发展中国家白内障手术的现状

随着人口的老龄化白内障的发病率也在升高,白内障已经成为发展中国家最常见的致盲眼病,在发展中国家中,盲和视觉损伤已经成为严重的公共卫生、社会和经济问题。虽然白内障手术是最具有成本效益的干预方式,但在发展中国家提供白内障手术服务仍存在很多问题和挑战,在过去10a中一些国家在治疗白内障时采用手法小切口白内障摘除术这种手术方式并取得了较好的效果。另外,制定不同的可持续发展的防盲模式在这些发展中国家也是一个挑战。本文就近年发展中国家的白内障手术情况做一综述。     

白内障小切口手法摘除术与超声乳化吸出术临床疗效比较观察

目的比较小切口白内障摘除术与超声乳化吸出术对术后视力、角膜散光、手术并发症的影响。方法随机选择102例（102只眼）白内障分别行小切口手法非超声乳化摘除与超声乳化吸出术,观察两组术后临床疗效。结果术后3个月手法组及超声乳化组的散光分别为（1.58±0.89）D及（1.57±0.88）D,术后最好矫正视力大于0.3者分别为95.02%及95.89%,角膜水肿于术后半个月后均消退。结论术后3个月两种手术方式疗效相近,无超声乳化仪的基层医院可推广白内障小切口手法摘除术。     

Cataract surgical techniques

Cataract surgery continues to evolve as modifications in techniques are introduced. Extracapsular surgery, whether by phacoemulsification or planned extracapsular cataract extraction, is a very safe and effective technique. Maintaining versatility in operative techniques, depending on the clinical situation, is a distinct challenge for the cataract surgeon. Adequate surgical planning, coupled with meticulous surgical technique, gives optimal results. Innovations in wound architecture provide intraoperative and postoperative advantages to the surgeon and to the patient. Capsulorhexis is the preferred method of capsulotomy in phacoemulsification and planned extracapsular cataract extraction. Hydrodissection and related techniques are useful in all types of extracapsular cataract extraction. This article reviews techniques in cataract surgery with an emphasis on the recent literature.     

High volume sutureless intraocular lens surgery in a rural eye camp in india.

BACKGROUND AND OBJECTIVE: To describe the use of small incision sutureless cataract surgery (SISCS) that permits high-volume, high-quality, and low-cost surgery. PATIENTS AND METHODS: We compared the speed, safety, and visual results of 1190 surgical techniques performed in a public eye camp in India. Intraocular lenses were received by 97% of patients (1154). Surgical techniques used were SISCS, phacoemulsification, and standard extracapsular cataract extraction (ECCE) technique. RESULTS: Postoperatively, 60.0% attained uncorrected vision of 6/24 or better. There was little difference in visual results or complication rates among the three techniques. The most striking finding is the speed of SISCS, which enables experienced surgeons to perform the technique in 3.8 to 4.2 minutes. CONCLUSION: We believe this surgical technique is of major importance especially in developing nations facing enormous surgical volumes and limited resources.     

Cataract surgical techniques

Cataract surgical techniques are constantly evolving and changing, offering the ophthalmologist new and sometimes improved options for optimal visual rehabilitation of their patients. This article reviews the surgical techniques used in cataract surgery with an emphasis on the recent literature. The following areas are covered: anesthesia, incisions and wound closure, capsulotomy, planned extracapsular cataract surgery, phacoemulsification, intraoperative management of the torn posterior capsule, trauma, and combined procedures. The use of phacoemulsification continues to increase in popularity in the developed countries. Small incisions for cataract surgery hasten visual rehabilitation, and continuous circular capsulorhexis has emerged as an advantageous capsulotomy technique. With proper intraoperative management, patients with torn posterior capsules have excellent visual results. Combined procedures allow for concurrent surgery in patients with cataract and coexistent ocular diseases. Cataract surgical techniques must be adapted to suit each patient. The modification of surgical techniques according to individual patient needs and associated ocular and systemic disorders offers a distinct challenge to the ophthalmic surgeon.     

手法小切口白内障手术在防盲中的应用体会

目的方法结果结论手法小切口白内障手术在防盲中的应用。在200例＂三星爱之光＂贫困白内障患者复明手术中,采用反眉状巩膜隧道切口,手法劈核将晶状体取出,植入后房型人工晶状体。术后第一天裸眼视力≥0.3者112眼（56%）,0.05-0.3者63眼（31.5%）,≤0.05者25眼（12.5%）。术后一月矫正视力≥0.3者168眼（84%）,0.05-30者.30眼（15%）,≤0.05者2眼（1%）。手法小切口白内障手术,不需特殊昂贵设备,易于掌握,手术费用低,疗效可靠,尤其对于核硬、黑核白内障优于超声乳化。适合中小医院开展,是一种可行手术方式。体会     

低倍镜补偿景深超声乳化手术和小切口白内障手术对比观察

目的：观察低倍镜补偿景深下超声乳化白内障摘除术和小切口白内障囊外摘除术的临床疗效。方法：回顾性分析869例1258眼白内障患者手术治疗的情况,其中采用超声乳化白内障摘除手术者共计247例432眼;采用小切口白内障摘除术者共计622例826眼,对患者的术后视力、角膜内皮计数、角膜水肿情况及并发症进行统计学分析。
　　结果：两组患者术后1wk,1mo 视力恢复情况和术后1d 角膜水肿情况无统计学差异(P >0.05);角膜内皮计数损失,小切口白内障摘除手术组较超声乳化白内障摘除组略好(P<0.05)。
　　结论：基层医院手术显微镜景深不够清晰的情况下,仍可采用低倍镜补偿景深开展小切口白内障囊外摘除术和超声乳化白内障摘除术。     

Cataract surgery. Anterior capsulorrhexis technique

The cataract surgery is in a continuous dynamic because of the technological progress. The last years the surgical technique for cataract has changed and the most important progresses are the use of small incisions that don't require sutures, the realise of the anterior capsulotomy with smooth margins (continuous circular capsulorrhexis) and the extracapsular extraction of the cataract by phacoemulsification. The authors described the most usual techniques of the anterior capsulotomy with the advantages offered by capsulorrhexis, an important surgical step from the manual extracapsular extraction of the cataract to phacoemulsification.     

小切口囊外摘除术与超声乳化术治疗白内障疗效比较

目的：探究小切口囊外摘除术与超声乳化术对白内障患者角膜内皮细胞数目、黄斑区厚度及手术源性角膜散光的影响。

方法：回顾性研究。选取我院2019-05/2023-02收治的年龄相关性白内障患者296例296眼。根据手术方式分为小切口囊外摘除术组144眼与超声乳化术组152眼。比较两组患者术前，术后7d，1、3mo裸眼视力、最佳矫正视力、角膜内皮细胞数目、黄斑区厚度、手术源性角膜散光及术后并发症发生情况。

结果：小切口囊外摘除术组患者术后7d裸眼视力和最佳矫正视力均优于超声乳化术组，术后7d， 1、3mo角膜内皮细胞数目均高于超声乳化术组，术后7d， 1mo黄斑区厚度均低于超声乳化术组，术后角膜水肿发生率及总并发症发生率均低于超声乳化术组(均P<0.05)，但术后1、7d， 1、3mo手术源性角膜散光值与超声乳化术组比较均无差异(P>0.05)。

结论：相较于超声乳化术，小切口囊外摘除术术后角膜内皮细胞数目及黄斑区厚度变化较小，视力恢复更快，并发症减少。     

手术治疗糖尿病性白内障60眼临床分析

目的:分析小切口白内障囊外摘出人工晶状体植入术和超声乳化白内障吸除人工晶状体植入术治疗糖尿病性白内障的疗效及并发症。方法:选择2006-01/2010-01确诊为糖尿病性白内障患者52例60眼,Ⅱ～Ⅲ级核47眼,采用超声乳化白内障吸除后房型人工晶状体植入术;Ⅳ～Ⅴ级核13眼,采用小切口白内障囊外摘出后房型人工晶状体植入术。结果:糖尿病患者52例60眼白内障术后视力均有不同程度的提高,其中50眼(83%)术后1wk裸眼视力≥0.4。术中术后主要并发症经处理对术后视力无影响。结论:对糖尿病性白内障患者采取恰当的术式,施行小切口白内障囊外摘出人工晶状体植入术或超声乳化白内障吸除人工晶状体植入术疗效肯定。     

微切口白内障手术的争论性问题及发展趋势

切口的不断缩小是白内障超声乳化手术发展的趋势.近年来随着手术器械及设备的发展,微切口白内障手术逐渐成为临床医生的首要选择.切口缩小的目的在于更好地提高术中及术后的安全性、更小地改变角膜形态以及使患者更大程度地受益等.作为一项新兴的手术方式,对于微切口白内障手术的最佳手术方式以及最合适切口大小的选择等一系列问题仍存在争议.且随着手术技术、超声乳化设备以及IOL设计的不断进步,特别是飞秒激光在白内障术中的应用日益广泛,未来微切口白内障手术的发展趋势将如何？这一系列问题,值得我们深入探讨.     

Elimination of avoidable blindness due to cataract: Where do we prioritize and how should we monitor this decade?

Background: In the final push toward the elimination of avoidable blindness, cataract occupies a position of eminence for the success of the Right to Sight initiative. Aims: Review existing situation and assess what monitoring indicators may be useful to chart progress towards attaining the goals of Vision 2020. Settings and Design: Review of published papers from low and middle income countries since 2000. Materials and Methods: Published population-based data on prevalence of cataract blindness/visual impairment were accessed and prevalence of cataract blindness/visual impairment computed, where not reported. Data on prevalence of cataract blindness, cataract surgical coverage at different visual acuity cut offs, surgical outcomes, and prevalence of cataract surgery were analyzed. Scatter plots were used to look at relationships of some variables, with Human Development Index (HDI) rank. Available data on Cataract Surgical Rate (CSR) was plotted against prevalence of cataract surgery reported from surveys. Results: Worse HDI Ranks were associated with higher prevalence of cataract blindness. Most studies showed that a significant proportion of the blind were covered by surgery, while a fifth showed that a significant proportion, were operated before they went blind. A good visual outcome after surgery was positively correlated with higher surgical coverage. CSR was positively correlated with cataract surgical coverage. Conclusions: Cataract surgical coverage is increasing in most countries at vision <3/60 and visual outcomes after cataract surgery are improving. Establishing population-based surveillance of cataract surgical need and performance is a strong monitoring tool and will help program planners immensely.     

白内障手法小切口摘除与超乳摘除临床疗效观察

目的对白内障手法小切口摘除术与超声乳化摘除术的手术疗效进行对比分析,探讨在医疗扶贫行动中推广实用的手术方法。方法回顾性比较我院2009年5-6月间200例老年性白内障分别行两种小切口白内障手术后的术后视力恢复情况、术中术后的并发症。结果手法小切口白内障摘除术组及超声乳化白内障吸除术组从术后视力、术中术后并发症方面比较远期效果,差异无统计学意义（〉0.05）。结论两种手术方式疗效相近,手法小切口摘除术所需设备简单,不受硬核白内障限制,经济价廉,更适合在防盲行动中推广应用。     

改良小切口手法碎核在白内障摘除术中的临床应用

目的探讨改良小切口白内障手法碎核摘除术的手术技术和临床应用效果。方法前瞻性病例研究116例(116只眼)随机分为两组:手法碎核58例(58只眼)1-3级核老年性白内障行3.2mm带球结膜的角巩膜缘隧道式切口的晶状体手法碎核摘除术,采用宽3.0mm的晶体碎核垫板作为垫板,以晶体定位钩作为劈核器进行劈核、分核、转核等方法。超声乳化组58例(58只眼),1-3级核老年性白内障行3.2mm透明角膜切口,常规超声乳化吸出术,采用劈核技术。观察比较两组术中、术后并发症,术后视力、角膜水肿情况、角膜内皮平均丢失率及术后角膜散光情况等变化。结果两组术中均无晶状体后囊破裂、晶体悬韧带断裂或虹膜损伤等并发症。手法碎核术后视力24小时视力:0.1-0.5者32只眼,占55%,0.5-0.8者26只占45%。超声乳化术后24小时视力:0.1-0.5者36只眼,占62%,0.5-0.8者22只眼占38%。两组术后1d,3d,一周,一个月,三个月视力,角膜内皮细胞平均丢失率,角膜散光变化值,两组数据比较差异均无统计学意义(P>0.05)。结论对于晶状体核硬一到三级核的白内障行3.2mm带球结膜的角巩膜隧道式切口,手法碎核摘除白内障术中可控性好,手术安全简单,其手术效果与切口同样大小的超声乳化手术效果相当,且术后患者只有轻度异物感,视力恢复快,术后感染率低。为手法小切口白内障手术提供一种更为安全有效俭省的手术方法。     

小切口白内障摘出人工晶状体植入术

目的：探讨小切口白内障摘出及人工晶状体植入术的效果。方法：对210例254眼行小切口白内障摘出,常规白内障囊外摘出和超声乳化术,比较分析术后视力和角膜曲率。结果：小切口白内障摘出术后视力恢复快,散光小,与超声乳化组结果相似,差异无显著性意义（P＞0.05）。与常规白内障囊外摘出组相比视力好,散光小,差异有显著性意义（P＜0.01）。结论：小切口白内障摘出是有效、经济的一种白内障复明术。     

手法小切口白内障手术与超声乳化术后糖尿病患者黄斑厚度的对比

目的 比较手法小切口白内障手术与超声乳化手术对Ⅱ型糖尿病患者黄斑中心凹厚度的影响.方法 56例（56只眼）合并Ⅱ型糖尿病患者的白内障随机分成两组,分别施行手法小切口白内障手术及超声乳化吸出手术.所有患者术前均行眼底检查及眼底照像,术前1个月、术后1周、4周、6周、3个月OCT测量黄斑中心凹厚度,并分析此厚度与最佳矫正视力的相关性.结果 26只眼手法小切口白内障手术,30只眼超声乳化吸出手术,两组患者术后黄斑水肿发生率差异无统计学意义.术后1周,手法组黄斑中心凹视网膜神经上皮层厚度明显高于超乳组（t=4.602,P=0.006）,最佳矫正视力明显低于超乳组（χ2=9.753,P=0.009）,4周后两组黄斑中心凹视网膜神经上皮层厚度和最佳矫正视力差异均无统计学意义.最佳矫正视力与黄斑中心凹视网膜神经上皮层厚度呈现负相关.结论 虽然Ⅱ型糖尿病患者的白内障手法小切口白内障手术和超声乳化吸出术后黄斑水肿发生率无差异,但是术后短期内手法小切口手术对黄斑中心凹视网膜神经上皮层厚度影响较大,并暂时影响最佳矫正视力.     

High-volume surgery in developing countries

BACKGROUND: Cataract remains the world's leading cause of blindness. In the developing world, many eye clinics provide cataract surgery for only a small proportion of those in need. This is partly because of low demand-caused by barriers related to awareness, bad services, cost, and distance--and partly because of deficiencies in the supply of services. This article reviews innovations in cataract surgery in poor countries that are intended to reverse this trend. CONCLUSIONS: Increasing the number of operations, through close involvement with the community, and improved surgical outcomes, enables the cost of surgery to be reduced, leading to further growth in volume. Recent innovations, such as low-cost intraocular lenses, and small-incision extracapsular cataract extraction, have contributed to improving the results of surgery without increasing the costs. Effective management enables the delivery of increasing the numbers of operations, while at the same time improving outcomes and controlling costs.     

Extracapsular cataract surgery in Vietnam: A I year follow-up study

Purpose: Unoperated cataract is the leading cause of blindness in the developing world. Many developing countries now use extracapsular cataract extraction (ECCE) with intra-ocular lens insertion (IOL) in their cataract blindness-prevention programmes. To date, little research has been directed at visual outcomes and complication rates of ECCE/IOL surgery in developing countries. Methods: We conducted a follow-up study of 155 eyes approximately 12 months after ECCE/IOL surgery by eight local eye surgeons in Central Vietnam. We report the findings for the 144 eyes (93%) successfully reviewed. All subjects underwent manual ECCE with insertion of a three-piece posterior chamber IOL. All eyes were also assessed for the presence and severity of posterior capsule opacification (PCO) using a newly developed grading system. Results: Overall, 110 eyes (75%) had uncorrected visual acuities ≥6/24 and 107 eyes (74%) had best spherically corrected visual acuities ≥6/18. Some degree of PCO was found in 40% of eyes, but was graded as visually significant in only 4% of eyes. No major sight-threatening complications were noted. A portable neodymium: yttrium aluminium garnet (Nd: YAG) laser was used to perform capsulotomies on all eyes with visually significant PCO. There were no laser complications noted. Conclusions: At approximately I year after ECCE/IOL, the visual outcomes for subjects in this cohort were favourable and complication rates were low. Posterior chamber opacification was not a major cause of vision impairment in this cohort. Portable Nd: YAG lasers may provide an effective solution to the problem of visually significant PCO occurring in developing countries as a late complication of extracapsular surgery. These findings support an increasing role for ECCE/PCIOL surgery by trained local eye surgeons in developing countries.     

Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience

PURPOSE: Phacoemulsification cataract surgery is one of the most important surgical procedures learned by ophthalmology residents during their residency training. We evaluated the visual outcomes and incidence of vitreous loss of phacoemulsification cataract surgeries performed by ophthalmology residents without prior planned extracapsular cataract extraction experience. DESIGN: Interventional case series. METHODS: A retrospective review was performed on 332 consecutive phacoemulsification cataract surgeries performed by third-year ophthalmology residents from July 1999 through June 2001. Data included are preoperative and postoperative best-corrected visual acuity, preexisting ocular comorbidities, and intraoperative and postoperative complications. RESULTS: Postoperative best-corrected visual acuity was 20/40 or better in 89% of eyes. After excluding the cases with preexisting ocular comorbidities, the percentage increased to 97.7%. Vitreous loss occurred in 4.8% of cases. CONCLUSIONS: Ophthalmology residents can learn to perform phacoemulsification cataract surgery safely and effectively without prior planned extracapsular cataract extraction experience.     

Cumulative Table of Contents

purpose To estimate the direct and indirect costs of three cataract surgery procedures: extracapsular cataract extraction with intra-ocular lens implantation (ECCE-IOL), phacoemulsification (PHACO) and manual small incision cataract surgery (MSICS) using economic costing principles in a well-established eye care programme (Aravind Eye Hospital) in Tamil Nadu, South India during 2000-01. Previous literature suggests that PHACO and MSICS have similar effectiveness. methods The average unit cost for each surgical procedure was calculated from the societal perspective using economic costing methods. Total annual provider's direct costs for each input to surgery were calculated and apportioned appropriately to different cataract surgery techniques using a 'micro-costing approach'. The patient's direct and indirect costs for each procedure were calculated by interviewing staff and patients and by using assumptions about prices for relevant cost items such as transportation, food, medicine, spectacles and economic productivity loss. results Average provider's direct costs were highest for PHACO procedures (US $25.55) compared to MSICS ($17.03) and ECCE-IOL ($16.25). The difference can be attributed to the cost of equipment and materials. Average direct and indirect patient costs were highest for ECCE-IOL ($19.85), while the costs for PHACO and MSICS were identical ($12.37). ECCE-IOL had the highest total costs and MSICS had the lowest total costs from the societal perspective. conclusions Our results suggest that MSICS may have a lower societal cost than other options. Government and NGO hospitals providing cataract surgeries should invest in regular cost analyses, reviews of the literature on effectiveness, and formal cost-effectiveness analyses in order to plan economically efficient interventions. Considering the small incremental cost for providers (less than US$1), improved outcomes, and lower patient costs, we also believe that MSICS is an important technique to use in efforts to eliminate cataract blindness in India and this result may be generalised to other developing countries.