先天性白内障的手术治疗及其进展

先天性白内障是一种常见眼病,该病严重影响儿童视觉发育和视力。手术是其主要治疗方法。由于儿童的术前评估、术中操作和术后管理都较成年人困难,使得手术效果往往不甚理想。因此,我们对近年来先天性白内障手术治疗的相关研究做一综述,以探讨该领域存在的问题和进一步发展的方向。     

先天性白内障手术的相关研究进展

先天性白内障是一种常见的儿童致盲性眼病.手术治疗是先天性白内障治疗的主要方式.由于其术前评估、术中操作、术后管理都较老年性白内障困难而且手术效果欠佳.因此,日益引起白内障专科医师及儿童眼科医师的高度关注.我们对近年来先天性白内障手术治疗的相关研究进展做一回顾,以探索该领域存在的问题和进一步的发展方向.     

Secondary glaucoma after pediatric cataract surgery

AIM:To determine the incidence and risk factors of secondary glaucoma after pediatric cataract surgery.METHODS: Two hundred and forty nine eyes of 148 patients underwent cataract surgery without intraocular lens (IOL) implantation (group 1), and 220 eyes of 129 patients underwent cataract surgery with IOL implantation (group 2) retrospectively, were evaluated between 2000 and 2011.The outcome measure was the presence or absence of post-cataract surgery glaucoma, defined as an intraocular pressure (IOP) ≥26mmHg, as measured on at least two occasions along with corneal or optic nerve changes.RESULTS: The mean follow-up periods of group 1 and 2 were (60.86±30.95) months (12-123 months) and (62.11±31.29) months (14-115 months) respectively. In group 1, 12 eyes of 8 patients (4.8%) developed glaucoma. None of the patients developed glaucoma after surgery in group 2. The mean age of the patients at the cataract surgery was (2.58±0.90) months (1 month-4 months) and the average period for glaucoma development after surgery was (9.50±4.33) months (4-16 months) in group 1. Three of the 12 glaucomatous eyes were controlled with antiglaucomatous medication and 9 eyes underwent trabeculectomy+mitomycin C surgery. One patient underwent a second trabeculectomy + mitomycin C operation for both of his eyes.CONCLUSION: The incidence of glaucoma after pediatric cataract surgery is very low in patients in whom IOL is implanted. The aphakic eyes after pediatric cataract surgery are at an increased risk for glaucoma development particularly if they underwent surgery before 4 months of age.     

Efficacy of microcatheter-assisted trabeculotomy on secondary glaucoma after congenital cataract surgery

AIM: To evaluate efficacy of microcatheter-assisted trabeculotomy (MAT) in eyes with secondary glaucoma after congenital cataract surgery and explore its correlation with the different degree of trabeculotomy. METHODS: A retrospective analysis was conducted on patients who underwent the said procedure between September 2019 and September 2020. The patients were classified into two groups according to the degree of trabeculotomy (group 1: ≤240-degree; group 2: 240–360-degree). The intraocular pressure (IOP) and anti-glaucoma drugs before and after operation was collected during the 12-month follow-up. RESULTS: Totally 27 eyes of 25 patients were included: 11 (40.7%) eyes in group 1 and 16 (59.3%) eyes in group 2. The mean IOP of all patients was 34.67±9.18 mm Hg preoperatively and 8.74±4.32, 9.95±5.65, 14.39±5.30, 16.02±4.37, 15.82±3.28, and 16.19±3.56 mm Hg 1d, 1wk, 1, 3, 6, and 12mo after surgery, respectively. In all patients, there were significant differences in IOP at each time point (F=65.614, P<0.01). In each group, IOP after surgery was lower than that before surgery (all P<0.01), but there was no difference in the rate of IOP reduction between the two groups (P=0.246). Furthermore, the amount of anti-glaucoma medications reduced to 0.30±0.67 (0–2) at 12mo from 2.63±0.49 (2–3) preoperatively (P<0.01), and there was no difference between the two groups (P>0.05). At the end of follow-up, the partial success rate was 81.8% in group 1 vs 93.75% in group 2 (P=0.549). Various amount of intraoperative and postoperative hyphema occurred in all eyes, which spontaneously absorbed or cleaned through paracentesis and irrigation. No other serious complications was observed. CONCLUSION: MAT can effectively reduce IOP in patients with secondary glaucoma after congenital cataract surgery with a high success rate and safety. And it can be used as the first choice for the treatment of secondary glaucoma after surgery for congenital cataracts.     

青光眼术后白内障超声乳化术

目的探讨青光眼术后白内障超声乳化手术适应症、时机、手术方法和并发症。方法回顾性分析2002年1月至2004年2月青光眼术后白内障患者44例,其中预防性虹膜周边切除术8例,滤过性手术36例。对39例术前眼压控制在正常范围或仅局部药物能控制正常的病例做上方透明角膜内切口或颞侧角膜缘巩膜隧道切口,避开功能滤过区行白内障超声乳化术;对3例术前眼压须全身药物才能控制的病人,控制眼压后避开原手术区行白内障超声乳化联合小梁切除术。随访半年。结果视力均有不同程度提高结论,0.5以上33例,视觉电生理检查视功能损害与术前有明显差别,眼压均在正常范围。结论超声乳化手术是治疗青光眼术后白内障的有效方法。     

青光眼术后经颞侧行小切口白内障手术

目的:探讨表面麻醉联合球结膜下麻醉经颞侧施行小切口白内障囊外摘出人工晶状体植入手术效果。方法:对32例40眼青光眼小梁切除术后的白内障患者用倍诺喜表面麻醉联合球结膜下注射20g/L利多卡因麻醉,行改良小切口白内障囊外摘出联合后房型人工晶状体植入术,分析手术的麻醉效果及手术后的治疗效果。结果:全部患眼均能达到理想的麻醉镇痛效果,顺利完成手术,术后视力<0.1者5眼(12.5%),视力0.1～0.4者9眼(22.5%),术后视力≥0.5者26眼(65.0%),所有患眼术后视力与术前比较均有提高。结论:表面麻醉联合球结膜下麻醉经颞侧施行小切口白内障囊外摘出人工晶状体植入手术,是治疗青光眼小梁切除术后白内障有效的手术方式,手术操作简便,不需要昂贵的手术设备,适用于基层医院开展。     

先天性白内障术后屈光变化及矫正

对先天性白内障的患儿实施白内障摘除手术已经基本达成共识,但先天性白内障手术后是否植入晶状体、植入晶状体的年龄及植入的人工晶状体度数仍是一个很有争议的问题。本文就先天性白内障患儿术后的屈光变化及残余屈光度的矫正进行综述。     

婴幼儿先天性白内障手术后视力和继发青光眼的临床分析

目的：探讨婴幼儿先天性白内障手术后视力和继发青光眼的相关分析。

方法：回顾性系列病例研究。观察我院2006-05/2018-01期间收治的婴幼儿先天性白内障患儿48例86眼,均行白内障吸除、后囊膜及前段玻璃体切除手术及人工晶状体(IOL)植入术。术后随访最长13a。对最佳矫正视力(BCVA,LogMAR),继发性青光眼进行临床观察。数据采用独立样本t检验、Fisher确切概率法分析、Logistic多元回归分析进行统计学分析。

结果：继发青光眼13眼(15%),BCVA 0.63±0.20; 无继发青光眼73眼(85%),BCVA 0.44±0.27; 两组BCVA比较有差异(t=2.417,P<0.05)。白内障摘除手术年龄≤3、>3～12、>12月龄,继发青光眼概率分别29%(6/21)、18%(6/34)、3%(1/31); Fisher分析,手术年龄≤3月龄继发青光眼概率要高于手术年龄>12月龄的(P<0.05)。继发青光眼组眼轴长度(AL)长于未继发青光眼组(t=-2.92,P=0.004); 继发青光眼组屈光度小于未继发青光眼组(t=4.00,P=0.0001)。Logistic多元回归分析显示：白内障手术年龄≤12月龄是术后继发青光眼的危险因素,发生率是手术年龄>12月龄的8.372倍(OR=8.372,95%CI：1.033～67.864,P=0.047)。

结论：婴幼儿先天性白内障术后可获得一定视力并有一定继发性青光眼发生率,青光眼对术后视力有极大影响。白内障手术年龄≤12月龄是术后继发青光眼的危险因素,尤其3月龄前手术的青光眼发生率远高于12月龄以后。继发青光眼患儿AL更长,屈光度更小,有着更明显的近视漂移。     

双眼先天性白内障同时手术的评价

目的 评价双眼同时手术治疗双眼先天性白内障的疗效。方法 通过对6例先天性白内障施行双眼同时手术,术后联合弱视训练进行分析。包括手术方式、手术操作、术后炎症反应、后囊膜浑浊、术后视力情况、脱盲、脱残情况等。结果 手术方式分单纯白内障吸出术、白内障吸出加人工晶状体植入、白内障囊外摘除加人工晶状体植入术。所有手术眼术后视力较术前均有提高,5例7眼术后出现前房纤维素样渗出、1例1眼出现人工晶状体前后膜,全部发生后囊膜混浊,但程度不等。需激光后囊切开的有3例6眼。经过手术前后对比,术后眼球震颤的程度都有减轻。结论 双眼先天性白内障同时手术是可行的,有利于避免遮盖导致的剥夺性弱视,利用双眼视的建立,减少全麻手术的风险。如果双眼先天性白内障视力均低于0.1,双眼无明显的差别,可以选择同时手术。     

微小切口婴儿先天性白内障手术

目的评价利用玻璃体切除器完成微小切口婴儿先天性白内障手术的临床效果。方法对36例（72眼）3～5个月婴儿先天性白内障,通过两个1．4mm透明角膜切口,利用玻璃体切除器的切割头完成前后囊环形切除、皮质吸出及前部玻璃体切除等手术步骤,术后应用抗炎及散瞳滴眼剂治疗,随访24个月,观察术后葡萄膜炎、后发性向内障及继发性青光眼等并发症情况。结果所有患眼术后葡萄膜炎症反应轻微,前后囊环形切除孔居中,直径理想,无玻璃体疝、瞳孔移位、继发性青光眼、后发性白内障或视网膜脱离等并发症发生。结论利用玻璃体切除器的切割头完成婴儿微小切口先天性向内障手术具有创伤小,并发症少的优点。     

微导管辅助360°小梁切开术治疗先天性白内障术后继发青光眼的临床研究

目的探讨微导管辅助360°小梁切开术治疗先天性白内障术后继发青光眼患者的效果及安全性。 方法收集2015年4月至2022年2月于首都医科大学附属北京同仁医院眼科中心接受微导管辅助360°小梁切开术的先天性白内障术后继发青光眼患者27例(30只眼)。其中,男性18例(20只眼),女性9例(10只眼),年龄8月龄至20岁,平均(6.9±5.9)岁。全部患者行微导管辅助的360°小梁切开术治疗。记录术前及术后1 d、术后1周、术后1个月、术后3个月及术后6个月患者的眼压和需用不同药物的眼数。其中,各时间点患者眼压的检测结果符合正态分布,以(±s)表示,需用药物的眼数以频数和百分比表示。各时间点患者眼压的比较使用单因素重复测量方差分析,各时间点需用药物眼数的比较使用广义估计方程法。计算各时间点的手术总成功率及完全成功率并采用广义估计方程法进行比较。 结果术前、术后1 d、术后1周、术后1个月、术后3个月及术后6个月的眼压分别为(35.97±7.67)mmHg(1 mmHg＝0.133 kPa)、(14.83±6.54)mmHg、(16.40±5.01)mmHg、(17.90±4.97)mmHg、(17.53±4.13)mmHg及(18.00±3.34)mmHg。术前与术后各时间点患者眼压的总体差异具有统计学意义(F＝92.75,P<0.05),术前与术后各时间点眼压的差异具有统计学意义(t＝11.49,10.08,9.52,9.87,8.54;P<0.05),术后各时间点间患者眼压的差异无统计学意义(t＝0.54,1.56,1.21,1.62,0.85,0.78,0.90,0.62,0.47,0.65;P>0.05)。术后1周、术后1个月、术后3个月及术后6个月需用药物0种、1种、2种、3种、4种及5种者分别为19例(22只眼)、3例(3只眼)、1例(1只眼)、2例(2只眼)、2例(2只眼)及0例(0只眼),18例(20只眼)、3例(3只眼)、2例(2只眼)、3例(3只眼)、2例(2只眼)及0例(0只眼),18例(20只眼)、4例(4只眼)、2例(2只眼)、3例(3只眼)、1例(1只眼)及0例(0只眼),17例(19只眼)、4例(4只眼)、1例(1只眼)、5例(5只眼)、1例(1只眼)及0例(0只眼);分别占73.33%、10.00%、3.33%、6.67%、6.67%及0.00%,66.67%、10.00%、6.67%、10.00%、6.67%及0.00%,66.67%、13.33%、6.67%、10.00%、3.33%及0.00%,63.33%、13.33%、3.33%、16.67%、3.33%及0.00%。术后1周与术后1 d、术后1个月、术后3个月及术后6个月需用药物者的差异具有统计学意义(χ²＝30.26,61.05,55.36,48.86;P<0.05)。术后1个月与术后3个月及术后6个月需用药物者的差异具有统计学意义(χ²＝72.08,76.05;P<0.05)。术后3个月与术后6个月需用药物者的差异具有统计学意义(χ²＝94.80,P<0.05)。全部患者27例(30只眼)中,术后1周、术后1个月、术后3个月及术后6个月的手术基本成功者分别为3例(3只眼)、4例(4只眼)、4例(4只眼)及4例(4只眼),分别占10.00%、13.33%、13.33%及13.33%;手术完全成功者分别为19例(22只眼)、17例(19只眼)、17例(19只眼)及16例(18只眼),分别占73.33%、63.33%、63.33%及60.00%。术后各时间点手术完全成功率的差异无统计学意义(χ²＝2.90,P>0.05)。术后1周、术后1个月、术后3个月及术后6个月的手术总成功率分别为83.33%、76.67%、76.67%及73.33%,术后各时间点手术总成功率的差异无统计学意义(χ²＝1.42,P>0.05)。 结论微导管辅助360°小梁切开术对先天性白内障术后继发青光眼有较好的治疗效果及安全性。     

先天性白内障术后继发青光眼与中央角膜厚度的研究

目的:探讨儿童先天性白内障手术后无晶状体眼或人工晶状体眼的平均中央角膜厚度(CCT)的改变,并与同年龄组健康人群的中央角膜厚度进行对照研究。方法:该实验包括随机抽样的先天性白内障术后的45个无晶状体眼及人工晶状体眼患者共45眼,同时有46个健康的进行性别和年龄配比的志愿者作为对照研究,对他们进行包括中央角膜厚度及眼压(Goldmann眼压计及Tonopen眼压计)的全面的眼部检查。将测得的眼压与角膜中央厚度结果进行分组比较。结果:研究对象的45眼中包括35只无晶状体眼与10只人工晶状体眼,其角膜厚度中位数为626μm(范围为523~870μm),而正常对照组的中央角膜厚度为556.0μm(范围为490~640μm)其差异有统计学意义(P<0.05);先天性白内障患儿术后无晶状体眼与手术时一期植入人工晶状体的眼之间的中央角膜厚度的差异有统计学意义(P=0.011)。但先天性白内障术后的患儿中二期植入人工晶状体眼与无晶状体眼之间中央角膜厚度的差异则不具备统计学意义(P=0.847)。患者的年龄中位数为36mo(年龄从1wk到10岁不等),且其年龄与CCT之间呈负相关(r=-0.485,P=0.001)。结论:儿童先天性白内障术后无晶状体眼与人工晶状体眼的患者显著比正常对照组的角膜变厚。这种差异对解释术后眼内压升高有重要的作用,同时对儿童先天性白内障无晶状体眼患者术后最常见的继发青光眼的并发症的解释有重要的作用。     

先天性无虹膜症青光眼白内障手术后眼压持续升高

【摘要】 一例11岁男孩,6个月时因双眼先天性无虹膜症、青光眼而行双眼小梁切除术,10岁时行超声乳化晶状体吸出人工晶状体植入术。术后6个月非接触眼压32、34 mm Hg,超声测量中央角膜厚度（CCT）：右眼850、左眼827 μm。眼底C/D 0.2。此患者需要继续治疗吗？（眼科,2012,21：234-238）     

儿童先天性白内障不同术式的后发障发生率

目的探讨减少儿童白内障术后后发障的手术方法。方法15岁以下的先天性白内障117例(158眼)。分为3组:A组进行超声乳化吸出术及后囊抛光术,共79眼;B组进行超声乳化及后囊连续环形撕囊术,共32眼;C组进行超声乳化、后囊连续环形撕囊及前部玻璃体切除术,共47眼。≥3岁者一期囊袋内植入人工晶状体。观察术后后发障的发生情况。结果A组有71眼在术后25天～3年期间出现后发障,占89.87%,平均出现时间为11月。B组有24眼在术后45天～2年半期间出现后发障,占75.00%,平均出现时间为1年5月。C组有6眼在术后50天～2年期间出现后发障,占12.77%,平均出现时间为1年3月。结论3岁以下婴幼儿进行白内障吸出、后囊环形撕囊术并行前部玻璃体切除术,二期植入人工晶状体。3～15岁的患儿进行白内障吸出、后囊环形撕囊术并行前部玻璃体切除术,〗并囊袋内植入人工晶状体可有效预防后发障的发生。     

婴幼儿白内障摘除术后青光眼的患病率及危险因素

婴幼儿白内障术后青光眼是一种迟发性白内障术后并发症,患病率依随访时间的延长而升高.其患病相关危险因素有:患儿接受白内障手术时的年龄、小角膜、中央角膜厚度、持续性胎儿血管化、白内障手术过程以及遗传因素等.一期后房植入人工晶状体可能是保护性因素.多数治疗方式效果欠佳,目前青光眼引流物植入术仍是治疗该病的较有效方式.为减少本病患儿视功能损害,应加强白内障患儿手术后随访.     

Management of cataract surgery in Lowe syndrome

AIM: To evaluate the ophthalmic and anesthesiologic management of cataract surgery in children with Lowe syndrome receiving lens removal, the development and management of secondary glaucoma. METHODS: This retrospective case series included 12 eyes of 6 children with genetically verified Lowe syndrome receiving cataract removal. Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intra- and postoperative complications were noted as well as clinical examinations such as visual acuity and funduscopy. RESULTS: All children received simultaneous bilateral cataract surgery at the mean age of 8.98±3.58wk. Lensectomy combined with posterior capsulotomy and anterior vitrectomy was performed in all children. The mean time for cataract surgery per eye was 35.83±8.86min, whereas the total time of surgery was 153.33±22.11min. The mean extubation time and duration at recovery room was 42.33±22.60min and 130.00±64.37min, respectively. During surgery, a decrease of oxygen saturation below 93% was found in only one child. During the postoperative follow-up, nystagmus (6 children) and strabismus (5 children) was commonly found in contrast to no case of visual axis opacification. Secondary glaucoma developed in five eyes of three children, which was treated with topical eye drops in only one child. A trabeculectomy was performed in both eyes of one child, whereas removal of syechia and an iridectomy in one eye of one child. CONCLUSION: Bilateral simultaneous cataract surgery under general anesthesia is a safe surgical procedure in Lowe syndrome children. The glaucoma screening with intraocular pressure measurements is crucial in the postoperative management of Lowe syndrome patients to avoid additional visual impairment.     

Clinical characteristics of congenital and developmental cataract in Kazakhstan

Purpose:To study and describe clinical characteristics of congenital and developmental cataract at a tertiary eye care facility.Methods:In this retrospective study, 942 children (1311 eyes) presenting with congenital/developmental cataract over a 10-year study period were included. Gender, age at surgery, main presenting complaint, morphologic type of cataract, laterality, family history, and associated findings were recorded.Results:The overall proportion of boys and girls undergoing cataract surgery was approximately equal (P = 0.110). However, in the cases of bilateral cataract, the proportion of boys was larger than girls (P = 0.028). More than half (62.3%) of the patients underwent surgery at the age of >3 years. The main presenting complaint was white pupils, accounting for 48.1% of cases. Total cataract was the most common morphologic type in all age groups. In total, 133 children out of 942 (14.1%) had a positive family history of congenital/developmental cataract. Strabismus and nystagmus were seen in 27.2% and 19.3% of the eyes, respectively. Additional ocular dysmorphology was found in 97 (10.3%) of patients. Coexisting systemic disease was found in 149 (15.8%) cases. Among syndrome-associated cataracts, Down syndrome accounted for the majority of cases.Conclusion:High prevalence of total cataracts as well as frequent association with strabismus and nystagmus are likely to be the consequences of delayed presentation.     

先天性白内障后发障形成的危险因素分析

目的评价先天性白内障摘除术后导致晶体后囊膜混浊(PCO)的危险因素。方法53例(87眼)先天性白内障病人的临床资料。所有眼均行巩膜隧道切口白内障摘除术,35眼保持后囊膜完整、19眼行后囊连续环形撕囊(PCCC)、33眼行PCCC联合前部玻璃体切除术(AV)。51眼I期植入人工晶体(IOL)。结果平均随访时间为18个月,30眼(34.48%)发生PCO,其中后囊完整组19眼(54.29%)、PCCC组5眼(26.32%)、PCCC AV组6眼(18.18%)。PCO的形成与术中未行PCCC AV(P<0.01)及I期IOL植入(P<0.05)有关。手术年龄越小,PCO形成的几率越大(P<0.05)。结论手术年龄小、I期IOL植入及保持后囊完整是PCO形成的危险因素。