1例复杂性角膜盲治疗体会

角膜病是眼科常见疾病,治疗主要以病因治疗为主.角膜疾病治疗不及时会发展为角膜云翳、角膜斑翳、角膜白斑甚至丧失视力.本例患者主要是一例因外伤形成角膜白斑致使视力低下,于三峡大学附属仁和医院行自体穿透性角膜移植(autologous penetrating keratoplasty,APK)的特殊病例.     

自体穿透性角膜移植治疗角膜盲的临床观察

目的：观察自体穿透性角膜移植手术治疗角膜盲的临床效果。

方法：采用回顾性分析,选择2014-01/2018-03行自体穿透性角膜移植治疗的患者8例8眼(角膜盲),随访1a,观察术中并发症、术后视力、术后角膜透明度和术后并发症等。

结果：术后1wk时8眼患者术后裸眼视力均>0.02,复明率100%; 术后1mo时5眼患者矫正视力超过0.3,3眼患者因术前白内障影响术后矫正,视力提高到0.08～0.2; 术后1a,8眼患者原角膜盲眼植片均透明,无感染复发或继发感染情况发生。

结论：自体角膜移植手术后角膜植片易于生长,无排斥反应,术后并发症较少,且治疗花费少,既可为单眼失明合并角膜盲的患者提供长期的有用视力,又可减轻其经济负担,为患者带来巨大利益。     

复合型人工角膜植入治疗重度角膜盲及并发症处理

目的 探讨钛支架复合型人工角膜植入治疗重度角膜盲的临床价值,以及并发症的处理.方法 回顾性系统病例研究.2002年3月至2005年6月期间中山大学中山眼科中心共完成永久性人工角膜植入9例(单侧眼9只),均为男性,年龄28～52岁.所有患者均为双眼损伤,受伤时间为1.5～5.0年.其中碱烧伤6只眼,爆炸伤3只眼,术前视力均为光感,其中2例光定位不准;均为多次角膜移植以及眼表重建手术失败的难治性重度角膜盲患者.手术分两阶段:一期手术显微镜下行钛支架复合型人工角膜植入联合自体耳软骨移植加固,二期行人工角膜前膜剪开,建立镜柱光学通路.术后评价视力恢复情况,分析并发症的发生原因,探讨相应的处理对策.结果 患者随诊时间1～3年.术后7只眼裸眼视力≥0.1,其中2只眼经镜片矫正后达到0.6.术前光定位不准的2例患者术后视力为0.02和0.04.术后并发症的发生情况为复发性人工角膜前膜5例,进行前膜切除,其中1例联合施行自体唇黏膜移植;角膜局限性融解1例,进行脱细胞真皮加固;人工角膜后膜1例,显微镜下施行后膜钩除术.以上并发症经相应处理均得到控制.随访期内所有人工角膜均保持原位,未发生人工角膜排出、房水渗漏.结论 人工角膜移植是使严重角膜盲患者复明的有效手段,联合自体耳软骨加固可减少并发症的发生,提高人工角膜植入的生物相容性.(中华眼科杂志,2009,45:104-109)     

人工角膜的进展

人工角膜的研制在近年来有了较大的进步 ,传统的非组织工程化人工角膜在材料处理和设计方式上有所创新 ,同时有活性的工程化人工角膜的出现为人工角膜的研制开辟了一条新途径。     

用自体与异体角膜施行双眼角膜移植三例

自体角膜移植的机会极少,我中心4000多例角膜移植的病例中,仅遇3例,不足0.1%。这三例均有一眼因眼底病失明而角膜基本正常,伴随眼则主要因角膜病变而盲目,为此我们利用自体角膜作另一眼自体角膜移植,为了保存眼球与美容,同时又取同种异体角膜作供眼侧的角膜移植。一次完成双眼手术,国内尚未见报告,现将作者治疗的三例报告如下。     

人工角膜植入术的研究进展

对伴有严重干眼病及角膜新生血管的角膜混浊性失明，用常规角膜移植手术治疗通常是失败的，用透明材料制作的人工角膜是治疗这类疾病的唯一有效的途径，但由于晚期严重并发症发生率高，影响了该手术的疗效，如何通过对人工角膜的材料，设计手术技巧以及术后处理进行改进，提高手术的成功率，是目前在这一领域的研究热门课题，本文对人工角膜手术的研究历史，现状及临床应用进行综述。     

自体结膜移植治疗化学烧伤后角膜血管翳性混浊

采用自体结膜移植术或联合板层角膜移植术治疗化学烧伤后角膜的血管性混浊26例(26只眼),随访半年到一年其中21例视力获不同程度的提高。18例无角膜新生血管生长,透明愈合。该手术是在Thoft(1977)和Herman(1983)手术方法的基础上加以改进。具有取材方便、术后无排斥反应之优点。并就手术的选择,手术要点等进行了讨论。     

新型人工角膜的研究

目的 对于已不能行角膜移植或行角膜移植术预后不良及多次移植失败的角膜盲患者，人工角膜移植术已成为复明的最后希望。标准人工角膜是用异质成形材料取代浑浊角膜组织而制成的一种特殊屈光装置。人工角膜与角膜组织之间的长期密贴、透明及生物相容性是影响人工角膜植入术成败的关键因素，因此研制与应用符合这种要求的人工角膜材料以避免植片溶解、脱落、继发青光眼及人工角膜后膜等严重并发症的发生，是人工角膜移植术后长期复明的关键问题。     

活性人工角膜的研究

具有生物活性,与人体角膜特性相近的人工角膜移植是人们努力探求的目标.近年来随着组织工程的发展,活性人工角膜取得了迅速的发展.     

Management of corneal melt in patients with Boston Keratoprosthesis Type 1: Repair versus repeat

PurposeTo evaluate outcomes of Boston keratoprosthesis (KPro) repair versus repeat KPro as treatment for corneal melt in KPro patients.MethodsRetrospective study of adult KPro patients with melt managed by KPro repair or repeat KPro by one surgeon (MH-D). Incidence of sight- or globe-threatening complications, risk of recurrence of melt and change in BCVA before and 3 months after the procedure were compared between both treatment groups. Change from pre-melt BCVA to final BCVA was compared between primary versus secondary repeat KPro after repair attempt.ResultsThis study included 19 eyes of 19 patients with melt and mean follow-up of 8.7 years. Primary repeat KPro was performed in 6 eyes (32%) and KPro repair in 13 eyes (68%). There were no significant differences in gender, age, or incidence of complications after KPro repair versus after repeat KPro (92% and 83% complication rate respectively, p > 0.05). The odds ratio for melt recurrence after KPro repair versus repeat KPro was 24 (95% CI 1.68–340). Change in BCVA was not significantly different in KPro repair versus repeat KPro nor in primary versus secondary repeat KPro (p > 0.05).ConclusionsRepeat KPro offers a lower risk of recurrence of melt compared to KPro repair. However, repair may be considered when timely access to a new KPro and corneal graft is not possible. Delaying repeat KPro does not significantly affect final BCVA. Finally, repeat KPro is the only effective treatment when melt has led to extrusion or uncontrollable infection.     

Boston keratoprosthesis type 1 for limbal stem cell deficiency after severe chemical corneal injury: A systematic review

Purpose

To systematically review the published literature on outcomes of Boston keratoprosthesis type 1 for the treatment of limbal stem cell deficiency secondary to severe chemical corneal injury.

Boston Type I Keratoprosthesis Implantation Following Autologous Submandibular Gland Transplantation for End Stage Ocular Surface Disorders

Purpose: To describe the results of Boston keratoprosthesis implantation in a patient with Stevens–Johnson syndrome following autologous submandibular gland transplantation.

Design: Observational case report.

Methods: We report the case of a man diagnosed with Stevens–Johnson syndrome. Autologous submandibular gland transplantation was performed in the right eye in 2008 to ameliorate tear film deficiency. Due to the improvement in the microenvironment of the ocular surface, Boston keratoprosthesis implantation was performed in the right eye in 2011.

Results: He maintained a VA of 20/100 for 12 months. At the last follow-up visit (54 months), his VA had declined to finger count level due to de novo glaucoma, which was treated with glaucoma drainage device implantation, cyclophotocoagulation and topical anti-glaucoma medications.

Conclusions: The procedures described provide patients with end-stage ocular surface disease an option to lessen the severity of keratoconjunctivitis sicca and to regain their VA.     

Importance of nutrition to corneal grafts when used as a carrier of the Boston Keratoprosthesis

PURPOSE: Necrosis, melt, and perforation have historically been frequent around a Keratoprosthesis (KPro), even resulting in extrusion or endophthalmitis. Autoimmune diseases such as Stevens-Johnson Syndrome (SJS) and Ocular Cicatricial Pemphigoid (OCP) have been notorious in this respect. The purpose of this study was to compare the frequency of tissue melt after implantation of two designs of the Boston KPro, one allowing much better access of nutrition from the aqueous humor to the carrier graft. METHODS: We retrospectively reviewed charts of 157 eyes implanted since 1990 with a poly (methylmethacrylate) Boston KPro, including 79 eyes implanted with the model having 8 small (1.3-mm diameter) holes in the back plate, and 78 eyes implanted with the older solid back plate. We compared the frequency of tissue melts between the two KPro designs, for all implants as well as for subgroups based on preoperative diagnosis. RESULTS: In total, 48/157 eyes (31%) developed some degree of tissue melt around the stem, including 8/79 eyes (10%) in the back plate with holes group and 40/78 eyes (51%) in the solid back plate group (P < 0.0001). Among the melts in the back plate with holes group, 4/8 (50%) suffered from an underlying autoimmune disease such as SJS or OCP. CONCLUSIONS: The Boston KPro design with a back plate containing holes protects the overlying corneal tissue from necrosis and melts. This improved situation is likely due to increased aqueous access and better nutrition to the corneal graft cells. In addition, this study confirms earlier work regarding the particular corneal fragility of patients with autoimmune diseases.     

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。     

国产化人工角膜植入兔眼的稳定性评估

目的 评价国产化人工角膜在兔眼角膜中的中长期稳定性.方法 实验研究.采用长耳大白兔10只,均选右眼作为国产化Moroz改良型永久性人工角膜植入眼,左眼为对照眼.手术分两期完成,一期手术用第三眼睑(软骨组织与人耳软骨有类似效果)加固角膜前层,联合自体结膜遮盖植入人工角膜支架;3个月后进行二期手术,植人人工角膜镜柱.全部手术完成后观察6个月以上.术后抗生素滴眼预防感染,定期观察,照相记录.最终行眼组织病理学检查.并与左眼进行对照.结果 除1只兔在二期术中因麻醉意外死亡外,9只兔均顺利完成手术和术后观察,术后各观察时间点人工角膜均在位,眼表血管化良好,未发生角膜组织融解、房水渗漏、高眼压、感染等严重并发症.组织病理学检查显示:加固的软骨组织均在位,人工角膜支架与周围组织紧密结合,有较活跃的纤维组织增生包绕,角膜炎症反应很轻.对侧眼无异常.结论 国产化人工角膜具有良好的生物相容性和中长期在位稳定性,用耳软骨加固和自体结膜遮盖有助于提高人工角膜稳定性.     

The Usage of a Conjunctival Flap to Improve Retention of Boston Type 1 Keratoprosthesis in Severe Ocular Surface Disease

Purpose: The Boston keratoprostheses type 1 devices (KPro) are utilized in cases unfavorable to penetrating keratoplasty. The prognosis remains guarded in cases of ocular surface disease due to risk of tissue necrosis. We describe a novel surgical approach using a conjunctival flap with a delayed opening to improve retention.

Methods: In three patients with advanced cicatrizing conjunctivitis, a Type 1 keratoprosthesis was stabilized using a full tarsal conjunctival flap. Three months postoperatively, an opening was created in the flap overlying the optical portion of the device.

Results: All patients had no device related complications over a mean follow-up period of 17.7 months (range 15-21 months) and vision remained excellent at better than 20/200 for all patients.

Conclusions: Utilization of a tarsal flap either primarily as part of a two stage modified technique or secondarily in cases of tissue necrosis and impending device extrusion might maximize retention of the type 1 KPro.     

Improving the practicality and safety of artificial corneas: Pre-assembly and gamma-rays sterilization of the Boston Keratoprosthesis

Purpose

To make the Boston keratoprosthesis (B-KPro), together with its carrier corneal graft, more easily procured, transported and stored, as well as less expensive, easier for the surgeon to implant and safer for the patient, it is proposed that the B-KPro-graft combination be pre-assembled by an expert technician, followed by sterilization with gamma ray irradiation (GI) allowing long-term storage at room temperature. For this to be possible, it must be shown that the B-KPro itself (not only the graft) remains unharmed by the irradiation.

部分环状板层角膜移植治疗蚕蚀性角膜溃疡

目的 观察部分环状板层角膜移植治疗早期药物治疗无效的进展性蚕蚀性角膜溃疡的临床疗效.方法 回顾性系列病例研究.10例(11眼)常规给予局部及全身免疫抑制剂和对症治疗1周及以上、病灶不断扩散的蚕蚀性角膜溃疡患者,行部分环状板层角膜移植手术,角膜供体选自部分穿透性角膜移植术后残留的环形供体角膜.手术方法:采用7.75～8.00 mm的环钻在角膜中央压痕,在彻底切除病灶后,覆盖与病灶范围相同的供体角膜.随访6～36个月,观察患者的视力、角膜植片愈合时间及是否复发等.采用重复测量方差分析比较手术前后视力变化.结果 患者裸眼视力术后1个月平均提高(1.36±1.21)行,术后3个月平均提高(1.72±1.47)行,术后6个月平均提高(1.86±2.04)行;最佳矫正视力术后1个月平均提高(0.46±0.93)行,术后3个月平均提高(0.73±1.10)行,术后6个月平均提高(1.55±1.75)行.手术前后裸眼视力(F=5.630,P＜0.05)与最佳矫正视力(F=5.925,P＜0.05)差异均有统计学意义.术后患者角膜植片上皮平均愈合时间为(7.00±5.31)d;1例患者术后角膜植片上皮愈合不良,行羊膜移植术后20 d愈合;1例患者术后19个月复发,行二次部分板层角膜移植.所有患者随访期间未发生免疫排斥反应等并发症.结论 使用环形供体角膜的部分板层角膜移植能有效控制早期药物治疗无效的蚕蚀性角膜溃疡的发展,保存视轴区透明角膜,术后视觉效果良好,同时节约角膜供体材料.     

Expanding Application of the Boston Type I Keratoprosthesis Due to Advances in Design and Improved Post-operative Therapeutic Strategies

Purpose:?To evaluate how the advances in design of the Boston type I keratoprosthesis and in the treatment strategies to conquer the post operative complications have expanded the indications and application of this technology.

Methods:?A review and analysis of the keratoprosthesis literature specifically examining design modifications, treatment of post operative complications, and patient selection was performed.

Results:?Over the past two decades, many modifications to the design of the Boston type I keratoprosthesis and treatment of the patient in the post operative period have occurred. Also, the technology has been more widely accepted as a primary surgical option for patients with a poor preoperative prognosis for traditional penetrating keratoplasty. The outcomes of visual acuity, retention, and post-operative infection rates have all significantly improved since the technology has been modified and offers patients an alternative for visual rehabilitation.

Conclusions:?Thanks to advances in design and perioperative care, the boston type i keratoprosthesis can now be considered a viable option for surgical visual rehabilitation in many patients with corneal pathology, and in certain groups the primary surgical procedure of choice.