A new multiple noncontinuous puncture (pointage) technique for corneal tattooing

AIM:To assess the safety and cosmetic efficacy of a new multiple noncontinuous transepithelial puncture technique for tattooing a decompensated cornea.METHODS:It was anon-comparative clinical case series study.The study examines 33 eyes in 33 patients with total corneal opacity due to corneal decompensation, which developed following intraocular surgery.Corneal tattooing was performed using the multiple noncontinuous transepithelial puncture technique (i.e. pointage). The safety of this new surgical strategy was assessed by occurrence of adverse events for the follow-up period. The cosmetic efficacy was determined by the patient’s cosmetic satisfaction and independent observer’s opinion about patient appearance.RESULTS:Seven women and 26 men were included in the study. The mean age was 46.4±17.5y (range:7-67). In total, 30 of 33 patients (91%) reported cosmetic satisfaction within the follow-up period. Only 3 patients (9%) required additional tattooing due to cosmetic unsatisfaction. Cosmetic outcomes were analyzed and classified as excellent or good in 13 (39%) and 17 (52%) patients, respectively. No serious adverse events developed, except delayed epithelial healing in 3 cases.CONCLUSION:The cosmetic outcomes of the multiple noncontinuous transepithelial puncture technique for corneal tattooing were good. The safety of this method is higher than conventional procedures. This new procedure also provides improved cost-effectiveness and safety over current corneal tattooing techniques.     

后弹力层角膜内皮移植术应用与手术技术

角膜内皮移植(endothelial keratoplasty,EK)是针对内皮细胞功能障碍的靶向性治疗方法.目前已成为国际上治疗角膜内皮病变的首选方法.而后弹力层角膜内皮移植术(Descemet's membrane endothelial keratoplasty,DMEK)是目前EK最新技术,也称为小切口角膜内皮移植术,从解剖学角度完美恢复了角膜组织的正常结构,可更好更快恢复视力,且术后排斥反应显著降低,受到了广泛关注和认可.然而,DMEK作为一项新技术,虽然具有显著的优点,也面临着技术上的挑战.最受关注的是供体制备过程中内皮片的丢失、植入受体的展开和位置调整.目前随着手术方法和设备的不断改进,植入技术不断改进,学习曲线正在逐渐减低,越来越多的眼科医生掌握了该技术.由于角膜材料与手术适应证等限制,目前我国尚无开展DMEK的报道.     

Orthokeratology review and update

Orthokeratology (OK) is a clinical technique that uses specially designed rigid contact lenses to reshape the cornea to temporarily reduce or eliminate refractive error. This article reviews the history of traditional daily‐wear OK (1960s to 1980s) and discusses the reasons for the recent resurgence in interest in the new modality of overnight OK, using reverse‐geometry lens designs (1990s to the present). The clinical efficacy of the current procedure is examined and outcomes from clinical studies in terms of refractive error change and unaided visual acuity are summarised. Onset of the effects of overnight OK lens wear is rapid, with most change after the first night of lens wear and stability of refractive change after seven to 10 days. Mean reductions in myopic refractive error of between 1.75 and 3.33 D and individual reductions of up to 5.00 D have been reported. There appear to be slight reductions or minimal changes in astigmatism with the use of reverse‐geometry lenses and most patients are reported to achieve 6/6 unaided vision or better. The induction of higher order aberrations, in particular, spherical aberration, has been reported and this may affect subjective vision under conditions of low contrast and pupil dilation. Patient satisfaction with overnight OK has been reported as similar to or better than with other popular modalities of contact lens wear. Available evidence suggests that the corneal changes induced by overnight OK are fully reversible. The refractive effect in OK is achieved by central epithelial thinning and this has raised concerns about compromise of the epithelial barrier to microbial infection. Recent reports of microbial keratitis in the modality are reviewed and the overall safety of the procedure is examined critically. Recent research on stromal contributions to the OK effect, particularly relating to overnight oedema, is summarised. Emerging issues in OK, including myopic control, correction of other refractive errors and permanency of the OK effect, are discussed.     

一种新的角膜缘干细胞分选方法

目的用平板离心法建立一种新的角膜缘干细胞分选方法。方法用人角膜缘组织块培养法培养出角膜上皮细胞,收获细胞后用转速1400r·min-1和1800r·min-1分别将细胞用平板离心法于未包被的六孔板上进行分选。ATC1为1400r·min-1贴壁的细胞,ATC2为1800r·min-1贴壁的细胞,NAC为1800r·min-1离心力作用下漂浮而不能贴壁的细胞。分选出的三群细胞采用免疫组织化学、克隆形成实验、Ki67流式细胞仪进行分析。结果细胞计数显示用转速1400r·min-1筛选出的ATC1占总体细胞量的(11.32±2.46)%。在离心速度为1800r·min-1时,筛选出ATC2为(18.55±2.79)%,而NAC则为(68.29±4.07)%。ATC1表达角膜缘干细胞标志ABCG2、p63,而不表达角膜上皮细胞分化标志K3。ATC2较少表达ABCG2和p63,大部分表达K3。NAC则不表达ABCG2、p63,而几乎完全表达K3。在这三群细胞中ATC1细胞群具有最强的细胞增殖活性,其克隆形成率和Ki67阳性细胞检测率分别为(3.90±0.17)%和(56.78±2.39)%。ATC2克隆形成率和Ki67阳性细胞检测率分别为(2.48±0.19)%和(9.67±1.88)%。NAC克隆形成率和Ki67阳性细胞检测率分别为(0.84±0.89)%和(4.76±0.57)%。结论平板离心法是一种新的角膜缘干细胞的分选方法。ATC1、ATC2和NAC可能分别为角膜缘干细胞、短暂扩充细胞和终末分化细胞。     

角膜保存的现状与展望

角膜保存的关键是保存角膜内皮细胞的活性,因此关于角膜保存的研究主要是围绕角膜内皮细胞进行的。近年来随着眼库技术的发展,诸多学者针对各种保存方法中对内皮细胞的有利及有害因素进行了深入研究,取得了较大进展,使角膜保存质量有较大提高,时间也明显延长。对于一些原来认为是非活性保存的方法,现在也认为能保存一部分内皮细胞活性,有应用于穿透性角膜移植获得成功的报道。现就角膜保存技术近年来所取得的进展及未来发展趋势进行综述。     

Controlled reduction of postkeratoplasty astigmatism

Corneal transplants were performed in 50 eyes using eight deeply placed interrupted 24 micron (10--0) monofilament nylon sutures followed by a more superficial continuous 16 micron (11--0) monofilament nylon suture placed around the wound in 16 equal bites. After surgery the 24 micron sutures in the steepest corneal meridian based on central and peripheral keratometry were cut. This suture technique permitted the donor cornea to assume its normal shape more rapidly while reducing the induced postkeratoplasty astigmatism. With this technique corneal astigmatism was reduced an average of 3.4 diopters (range 0--10 diopters), which allowed patient to achieve a mean visual acuity at three months of 20/50 and at 11 to 13 months of 20/35. Although this suture technique does not eliminate postkeratoplasty astigmatism, it permits the surgeon to reduce actively high degrees of astigmatism present after corneal transplantation.     

Castroviejo''s square corneal grafts

The evolutionary history of the modern day keratoplasty technique is filled with numerous attempts to implant all manner of material using very creative surgical techniques. Many different shapes of incisions were tried. Castroviejo introduced a square shaped keratoplasty technique which had considerable success. He also introduced new surgical instruments which made the procedure easier to perform. This technique remained popular until the 1950s when improved instrumentation along with the demand for the most cosmetically pleasing result displaced the square keratoplasty technique as the keratoplasty procedure of choice.     

抑制角膜新生血管生长的研究进展

角膜新生血管(CNV)多见于感染、炎症、外伤或角膜手术后。CNV是眼表疾病的显著特征之一,血管化的角膜不但严重影响视力,而且是角膜移植失败的主要原因。近年来,随着对CNV的深入研究,在血管的形成机制和治疗方面取得了一些成果,主要就CNV治疗的新进展作一综述。     

自体板层巩膜置换并结膜移植术治疗复发性胬肉

设计一种自体板层巩膜置换并结膜移植术,治疗17例复发性胬肉,仅2例复发(11.11%)。本法能重建新的角膜缘后缘,以防再发。     

PHOTOKERATOSCOPY: SOME THEORETICAL AND PRACTICAL CONSIDERATIONS OF THE TECHNIQUE

Some theoretical limitations of photokeratoscopy associated with the quantification of keratograms are discussed.
Representative keratograms of normal and abnormal corneas are presented to illustrate the practical limitations of any mire imaging technique.     

微小切口推注式人工晶状体睫状沟悬吊术临床应用

目的:探讨微小切口推注式折叠人工晶状体睫状沟悬吊术的有效性和安全性。方法:选择因晶状体后囊破裂或悬韧带断裂不能正常植入后房型人工晶状体的患者52例52眼,利用推注器系统,通过3.2mm的透明角膜小切口,把襻预扎了聚丙烯缝线的折叠人工晶状体植入后房并缝合固定于睫状沟,观察术后视力、角膜散光度及并发症。结果:所有患者术后裸眼视力均提高,其中1.0以上8眼,0.6～0.8为18眼,0.4～0.6为16眼,0.4以下10眼。术后1wk;1,3mo视力在0.5以上者分别为33眼(63%)、39眼(75%)、41眼(79%)。术前及术后1wk;1,3mo的平均角膜散光度分别为1.86±1.65D,2.09±1.28D,1.92±1.34D和1.77±1.16D,术后各时期与术前的角膜散光度差别均无统计学意义(P>0.05)。术中、术后没有出现严重并发症。结论:微小切口推注式折叠人工晶状体睫状沟悬吊术为治疗晶状体、玻璃体切除术后,无晶状体囊支持的患者,提供了一个更安全可靠的人工晶状体植入方法。     

Corneal preservation: Recent advances

New methods of corneal preservation for penetrating keratoplasty have recently been developed to meet the increasing demand for donor corneal tissue. Techniques utilized in the laboratory to evaluate the viability of the corneal endothelium and the clinical results obtained with each method are discussed. All of the new methods (storage in serum or McCarey-Kaufman medium, cryopreservation and organ culture) require excision of the cornea from the donor eye. Good clinical results have been obtained in several ophthalmology centers with cryopreservation and storage in McCarey-Kaufman (M-K) medium. Storage in M-K medium has rapidly become popular because it is a simple and inexpensive method and appears to maintain endothelial viability for about 4 days. Cryopreservation is a more complicated procedure, but it enables longterm storage of donor tissue. Organ culture is still experimental and requires careful technique, but offers promise of maintaining endothelial viability for 3 to 4 weeks.     

国外角膜屈光测量技术的发展

角膜是人眼屈光系统的主要部分，同时也是人眼屈光手术的最主要、最直接的作用对象，从而使得角膜测量技术也变得尤其重要。目前国外关于此技术的研究已有了长足的发展，笔者总结近年来的研究资料，对国外角膜屈光测量技术的发展予以简单介绍。     

A novel method of tunnel creation using intraoperative optical coherence tomography-guided deep anterior lamellar keratoplasty

The big bubble technique has become the technique of choice for performing deep anterior lamellar keratoplasty (DALK) since its inception in 2002. The main challenge with this technique is in achieving a big bubble while preventing inadvertent perforation of the Descemet’s membrane. Although femtosecond lasers have increased the safety, accuracy, and predictability of corneal dissection in DALK, the challenge of achieving a big bubble still exists. To overcome this challenge, Zeimer Z8 Femto LDV has launched a new software module for DALK, which has an added advantage of real-time optical coherence tomography–assisted femtosecond tunnel creation for achieving a big bubble.     

角膜交联术新进展与临床运用

紫外光核黄素角膜交联术(corneal collagen cross-linking,CCL)是一种二十一世纪初应用于临床的最新的角膜成形技术。以核黄素作为光敏剂应用370nm紫外线对角膜进行局部照射,刺激胶原纤维交联,增加角膜硬度。该技术已经在临床崭露头角,有望成为人们比较熟悉的角膜成型技术如传导性角膜成形术和角膜基质环植入术的辅助治疗手段。这些被称为角膜成形学的治疗或手术技术,可望开辟一个新的领域,治疗以往无法治疗的某些角膜疾病。利用CCL,眼科医生可重塑角膜结构,而不需使用如穿透性角膜移植术或板层角膜移植术等创伤性技术。用这种方法代替角膜基质环植入术,或与之相结合,可显著提高圆锥角膜的治疗效果。经过几年的苦心研究,CCL的技术方法得到了改进,治疗范围也有所扩大。不仅用来治疗进展性圆锥角膜,同时也为难治性角膜溃疡、角膜变性、术后角膜扩张病等角膜疾病的治疗带来希望。     

Mapping the entire human corneal nerve architecture

We developed an approach to generate a three-dimensional map that facilitates the assessment of epithelial nerve density in different corneal areas to define aging and gender influence on human corneal nerve architecture. Twenty-eight fresh human eyes from 14 donors of different ages were studied. Corneal nerves were stained and consecutive images acquired with a fluorescence microscope, recorded at the same plane, and merged for viewing the complete epithelial and stromal nerve architecture. After whole mount examination, the same cornea was also used for transection. Stromal nerves entered the cornea in a radial pattern, subsequently dividing into smaller branches. Some branches connected at the center of the stroma, but most penetrated upward into the epithelium. No differences were observed between nerve densities in the four corneal quadrants. Epithelial innervation in the limbal and most of the peripheral area was supplied by a superficial network surrounding the limbal area. Central epithelial nerves were supplied by branches of the stromal nerve network. Epithelial nerve density and terminal numbers were higher in the center of the cornea, rather than the periphery. There were no differences in epithelial nerve density between genders, but there was a progressive nerve density reduction concomitant with aging, mainly in eye samples of donors 70-years of age and older. The modified technique of tissue preparation used for this study allowed for observation of new nerve structure features and, for the first time, provided a complete view of the human corneal nerve architecture. Our study reveals that aging decreases the number of central epithelial nerve terminals, and increases the presence of irregular anomalies beneath the basal layer.     

关于生物工程角膜应用的研究进展

角膜病是我国主要的致盲性眼病之一，其中感染性角膜炎是角膜盲的主要原因。对于药物难以控制的角膜感染，角膜移植手术是控制感染，同时为患者复明的唯一希望。由于我国角膜供体严重匮乏，致使大多数患者在黑暗中苦苦等待，甚至丧失了眼球。因此，寻找新的角膜供体材料成为了眼科界研究的热点问题。近年来，生物工程角膜的研究取得了很大的进展。本文就已应用于临床的生物工程角膜基质的情况和生物角膜内皮的研究前景进行综述，探讨利用生物角膜代替人角膜供体应用于角膜移植手术的可行性。     

A new surgical technique for deep stromal, anterior lamellar keratoplasty

AIMS: To describe a new surgical technique for deep stromal anterior lamellar keratoplasty. METHODS: In eye bank eyes and sighted human eyes, aqueous was exchanged by air, to visualise the posterior corneal surface--that is, the "air to endothelium" interface. Through a 5.0 mm scleral incision, a deep stromal pocket was created across the cornea, using the air to endothelium interface as a reference plane for dissection depth. The pocket was filled with viscoelastic, and an anterior corneal lamella was excised. A full thickness donor button was sutured into the recipient bed after stripping its Descemet's membrane. RESULTS: In 25 consecutive human eye bank eyes, a 12% microperforation rate was found. Corneal dissection depth averaged 95.4% (SD 2.7%). Six patient eyes had uneventful surgeries; in a seventh eye, perforation of the lamellar bed occurred. All transplants cleared. Central pachymetry ranged from 0.62 to 0.73 mm. CONCLUSION: With this technique a deep stromal anterior lamellar keratoplasty can be performed with the donor to recipient interface just anterior to the posterior corneal surface. The technique has the advantage that the dissection can be completed in the event of inadvertent microperforation, or that the procedure can be aborted to perform a planned penetrating keratoplasty.     

早期圆锥角膜的诊断技术研究进展

早期圆锥角膜(keratoconus,KC)的诊断有助于在患者出现典型临床症状之前识别需要监测的患者。及时干预患者的病情进展并改善患者的长期预后,对预防医源性角膜扩张和减轻角膜移植负担至关重要。早期KC的诊断技术种类繁多,包括角膜地形图、角膜像差、角膜上皮和全层厚度测量、角膜共聚焦显微镜、角膜生物力学测量和基因检测等。由于单用一种技术往往难以获得足够的敏感度和特异度,因此,使用多种评估技术有助于更为全面地评估角膜,这将成为今后早期KC诊断的发展趋势。     

初学LASIK者术中常见的并发症及其预防

目的探讨初学者准分子激光原位角膜磨镶术(LASIK)术中易出现的并发症类型、相关原因、避免这些并发症的技术关键。方法在作者初行LASIK的312例(598眼)中，对在术中出现不同类型并发症的19例(24眼)进行相关原因分析。结果LASIK术中主要并发症表现为与角膜瓣有关的瓣游离、碎瓣、薄瓣、角膜瓣上皮局限缺损和瓣下异物存留等。这些并发症的发生与术者操作技术和患者配合等因素密切相关。结论初学LASIK者术中存在一定的并发症，但高度重视每个手术环节，熟知仪器性能，提高手术技巧，同时争取患者的积极配合，是避免这些并发症和取得手术成功的关键。