小梁切除术对角膜内皮细胞影响的研究

目的探讨小梁切除术对角膜内皮细胞的影响。方法对29例（37眼）青光眼行小梁切除术。分别于术前和术后3月内进行角膜内皮照相并分析其形态和定量指标。结果角膜内皮细胞密度、平均细胞面积、六角形细胞所占比例及变异系数4种指标术前术后差异无统计学意义（P〉0．05）。小梁切除术后正常前房和Ⅰ、Ⅱ度浅前房者，术前术后中央角膜内皮细胞密度差异无统计学意义（P〉0．05）。Ⅱ度浅前房中央内皮细胞丢失率为69．11％。结论正常过程小梁切除术对角膜内皮细胞影响不显著，小梁切除术后浅前房是角膜内皮细胞丢失的主要因素，尤其是Ⅲ度浅前房。     

Corneal Endothelial Changes in Primary Acute Angle-closure Glaucoma

In 20 patients, corneal endothelium was examined by specular microscopy after acute angle-closure glaucoma, and before any surgical treatment in order to assess possible damage during pressure induced abnormal hydration of the cornea. The mean intraocular pressure was elevated to 55 mm Hg and had lasted, on an average, 47 (5–192) hours. The mean endothelial cell density in the affected eye was 1534 and in the nonaffected fellow eye 2243 cells/mm² (mean decrease 33%, P = 0.002). The amount of cell loss correlates with the duration of the intraocular pressure increase. Thirty-five percent of these patients presented a bilateral cornea guttata. This high incidence of endothelial dystrophy was confirmed in a retrospective specular microscopic study in 20 patients with a history of unilateral acute angle-closure glaucoma. The decreased number of endothelial cells after acute angle-closure glaucoma frequently combined with bilateral cornea guttata, accounts for the corneal degeneration in these patients following a later cataract extraction.     

The effect of liquid silicone on the corneal endothelium in rabbits

Specular microscopic and histopathologic findings in the corneal endothelium were compared after the injection of liquid silicone into the anterior chamber of both eyes in 15 rabbits. The findings demonstrated serious damage to the endothelium in the area of contact of liquid silicone with the posterior surface of the cornea and disclosed some problems in the interpretation of specular microscopic findings. An abnormal endothelial mosaic can be probably found even in a zone of preserved intercellular borders or in a zone with a relief of the bases of extinct endothelial cells.     

小梁切除术中应用玻璃酸钠的临床研究

目的:研究透明质酸钠在青光眼小梁切除术中的临床效果.方法:将46例青光眼患者随机分为观察组(23眼)和对照组(23眼).观察组在小梁切除术中应用0.4g/L的MMC棉片,缝合结膜瓣前在巩膜瓣下及前房内注入少量玻璃酸钠.对照组仅应用MMC,而不用玻璃酸钠.术后观察前房形成、眼压、角膜内皮损伤、滤过泡形成情况等.结果:术后1d观察组眼压高于对照组,差异有统计学意义(P<0.05);术后3d,1、6mo两组患者眼压比较差异无统计学意义(P>0.05);术后3d,观察组视力下降2眼(9%),对照组8眼(35%),差异有统计学意义(P=0.035),术后6mo,观察组视力下降0眼(0),对照组5眼(22%),差异有统计学意义(P=0.025);术后7 d观察组与对照组的浅前房发生情况、术后6 mo的滤过泡形成情况、角膜内皮细胞计数等项比较,两组差异均有统计学意义(P<0.05),观察组结果优于对照组,术后并发症观察组少于对照组.结论:在青光眼小梁切除术中联合应用玻璃酸钠,可以增加手术安全性,有效预防早期浅前房、晚期滤过泡瘢痕化的发生.     

Clinical and specular microscopic manifestations of iridocorneal endothelial syndrome

PURPOSE: To investigate the correlation between the clinical pictures and the specular microscopic findings in patients with iridocorneal endothelial (ICE) syndrome. METHODS: The records of 15 patients with ICE syndrome who presented at the National Taiwan University Hospital between 1993 and 1996 were examined. The medical history, clinical pictures of the cornea, iris and anterior chamber angle, intraocular pressure, specular microscopic findings, and the correlation between clinical and specular microscopic findings were assessed. RESULTS: Endothelial changes in specular micrographs were found in all the patients, even in those patients with minimal angle involvement by peripheral anterior synechiae. Corneal decompensation resulting in corneal edema and bullae formation was the main cause of visual impairment. Neither ICE grading nor endothelial cell density correlated with corneal edema or intraocular pressure, but they correlated with the angle involvement in ICE syndrome. The intraocular pressure was difficult to control in 8 of these patients, even after treatment with anti-glaucoma agents and trabeculectomy, especially in the patients with Cogan-Reese syndrome. CONCLUSION: Although specular microscopy provides an invaluable method for the diagnosis of ICE syndrome, it is not a reliable tool for predicting prognosis. Close follow-up of intraocular pressure and early detection of glaucoma are important steps to preserve visual functions in patients with ICE syndrome.     

Clinical and specular micrographic findings in corneal guttata and Fuchs' corneal endothelial dystrophy

Focal excrescenses of altered basement membrane material, known as corneal guttata, are a common occurrence in the elderly. A small proportion of those who develop this condition exhibit signs of corneal endothelial dysfunction and progress to Fuchs' corneal endothelial dystrophy. The relationship between the distribution and relative density of guttata and the morphological appearance of the corneal endothelium is as yet poorly understood. In this study, 40 eyes of 20 caucasian patients (5 male and 15 female) identified as having central corneal endothelial guttata were examined (mean age 76 years). Ten eyes noted as having a previous history of ocular trauma, surgery or anterior segment inflammation were excluded from the study. Clinical and specular micrographic findings are compared. Clinical examination confirmed that guttata were most densely distributed in the central cornea. Examination of all four mid-peripheral quadrants identified the superior cornea as being least severely affected in the majority of cases. In 26 of the 30 eyes examined there was evidence of pigmentary dusting of the corneal endothelium. The severity of guttata did not appear to correlate with the density or distribution of the pigment. In cases of moderate to advanced disease, where guttata had become confluent and thus obscured the view of the corneal endothelium, the clinical differentiation of pigment, guttata and diffuse scarring became difficult. Specular microscopy confirmed the accuracy of the clinical five-point scale used to quantify the distribution and density of guttata in the study. Quantitative analysis of corneal endothelial cells from the mid-peripheral cornea indicated that the severity of guttata did not necessarily correlate with a reduced cell count. Central cell counts proved elusive as reflections from the irregular surface created by confluent guttata failed to produce specular images of the underlying endothelium. The authors conclude that the specular microscope is a useful diagnostic tool in the differentiation of guttata from other abnormalities of the endothelium and Descemet's membrane. Specular micrographic imaging also enables the examiner to quantify the distribution and density of guttata. The relationship between the severity of corneal guttata, endothelial cell counts and pigmentation is not well defined and further study of the progression of the disease process is required.     

小梁切除术对角膜内皮细胞的影响

目的探讨滤过手术对角膜内皮细胞的影响及其原因。方法检查64只接受小梁切除的原发性青光眼，手术前、后的角膜内皮细胞数量及术后前房深度的变化和炎症反应情况。结果术后64只眼角膜内皮细胞数均比术前减少，差异有显著性（t＝2．508，P＜0．05）；术后前房越浅，内皮细胞损失率越大，相关分析表明，两者间存在着一定的相关关系，（r＝0．7587，t＝9．170，P＜0．01）；炎症反应重的眼比炎症反应轻的眼内皮细胞损失率高。结论提高手术质量，减少术后浅前房和炎症反应的发生或缩短其存在的时间，可降低术后内皮细胞的损失率。     

Confocal microscopy in cornea guttata and Fuchs'' endothelial dystrophy

AIMS: To report the appearances of cornea guttata and Fuchs' endothelial dystrophy from white light confocal microscopy. METHODS: Seven eyes of four consecutive patients with cornea guttata were prospectively examined. Of the seven eyes, three also had corneal oedema (Fuchs' dystrophy). In vivo white light tandem scanning confocal microscopy was performed in all eyes. Results were compared with non-contact specular microscopy. RESULTS: Specular microscopy was precluded by corneal oedema in one eye. In the remaining six eyes, it demonstrated typical changes including pleomorphism, polymegathism, and the presence of guttae appearing as dark bodies, some with a central bright reflex. In all seven eyes, confocal microscopy revealed the presence of round hyporeflective images with an occasional central highlight at the level of the endothelium. Changes in cell morphology and size were readily appreciated. CONCLUSION: By comparison with specular microscopy, the hyporeflective images with an occasional central highlight seen on confocal microscopy are consistent with the presence of guttae. Confocal microscopy may confirm the diagnosis of cornea guttata and Fuchs' endothelial dystrophy by demonstrating the presence of guttae. This technique is especially valuable in cases of corneal oedema, where specular microscopy may fail to visualise the endothelium. However, specular microscopy should remain the method of choice to evaluate the endothelium, principally because it is easier to use.     

Specular and scanning electron microscopy in diffuse silicone keratopathy

In a 50-year-old man, penetrating keratoplasty was carried out to treat a diffuse silicone keratopathy that developed 2 years after a pars plana vitrectomy combined with an intravitreal silicone injection for a complicated retinal detachment in the only aphakic eye. At 2 weeks after the intravitreal silicone injection, specular microscopy revealed a mild pleomorphism in the corneal endothelium and an endothelial cell loss of 26%. After 5 months, a small silicone drop floated in the anterior chamber and the first signs of diffuse keratopathy were observed. At the same time, specular microscopy revealed severe damage to the endothelial cells and a cell loss of 69%. After the keratoplasty, scanning electron microscopy of the corneal button showed a filamentous structure of the posterior surface of the cornea, with fibroblast-like cells; the endothelial cells were absent.     

Recurrent Annular Peripheral Choroidal Detachment after Trabeculectomy

We report a challenging case of recurrent flat anterior chamber without hypotony after trabeculectomy in a 54-year-old Black male with a remote history of steroid-treated polymyositis, cataract surgery, and uncontrolled open angle glaucoma. The patient presented with a flat chamber on postoperative day 11, but had a normal fundus exam and intraocular pressure (IOP). Flat chamber persisted despite treatment with cycloplegics, steroids, and a Healon injection into the anterior chamber. A transverse B-scan of the peripheral fundus revealed a shallow annular peripheral choroidal detachment. The suprachoroidal fluid was drained. The patient presented 3 days later with a recurrent flat chamber and an annular peripheral choroidal effusion. The fluid was removed and reinforcement of the scleral flap was performed with the resolution of the flat anterior chamber. A large corneal epithelial defect developed after the second drainage. The oral prednisone was tapered quickly and the topical steroid was decreased. One week later, his vision decreased to count fingers with severe corneal stromal edema and Descemet''s membrane folds that improved to 20/50 within 24 h of resumption of the oral steroid and frequent topical steroid. The patient''s visual acuity improved to 20/20 following a slow withdrawal of the oral and topical steroid. Eight months after surgery, the IOP was 15 mm Hg without glaucoma medication. The detection of a shallow anterior choroidal detachment by transverse B-scan is critical to making the correct diagnosis. Severe cornea edema can occur if the steroid is withdrawn too quickly. Thus, steroids should be tapered cautiously in steroid-dependent patients.Key words: Annular peripheral choroidal detachment, Trabeculectomy, Steroid withdrawal, Ultrasonography, Glaucoma     

Corneal endothelial cell changes after trabeculectomy and deep sclerectomy

PURPOSE: To compare the effect of trabeculectomy and deep sclerectomy on the corneal endothelium. METHODS: This prospective comparative study investigated 62 eyes of 62 patients scheduled for a single trabeculectomy (n=18), a single deep sclerectomy (n=14), a combined trabeculectomy and phacoemulsification (n=11), or a combined deep sclerectomy and phacoemulsification (n=19). Exclusion criteria were history of corneal disease, ocular trauma, inflammation, or previous glaucoma or cataract surgery. Preoperative, 3-month and 1-year postoperative noncontact specular microscopies were performed on central and superior corneas. Endothelial cells were counted with a computer-assisted analyzer. RESULTS: In central cornea, a statistically significant postoperative endothelial cell loss was found after trabeculectomy and deep sclerectomy (alone and combined with cataract extraction) at 3 and 12 months. Cell loss was 7% after penetrating surgery and 2.6% after nonpenetrating surgery (noncombined surgeries). This difference in cell loss was statistically significant. Cell loss increased significantly over the course of the study at 12 months (9.6% and 4.5%, respectively). Cell loss was also significantly higher after trabeculectomy than sclerectomy in upper cornea only in noncombined surgeries. No statistically significant difference in coefficient of variation of cell size (CV) and percentage of cell hexagonality (Hex %) was noted. CONCLUSIONS: Endothelial cell loss was moderate 3 and 12 months after glaucoma surgery. However, it was greater after trabeculectomy, suggesting less corneal damage after deep sclerectomy. This observation deserves further clinical study.     

EX-PRESS引流钉植入术对POAG患者角膜内皮细胞及眼压的影响

目的：评价EX-PRESS引流钉植入术对原发性开角型青光眼(POAG)患者角膜内皮细胞及眼压的影响。

方法：前瞻性临床研究。收集2016-05/2017-12在我院行EX-PRESS引流钉植入术的原发性开角型青光眼患者32例38眼,随访至术后24mo,观察中央、鼻侧、颞侧、上方、下方5个方位的角膜内皮细胞密度、眼压及最佳矫正视力情况,并观察前房深度及引流钉与虹膜、角膜的位置情况及手术疗效。

结果：手术前后,本组患者5个方位的角膜内皮细胞密度和最佳矫正视力均无明显变化(P>0.05),但术后各时间点眼压均较术前明显降低(P<0.05)。术后24mo,本组患者手术完全成功率为66%,条件成功率为21%,失败率为13%,手术失败的主要原因为滤过泡包裹。本组患者术中和术后随访期间均未出现前房完全消失; 术后1眼出现浅前房,5眼引流钉与虹膜面相贴,余32眼引流钉均位于虹膜与角膜内皮之间,位置良好。

结论：EX-PRESS引流钉植入术对POAG患者角膜内皮细胞无明显影响,且能有效控制眼压,是治疗原发性开角型青光眼的安全有效的方法。     

Corneal endothelial abnormalities associated with thalidomide toxicity

PURPOSE: To describe bilateral corneal endothelial abnormalities associated with thalidomide toxicity. METHODS: Observational case report. RESULTS: A 30-year-old man, born with bilateral hypoplastic upper limb defects (phocomelia) caused by thalidomide toxicity, presented with bilateral symmetrical corneal endothelial changes resembling guttata without corneal edema. Pachymetry, specular microscopy, and confocal microscopy were performed. Biomicroscopy findings over a 10-year follow-up showed no changes. CONCLUSIONS: Nonprogressive bilateral corneal endothelial changes resembling cornea guttata should possibly be included in the ocular manifestations of thalidomide toxicity. We postulate that thalidomide may have affected the migration and development of the mesenchymal neural crest cells, which are the developmental precursors of the corneal endothelium and stroma.     

青光眼术后浅前房的观察及处理

目的:探讨青光眼滤过术后浅前房的原因及处理方法。方法:回顾性分析298例462眼青光眼行滤过手术后发生浅前房的原因、类型及处理方法。结果:患者298例462眼中,浅前房99眼,浅前房发生率21.4%。小梁切除术358眼,浅前房77眼,发生率21.5%;小梁切除+MMC(丝裂霉素C)85眼,浅前房20眼,发生率23.5%;青光眼联合白内障超声乳化人工晶状体植入术19眼,浅前房2眼,发生率10.53%。浅前房发生的时间多在术后1～5d,其中滤过过强42眼,占42.4%,脉络膜睫状体脱离29眼,占29.3%;结膜瓣渗漏20眼,占20.2%,恶性青光眼6眼,占6.1%,恶性青光眼并睫状体脉络膜脱离2眼,占2.0%。79眼通过保守治疗恢复前房、20眼经手术治疗恢复前房。结论:浅前房的发生主要与术前高眼压、眼部炎症反应以及术后滤过强、结膜瓣渗透、脉络膜脱离有关,大多数浅前房通过保守治疗可治愈,必要时需手术干预。     

Iridocorneal endothelial syndrome with contralateral guttate endothelial dystrophy. A light and electron microscopic study

Both eyes from a 75-year-old woman who had unilateral closed-angle glaucoma, characteristic endothelial specular microscopic findings, and slowly progressive tractional iris abnormalities consistent with essential iris atrophy were obtained postmortem and studied by light, scanning, and transmission electron microscopy. Clinically, the nonglaucomatous right eye had an open-angle, normal iris, and severe endothelial dystrophy with three-plus corneal guttae. In this eye, results of histopathologic examination disclosed marked endothelial degeneration and typical guttate excrescences on Descemet's membrane. In contrast, the endothelium in the fellow eye with the essential iris atrophy variant of the iridocorneal endothelial (ICE) syndrome was strikingly different. The endothelial cells were relatively well preserved and exhibited marked pleomorphism, anisocytosis, and flat, occasionally paired oval nuclei. Binucleate cells also were observed. The endothelial monolayer had secreted a new layer of fibrillar extracellular matrix material on the posterior surface of Descemet's membrane. Extracellular matrix material was found interposed between the iris and cornea in zones of synechial closure, and an endothelial membrane was present on the anterior surface of the iris. These observations support the hypothesis that the iris abnormalities in essential iris atrophy are secondary to endothelial proliferation. The endothelial cells displayed neither tonofilaments nor abundant apical microvilli. The latter observation suggests that increased numbers of endothelial microvilli are not responsible for the characteristic specular microscopic picture seen in the ICE syndrome.     

Cell density of the corneal endothelium following cataract surgery

Endothelial cell loss following extracapsular cataract extraction and implantation of a posterior chamber lens was studied and the influence of various factors analyzed. In 56 eyes, the mean reduction in cell density in the superior zone of the cornea was 19%. In the eyes with epithelial edema endothelial damage was more severe than average. Lower cell density was also found in particular in patients over 75 years old and those with pre-existing cornea guttata. In contrast, preexisting glaucoma, a history of corneal trauma, and, astonishingly, the surgeon's experience had no detectable influence on endothelial cell damage.     

A COMPARISON OF CORNEAL ENDOTHELIAL MORPHOLOGY IN CORNEA GUTTATA, FUCHS' DYSTROPHY AND BULLOUS KERATOPATHY

Changes on corneal endothelial specular microscopy were compared in 14 patients with cornea guttata, 4 patients with Fuchs' corneal dystrophy and 19 patients with various forms of bullous keratopathy. The patients with cornea guttata showed well marked guttae 1 to 6 endothelial cells in diameter in the endothelial mosaic and in the relief mode while the endothelial mosaic was usually otherwise within normal limits. In 2 patients with Fuchs' dystrophy the endothelium could be examined, showing gross guttae but a few areas of relatively normal endothelial cells. The unaffected eye of 3 other patients snowed findings similar to cornea guttata, but with some reduction in endothelial cell count in 2 patients. The patients with bullous keratopathy fell into 2 groups, one with gross reduction in cell count in a markedly abnormal endothelial cell mosaic, the other a mixed group with moderate reduction in cell count and numerous guttae. Some miscellaneous cases included one of aphakic peripheral bullous keratopathy, one associated with cyclitis and aphakia and 2 with idiopathic non-surgical bullous keratopathy. We believe the corneal endothelium is not grossly abnormal away from the guttae in Fuchs' dystrophy, but the gross guttata formation determines the endothelial dysfunction.     

Twenty-three Cases of Primary Cornea Guttata

Purpose: An evaluation of the clinical aspects of patients with primary cornea guttata and the morphology of their corneal endothelial cells.Methods: Twenty-three patients who visited Kanazawa Medical University Hospital or related hospitals in Ishikawa or Fukui prefectures and were diagnosed as having primary cornea guttata by slit lamp microscopy and contact specular microscopy underwent an analysis of corneal endothelial cells as well as their clinical status.Results: In 23 cases, the number of men and young people under 30 years of age was low, with 4 and 2 cases respectively. There was no visual impairment due to cornea guttata. In the specular microscopic findings, the size and density of dark areas varied according to each case and there was asymmetry in some cases. The parameters of the endothelial cells, comprising mean cell area, hexagonality, and the coefficient of variation, were almost within normal limits except for one eye of a 79-year-old man who was speculated to be at an early stage of Fuch's endothelial corneal dystrophy. Three cases had received cataract surgery, but showed no statistical changes in endothelial morphology before or after the surgery.Conclusion: Cornea guttata is thought to be a disease which is not uncommon in Japanese people and which does not bring about visual impairment or abnormalities in corneal endothelial cell parameters except for a small number of patients. Such cases with remarkably decreased cell densities should be considered to be at an early stage of Fuch's dystrophy.     

Twenty-three cases of primary cornea guttata

PURPOSE: To evaluate the clinical aspects of patients with primary cornea guttata and the morphology of their corneal endothelial cells. METHODS: Twenty-three patients who visited Kanazawa Medical University Hospital or related hospitals in Ishikawa or Fukui prefectures and were diagnosed as having primary cornea guttata by slit lamp microscopy and contact specular microscopy underwent an analysis of corneal endothelial cells as well as their clinical status. RESULTS: In 23 cases, the number of men and young people under 30 years of age was low, with 4 and 2 cases respectively. There was no visual impairment due to cornea guttata. In the specular microscopic findings, the size and density of dark areas varied according to each case and there was asymmetry in some cases. The parameters of the endothelial cells, comprising mean cell area, hexagonality, and the coefficient of variation, were almost within normal limits except for 1 eye of a 79-year-old man who was speculated to be at an early stage of Fuchs' endothelial corneal dystrophy. Three cases had received cataract surgery, but showed no statistical changes in endothelial morphology before or after the surgery. CONCLUSION: Cornea guttata is thought to be a disease which is not uncommon in Japanese people and which does not bring about visual impairment or abnormalities in corneal endothelial cell parameters except for a small number of patients. Such cases with remarkably decreased cell densities should be considered to be at an early stage of Fuchs' dystrophy.     

A fluorophotometric study of corneal endothelium after trabeculectomy using different concentrations of Mitomycin-C

The aim of the study was to determine the corneal endothelial permeability coefficient (Pac) in subjects after trabeculectomies using different concentrations of Mitomycin-C (MMC). MMC, a highly toxic drug, is not without drawbacks and complications such as corneal damage. To ascertain a possible relationship between a level of endothelial permeability (Pac) and concentrations of MMC used, we performed, in a prospective study, trabeculectomies in cases of primary open-angle glaucoma (POAG), younger than 50 years, with either concentrations of 0.5 mg/ml of MMC (group 1: 11 eyes) or 0.2 mg/ml of MMC (group 2: 10 eyes). Group 3 consisted of 8 patients after a typical trabeculectomy without MMC and served as a control group (8 eyes). In all groups, before surgery and again 1, 3 and 6 months after surgery, corneal endothelial permeability (Pac) was determined by using anterior segment fluorophotometry (Fluorotron Master). The thickness of the cornea (CT) was measured with a DGH Technology ultrasonic pachymeter. One month after surgery the mean values of Pac were statistically significantly higher in groups 1 and 2 (group 1: 4.78 × 10^–4 cm/min, group 2: 4.67 × 10^–4 cm/min) in comparison with the control group (group 3: 3.37 × 10^–4 cm/min), but the differences between groups 1 and 2 were not statistically significant (p = 0.05). Six months after operation the mean values of Pac in all groups were normalized. In eyes that underwent trabeculectomy with MMC, higher concentrations of MMC were likely to have a transient adverse effect on corneal endothelial permeability.In light of the resulting toxic intraocular effect of MMC, the damage in the function of the corneal endothelial barrier is greater with greater concentrations of MMC.