飞秒激光在治疗性角膜手术及晶状体手术中的应用

飞秒激光代表了目前屈光手术领域的最新技术．其新型扫描模式的屈光效应正在探索中。飞秒激光以其扫描的高精确度及安全性,已从单纯角膜屈光矫正向全方位治疗性应用方向转变,已被应用于穿透角膜移植、板层角膜移植、基质环隧道的制作以及辅助角膜胶原交联以治疗圆锥角膜,此外其在角膜缘移植和角膜活组织检查中的应用分别为眼表重建及角膜病理学诊断提供了新的手段,而飞秒激光辅助白内障手术及经晶状体矫正老视等方面的应用尚处于实验探索阶段。随着相关技术的日趋完善,飞秒激光的临床应用将更加广阔。就飞秒激光在治疗性角膜手术及晶状体手术中的应用进行综述。     

屈光手术的回顾和展望

屈光手术和眼前节成像系统的发展大大提高了手术的安全性、有效性、可预测性和稳定性。飞秒激光可用于制作角膜瓣,进行角膜基质内切割,制作角膜基质环植入隧道等。与传统激光切削模式相比,波前像差引导等个性化切削模式能提高患者术后的视觉质量。角膜胶原交联术是一种治疗圆锥角膜的全新方法。有晶状体眼人工晶状体植入术和屈光性人工晶状体置换术对于高度近视和远视的治疗有着重要的临床应用价值。现有的老视手术有助于提高患者的生活质量。本文对各种屈光手术新技术及相关的眼前节成像系统进行了评述,并展望了屈光手术未来的发展趋势,强调了解屈光手术新技术和新设备的重要性,提出应该积极稳妥地推进屈光手术新技术在临床上的应用。     

虹膜固定型有晶状体眼人工晶状体植人术矫治高度近视

近视眼的手术矫正方法有多种,而-12.00D以上高度近视眼由于激光手术中切削的角膜组织较多,角膜失去稳定性,光学区小,暗光下有明显的视觉障碍[1]等缺陷,并易引起角膜膨隆、圆锥角膜,而且屈光矫正效果、预测性及稳定性差,故一般不适合应用角膜屈光手术矫正[2].虹膜夹前房型人工晶状体植入矫治高度近视其有良好的术后视觉质量、保留调节力、潜在的可逆性等优点,其手术并发症少、屈光效果好、可预测性、稳定性好,是屈光手术的有益补充.     

白内障术后屈光状态的影响因素

白内障术后的屈光状态及其稳定性是保证良好术后视觉质量的重要环节,术后屈光状态受生物测量的准确性（包括角膜屈光力、眼轴长度、前房深度、人工晶状体计算公式等）、角膜屈光状态（如角膜散光、圆锥角膜及角膜屈光手术史等）、人工晶状体有效位置及晶状体囊膜等因素影响。眼科医师应重视这些因素,在制定手术方案、实施手术过程中认真对待。这对促使我国白内障手术水平向屈光手术标准迈进具有重要意义。（眼科, 2013, 22: 73-76）     

屈光性手术前ORBSCAN-Ⅱ角膜地形图40838例筛选分析

目的 对40838例屈光性手术前,进行 Orbscan-Ⅱ角膜地形图检查结果的筛选分析,为临床诊断角膜病及应用提供可靠依据.方法 通过Orbscan-Ⅱ角膜地形图检测,针对角膜地形,全角膜厚度,角膜前、后表面高度及角膜屈率的数据进行分析,筛选出821例(1368眼),由8种特殊原因进行的结果分析.结果 (1)进行选择性的治疗方式:后巩膜加固术,屈光性晶状体摘出联合人工晶状体置入术,有晶状体眼前房型人工晶状体植入矫治高度近视术.(2)避免一些手术禁忌症进行准分子激光屈光性手术:圆锥角膜、后圆椎角膜.(3)筛选450例1468项不正常的数据,不能进行任何治疗.结论 Orbscan-Ⅱ角膜地形图检查对手术方式的选择、术前手术方案的设计、术后疗效的评价、避免一些手术禁忌症的病例进行手术是至关重要的检查工具.     

飞秒激光在晶状体手术中应用的研究进展

飞秒激光主要用于角膜屈光手术,近年来随着全飞秒激光技术的问世,角膜屈光手术发生了巨大的变革和发展。飞秒激光的光致分解作用可使人体组织发生电离,可在组织内进行精确切削,而对切削区以外的组织影响较小,具有极高的安全性。飞秒激光在白内障手术中的应用包括透明角膜切口的操作、晶状体前囊膜的切开、晶状体核的碎核等,在晶状体屈光手术方面主要用于老视眼的矫治。就近年来飞秒激光技术在白内障手术和晶状体屈光手术中的应用进行综述。     

角膜屈光手术后角膜形态的变化及其临床意义

目前一些屈光不正患者接受了角膜屈光手术,随着检查技术的不断发展,很多研究开始关注角膜屈光手术后角膜形态的变化,尤其是术后出现的角膜后表面前凸。它不仅会导致角膜屈光度的测量产生误差而引起人工晶状体度数估计错误,严重者可出现继发性圆锥角膜。     

虹膜固定型有晶状体眼人工晶状体植入术矫治高度近视

近视眼的手术矫正方法有多种，而-12．00D以上高度近视眼由于激光手术中切削的角膜组织较多，角膜失去稳定性，光学区小，暗光下有明显的视觉障碍等缺陷，并易引起角膜膨隆、圆锥角膜，而且屈光矫正效果、预测性及稳定性差，故一般不适合应用角膜屈光手术矫正。虹膜夹前房型人工晶状体植入矫治高度近视其有良好的术后视觉质量、保留调节力、潜在的可逆性等优点，其手术并发症少、屈光效果好、可预测性、稳定性好，是屈光手术的有益补充。     

准分子激光原位角膜磨镶术适应证的选择

准分子激光原位角膜磨镶术是目前临床最常用的角膜屈光手术.术前应当严格把握适应证,特别是对角膜厚度薄、瞳孔大、顿挫型圆锥角膜或其他角膜扩张、自身免疫性疾病、单纯疱疹病毒角膜炎、青光眼、角膜的生物力学异常以及角膜屈光术后、白内障术后和穿透性角膜移植术后残留屈光不正等一些特殊患者的手术方式选择及相应处理,才能更好地提高手术成功率,并减少术后并发症.     

准分子激光原位角膜磨镶术适应证的选择

准分子激光原位角膜磨镶术是目前临床最常用的角膜屈光手术.术前应当严格把握适应证,特别是对角膜厚度薄、瞳孔大、顿挫型圆锥角膜或其他角膜扩张、自身免疫性疾病、单纯疱疹病毒角膜炎、青光眼、角膜的生物力学异常以及角膜屈光术后、白内障术后和穿透性角膜移植术后残留屈光不正等一些特殊患者的手术方式选择及相应处理,才能更好地提高手术成功率,并减少术后并发症.     

提高准分子激光角膜屈光手术后角膜的安全性

自70年代至今,屈光手术经过不断的革新、改进,目前准分子激光角膜屈光手术成为矫正近视的重要方法。由于其在正常的角膜组织上通过不同方式制作各种角膜瓣后进行激光切削,因而其术后长期的安全性一直是眼科医生担心和关注的主题。本文通过比较临床应用的不同技术方法的利弊,从角膜安全性角度阐述其各自的适应证,以期为临床合理治疗提供资料。     

如何引领角膜屈光手术的发展

准分子激光角膜屈光手术是目前矫正屈光不正最常见的手术方式.本文分析了我国准分子激光角膜屈光手术的发展状况,实施角膜表层切削还是LASIK术的依据以及如何解决两者间的矛盾,LASIK术中不同的角膜瓣制作方式对角膜生物力学稳定性和术后视觉质量的影响.讨论了角膜地形图引导的个体化切削、波前像差引导的个体化切削、Q值调整的个体...     

应重视准分子激光角膜屈光手术对角膜生物力学结构完整性的影响

准分子激光角膜屈光手术,仍然是屈光手术的主流术式,角膜扩张或继发性圆锥角膜是术后严重的并发症之一,其主要原因为角膜生物力学结构完整性遭受破坏.保持正常角膜生物力学结构的完整性,是维持手术疗效及长期稳定性与安全性的基础.合理的手术适应证、术式选择及围手术期用药,对于保持术后角膜生物力学的完整性、避免屈光回退、角膜扩张甚至继发性圆锥角膜的风险均具有十分重要的意义.

Abstract：

Until now, in the territory of surgical methods, excimer laser refractive surgeries have being the main stream for correcting the ametropic eyes. The main cause of iatrogenic corneal ectasia and keratoconus, one of the most severe complications of corneal refractive surgeries, is the destruction of corneal biomechanics. Keeping corneal biomechanical integrality is the basis for long term effectiveness, stableness,and safety of the corneal refractive surgeries. The reasonable indication and surgical method decision,perioperative medical cares play very important roles in preventing those severe complications.     

预防为主提高准分子激光角膜屈光手术的安全性

准分子激光角膜屈光手术的首要问题是安全,贯穿着准分子激光矫正屈光不正手术流程的每一个环节。本文主要从预防的角度总结准分子激光角膜屈光手术的术前、术中与术后注意事项及经验和方法,从细节做起,提高准分子激光角膜屈光手术的安全性。     

Caution to perform excimer laser corneal ablation on the ametropia with corneal guttata

It is very important to avoid inadequate patients to perform excimer laser keratectomy in order to prevent from surgical complications. The ametropic eyes with corneal guttata is considered very carefully whether to perform excimer laser corneal ablation or not, especially for the patient with corneal guttata companied by Fuchs endothelial dystrophy family history is contraindicated to perform laser corneal refractive surgery.     

三种全激光角膜屈光手术技术要点与前景

近视激光手术已经迈入“无刀”的全激光时代,其特点是手术的安全性、准确性和可预测性都有很大程度提高。现有的全激光手术可分为3类：飞秒激光联合准分子激光手术、单准分子激光手术和单飞秒激光手术。全激光手术具有提高角膜制瓣和基质切削的准确性,减少手术器械对角膜的接触损伤,减少术后角膜生物力学的改变等优点,是目前屈光手术发展的大方向和趋势。笔者对这3种全激光手术各自的技术要点,包括患者的选择、手术的优势、手术的缺点及并发症、术后的矫正效果、视觉质量等方面和全激光角膜屈光手术的技术发展前景进行详细的科学阐述。     

First clinical results with the femtosecond neodynium-glass laser in refractive surgery

PURPOSE: We evaluated four femtosecond laser intrastromal cutting procedures: creation of a corneal flap for laser in situ keratomileusis (LASIK), tunnel and entry cut for intracorneal ring, corneal flap and removable lens for keratomileusis, and intrastromal ablation for myopia and hyperopia. METHODS: A clinical trial using a femtosecond surgical laser (IntraLase Corporation) was performed in partially sighted eyes. Femto-LASIK treatment was performed on 46 eyes up to -14.00 D; 16 patients received intracorneal ring segments (Femto-ICRS); 5 patients each with one highly myopic eye had femtosecond laser keratomileusis (FLK), and 13 patients each with one myopic or hyperopic eye had intrastromal ablation (ISPRK). In Femto-LASIK, excimer laser ablation was done under the flap. In Femto-ICRS, ring segments were introduced into the laser-created channels. In femtosecond laser keratomileusis, a lens-shaped block of stroma was removed manually from under the flap. RESULTS: No difference was found between the results obtained with Femto-LASIK and a standard microkeratome. No refractive effects occurred when the created flap was not elevated. In cases of Femto-ICRS and conventional ICRS produced the same refractive results. With Femto-ICRS, no intraoperative complications occurred and visual acuity improved immediately after surgery. In femtosecond laser keratomileusis, high myopia was corrected without using excimer laser ablation; centralization of the treatment area was excellent. In intrastromal ablation, 1 to 2 hours after surgery the corneas were highly transparent; refractive results were stable. CONCLUSIONS: Femtosecond lasers can produce precise intrastromal cutting, offering significant safety and other advantages (no razor blades, corneal trauma, partial resections, or sterilization issues) over current techniques.     

准分子激光术后超微结构变化与生物组织反应

目的 以超微结构为基础,了解准分子激光表面切削术后角膜生物组织反应特点。方法 透射电镜对38只兔眼4,8,12周角膜组织进行观察和分析,并设对照。结果 角膜基质细胞线粒体和粗面内质网损害;出现功能不良性角膜实质细胞;在各种细胞中有成堆的骶鳞体积聚,提示大量自由基的产生;免疫细胞反应和淋巴细胞的凋亡;气化性碎屑产生;角膜胶原纤维区域性溶解等。结论 准分子激光可使角膜组织产生特异性的生物组织反应,可能是临床合并症的组织病理学基础。     

Corneal optical coherence tomography before and immediately after excimer laser photorefractive keratectomy

PURPOSE: To investigate the representation of the corneal structure with optical coherence tomography before and immediately after excimer laser photorefractive keratectomy. METHODS: Twenty-four eyes of 24 patients with myopia and myopic astigmatism were prospectively studied. The corneal thickness and the corneal profile were assessed with slit-lamp-adapted optical coherence tomography preoperatively and immediately after excimer laser photorefractive keratectomy. RESULTS: The attempted mean spherical equivalent of the refractive corrections was -6.7 +/- 3.6 (mean +/- SD) diopters with a mean calculated stromal ablation depth of 91 +/- 38 microm. The corneal optical coherence tomography was reproducible in all patients, demonstrating a mean decrease of central corneal thickness after epithelial debridement and excimer laser photorefractive keratectomy of 118 +/- 45 microm. The comparison of the calculated stromal ablation depth and the corneal thickness changes determined by corneal optical coherence tomography revealed a significant linear relationship with a correlation coefficient of 0.88 (P <.001). The flattening of the corneal curvature was confirmed in all patients with the optical coherence tomography system and correlated with the attempted refractive correction (r =.82, P <.001). CONCLUSIONS: The slit-lamp-adapted optical coherence tomography system presented in this study allowed noncontact, cross-sectional, and high-resolution imaging of the corneal configuration. This initial clinical evaluation demonstrated that corneal optical coherence tomography could be a promising diagnostic modality to monitor corneal changes of thickness and curvature before and after excimer laser photorefractive keratectomy.