内窥镜在眼科的应用现状和发展

近20年来医用内窥镜技术发展迅速,目前应用于眼科手术治疗的内窥镜主要有应用于眼球内手术的眼内窥镜、应用于泪道手术的泪道内窥镜以及应用于视神经管减压术、泪囊鼻腔吻合术的鼻内窥镜.内窥镜手术已成为眼科手术的一个新的发展和重要补充.本文就内窥镜在眼科应用的历史、眼内窥镜类型和工作原理、手术入路以及内窥镜在眼科手术中应用的适应证、疗效和并发症作一综述.     

显微内窥镜在眼外伤中的应用

1934年Thorpe最早应用内窥镜技术摘出眼内异物。随着科技进步,内窥镜发展迅速,从硬式内窥镜到纤维内窥镜再发展到现在的电子激光内窥镜。内窥镜作为一种新型技术在眼科某些领域成为眼科手术和检查很好的补充。现就内窥镜在眼外伤中的应用综述如下：     

第二届全国眼科内镜微创外科高峰论坛暨眼科内镜微创手术培训班通知

眼科内镜微创外科主要是以内窥镜微创技术为核心,以转化医学理念为引导,将眼外科技术与内窥镜技术有机结合,进行视神经疾病、眼眶与眼整形疾病、泪道疾病及严重眼外伤、难治性青光眼等眼科疾病诊疗的一门新兴交叉学科。近几年,眼科内镜微创外科发展迅速,成为当今眼科临床诊疗发展与经济增长的又一热点领域。     

眼内窥镜应用进展

内窥镜在眼科的应用有力地推动了眼科手术的进步 ,它可以顺利完成以往手术所不能达到和进行的操作 ,目前主要应用于玻璃体视网膜手术、人工晶状体植入术、青光眼手术等 ,同时为进行视网膜下手术、前段增生性玻璃体视网膜病变手术、睫状体手术开创了广阔的前景。     

内窥镜下手术在眼科的应用

近年来，内窥镜下手术在眼科的应用有了很大进展，并且逐渐展现出其创伤小、并发症少、直视下操作、安全有效的优点。眼内窥镜联合激光可应用于青光眼前房角手术、青光眼睫状体光凝术、周边部视网膜玻璃体手术等等；另外泪道内窥镜在泪器疾病中的应用、鼻内窥镜在鼻眼相关手术中的应用也有很大的发展。眼内窥镜的应用开创了眼科微创手术时代。本文就眼用内窥镜的基本工作原理、应用现状和发展前景进行综述。     

内窥镜在眼科的应用

本文介绍了眼科内窥镜的结构、特性及其在眼科研究和临床应用中的现状,并对内窥镜在眼科领域的发展趋势作了概述。     

第二届全国眼科内镜微创外科高峰论坛暨手术培训班第二轮通知

近年来,内窥镜技术在眼科迅速发展,诊疗范畴涉及神经眼科、眼眶／眼整形外科、泪道疾病、严重眼外伤及玻璃体视网膜疾病、难治性青光眼等众多领域,赋予了眼科全新的诊疗理念与内涵,正成为眼科发展的又一新热点。     

内窥镜在眼科手术中的应用

近年来,眼科内窥镜技术及相关治疗方法已经逐步丰富完善,内窥镜在泪道手术、青光眼手术、晶状体手术、眼后段手术、眼眶手术及眼整形美容手术中逐渐推广应用,开创了眼科微创手术的新时代。其创伤小、并发症少、直视下操作、安全有效的优点得到了广大眼科医生认同。本文就眼用内窥镜的发展过程、内窥镜在眼科手术中的应用现状和发展前景进行综述。     

泪道疾病的通用图示标准初探

泪道疾病是眼科常见病、多发病。发病率居眼科疾病第二位。泪道是人体中少有的不易见的腔隙,虽然已经有了泪道内窥镜可以直观的观察和照相、录像,但是因其昂贵的价格和分辨率较低等技术因素暂无法普及,绝大部分医院依然依靠医生感觉和经验来诊治和凭借文字描述交流,在实际工作中大多没有完整的泪道情况作图和描述及告知患者,造成了患者在每个经手医务人员的诊疗过程中都重新检查,很多     

重视微创技术治疗泪道阻塞性疾病

泪道阻塞性疾病是眼科常见病.泪道微创治疗技术近年来在发达国家有替代传统疗法的趋势,国内少数医院眼科已开展了微创技术诊治泪道疾病.新一代磷酸钛氧钾(KTP)激光技术与泪道置管术联合使用,扩大了泪道置管术的适应证.具有记忆功能的专用置管工具改进了逆行置管系统.鼻腔内窥镜下鼻腔泪囊吻合手术拓展了医治空间,清晰的鼻腔内窥镜树立了泪道内窥镜质量追求标准.泪道微创技术的健康发展有利于促进泪道疾病的早期诊治,扩大微创手术适应证.规范地应用基本检查方法,恰当选择影像学检查项目,术前确立有阻塞部位、性质、程度、原因等内容的完整诊断.我国泪道阻塞性疾病的诊治常规也亟待建立.(眼科,2008,17:79-81)     

Ophthalmic laser microendoscope endophotocoagulation.

PURPOSE: The purpose of this article is to describe the function of the ophthalmic laser microendoscope as it pertains to endophotocoagulation in the management of vitreoretinal disease. METHODS: Fifty-four consecutive vitrectomies with endophotocoagulation were performed using the ophthalmic laser microendoscope instead of endoillumination and endophotocoagulation probes. Intraoperative and postoperative efficacy and complications were evaluated. RESULTS: The ophthalmic laser microendoscope was used to illuminate and view the retina and to deliver diode laser energy in the management of posterior retinal breaks, proliferative retinopathies, and proliferative vitreoretinopathy. The technique of endophotocoagulation was similar to that used routinely in vitreoretinal surgery. The photocoagulation lesions that were created were identical to those delivered by standard endophotocoagulation probes. Intraoperative complications were few, consisting of transient mild retinal or choroidal hemorrhages. Severe postoperative complications related to endophotocoagulation or to use of the ophthalmic laser microendoscope were not observed. CONCLUSION: The ophthalmic laser microendoscope appears to be a safe and effective method of delivering diode laser energy to the retina while simultaneously providing illumination, video recording, and a clear endoscopic view despite anterior segment conditions that might otherwise preclude adequate visualization and treatment. Fewer instrument insertions/removals were required for endophotocoagulation. Post-treatment search for peripheral iatrogenic retinal breaks was accomplished by endoscopy.     

Treatment of a cyclodialysis cleft by means of ophthalmic laser microendoscope endophotocoagulation

PURPOSE: To report on the repair of a cyclodialysis cleft by means of endolaser photocoagulation. METHOD: Case report. We describe treatment of a cyclodialysis cleft by means of endolaser photocoagulation with a diode laser. RESULTS: In a 8-year-old boy with pseudophakia and secondary glaucoma in the right eye, combined trabeculectomy/trabeculotomy was performed. Ten months later, the patient was seen with persistent hypotony with a flat filtration bleb. The hypotony was unresponsive to all forms of medical therapy. Reformation of the anterior chamber along with synechialysis revealed a 2.5 clock-hour cyclodialysis cleft by means of gonioscopy. A laser microendoscope probe was used and laser was applied to both the internal scleral and external ciliary body surfaces within the depths of the cleft. Within 3 weeks after treatment, intraocular pressure increased to 15 mm Hg and has remained at that level as of 9 months after the endolaser photocoagulation procedure. CONCLUSION: Endolaser photocoagulation with the ophthalmic laser microendoscope may be an appropriate procedure, after failure of medical therapy, for the diagnosis and repair of a cyclodialysis cleft, especially in the pediatric population.     

Intraocular microendoscopy: experiments in pig eyes

A new microendoscope is introduced for intraocular use. The probe diameter measures 0.96 mm. The resolving power is 360,000 pixels. Initial experiments on porcine eyes show the image quality to be excellent. This new endoscope may be helpful in lacrimal duct surgery, in cases of hazy corneas with intraocular pathology, for removal of intraocular foreign bodies, and in the diagnosis of tumors of the ciliary body or orbit.     

Ophthalmic laser microendoscope ciliary process ablation in the management of neovascular glaucoma.

PURPOSE: To evaluate the potential efficacy of ophthalmic laser microendoscope photocoagulation of the ciliary processes in the management of intractable neovascular glaucoma. METHODS: Ten patients with intractable neovascular glaucoma underwent ophthalmic laser microendoscope ciliary process ablation via a pars plana incision. The device and surgical technique are discussed. RESULTS: Preoperative intraocular pressure (IOP) ranged from 36 mmHg to 62 mmHg (mean, 43.6 mmHg). Postoperative final IOP ranged from 3 mmHg to 27 mmHg (mean, 15.3 mmHg). This represents an absolute decrease of 28.3 mmHg (65%). Postoperatively, 9 eyes had an IOP of less than 21 mmHg, although 3 of these eyes required medication. One eye attained a final IOP of 27 mmHg. All eyes were treated once. Nine patients were treated with carbonic anhydrase inhibitors preoperatively, and six patients were able to discontinue this medication postoperatively. Phthisis was not observed, but hypotony evolved in two eyes with chronic retinal detachment. Follow-up ranged from 6 to 11 months (mean, 8.8 months). CONCLUSION: This new therapeutic modality, which combines endoscopic visualization of the ciliary processes with diode laser photocoagulation, can be effective in the management of intractable neovascular glaucoma.     

Microendoscopic trabecular surgery in glaucoma management

OBJECTIVE: To evaluate the safety and efficacy of trabecular surgery under microendoscopic control in the management of advanced chronic open-angle glaucoma when the presence of corneal opacification obscures adequate visualization of the anterior segment. STUDY DESIGN: Comparative interventional case series. PARTICIPANTS AND INTERVENTION: Fifteen eyes of 15 patients with medically uncontrolled open-angle glaucoma and moderate-to-severe corneal opacification underwent trabecular surgery under microendoscopic control. Seven eyes were treated by photoablative laser goniopuncture and eight eyes by goniocurettage. MAIN OUTCOME MEASURES: The intraocular pressure (IOP) and number of medications before and after surgery were measured. Intraoperative and postoperative complications were analyzed. RESULTS: The ophthalmic microendoscope was successfully used in visualizing and identifying the anterior chamber angle structures and in controlling the trabecular surgical procedures in all eyes. The IOP dropped from 34.5 +/- 6.9 millimeters of mercury (mmHg) (range, 27-46 mmHg) under maximal-tolerated medical therapy before surgery to 18.5 +/- 3.0 mmHg (range, 15-23 mmHg) at 21 months after surgery. Medication averaged 2.3 +/- 0.6 before surgery and dropped to 1.0 +/- 0.7 at last follow-up. No difference was observed in the surgical outcome between the laser-treated eyes and those receiving goniocurettage. No severe intraoperative or postoperative complications relating to either the trabecular surgery or to the use of the microendoscope were observed. CONCLUSION: The ophthalmic microendoscope appears to be safe and effective in simultaneously providing illumination, video recording, and clear endoscopic view of the fine details of the anterior chamber angle structures. Microendoscopy enables various trabecular surgical procedures, such as goniocurettage or photoablative laser goniopuncture, which can be performed in the presence of corneal opacification that might otherwise preclude adequate visualization and treatment. It thus appears that microendoscopic trabecular surgery may in the future be considered as an alternative choice of surgical treatment in some cases of open-angle glaucoma.     

Micro-endoscopy of the lacrimal apparatus combined with Erbium YAG laser: an anatomical study. New methods of imaging]

PURPOSE: To study the anatomic structure and the endoscopic aspect of the lacrimal drainage system and to evaluate the efficacy of the Erbium laser with microendoscope in lacrimal obstruction. METHODS: Twenty lacrimal ducts from ten fresh cadaver heads were used to lead a special rigid probe of 1.1. mm diameter (Endognost Schwind). This probe combined a flexible endoscopic probe of 500 mu, an Erbium laser fiber of 375 mu and an irrigation. The probe was introduced through the inferior canaliculus. Progressing in the lacrimal system, all the images were analysed. Then, we used the laser fiber to open the lacrimal sac mucosa and the lacrimal bone. RESULTS: The anatomo-endoscopic analysis was performed using endoscopic data. We appreciated essentially the walls of valves and sinuses that appeared only functional when increasing the irrigation flow. The laser could easily open the mucosa and the lacrimal bone but not the maxilla. DISCUSSION: The small size of the cannula allows to use the system for the diagnosis of lacrimal obstructions. The combined laser allows to treat at same time canalicular obstructions and lower obstructions. CONCLUSION: The endocanalicular study of the lacrimal drainage system can diagnose the type of obstruction and can treat it. A clinical study is requested to confirm these results.     

Endoskopisch kontrollierte Chirurgie mit dem Mikrobohrer und Intubation der Tränenwege

Purpose. Operative procedures to manage lacrimal outflow obstruction were made traditionally without endoscopic assistance. For dacryoendoscopy we previously used a 0.5-mm endoscope with a special wash cannula. We now use the microendoscope Vitroptic T for dacryoendoscopy and for endoscopically controlled surgery with a microdrill. Methods. In an attempt to perform microinvasive lacrimal surgery we use a 1.1-mm endoscope (Vitroptik T) with a wash cannula, a channel for the microoptic and a channel for a microdrill. We report on our initial experiences and on the results of eight patients with stenosis of the lacrimal outflow system who were treated with an endoscopic microdrill and silicone tubing. One patient had lacrimal stenosis after external dacryocystorhinostomy (DCR), and seven patients showed punctual stenosis in the nasolacrimal duct. Results. Using the dacryoendoscope (Vitroptic T) we were able to visualize pathologic changes of the lacrimal outflow system. Intraoperative situations during dacryoendoscopy are demonstrated. The Vitroptic T allows dacryoendoscopy and endoscopically controlled surgery of the lacrimal drainage system. Three months after surgery in six patients (75%) the lacrimal outflow system was patent with the silicone tube in place, and these patients had no epiphora. The patient with re-stenosis after external DCR showed patency. Conclusions. Dacryoendoscopy and endoscopic controlled surgery of the lacrimal drainage system enables atraumatic and minimally invasive surgery. The Vitroptik T with the microdrill allows endoscopically controlled microsurgery. Possible indications for the microdrill are punctual stenosis and re-stenosis after external DCR.     

Effects of elevated intraocular pressure on haemoglobin oxygenation in the rabbit optic nerve head: a microendoscopical study.

Intraocular pressure dependent reactions of optic nerve head vasculature and intracapillary haemoglobin oxygenation (HbO(2); oxygen saturation) were studied in the center and at the rim of the rabbit optic nerve head (ONH) as well as in the choroid, by a new combination of microendoscopy and simultaneous haemoglobin spectrophotometry.In 13 anesthetized albino rabbits the vasculature and the intracapillary Hb-oxygenation were studied by a microendoscope which was introduced into the eye bulb. Photometric measurements were performed via a beam splitter with the Erlangen micro-lightguide spectrophotometer (EMPHO) from the center of the endoscopic picture. The haemoglobin oxygenation was calculated by real time analysis of the spectral curves. Intraocular pressure was elevated stepwise from 20-80 mmHg.At the rim of the optic nerve head the vascular diameters as well as the intracapillary HbO(2)-values were stable till an intraocular pressure of 60 mmHg and decrease after IOP elevation to 70 and 80 mmHg. In contrast, in the center of the optic nerve head and in the choroid these parameters decline already from 40-50 mmHg on. At an IOP of 60 mmHg (P<0.01) and 70 mmHg (P<0.05) HbO(2)is significantly lower in the ONH center than at the rim. In the center and the choroid HbO(2)is well maintained between 20 and 40 mmHg. After pressure release at the end of the experiment HbO(2)increased to 94.3+/-4.6% (rim) and 98.8+/-1.5% (center) of the initial value at 20 mmHg (difference not significant).By the high spatial resolution of this new optical method we were able to demonstrate that the center of the optic nerve head is more sensitive to changes in intraocular pressure than the optic nerve head rim. Thus, tissue damage after critical haemodynamic and oxygenation parameters seems more probable in the relatively poor perfused center of the ONH than in the overperfused rim.     

Experimental microendoscopic photoablative laser goniotomy as a surgical model for the treatment of dysgenetic glaucoma

Purpose: The aim of this study was to investigate the feasibility of photoablative Er:YAG laser goniotomy under microendoscopic control in a surgical cloudy corneal model of primary infantile glaucoma. Methods: Pectinate ligaments of 12 freshly enucleated cadaver porcine eyes were treated by ab interno single-pulse (5 mJ, 200 s) Er:YAG laser (2.94 m) photoablation. Through a clear corneal incision near the limbus an ophthalmic microendoscope (18 and 20 gauge) was inserted into the anterior chamber. Internal structures were observed and photoablative laser goniotomy was conducted under video guidance. Following treatment all eyes were prepared for light and scanning electron microscopy. Results: Anterior chamber angle structures and tissue photoablation were clearly visualized on the videoscreen using ophthalmic microendoscopy. Energy settings of 5 mJ per pulse proved to be sufficient for reproducible photoablation of pectinate ligaments, accompanied by the root of the iris falling back and exposing trabecular meshwork. This was confirmed histopathologically. Scatter thermal damage was less than 30 m. Conclusion: This new therapeutic modality, which combines endoscopic visualization of the internal structures with photoablative laser goniotomy, can be effective in the management of dysgenetic glaucoma in the presence of a cloudy cornea. High reproducibility of contact laser photoablation enabled sufficient control of incision depth and was not accompanied by inadvertent tissue damage to adjacent intraocular structures.     

眼科手术麻醉并发症的预防和处理

眼科手术技术的不断进步和手术器械的不断发展使得眼科手术变碍越来越安全,同时眼科麻醉的方式和选择也发生了相应的改变,但目前仍没有绝对安全的眼科麻醉方法,临床上眼科手术麻醉的并发症仍有发生.眼科手术中麻醉方式的选择主要取决于手术方式、医生的需要、患者的期望及配合程度,大多数眼科手术在局部麻醉下即可完成,但是眼科局部麻醉过程中注射针接近血管、视神经和脑干等重要结构时,可增加相关组织结构损伤的风险,其中最严重的并发症是脑干麻醉,麻醉师和眼科医师应充分认识到这些并发症甚至有危及生命的可能.为了避免麻醉过程中药物意外注射到周围的血管、眼球和脑脊液中而造成神经组织的损伤,需要麻醉师和眼科医师对相关区域的解剖结构进行精确评估,特别是注射部位、深度以及眼球位置的判断.因此,应强调眼科医师提高对眼科手术麻醉并发症,特别是脑干麻醉等严重并发症预防及合理处理的意识.