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.     

使用黏弹剂分离至后弹力层行大植片深板层角膜移植的疗效

深板层角膜移植术（deep lamillar keratoplasty,DLKP）是指去除受体病变的角膜基质组织直至暴露后弹力层,再移植已去除后弹力层及内皮层的供体角膜的手术方式,既减少了眼内手术并发症的危险和由内皮细胞引起的排斥反应,又能达到视力的良好恢复。对我院69例角膜内皮功能正常的角膜病患者,采用黏弹剂注入法施行DLKP,效果良好,报告如下。     

后弹力层角膜内皮移植术的标准化“非接触”技术

作者介绍一种“非接触”后弹力层角膜内皮移植（Descemet membrane endothelial keratoplasty,DMEK）的标准化技术,与深板层角膜内皮移植术以及后弹力层剥除（自动）角膜内皮移植术（DSEK／DSAEK）相比,DMEK可使大多数患者的视力得到较为快速而完全的恢复,移植物的存活率更高,并且以较少的投入就可以使供体角膜组织得到更充分的利用。     

带后弹力层的角膜内皮移植术

随着眼科技术的发展,角膜内皮移植术取得了长足进展。从后板层角膜移植术（PLK）开始到深板层角膜移植术（DLEK）,以及目前运用的后弹力层撕除角膜内皮移植术（DSEK/DSAEK）,乃至具有更好视觉恢复效果的带有后弹力层（Descem et膜）的角膜内皮移植术（DMEK）,眼科医生们不断寻求着更快更好的治疗方法。而DMEK从解剖学角度完美的恢复了角膜组织的正常结构,术后视力恢复快,是角膜内皮移植手术的发展趋势。现主要就DMEK的手术方法、特点以及进一步的改进进行综述。     

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.     

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.     

角膜后弹力层剥除联合自动角膜刀取材内皮移植术的临床研究

目的 探讨角膜后弹力层剥除联合自动角膜刀取材内皮移植术的术后疗效、并发症、处理及适应证的选择.方法 临床病例系列研究.2007年9至12月期间,北京大学第三医院、北京大学眼科中心选择9例角膜内皮失代偿的患者行角膜后弹力层剥除自动角膜刀取材及角膜内皮移植手术,术后观察视力、角膜透明性的恢复、植片的脱位率、角膜厚度、角膜曲率及角膜内皮细胞数,随访时间3～7个月.结果 手术中1例虹膜角膜内皮综合征患者的角膜内皮植片植入失败,改行穿透性角膜移植术;其余8例患者术后植片明显脱位1例,再处理后复位.术后8例手术成功患者视力全部提高,植片透明,角膜厚度为(775±30)μm;角膜曲率为(44.19±2.28)D;角膜散光度数为(2.20±0.83)D;角膜内皮细胞数为(1439±296)个/mm~2.结论 角膜后弹力层剥除联合自动角膜刀取材内皮移植术有可能成为一种治疗角膜内皮失代偿的重要术式.     

后弹力层角膜内皮移植术

后弹力层角膜内皮移植术(DSEK)是一项新近开展起来的眼科手术,主要用于治疗因角膜内皮功能不良引起的角膜失代偿.虽然DSEK手术应用于临床尚不足4年,但因其术后视力恢复快,与传统角膜移植手术相比,极大地降低了术后并发症的发生,而迅速成为角膜内皮功能不良患者行角膜移植的首选手术.由于其应用时间短,远期疗效尚待观察.就后弹力层角膜内皮移植术的手术特点以及与传统角膜移植手术相比较的优缺点进行综述.     

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。     

Endothelial keratoplasty: a revolution in evolution

Endothelial keratoplasty (EK) is continually evolving both in surgical technique and clinical outcomes. Descemet's stripping endothelial keratoplasty (DSEK) has replaced penetrating keratoplasty (PK) as the treatment of choice for corneal endothelial dysfunction. It is safe and predictable and offers early visual rehabilitation. Newer iterations include Descemet's membrane endothelial keratoplasty, Descemet's membrane automated endothelial keratoplasty, and other hybrid techniques. Early data on these newer EK techniques suggests that they provide significantly better visual outcomes compared to DSEK. Initial 5-year survival data indicates that EK is at least comparable to PK, and more widespread survival data is anticipated. Further work is needed to simultaneously optimize visual outcomes, refractive predictability, and endothelial cell survival, as well as surgical techniques of donor preparation and insertion.     

Descemet's stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant

PURPOSE: To evaluate early visual and refractive outcomes following treatment of corneal endothelial dysfunction with a corneal transplantation technique, Descemet's stripping with endothelial keratoplasty (DSEK). METHODS: Visual and refractive outcomes of the first 50 consecutive cases of DSEK performed by a single surgeon between December 2003 and July 2004 were analyzed retrospectively. The DSEK technique consisted of stripping Descemet's membrane and endothelium from a recipient cornea and transplanting the posterior stroma and endothelium of a donor cornea through a 5-mm incision. RESULTS: Results are reported for 50 eyes in 47 patients (30 women and 17 men). Mean patient age at surgery was 70 +/- 12 years (range: 34 to 89 years). Five eyes were treated for corneal edema or bullous keratopathy and 45 for Fuchs' endothelial dystrophy. Seven eyes were phakic and 43 were pseudophakic. Six months after surgery, mean manifest cylinder was 1.5 +/- 0.94 diopters (D), unchanged from preoperative cylinder of 1.5 +/- 1.0 D. Mean manifest spherical equivalent refraction was 0.15 +/- 1.5 D at 6-month follow-up compared with -0.36 +/- 1.4 D preoperatively (P = .10) At 3- and 6-month follow-up, significant improvement was noted in mean best spectacle-corrected visual acuity compared with the preoperative mean of 20/100 (P = .007). At 6-month follow-up, 31 (62%) eyes refracted to > or = 20/40 and 38 (76%) eyes saw > or = 20/50. CONCLUSIONS: Compared to standard penetrating keratoplasty, DSEK causes minimal refractive change and provides rapid visual recovery for patients with endothelial dysfunction. This technique maintains the structural integrity of the cornea by preserving the recipient's epithelium, Bowman's layer, and entire stromal thickness.     

Descemet's stripping endothelial keratoplasty

PURPOSE OF REVIEW: Descemet's stripping endothelial keratoplasty (DSEK) is rapidly becoming the preferred treatment for corneal endothelial dysfunction. Familiarity with recent advances in techniques and instrumentation can help reduce the initially steep learning curve and incidence of complications. RECENT FINDINGS: DSEK produces excellent visual outcomes with minimal change in corneal surface topography or refraction. It can successfully treat corneal dysfunction associated with Fuchs' endothelial dystrophy, bullous keratopathy, iridocorneal endothelial syndrome or a failed penetrating graft. Donor dissection has become automated, and new techniques have been devised to facilitate graft insertion and unfolding. Some surgeons now routinely perform DSEK with topical anesthesia. Graft detachment is the most frequent early postoperative complication, but new methods can help promote donor adherence. The incidence of graft-rejection episodes is lower after DSEK compared with standard penetrating keratoplasty, possibly because wound healing is a lesser concern, and many DSEK patients are maintained on low-dose topical steroids indefinitely. Early efforts to transplant just the endothelial cell layer show promise. SUMMARY: DSEK provides quicker visual rehabilitation and an improved safety profile compared with standard penetrating keratoplasty. Continued evolution of this relatively new technique is helping to reduce complications and further improve outcomes.     

Descemet's stripping with endothelial keratoplasty in 200 eyes: Early challenges and techniques to enhance donor adherence

PURPOSE: To describe early challenges and techniques to promote donor tissue adherence in Descemet's stripping with endothelial keratoplasty (DSEK). SETTING: Price Vision Group, Indianapolis, Indiana, USA. METHODS: The first 200 consecutive cases of DSEK performed by a single surgeon were analyzed retrospectively. Follow-up was 7 to 20 months for 124 eyes and 2 to 6 months for 76 eyes. The surgical technique consisted of stripping Descemet's membrane and endothelium from the recipient's central cornea and transplanting an 8.0 to 9.0 mm disc of donor endothelium and posterior stroma through a 5.0 mm incision, with sutures used only to close the incision. RESULTS: The most frequent challenge was inadequate donor attachment. Using techniques to remove fluid from the donor-recipient graft interface, the donor detachment rate in the last 64 cases was 6%, with half attributable to patient eye rubbing. Detached grafts were reattached by injecting an air bubble to press the donor against the recipient cornea. There were 7 primary graft failures, with only 1 occurring in the second 100 cases, which primarily used microkeratome-dissected donor tissue. Other complications were infrequent and included pupillary block glaucoma (1), aqueous misdirection syndrome (1), and cataract development in 2 of 27 phakic eyes. The DSEK procedure was performed safely before and after laser in situ keratomileusis (1 each). CONCLUSIONS: Early outcomes in the initial 200 consecutive DSEK procedures suggest the technique provides significant advantages over penetrating keratoplasty, including more rapid healing, more predictable refractive outcomes, and better retention of corneal strength and integrity. Although donor adherence was more challenging, DSEK was technically easier and should be less traumatic to anterior chamber structures than earlier posterior grafting techniques.     

Descemet stripping with endothelial keratoplasty for treatment of iridocorneal endothelial syndrome

PURPOSE: To describe use of Descemet stripping with endothelial keratoplasty (DSEK) to treat corneal edema associated with iridocorneal endothelial (ICE) syndrome. METHODS: In this retrospective, consecutive, interventional case series, the corneal endothelium was selectively replaced by the DSEK technique in eyes with ICE syndrome. Three eyes were treated at 1 center between June 2005 and July 2006. Descemet membrane and endothelium were stripped from the recipient and an 8- or 8.5-mm-diameter donor button consisting of posterior stroma and healthy endothelium was folded and implanted through a 5-mm incision. An air bubble was used to press the donor tissue against the recipient cornea, allowing it to attach without sutures. In 1 case with extensive peripheral anterior synechiae (PAS), after the PAS were broken, the anterior chamber was shallow, so a temporary anchor suture was placed in the peripheral edge of the donor tissue to help ensure that it would unfold in the correct orientation. RESULTS: DSEK successfully resolved corneal edema in 3 male patients with unilateral ICE syndrome who were 47 to 67 years of age. Follow-up ranged from 1 to 14 months. Best spectacle-corrected visual acuity at the most recent visit was 20/20 to 20/30, with a mean refractive cylinder of 1.2 D. CONCLUSIONS: Selective replacement of dysfunctional endothelium with DSEK can successfully treat corneal edema and associated visual loss and pain caused by ICE syndrome. Visual recovery is rapid and refractive changes are minimal compared with replacement of the full corneal thickness with a traditional penetrating keratoplasty.     

Graft survival and endothelial outcomes in the new era of endothelial keratoplasty

Corneal endothelial cells do not proliferative in?vivo sufficiently to enable endothelial regeneration, and thus diseases of the corneal endothelium, which cause poor vision and discomfort, require treatment by transplantation of cadaveric donor corneal endothelial cells. The two major goals of any corneal transplant procedure are to restore vision and to promote longevity of the donor cornea by maintaining a healthy donor endothelial cell density. Over the last decade, the surgical treatment for endothelial disease has rapidly evolved toward endothelial keratoplasty, or selective tissue transplantation, and away from full-thickness penetrating keratoplasty (PK). While endothelial keratoplasty offers distinct advantages over PK in terms of visual outcomes and a smaller incision, the new surgical manipulations of the fragile donor tissue cause significant donor endothelial cell trauma. As a result, donor endothelial cell loss is much higher during the first month after Descemet stripping endothelial keratoplasty (DSEK) compared to after PK, and the primary (or more appropriately, iatrogenic) graft failure rate of 5% remains unacceptably high. Nevertheless, the rate of endothelial cell loss rapidly decreases beyond 6 months after DSEK, and thus endothelial cell loss at 5 years after DSEK appears to be lower than that at 5 years after PK. In the absence of primary (iatrogenic) graft failure, graft survival through 5 years after DSEK is similar to that after PK. Given the promising longer-term endothelial outcomes of DSEK, the quest for optimizing the visual outcomes has spurred interest in Descemet membrane endothelial keratoplasty (DMEK). While early results after DMEK suggest better visual outcomes than after DSEK, the technique needs to be simplified, and longer-term outcomes must show an advantage over DSEK with respect to vision, endothelial cell loss, and graft survival. DMEK also has a high rate of primary (iatrogenic) graft failure, and additional donor tissue wastage occurs when preparation of DMEK grafts is unsuccessful. This review discusses endothelial keratoplasty techniques and the associated endothelial outcomes.     

Diagnosis of residual Descemet's membrane after Descemet's stripping endothelial keratoplasty with anterior segment optical coherence tomography

We present a patient with residual Descemet's membrane diagnosed by anterior segment optical coherence tomography (AS-OCT) after Descemet's stripping endothelial keratoplasty (DSEK). Postoperatively, persistent partial corneal edema and interface fluid without dislocation of the donor button were observed. No improvement of interface fluid was found during the follow-up period. A primary donor graft failure was diagnosed within 4 months, and the patient was regrafted with penetrating keratoplasty. Pathology examination of the specimen revealed the presence of residual Descemet's membrane in the recipient corneal button, confirmed using AS-OCT imaging. This case report demonstrates that inadequate Descemet's stripping in the recipient button could be a potential cause of DSEK failure; AS-OCT is a useful and noninvasive instrument for diagnosing and monitoring this post-DSEK complication.     

利用后弹力层撕除术建立兔眼角膜内皮失代偿模型的评估

目的利用后弹力层撕除术建立一种新的角膜内皮失代偿模型以便更好地了解该手术的组织反应。方法根据手术方法的不同将40只新西兰成年兔平均分为4组：角膜内皮刮除组、后弹力层撕除组、后弹力层撕除角膜内皮移植术（DSEK）组及DSEK供体组;右眼为手术眼。每组定期通过角膜内皮活体染色,眼前节照相和UBM至少观察2个月。结果后弹力层撕除组角膜始终保持混浊,角膜内皮刮除组和DSEK组角膜逐渐透明,角膜厚度逐渐降低。活体染色显示角膜后弹力层撕除组术后2个月仍无角膜内皮生长。结论后弹力层撕除术建立的角膜内皮失代偿模型显示了后弹力层撕除后角膜内皮愈合过程,可用于角膜内皮移植的研究。