深板层角膜移植术与穿透性角膜移植术治疗圆锥角膜的临床分析

目的 探讨深板层角膜移植术（DLKP）与穿透性角膜移植术（PKP）对圆锥角膜的不同临床疗效。方法采用病例对照研究设计,选择自2003年4月至2006年4月期间于我院行DLKP11例（11只眼）和PKP18例（18只眼）的29例圆锥角膜患者资料。对术前、术后的未矫正视力（UCVA）、最好矫正视力（BCVA）、植片情况、散光状况及手术并发症等进行分析。结果DLKP术后9例患者BCVA高于0．5,PKP术后14例患者BCVA高于0．5。DLKP组术后的平均球镜度数（DS）为（-1．21±3．36）D,平均柱镜度数（DC）为（-4．03±1．87）D,PKP组术后平均DS和DC分别为（-3．86±2．43）D和（-3．43±2．31）D,两组间比较差异均无统计学意义（DS：t=2．135,P=0．46;DC：t=-0．643,P=0．528）。共焦显微镜检查显示,DLEK组与PKP组术后角膜植片的上皮细胞、上皮细胞基底层及前弹力层角膜在形态上基本相似,均表现为植片基质细胞胞核略小,排列稍显紊乱,有裂隙样暗纹。DLKP组患侧眼内皮细胞的形态基本正常,平均密度为（2311．72±439．73）个／mm^2,对侧眼为（2477．81±535．92）个／mm^2,二者差异无统计学意义（t=1．06,P=0．78）;PKP组患侧眼内皮细胞面积较大,细胞大小不均匀,非六角形细胞比例高,平均密度为（1642．17±583．41）个／mm^2,明显低于对侧眼（2739．05±401．77）个／mm^2,二者之间比较差异有统计学意义（Z=7．32,P=0．006）。DLKP组的并发症主要是术中后弹力层穿孔、缝线松脱及层间浑浊等。PKP组的并发症主要是缝线松脱、眼压升高、排斥反应及内皮功能衰竭。结论DLKP术后的屈光状况与PKP术接近,虽然手术操作难度较高,但是术后发生内皮排斥和内皮衰竭的机率低、安全性高。（中华腰群杂志,2007,43：583-588）     

深板层角膜移植与穿透性角膜移植治疗圆锥角膜的比较

目的 评比深板层角膜移植术(DLKP)和穿透性角膜移植术(PKP)两种术式治疗圆锥角膜的临床疗效.方法 对我院连续收治的圆锥角膜48例48眼进行两种术式治疗,其中DLKP23眼,PKP 25眼,对两种手术疗效进行分析比较.术后随访6～24个月.术后分析最佳矫正视力、植片透明情况和并发症.结果 术后矫正视力≥0.5者,DLKP 19眼(82.61%),PKP 24眼(96.00%),两组患者的术后视力差别无统计学意义(P＞0.05).DLKP术后并发症为后弹力层皱折5眼,后弹力膜穿孔2眼,移植片排斥反应3眼(13.04%);PKP术后发生继发性青光眼3眼,虹膜前粘连5眼及排斥反应6眼(24.00%).结论 DLKP比PKP并发症少,它能减少内皮型排斥反应的发生,且术后最佳矫正视力与PKP近似,DLKP为治疗圆锥角膜提供了-个更安全有效的选择.     

深板层角膜移植术与穿透性角膜移植术治疗真菌性角膜溃疡的效果比较

目的 比较深板层角膜移植术(DLKP)和穿透性角膜移植术(PKP)两种术式治疗真菌性角膜溃疡的效果.方法 回顾性系列病例研究.2004至2006年在宁波鄞州人民医院眼科中心临床诊断明确的真菌性角膜溃疡患者17例(17眼),其中8例行DLKP,平均年龄38.6岁,9例行PKP,平均年龄51.0岁.术后随访时间12～24个月,记录两组患者的最佳矫正视力、角膜屈光状态、角膜内皮计数及并发症.计数资料采用x2检验,计量资料采用独立样本t检验进行分析.结果 两组患者术后的视力均较术前提高,最好的最佳矫正视力达1.0,两组差异无统计学意义.DLKP组术后散光小于PKP组,差异有统计学意义(x2=12.07,P<0.05),两组散光度均低于5.00 D.术后6个月、12个月角膜内皮细胞计数DLKP组较PKP组高,差异有统计学意义(t=3.899、7.618,P<0.05).深板层角膜移植患者排斥反应的发生率较穿透性角膜移植患者低(x2=132.26,P<0.01).结论 真菌性角膜溃疡患者DLKP术后最佳矫正视力略优于PKP,角膜散光度比PKP低,并发症也较少.DLKP能减少排斥反应的发生,降低手术的失败率,是治疗真菌性角膜溃疡的一种安全有效的方法.     

两种术式角膜移植治疗圆锥角膜疗效比较

目的 比较深板层角膜移植和穿透性角膜移植术治疗圆锥角膜的临床效果。方法 2001年1月～2004年6月共收治圆锥角膜连续病例65例76眼，其中行深板层角膜移植术（指植床仅保留角膜后弹力层和内皮层）43眼，穿透性角膜移植术33眼，术后随访8个月～3年，比较不同术式下视力、角膜内皮计数、并发症、角膜植片透明等情况。结果 43眼行深板层角膜移植术后，裸眼视力≥0．4的25眼，33眼行穿透角膜移植术后，裸眼视力≥0．4的18眼，两组矫正视力均≥0．4，二者差异无统计学意义（X^2=0．089，P〉0．05）。深板层角膜移植术后角膜内皮计数平均（2870±340）个／mm^2，而穿透性角膜移植术后角膜内皮计数平均（2120±290）个／mm^2，二者差异有统计学意义（t=10．15，P〈0．05），深板层角膜移植术并发症为植床小穿孔4眼，后弹力层皱褶3眼，层间薄翳3眼，散光（〉2D）18眼；穿透性角膜移植术的并发症主要为植片排斥3眼，虹膜局限性前粘连5眼，散光（〉2D）15眼。两种方式术后均未见圆锥角膜复发，所有植片均透明。结论 深板层角膜移植治疗圆锥角膜可获得与穿透角膜移植一样的视力效果，且并发症较少，但与后者相比有一定局限性。     

穿透性角膜移植术与板层角膜移植术治疗圆锥角膜术后客观视觉质量比较

目的：探讨采用双通道视觉质量分析系统（OQAS）评估圆锥角膜患者行穿透性角膜移植术（PKP）和 板层角膜移植术（LKP）后的客观视觉质量。方法：前瞻性临床研究。收集2016年1月至2017年12 月在青岛眼科医院因圆锥角膜行角膜移植的患者40例进行研究,其中PKP组23例（24眼）,LKP组 17例（19眼）,术前2组患者最佳矫正视力、屈光度和临床分期差异均无统计学意义,术后随访并应 用OQAS检查术后的客观视觉质量,检查指标包括客观散射指数（OSI）、调制传递函数（MTF）截止 频率、客观对比度视力和泪膜质量OSI变化。分类变量比较采用χ2 检验,组间连续变量比较采用独 立样本t检验。结果：术后随访23～25个月,PKP组和LKP组患者角膜植片均保持透明状态,2组间 最佳矫正视力、球镜度和柱镜度差异均无统计学意义,但PKP组角膜内皮细胞计数明显低于LKP组 （t=3.91,P<0.001）。PKP组的斯特列尔比、20%对比度视力、9%对比度视力以及OSI与LKP组相比, 差异均无统计学意义。PKP组的MTF截止频率和100%对比度视力较LKP组高,差异均有统计学意 义（t=2.58,P=0.01;t=2.66,P=0.01）。泪膜质量OSI在LKP组明显高于PKP组,差异有统计学意义 （t=3.48,P<0.001）。结论：双通道OQAS测量结果表明圆锥角膜患者行PKP术后的客观视觉质量优 于行LKP术后,PKP术后的MTF截止频率和对比度视力高于LKP术后。     

深板层角膜移植术

深板层角膜移植术（DLKP）是一种完全去除病变的角膜基质组织直至暴露后弹力层，再移植供体角膜组织的手术方法，适用于所有未累及后弹力层和内皮的角膜疾病。目前有多种DLKP手术方法，该手术具有穿通性角膜移植术和板层角膜移植术的优点，同时避免了两者的缺点。本文综述深板层角膜移植术的适应证、手术方法进展、并发症、优点及联合手术。     

角膜移植术后应用环孢霉素滴眼液的临床观察

目的对比研究穿透性角膜移植术不同术后处理方法及其术后排斥反应的发生率。方法2组（48例）行穿透性角膜移植术角膜病患者，一组术后单独使用0．1％地塞米松滴眼，另一组采用环孢霉素A（1％CsA）和0．1％地塞米松（0．1％DXM）联合滴眼，对比2组术后排斥反应的发生率。结果采用1％CsA联合0．1％DXM，术后治疗组排斥反应发生率明显低于单纯使用地塞米松组（P〈0．05）。结论术后采用CsA联合DXM治疗，可有效降低角膜移植术后的排斥反应发生率。     

穿透性角膜移植术后的屈光状态分析

目的探讨穿透性角膜移植术（PKP）后屈光状态的变化趋势及原发病种和拆线时间对屈光状态的影响。方法对接受PKP治疗的各种病因患者共84例（90只眼）进行回顾性研究，通过分组比较术后不同时间点的最佳矫正视力（BCVA）、等效球镜、角膜曲率及角膜散光值，分析术后屈光状态的变化趋势以及原发病种和拆线时间对屈光状态的影响。结果PKP术后2年内，BCVA逐渐上升至0．67±0．20；等效球镜向近视方向移动，由术后6个月的（-0．80±3．79）D增至术后24个月的（-4．36±3．83）D；角膜曲率呈增加趋势，术后24个月达（45．41±2．54）D；角膜散光逐渐减小并趋于稳定。圆锥角膜组术后BCVA高于其他病种组（P〈0．05），两组间其他屈光指标无明显差异（P〉0．05）。术后12个月拆线组在术后24个月时的等效球镜和角膜曲率均高于术后24个月拆线组（P〈0．05），两组间BCVA和角膜散光无统计学差异（P〉0．05）。结论PKP术后等效球镜向近视方向移动，角膜曲率逐渐增大而角膜散光减小；原发病种对术后屈光状态无明显影响；术后晚拆线可在一定程度上减缓近视等效球镜和角膜曲率的增加趋势。     

穿透性角膜移植术后排斥反应的危险因素分析

目的探讨导致穿透性角膜移植术后排斥反应的危险因素。方法对168眼穿透性角膜移植术后排斥反应发生情况进行回顾性分析,总结免疫排斥反应发生的时间、次数,原因以及预后等。结果168眼中发生免疫排斥反应46眼,总发生率27．38％。各病种排斥反应发生率不同,圆锥角膜3．85％（1／26）;角膜内皮营养不良9．09％（1／11）;单纯疱疹性角膜炎29．55％（13／44）;真菌性角膜炎34．48％（20／58）;细菌性角膜炎40％（6／15）;角膜内皮细胞功能失代偿40％（2／5）;热、化学伤33．33％（3／9）。结论免疫排斥反应的发生是角膜移植手术失败的主要原因,其发生的时间与发生率同角膜疾病的种、角膜植片的位置及大小密切相关。     

圆锥角膜穿透性角膜移植术后远期疗效动态分析

目的 动态分析圆锥角膜穿透性角膜移植术后的远期效果。方法 收集本院22例27只眼因圆锥角膜行部分穿透性角膜移植术12m至192m的患者，分别进行视力、屈光度、散光及角膜地形图的检查，并对数据进行分析。结果 术前与术后1周，拆线前、后与术后2y～5y视力比较，差异有显著意义（P＜0．01或P＜0．05）。术后2y～5y与术后5y～16y相比差异无显著性（P＞0．05）。术后各随访阶段散光度比较差异无显著意义（P＞0．05）。圆锥角膜术后两种类型角膜地形图参数差异有显著意义（P＜0．01）。结论 圆锥角膜穿透性角膜移植术后疗效显著，无复发倾向，穿透性角膜移植术是圆锥角膜重要的治疗方法。     

Comparison of Clinical Outcomes of Same-size Grafting between Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus

Purpose

To compare the clinical outcomes between deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PKP) with same-size grafts in patients with keratoconus.

Methods

Medical records of 16 eyes from 15 patients treated from June 2005 through April 2011 were retrospectively reviewed. Patients with contact lens intolerance or who were poor candidates for contact lens fitting due to advanced cone underwent keratoplasty. The transplantations consisted of 11 DALK and 5 PKP with same-size grafting for keratoconus. Best-corrected visual acuity (BCVA), refractive error, corneal topographic profiling, and clinical course were compared between DALK and PKP groups.

Results

The follow-up period was 30 ± 17 months in the DALK group and 45 ± 20 months in the PKP group (p = 0.145). At final follow-up, the DALK and PKP groups achieved a BCVA (logarithm of the minimum angle of resolution) of 0.34 and 0.52, respectively (p = 0.980). Postoperative refractive error and mean simulated keratometric index showed myopic astigmatism in both groups without any statistical difference. Corneal irregularity index measured at 5 mm in the DALK group was less than that of the PKP group at 1-year follow-up (p = 0.021); however, at final follow-up, there was no longer a statistically significant difference. Endothelial cell counts were lower in the PKP group than in the DALK group at final follow-up (p = 0.021).

Conclusions

The optical outcomes of DALK with same-size grafts for keratoconus are comparable to those of PKP. Endothelial cell counts are more stable in DALK compared to PKP.     

Randomized clinical trial of deep lamellar keratoplasty vs penetrating keratoplasty

PURPOSE: To prospectively compare the safety and efficacy of deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP). DESIGN: Prospective, randomized clinical trial. METHODS: Consecutive 26 eyes of 24 patients who had stromal opacity without endothelial abnormalities were randomly assigned to either PKP or DLKP. Best-corrected visual acuity (BCVA), contrast visual acuity, glare test, intraocular pressure, corneal topography, endothelial density, and pachymetry were measured before and after surgery. RESULTS: Two eyes in the DLKP had rupture of the Descemet membrane and one of the eyes developed endothelial decompensation. One eye in the PKP group showed decreases in vision due to secondary glaucoma. None of the eyes developed immunologic rejection. The PKP group showed a tendency of faster recovery in BCVA than the DLKP group, but the difference was not statistically significant. Contrast visual acuity, glare test, and corneal topography did not show significant differences between the two groups. The intraocular pressure was significantly higher at 12 months in the PKP group (P =.004), but not in the DLKP group (P =.41) compared with preoperative values. While the PKP group showed progressive decrease in endothelial density over 24 months, this was not observed in the DLKP group after surgery. Difference in endothelial density at 24 months reached statistical significance (P =.04). CONCLUSIONS: We found that DLKP was superior to PKP in its safety such as continuous decreases of endothelium or increases in intraocular pressure. However, endothelial damage can also occur in DLKP, especially in cases of intraoperative Descemet membrane rupture. With the development of easier surgical techniques, DLKP may be a first choice of keratoplasty in most eyes without endothelial abnormalities.     

甘油冷冻保存角膜深板层角膜移植术治疗圆锥角膜

目的分析甘油冷冻保存角膜深板层角膜移植术（DALK）治疗圆锥角膜术后角膜内皮细胞密度及屈光状态变化。方法回顾性病例研究。分析圆锥角膜患者用甘油冷冻保存的角膜材料行DALK治疗的44例（49眼）病例资料,其中17例（17眼）患者于术后1个月、1年、2年、3年、4年按期进行随访,且随访资料完整。分析术后角膜内皮细胞丢失率、视力以及屈光状态。结果患者平均随访时间为（39．0±12．6）个月,无一例发生植片免疫排斥。术前平均内皮细胞密度（ECD）为（2597±578）个／mmz．术后1个月、1年、2年、3年、4年时平均ECD为（1790±409）cells／mm2、（1703±443）cells／mm2,（1632±389）cells／mm2、（1638±357）cells／mm2、（1675±283）cells／mm2、（1611±421）cells／mm2。术后4年ECD较术前减少34．2％。术前平均裸眼视力（UCVA）为（1．40±0．60）logMAR,平均最佳矫正视力（BCVA）（0．98±0．54）logMAR,术后1个月、1年、2年、3年、4年平均BCVA分别为（0．44±0．12）logMAR、（0．36±0．20）logMAR、（0．32±0．23）logMAR、（0．29±0．20）logMAR、（0．27±0．16）logMAR。结论使用甘油冷冻保存的角膜材料的角膜移植术治疗圆锥角膜可获得较好的视力,角膜内皮细胞丢失率低．远期疗效较好。     

Comparison of deep lamellar keratoplasty and penetrating keratoplasty for lattice and macular corneal dystrophies

PURPOSE: To compare the therapeutic outcomes after deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP) in patients with lattice corneal dystrophy (LCD) and macular corneal dystrophy (MCD). DESIGN: Age-matched control study. METHODS: We reviewed the clinical records of 84 eyes with LCD or MCD who had DLKP (41 eyes) or PKP (43 eyes). Primary pathology consisted of 60 eyes with LCD and 24 eyes with MCD. DLKP was performed by either removing stromal tissue gradually, or by viscodissection of Descemet's membrane. Graft clarity, best-corrected visual acuity (BCVA), endothelial density, and complications were compared between DLKP and PKP, as well as between LCD and MCD. RESULTS: All 84 eyes showed a postoperative improvement in visual acuity. The median final BCVA was not significantly different between PKP and DLKP groups. Endothelial cell loss rates were similar for DLKP and PKP. While the MCD-DLKP group showed progressive decrease in endothelial density, this was not observed in the LCD-DLKP group after surgery. In the DLKP group, most of the complications occurred intraoperatively or in the early phase, whereas late phase complications such as endothelial rejection and secondary glaucoma were the main complications in the PKP group. CONCLUSIONS: PKP is no longer an automatic choice for the surgical treatment for LCD and MCD; DLKP seems to be a safe alternative. While DLKP is a favorable method for LCD, MCD may not be a good candidate, as it might show progressive decrease in the corneal endothelium postoperatively.     

78例失败穿透角膜移植片的组织病理学研究

目的通过观察穿透角膜移植（PKP）失败植片的组织病理学改变,探讨不同原因所致移植失败的组织病理学演变过程。方法对行二次PKP取下的78例失败角膜植片行组织病理学检查。将植片按移植失败原因分为4组,将各组植片按原发病归类,光学显微镜下观察组织病理学表现。结果原发病复发组呈现与原发病相似的组织病理学表现。排斥组植片的各层结构基本存在,伴有炎症、成纤维细胞活跃和角膜新生血管（CNV）生长。根据原发病和二次手术时机的不同,又各有不同特点。植片溃疡组中,根据原发病不同呈现以慢性或急性炎性细胞浸润的不同表现。内皮失代偿组植片结构破坏较轻,均以上皮大泡和基质板层变性为主要病理学表现。结论PKP失败植片的组织病理学改变提示了各种移植失败原因的不同病理学演变过程。     

Deep anterior lamellar keratoplasty in the management of keratoconus

Advanced cases of keratoconus often require surgical intervention to restore corneal anatomy and improve eyesight. Penetrating keratoplasty (PK) although commonly performed has potential risk of immunological rejection and is now no longer automatically the first choice of surgery. DALK procedures have evolved, which allows surgical replacement of recipient''s corneal stroma, leaving behind healthy descemet membrane (DM) and endothelium. This reduces the risk of allograft endothelial rejection and late graft failure. In recent times, DALK techniques have led to significant improvements in visual outcome and current results are comparable to PK. Big bubble technique of DALK has become the most popular among the various surgical techniques described. Manual near DM DALK also gives good outcome although the visual recovery is often delayed. Future integration of femtosecond laser technology along with diagnostic imaging technology is likely to further improve outcomes of DALK in keratoconus.     

增视性角膜移植术后角膜植片透明率及影响因素

目的：探讨增视性角膜移植术后角膜植片的透明率及其影响因素。 方法：回顾性病例研究。选择2004-01/2005-12于青岛眼科医院行增视性穿透性角膜移植术（optical penetrating keratoplasty,PKP）的患者97例105眼,包括圆锥角膜,角膜基质营养不良,外伤、感染等因素导致的角膜白斑,单纯疱疹病毒性角膜炎稳定期,角膜内皮细胞功能失代偿等。统计分析术前视力及术后最佳矫正视力、角膜植片透明情况、内皮细胞计数、是否排斥、植片混浊原因,采用R×C表及四格表的χ2检验。 结果：增视性PKP术后角膜植片透明率：术后1a 89.8%,术后2a 83.7%,术后3a 78.3%,术后4a 67.1%,术后5a 63.6%。术后5a时圆锥角膜角膜植片透明率最高,达94.1%,角膜内皮功能失代偿最低,为14.3%。术后最佳矫正视力0.05~1.0,0.8以上者圆锥角膜所占比例最多,达72.5%,角膜内皮功能失代偿最少,占6.3%。导致角膜植片混浊的主要原因为角膜植片免疫排斥及角膜植片内皮细胞功能失代偿。 结论：增视性PKP术后角膜植片透明率逐年稳定下降,相邻两年之间无显著性差异;原发病不同,角膜植片透明率有差异,圆锥角膜手术效果最佳;角膜植片混浊的主要原因为免疫排斥及角膜植片内皮功能失代偿。     

Penetrating keratoplasty versus deep anterior lamellar keratoplasty for the treatment of keratoconus

Purpose To compare the outcome of penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) in the surgical management of keratoconus (KC). Patient and methods A retrospective review was conducted of the medical records of all patients treated with PKP or DALK for KC at University of Iowa Hospitals and Clinics from January 1, 2000, to December 31, 2006. The main outcome measures were visual outcome, graft survival, and complications. Cases with a minimum follow-up of 6 months were included in the statistical analysis. Results Of 41 eyes that met the inclusion criteria, 30 eyes were treated with PKP and 11 eyes were treated with DALK. The mean follow-up was almost identical for eyes treated with PKP or DALK (21.9 vs. 22.5 months, respectively). At the most recent examination, the mean best spectacle-corrected visual acuity (BSCVA) was 20/28 for the PKP group and 20/29 for the DALK group (P = 0.77). The percentage of eyes that achieved BSCVA of 20/25 or better was higher in the PKP group than in the DALK group (77.3 vs. 45.5%, respectively), but this difference was not statistically significant (P = 0.72). Endothelial rejection occurred in 4 (13.3%) eyes after PKP. Visually significant interface haze occurred in the early postoperative course in 2 (18.2%) eyes after DALK. No cases of late-onset endothelial failure were found in either group. Conclusion Treatment of KC with PKP or DALK is associated with similar visual outcomes, graft survival, and prevalence of sight-threatening complications.