准分子激光治疗性角膜切削术治疗角膜浅层病变的临床观察

目的：评估眼前节OCT辅助的准分子激光治疗性角膜切削术治疗角膜浅层病变的临床效果。
　　方法：分析2012-09/2013-09在我院就诊并手术的诊断为角膜浅层病变患者15例28眼,行准分子激光治疗性角膜切削手术;术前均进行眼前节OCT检查,辅助判断病变的形态和深度,并指导PTK术中切削深度、直径等参数的设定,均随访6mo,分别观察术后6,15d;1,2,3,6mo的角膜情况、裸眼视力( uncorrected visual acuity, UCVA)、等效球镜( spherical equivalent, SE )、角膜上皮下雾状混浊( haze)的发生等。
　　结果：术后所有患者的角膜病情均有不同程度的改善,疾病的发作受到控制或发作频率明显下降,UCVA, SE,haze的发生与术前无统计学差异。
　　结论：对于角膜浅层病变的患者,眼前节OCT辅助下的准分子激光治疗性角膜切削术可以有效、准确地去除病灶,获得较好的治疗效果。但需注意控制切削深度,避免术后出现过多的远视。     

Avellino角膜营养不良在共焦显微镜下的形态学特征

目的 探讨Avellino角膜营养不良（ACD）患者的共焦显微镜图像特点。方法对经基因型检测明确为ACD患者（R124H突变）的10例20眼角膜进行共焦显微镜检查，其中1例2眼为穿透角膜移植（PK）术后眼，一眼病变复发，另一眼无复发表现。并取颗粒状角膜营养不良I型（GCD I，R555W突变）患者9例18眼作为对照。结果ACD患者未手术眼共焦显微镜图像特点：基底上皮、Bowman膜及整个角膜基质均可见不同程度的异常反光改变；PK术后复发眼Bowman膜及紧邻其下的前基质可见由细小沉积物组成的不规则混浊；PK术后无复发表现眼角膜各层未见明显异常。GCD I型最显著的共焦显微镜图像特点为角膜基质内以大型沉积物为主。结论首次对经基因检测确诊的Avellino角膜营养不良患者的角膜进行活体共焦显微镜检查。ACD患者基底上皮、Bowman膜及整个角膜基质均可见不同程度的异常反光改变，但较GCD I型患者的沉积物为小。     

准分子激光治疗性角膜切削术治疗角膜浅层病变的实验和临床研究

目的：观察准分子激光治疗性膜切削术（photo-therapeutic keratectomy,PTK)后兔角膜组织的修复情况,探讨PTK的临床疗效,适应证和治疗参数。方法：（1）实验组采用8．17％硫酸烧灼法制作兔角膜浅层瘢痕模型,2周后行PTK;于术后不同时间进行角膜活体共焦显微镜,神经染色,光镜和透射电镜检查,并与对照组进行比较。（2）根据临床治疗组26例（30只眼）角膜浅层病变患者的病变种类,分别行去除上皮和非去除上皮PTK。观察术后不同时间患者的视力,屈光状态和角膜曲率变化情况,以及角膜雾状混浊（haze)的程度,随访时间6个月。结果：（1）实验组兔角膜切削区PTK术后早期多形 性粒细胞和巨噬细胞浸润。浅基质成纤维细胞增生活跃,新生胶原纤维排列紊乱,疏松;术后6个月趋于正常,组织修复稳定。（2）临床治疗组PTK术后6个月最佳矫正视力与术前比较,21只眼提高,5只眼不变,4只眼下降;其中PTK治疗角膜营养不良和角膜带状变性的效果最佳;术后6个月haze 0级23只眼,0．5级5只眼,1级2只眼,平均远视移动度数＋1．52D。结论：兔角膜PTK术后6个月组织修复趋于稳定;临床PTK治疗角膜浅层病变患者,方法简便,安全,有效,其中以治疗角膜营养不良和角膜带状变性的效果最佳,采用PTK治疗的角膜病变以不超过角膜前1／3厚度为宜。     

Avellino角膜营养不良家系的βIGH3基因突变研究

目的研究Avellino角膜营养不良（Avellinocornealdystrophy,ACD）一个家系的临床表现及其βIGH3基因突变类型。设计实验研究。研究对象Avellino角膜营养不良一个中国家系。方法详细采集该家系5代75人病史,进行视力、裂隙灯显微镜、外眼照相、眼底、眼前节光学相干断层扫描（anteriorsegmentopticalcoherencetomography,AS-OCT）检查,应用聚合酶链反应（polymerasechainreaction,PCR）并结合DNA测序技术进行βIGH3基因第4、11和12外显子突变检测。主要指标基因序列。结果本病临床特征为角膜基质层颗粒状及格子状混浊。AS-OCT显示角膜病灶位于角膜上皮层及浅、中基质层。基因检测发现该家系患者βIGH3基因第4外显子370位点碱基C→T,即R124C突变。家系中正常成员无该位点的基因突变。结论R124C突变与Avellino角膜营养不良的发生有关,该基因的突变可导致不同类型角膜营养不良的发生。     

前节OCT辅助准分子激光治疗性角膜切削术治疗真菌性角膜溃疡

目的 评价前节OCT辅助准分子激光治疗性角膜切削术(excimer laser phototherapeutic,PTK)治疗真菌性角膜溃疡的临床效果.方法 回顾性分析已确诊为真菌性角膜溃疡且应用局部和全身抗真菌药物治疗7d后无效或病情加重的24例(24眼)患者,角膜溃疡深度均未超过1/3角膜厚度,将患者分为两组,治疗组接受前节OCT辅助的PTK治疗,共14例(14眼),对照组采用角膜病灶板层切除手术治疗,共10例(10眼).随访至少6个月.记录治疗前后最佳矫正视力(best corrected visual a-cuity,BCVA)、角膜厚度、共焦显微镜检查情况.观察术后角膜上皮修复时间、治疗时间及并发症情况.结果 两组术后BCVA均较术前明显提高,差异均有统计学意义(均为P＜0.01),治疗组BCVA提高程度明显优于对照组,差异有统计学意义(P＜0.05).治疗组术后治疗持续时间为(19.43±5.68)d,短于对照组的(34.40±5.38)d,差异有统计学意义(P＜0.05).治疗组术后剩余角膜厚度与对照组相比差异无统计学意义(P＞0.05).共焦显微镜检查亦治疗组术后残余菌丝较对照组明显减少.治疗组术后上皮修复时间为(4.00±1.11)d,短于对照组的(6.20±1.39)d,差异有统计学意义(P＜0.05).随访期内,治疗组术后无一眼复发,对照组术后0.5a有3眼复发,1眼药物控制有效,另2眼病情加重,进一步行角膜移植手术.结论 前节OCT辅助PTK治疗真菌性角膜溃疡可以有效清除病灶、加速上皮愈合,为治疗早期浅层真菌性角膜溃疡提供了一个全新的选择.     

激光治疗性角膜切除术联合丝裂霉素C预防角膜浅层病变复发

激光治疗性角膜切除术（PTK）采用193nm氟化氩激光切除浅层角膜组织，以暴露其下透明的角膜基质层。其手术适应证包括上皮基底膜营养不良、Salzmann结节样变性、颗粒状角膜营养不良、格子样角膜营养不良和Reis—Bnckler角膜营养不良。尽管PTK可清除浅基质层角膜病变，但许多患者可复发。作者总结了13例PTK术中联合丝裂霉素C治疗浅层角膜病变以预防复发的疗效。     

光导纤维辅助照明用于合并颗粒状角膜营养不良的白内障手术一例

一例66岁男性双眼白内障及颗粒状角膜营养不良,采用23G光导纤维经角膜缘透明区域辅助照明下行左眼白内障超声乳化IOL植入术,手术全程顺利,无并发症,术后1个月复查视力0.6。此例的手术方法 为角膜混浊患者眼前节手术提供了新思路。（眼科,2023,32:76-77）     

准分了激光原位角膜磨镶术术角膜瓣下角膜上皮内生的治疗

目的：探讨准分子激光治疗性角膜切削术（phototherapeutic keratectomy,PTK）治疗准分子激光原位角膜磨镶术（laser in situ keratomileusis,LASIK）术后角膜瓣下角膜上皮内生的疗效。方法：对LASIK术后发生角膜瓣下角膜上皮内生患者6例（6只眼）行PTK，术中重新掀开角膜瓣，刮除植入的角膜上皮组织，采用直径7mm光斑，以5－10个脉冲切削角膜瓣基质面和基质层表面，层间冲洗，复位角膜瓣，采用直径3mm光斑，以50－75个脉冲沿角膜瓣边缘进行切削。术后随访时间5－12个月。结果：5只眼表现为颞侧角膜瓣边缘下出现匍行性灰白色物质，局部角膜瓣边缘水肿和融解；1只眼表现为角膜瓣下局限性灰白色团块状物质，角膜瓣下基质层局部融解。全部术眼PIK术后无角膜瓣下角膜上皮内生复发；除1只眼残留轻度角膜瘢痕外，余5只眼角膜恢复透明；术后视力均达到LASIK术前最佳矫正视力。结论：采用PTK治疗LASIK术后角膜瓣下角膜上皮内生，不仅效果良好，而且可有效防止复发。     

准分子激光治疗性角膜切削术治疗浅层角膜病变的临床研究

目的：评价准分子激光治疗性角膜切削术（PTK）治疗浅层角膜病变的效果。方法：采用准分子激光裂隙扫描和飞点状照射法切削治疗32例39只眼,术后随访观察1年并对结果进行分析。结果：术后1,3,6,12个月检查：矫正视力提高2行以上者,分别为48.7％,53.8％,51.3％,46.1％;等值球镜分别为＋1.8,＋2.2,＋2.0,＋1.6;部分患者角膜内皮细胞密度检查,术前、术后无明显差别。结论：PTK治疗浅层角膜病变具有操作简单、安全有效,部分患者可避免角膜移植手术或延迟角膜移植手术时间,但术后存在原有疾病复发和远视化问题。     

重视飞秒激光角膜屈光术前Avellino角膜营养不良的临床检查和基因筛查

随着飞秒激光技术的快速发展,多元化的角膜屈光手术给屈光不正患者带来了满意的临床效果。同时,飞秒激光角膜屈光术的安全性、有效性、稳定性及可预测性均得到了进一步的提高。然而,伴有角膜营养不良的屈光不正患者,尤其是Avellino角膜营养不良的年轻患者,在行飞秒激光角膜屈光术后,其病情将进一步加重,从而对视功能造成影响。本文中笔者对国内外报道的伴有Avellino角膜营养不良的屈光不正患者在行角膜屈光手术后,出现的角膜混浊程度加重、视力下降等情况进行分析,归纳已经报道的Avellino角膜营养不良的临床表现和基因筛查位点。研究结果表明,Avellino角膜营养不良应列为飞秒激光角膜屈光术的绝对禁忌证,故建议临床医师应在行飞秒激光角膜屈光术前加强对Avellino角膜营养不良的临床检查和基因筛查。     

Alteration of the ocular surface with recurrence of granular/avellino corneal dystrophy after phototherapeutic keratectomy: report of five cases and literature review

PURPOSE: To study the changes in ocular surface findings with recurrence after phototherapeutic keratectomy (PTK) in patients with Avellino and granular dystrophy. DESIGN: Observational case series. PARTICIPANTS: Five eyes of five patients with recurrent granular/Avellino corneal dystrophy after PTK seen at Kobe Kaisei Hospital were studied. INTERVENTION: The patients underwent routine ophthalmic examinations, corneal sensitivity measurements, tear film breakup time (BUT), Schirmer test, tear film lipid layer interferometry, and conjunctival impression cytology. MAIN OUTCOME MEASURES: The alterations of clinical features, tear function, and conjunctival impression cytology parameters with a recurrence after PTK were investigated. RESULTS: The average pre-PTK corneal sensitivity and tear film breakup time were low in all five patients. Tear film lipid layer interferometry grade and conjunctival squamous metaplasia displayed higher grades before PTK. All of these parameters improved gradually after PTK and were maintained until a recurrence, which was associated with further worsening of the corneal sensitivity, tear function, and impression cytology parameters. CONCLUSIONS: Although PTK improves the ocular surface health in granular/Avellino corneal dystrophies, recurrence of the initial dystrophy is associated with decline of the ocular surface health parameters. Our findings also suggest that corneal epithelium is most probably involved in the recurrence of the disease process in Avellino/granular corneal dystrophy.     

角膜基质针刺联合羊膜移植术治疗大泡性角膜病变

目的：探讨施行角膜基质针刺联合羊膜移植术治疗大泡性角膜病变（bullous keratopathy,BK）的临床疗效。方法：对35例35眼大泡性角膜病变者施行角膜基质针刺联合羊膜移植术,所有患者术前、术后均行前节OCT、角膜地形图、角膜知觉、共焦显微镜检查。观察患者术后眼部症状、大泡复发情况、角膜知觉改变、角膜厚度变化、角膜各层组织结构变化。结果：角膜基质针刺联合羊膜移植术后随访6～18mo。32例（91%）均在术后第1d疼痛感消失,并在随访期间未再出现疼痛,另外3例（9%）疼痛感减轻并在3d后消失。9例（26%）术后角膜上皮在1wk内愈合,21例（60%）在2wk内愈合,5例（14%）在3wk内愈合。随访期间BK无复发,2例（6%）在术后3,4wk在周边区域见少量微小水泡,无自觉症状,随时间延长未见加重。所有患者无新生血管发生,角膜表面光滑。30例（86%）移植的羊膜于术后2mo变薄,部分溶解吸收,3mo时肉眼基本不见羊膜。34例（97%）视力无改变,1例（3%）由光感到手动/眼前。30例（86%）术后2mo角膜知觉减退,下降幅度为20±7mm,所有患者角膜厚度均增加,由术前的788±35μm,增至940±43μm,术后12mo,角膜厚度增至1 060±27μm。共焦显微镜结果：术后3mo,角膜基底膜下三叉神经纤维数量密度降低,浅基质层基质细胞成纤维化,深基质层更加疏松、细胞肿胀明显,内皮细胞数量较术前减少且肿胀更加明显。结论：角膜基质针刺联合羊膜移植术能有效控制BK的症状,防止BK的复发,尤其是对症状明显,视功能差的患者是简单、安全、实用的方法。     

Deep anterior lamellar keratoplasty in Korean patients with Avellino dystrophy

PURPOSE: To evaluate the surgical outcome of deep anterior lamellar keratoplasty (DALK) in Korean patients with Avellino dystrophy. METHODS: A retrospective study was performed in 4 eyes (4 patients) with recurrent Avellino dystrophy after phototherapeutic keratectomy (PTK). Genetic study was performed on 2 patients to confirm the diagnosis. Partial-thickness donor cornea (devoid of endothelium and Descemet membrane) was transplanted onto a recipient bed after deep lamellar dissection and removal of recipient stroma. Visual acuity, refractive error, keratometry values, topographic astigmatism, and complications were evaluated after a follow-up period of at least 14 months. RESULTS: The mean age of the patients was 52.5 +/- 3.32 years, and the mean follow-up period was 17.5 +/- 3.11 months. Visual acuity was improved to > or = 20/25 in all cases. Postoperative topographic astigmatism ranged from 1.2 to 4.9 D. In 1 case, double anterior chamber developed after the operation, which resolved after gas injection into the anterior chamber. During the follow-up period, there were no signs of graft rejection, and all grafts were transparent except one, in which small opacity recurred in the peripheral corneal stroma 13 months postoperatively. CONCLUSIONS: DALK is considered a good primary surgical option in patients with recurrent Avellino dystrophy after PTK.     

Avellino corneal dystrophy after LASIK

OBJECTIVE: To report cases of Avellino corneal dystrophy (ACD) exacerbated by LASIK for myopia. DESIGN: Retrospective, noncomparative, interventional case series and review of the literature. PARTICIPANTS: Seven patients. INTERVENTION: Six patients with exacerbation of granular corneal deposits after LASIK were examined for TGFBI mutations by polymerase chain reaction sequencing of DNA. One previously reported patient who was heterozygous for the ACD gene was followed up for 16 months after mechanical removal of granular deposits from the interface after LASIK. MAIN OUTCOME MEASURES: Slit-lamp examination, visual acuity, manifest refraction, and DNA sequencing analysis. RESULTS: All patients were heterozygous for the Avellino dystrophy gene. Corneal opacities appeared 12 months or more after LASIK. Best spectacle-corrected visual acuity decreased as the number and density of the opacities increased. One patient underwent mechanical removal of granules from the interface and had a severe recurrence within 16 months. Another patient had removal of the granules from the interface with PTK, followed by treatment with topical mitomycin C. In this patient, the cornea has remained relatively clear for 6 months. CONCLUSIONS: Laser in situ keratomileusis increases the deposition of visually significant corneal opacities and is contraindicated in patients with ACD. Mechanical removal of the material from the interface does not prevent further visually significant deposits. Mitomycin C treatment, in conjunction with surgical removal of opacities, may be an effective treatment.     

Exacerbation of granular corneal dystrophy type II (Avellino corneal dystrophy) after LASEK

PURPOSE: To report cases of granular corneal dystrophy type II (Avellino corneal dystrophy) that were exacerbated by uncomplicated laser epithelial keratomileusis (LASEK) for myopia. METHODS: Eight patients (15 eyes) with granular corneal dystrophy type II who underwent LASEK were examined by DNA sequencing, slit-lamp microscopy, and confocal microscopy. RESULTS: The number and density of the opacities increased after LASEK. Best spectacle-corrected visual acuity decreased after LASEK as the density of the opacities increased. In three patients, mitomycin C was used intraoperatively, but corneal deposits also worsened in these patients. CONCLUSIONS: LASEK is contraindicated in patients with granular corneal dystrophy type II because vision may be reduced from an increase in the density of corneal opacities postoperatively.     

Recurrence of corneal dystrophy after excimer laser phototherapeutic keratectomy.

BACKGROUND: Excimer laser phototherapeutic keratectomy (PTK) can be useful to treat anterior corneal dystrophies both before and after penetrating keratoplasty. OBJECTIVE: To evaluate the recurrence of corneal dystrophies after excimer laser PTK. DESIGN: Retrospective case series. PARTICIPANTS: Fifty excimer laser PTK procedures were performed in 43 eyes of 33 patients with corneal dystrophies. Preoperative diagnoses included Reis-Bücklers dystrophy (13 eyes), granular dystrophy (11 eyes), anterior basement membrane (ABM) dystrophy (11 eyes), lattice dystrophy (7 eyes), and Schnyder crystalline dystrophy (1 eye). INTERVENTION: Two excimer lasers (VISX 20/20 model B and VISX Star) were used to perform all PTKs. MAIN OUTCOME MEASURES: After PTK, patients were followed on a regular basis with measurement of best-corrected visual acuity and biomicroscopic examination. Evidence of recurrent dystrophy was noted according to specific criteria. RESULTS: Follow-up range was from 1.1 to 71.2 months (mean, 19.5 months). Clinically significant recurrent dystrophy occurred in 17 eyes. The ABM dystrophy recurred in the form of recurrent corneal erosions in 5 (42%) of the 12 eyes within 6 to 9 months of PTK. Four of these five eyes had mild erosions, which were treated successfully with topical medications while one eye required an additional PTK for an erosion outside the initial treatment area. Eight (47%) of 17 eyes with Reis-Bücklers dystrophy developed clinically significant recurrence an average of 21.6 months after PTK. Three (23%) of 13 eyes with granular dystrophy were found to have a significant recurrence a mean of 40.3 months after PTK. Only one (14%) of seven eyes with lattice dystrophy developed a significant recurrence at 6 months after PTK. Six eyes with significant recurrence after PTK were retreated successfully with additional PTK. Three eyes later developed recurrence of granular and Reis-Bücklers dystrophy after the second PTK. The probability of recurrence of these dystrophies after PTK was calculated using the Kaplan-Meier survival analysis. CONCLUSION: Phototherapeutic keratectomy can restore and preserve useful visual function for a significant period of time in patients with anterior corneal dystrophies. Even though corneal dystrophies are likely to recur eventually after PTK, successful retreatment with PTK is possible.     

Automated lamellar keratoplasty for recurrent granular corneal dystrophy after phototherapeutic keratectomy

PURPOSE: To evaluate the safety and efficacy of automated lamellar keratoplasty for the treatment of recurrent granular corneal dystrophy after phototherapeutic keratectomy (PTK). METHODS: We performed a prospective interventional noncomparative case study of nine eyes (seven patients) with severe recurrent granular corneal dystrophy after PTK. An automated microkeratome was used to cut partial-thickness sections through the anterior surface of the donor and host corneas. The donor disc was placed on the recipient bed with four or eight interrupted sutures. The sutures were removed between 4 and 6 weeks postoperatively. Visual acuity, corneal clarity, corneal thickness, and corneal topography were assessed before and at different time points after surgery. RESULTS: During a mean follow-up period of 18.9 +/- 4.1 months, all grafts were transparent without visible opacity at the interface, and no serious complications occurred. In all cases, the visual acuity improved: seven eyes had best spectacle-corrected visual acuity of > or = 20/40; two eyes reached 20/25. At last follow-up > 12 months postoperatively, the mean corneal refractive power had significantly increased by 2.34 +/- 0.93 diopters (D) (P<.001), and the corneal astigmatism significantly decreased by 0.91 +/- 0.98 D (P<.05). The mean corneal thickness was 477.4 +/- 26.9 microm preoperatively and 507.8 +/- 23.4 microm at last follow-up (P<.001). CONCLUSIONS: Our findings suggest that automated lamellar keratoplasty for the treatment of recurrent granular corneal dystrophy is a safe and effective method of improving visual acuity, but recurrence remains a risk.