Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage is a feared complication of all types of intraocular surgery. Although rare, it is typically associated with severe visual disability, and this has prompted efforts to better understand the pathogenesis of this condition, to identify the patients at risk for this event, and to improve treatment of patients who develop this condition either intraoperatively or postoperatively. Controversy still exists regarding the best course of treatment for these patients. Although the introduction of perfluorocarbon liquids as a surgical adjunct during vitrectomy surgery may assist in the removal of suprachoroidal hemorrhage, the visual outcomes still remain disappointing.     

内眼手术术中及术后暴发性脉络膜上腔出血的原因、处理和预后

目的　分析与评价内眼手术及术中术后暴发性脉络膜上腔出血的原因、处理和预后。方法　选取暴发性脉络膜上腔出血患者１１例,术前５例合并高度近视,４例合并高眼压,２例有既往内眼手术史,２例患者发生二次出血。出血后采取保守或于出血后１０～１６ｄ（平均１２．１ｄ）手术治疗。手术方法包括单纯后巩膜脉络膜上腔积血穿刺放液术,或联合玻璃体切割及硅油填充术。结果　１１例患者中有７例发生于术中,４例发生在术后１～３ｄ,约占同期我科内眼手术的０．１５％（１１／７２０４）。１１例患者中,２例保守治疗,４例行单纯后巩膜脉络膜上腔积血穿刺放液术,１例行玻璃体切割及后巩膜脉络膜上腔积血穿刺放液术,另外４例行玻璃体切割硅油填充及后巩膜脉络膜上腔积血穿刺放液术。平均随访８．２个月,术后７例患者视力改善,１例无变化,３例恶化。结论　术前高眼压、高度近视及既往内眼手术史是暴发性脉络膜上腔出血的高危因素。通过术中迅速关闭切口,术后采取保守治疗,择机行后巩膜脉络膜上腔积血穿刺放液术,视网膜脱离时联合玻璃体切割术,可保留患者部分视力。     

内眼手术并发脉络膜上腔出血的临床分析

目的：探讨内眼手术术中和术后并发脉络膜上腔出血(suprachoroidal hemorrhage, SCH)的临床特点以及发生的危险因素,观察其视力预后。

方法：回顾性分析2005-06/2015-06共10a间本科收治的手术相关的SCH患者13例13眼,年龄22～76岁。13例13眼患者中,合并高度近视者6眼(46%),有高眼压病史者6眼(46%),合并高血压病者4眼(31%)。术中发生的驱逐性出血8眼,术后发生者迟发性出血5眼; 7眼为硅油取出术并发,4眼为白内障囊外取出术并发,1眼为小梁切除联合白内障囊外摘除术并发,1眼为晶状体脱位行晶状体切除联合玻璃体切除手术并发。5眼药物治疗,4眼行巩膜外放液引流联合玻璃体注气术,4眼行玻璃体切割联合重水和硅油注入。

结果：随访10mo,所有SCH全部吸收,最终视力除1眼放弃治疗无光感之外,其余12眼视力光感～0.4。

结论：内眼手术并发的SCH后果严重,高龄、高血压、高度近视和高眼压可能为其危险因素,手术切口导致术中眼压波动大可能与其发生有关,积极治疗后可以维持一定视力。     

白内障摘出术中脉络膜下爆发性出血的临床分析

目的探讨白内障摘出术中发生脉络膜下爆发性出血的原因及其处理及预防方法。方法对我院2540例（2810跟）白内障摘出术中发生脉络膜下爆发性出血的3例（3眼）：术中给予关闭切口,降低眼压、血压及镇静处理,必要时及时切开巩膜放血,术后给予止血、消炎、镇静及甘露醇静脉滴注,并进一步控制患者的眼压、血压。结果1例（1眼）由于术后视网膜脱离,而无光感。1例（1眼）经术中及时发现和果断处理而阻止了脉络膜下爆发性出血,从而获得了较好的术后视力,为0．3。最后1例（1眼）成功引流脉络膜下积血,也保留了部分视力,为0．1。结论眼球切开后,眼压迅速降低至零,脉络膜血管显著扩张后出现破裂是白内障手术中出现脉络膜下爆发性出血的直接原因,其相关因素有高度近视、高血压、高眼压、高血糖,咳嗽,哮喘及患者精神过度紧张等,在经过上述及时果断处理后大部分患者可治愈并保存一定的视力。     

脉络膜上腔出血

脉络膜上腔出血是各种内眼手术当中或之后都可能发生的严重并发症,尽管发生率很低,但往往对视力造成严重影响,因而,对其发病机制进行研究以明确促其发生的危险因素非常重要,从而最终达到有效治疗该并发症的目的。本复习了有关脉络膜上腔出血的国外献,总结介绍了脉络膜上腔出血的病因、发病率、危险因素及防治措施等情况。     

青光眼患者白内障手术人工晶状体计算公式的选择

青光眼与白内障是导致失明的主要原因,手术是重要的治疗方式。青光眼患者具有高眼压、浅前房及短眼轴等临床特征,小梁切除术等抗青光眼术后眼部结构常发生改变。这些变化也导致了抗青光眼术后行白内障手术或青白联合手术与单纯白内障手术在人工晶状体(intraocular lens, IOL)屈光度计算准确性方面存在差异。同时青光眼患者自身的临床特征与抗青光眼手术造成的结构改变对于IOL屈光度预测准确性、屈光漂移的类型等方面的影响也表现出差异。本文就青光眼或抗青光眼术后患者行白内障手术或青白联合手术时屈光误差(refractive error, RE)产生的原因、屈光漂移特征及选择最合适IOL计算公式的最新研究进展进行综述。     

Factors that influence intraocular pressure after cataract surgery in primary glaucoma

Objective: We sought to find predictive factors for favourable postoperative intraocular pressure (IOP) after cataract surgery in patients with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).Study Design: Retrospective evaluation of patients who had undergone cataract surgery.Participants: Forty-eight patients with POAG and 48 patients with PACG.Methods: Various clinical factors were evaluated retrospectively in 96 patients. All patients had undergone standard 2.75-3.5 mm limbal incision cataract surgery. Clinical parameters in patients with successful postoperative IOP courses were compared with those in unsuccessful patients. Success was defined as an IOP between 6 and 21 mm Hg, with fewer antiglaucoma medications needed compared with before surgery, and no need of additional glaucoma surgery.Results: In POAG, eyes with a highest preoperative IOP of <31 mm Hg or those being treated with <3 antiglaucoma medications before surgery had a significantly higher probability of success. In PACG, the probability of success was significantly higher if the highest preoperative IOP was <42 mm Hg, the number of antiglaucoma medications before surgery was <3, or the areas of peripheral anterior synechiae were <4 clock hours.Conclusions: Primary small-incision cataract surgery using phacoemulsification and foldable intraocular lens implantation may be the procedure of choice in patients with medically controlled glaucoma and coexisting visually significant cataracts, considering the highest preoperative IOP and number of antiglaucoma medications in POAG and PACG, and the area of peripheral anterior synechiae in PACG.     

Effect of phacoemulsification on intraocular pressure in patients with primary open angle glaucoma and pseudoexfoliation glaucoma

AIM: To compare the effect of phacoemulsification on intraocular pressure (IOP) in patients with primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG). METHODS: A retrospective comparative case series conducted at the Glaucoma Department at the Association to Prevent Blindness in Mexico. The study enrolled consecutive patients having phacoemulsification with intraocular lens (IOL) implantation and a diagnosis of POAG or PXG. Data about IOP values and number of glaucoma medications used was collected at baseline, 1, 3, 6 and 12mo postoperatively. RESULTS: The study enrolled 88 patients (88 eyes). After phacoemulsification, there was a statistically significant reduction in IOP values and glaucoma medications use compared to baseline in both POAG and PXG patients (P<0.001). In the POAG group, a 20% decrease in IOP values was evidenced, and a 56.5% reduction in the number of medications used at the one-year follow-up. The PXG group showed a 20.39%, and a 34.46% decrease in IOP and number of medications used, respectively. A significant difference in the mean ΔIOP (postoperative changes in IOP) was evidenced between groups (P=0.005). The reduction of the postsurgical IOP mean values in both groups, the POAG group showed a greater reduction in IOP values compared to the PXG group. CONCLUSION: In both types of glaucoma, phacoemulsification cataract surgery can result in a significant IOP reduction (20%) over a 12mo follow-up period. The number of medications used is also significantly reduced up to 12mo after surgery, especially in the PXG group.     

晶状体溶解性青光眼患者白内障手术后高眼压的危险因素

目的：探讨晶状体溶解性青光眼(PLG)患者白内障手术术后高眼压的危险因素。

方法：回顾性分析。2010-01/2020-12我院148例148眼行白内障手术治疗的PLG患者的临床资料,根据其术后高眼压发生情况分为非高眼压组(126例)与高眼压组(22例)。采用Logistic回归分析评估PLG患者白内障手术术后高眼压的危险因素。构建列线图预测模型,并绘制受试者工作特征曲线(ROC)评估列线图模型的预测能力。

结果：两组患者年龄、性别、BMI、白内障晶状体核分级、合并高血压及手术方式均无差异(P>0.05); 高眼压组患者合并糖尿病、高度近视、术前合并色素膜炎、术前合并眼外伤及术中并发症占比均高于非高眼压组(P<0.05)。Logistic回归分析显示,合并糖尿病、高度近视、术前合并色素膜炎、术前合并眼外伤及术中并发症是PLG患者白内障手术术后高眼压的影响因素。本研究构建的列线图模型拟合效果良好,其ROC曲线下面积为0.906(0.890～0.921),表明具有较强的预测能力。

结论：术中并发症、术前合并色素膜炎、合并眼外伤、合并糖尿病及高度近视的PLG患者白内障手术后发生高眼压的风险较高,临床应对这些患者予以重视,以期改善患者的预后。     

[In Press] Effect of phacoemulsification on intraocular pressure in patients with primary open-angle glaucoma and pseudoexfoliation glaucoma

AIM: To compare the effect of phacoemulsification on intraocular pressure (IOP) in patients with primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG). METHODS: A retrospective comparative case series conducted at the Glaucoma Department at the Association for Preventing Blindness in Mexico. The study enrolled consecutive patients having phacoemulsification with IOL implantation and a diagnosis of POAG or PXG. Data about IOP values and number of glaucoma medications used was collected at baseline, month 1, 3, 6 and 12 postoperatively. RESULTS: The study enrolled 88 patients (88 eyes). After phacoemulsification, there was a statistically significant reduction in IOP values and glaucoma medications use compared to baseline in both POAG and PXG patients (P<0.001). In the POAG group, a 20% decrease in IOP values was evidenced, and a 56.5% reduction in the number of medications used at the one-year follow-up. The PXG group showed a 20.39%, and a 34.46% decrease in IOP and number of medications used, respectively. A significant difference in the mean ΔIOP (postoperative changes in intraocular pressure) was evidenced between groups (P=0.005). The reduction of the postsurgical IOP mean values in both groups, the POAG group showed a greater reduction in IOP values compared to the PXG group. CONCLUSION: In both types of glaucoma, phacoemulsification cataract surgery can result in a significant IOP reduction (20%) over a 12-month follow-up period. The number of medications used is also significantly reduced up to 12mo after surgery, especially in the PXG group.     

Complications of intraocular lenses. A historical and histopathological review

Recent improvements in intraocular lens (IOL) design, manufacturing techniques, and surgical techniques have greatly reduced the incidence of complications following implantation, and many authors now consider IOL implantation to be among the most safe and effective major surgical procedures. However, adverse reactions are still seen — some as late sequelae of carlier IOL designs and implantation techniques and some as sequelae of more recent implantations using “state-of-the-art” lenses and surgical techniques. Complications may be due to various factors, including surgical technique, IOL design, or the inability of some eyes with preexisting disease to tolerate an implant. The authors trace the evolution of IOLs since Ridley's first implant, summarizing the modifications in lenses and surgical techniques that were made as complications were recognized. They then review the clinical and histopathological features of selected cases from more than 200 IOLs and/or globes removed due to IOL-related complications and studied in the University of Utah Ocular Pathology Laboratory. It is hoped that this review will provide insights into the pathogenesis of IOL complications, enhancing the current success of implant procedures and stimulating further basic and clinical research in this area.     

Considerations of glaucoma in patients undergoing corneal refractive surgery

Glaucoma patients present a unique set of challenges to physicians performing corneal refractive surgery. Corneal thickness, which is modified during corneal refractive surgery, plays an important role in monitoring glaucoma patients because of its effect on the measured intraocular pressure. Patients undergo a transient but significant rise in intraocular pressure during the laser-assisted in situ keratomileusis (LASIK) procedure with risk of further optic nerve damage or retinal vein occlusion. Glaucoma patients with filtering blebs are also at risk of damage to the bleb by the suction ring. Steroids, typically used after refractive surgery, can increase intraocular pressure in steroid responders, which is more prevalent among glaucoma patients. Flap interface fluid after LASIK, causing an artificially low pressure reading and masking an elevated pressure has been reported. The refractive surgeon's awareness of these potential complications and challenges will better prepare them for proper management of glaucoma patients who request corneal refractive surgery.     

新型经脉络膜上腔引流房水植入装置Suprajet的疗效观察

目的:评估一种由睫状体前和脉络膜上腔引流房水的新型植入装置Suprajet的有效性和安全性.方法:该项研究使用5只兔子.每只兔子的一眼植入Suprajet.引流器通过位于上方的透明角膜切口,经由前房置入脉络膜上腔.引流器近端位于睫状体根部,远端位于脉络膜上腔.兔子饲养、观察4 wk.使用Tonopen AVIA测量术前和术后的眼压.最后一次随访观察时,兔子被牺牲处死,眼球摘除,进行大体上和组织学的观察评估.结果:术前眼压为18.6±6.1mmHg.术后1wk眼压为8.4±1.1 mmHg.术后2 wk 1只兔子死亡.因此,仅有4只兔子进行了后续观察.术后2wk眼压为11.0±2.8mmHg,术后3wk为9.50±3.1mmHg,术后4wk为11.3±3.3mmHg.与术前平均眼压相比,仅第1周的平均眼压显著降低(P=0.042),术后2 wk、3 wk和术后4 wk的平均眼压无明显变化(P=0.66,P=0.66,P=0.102).术中并发症包括3眼少量出血.术后2d出血已经完全吸收.对摘除眼球的大体观察发现,1眼中引流器的远端位于玻璃体内,而不是位于脉络膜上腔;其它3眼引流器的远端位于脉络膜上腔.所有眼中,近端都位于前房角.对摘除眼的组织学检查发现:不规则的胶原蛋白束和纤维沉积,包括引流器周围大量的成纤维细胞和组织细胞.结论:这一项初始动物研究显示,青光眼中Suprajet植入是一项有前景的术式.需要进行更进一步的研究以评估其有效性和安全性.     

眼压对青光眼—白内障联合术患者人工晶状体计算公式选择的影响

目的　探讨眼压对青光眼—白内障联合术患者人工晶状体计算公式选择的影响,为临床上避免屈光误差（refractive error,RE）提供参考依据。方法　选取2014年5月至2017年4月在我院行白内障超声乳化吸出并人工晶状体植入联合复合式小梁切除术的原发性闭角型青光眼（primary angle-closure glaucoma,PACG）合并白内障患者72例（80眼）,依术前平均眼压将测试眼分为两组:正常眼压组（10～21 mmHg,1 kPa=7.5 mmHg）和高眼压组（＞21 mmHg）,分别为28眼和52眼。比较各组内术后3个月验光所得实际等效球镜度与术前人工晶状体 Master中 4种人工晶状体计算公式（SRK/T、Holladay1、Hoffer Q及Haigis）相应预测等效球镜度的差异。定义实际等效球镜度减去预测等效球镜度即为RE,当RE＜0时为屈光近视漂移,而RE＞0则为屈光远视漂移,RE取绝对值为绝对屈光误差（absolute refractive error,ARE）,评估眼压对各公式术后ARE及RE的影响。术后随访6个月。结果　全部患者术后3个月眼压较术前下降明显,差异有统计学意义（t=9.96,P=0.000）,且眼压降低幅度与术前平均眼压呈正相关（r=0.974,P=0.000）。正常眼压组SRK/T、Holladay1、Hoffer Q、Haigis公式ARE的中位数差异有统计学意义（P=0.008）;高眼压组各公式ARE的中位数差异亦有统计学意义（P=0.004）。正常眼压组和高眼压组远视漂移时SRK/T、Holladay1、Hoffer Q、Haigis公式RE总体差异均无统计学意义（P=0.633、0.422）。正常眼压组近视漂移时各公式RE间总体差异有统计学意义（P=0.000）,经LSD两两比较,SRK/T公式较其他公式的RE小（均为P<0.01）,Haigis公式较其他公式的RE大（均为P<0.05）,其他各公式RE差异均无统计学意义（均为P＞0.05）。而高眼压组近视漂移时各公式RE总体差异亦有统计学意义（F=6.757,P=0.000）,经LSD两两比较,Hoffer Q公式RE较其他公式的小（均为P<0.01）,其他各公式RE差异均无统计学意义（均为P＞0.05）。结论　青光眼—白内障联合术可提高患者视力并改善眼压,术后眼压降低幅度与术前平均眼压呈明显正相关。计算青光眼—白内障联合术人工晶状体度数时,术前平均眼压正常者应选SRK/T公式较为准确,而术前平均眼压高时Hoffer Q公式更合适。     

白内障合并青光眼的联合手术治疗

白内障超声乳化人工晶状体植入联合小梁切除术在手术并发症,眼内压以及视敏度等方面比其他联合手术取得了更大的成功。一切口式与二切口式联合手术有相同的手术效果。白内障超声乳化联合小梁切除术并配合使用MMC比单纯白内障超声乳化联合小梁切除术能更好的降低眼压,但带来更多的手术并发症;5-FU没有MMC的效果,而且还对手术结果有不同的影响。近年来联合手术中的小梁切除术有一定的进展,但还没有进行长期的术后随访研究。国内外有关白内障合并青光眼的联合手术治疗的报道很多,本主要对这些报道进行客观的总结评价和总结。     

Suprachoroidal Hemorrhage as an Intraoperative Complication of 25-Gauge Pars Plana Vitrectomy

Purpose: To describe a case of suprachoroidal hemorrhage occurring during 25-gauge vitrectomy. Methods: Retrospective case review. Results: An 80-year old pseudophakic man developed intraoperative suprachoroidal hemorrhage during a vitreous biopsy procedure for chronic intraocular inflammation. Despite drainage of the choroidals, visual outcome was poor. Conclusions: 25-gauge vitrectomy is often referred to as a “less-invasive” procedure than 20-gauge vitrectomy, but it is not necessarily less risky and probably carries a similar risk profile.     

巩膜下小梁咬切、白内障超声乳化、人工晶状体植入三联术65例临床分析

目的:观察巩膜下小梁咬切联合白内障超声乳化及人工晶状体植入三联术治疗青光眼并发白内障的临床治疗效果。方法:对我院眼科1999-04/2003-04施行三联术的65例(65眼),随访3～48mo,比较手术前后眼压、视力及并发症发生的情况。结果:术前最佳矫正视力:光感/5m～0.6,眼压22～65(平均36.3)mmHg。术后最佳矫正视力:0.1～1.2,不用药或局部用一种β受体阻滞剂眼压在8～22(平均16.8)mmHg。术后角膜水肿7例,纤维素性渗出5例,前房出血2例,所有术后并发症均获治愈。结论:三联手术对白内障、青光眼治疗效果良好,术后无不良反应,是治疗青光眼并发白内障患者的首选方法。前囊连续环行撕囊,囊袋内拦截劈核法碎核及高负压低能量完成白内障摘除手术,人工晶状体囊袋内植入是取得良好手术效果的有力保证。     

持续性高眼压青光眼小梁切除术的临床观察

目的观察持续性高眼压青光眼小梁切除术疗效。方法对30例(30眼)持续性高眼压青光眼患者采用透明角膜穿刺术,缓慢降低眼压,然后采用小梁切除术,完成手术。术后随访3～14mo。结果术后平均眼压为17.07mmHg,比术前平均眼压降低34.37mmHg,手术成功率为90%。全部病例无严重并发症。结论透明角膜穿刺术联合小梁切除术降低眼压的术式,可有效地控制眼压,减少并发症,提高一次手术成功率。     

飞秒激光辅助白内障手术在青光眼治疗中的应用进展

飞秒激光辅助白内障手术(FLACS)的应用已有10余年的历史,其安全性与精准性已得到验证。近年来FLACS已逐步应用于青光眼合并白内障患者,尤其是原发性闭角型青光眼(PACG)患者,因其独特的解剖特点使得常规白内障手术晶状体摘除难度与潜在并发症增加,FLACS用于PACG患者优势明显。新近报道FLACS联合微创青光眼手术(MIGS)应用于开角型青光眼患者、联合房角分离术(GSL)用于闭角型青光眼患者,甚至用于抗青光眼术后存有滤过泡的患者,其适应证日趋拓展。FLACS可导致术中短暂眼压升高,眼部参数对术中眼压可产生一定影响,对眼压的远期影响有待进一步研究。FLACS对青光眼患者视功能的影响及其产生的相关并发症应引起重视。文章就FLACS在各类青光眼中的应用、对眼压和视功能的影响、特殊并发症及应用前景做一综述。     

高眼压青光眼滤过手术中恶性青光眼的处理体会

目的：探讨高眼压青光眼滤过手术中恶性青光眼的手术处理,应用前房注气技术联合可调整缝线,可解除睫状环阻滞,减少恶性青光眼的发生。

方法：高眼压闭角型青光眼患者30例,初诊眼压大于60mmHg,经详细检查,符合复合式小梁切除手术适应证,药物降眼压,手术前眼压大于45mmHg。采用复合式小梁切除术,手术中完成巩膜瓣缝线后,出现无前房高眼压(睫状环阻滞)状态,采取加缝巩膜瓣可调整缝线并行前房注射消毒空气形成前房。

结果：术后随访6mo,30例均未出现恶性青光眼,前房深度稳定,25例眼压小于18mmHg,5例滤泡局限后眼压22～28mmHg。

结论：高眼压状态下行青光眼滤过手术,手术中出现高眼压无前房(睫状环阻滞)状态的机会很高,本文通过集中归纳30例此类手术情况,认为手术中加缝巩膜瓣可调整缝线并采用前房注射消毒空气形成前房的方法可以缓解术中睫状环阻滞,避免此类青光眼术后发生恶性青光眼情况。