小切口深板层角膜内皮移植的初步临床结果

目的 探讨小切口深板层角膜内皮移植(Deep lamellar posterior endothelial keratoplasty,DLEK)的手术方法、临床效果及手术并发症.方法 无对照的前瞻性临床研究.受体后板层通过5 mm切口从眼内取出,植片折叠后通过该切口移植到受体眼内.术后随访角膜伤口的愈合、角膜厚度、角膜散光、角膜内皮细胞密度和矫正视力.结果 21例大泡性角膜病变的患者中,20例完成DLEK术,19例术后获得透明角膜.3个月时平均角膜厚度(497.4±35.3)μm,平均角膜内皮细胞密度(1540.5±515.7)个/mm2,平均角膜散光(2.7±1.2)D.术后矫正视力较术前均有提高.主要并发症为术中植床的穿破,术后植片脱落及植床、植片间的间隙.结论 小切口深板层角膜内皮移植可有效治疗大泡性角膜病变,初步临床效果满意.(中国眼耳鼻喉科杂志,2006,6354～356)     

玻璃体视网膜手术后角膜内皮细胞的形态学改变

目的：观察不同术式的玻璃体视网膜手术（vitreoretinal surgery,VRS)后角膜内皮细胞的形态学改变。方法：采用Topcon SP9000型非接触型角膜内皮显微镜对66例66眼行玻璃体视网膜手术前，术后1、3个月角膜内皮细胞的4项形态学定量指标（角膜内皮细胞密度，角膜内皮细胞平均面积、内皮细胞面积变异系数，六角形细胞比率）进行观测，结果：VR术未摘除晶状体组，手术前后角膜内皮4项形态学定量指标相比较，差异均无显著性（P＞0．05），晶状体玻璃体视网膜联合手术（lenticular vitreoretinal surgery,LVRS)组术后角膜内皮细胞密度，六角形细胞比率明显降低，平均细胞面积和变异系数明显增大，与术前相比差异有极显著性（P＜0．001）。结论：LVR术损伤角膜内皮，VR术未摘除晶状体，对角膜内皮无显著影响，为减少手术对角膜内皮的损伤，术前检查角膜内皮，选择合适的手术方式，提高手术技巧，积极控制炎症是十分必要的。     

大泡性角膜病变的病因与临床治疗进展

大泡性角膜病变是临床上常见的致盲性角膜病.由于各种原因损害角膜内皮细胞,导致角膜内皮失代偿,不能维持正常的泵功能,产生角膜基质水肿、上皮下水肿,并使角膜上皮形成水泡状隆起.常继发于某些内眼手术、眼外伤、眼内炎症等,治疗比较棘手.目前主要的治疗方法是穿透性角膜移植术.尽管该手术安全有效,能减轻症状,改善视力,但仍受供体角膜缺乏、供体老龄化、术后并发症多等现状的制约.近年来,深板层内皮角膜移植术成为一种新的手术方法,已在临床上进行实践,体外培养角膜内皮细胞进行移植成为当前研究的热点,它将取代传统的穿透性角膜移植术来治疗角膜内皮功能损伤的疾病.本文就大泡性角膜病变的病因与临床治疗进展作一综述.     

外伤性无晶体眼二期人工晶状体植入术后角膜内皮形态及角膜厚度的改变

目的:了解外伤性无晶体眼患者二期人工晶状体植入术对角膜内皮形态及角膜厚度的影响。方法:将2004年12月至2005年5月于中山眼科中心外伤科2组行二期人工晶状体植入术的所有患者纳入本研究,测量患者术前、术后角膜5个方位的角膜内皮细胞形态及角膜厚度,比较术前、术后角膜内皮细胞形态及角膜厚度的变化。结果:纳入研究患者21例,11例行经上方角巩缘植入PMMA人工晶状体植入术,10例在平坦部玻璃体腔内灌注下行经上方角巩缘植入PMMA人工晶状体缝襻固定术。手术前后上方角膜内皮细胞的变异系数增加,而六角形细胞的比例下降;其他位置角膜内皮细胞的变异系数及六角形细胞的比例都没有明显改变。没有眼内灌注及缝襻固定的患者术后一周及一个月复查角膜厚度均同术前无明显差别;而行眼内灌注缝襻固定术的患者术后一周发现角膜明显变厚。结论:角膜穿通伤口附近的角膜容易出现术后持续性水肿。手术操作容易损伤手术切口附近的角膜内皮。人工晶状体手术切口应避免角膜穿通口位置。短时间的眼内灌注会暂时影响角膜内皮细胞的功能而导致角膜水肿。手术中器械损伤是角膜内皮损伤的主要原因。     

无缝线深板层角膜内皮移植术的研究进展

角膜内皮失代偿可严重影响视力,以往多采用的穿透性角膜移植手术(PKP)具有术后高度散光、移植片排斥等并发症,严重限制了术后视力的提高.如果能够单纯地进行后弹力层和内皮细胞层的移植,将减少手术操作所带来的受体角膜损伤并能更好地恢复术后视力.近年来,无缝线深板层角膜内皮移植手术的优点已逐渐获得公认;其中深板层角膜内皮细胞移植手术(DLEK)手术难度较大,限制了其在临床的广泛开展.而通过剥除受体角膜的后弹力层和内皮层来制作植床的角膜内皮移植手术即角膜后弹力层剥除内皮细胞移植手术(DSEK)已经取得了较好的手术效果.本文归纳、分析了DSEK的手术方法、效果及并发症等.     

外伤性无晶体眼二期人工晶体植入术前后角膜内皮的改变

目的了解外伤性无晶体眼患者角膜内皮的分布特点及二期人工晶体植入术对角膜内皮的影响。方法2004年12月至2005年5月于中山眼科中心外伤科2组的所有行二期人工晶体植入术的患者纳入本研究。测量患者术前术后角膜5个方位的角膜内皮细胞密度。比较术前术后角膜内皮细胞的变化。结果21例患者纳入研究,11例行上方角巩膜缘植入PMMA人工晶体,10例行在平坦部玻璃体腔内灌注下经上方角巩膜缘植入PMMA人工晶体缝襻固定术。术前伤口附近及上方角膜比其他位置的角膜的内皮细胞密度分别低417.8个/mm2及141.0个/mm2。二期人工晶体植入术后1周角膜内皮损失约129.2个/mm2,术后1个月比术后1周角膜内皮密度进一步下降。有眼内灌注及缝襻固定比无眼内灌注无缝襻固定的患者术后多丢失的角膜内皮数目大概为124个/mm2。术前角膜内皮细胞密度差异大,手术丢失的角膜内皮细胞的数目与术前角膜内皮细胞密度呈反比。结论多点测量角膜内皮为二期人工晶体植入术提供更客观全面的依据。手术丢失的角膜内皮细胞数目与术前角膜内皮细胞数目呈负相关。人工晶体手术切口应避免角膜穿通口位置。     

角膜板层剥离瓣下烧灼术治疗大泡性角膜病变

白内障术后发生持续性角膜水肿即大疱性角膜病变，是白内障术后比较严重的并发症，根本原因是角膜内皮受损失代偿。超声乳化术、现代囊外术、非超小术、针吸术都可以发生。引起角膜疱性病变的原因很多，如术前已出现角膜内皮病变或细胞密度低下；术中过度损伤角膜内皮；不良眼内灌注液；玻璃体、虹膜或晶体囊膜粘连于手术切口；术中使用高浓度的乙酰胆碱、肾上腺素所致的化学损伤；[第一段]     

超声乳化术对角膜内皮细胞的损伤及预防

随着白内障超声乳化摘出术在国内的逐渐普及,该手术引起的一些并发症也受到临床医生的重视,超声乳化手术对角膜内皮的损伤已有报道,手术造成角膜内皮细胞严重损伤会影响术后视力的恢复。本研究采用较先进的角膜内皮细胞分析仪观察手术前后的角膜内皮细胞的变化,了解手术对角膜内皮的损伤程度,并寻找减少角膜内皮细胞损伤的措施。     

玻璃体视网膜手术方式对角膜内皮的影响

目的探讨玻璃体视网膜手术方式及各种眼内填充物对角膜内皮的影响。方法对１２９例患者（１３６只眼）,其中糖尿病患者４８人（５４只眼）,行单纯玻璃体切割术、玻璃体切割硅油填充术及玻璃体切割六氟化硫（ＳＦ６）注入术,测定了术前、术后２、４、８周、３月及６月的角膜内皮细胞密度。结果在眼压控制良好的情况下,有晶状体眼行玻璃体视网膜手术的手术方式、眼内填充物的选择及糖尿病对角膜内皮细胞密度均无显著影响。结论在眼压控制良好的情况下,无论是糖尿病还是非糖尿病患者有晶状体眼行玻璃体视网膜手术对角膜内皮是较为安全的     

人工晶状体植入术后角膜内皮变化

目的 评价白内障囊外摘出人工晶状体植入术后角膜内皮损伤情况。方法 使用Ｋｏｎａｎ非接触型角膜内皮分析仪观察２８眼白内障囊外摘出人工晶状体植入术前后角膜中央区内皮细胞变化。结果 ２８眼术后１月角膜内皮细胞密度下降２１．７４％、其中１４眼术后３月角膜内皮细胞密度下降１８．１２％，经统计学处理（Ｐ〈０．０１）。细胞形态学表现为代偿性扩大。结论 术前术后角膜内皮细胞测定，对严格掌握手术适应证和评判手术预后     

角膜内皮移植术

角膜内皮移植是一种新的治疗角膜内皮病变的手术方法,主要是采用健康的角膜内皮片替代病变内皮层.该方法因为几乎不改变患者的角膜曲率和屈光状态,损伤小,视力恢复快,近年来在临床上逐渐被推广应用,取得较好愈后效果.该方法是角膜移植手术不断精细化和向屈光性手术转化的具体体现.角膜内皮移植术后良好的屈光效果和可能的低排斥率,使其有望成为角膜内皮病变治疗的重要方式.但是,目前内皮移植手术仍然需要完善,改进植入方法以减少脱片率和内皮细胞损失率,利用飞秒激光等进一步提高屈光效果,以及观察术后免疫排斥率是今后眼科学者的研究重点.     

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.     

Outcomes of keratoplasty in a cohort of Indian patients with xeroderma pigmentosum

Purpose:To evaluate the outcomes of keratoplasty for xeroderma pigmentosum (XP) performed at a tertiary eye care center.Methods:A retrospective review of medical records of those patients who were clinically diagnosed to have XP (54 eyes of 36 patients) and underwent keratoplasty; either deep anterior lamellar keratoplasty (DALK, four eyes), endothelial keratoplasty (EK, eight eyes), or penetrating keratoplasty (PK, 42 eyes) from 1994 to 2018.Results:The median age at surgery was 20.6 years (interquartile range [IQR], 14.6–27.6 years) and 20 (55.6%) were males. Graft failure occurred in 15 eyes (35.7%) in the PK group and two eyes (50%) in the DALK group; none failed in the EK group. The probability of graft survival in the PK group was 97.2% ± 2.7% at 1 year, 74.0% ± 8.0% at 2 years, and 54.8% ± 11.7% at 5 years. In the PK group, 13 eyes needed antiglaucoma medications, 11 eyes developed graft infiltrate, and 13 eyes needed secondary interventions (cataract surgery, excision biopsy, and tarsorrhaphy). In the EK group, three eyes needed secondary interventions (excision biopsy). Median postoperative endothelial cell density at the last follow-up in the PK group was 1214 cells/mm² (IQR, 623–2277 cells/mm²).Conclusion:Despite the complexities of the ocular surface and adnexal issues in XP, keratoplasty had reasonably good outcomes. More than half of the PK grafts survived 5 years with no failures in the EK group. Regular follow-up and timely management of suture-related infections raised intraocular pressure, and suspicious ocular surface lesions, in addition to solar protection, are important for the success of keratoplasty in these eyes.     

Donor descemet membrane detachment after endothelial keratoplasty

PURPOSE: To describe histopathologic characteristics of an endothelial keratoplasty (EK) that was performed to treat a previously failed penetrating keratoplasty (PK) and in which the cornea failed to clear after partial detachment of Descemet membrane from the EK donor button. The Descemet membrane and endothelium from the PK were intentionally retained during the EK procedure. METHODS: After EK, the cornea failed to fully clear in 5 months, and a PK was performed. The removed corneal button was grossly described and routinely processed for hematoxylin-eosin (H&E) and periodic acid-Schiff (PAS) staining, with photographs taken of any pertinent findings. RESULTS: Grossly on the endothelial side, there was some adherent iris pigment delineating an off-center fold in the EK Descemet membrane, consistent with intraoperative observation of a fold across the width of the donor button and postoperative slit-lamp images showing partial detachment of Descemet membrane. Microscopic examination revealed a recipient corneal button from a prior PK centrally and EK donor button attached posteriorly. Descemet membrane was not stripped from the prior PK during EK and was intact. No endothelial cells were detected on the PK Descemet membrane. The anterior stromal surface of the EK was well apposed to the prior PK Descemet membrane, with no pseudoanterior chamber or cleft of any type noted between them. The EK Descemet membrane had a central fold, and the endothelium was markedly attenuated. CONCLUSION: The EK graft was well apposed with apparent good adherence to the recipient's prior failed PK, and early endothelial failure was attributable to partial Descemet membrane detachment.     

自动角膜板层刀切割一个供体角膜用于两位患者

目的评估应用自动角膜板层刀切割一个供体角膜用于深板层角膜移植和角膜内皮移植的临床疗效及安全性。方法回顾性系列病例研究。应用自动角膜板层刀预先将新鲜供体角膜进行切割,将带部分基质的角膜内皮植片用于角膜内皮移植术,剩余前板层用于深板层角膜移植术。回顾性分析2010年3—8月期间在温州医学院附属眼视光医院行角膜内皮移植术的17例患者及分别来自同一供体角膜的行深板层角膜移植的17例患者。术后随访19～24个月,分别观察角膜内皮贴附情况及前板层角膜植片愈合情况。随访资料包括医学验光、前节光学相干断层扫描及角膜内皮细胞计数。手术前后视力比较采用配对t检验。结果17例角膜内皮移植患者术后角膜内皮植片均贴附良好,术后视力较术前均有提高。除1例碱烧伤患者因晶状体混浊,无法验光外,其余术后平均散光为（1．69±0．60）D。17例角膜内皮移植患者平均角膜内皮细胞计数为（2128±244）个／mm^2,平均角膜内皮植片厚度为（152±46）μm。17例前板层角膜移植患者角膜植片均透明,术后最佳矫正视力较术前提高,平均散光为（2．50±0．90）D;平均前板层角膜植片厚度为（343±39）μm。结论利用角膜板层刀将一个供体角膜用于两位患者的方法在临床实际应用中切实可行。经长期随访,角膜植片未出现明显并发症。该方法可以更充分地利用供体角膜,缓解中国供体角膜匮乏现状,意义重大。     

前房冲洗在严重前房积脓性角膜溃疡的角膜移植术中应用

目的 探讨感染性角膜溃疡伴有大量前房积脓患者于角膜移植术前行前房冲洗的临床意义.方法 回顾性系列病例研究.2008年1月至2009年6月于山东省眼科医院接受手术的角膜溃疡伴有严重前房积脓的患者20例(20只眼),前房积脓均超过3 mm,其中13例患者伴有明显的角膜内皮斑,术前裂隙灯显微镜下病灶边缘难于判断.对20例患者采用前房穿刺冲洗联合穿透或板层角膜移植手术治疗.供体采用角膜中期保存液保存或甘油干燥冷冻保存.对术中与术后并发症、视力、免疫排斥反应等进行观察,随访时间术后6～12个月.结果 20例患者均成功行前房穿刺冲洗联合角膜移植手术,其中11只眼行穿透性角膜移植,9只眼行板层角膜移植.10例接受穿透性角膜移植的患者采用角膜中期保存液保存的供体角膜,其余10例患者采用甘油脱水冷冻保存的供体角膜.术中并发症主要为虹膜出血(11例),术后并发症主要包括部分虹膜后粘连(8例)、一过性眼压高(4例)、前房积血(5例),药物治疗均缓解.真菌复发1例,行扩大病灶切除再次穿透性角膜移植手术后感染控制.4例患者发生内皮型免疫排斥反应,3例抗排斥治疗后控制,1例发生植片混浊.至2009年12月最后随访,9例接受角膜中期保存液保存角膜供体患者的植片透明,1例植片水肿混浊;8例接受甘油脱水冷冻保存角膜供体患者的植片透明,2例植片水肿.结论 常规角膜移植前行前房穿刺冲洗,对严重前房积脓性角膜溃疡病灶边缘的判断和手术方式选择具有重要意义,可以提高手术的安全性.     

Corneal transplant rejection rate and severity after endothelial keratoplasty

PURPOSE: To examine the corneal transplant rejection rate and the rate of graft failure subsequent to rejection in the first 2 years after endothelial keratoplasty (EK) and to compare this to background data for similar cases of penetrating keratoplasty (PK). METHODS: Anonymized data from consecutive cases of EK [deep lamellar (DLEK) or Descemet stripping (DSEK)] for Fuchs corneal endothelial dystrophy or pseudophakic bullous keratopathy operated on before August 2004 were collected in 4 participating centers. The number and timing of rejection episodes and cases of subsequent graft failure were recorded, together with the time to cessation of topical steroid medication. Two-year postoperative findings were compared with background data for similar patients undergoing PK recorded in the Swedish Corneal Transplant Registry. RESULTS: Rejection episodes were less frequent after EK than PK (P = 0.035). Fifteen (7.5%) of 199 EK cases had a rejection episode in the first 2 years after surgery versus 92 (13%) of 708 PK cases. Graft failure after rejection in EK may have been less frequent than in PK (P = 0.063), with only 1 (6.7%) case of rejection after EK versus 26 (28.3%) cases of rejection after PK proceeding to graft failure. A strong trend toward continued use of low-dose topical steroid medication was observed in the EK group. Eighty percent of EK patients were still taking topical steroid medication 2 years after surgery, whereas topical steroid medication had been ceased within a year of surgery in almost all PK patients in the comparator group. CONCLUSIONS: Corneal transplant rejection is less frequent and may be less severe after EK than after PK. It is not yet clear whether these apparent differences are simply a product of relatively prolonged postoperative topical steroid cover in EK patients.     

组织工程角膜研究和应用进展

中国角膜供体材料的严重缺乏导致众多的角膜盲患者不能通过角膜移植来复明仍是临床棘手的问题。近年来,细胞生物学、组织工程学和材料学的发展为替代人角膜材料开辟了更广阔的前景;而且以深板层移植和内皮移植为代表的成分板层移植的推陈出新从临床技术上有力地推动了组织工程角膜的研发。现就脱细胞角膜基质板层材料、上皮细胞和内皮细胞组织工程的基础研究和临床应用进展进行述评。     

角膜深板层内皮移植术的临床初步研究

目的　探讨用微型角膜刀行角膜深板层内皮移植术的适应证、手术原则、临床疗效及并发症的预防及处理。方法　用微型角膜刀对 6例患者 6只患有大疱性角膜病变眼行深板层角膜内皮移植术。其中 1例为前段玻璃体切除加后房型人工晶状体缝线固定术联合角膜深板层内皮移植术 ,1例为临时人工角膜下玻璃体切除加球内异物取出术联合角膜深板层内皮移植术。术后随访 6～ 9个月。结果　 5例患者视力明显提高 ,患者术后平均角膜内皮细胞密度为 (2 4 81± 2 12 )个 /mm2 ,角膜中央厚度平均为 (5 4 9± 6 1) μm ,散光为 (2 0 4± 1 19)D ,未发生严重并发症。 结论　用微型角膜刀行角膜深板层内皮移植术是治疗大疱性角膜病变的可选术式。与传统的穿透性角膜移植相比 ,该术式有望成为角膜内皮移植的技术平台 ,但远期疗效尚需继续随访。     

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.