); 住院天数2～6(平均3.8±1.48)d。5例患者均未发现感染及手术相关并发症。

结论：在COVID-19疫情期间,疫区原发性急性闭角型青光眼慢性进展期患者发作时间长、病情重,双眼发作比例高; 白内障超声乳化人工晶状体植入联合房角分离术可以安全、有效地降低原发性急性闭角型青光眼患者的眼压; 疫情期间规范的防控措施可有效保障医患安全,但加大手术难度。     

新型冠状病毒肺炎疫情期间眼科急诊及手术的防控策略

新型冠状病毒(SARS-CoV-2)感染的肺炎,新型冠状病毒肺炎(COVID-19)已被中国列为按照甲类传染病管理的乙类传染病,由医院相关性传播导致的COVID-19并不少见,给临床医护人员和住院患者造成严重威胁。本文介绍眼科医生应掌握COVID-19的流行病学特点和临床表现,眼科医生如何应对眼科急诊患者,围绕眼科急诊及手术的感染防控要点和加强具体防控措施,为战疫在一线的眼科医护感染防控提供参考。     

康柏西普联合EX-PRESS青光眼引流器植入对NVG患者视力及并发症的影响

目的：探讨玻璃体腔注射康柏西普联合EX-PRESS青光眼引流器植入对新生血管性青光眼(NVG)患者视力及并发症的影响。

方法：选取2016-02/2018-10我院眼科收治的NVG患者128例,依据患者的治疗方法分为EX-PRESS组(n=66)和小梁切除术组(n=62),两组患者接受玻璃体腔注射康柏西普治疗,EX-PRESS组患者加行EX-PRESS青光眼引流器植入术治疗,小梁切除术组患者则加行小梁切除术治疗。比较两组手术疗效及术后眼压变化、视力改善情况及并发症发生情况。

结果：术后12mo时,EX-PRESS组、小梁切除术组手术治疗总成功率分别为81.8%(54/66)、72.6%(45/62)(P>0.05); 术后1、7d,1、3、6、12mo,两组患者眼压均显著低于术前(P<0.05),但两组患者眼压无差异(P>0.05); 术后6mo,EX-PRESS组患者视力改善情况显著优于小梁切除术组患者(P<0.05); EX-PRESS组、小梁切除术组术后并发症总发生率分别为27.3%(18/66)、37.1%(23/62)(P>0.05)。

结论：玻璃体腔注射康柏西普联合EX-PRESS青光眼引流器植入术与联合小梁切除术治疗NVG的有效性、安全性相似,而前者在改善视力方面更具优势。     

七氟烷联合右美托咪啶对眼科患儿全身麻醉苏醒期躁动的影响

目的：研究七氟烷联合右美托咪啶对眼科患儿全身麻醉苏醒期躁动(EA)的影响。

方法：抽取2018-05/12我院84例择期行眼科手术的患儿为研究对象,随机分为研究组和对照组各42例。均给予吸入七氟烷维持全身麻醉,麻醉插管完成后研究组患儿给予右美托咪啶0.5μg/kg静脉恒速泵注,对照组患儿给予等容量生理盐水。获取苏醒期心率(HR)、平均动脉压(MAP)及血清应激反应指标去甲肾上腺素(NE)、皮质醇(Cor)监测数据,并记录麻醉恢复、EA及并发症发生情况。

结果：对照组患儿清醒时、拔管后1、5、10min的HR、MAP均明显波动,各时点有明显差异(P<0.05),而研究组无差异(P>0.05),且研究组各时点HR、MAP均低于对照组(P<0.05)。研究组患儿清醒时、拔管后10min血清NE、Cor水平均低于对照组(P<0.05)。两组患儿自主呼吸恢复时间、清醒时间无差异(P>0.05),但与对照组相比,研究组患儿拔管时间短,拔管质量评分低(P<0.05)。研究组患儿EA发生率仅12%,低于对照组的31%(P<0.05),EA程度及并发症发生率无差异(P>0.05)。

结论：七氟烷联合右美托咪啶可有效稳定眼科患儿全身麻醉苏醒期血流动力学,减轻应激反应,有效降低EA发生率,且不影响麻醉恢复质量,安全性较高,但需注意过度镇静现象。     

康柏西普玻璃体腔注射联合EX-PRESS青光眼引流器植入治疗NVG

目的：观察康柏西普玻璃体腔注射应用EX-PRESS青光眼引流器植入治疗新生血管性青光眼的疗效。

方法：选择2015-01/2018-01在我院眼科就诊的新生血管性青光眼患者37例37眼,随机分为试验组与对照组,两组在术前均行康柏西普玻璃体腔注射,试验组和对照组分别选择EX-PRESS青光眼引流器植入术和小梁切除术。对比两组术后成功率、最佳矫正视力、眼压、滤过泡、并发症。

结果：术后12mo, 两组手术成功率、BCVA及滤过泡率均无差异(P>0.05)。两组不同时间点眼压比较有差异(F_组间=10.0,P_组间=0.003; F_时间=496.27,P_时间<0.0001)。所有并发症经对症处理后改善。

结论：EX-PRESS青光眼引流器植入联合康柏西普玻璃体腔注射治疗新生血管性青光眼对降低眼压、减少术后并发症有一定的临床价值。     

雷珠单抗联合玻璃体切割术治疗DR合并新生血管性青光眼

目的：探究雷珠单抗联合玻璃体切割术治疗DR合并新生血管性青光眼(NVG)的临床效果。

方法：选取2016-01/2018-02我院眼科收治的DR合并NVG患者198例,根据治疗方案不同分为观察组(103例)和对照组(95例),观察组采用术前注射雷珠单抗联合玻璃体切割术治疗,对照组单纯采用玻璃体切割术治疗,玻璃体切割术后10～15d Ⅱ期实施Ahmed房水引流阀植入。观察两组治疗后眼压、BCVA、VEGF等指标变化情况。

结果：观察组的玻璃体切割术的手术时间、新生血管出血次数、电凝次数均低于对照组(P<0.001)。观察组在玻璃体切割术后1wk和Ⅱ期Ahmed房水引流阀植入术后1mo BCVA、眼压均低于对照组(P<0.001)。观察组Ⅱ期Ahmed房水引流阀植入术前VEGF和术后1mo视网膜黄斑中心凹厚度均低于对照组(P<0.001)。观察组总并发发生率低于对照组(10.7% vs 28.4%,P<0.05)。

结论：雷珠单抗联合玻璃体切割术治疗DR合并NVG的疗效显著,且使Ⅱ期Ahmed房水引流阀植入手术难度下降,对患者视力、眼压水平恢复较好。     

成人水平斜视手术中局部麻醉监护指标变化的研究

目的：观察局部麻醉监护情况下成人水平斜视手术中心电图、呼吸、血氧饱和度、血压的变化情况。

方法：临床确诊为水平斜视的17例成人患者19眼36条眼外肌纳入研究。其中男10例,女7例。年龄18～71(平均32.65)岁; 外斜视14例(男8例,女6例),内斜视3例(男2例,女1例)。所有患者均进行最佳矫正视力(BCVA)、裂隙灯显微镜、间接检眼镜、角膜荧光及眼科同视机检查。术中由专业麻醉医师采用监护仪对手术采取全程密切监控。对比分析术前与局部麻醉监护术中的心电图、呼吸频率、血氧饱和度及血压的变化情况,对比内外直肌、不同性别及不同年龄组的区别。

结果：局部麻醉监护下17例成人水平斜视手术中牵拉眼外肌共36条,眼心反射发生率86.1%; 牵拉内、外直肌,眼心反射阳性率分别为100%,72.2%。眼心反射在男女性别间无统计学差异。18～30岁眼心反射阳性率明显高于31～71岁。术中呼吸频率的增高与眼心反射同步,与牵拉内外直肌、性别及不同年龄组无关。血氧饱和度无明显变化。血压在手术刚开始时出现一过性增高,首次牵拉眼内外直肌时出现一过性降低,在性别和年龄上无明显差异。

结论：在局部麻醉监护下成人水平斜视手术中,眼心反射发生率高,牵拉内直肌时100%发生; 呼吸增快与眼心反射同步; 手术即将开始时血压增高、牵拉眼内外直肌时血压降低。     

Catquest-8SF量表分析年龄相关性白内障患者的效果

目的：应用Catquest-8SF量表研究PHACO+SIOL植入术患者主观报告的效果,评估Catquest-8SF量表在中国北方白内障人群的适用性及其对白内障手术的敏感性。

方法：前瞻性临床病例随访研究。泰安市中心医院白内障患者术前和术后3mo完成面对面的Catquest-8SF量表填写。

结果：术前共120例白内障患者完成了Catquest-8SF量表。术前Catquest-8SF量表得分与术前双眼加权logMAR视力及年龄呈显著负相关(P<0.05),与文化程度呈正相关(P<0.001),无全身合并症的患者量表得分高于有全身合并症的患者(P<0.05)。102名(85%)患者完成术后3mo量表,单眼手术组和双眼手术组比较,术后视力均显著提高(t=10.404, P<0.001),术后量表得分均明显提高(P<0.001)。两组在量表得分提高值上差异无统计学意义。92.2%的患者对手术效果满意。满意度与量表得分的提高值显著相关(P<0.05)。

结论：中文版Catquest-8SF量表在我国北方ARC人群中适用性好,简短高效,可以作为白内障常规临床评估的一部分。     

罗哌卡因利多卡因混合液眼球筋膜囊下麻醉在斜视手术中的应用研究

目的：评价罗哌卡因利多卡因混合液眼球筋膜囊下麻醉在斜视手术中应用的优越性。

方法：选择80例局部麻醉手术的水平性斜视患者,分为试验组和对照组,用7.5g/L罗哌卡因混合20g/L利多卡因分别作眼球筋膜囊下麻醉和结膜下浸润麻醉,并进行疼痛和眼心反射的评估。

结果：患者80例均能在局部麻醉下顺利完成手术,疼痛的评估结果：根据视觉模拟评分法(VAS),试验组评为“优”者12例,“良”者21例,“可”者6例,“差”1例。对照组“优”者2例,“良”者25例,“可”者12例,“差”1例。两组进行秩和检验,P<0.01,两组有显著差异。术中牵拉眼内外直肌数量和出现眼心反射情况为：试验组牵拉肌肉共74条,发生眼心反射26次,对照组牵拉肌肉共76条,发生眼心反射48次,采用χ²检验,P<0.01,两组间眼心反射发生率差异有统计学意义。两组间眼心反射等级差别采用秩和检验,P>0.05,在发生眼心反射患者中,两组间眼心反射等级分布差异无统计学意义。

结论：应用7.5g/L罗哌卡因混合20g/L利多卡因作眼球筋膜囊下麻醉在斜视手术应用有一定的优越性,值得推广应用。     

不同麻醉方式下儿童睑板腺囊肿切除术的综合疗效分析

目的：对比全身麻醉与局部麻醉下进行儿童霰粒肿切除术的综合疗效。

方法：回顾性病例对照研究。将2015-01/2016-12在我院接受霰粒肿切除手术的双眼霰粒肿患儿(4～10周岁),根据采用的麻醉方法分为两组：全身麻醉组(全麻组,67例134眼)和局部麻醉组(局麻组,72例144眼)。分析两组患者的疼痛及术后心理创伤,以及术后1mo眼表健康状况、术后1a内复发率和并发症等四个方面的差异。

结果：全麻组和局麻组患儿均未出现麻醉相关并发症和意外。全麻组患儿术中不存在疼痛,术后3h的面部表情疼痛量表(FPS-R)值为4.94±1.23分,低于局麻组(7.00±1.14分),差异有统计学意义(P<0.001)。全麻组患儿有12例出现再次就医回避,局麻组为35例,差异有统计学意义(P<0.01)。全麻组的泪膜破裂时间、泪膜脂质层厚度和泪河高度均高于局麻组,差异有统计学意义(P<0.001); 其睑脂性状评分也低于局麻组,差异有统计学意义(P<0.01)。全麻组患儿囊肿复发率为6.0%,低于局麻组的20.8%,差异有统计学意义(P<0.05)。全麻组患儿出现并发症发生率为4.5%,局麻组为15.3%,差异有统计学意义(P<0.05)。

结论：全身麻醉下进行儿童霰粒肿手术具有术后疼痛轻、患儿依从性好的基本优点。与局部麻醉下手术相比,全身麻醉术中能够进行精细操作,术后眼表健康情况更好,并发症更少。     

新型冠状病毒肺炎疫情期间眼科手术安全性及防控对策

目的:探讨新型冠状病毒肺炎疫情期间开展眼科手术的安全性,并提出相关防控对策。方法:收集2020年1月25日至2020年2月28日新型冠状病毒肺炎疫情期间,在天津医科大学总医院眼科接受手术治疗者11例(12眼)的资料。其中眼球破裂,角膜穿孔伤,角膜穿孔伤合并外伤性白内障,眼内异物各1例(1眼),泪小管断裂2例(2眼),孔源性视网膜脱离4例(4眼),青光眼1例(2眼)。所有患者进行体温监测和流行病学调查。按照国家疫情防控要求和医院的应急管理流程,制订了眼科诊疗流程,所有患者均严格按照此流程进行管理,围手术期严格监测体温、呼吸道等全身情况。结果:11名患者就诊前行体温监测、流行病学调查、临床及影像学检查均正常,并请感染科专家会诊排除新型冠状病毒肺炎。所有患者均为眼外伤和急性眼病,包括急诊手术6眼,限期手术6眼,严格遵照眼科诊疗流程进行手术治疗,术后恢复良好,均未出现严重手术并发症。住院及随访期间患者、家属及医护人员均未发生新型冠状病毒肺炎。结论:新型冠状病毒肺炎疫情期间严格筛查患者,严格按照疫情期间防控工作流程要求,眼科手术是安全可行的。     

Resurgence of combined intravenous Ketamine and regional anesthesia in pediatric ocular surgery in COVID-19 pandemic

Purpose:The current pandemic of COVID-19 has made airway procedures like intubation and extubation, potential sources of virus transmission among health care workers. The aim of this work was to study the safety profile of combined ketamine and regional anesthesia in pediatric ocular surgeries during the COVID-19 pandemic.Methods:This prospective study included pediatric patients undergoing ocular surgery under general anesthesia from April to October 2020. Children were premedicated with oral midazolam (0.25–0.50 mg/kg) or intramuscular ketamine (7-10 mg/kg), ondensetron (0.1 mg/kg) and atropine (0.02 mg/kg). Anesthesia was achieved with intravenous ketamine (4–5 mg/kg) and local anesthesia (peribulbar block or local infiltration). The patient''s vital signs were monitored. Serious complications and postoperative adverse reactions related to anesthesia were documented.Results:A total of 55 children (62 eyes) were operated. Lid tear was the most common surgical procedure performed [n = 18 (32.7%)]. Dose of ketamine needed ranged from 30 to 120 mg (66.67 ± 30.45). No intubation or resuscitation was needed. Four children complained of nausea and two needed an additional dose of intravenous ondansetron due to vomiting in the post-operative period. Incidence of postoperative nausea and vomiting was not affected by age, duration of surgery or dose of ketamine used (P > 0.05). There was no correlation between increase in pulse and dose of ketamine.Conclusion:Combined ketamine and regional anesthesia is a safe and effective alternative to administer anesthesia in a child during ocular surgeries.     

Collateral damage: Corneal injury due to mask use during the COVID-19 pandemic - A case series

Though masks are the best shield against COVID-19, they can be a source of discomfort and ocular side effects. We discuss three cases of corneal injury due to mask use. Three patients, who were healthcare workers, presented with discomfort, photophobia, and pain in the eyes. While adjusting the mask, they had an ocular injury. There were multiple superficial linear abrasions in the eyes. They recovered with treatment. Though masks are imperative during the COVID-19 pandemic, it is important to be aware of a possible mask injury.     

Managing vitreoretinal surgeries during COVID-19 lockdown in India: Experiences and future implications

Purpose:The study aims to describe the clinical and demographic profile of patients who required vitreoretinal surgeries during the novel coronavirus disease-2019 (COVID-19) lockdown in India. It also reports our operating protocols and initial experience while performing vitreoretinal surgeries during COVID-19 times at a government tertiary eye care hospital.Methods:This is a retrospective cross-sectional observational study of patients requiring emergent/urgent vitreoretinal surgeries between March 25, 2020 and May 31, 2020. A modified working protocol focussing on the enforcement of standard COVID-19 precautions, OT sterilization, and formation of dedicated infection control and disease surveillance committee was adopted. Patients underwent standard vitreoretinal procedures under general/local anesthesia. Relevant demographic and clinical data were recorded and analyzed. Surveillance data of healthcare workers (HCW) was also analyzed.Results:Eighty six patients were considered for vitreoretinal surgery in this period. Finally, 83 patients underwent surgery. The mean age of the patients was 38.4 ± 20.1 years (Range, 1 month - 75 years). Majority of them were males (66%) and adults (82.6%). Majority of them came from nearby hotspot areas. Most common indications were acute retinal detachment (38.5%) and diabetic vitrectomies (22.9%). Trauma-related cases (14.4%) were less. Surgery was deferred in 3 patients who turned out to be COVID-19 positive. 4 HCWs were quarantined but none of them developed COVID-19 disease.Conclusion:During COVID-19 lockdown, vitreoretinal surgeries were most commonly performed for retinal detachment and diabetic complications. Proper implementation of infection control protocols helps in delivering adequate patient care while ensuring the safety of caregivers during this pandemic.     

新型冠状病毒肺炎防控时期眼外伤急救流程管理

2019年12月初开始于武汉的新型冠状病毒肺炎传染力强、致病率高、影响范围广,全国各地相继迅速启动紧急防控措施。新型冠状病毒肺炎防控期间,全民防疫为主,眼科疾病诊疗部分受限。眼外伤是眼科常见眼科急症,可导致不可逆转的视力丧失,甚至眼球摘除。眼外伤的急诊救治效果与患者的视力预后密切相关,需伤后短时间内做出正确诊断和及时处理。因此,新型冠状病毒肺炎防控期间如何能够安全完成眼外伤急诊的手术处理值得探讨。本文根据2020年1月24日天津市启动重大公共卫生事件一级防控响应以来,我科多例急诊眼外伤的处理流程,就疫情防控期间的眼外伤手术防控管理作一述评,以期为眼科同行在新型冠状病毒肺炎时期安全处理急诊眼外伤提供参考。     

Preoperative COVID-19 testing for elective vitreoretinal surgeries: Experience from a major tertiary care institute in South India

Purpose:To study the prevalence of asymptomatic SARS-CoV-2 virus infection (COVID-19) among patients undergoing elective vitreoretinal surgeries at a tertiary care eye hospital.Methods:This cross-sectional, observational study was performed between July 16, 2020 and August 31, 2020, in the retina clinic of a tertiary care eye hospital in south India. All patients undergoing elective retinal surgical procedures underwent RT-PCR testing for SARS-CoV-2 before being posted for surgery and after obtaining informed consent. Patients planned for surgery under general anesthesia underwent additional computed tomography of the chest. Testing strategies and outcomes were documented.Results:Out of a total of 413 patients who were given appointments for surgery during this period, nine patients (2.2%) were found to have positive RT-PCR for SARS-CoV-2, and their surgeries were postponed. The test positivity (prevalence) rate of asymptomatic COVID-19 infection among all elective vitreoretinal surgical patients in our hospital was 2.2%. None of the patients were symptomatic for COVID-19.Conclusion:Our results showed that among patients visiting high volume ophthalmic centers in the near future, approximately 1 in 45 patients may be asymptomatic, SARS-CoV-2 RT-PCR positive. Asymptomatic COVID-19 patients may lead to chances of transmission of the virus inside healthcare facilities among other visiting patients and healthcare workers.     

Assessment of dry eye disease in N95 versus surgical face mask wearers during COVID-19

Purpose:Investigating the effect of different face masks on dry eye disease (DED) among healthcare workers during the COVID-19 pandemic.Methods:This was a comparative, cross-sectional study. Participants were included into two groups: group 1 (n = 30) wore surgical masks, and group 2 (n = 30) wore N95 masks with face shields. Demographic and ocular surface disease index questionnaires (OSDI) were performed. In addition, Tear break-up time (TBUT), corneal and conjunctival fluorescein staining, and meibography to assess meibomian gland loss (MGL) were performed on all participants. Independent T-test was used to compare continuous parameters and Chi-square test for categorical variables. The relationship between continuous variables was tested using bivariate Pearson correlation.Results:Sixty healthcare workers participated in this study (36 females and 24 males). The mean (±SD) age of the surgical mask and N95 groups was 35.33 (±14.94) and 36.63 (±10.64) years, respectively. Both masks caused dryness according to TBUT, MGL, and OSDI scores. DED per DEWS II definition was observed in 14 (46.7%) and 16 (53.3%) patients in groups 1 and 2, respectively. Comparing the two groups, N95 mask caused significantly more dryness according to TBUT (P = 0.042) and fluorescein staining (P = 0.038 for the right eye and P = 0.015 for the left eye).Conclusion:Physicians should be aware of the potential dry eye signs secondary to face mask wear during the COVID-19 pandemic. Further attention should be taken in patients who suffer from preexisting dry eye syndrome and in patients who undergo intraocular operations.     

Insights on the possibility of SARS-CoV-2 transmission through the eyes

A novel coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or 2019-nCOV), causing coronavirus disease 2019 (COVID-19), has rapidly spread to most countries and regions worldwide since it broke out at the end of 2019. Epidemic of the virus produces a tremendous pressure on the global health systems. With progressive insight into SARS-CoV-2, the role of eye tissue has attracted wide attention in the spread of COVID-19. Whether SARS-CoV-2 can enter the human body through eyes and cause infection? The fact that unprotected exposure of the eyes to 2019-nCoV might have allowed the virus to infect the body implies that 2019-nCOV can invade eye tissue and set foot in organism. Facing the severe challenge of preventing spread of the COVID-19, combined with the high-risk environment of ophthalmology, it is crucial to investigate ocular tropism of coronavirus. This paper explores the possibility of coronavirus transmission through the eye from aspects of probable mechanisms, clinical cases, detection of coronavirus; and puts forward precautions for ophthalmologists and nurses. Consequently, this review reveals our understanding of ocular tropism of coronavirus and contributes to determining risk of ocular transmission, raising awareness of necessary eye protection among medical workers and reducing further prevalence of SARS-CoV-2.