飞秒激光辅助的两种深板层角膜移植治疗圆锥角膜疗效比较

目的比较飞秒激光辅助的切除75%以上基质层的深板层角膜移植(deep anterior lamellar keratoplasty,DALK)(preDescemetic DALK)和飞秒激光联合Anwar大气泡技术切除全部基质层DALK(Descemetic DALK)治疗圆锥角膜的临床效果。方法17例20眼圆锥角膜患者,9例10眼行飞秒激光辅助的pre-Descemetic DALK,8例10眼行飞秒激光辅助的Anwar大气泡Descemetic DALK,术后随访1 a,比较2组术后最佳矫正视力(best-corrected visual acuity,BCVA)、屈光状态、角膜曲率、内皮细胞丢失率及中央角膜厚度。结果所有手术顺利完成。术后1 a,pre-Descemetic DALK组BCVA为0.52±0.24,Descemetic DALK组BCVA为0.49±0.19,差异无统计学意义(P=0.758);pre-Descemetic DALK组近视度数为(-9.43±7.44)D,地形图测量角膜散光度数为(3.73±2.58)D,Descemetic DALK组近视度数为(-1.03±1.13)D,角膜散光度数为(3.21±3.10)D,两组间近视度差异显著(P=0.002),散光度数差异无统计学意义(P=0.684);角膜曲率pre-Descemetic DALK组为(44.30±4.18)D,Descemetic DALK组为(42.21±2.82)D,差异无统计学意义(P=0.208),内皮细胞丢失率分别为4.6%和6.4%,差异无统计学意义(P=0.258)。术后中央角膜厚度pre-Descemetic DALK组为(483.40±53.70)μm,Descemetic DALK组为(471.50±41.68)μm,差异无统计学意义(P=0.587)。结论飞秒激光辅助的大气泡Descemetic DALK术后屈光状态显示近视度数小,可作为治疗中晚期圆锥角膜的更好术式。     

飞秒激光辅助的大气泡法深板层角膜移植术治疗圆锥角膜后视觉质量

目的 观察飞秒激光辅助的大气泡法深板层角膜移植术(deep anterior lamellar keratoplasty,DALK)治疗圆锥角膜的视觉质量.方法 使用自身对照观察法,纳入30例(50眼)圆锥角膜患者,均行飞秒激光下大气泡法DALK治疗,随访1 a观察疗效.结果 30例(50眼)患者均顺利完成手术,术后早期术眼角膜植片均透明,角膜生理厚度恢复,植片与植床后弹力层贴合较好;术后7d、1个月、6个月、1 a患眼裸眼视力、最佳矫正视力均高于术前(均为P＜0.05),术后不同时间点间差异均无统计学意义(均为P＞0.05).术后不同时间点角膜曲率、角膜散光均较术前显著降低,角膜最薄点厚度较术前显著增加(均为P＜0.05),术后7d、1个月、6个月、1 a间各指标差异均无统计学意义(均为P＞0.05).术前内皮细胞密度为(2989.34±294.52)个·mm.,术后1 a为(2821.19±325.51)个·mm-2,角膜内皮细胞丢失率为(5.62±0.56)％,术后7d、1个月、6个月、1 a间差异不显著(均为P＞0.05).术中未见并发症发生;术后1眼伤口哆开,1眼缝线松弛,1眼发生基质层免疫排斥反应,未见其他并发症发生.结论 圆锥角膜行飞秒激光辅助的大气泡法DALK治疗,疗效确切,安全性高,是中晚期患者较佳的术式选择.     

飞秒激光辅助的大气泡法深板层角膜移植治疗圆锥角膜

目的评价飞秒激光辅助的大气泡法深板层角膜移植术治疗圆锥角膜临床效果及安全性。方法系列病例研究。9例（11眼）圆锥角膜患者采用飞秒激光辅助进行大气泡法深板层角膜移植手术。供体及受体角膜均采用500 kHz VisuMax飞秒激光进行垂直边切,术前超声测量角膜最薄点厚度,角膜厚度为（359.7±49.8）μm,术前UCVA为指数～0.1,术前BCVA为指数～0.12,供体直径为（7.51±0.14）mm,受体直径为（7.38±0.10）mm,随访时间为（7.70±2.88）个月。结果所有患者手术顺利,术中无并发症,术后早期所有角膜植片透明。角膜厚度为（481.4±51.3）μm,角膜地形图恢复正常形态。术后最后1次随访,UCVA为0.15～0.40,BCVA为 0.30～0.80。结论飞秒激光辅助的大气泡法深板层角膜移植对于圆锥角膜患者具有良好的临床效果及安全性。     

深板层角膜移植术治疗圆锥角膜疗效观察

目的:评价深板层角膜移植治疗圆锥角膜的效果。方法:采用深板层角膜移植术治疗132例140眼圆锥角膜,对其疗效进行观察分析。术后随访6～48mo。结果:术后矫正视力0.2～0.4者13例14眼,～0.8者92例96眼,>0.8者27例30眼,发生排斥反应5眼,植片透明131例139眼,半透明1例1眼,8眼出现后弹力层皱褶。结论:深板层角膜移植术具有并发症少,能减少内皮型排斥反应的发生,术后视力好,且对供体材料要求较低等优点,为治疗圆锥角膜提供了安全有效的选择。     

飞秒激光辅助角膜移植手术在圆锥角膜治疗中的应用

飞秒激光是一种以脉冲形式运转的红外线激光,在圆锥角膜的手术治疗中得到了很好的应用,与传统手术方式相比,飞秒激光辅助的穿透性角膜移植术和飞秒激光辅助的深板层角膜移植术在圆锥角膜患者术后均取得了良好的临床效果和更高的安全性。本文就近几年飞秒激光在圆锥角膜手术治疗中的应用进展进行综述,并结合我们临床应用中的经验和体会进行阐述。     

深板层角膜移植术治疗急性期圆锥角膜的探讨

目的 观察深板层角膜移植术治疗急性期圆锥角膜的手术时机及临床效果.方法 总结自2008年9月至2009年9月于邢台眼科医院住院的急性期圆锥角膜患者8例,均于发病后2～3周采用深板层角膜移植术治疗,术后随访观察6～12个月,观察角膜植片的透明度及视力情况.结果 8例患者中,术前裸眼视力4例为手动,4例为眼前指数,矫正均不提高;术后裸眼视力为0.2～0.5的6例,≥0.6的2例,术中发现后弹力层裂孔呈裂隙状;术后6例大部分裂孔已愈合,角膜植片透明;2例裂孔较大者(尚有约1mm未愈合)术后第3天发现少许层间积液,植片基质层轻度水肿,经前房补气及包扎后层间积液吸收,角膜植片恢复透明;全组病例后弹力层破裂处无明显混浊.结论 深板层角膜移植术治疗急性期圆锥角膜可以取得较好的临床效果.     

深板层角膜移植治疗圆锥角膜

目的探讨深板层角膜移植治疗圆锥角膜的价值。方法采用深板层全厚角膜供体植片治疗圆锥角膜22例(25眼),对其疗效进行观察、分析。结果术后平均随访5-26个月,术后裸眼视力≥0.2者20例(23眼)矫正视力≥0.4者17例(19眼),矫正视力≥0.7者3例(4眼),发生排斥反应3例(4眼),植片透明20例(23眼),植片半透明2例(2眼)。结论深板层角膜移植治疗圆锥角膜具有对材料要求条件低,不涉及前房及排斥反应低,治疗效果好等优点,在临床上值得推广应用。     

飞秒激光在深板层内皮角膜移植的应用前景

飞秒激光因其切割组织精密度高、对周围组织热损伤小,对角膜生物力学影响小被成功应用于LASIK手术中,但是越来越多的研究表明它可以完成其他角膜基质内手术,包括正受人们关注的深板层内皮角膜移植手术(deep lamellar endothelial keratoplast,DLEK),现就飞秒激光在DLEK手术中的应用前景作一综述。     

深板层角膜移植与穿透性角膜移植治疗圆锥角膜的比较

目的 评比深板层角膜移植术(DLKP)和穿透性角膜移植术(PKP)两种术式治疗圆锥角膜的临床疗效.方法 对我院连续收治的圆锥角膜48例48眼进行两种术式治疗,其中DLKP23眼,PKP 25眼,对两种手术疗效进行分析比较.术后随访6～24个月.术后分析最佳矫正视力、植片透明情况和并发症.结果 术后矫正视力≥0.5者,DLKP 19眼(82.61%),PKP 24眼(96.00%),两组患者的术后视力差别无统计学意义(P＞0.05).DLKP术后并发症为后弹力层皱折5眼,后弹力膜穿孔2眼,移植片排斥反应3眼(13.04%);PKP术后发生继发性青光眼3眼,虹膜前粘连5眼及排斥反应6眼(24.00%).结论 DLKP比PKP并发症少,它能减少内皮型排斥反应的发生,且术后最佳矫正视力与PKP近似,DLKP为治疗圆锥角膜提供了-个更安全有效的选择.     

Femtosecond laser-assisted deep anterior lamellar keratoplasty for keratoconus and keratectasia

AIM: To describe the initial outcomes and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK) for keratoconus and post-LASIKkeratectasia.METHODS:In this non-comparative case series, 10 eyes of 9 patients underwent DALK procedures with a femtosecond laser (Carl Zeiss Meditec AG, Jena, Germany). Of the 9 patients, 7 had keratoconus and 2 had post-LASIK keratectasia. A 500 kHz VisuMax femtosecond laser was used to perform corneal cuts on both donor and recipient corneas.The outcome measures were the uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal thickness, astigmatism, endothelial density count (EDC), and corneal power.RESULTS: All eyes were successfully treated. Early postoperative evaluation showed a clear graft in all cases. Intraoperative complications included one case of a small Descemet’s membrane perforation. Postoperatively, there was one case of stromal rejection, one of loosened sutures, and one of wound dehiscence. A normal corneal pattern topography and transparency were restored, UCVA and BCVA improved significantly, and astigmatism improved slightly. There was no statistically significant decrease in EDC.CONCLUSION: Our early results indicate that femtosecond laser-assisted deep anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology. This approach shows promise as a safe and effective surgical choice in the treatment of keratoconus and post-LASIK keratectasia.     

圆锥角膜深板层角膜移植术后高度散光的角膜楔形切除术

目的 分析圆锥角膜深板层角膜移植术后高度散光行角膜楔形切除的临床疗效.方法 回顾性分析了圆锥角膜深板层角膜移植术后继发较高度散光的6例(6眼),采用对称或不对称的受体角膜植床组织楔形切除的方法治疗.随访内容为:裸眼视力、电脑验光结果、最佳矫正视力、角膜地形图结果.结果 术后3年,矫正视力由术前的0.62±0.16,增加到0.73 ±0.16(P＞0.05).K散光由术前的(8.37±2.91)D,减低到(2.86±2.06)D(P ＜0.01).所有病例均能接受佩戴框架眼镜.结论 角膜楔形切除是矫正圆锥角膜深板层角膜移植术后高度散光的有效方法.     

深板层角膜移植术与穿透性角膜移植术治疗圆锥角膜的临床分析

目的 探讨深板层角膜移植术（DLKP）与穿透性角膜移植术（PKP）对圆锥角膜的不同临床疗效。方法采用病例对照研究设计,选择自2003年4月至2006年4月期间于我院行DLKP11例（11只眼）和PKP18例（18只眼）的29例圆锥角膜患者资料。对术前、术后的未矫正视力（UCVA）、最好矫正视力（BCVA）、植片情况、散光状况及手术并发症等进行分析。结果DLKP术后9例患者BCVA高于0．5,PKP术后14例患者BCVA高于0．5。DLKP组术后的平均球镜度数（DS）为（-1．21±3．36）D,平均柱镜度数（DC）为（-4．03±1．87）D,PKP组术后平均DS和DC分别为（-3．86±2．43）D和（-3．43±2．31）D,两组间比较差异均无统计学意义（DS：t=2．135,P=0．46;DC：t=-0．643,P=0．528）。共焦显微镜检查显示,DLEK组与PKP组术后角膜植片的上皮细胞、上皮细胞基底层及前弹力层角膜在形态上基本相似,均表现为植片基质细胞胞核略小,排列稍显紊乱,有裂隙样暗纹。DLKP组患侧眼内皮细胞的形态基本正常,平均密度为（2311．72±439．73）个／mm^2,对侧眼为（2477．81±535．92）个／mm^2,二者差异无统计学意义（t=1．06,P=0．78）;PKP组患侧眼内皮细胞面积较大,细胞大小不均匀,非六角形细胞比例高,平均密度为（1642．17±583．41）个／mm^2,明显低于对侧眼（2739．05±401．77）个／mm^2,二者之间比较差异有统计学意义（Z=7．32,P=0．006）。DLKP组的并发症主要是术中后弹力层穿孔、缝线松脱及层间浑浊等。PKP组的并发症主要是缝线松脱、眼压升高、排斥反应及内皮功能衰竭。结论DLKP术后的屈光状况与PKP术接近,虽然手术操作难度较高,但是术后发生内皮排斥和内皮衰竭的机率低、安全性高。（中华腰群杂志,2007,43：583-588）     

Femtosecond laser-assisted deep anterior lamellar keratoplasty in phototherapeutic keratectomy versus the big-bubble technique in keratoconus

AIM: To compare the functional and anatomic results of femtosecond laser (FSL)-assisted deep anterior lamellar keratoplasty (DALK) associated with phototherapeutic keratectomy (PTK) and FSL-assisted DALK performed using the big-bubble technique in keratoconus. METHODS: During the first phase of the study, an electron microscopy histopathology pilot study was conducted that included four unsuitable donor corneas divided into two groups: in FSL group, FSL lamellar cuts were performed on two corneas and in FSL+PTK group, PTK was performed at the stromal beds of two corneas after FSL lamellar cuts were made. During the second phase of the study, a randomized clinical trial was conducted that included two treatment groups of patients with keratoconus: group 1 (n=14 eyes) underwent FSL-assisted DALK associated with PTK and group 2 (n=12 eyes) underwent FSL-assisted DALK associated with the big-bubble technique. The main outcome measures were the postoperative visual acuity (VA) and optical coherence tomography (OCT) measurements, confocal microscopic findings, and contrast sensitivity. RESULTS: In the pilot study, histopathology showed a more regular stromal bed in the FSL+PTK group. In the clinical trial, group 1 had significantly worse best spectacle-corrected VA and contrast sensitivity (P<0.05 for both comparisons). The residual stromal bed measured by OCT was significantly (P<0.05) thicker in group 1. Confocal microscopy detected opacities only at the donor-receptor interface in group 1. CONCLUSION: Patients with keratoconus treated with FSL-assisted DALK performed using the big-bubble technique fare better than treated with FSL-assisted DALK associated with PTK.     

圆锥角膜行光学板层角膜移植术后早期缝线松动的影响因素

目的 探讨圆锥角膜行光学板层角膜移植术（LKP）后早期缝线松动的影响因素.方法 回顾性系列病例研究.对2006年1月至2010年5月存山东省眼科医院接受LKP的圆锥角膜患者手术前后眼部特点进行研究,对其中在2009年11月之前手术的52例（56眼）患者的病所资料进行回顾性研究,了解患者角膜地形图、曲率、眼轴、角膜横径、供体植片保存方式,分析这些因素与术后早期缝线松动发生率及松线部位的关联性;对在2009年11月至2010年5月期间行角膜移植手术且发生松线的9例（9眼）圆锥角膜患者进行了角膜光学相干断层扫描（OCT）及激光共焦显微镜检查,以期了解术后早期缝线在角膜组织中的位置特点及缝线附近角膜组织形态.计量资料采用秩和检验.计数资料采用卡方检验进行统计学分析.结果 52例（56眼）圆锥角膜患者中,术后早期发生缝线松动37眼（占66%）,其中27眼在松线的基础上发生角膜植片翘起（占73%）,96%的植片翘起发生在术后3个月内.松线主要发生在下方角膜（占62%）,47%的松线发生在术前角膜最薄点及圆锥顶点所在象限.松线组与未松线组比较：术前角膜最薄点（x2=3.49,P＞0.05）及圆锥顶点（x2=1.62,P＞0.05）位置分布差异无 统计学意义;角膜最薄点厚度（u=0.21,P＞0.05）、角膜中央厚度（u=0.11,P＞0.05）差异无统计学意义;供体植片保存方式（x2=3.06,P＞0.05）、角膜最大曲率（u=0.66,P＞0.05）、眼轴（u=1.06,P＞0.05）、角膜横径（u=1.68,P＞0.05）差异也无统计学意义.随访检查的9眼中,缝线存角膜组织中的跨越深度与角膜厚度的比值,松线组小于末松线组（0.4258±0.0420 vs 0.4869±0.0609,u=2.32,P＜0.05）,发生松线的患眼多伴有角膜缘新生血管浸润,且缝线多由植床侧割裂角膜组织而发生松线,松线周围角膜组织可见到坏死组织、瘢痕及炎性细胞浸润.结论 圆锥角膜行LKP术后早期（3个月内）,缝线松动易并发角膜植片翘起,松线部位多见于下方角膜.原凶可能与缝线在角膜组织中的跨越深度不足、术后炎症反应、新生血管的形成及术前角膜病变程度有关.     

Femtosecond laser deep lamellar keratoplasty

We aimed to develop a novel and effective technique for creating a smooth deep lamellar dissection of the cornea using a femtosecond (FS) laser for deep anterior lamellar keratoplasty (DALK), we conducted a retrospective eye bank study. Thirteen fresh human corneas were mounted on an artificial anterior chamber, and deep lamellar cuts were made with a 500-kHz VisuMax FS laser at a level of 50–80 mm anterior to the Descemet’s membrane (DM). A posterior diameter of 8 mm with a side cut angle of 110° was used for the anterior penetrating side cut. The anterior lamellar tissue was bluntly dissected. The residual posterior stromal beds and side cuts were examined with microscopy and intraoperative optical coherence tomography (OCT) and post-cut endothelial cell evaluations. All corneas revealed a smooth residual posterior stromal bed without any visible irregularities or ridges by microscopy and OCT imaging. Six corneas were suitable for post-cut endothelial cell evaluation 2 days after laser cut, with no significant endothelial cell loss post-laser and blunt dissection of the posterior stroma. FS laser deep lamellar keratoplasty utilizing an ultrafast laser to produce a smooth deep stromal dissection followed by blunt dissection and removal of the anterior stromal tissue yields a consistent and smooth residual stromal bed. The creation of a smooth lamellar dissection in the deep posterior cornea may result in more consistent DALK without the need for air bubble or manual baring of DM that has the risk for DM perforation.