要重视准分子激光角膜屈光手术围手术期的用药规范

随着准分子激光角膜屈光手术技术和设备的不断完善,角膜屈光手术的安全性、有效性和可预测性都有了极大的提高.目前准分子激光角膜屈光手术包括准分子激光屈光性角膜切削术(PRK)、准分子激光上皮下角膜磨镶术(LASEK)、准分子激光角膜原位磨镶术(LASIK)和全飞秒激光小切口基质透镜取出术(SMILE)等,无论哪种术式,最终目标都是为了增加术眼的舒适度和改善术眼的视觉质量.在手术技巧不断完善的情况下,围手术期用药的规范性成为提高准分子激光角膜屈光手术安全性的主要因素之一.眼科医师应严格掌握准分子激光角膜屈光术后各种常用药物的适应证和规范用法,以防发生药物相关性眼病.此外,眼科医师也应了解准分子激光角膜屈光手术后的常见并发症及其药物治疗方法,重视围手术期用药规范,提高患者的视觉质量和舒适度,减少术后并发症的发生.     

准分子激光屈光性角膜手术后角膜后表面改变的研究进展

准分子激光屈光性角膜手术通过激光切削角膜组织改变角膜前表面曲率,从而矫正屈光不正。由于偶有术后医源性角膜扩张的病例发生,手术后角膜发生怎样的改变是眼科医师一直关注的问题。本文综述了准分子激光屈光性手术后角膜后表面是否发生前移改变、角膜后表面屈光力、曲率、散光度、轴度、非球面特性以及最适球面等是否发生改变的研究进展。     

准分子激光角膜屈光手术与眼压

准分子激光角膜屈光手术是目前治疗屈光不正的主要手术方式,在改善视力的同时,我们更关心眼压和准分子激光角膜屈光手术的相互关系。本文就准分子激光角膜屈光手术的分类,24h眼压波动,术前、术后角膜厚度、曲率与眼压关系,高度近视合并青光眼的诊断,屈光回退及近视进展与眼压的关系,糖皮质激素性高眼压或青光眼做一综述,对眼科临床的诊断和治疗方面都具有重要意义。     

准分子激光角膜屈光手术后疱疹病毒性角膜炎的研究进展

准分子激光角膜屈光手术后并发单纯疱疹病毒（HSV）感染常可引起视力的严重损害。导致准分子激光角膜屈光手术后并发疱疹病毒感染的主要原因有：准分子激光照射和手术刺激诱发潜伏的HSV活化;术后局部长期应用糖皮质激素类滴眼液,也可是上述因素综合作用的结果。及时诊断及有效的抗病毒治疗是恢复视力的关键,血清抗体检测、病毒培养、角膜上皮刮片、组织细胞切片和Negative染色、聚合酶链反应（PCR）等实验室检测均存在一定的限制,而多重PCR可能会成为有效的实验室诊断方法。准分子激光角膜屈光手术后并发HSV感染的治疗方法主要是根据病情局部或全身应用抗病毒药物,对于术前曾有单纯疱疹病毒性角膜炎（HSK）病史的患者围手术期局部给予抗病毒药物可显著降低准分子激光角膜屈光手术后疱疹病毒感染的发生率。根据近年来国内外相关的临床研究及基础研究,对准分子激光角膜屈光手术后合并HSK的病因、诊断、治疗及预防进行综述。     

准分子激光角膜屈光手术后丝状角膜炎的临床分析及治疗

目的:观察准分子激光角膜屈光手术后丝状角膜炎的发病情况,总结采用唯地息凝胶治疗的效果,探讨其发病相关因素及防治方法。方法:所有患者2139眼,按术前有无角膜接触镜配戴史分为Ia组493眼(有角膜接触镜配戴史)与Ib组1646眼(无角膜接触镜配戴史),按术式分为IIa组1916眼(LASIK术后)与IIb组223眼(LASEK术后),比较其发病率,观察准分子激光角膜屈光手术后丝状角膜炎的发生情况,发病者迅速、足量使用唯地息凝胶治疗,观察其疗效,分析该病变的临床特征,相关发病因素及防治措施。结果:Ia组与Ib组术后丝状角膜炎发病率分别为3.45%和1.76%,两者有显著差异(P<0.05);IIa组与IIb组术后丝状角膜炎发病率分别为1.93%和4.04%,两者有显著差异(P<0.05)。唯地息凝胶治疗准分子激光角膜屈光手术后丝状角膜炎的平均疗程1.22±0.63d,随访6mo未见复发。结论:与准分子激光角膜屈光手术后丝状角膜炎发生的相关因素包括:术前配戴角膜接触镜继发干眼及眼表炎症、术中角膜损伤、术后角膜上皮愈合及术后用药等。唯地息凝胶治疗准分子激光角膜屈光手术后丝状角膜炎,疗程短、效果显著。     

亲水性软性角膜接触镜在准分子激光屈光性角膜手术中的应用

目的:了解亲水性软性角膜接触镜作为物理屏障在准分子激光屈光性角膜手术的作用。方法:对临床观察23例(40眼)准分子激光屈光性角膜切削术后配戴角膜接触镜者进行观察,包括各种临床症状;角膜上皮愈合及角膜瓣对位等,平均配戴1～15d,术后随诊1～3mo。结果:术后配戴角膜接触镜,患者角膜上皮愈合不适症状减轻,角膜瓣无1例发生移位,对位好。结论:准分子激光屈光性角膜手术中及术后早期配戴角膜接触镜具有促进角膜上皮愈合,稳定角膜瓣的作用。     

《激光角膜屈光手术技术规范 第1部分：准分子激光角膜屈光手术》团体标准解读

我国近视眼患病率逐年增高, 准分子激光及飞秒激光角膜屈光手术已成为我国18岁以上青壮年屈光不正患者矫正视力的主要方法。而激光角膜屈光手术作为选择性手术, 具有明显的特殊性, 手术细节要求高, 亟需加强行业技术规范管理。由中国民族卫生协会眼学科分会组织国内相关专家在参阅国内外角膜屈光手术相关临床指南和专家共识的基础上, 共同编制的团体标准《激光角膜屈光手术技术规范第1部分:准分子激光角膜屈光手术》于2022年12月15日发布。本文对其中的重要技术规范要点进行探讨和解读, 以期更好地为临床工作提供指导意见。     

疑难性角膜屈光手术分析

目的分析疑难性准分子激光角膜屈光手术的原因、分类、方案设计及治疗效果。设计回顾性病例系列。研究对象非常规疑难性准分子激光屈光性角膜手术患者47眼。方法分析患者进行屈光手术的原因、方案设计及治疗效果。除视力（裸眼、矫正、小孔视力）、屈光度（散瞳和显然验光）、主视眼、角膜厚度、角膜地形图、像差检查等常规术前检查外,还要依据患者情况进行相应的特殊检查,包括角膜多点厚度、角膜曲率时间变化、眩光仪、对比敏感度、眼肌功能、VEP等检查。手术前对患者进行个性化手术设计以及可能的预后评估。主要指标治疗前角膜厚度、视力、角膜地形图变化、屈光度、手术次数。结果疑难角膜屈光手术的界定：除最佳矫正视力小于0．8,还伴有角膜形态、结构异常或屈光参差、弱视等异常,或曾行屈光角膜手术但效果不佳,最佳矫正视力低于0．5,需再次进行角膜屈光手术的患者。疑难角膜屈光手术分类：（1）根据角膜屈光手术史分为手术原性屈光状态异常性、手术原性角膜结构异常性;（2）根据角膜情况分为角膜结构异常性、角膜曲率异常性;（3）根据双眼屈光状态差异分为高度近视伴弱视性、屈光参差性疑难角膜屈光手术。治疗方法：个性化设计手术,地形图引导手术,角膜屈光手术方式包括准分子激光角膜屈光手术（PRK）、上皮下准分子激光角膜磨镶术（Epi—LASIK）、准分子激光角膜表层磨镶术（LASEK）、准分子激光原位角膜磨镶术（LASIK）、治疗性角膜屈光手术（PTK）以及联合手术等。治疗效果：所有患者达到预期最佳矫正视力,其中超过预期矫正视力2行以上者为51．1％（24眼）,超过3行以上者为23．4％（11眼）。预期性：实际矫正度在预期矫正度±0．5D之间者45眼。患者对手术效果满意,随访2     

激光原位角膜磨削术在青光眼患者中的应用

激光原位角膜磨削术是否可以应用到青光眼患者是一个重要临床问题,屈光手术所造成角膜厚度和角膜曲度的改变可影响眼压的测量从而影响青光眼的诊断和治疗;在手术过程中一过性但极高的眼压可能引起视网膜神经纤维损害或视网膜中央动脉阻塞,青光眼患者或皮质类固醇敏感者屈光手术后常规应用激素类眼药水可能出现激素诱导性眼压升高。虽然如此,激光原位角膜磨削术并非青光眼手术的绝对禁忌证。本文就激光原位角膜磨削术在青光眼患者中应用的安全性以及影响作出综述。     

准分子激光术治疗非常态角膜病例的屈光不正

目的　探讨准分子激光治疗眼外伤、角膜瘢痕和眼部手术后屈光不正的疗效。方法　眼外伤、角膜瘢痕和眼部手术屈光不正 16例 17眼。术前裸眼视力 0 .0 5～ 0 .2 5 ,平均 0 .11± 0 .0 7。最佳矫正视力 0 .2～ 1.5 ,平均 0 .84± 0 .45。 12例 13眼行准分子激光上皮下角膜磨镶术 (Lasek) ,4例 4眼行准分子激光原位角膜磨镶术 (Lasik)。随访 3～ 12月 ,平均 9月。结果　术后裸眼视力 0 .2～ 1.5 ,平均 0 .77± 0 .3 8。术后裸眼视力较术前明显提高 ,差异有显著性意义 (t=-7.5 16,P <0 .0 5 )。术后裸眼视力与术前矫正视力相比差异无显著性意义 (t=1.689,P >0 .0 5 )。无眼压升高、haze、角膜裂开等并发症。结论　准分子激光术是矫治眼外伤、角膜瘢痕和眼部手术后非常态眼屈光不正的一种可行的方法。     

The corneal thickness and intraocular pressure story: where are we now?

A review of the current literature was conducted regarding the effect of corneal thickness on the diagnosis of glaucoma, and the influence of excimer laser refractive surgery on intraocular pressure (IOP) measurement with Goldmann applanation tonometry. In general, normals and primary open angle glaucoma patients have a similar distribution of corneal thickness; however, there is a wide variation, ranging from 427 to 716 micro m. Normal tension glaucoma patients have a tendency towards thinner corneas than normals; however, there is an overlap of thickness measurements of more than two-thirds in 95% of patients. There is a trend for ocular hypertensives to have thicker corneas than normals, but again there is an overlap of about one-third in 95% of patients. The general trend after excimer laser refractive surgery is for a decrease in IOP, with a mean fall in IOP measured of 0.63 mmHg per dioptre correction. There is, however, a large scatter of values with some patients having the same or lower IOP post-laser, but with other patients measuring higher pressures. Corneal thickness can influence IOP measurement by Goldmann applanation tonometry; however, the magnitude of the effect is subject to much individual variation.     

Laser refractive surgery in glaucoma patients

Glaucoma may not be an absolute contraindication to Laser-Assisted in situ Keratomileusis (LASIK), but so far it is a relative one. People who are glaucoma suspects or who have glaucoma are just as likely as any other to seek laser refractive surgery. LASIK is a popular ocular procedure, relatively pain free and it is carried out with an extremely precise computer-controlled excimer laser emission. On the other hand, glaucoma is a group of diseases manifested by optic nerve damage with visual field changes. Patients that undergo a transient but significant rise in intraocular pressure during LASIK procedure have risk of further optic nerve damage. Furthermore, steroids which are typically used after refractive surgery can increase intraocular pressure (IOP) especially in steroid responders, who are more prevalent among glaucoma patient. Glaucoma patients interested in LASIK surgery may visit a glaucoma specialist or another LASIK surgeon who has had experience with performing LASIK in glaucoma patients. PRK (photorefractive keratectomy), LASEK (laser epithelial keratomileusis) are good alternatives for glaucoma patients. Refractive surgeons might want to consider giving patients a photo of their optic nerve, or a drawing, or an objective record of their preoperative examination.     

Prospective, long-term evaluation of steroid-induced glaucoma

PURPOSE: To evaluate the intraocular pressure (IOP) after cessation of steroid use in steroid-induced glaucoma and its control with medication or surgery. METHODS: Thirty-four eyes of 34 patients having steroid-induced glaucoma were prospectively evaluated after cessation of steroid for IOP, visual acuity, and optic disc status at 3 months, and every 3 months for 18 months. RESULTS: Topical steroid use (73.5%) was the most frequent cause for glaucoma. The baseline IOP was 35.47+/-12.59 mmHg. The baseline vertical cup-disc ratio correlated with duration of steroid use (P=0.014) and the baseline IOP (P<0.0001). In 25 patients (73.5%), IOP could be controlled by topical medications alone, whereas nine patients (26.5%) required surgery. The mean baseline IOP in eyes requiring surgery was 49.67+/-13.28 mmHg and in eyes managed medically, 30.36+/-7.51 mmHg (P=0.002). The vertical cup-disc ratio in surgically treated patient was 0.87+/-0.13:1 as compared to 0.71+/-0.15:1 (P=0.012) in the medically treated group. At 6, 12, and 18 months follow-up, 22 (64.7%), 33 (97.1%), and all 34 (100%) patients were off treatment, respectively. CONCLUSIONS: Patients with steroid-induced glaucoma, who were 相似文献   

Surgical treatment of open-angle glaucoma

The influence of intraocular pressure (IOP) on the visual field of glaucoma patients is discussed; the criterion level for postoperative IOP control was set at 20 mmHg. When the IOP exceeded this level for two consecutive months, the IOP control was judged to be a failure, and the surgical results were analysed by a life-table method. Argon laser trabeculoplasty (ALT) with 50 shots over 180 degrees of the angle was used routinely, because of fewer complications than with 360 degrees ALT. A second session sometimes improved the final success rate, which was about 57% in primary open-angle glaucoma and 94% in capsular glaucoma after a follow-up period of two years and two months. All patients (120 eyes) required drugs, but their use could be reduced in about 35%. The IOP distribution in successful cases showed a peak at 16 to 17 mmHg, and the IOP was 15 mmHg or less in 21%. In trabeculectomy, pretreatment with topical indomethacin and steroid drip infusion was advocated, and concentrated sodium hyaluronate was used during surgery. These procedures reduced the incidence of shallow anterior chamber and associated choroidal detachment. The final success rate was about 60% after five years of follow-up. The IOP distribution after more than two years peaked at 13 to 15 mmHg, and the IOP was 15 mmHg or less in 53%.     

SURGICAL TREATMENT OF OPEN-ANGLE GLAUCOMA

The influence of intraocular pressure (IOP) on the visual field of glaucoma patients is discussed; the criterion level for postoperative IOP control was set at 20 mmHg. When the IOP exceeded this level for two consecutive months, the IOP control was judged to be a failure, and the surgical results were analysed by a life-table method.
Argon laser trabeculoplasty (AL T) with 50 shots over 180° of the angle was used routinely, because of fewer complications than with 360° ALT. A second session sometimes improved the final success rate, which was about 57% in primary open-angle glaucoma and 94% in capsular glaucoma after a follow-up period of two years and two months. All patients (120 eyes) required drugs, but their use could be reduced in about 35%. The IOP distribution in successful cases showed a peak at 16 to 17 mmHg, and the IOP was 15 mmHg or less in 21%.
In trabeculectomy, pretreatment with topical indomethacin and steroid drip infusion was advocated, and concentrated sodium hyaluronate was used during surgery. These procedures reduced the incidence of shallow anterior chamber and associated choroidal detachment. The final success rate was about 60% after five years of follow-up. The IOP distribution after more than two years peaked at 13 to 15 mmHg, and the IOP was 15 mmHg or less in 53%.     

玻璃体切割术后持续性继发性青光眼的临床分析

目的:探讨玻璃体切割术后持续性继发性青光眼的可能原因及其治疗方法。方法:回顾性分析2004-01/2010-01在我院行玻璃体切割术后出现持续性继发性青光眼的患者20例20眼,对患者进行眼压监测,行房角镜,超声生物显微镜检查,确定继发性青光眼的原因,并根据不同的原因相应地给予药物或手术治疗,观察治疗后眼压、视力等变化。结果:玻璃体切割术后持续性继发性青光眼患者20例20眼,高眼压发生的时间为玻璃体切割术后2wk～3mo,眼压均在30～50mmHg之间,房角镜及超声生物显微镜示房角关闭15例15眼,房角开放5例5眼;继发性青光眼发生的原因可能为:局部应用皮质类固醇时间过长引起的青光眼3例3眼,新生血管性青光眼4例4眼,术后炎性物质堵塞房角8例8眼,术后前房积血,玻璃体积血堵塞房角3例3眼,另2例原因不明。结论:玻璃体切割术后继发性持续性青光眼引起的原因包括局部应用皮质类固醇时间过长,患者新生血管形成,术后炎性物质或者出血堵塞房角,其治疗方法应根据不同的原因相应地治疗:停用皮质类固醇;810激光睫状体光凝术;小梁切除术或引流阀植入术等。     

Refractive error and glaucoma.

PURPOSE: To study the association between refractive error, glaucoma damage and IOP in a large population. METHODS: We examined 32,918 citizens of the city of Malm?, Sweden, 57-79 years of age, searching for individuals with undetected glaucoma. Refraction was measured with autorefractors. Glaucoma damage was defined as reproducible visual field defects with the Humphrey Full Threshold 24-2 program. RESULTS: Glaucoma prevalence was clearly associated with refractive state, increasing gradually with increasing myopia. This was seen both in males and females and persisted over the full age range. Glaucoma was significantly more common in myopic than in hyperopic eyes with low IOP readings (p=0.024). The overrepresentation of glaucoma in myopic eyes declined with increasing IOP and no relationship was observed in eyes with IOP > or =31 mmHg. CONCLUSION: In this large population, the prevalence of glaucoma increased with increasing myopia. The association between myopia and glaucoma was strong at lower IOP levels, and weakened gradually with increasing IOP. Our findings indicate that myopia is an important risk factor for glaucoma and particularly for normal tension glaucoma.     

Steroid-induced iatrogenic glaucoma

Steroids in susceptible individuals can cause a clinical condition similar to primary open-angle glaucoma. Five percent of the population are high steroid responders and develop an intraocular pressure (IOP) elevation of more than 15 mm Hg above baseline. IOP elevation may occur as early as 1 day to as late as 12 weeks after intravitreal triamcinolone in 20-65% of patients. On average, 75% of eyes with steroid implants require IOP-lowering therapy at some point within 3 years of follow-up. The exact mechanism of steroid-induced glaucoma is not totally understood, but decreased trabecular meshwork outflow is regarded as the main cause of IOP elevation. High-risk patients who receive steroids should be monitored closely and if they develop elevated IOP, steroids with lower potency or steroid-sparing agents should be used. The IOP usually returns to normal within 2-4 weeks after stopping the steroid. About 1-5% of patients do not respond to medical therapy and need surgery. Trabeculectomy, trabeculotomy, shunt surgery, and cyclodestructive procedures are among the methods employed. Removal of residual sub-Tenon or intravitreal steroids may help hasten the resolution of the steroid response. Early results with anecortave acetate, an analog of cortisol acetate with antiangiogenic activity, in controlling IOP have been promising.     

角膜屈光手术与青光眼(英文)

角膜屈光手术改变了角膜厚度及曲率,影响术后眼压(in-trocular pressure,IOP)的测量,但动态轮廓眼压计(dynamiccontour tonometer ,DCT)不受此影响。激光原位角膜磨镶术(LASIK)中一过性的IOP升高,增加了视神经损害的风险。同时,功能性滤过泡的存在,影响屈光手术的选择和效果,甚至可能成为手术的禁忌。术后患者使用激素点眼,还可能导致激素性青光眼,故应严密监测术后眼压,并且注意角膜瓣层间积液可能掩盖高眼压。对于已接受屈光手术的青光眼患者,药物治疗方案与其他青光眼患者基本相同。本文就角膜屈光手术对眼压测量、青光眼相关特殊检查的影响、屈光手术并发症及其治疗、手术安全性等问题进行了详细综述。