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。     

圆锥角膜行角膜胶原交联联合不规则角膜激光切削术的思考

如今圆锥角膜的诊疗理念不断更新,人们不仅关注于如何延缓圆锥角膜进展,也在努力提高患者的视觉质量。随着准分子激光和飞秒激光技术在眼科的应用,角膜胶原交联术联合不规则角膜准分子激光切削术的治疗方案已成为圆锥角膜治疗的新策略。然而已逐渐变薄的圆锥角膜患眼是否可再进一步行准分子激光切削、该方案两种手术同期和分期执行孰优孰劣等关...     

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。     

迎接角膜移植手术发展的新阶段

穿透性角膜移植已经不是角膜手术的唯一标准和手段,成分移植的理念带来了手术方式的新突破,由此涌现出的深板层移植、内皮移植等显著降低了术后的排斥反应等并发症,提高了视觉质量和供体角膜的利用度。飞秒激光的应用将角膜移植手术带入了屈光手术时代。角膜胶原交联技术的出现,丰富了医生的治疗手段,使圆锥角膜等角膜疾病大幅度摆脱了对角膜移植手术的依赖。这一系列进步使角膜移植手术进入了精准医疗的范畴。     

飞秒激光辅助深板层角膜移植术治疗圆锥角膜的临床观察

目的 观察飞秒激光辅助完成深板层角膜移植术治疗圆锥角膜的临床效果.方法 对5例（5眼）圆锥角膜患者施行飞秒激光辅助完成的深板层角膜移植术进行随访观察.术后6个月后观察其最佳矫正视力,角膜最薄点厚度,中央区角膜内皮细胞密度的变化情况.结果 术后视力均有明显提高,角膜最薄点的厚度较术前明显增加,中央区角膜内皮细胞的密度变化不大.结论 飞秒激光可以有效帮助深板层角膜移植术的实施.     

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。     

圆锥角膜的治疗

圆锥角膜是一种病因不明的双侧进行性角膜病变,以角膜前凸产生不规则散光为特征,常伴有不同程度的视力损伤,多发生于女性.圆锥角膜的治疗可根据病情进展的不同阶段采取不同方法,早期可用框架眼镜、角膜接触镜,晚期则采取角膜移植术来改善视功能.常用手术方法有穿透性角膜移植术、深板层角膜移植术、激光角膜切削术、表面角膜镜片术等.近年来新型治疗方法如紫外光-核黄素交联疗法、角膜基质内环植入术、增视性虹膜切除术等也开始广泛应用.本文就其目前治疗方法综述如下.     

紫外光A核黄素介导角膜交联治疗感染性角膜炎

角膜胶原交联（CXL）技术是一种治疗圆锥角膜、准分子激光术后角膜扩张、难治性角膜溃疡、角膜炎等角膜疾病的有效方法。它通过紫外光A和感光剂核黄素,介导角膜基质内胶原纤维相互交联而提高角膜机械硬度和角膜基质的生物力学稳定性,从而阻止圆锥角膜等角膜扩张性疾病和难治性角膜炎等的发展。本文就紫外光A核黄素介导角膜交联术治疗感染性角膜炎的基本原理、实验和临床研究现状及其相关安全性等问题进行综述。     

圆锥角膜治疗进展

圆锥角膜是一种以角膜扩张为特征,病因不明的双侧进行性角膜病变。角膜接触镜是轻中度圆锥角膜最常用的矫正方法。角膜表层镜片术、深板层角膜移植术、角膜基质环植入术、角膜交联疗法及穿透性角膜移植术是临床上常用的手术治疗方法。     

角膜胶原交联治疗激光角膜原位磨镶术后继发圆锥角膜二例

笔者应用核黄素紫外线角膜胶原交联疗法治疗两例准分子激光原位角膜磨镶术(laser in situ keratomileusis,LASIK)后继发圆锥角膜患者,报告如下.     

圆锥角膜的治疗进展

本文通过对圆锥角膜治疗方法的综述,为临床医生选择合适的治疗方法做出参考。通过数据库对“圆锥角膜”“隐形眼镜”“角膜胶原交联”“Intacs(角膜环)”“角膜成形术”“基因治疗”“不规则散光”等关键词进行搜索,并根据相关文献对圆锥角膜的治疗方法进行综述。眼镜和隐形眼镜可用于圆锥角膜早期,而疾病晚期时可采用前弹力层移植术、穿透性角膜成形术(PK)和深层前板层角膜成形术(DALK)、传导性角膜成形术和基因治疗。此外,角膜胶原交联可以阻止圆锥角膜进展,角膜基质环植入术(ICRS)通过使变形角膜变平,减少屈光不正以达到治疗目的。总得来说,眼科诊断技术和治疗方法的发展可以减缓圆锥角膜进展,从而减少晚期角膜圆锥患者对角膜移植的需要。选择恰当的圆锥角膜治疗方案可以帮助患者改善视力和预防失明。     

Current surgical options for keratoconus

The treatment of keratoconus is partly dependent on the severity of the disease process. When contact lenses fail because the patient is intolerant or they do not provide sufficient acuity to meet the patient's needs, penetrating keratoplasty is the usual surgical modality for adequate visual rehabilitation. Keratoconus is considered a contraindication to incisional refractive surgery such as radial keratotomy and laser in situ keratomileusis because of the corneal instability conferred by these procedures. When the cornea is transparent, intrastromal corneal ring implantation is a refractive modality that may improve visual function and, in select keratoconus patients, obviate the need for corneal transplantation.     

New techniques in lamellar keratoplasty

In the past years, several lamellar keratoplasty surgical techniques have been developed, modified or improved in the past years, including microkeratome assisted anterior and posterior lamellar keratoplasty, anterior lamellar keratoplasty using air-dissection or visco-dissection, sutureless posterior lamellar keratoplasty, LASIK for postkeratoplasty astigmatism, and excimer laser assisted keratophakia for keratoconus or to manage complications after LASIK. These procedures may continue to gain interest as alternative procedures for a penetrating keratoplasty in the treatment of various corneal disorders.     

Postkeratoplasty keratoconus in a nonkeratoconus patient

PURPOSE: To determine whether postkeratoplasty keratoconus is caused by a recurrence of the host disease or transferred from the donor. METHODS: Penetrating keratoplasty was performed on the right eye of a 73-year-old woman with pseudophakic bullous keratopathy; her other eye was normal. After keratoplasty, visual acuity decreased secondary to the appearance of irregular astigmatism, central corneal thinning, and stromal striae in the graft. A repeat keratoplasty was performed. Clinical corneal topographic analysis and histopathologic studies were performed. RESULTS: Clinical findings and histopathology of the corneal graft were consistent with keratoconus. The second graft has remained clear for 2 years without signs of keratoconus. CONCLUSION: Classic keratoconus developed in a corneal graft in a patient without preexisting keratoconus. This supports the theory that postkeratoplasty keratoconus may be secondary to transfer of the disease from the donor.     

Recurrent keratoconus 40 years after keratoplasty

Recurrent keratoconus is a corneal dystrophy that degrades the optical function of the corneal graft. Recurrence of keratoconus after keratoplasty has been reported previously in some scattered case reports, but the aetiology is still unclear. This report describes the case of a 74-year-old white woman, who presented recurrent keratoconus 40 years after keratoplasty. Ophthalmological and videokeratographic data are presented. The patient obtained satisfactory vision with soft contact lenses, and recurrent keratoconus remained stable during a 2-year period. Recurrent keratoconus generally has a moderate to severe effect on visual performance, but contact lenses usually optimise visual acuity. In cases in which the visual defect is severe, a second penetrating keratoplasty should be considered.     

角膜内镜片的发展

圆锥角膜是一种易致盲的眼病，且发病率较高，约为1/2000，目前治疗圆锥角膜的方法主要有配戴硬性透氧性角膜接触镜(rigid gas permeable contact lens，RGP)、角膜交联术、角膜移植术等，上述治疗方法费用高、耗时长、疗效不肯定。随着科学技术的发展，角膜内镜片逐渐成为治疗圆锥角膜的一种新技术。角膜内镜片技术尝试在角膜层间植入一定度数的镜片，在治疗圆锥角膜的同时使视力得到最佳恢复。本文就角膜内镜片的研究进展及发展前景进行综述。     

Microkeratome-assisted lamellar keratoplasty for keratoconus: stromal sandwich

PURPOSE: To evaluate microkeratome-assisted lamellar keratoplasty for the treatment of keratoconus when it is not possible to correct the astigmatic ametropia with contact lenses. SETTING: Ophthalmology Department, School of Medicine, Gazi University, Ankara, Turkey. METHODS: This prospective study comprised 9 eyes of 7 keratoconus patients with contact lens intolerance. The donor cornea was prepared with a microkeratome and punched with a 7.25 mm or 7.50 mm trephine. Following the creation of a standard 9.0 mm corneal flap in the host cornea, the donor stromal button was implanted under this corneal flap like a sandwich. Transepithelial photorefractive keratectomy or laser in situ keratomileusis was performed when the corneal topography and refraction stabilized by the end of the sixth postoperative month. Follow-up ranged from 7 to 22 months. RESULTS: All patients gained 5 or more lines (mean 7.2 lines +/- 1.6 [SD]), and no patient lost a line of vision. The mean corneal thickness was 432.7 +/- 36.1 micrometers preoperatively and 578.1 +/- 45.1 micrometers after refractive surgery. CONCLUSION: The early visual results of this surgical technique are promising and seem to be comparable to those with penetrating keratoplasty.     

Excimer laser-assisted anterior lamellar keratoplasty for keratoconus, corneal problems after laser in situ keratomileusis, and corneal stromal opacities

PURPOSE: To evaluate excimer laser-assisted anterior lamellar keratoplasty to augment thin corneas as in keratoconus (<350 microm) and corneal ectasia after laser in situ keratomileusis (LASIK) and to treat anterior stromal opacities. SETTING: Ophthalmology Department, School of Medicine, Gazi University, Ankara, Turkey. METHODS: Thirteen eyes (5 keratoconus, 3 macular dystrophies, 1 post-LASIK ectasia, 1 post-LASIK interstitial keratitis, 3 post-herpetic keratitis sequelae) of 13 patients were included in this prospective study. The treatment group was divided into corneal ectasia and stromal opacity groups. A donor stromal button approximately 350 microm thick received a 100 microm excimer laser ablation on the endothelium. The remaining cornea (epithelium, Bowman's membrane, and stroma) was punched with a 7.5 or 7.7 mm trephine. After transepithelial ablation of the host cornea to 200 mum thickness, the corneal button was sutured with interrupted 10-0 monofilament nylon. Sutures were removed between 3 months and 6 months postoperatively. Preoperative and postoperative simulated keratometric cylinders and corneal thickness values were compared using the Wilcoxon signed rank test. The postoperative spherical equivalent refraction and best spectacle-corrected visual acuity (BSCVA) between the groups were compared using the Mann-Whitney U test. RESULTS: The mean follow-up was 27.6 months +/- 8.3 (SD). All patients gained 2 lines or more of BSCVA, and no patient lost a line. The mean corneal thickness was 381.2 +/- 88.2 microm preoperatively, which significantly increased to 534.9 +/- 96.6 microm postoperatively (P < .05). The mean preoperative simulated keratometric cylinder was 7.44 +/- 7.18 diopters (D); postoperatively, it decreased to 2.61 +/- 1.73 D (P < .05). There was no significant difference in postoperative spherical equivalent refraction or BSCVA between the groups (P > .05). CONCLUSIONS: This technique presents a different modality for the treatment of keratoconus, post-LASIK corneal problems, and other corneal stromal opacities with anterior lamellar keratoplasty. Additional studies with more patients and longer follow-up will help determine the role of this technique as a substitute for penetrating keratoplasty in these patients.