眼烧伤后重度睑球粘连眼表重建的临床研究

目的探讨新鲜供体带角膜缘板层角膜移植（LKP）联合带角膜缘干细胞自体球结膜移植和羊膜移植治疗眼烧伤后重度睑球粘连的眼表重建效果。方法选择1998年2月至2003年2月我院收治的眼烧伤后重度睑球粘连患者26例（26只眼）。根据视功能受损程度将睑球粘连分为4度．其中Ⅲ度19只眼、Ⅳ度7只眼。手术方法：（1）分离睑球粘连,保留假性胬肉;（2）利用新鲜供体行带角巩膜缘的部分LKP（19只眼）或全LKP（7只眼）;（3）取带角膜缘组织自体球结膜瓣移植于粘连最重的创面;（4）假性胬肉后徙,部分替代球结膜,联合羊膜移植重建结膜囊。术后随访8～36个月,观察结膜囊情况、眼球活动、角膜植片免疫排斥反应情况以及羊膜和假性胬肉的转归。结果除1只眼因睑裂闭合不全行永久性睑裂缝合术外,其余25只眼的眼表情况均得到不同程度改善。（1）睑球粘连：17只眼（65％）第一次手术后粘连完全分离,复视消失;8只眼（31％）在单纯羊膜覆盖的创面区复发条带状睑球粘连,其中5只眼经再次手术粘连完全解除,3只眼残余Ⅰ度粘连。（2）羊膜在术后1周开始自溶,3个月时完全消失;保留的假性胬肉术后1～3个月充血消退,逐渐变薄,相应区域无睑球粘连复发。（3）角膜情况：6只眼角膜植片发生免疫排斥反应,其中3只眼治疗后植片恢复透明,2只眼因植片混浊行二次LKP。结论新鲜供体带角膜缘LKP联合带角膜缘干细胞自体球结膜移植和羊膜移植是治疗眼烧伤后重度睑球粘连的有效方法,假性胬肉可部分替代球结膜重建结膜囊,羊膜移植在重度睑球粘连的治疗中仅发挥暂时支持创面促进眼表恢复的作用。（中华眼科杂志,2005,41：791-795）     

化学及热烧伤后睑球粘连的手术治疗

目的评价眼化学及热烧伤所致睑球粘连，行睑球粘连分离后单纯羊膜移植术及羊膜移植同时联合板层角膜移植手术的疗效。方法44例(44眼)化学及热烧伤后睑球粘连行睑球粘连分离，对18眼结膜缺损处行单纯羊膜移植术；对26眼睑球粘连牵涉角膜或角膜有大量新生血管者，行羊膜移植联合板层角膜移植术，其中12眼联合新鲜大板层角膜移植术，14眼联合干燥保存供体板层角膜移植术。结果44眼术后睑球粘连治愈16眼(36．4％)，好转20眼(45．5％)，无效8眼(18．1％)。结论对于化学及热烧伤后睑球粘连，单纯羊膜移植术或羊膜移植联合板层角膜移植术，可有效地缓解睑球粘连或部分达到治愈。     

羊膜移植治疗眼表损伤

目的 观察羊膜移植术在急性期及瘢痕期眼表损伤中的治疗效果。方法 选择眼表理化生物损伤急性期10例(14眼)，及瘢痕期6例(7眼)，行新鲜及保存羊膜移植，部分联合板层或穿透性角膜移植，随访6～22月：结果 急性期者无一例发生角膜融解或睑球粘连；瘢痕期严重睑球粘连者中1例术后部分复发；联合角膜移植者均未见新生血管长入。结论 羊膜移植对急性期和瘢痕期眼表损伤防止角膜融解、睑球粘连，改良眼表基底及重建眼表上皮均有肯定效果。     

羊膜移植重建急性期严重烧伤眼表的临床研究

目的探讨羊膜重建急性烧伤期眼表面的可行性,比较新鲜和保存羊膜的疗效差异,评价手术方法及其疗效.方法全角膜Ⅲ度以上烧伤且全周角膜缘坏死的临床连续病例分别接受羊膜移植(19例20只眼)或全板层角膜移植手术(22例24只眼).19例羊膜移植患者中8例8只眼接受新鲜羊膜移植,11例12只眼接受保存羊膜移植.患者术后随访12～26个月,平均(15±2)个月.结果羊膜移植后眼表迅速稳定.新鲜羊膜移植者眼表面迅即并维持上皮化.保存羊膜移植者第2或3周才完成上皮化,且12只眼中有3只眼不能完全上皮化,最后由于持续性上皮缺损而发生羊膜融解,其后接受了板层角膜移植.眼表上皮化的术眼随着时间的延长新生血管开始沿着羊膜从角膜周边长入,羊膜被逐渐吸收.新生血管多为表浅性.新鲜羊膜多数(7/8)在术后2～8(4.3±0.8)个月、保存羊膜多数(10/12)在术后1～3(2.0±0.3)个月基本被吸收或融解(t=4.22,P<0.01).羊膜移植重建的结膜眼表均获成功,仅1例发生影响眼球运动的中度睑球粘连.板层角膜移植组22例(24只眼)均保全眼球,但在术后大多发生角膜植片上皮反复脱落,最终植片新生血管化,其中4只眼由于角膜植片融解而接受植片更换,7只眼因植片上皮持续性缺损而行睑缘缝合术,5只眼发生轻中度睑球粘连.在无合并青光眼和白内障的患者中,羊膜移植术后的视力基本保留了眼前手动,而板层角膜移植者则多见眼前指数.结论羊膜尤其新鲜羊膜的移植可以减轻角膜急性烧伤期的炎症反应,阻止眼表的进行性溃烂和融解,加速眼表的稳定;同时减少角膜新生血管的形成,并在相当长的时间内将其局限在角膜周边部,从而为后续的角膜复明手术打下良好的基础.     

带角膜缘的深板层角膜移植联合自体结膜移植和羊膜移植治疗严重眼表烧伤

目的探讨带异体角膜缘干细胞的深板层角膜移植联合自体球结膜移植和羊膜移植治疗严重眼烧伤的临床疗效。方法陈旧性热烧伤和化学腐蚀伤的患者19例19眼。无睑球粘连6眼,轻度睑球粘连5眼,重度睑球粘连8眼。采用带巩膜环的全厚角膜移植,缺失的结膜组织用羊膜和自体结膜修补,随访时间为9m～26m,观察视力、角膜上皮修复情况、角膜透明性、睑球粘连复发情况及排斥反应的发生情况。结果术后半年角膜植片透明率为89.5%,睑球粘连复发率为23.1%(3/13);术后矫正视力在0.3以上的为52.6%,在0.1-0.3为89.5%,2例出现持续上皮缺损和排斥反应,术后一年以上植片透明率为57.8%,睑球粘连复发率为38.5%(5/13);术后最佳矫正视力在0.3以上的为36.8%,在0.1-0.3为57.9%,有8例(42.2%)患者出现排斥反应同时有角膜上皮的缺损。结论带异体角膜缘干细胞的深板层角膜移植手术是治疗重症眼烧伤角膜混浊的有效方法,具有良好的光学性能;自体结膜联合羊膜移植是治疗重症睑球粘连的有效方法,而羊膜在这类病例中只能起到暂时支架的作用;排斥反应是异体角膜缘移植失败的主要原因。     

羊膜移植联合角膜缘干细胞移植治疗严重眼烧伤

目的观察羊膜移植联合上下角膜缘干细胞移植治疗严重眼烧伤的效果。方法采用新鲜羊膜移植联合上下角膜缘干细胞移植治疗严重眼烧伤患者15例（17眼）。术后随访平均2月，观察其效果。结果视力大于0．05者12眼占70．59％，10眼角膜无明显新生血管，2眼角膜中央留有薄翳，12眼角膜稍有浑浊。17眼全部瘢痕愈合，眼表稳定。结论烧伤早期行羊膜移植联合上下角膜缘干细胞移植可明显减少睑球粘连并可使早期眼表稳定。     

全板层角膜移植羊膜移植治疗严重眼表损伤

目的观察带角膜缘的全板层角膜移植联合新鲜羊膜移植，治疗严重眼表损伤的临床效果。方法12例（13眼）严重眼表损伤行带角膜缘的全板层角膜移植联合新鲜羊膜移植的回顾性分析。其中，碱烧伤4例（5眼）、酸烧伤5例（5眼）、热烧伤3例（3眼）。术后均予以抗感染、抗炎、抗排斥等治疗。术后随访12～24月。结果所有患眼治疗后均形成了稳定的眼表，保住了眼球，视力均有不同程度的提高。3例（3眼）因严重的眼干燥症，需长期滴用人工泪液。结论带角膜缘的全板层角膜移植联合新鲜羊膜移植，能有效地修复严重的眼表损伤，具有较好的疗效。     

羊膜移植联合带角膜缘的全板层角膜移植治疗眼部重度碱烧伤

目的 探讨羊膜移植联合带角膜缘的全板层角膜移植对眼部重度碱烧伤的治疗效果.方法 选择住院行羊膜移植联合带角膜缘的全板层角膜移植的眼部重度碱烧伤12例(13眼).术后观察羊膜、角膜植片及视力情况,并随访10-14个月.结果 2眼术后2周时羊膜融解、脱落,出现部分睑球粘连,其余11眼羊膜植片愈合良好;1眼移植角膜发生轻度排斥反应,有少量新生血管长入,其余12眼角膜植片恢复透明;13眼视力均有提高.结论 对于眼部重度碱烧伤,羊膜移植联合带角膜缘的全板层角膜移植是一种安全有效的手术治疗方法.     

显微羊膜移植技术重建严重眼表烧伤临床观察

目的 评价显微羊膜移植技术重建眼表烧伤的临床效果。方法 对22例（24眼）严重眼表烧伤患者分别采用单纯羊膜移植术，羊膜移植联合异体新鲜角膜缘移植术，羊膜移植结膜囊成形术，并随访观察术后疗效，结果 13例（15例）单纯羊膜移植患者中，11例（17眼）无角膜结膜进行性溶解和穿孔，无新生血管和假性胬肉侵入角膜表面，2例因眼睑缺损，眼表干燥导致羊膜，角膜溶解穿孔，眼球萎缩，羊膜联合异体角膜缘移植术5例中，眼表结构恢复正常。无假性胬肉及睑球粘连发生，羊膜移植结膜囊成形术4例中，3例恢复了眼球的运动功能，1例因植片下积血，预后较差，再次发生眼球粘连，结论 运用显微手术羊膜移植重建眼表烧伤，可有效减少角膜溃疡穿孔，预防或修复睑球粘连，减少眼表新生血管，羊膜被认为是眼表重建较为理想的生物膜。     

新鲜羊膜移植在治疗早期重度眼烧伤中的临床观察

目的研究新鲜羊膜移植术对治疗早期重度眼烧伤的临床效果.方法采用新鲜羊膜治疗碱烧伤5例(5眼),酸烧伤3例(3眼),热烧伤8例(8眼).烧伤部位包括角膜、结膜.受伤到手术时间1～14 d,平均7 d.结果16眼均无羊膜移植排斥反应和继发感染,眼表稳定.术后3～7 d眼部炎症均可控制,无角巩膜溶解穿孔、虹膜萎缩,视力较前有不同程度提高,其中7眼角膜恢复透明,8眼角膜无新生血管,合并角膜不同程度斑翳,1眼全角膜浑浊.结论运用羊膜移植重建眼表烧伤,可有效促进上皮细胞分化移行,抑制局部炎症,阻止新生血管和瘢痕形成,预防或修复睑球粘连.早期新鲜羊膜移植可用作重度眼烧伤后重建眼表的第一步.     

早期多次新鲜羊膜移植治疗重度眼表烧伤的疗效

目的:探讨早期多次新鲜羊膜移植治疗重度眼表烧伤的治疗效果。方法:回顾性分析我院2007-01/2011-12收治的25例25眼重度眼表烧伤患者早期采用两次及以上羊膜移植的治疗效果。术后对眼表稳定情况、角膜上皮愈合情况及新生血管、视力等进行观察随访。结果:患者25例25眼中,20眼在行2次羊膜移植术后6～14d羊膜开始溶解,拆线后羊膜脱落。眼表炎症控制,荧光素钠染色角膜上皮完整;角膜缘缺血改善。4眼2次羊膜移植术后,羊膜溶解脱落后表现为角膜上皮未愈合,直径大于2mm以上,角膜缘缺血大于1/4象限,再行第3次移植。最终眼球保存完整,眼表稳定。1眼2次术后3d出院,未能继续跟踪观察。结论:重度眼表烧伤采取早期多次新鲜羊膜移植治疗,对稳定眼表十分有效。     

Reconstruction of ocular surface with heterologous limbal epithelium and amniotic membrane in a rabbit model

PURPOSE: To report in vivo reconstruction of the ocular surface using amniotic membrane and heterologous transplants of epithelial limbal cells in rabbits with chemical burns. METHODS: After severe damage to the ocular surface with n-heptanol and keratectomy, 15 rabbits developed total limbal deficiency with conjunctival epithelialization, vascularization, and chronic inflammation. One month later, a complete keratectomy was performed in all eyes: 12 received additional transplantation of human amniotic membrane and heterologous limbal epithelial cells in a double amniotic membrane layer, 2 received amniotic membrane only, and 1 control eye received no procedure. RESULTS: After 1 month of follow-up, corneas in eight of the operated eyes presented minimal vascularization, without signs of rejection. Corneal surface reconstruction was demonstrated with the growth of new corneal-like epithelial phenotype and integration of amniotic membrane to the basal corneal surface. A superficial amniotic membrane (with the amnion side up as a dressing) peeled off after 7 to 10 days. The epithelialization with heterologous limbal epithelial cells was evident underneath. The other four operated eyes were followed for 6 months; the ocular surface was also stable with a corneal-like epithelial phenotype. CONCLUSION: Simultaneous transplantation of amniotic membrane and heterologous limbal epithelial cells in severe ocular surface disorders could restore ocular surface and may be useful in patients with severe bilateral limbal epithelial loss, giving new perspectives for the treatment of severe ocular surface disorders.     

Management of severe ocular burns with symblepharon

Background  To evaluate the effect of lamellar keratoplasty combined with limbal stem cells, using amniotic membrane, autologous conjunctiva, and pseudopterygium to reconstruct external eyes for severe ocular burns with symblepharon. Methods  Thirty eyes of 29 patients had severe symblephara resulting from eye burns. According to the range of the symblepharon and the loss of limbal stem cells, partial lamellar keratoplasty combined with partial limbal stem cell treatment was performed in 19 eyes, and total lamellar keratoplasty with total limbus was performed in 11 eyes. All patients had amniotic membrane and autologous conjunctival transplantation, and the pseudopterygium was preserved to reconstruct the fornix. Results  Symblephara were completely relieved in 19 eyes. They remained partially in ten eyes in strip-like form, but seven of these were completely relieved after further autologous conjunctival transplantation. One eye was treated with tarsorrhaphy for eyelid malformation. The remaining pseudopterygium became thinner after the operation and showed no symblepharon. Immune rejection occurred in eight corneal grafts; clarity was restored in four of these, while there was graft neovascularization in the remaining four. Conclusions  Depending on the area of symblepharon and the loss of limbal stem cells, partial or total lamellar keratoplasty combined with limbal stem cells, using amniotic membrane, autologous conjunctiva and pseudopterygium to reconstruct external eyes appears to be effective in treating severe ocular burns with symblepharon. Pseudopterygium can partly substitute autologous conjunctiva in ocular surface reconstruction.     

冻存羊膜移植治疗早期中度及重度眼表烧伤的临床研究

目的探讨冻存羊膜移植在治疗早期中、重度眼表烧伤中的疗效。方法对28例（33眼）中、重度眼表烧伤施行羊膜移植术。随访6～12月,观察临床疗效。结果术后大部分患者保存了眼球,1眼发生角膜穿孔。角膜恢复透明12眼,角膜斑翳7眼,角膜白斑3眼,角膜新生血管9眼,睑球粘连1眼。13眼视力提高〉3行。无急性排斥反应和继发感染发生。结论羊膜移植是治疗早期中、重度眼表烧伤的一种较安全有效的方法。     

组织粘合剂粘合羊膜手术在眼烧伤中的应用

目的:评价组织粘合剂粘合羊膜手术在眼烧伤治疗中的疗效。方法:选择2002年9月～2004年6月在中山眼科中心外伤病区住院的眼烧伤患者29例34只眼。其中Ⅱ度烧伤4只眼,Ⅲ度5只眼,Ⅳ度25只眼。Ⅳ度烧伤中角膜缘100%缺血者7只眼,角膜缘缺血小于100%者18只眼;结膜严重坏死累及巩膜者12只眼。全部患者行组织粘合剂粘合羊膜手术前均予常规的药物治疗。术后随访2～6个月,观察角结膜上皮生长情况,羊膜、组织粘合剂贴附情况,炎症及视力等。结果:Ⅱ、Ⅲ度烧伤及部分Ⅳ度烧伤[角膜缘缺血小于100%有27只眼,手术后全部上皮缺损愈合,缺损愈合时间为术后8～42d,(23.9±8.0)d;Ⅳ度烧伤角膜缘100%缺血角膜溃疡溶解的7只眼,除1只眼失访外,6只眼局部溃疡静止。4只眼视力无变化,29只眼视力均有不同程度的提高。结论:组织粘合剂粘合羊膜手术可以迅速恢复烧伤眼表的完整性,有效地防止持续性角膜上皮缺损,角巩膜溃疡穿孔,睑球结膜粘连等并发症的发生;对于严重的Ⅳ度烧伤(角膜缘100%缺血),组织粘合剂粘合羊膜手术有助于阻止角巩膜溃疡穿孔,重建结膜表面,恢复眼前段血供,防止睑球粘连,但由于角膜缘干细胞完全缺陷,恢复角膜表面的完整性,尚需行角膜缘干细胞移植术。     

Amniotic membrane transplantation in acute chemical burns

PURPOSE: To evaluate the outcome of fresh amniotic membrane transplantation (AMT) for ocular surface reconstruction in acute chemical burns. METHODS: A prospective study of 15 consecutive eyes with acute chemical burns was performed. In all, 10 eyes had lime burns and five eyes had acid burns. There were three eyes of grade II, four eyes of grade III and eight eyes of grade IV burns. AMT was performed within 3 weeks of injury. RESULTS: Patients were followed up for 10.14 +/- 4.41 months. All patients had immediate relief of pain postoperatively. Of 15 eyes, nine (60%) showed epithelialization within 1-4 weeks (15.33 +/- 9.91 days). The final visual acuity improved in 10 of 15 eyes (66.66%). Eyes with burns of grade II and III showed more visual improvement than those with grade IV burns. None of the eyes showed perforation. Symblepharon was seen in nine of 15 eyes (60%). Of 15 eyes, 12 (80%) experienced limbal stem cell deficiency and showed superficial corneal vascularization. CONCLUSIONS: Amniotic membrane transplantation with fresh amniotic membrane increases patient comfort and reduces inflammation. In mild burns, AMT alone restores corneal and conjunctival surfaces. In moderate to severe burns, it probably reduces conjunctival scarring sequelae, but does not prevent the sequelae of limbal stem cell deficiency that requires further limbal stem cell transplantation. In the acute stage, amniotic membrane transplantation probably has a protective role against the progressive melting and perforation.     

Komplikationen in der Sp?tphase nach Augenver?tzung

Severe chemical burns of the ocular surface frequently result in long-standing and ongoing disorders of the conjunctiva and the cornea including conjunctival scarring with shortening of the fornix, cicatricial entropion, complications caused by trichiasis and scarring or chronic ulceration of the cornea. Advanced destruction of limbal stem cells leads to limbal stem cell deficiency with conjunctivalization of the cornea. Surgical therapy aims at the correction of malpositioning of the lids, the reconstruction of the conjunctiva and the fornix utilizing applicable tissue grafts and the reestablishment of a stable, avascular and transparent corneal epithelium by e.g. transplantation of epithelial stem cells. Progressive corneal ulcerations unresponsive to medical therapy can be treated by amniotic membrane transplantation, corneal transplantation or by conjunctival covering depending on the extent of damaged tissue. The surgical therapy of patients after severe chemical burns of the ocular surface is generally performed in specialized centers and occasionally requires a multidisciplinary approach.     

羊膜及角膜缘上皮移植术治疗重度眼化学烧伤

目的 观察保存羊膜联合角膜缘上皮移植术在治疗重度角结膜化学烧伤及眼表重建中的应用价值。方法 采用保存羊膜联合角膜缘上皮移植术治疗9例(9眼)陈旧性重度眼化学烧伤。结果 经术后6月随诊，9例全部上皮愈合稳定，无新生血管生长，8例角膜透明或半透明，8眼脱盲。结论 羊膜移植联合角膜缘上皮移植治疗严重眼表面疾病是一种有价值的方法。