小切口下角膜后弹力层剥除联合深板层内皮移植术的实验研究

目的 探讨小切口下角膜后弹力层剥除联合深板层内皮移植术(DSEK)的手术方法、疗效、并发症、内皮细胞的评价及组织学检查.方法 为实验研究.将24只新西兰大白兔随机分为3组,每组8只兔(8只眼),供体为新西兰大白兔16只眼.A组于角膜缘处行5 mm长隧道切口,剥去角膜中央直径10 mm的后弹力层,将等大的带有少量基质的后弹力层内皮细胞膜片植入受体眼;B组行单纯角膜后弹力层环形撕除术;C组在角膜后弹力层剥除后行去内皮细胞的带少许角膜基质和后弹力层膜片植入.术后观察1个月,比较3组兔角膜的透明性、植片贴附情况、角膜内皮细胞密度及并发症情况.结果 A组8只眼术前角膜内皮细胞密度平均值为(2728±108)个/mm2,术后角膜均恢复透明,内皮细胞密度平均为(2195±77)个/mm2,差异有统计学意义(t=12.455,P＜0.001);组织切片证实角膜内皮细胞植片与受体植床愈合良好,层间无瘢痕形成.B组8只眼术后均有严重的角膜水肿,持续1个月未恢复,组织学检查术后28 d时仅在后弹力层剥除的交界处有极少数的内皮细胞长入.C组8只眼术后1周内角膜植片均水肿,5只眼植片脱位;术后至观察1个月,角膜中央水肿仍较明显,伴有角膜新生血管长入,组织学检查植片部位未见内皮细胞长入.结论 角膜后弹力层剥除联合深板层内皮移植术具有安全、损伤小、术后恢复快及无层间瘢痕的优点,是治疗大泡性角膜疾病的优选术式.     

角膜后弹力层剥除内皮移植术治疗大泡性角膜病变的初步疗效观察

目的 探讨角膜后弹力层剥除内皮移植手术的适应证、手术方法以及对大泡性角膜病变的疗效与并发症的处理.方法 非随机回顾性系列病例研究.选择2006年9月至2007年10月于中山大学中山眼科中心住院的8例(8只眼)大泡性角膜病变患者行角膜后弹力层剥除内皮移植术.术中剥除患眼角膜中央部直径7.75 mm的后弹力层和病变的内皮层,再将植床周边部基质表面刮粗糙,然后按常规角膜内皮移植术的方法植入内皮植片.术后观察植片与植床贴合和植片移位等情况.随访3～9个月,记录患者视力、植片透明度、角膜散光及内皮细胞密度.结果 8例患者术后植片与植床贴合良好,未出现植片移位.术后第1天,1例患者出现继发性闭角型青光眼,术后48 h后缓解.8例患者术后植片透明,术前存在眼痛的6例患者术后眼痛缓解.8例患者术后视力均提高,最好矫正视力为0.3～0.7,平均角膜散光度数为(1.90±0.70)D,平均内皮细胞密度为(2014±192)个/mm2.结论 与深板层角膜内皮移植术比较,角膜后弹力层剥除内皮移植术的操作较简单,对受体角膜和前房的创伤更小.术中将植床周边部基质表面刮粗糙,可有效预防术后植片移位.     

小切口无缝线深板层角膜内皮移植术的疗效观察

目的探讨小切口无缝线深板层角膜内皮移植术的手术方法、临床疗效及并发症的预防与处理。方法对9例（9只眼）大泡性角膜病变患者行小切口无缝线深板层角膜内皮移植术,其中6例联合前段玻璃体切割术。术后观察植片与植床贴合情况、植片移位的发生和处理。随访3～5个月,观察视力、植片透明度、角膜曲率、角膜散光及角膜内皮细胞密度。结果8例患者植片与植床贴合良好,1例患者术后第1天植片移位,经再次复位后贴合良好。6例患者不同程度提高视力,3例患者因术前长期高眼压,术后视力不提高。9例患者植片均透明,角膜曲率（43．96±3．38）D,角膜散光度数（3．32±1．20）D,角膜内皮细胞密度（2124±278）个／mm^2,未出现严重并发症。结论与穿透性角膜移植或板层角膜瓣下深板层角膜内皮移植术比较,小切口无缝线深板层角膜内皮移植术治疗大泡性角膜病变更有优势,有望成为治疗该病的手术方式之一。     

兔角膜后弹力层剥除联合深板层内皮移植术后植片与植床愈合的观察

目的 探讨小切口下兔角膜后弹力层剥除联合深板层内皮移植(DSEK)术后不同时间植片与植床的愈合情况.方法 30只新西兰大白兔,供体组10只(20只眼),受体组20只(20只眼),右眼为实验组,行同种异体DSEK手术,左眼为正常对照组.术后裂隙灯定期观察角膜透明度;应用SL-OCT观察植片与植床的贴附情况及角膜厚度;分别于术后1、2、3、4、8周各取兔4只,制作角膜组织病理学切片,光镜下观察植片与植床的愈合情况.结果 实验组中1只眼由于植片严重卷曲未与植床贴附导致角膜持续混浊水肿,其余19只眼全部恢复透明.裂隙灯下见术后第1d角膜水肿严重,以后逐渐减轻,术后4周角膜完全透明.SL-OCT见各个时间点植片与植床均紧密贴附,术后第1d角膜明显增厚,以后逐渐变薄,至第4周角膜恢复到正常的厚度和形态.光镜下组织学观察,术后早期植片与植床界面清晰易辨,胶原纤维间缝隙增宽,排列紊乱.术后4周植片与植床的界面辨认不清,胶原纤维结构和排列基本恢复正常,角膜中央光学区无瘢痕形成.结论 DSEK术后,植片与植床能迅速达到无瘢痕的组织学愈合,该愈合对角膜透明度的恢复起重要作用.     

不剥除后弹力层的深板层角膜内皮移植术治疗大泡性角膜病变的初步临床观察

目的 探讨不剥除后弹力层的深板层角膜内皮移植术治疗大泡性角膜病变的可行性和临床疗效.方法 前瞻性系列病例研究,收集自2007年9月至2009年1月在我院住院的大泡性角膜病变患者,进行不剥除后弹力层的深板层角膜内皮移植术.术中均未处理患眼角膜内皮.直接用植入镊将制作好的直径为8.5mm的角膜内皮植片植入受体前房,气体顶压植片进行固定.术后随访6～20个月,观察植片贴附和植片移位等情况,对手术前后的视力进行比较,检查植片透明度和角膜内皮细胞密度.结果 5例患者术后植片与受体内皮面始终贴附良好;1例患者术后第2天出现层间裂隙,经改俯卧位后植片贴附良好.6例患者植片均透明,其中5例患者术后最佳矫正视力均有不同程度的提高;1例患者术后视力同术前,视力不提高的原因为眼外伤造成的视神经萎缩.6例术后平均角膜内皮细胞密度为(1648±384)个/mm~2.随访过程均未发现有免疫排斥反应发生.结论 不剥除后弹力层的深板层角膜内皮移植术治疗大泡性角膜病变具有安全、有效、操作简便等特点,有望成为治疗该病的手术方式之一.     

小切口深板层角膜内皮移植的初步临床结果

目的 探讨小切口深板层角膜内皮移植(Deep lamellar posterior endothelial keratoplasty,DLEK)的手术方法、临床效果及手术并发症.方法 无对照的前瞻性临床研究.受体后板层通过5 mm切口从眼内取出,植片折叠后通过该切口移植到受体眼内.术后随访角膜伤口的愈合、角膜厚度、角膜散光、角膜内皮细胞密度和矫正视力.结果 21例大泡性角膜病变的患者中,20例完成DLEK术,19例术后获得透明角膜.3个月时平均角膜厚度(497.4±35.3)μm,平均角膜内皮细胞密度(1540.5±515.7)个/mm2,平均角膜散光(2.7±1.2)D.术后矫正视力较术前均有提高.主要并发症为术中植床的穿破,术后植片脱落及植床、植片间的间隙.结论 小切口深板层角膜内皮移植可有效治疗大泡性角膜病变,初步临床效果满意.(中国眼耳鼻喉科杂志,2006,6354～356)     

深板层内皮角膜移植术治疗角膜内皮病变

目的探讨深板层角膜内皮移植术(deeplamellarendothelialkeratoplasty,DLEK)治疗角膜内皮性病变的临床疗效。方法对5例6眼因角膜内皮病变导致角膜水肿或大泡性角膜病变眼行深板层角膜内皮移植术。1眼供、受体角膜和植片均用微型角膜刀制备,另5眼供体深板层内皮植片用微型角膜刀制作,受体带蒂角膜瓣以虹膜恢复器分离制作;其中1例2眼为先天性角膜内皮营养不良,4例4眼为白内障术后大泡性角膜病变。结果4眼随访12个月以上,2眼随访4个月。所有病例角膜持续透明,术后视力均有明显提高,患者术后1个月平均角膜内皮细胞密度为2189/mm2(1594～2641),角膜厚度平均为568μm(510～675)。结论与传统的PKP比较,DLEK具有术后视力恢复快、角膜高度散光机率小、排斥反应风险小等优点,是一种治疗角膜内皮性病变的有效方法。     

无缝线深板层角膜内皮移植术的研究进展

角膜内皮失代偿可严重影响视力,以往多采用的穿透性角膜移植手术(PKP)具有术后高度散光、移植片排斥等并发症,严重限制了术后视力的提高.如果能够单纯地进行后弹力层和内皮细胞层的移植,将减少手术操作所带来的受体角膜损伤并能更好地恢复术后视力.近年来,无缝线深板层角膜内皮移植手术的优点已逐渐获得公认;其中深板层角膜内皮细胞移植手术(DLEK)手术难度较大,限制了其在临床的广泛开展.而通过剥除受体角膜的后弹力层和内皮层来制作植床的角膜内皮移植手术即角膜后弹力层剥除内皮细胞移植手术(DSEK)已经取得了较好的手术效果.本文归纳、分析了DSEK的手术方法、效果及并发症等.     

自动板层刀辅助的后弹力层前膜角膜内皮移植术

角膜内皮移植已成为治疗角膜内皮病变的首选方法.作为目前主流的2种角膜内皮移植手术——后弹力层剥除自动板层刀制备的角膜内皮移植术和后弹力层角膜内皮移植术,前者手术操作易于掌握,但角膜植片仍带有部分基质;后者术后视觉质量好,但手术操作较难掌握,二次手术率较前者高.大气泡和自动板层刀辅助的后弹力层前膜角膜内皮移植术在自动板层刀制备角膜内皮植片的基础上,用大气泡法暴露中央6.5 mm直径的后弹力层前膜,本术式既有后弹力层角膜内皮移植术后的视觉效果,手术操作又易于掌握,值得推广.     

自动角膜板层刀切割一个供体角膜用于两位患者

目的评估应用自动角膜板层刀切割一个供体角膜用于深板层角膜移植和角膜内皮移植的临床疗效及安全性。方法回顾性系列病例研究。应用自动角膜板层刀预先将新鲜供体角膜进行切割,将带部分基质的角膜内皮植片用于角膜内皮移植术,剩余前板层用于深板层角膜移植术。回顾性分析2010年3—8月期间在温州医学院附属眼视光医院行角膜内皮移植术的17例患者及分别来自同一供体角膜的行深板层角膜移植的17例患者。术后随访19～24个月,分别观察角膜内皮贴附情况及前板层角膜植片愈合情况。随访资料包括医学验光、前节光学相干断层扫描及角膜内皮细胞计数。手术前后视力比较采用配对t检验。结果17例角膜内皮移植患者术后角膜内皮植片均贴附良好,术后视力较术前均有提高。除1例碱烧伤患者因晶状体混浊,无法验光外,其余术后平均散光为（1．69±0．60）D。17例角膜内皮移植患者平均角膜内皮细胞计数为（2128±244）个／mm^2,平均角膜内皮植片厚度为（152±46）μm。17例前板层角膜移植患者角膜植片均透明,术后最佳矫正视力较术前提高,平均散光为（2．50±0．90）D;平均前板层角膜植片厚度为（343±39）μm。结论利用角膜板层刀将一个供体角膜用于两位患者的方法在临床实际应用中切实可行。经长期随访,角膜植片未出现明显并发症。该方法可以更充分地利用供体角膜,缓解中国供体角膜匮乏现状,意义重大。     

Small-incision deep lamellar endothelial keratoplasty (DLEK): six-month results in the first prospective clinical study

PURPOSE: To evaluate the visual, topographic, and endothelial survival results in 25 consecutive patients who have received small-incision deep lamellar endothelial keratoplasty (DLEK) transplant surgery. METHODS: DLEK surgery was performed in 25 patients with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy utilizing a 5-mm scleral access incision. Snellen visual acuities, refractive astigmatism, endothelial cell counts, and corneal topography were prospectively measured at preop and at 6 months after small-incision DLEK endothelial replacement surgery. RESULTS: Best spectacle-corrected visual acuity improved from an average of 20/90 (range 20/25 to 2'/200) before surgery to an average of 20/44 (range 20/25 to 20/200, P < 0.001) 6 months after surgery, with 56% of patients 20/40 or better at 6 months. Average refractive astigmatism at 6 months was 1.31 +/- 0.59 diopters (range 0.25 to 2.50 diopters), representing an average increase in astigmatism of 0.45 diopters from preop. Despite folding of the donor graft for placement into the recipient posterior lamellar bed, the average postoperative endothelial cell count at 6 months was 2122 +/- 510 cells/mm2 (range 1097 to 3202 cells/mm2) or an average 24% cell loss from donor eye preop measurements, a level of cell loss comparable to that reported after PK or after large-incision DLEK surgery. CONCLUSION: Small-incision DLEK surgery preserves the recipient corneal topography, resulting in very little change in astigmatism from preop. The excellent postoperative donor endothelial cell counts attest to the survival of donor endothelium despite folding of the graft for insertion. The small-incision DLEK technique may become the standard for endothelial replacement surgery in the future.     

A practical femtosecond laser procedure for DLEK endothelial transplantation: cadaver eye histology and topography

PURPOSE: The manual dissection technique for deep lamellar endothelial keratoplasty (DLEK) surgery is technically difficult and may not be smooth enough for consistently optimal postoperative vision. We evaluated the feasibility and efficacy of using a femtosecond laser to perform the dissections in the DLEK procedure. METHODS: The Intralase femtosecond laser (with standard LASIK surgery spot settings) was used to create a 9.4-mm wide, 400-microm deep lamellar pocket dissection and a 5.0-mm wide side cut near-exit incision in 10 "recipient" whole cadaver eyes and in 10 "donor" cadaver corneal-scleral caps mounted onto an artificial anterior chamber. Recipient and donor disks were resected with special scissors, and the donor tissue was transplanted using the small incision (5.0-mm) DLEK technique. Topography of the recipient eyes was measured pre- and postlaser dissection, and the recipient and donor tissues were sent for scanning electron microscopy (SEM) analysis of the smoothness of the dissections. RESULTS: Successful lamellar dissections were obtained in all tissues. The mean recipient topographic corneal curvature postoperatively was 43.3 +/- 1.7 diopters, which was not a significant change from the preoperative curvature of 44.0 +/- 0.8 diopters (P = 0.430). The mean recipient topographic astigmatism postoperatively was 1.7 +/- 0.8 diopters, which was not a significant change from the preoperative recipient astigmatism of 1.6 +/- 0.7 diopters (P = 0.426). Comparison of the histology of the laser-formed stromal dissections by scanning electron microscopy, however, did not appear significantly better than histology after manual DLEK dissections in either the recipient or the donor tissues. CONCLUSIONS: A femtosecond laser can create the lamellar dissections for the DLEK procedure, making this procedure easier and faster. As in the manual technique, corneal topography is unchanged by this surgery. More work will need to be done, however, to optimize the laser settings to provide even smoother interface surfaces.     

Endothelial keratoplasty using donor tissue not suitable for full-thickness penetrating keratoplasty

PURPOSE: To evaluate the use of corneal donor tissue deemed unsuitable for full-thickness penetrating keratoplasty (PK) for use in deep lamellar endothelial keratoplasty (DLEK) and to compare postoperative results to those of DLEK surgery using donor tissue that is suitable for PK. METHODS: Small-incision DLEK surgery was performed using 39 donor corneas unsuitable for PK. Thirty-five donors had anterior scars or opacities, 3 donors had pterygia within the 8-mm zone, and 1 had prior LASIK. All donor preparation was completed by manual stromal dissection. The DLEK surgical and postoperative courses were reviewed. Preoperative and 6-month postoperative results of this study group were compared with a control group consisting of the first 55 consecutive small-incision DLEK patients receiving donor corneas that had no criteria excluding them from use in PK. Four eyes in the study group and 1 eye in the control group had the confounding variables of the presence of an anterior-chamber lens or surgical vitrectomy with macular disease in the recipient eye. RESULTS: There was no significant difference in preoperative measurements of best spectacle-corrected visual acuity (BSCVA; P = 0.372), donor endothelial cell density (ECD; P = 0.749), or corneal topography [surface regularity index (SRI), P = 0.485; or surface asymmetry index (SAI), P = 0.154] between the 2 groups. For the patients receiving corneas deemed unacceptable for PK, at 6 months after surgery, the vision (P = 0.002) and corneal topography measurements improved significantly from before surgery (SRI, P < 0.001; SAI, P < 0.001), and there was no significant change in refractive astigmatism (P = 0.240). There was a significant difference in the vision at 6 months postoperatively between the overall study group and the control group, with the mean vision of the study group at 20/56 and the control group at 20/43 (P = 0.015). If eyes with known cystoid macular edema (CME) and vitrectomy are removed from each group, there is no significant difference in vision at 6 months between the study group and the control group (P = 0.110), with the average BSCVA of those receiving donor corneas unsuitable for PK equal to 20/48 (range, 20/25-20/200) and the average vision for those receiving PK-acceptable donor tissue equal to 20/43 (range, 20/20-20/80). The 6-month average refractive astigmatism of the study group was 1.12 +/- 0.99 D (range, 0.00-4.00 D), and the average endothelial cell count was 2064 +/- 396 cells/mm(2) (range, 1208-2957 cells/mm(2)). There was no significant difference in 6-month postoperative endothelial cell count (P = 0.443), refractive astigmatism (P = 0.567), or corneal topography (SRI, P = 0.332; SAI, P = 0.110) in study patients who received corneas unsuitable for PK compared with control patients who received corneas suitable for PK. CONCLUSIONS: Endothelial keratoplasty such as DLEK surgery with manual donor preparation broadens the donor pool by enabling corneas that cannot be used for PK to be used for selective endothelial transplantation without deleterious postoperative results.     

Replacing the endothelium without corneal surface incisions or sutures: the first United States clinical series using the deep lamellar endothelial keratoplasty procedure

PURPOSE: To report the 6- and 12-month results of the first United States clinical series of deep lamellar endothelial keratoplasty (DLEK) in the treatment of endothelial dysfunction. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Eight eyes of eight patients with corneal edema from Fuchs' dystrophy and pseudophakia. METHODS: A 9.0-mm limbal, scleral, partial-depth incision provided access for a deep lamellar corneal pocket dissection. A 7.5- to 8.0-mm posterior lamellar disc of recipient tissue was then excised and replaced through the pocket with a same size donor disc containing healthy endothelium. A temporary air bubble in the anterior chamber was used for donor tissue adherence, and no surface corneal incisions or sutures were necessary. MAIN OUTCOME MEASURES: Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction astigmatism, TMS-1 topography, ultrasonic pachymetry, Orbscan topography, and endothelial cell density were evaluated. Intraoperative and postoperative complications are reported. RESULTS: At 6 and 12 months after surgery, all eight corneas were clear and the grafts were healed in good position. At 6 months, the BSCVA varied between 20/30 and 20/70, the average change in astigmatism from before surgery was +1.13 diopters (D; +/-1.50 D), the average change in corneal power was -0.4 D (+/-1.7 D), the average pachymetry was 648 micro m (+/-134 micro m), and the average endothelial cell count was 2290 cells/mm(2) (+/-372 cells/mm(2)). At 12 months, three of the four eyes reaching this time gate were 20/40 or better, with a change in astigmatism from before surgery of only +0.81 D (+/- 0.55 D), a corneal power change of -1.3 D (+/- 0.4 D), and an endothelial density of 2409 cells/mm(2) (+/- 154 cells/mm(2)). One of the original nine eyes entered into this study required conversion to standard penetrating keratoplasty as a result of a microperforation during recipient pocket dissection and has experienced no ill effects. CONCLUSIONS: The DLEK procedure, with its absence of corneal surface incisions and sutures, is a safe procedure that preserves the normal corneal topography, minimizes astigmatism and corneal power changes, and provides a healthy donor endothelial cell count and function. If interface optical clarity can be maintained, then this technique offers considerable advantages over penetrating keratoplasty in the treatment of endothelial dysfunction.     

Use of indocyanine green in deep lamellar endothelial keratoplasty

A new technique using indocyanine green (ICG) during deep lamellar endothelial keratoplasty (DLEK) to stain the corneal stroma of the donor disk facilitated surgical placement of the disk in the host corneal opening created to match the donor disk. Two female patients, aged 82 and 77 years, had ICG staining of the donor corneal disk during DLEK for pseudophakic bullous keratopathy and Fuchs' corneal dystrophy. By 24 hours postoperatively, no ICG was detected clinically by biomicroscopy of the sutureless (no corneal sutures) lamellar transplanted corneas. This is the first report of the use of ICG during DLEK and the first intrastromal use of ICG in the human cornea. The use of ICG facilitated the DLEK procedure and appears to be safe for intraoperative use in the cornea.     

Case report: femtosecond laser-assisted small incision deep lamellar endothelial keratoplasty

PURPOSE: To report two cases of femtosecond laser-assisted small incision deep lamellar endothelial keratoplasty (DLEK) for patients with corneal endothelial decompensation by Fuchs dystrophy and glaucoma METHODS: Femtosecond laser (IntraLase; IntraLase Corp., Irvine, CA) with 15 kHz of repetition rate, was used for a 9.5 mm diameter by 400 micrometer thickness donor corneal lamellar dissection. RESULTS: In Case 1, the graft was clear and compact without interface haze, Orbscan showed smooth and regular corneal surface, specular microscopy was unremarkable without sign of corneal endothelial damage, and Optical coherence tomography showed uniform graft well attached to recipient stroma with minimal interface reflection at 2 months postoperation. In Case 2, the graft was clear and compact with minimal interface haze at 1 month postoperation. Femtosecond laser-assisted small incision DLEK was safe and technically feasible in our cases; however, further evaluation is required to determine long-term effects.     

Deep lamellar endothelial keratoplasty (DLEK): pursuing the ideal goals of endothelial replacement

Endothelial dysfunction is a leading cause of corneal vision loss and treatment requires surgical replacement with donor endothelium. Standard penetrating keratoplasty (PK) suffers from the inherent problems of surface corneal incisions and sutures and poor wound healing of vertical stromal wounds. This often results in high irregular astigmatism, unpredictable corneal power, and the risk of long-term visual loss from suture-induced vascularization, ulceration, rejection, and late wound rupture. This paper delineates five ideal goals of endothelial replacement, which include: (1) a smooth surface topography without significant change in astigmatism from preoperative to postoperative; (2) a highly predictable and stable corneal power; (3) a healthy donor endothelium that resolves all oedema; (4) a tectonically stable globe, safe from injury and infection; and (5) an optically pure cornea. Deep lamellar endothelial keratoplasty (DLEK) is a surgical method of endothelial replacement that is performed through a limbal scleral incision that leaves the surface of the recipient cornea untouched. The early results of this innovative surgery are discussed and compared to the results of PK in terms of fulfillment of the five ideal goals of endothelial replacement. With further refinement of interface creation, DLEK surgery may be the ideal method for endothelial replacement.