结膜下注射CTGF抗体对兔青光眼滤过手术后眼压和滤过泡面积的影响

目的:探讨结缔组织生长因子(connective tissue growth factor,CTGF)抗体对兔青光眼滤过手术后滤过泡瘢痕化的抑制作用。方法:家兔5只双眼制作青光眼滤过手术模型。随机选取家兔一眼作为抗体组,分别于手术完成当时和术后5d结膜下注射0.1mL浓度为50mg/L的CTGF抗体;另一眼作为对照组在相同时间点结膜下注射0.1mL磷酸盐缓冲液。术后1,3,5,7,10,14d分别观察滤过泡形态并测量其面积和眼压值。结果:术后7,10和14d抗体组滤过泡面积均大于对照组(P<0.05),眼压均小于对照组(P<0.05)。结论:结膜下注射CTGF抗体可维持兔眼滤过手术后较大的滤过泡面积和较低的眼压。     

结膜瓣大小对小梁切除术后滤过泡形态及眼压的影响

目的:探讨以穹隆部为基底的不同大小结膜瓣切口对小梁切除术后滤过泡的形态及眼压的影响。方法:选择施行小梁切除术的患者61例66眼,根据结膜瓣大小不同随机分为两组,A组33眼为大结膜瓣(3个时钟范围),B组33眼为小结膜瓣(2个时钟范围),密切随诊观察术后滤过泡的形态及眼压情况。结果:术后功能性滤过泡形成率A组(91%)>B组(73%);眼压控制率A组(94%)>B组(76%)。结论:采用以穹隆部为基底的大结膜瓣可提高小梁切除术后功能性滤过泡形成率,从而能更好地控制眼压。     

Effect of phacoemulsification on intraocular pressure and bleb function in eyes with previous trabeculectomy

AIM: To observe the intraocular pressure (IOP) control and bleb function after phacoemulsification in patients with previous history of successful/qualified success mitomycin-C augmented trabeculectomy. METHODS: This was a retrospective cohort study. Data of patients who had undergone trabeculectomy with subsequent cataract surgery were extracted from server. All patients had previous either success/qualified success trabeculectomy done. They went through uncomplicated phacoemulsification via clear corneal incision. Postoperative follow-up, review of bleb and IOP readings using Goldmann tonometer were taken. Details that were investigated include postoperative IOP control, visual improvement, number of anti-glaucoma medications, as well as the timing from trabeculectomy to phacoemulsification. Comparison with control group was made. RESULTS: Fifteen eyes from thirteen patients fulfilled the criteria for study and had undergone uncomplicated phacoemulsification between January 2014 to June 2016 on a post-trabeculectomy eye. Two of the eyes had secondary glaucoma while the other thirteen had primary glaucoma. All phacoemulsifications were done at least 6mo after trabeculectomy (mean 14.7±4.3mo). There was only 1 eye (6.7%) requiring anti-glaucoma medications before the cataract surgery. This number increased to 4 (26.7%) at 1-year post phacoemulsification. The number further increased to eight (53.3%) at 2y post-phacoemulsification. The number of anti-glaucoma drops needed after surgery at 2y ranged from 2-4. In all the 15 eyes, there was no statistically significant change in IOP control between pre-cataract surgery (mean 13.4±2.9 mm Hg) compared to 1y (mean 14.1±3.2 mm Hg, P=0.357) and 2y (mean 15.1±3.3 mm Hg, P=0.212) post phacoemulsification. Visual improvement after phacoemulsification however is significant, from a preoperative average visual acuity of logMAR 1.52±1.00 to a postoperative average visual acuity of 0.53±0.54 (P=0.000, paired t-test). CONCLUSION: This analysis shows significant visual improvement following cataract surgery in post-trabeculectomy patients without compromising IOP control. However, a reduced bleb function is noted following the surgery evidenced by the increase in number of anti-glaucoma drops used after surgery especially two years after the cataract surgery. Patients should be counselled regarding the possibility of restarting on anti-glaucoma medications post-phacoemulsification. The timing and sequence of cataract and glaucoma surgery should be optimized for best outcome.     

超声乳化术对小梁切除术患者眼压及滤过泡功能的影响

目的：观察使用丝裂霉素C小梁切除术成功/合格史的患者超声乳化术后眼压(IOP)控制及滤过泡功能。

方法：回顾性队列研究。收集2013-01-01/2015-12-31期间接受小梁切除术并随后进行白内障手术患者的数据。所有患者都曾成功/合格地进行过小梁切除术。他们通过透明角膜切口进行了简单的超声乳化手术。用Goldmann眼压计进行术后眼压随访,复查滤过泡情况。观察术后IOP控制、视力改善、抗青光眼药物的数量以及从小梁切除术到超声乳化术的时间,并与对照组进行比较。

结果：共13例15眼患者满足了研究标准,并且在小梁切除术后进行了简单的超声乳化术。其中2眼为继发性青光眼,13眼为原发性青光眼。所有的超声乳化术均在小梁切除术后至少6mo进行(平均14.7±4.3mo)。白内障术前仅1眼(6.7%)需要抗青光眼药物治疗,超声乳化术1a后,增加到4眼(26.7%),超声乳化术2a后,进一步增加到8眼(53.3%)。术后2a所需抗青光眼药水的数量在2～4种之间。在15眼中,白内障术前(平均13.4±2.9 mmHg)与超声乳化术后1a(平均14.1±3.2 mmHg,P=0.357)和2a(平均15.1±3.3 mmHg,P=0.212)的IOP控制无显著性差异。然而,术前平均LogMAR视力为1.52±1.00, 术后平均视力为0.53±0.54,超声乳化术后的视力改善是显著的(P=0.000)。

结论：结果显示,在不影响眼压控制的情况下,小梁切除术后白内障患者的视力明显改善。然而,手术后,特别是白内障手术后2a,抗青光眼眼药水的使用数量增加,证明了术后滤过泡功能的降低。白内障超声乳化手术后,患者应该被告知重新开始服用抗青光眼药物的可能性。白内障和青光眼手术的时机和顺序应优化,以获得最佳的手术效果。     

青光眼滤过术后滤过泡的观察方法

青光眼滤过术以其良好的控制眼压效果和较少的术后并发症成为临床上常用的抗青光眼手术方式之一。术后眼压的良好控制均依赖于建立和长期维持有功能的滤过泡。因此对术后滤过泡的形态、演化过程及其与临床功能间关系的研究就显得尤为重要。本文就滤过泡形态方面的相关问题做一综述。     

Can early postoperative intraocular pressure predict success following mitomycin-C augmented trabeculectomy in primary angle-closure glaucoma

Purpose

To evaluate the association between early and late postoperative intraocular pressure (IOP) and determine if early postoperative IOP can predict the surgical outcome.

Methods

A total of 165 consecutive patients with primary angle-closure glaucoma (PACG) undergoing primary mitomycin-C-augmented trabeculectomy underwent a comprehensive eye examination before surgery and were followed-up on days 1, 7, 14, and 30, and months 3, 6, 12, and 18. IOPs on days 1, 7, 14, and 30 were stratified into groups A (<10 mm Hg), B (≥10 and <15 mm Hg), C (≥15 and <20 mm Hg), and D (≥20 mm Hg). Differences between groups were analyzed using analysis of variance (ANOVA) and Fisher''s exact test. Multivariable regression was used to exam the predictive ability of early IOP for final outcome.

Results

The mean age was 62.5±7.9 years and 41.21% (n=68) were males. Stratified by IOP on days 1, 7, 14, and 30, respectively, mean IOPs at month 18 were different among groups A, B, C, and D (ANOVA, P=0.047, P=0.033, P=0.008, and P<0.001, respectively). Once the IOPs were settled with interventions on day 7 a higher IOP level was associated with decreasing success rate under different outcome definitions, final IOP <15 mm Hg (Fisher''s exact P=0.001) and <20 mm Hg (P=0.039) without medication. Multiple regression showed early IOP predicted final IOP independently from baseline variables. A cutoff value of 13.5 mm Hg on day 7 achieved an accuracy of 80.0 and 57.1% in predicting IOP<15 mm Hg without medication and failure after surgery, respectively.

Conclusions

The IOP at 18 months following primary antifibrotic-augmented trabeculectomy in PACG patients is associated with and predicted by the postoperative IOPs at 1 month. Control of early IOP to 13.5 or less may provide better outcomes.     

活动期葡萄膜炎性青光眼患者接受小梁切除术后的炎症反应及眼压情况

目标:分析活动期葡萄膜炎患者在小梁切除术后的炎症反应及眼压情况.方法:我们回顾了2006-10/2011-03期间,接受了小梁切除术的活动期葡萄膜炎性青光眼患者纪录.手术前后的炎症反应、复发频率、类固醇依赖度及眼压均以配对t检验作比较.结果:在29例29眼患者中,90％的患眼在手术时正在接受局部类固醇治疗.患者平均年龄为58.3±14.0a,术前眼压为35.7±8.9mmHg.患者平均复诊时期为35.2±18.7mo.术后3mo前房炎症反应分级平均减少了0.4±0.6(P＜0.01).复发频率在复诊期内每年减少了2.3±2.1次(P＜0.01).术后1a的平均眼压为13.1±4.5mmHg,而其中44.8％患者的眼压无需用药亦能维持在21 mmHg或以下.结论:小梁切除术后的葡萄膜炎性青光眼患者在炎症反应及眼压方面均有改善,但成功率较原发性青光眼患者低.小梁切除术可以作为活动期葡萄膜炎性青光眼患者早期控制眼压和炎症反应治疗的一个选择.     

下方小梁切除术治疗青光眼滤过术后眼压失控的疗效和安全性

目的：观察下方小梁切除术治疗青光眼滤过术后眼压失控的疗效和安全性。

方法：回顾性分析51例61眼青光眼滤过术后眼压失控行下方小梁切除术患者的资料,统计术前、术后眼压、视力和降眼压药物的数量,以及术中、术后并发症。采用Kaplan-Meier生存分析计算手术成功率。

结果：术后随访时间为6～76(平均30.15±14.10)mo。61眼术前眼压35.98±10.01mmHg,术后1wk,1、3、6mo,1a及末次随诊眼压分别为9.62±4.90、13.15±4.51、16.05±7.37、16.48±6.81、16.68±6.42、16.77±7.56mmHg,与术前眼压相比,均有差异(P<0.001)。术后6mo,1、2a的完全成功率分别是62%、49%、36%,部分成功率分别是93%、85%、81%,34眼(56%)形成功能性滤过泡,术前采用降眼压滴眼液3.33±0.77种,术后3mo降至1.41±1.44种(t=9.86,P<0.001)。术后未出现滤过泡感染、眼内炎等严重并发症。

结论：下方小梁切除术操作难度相对较大,但对于青光眼滤过术后眼压控制不佳的患者,仍可以作为一种安全有效的治疗方案。     

超声乳化术对小梁切除术后闭角型青光眼患者眼压的长期影响

目的评价超声乳化术对小梁切除术后闭角型青光眼患者眼压的长期影响。方法研究为系列病例观察性研究。选取已接受小梁切除术具有功能性滤过泡的原发性闭角型青光眼和年龄相关性白内障需行超声乳化术的患者19例,每例随机选择1眼进入研究。记录患者超声乳化术前,术后1、3、6个月,1年、2年的眼压和抗青光眼药物治疗情况。用Kaplan-Meier法计算生存率;比较术前、术后1个月、术后2年超声生物显微镜（UBM）对滤过泡和前房的生物测量值。结果共15例患者完成2年的随访,纳入的患者中2例因死亡、另2例因依从性差而失访。超声乳化术前及术后各随访时间点的眼压为（13.5±2.9）、（12.8±2.9）、（12.9±2.7）、（13.0±3.5）、（13.4±3.6）、（12.7±2.9）mmHg,差异无统计学意义（F=0.443,P=0.817）。超声乳化术后2年滤过泡的累积成功率为100%,绝对成功率为87%。UBM测量结果显示,术后前房深度加深,房角进一步开放的象限数量增加,滤过泡的高度下降,三者与术前比较差异均有统计学意义（Z=-3.411,P=0.001;χ2=8.775,P=0.006;Z=-2.927,P=0.003）,但滤过泡的反射率及滤过道差异无统计学意义,术后1个月和术后2年的形态学变化差异无统计学意义。结论长期随访显示,小梁切除术后的原发性闭角型青光眼患者进行超声乳化术眼压控制良好。     

原发性闭角型青光眼小梁切除早期滤过泡形态与24h眼压关系

目的 观察原发性闭角型青光眼小梁切除术后1个月时结膜滤过泡形态与术后24h眼压(IOP)的关系.方法 对46例施行小梁切除术的原发性闭角型青光眼患者进行随访观察.采用IBAGS滤过泡分级系统(Indiana Bleb Grading Scale,IBAGS)对术后1个月的滤过泡进行记录,应用Goldmann压平眼压计进行眼压测量.采用线性回归分析方法检验滤过泡与24 h眼压的关系,采用t检验的方法对有无微囊结构滤过泡的24 h眼压进行比较.结果 线性回归分析显示滤过泡高度(H)每增加1分术后24 h眼压波动值将降低0.60 mm Hg(95％可信区间为-1.183～-0.024),滤过泡范围(E)每增加1分术后24 h眼压波动值将降低0.66 mm Hg(95％可信区间为-1.193～-0.122),滤过泡面积(即大小H+E)每增加1分术后24 h眼压波动值将降低0.43 mm Hg(95％可信区间为-0.756～-0.109),术后具有微囊结构的滤过泡其眼压波动范围较无微囊结构者平均降低1.02 mm Hg(95％可信区间为-1.876～-0.156).具有微囊特征滤过泡的患者上午10点的IOP、24h IOP平均值、波动值、24 h IOP 最大值及最小值均较无微囊者为理想(P值分别为0.0058、0.0039、0.0019、0.0014、0.0211.),差异有统计学意义.所有患者中仅有一例发生滤过泡渗漏.结论 滤过泡形态与术后24 h眼压具有一定的相关性.滤过泡的高度,范围及面积对术后24 h眼压的影响最明显.同时具有微囊结构滤过泡的病例术后24 h眼压控制良好.     

Effect of dexmedetomidine on intraocular pressure as an additive in peribulbar block during glaucoma surgery

Purpose:The purpose of this study is to assess the effect of dexmedetomidine on intraocular pressure (IOP) as an additive in peribulbar injections in glaucoma surgeries.Methods:A prospective, randomized, double-blind, parallel assignment interventional study was conducted for patients undergoing glaucoma surgeries at a tertiary eye care hospital in North India. Patients were randomized to two groups, Dexmed group and Placebo group. In the Dexmed group, dexmedetomidine (0.4 μg/kg body weight) was given as an additive along with peribulbar block. The primary outcome was change in IOP pre- and postperibulbar injections (IOP before the block, and after 5 and 15 min of the block). Secondary outcome measures were onset of block, adverse effects (bradycardia, hypotension, respiratory depression, and level 4 sedation), and surgeon satisfaction.Results:A total of 104 patients were randomized, 52 each in the Dexmed group and Placebo group. The percentage decrease in IOP was significantly more in the Dexmed group than in the Placebo group both at 5 and 15 min'' post block (P < 0.05). At 5 min, the mean percent decrease in IOP in Dexmed group was -10.48, whereas it was 2.85 in the Placebo group. At 15 min, the mean percent decrease in IOP was -22.59 and -9.42 in the Dexmed and Placebo group, respectively. There was no significant difference between the two groups in the onset of block and adverse effects. Surgeon satisfaction was significantly greater in the Dexmed group than the Placebo group (P < 0.05).Conclusion:Dexmedetomidine lowers IOP significantly in patients undergoing glaucoma surgeries with safe hemodynamic changes and sedative effect.     

CTGF在兔眼深层巩膜切除术中的表达

目的:探讨结缔组织生长因子(connective tissue growthfactor,CTGF)在兔眼深层巩膜切除术(deep sclerectomy,DS)中的表达。方法:制备人去内皮冻干辐照脐带静脉管(HUV);选取28只大耳白兔,其中24只按自身对照原则,双眼均行深层巩膜切除术,随机选取一眼于术中植入HUV,为植入组;另一眼不植入,为未植入组。分别于术后3,7,14d各处死8只;另4只8眼做正常对照组。应用半定量PCR检测兔眼深层巩膜组织中CTGF mRNA的表达,免疫组织化学检测CTGF蛋白的表达。结果:植入组3d后,CTGF mRNA和蛋白表达开始升高,至7d表达水平达到峰值,14d时表达水平开始下降,明显高于对照组(P<0.01),未植入组中不同时间点表达水平变化与植入组类似。植入组与未植入组比较无统计学意义(P>0.05)。结论:HUV在兔眼DS中没有明显的抗纤维增殖的作用,其瘢痕增殖的过程与正常瘢痕形成的过程是一致的。其维持减压室作用机制可能是机械引流的作用结果;HUV作为一种植入物,并未刺激局部的瘢痕过度形成。     

VEGF对青光眼术后滤过泡瘢痕化影响的研究进展

血管内皮生长因子( vascular endothelial growth factor,VEGF)作为血管生成的一个重要调节因素,经过实验证实其在滤过泡瘢痕形成过程中占据着特殊的地位.本文就目前有关VEGF的生物学特征、VEGF在青光眼滤过泡瘢痕形成中的作用以及抗VEGF治疗在防治青光眼滤过泡瘢痕化中的应用等方面的研究进展作一综述.     

针刺分离联合结膜下注射5-FU治疗青光眼术后早期滤过泡功能不良

目的:探讨对于青光眼术后早期功能不良的滤过泡采用针刺分离联合结膜下注射5-FU的治疗效果。方法:青光眼滤过术后3mo内25眼功能不良的滤过泡采用针刺分离滤过泡周围纤维瘢痕,然后结膜下注射5-FU5～10mg,隔日1次共5次,分析治疗后眼压和滤过泡形态的变化及治疗后的眼部并发症。结果:25眼中,21眼眼压控制在21mmHg以下,其中18眼在15mmHg以下;滤过泡形态:有19眼表现为功能性滤过泡;并发症:常见并发症有角膜上皮损伤、结膜下出血、滤过泡损伤等。结论:对于青光眼术后早期功能不良的滤过泡采用针刺分离联合结膜下注射5-FU是安全、有效的。     

Changes in choroidal thickness,axial length,and ocular perfusion pressure accompanying successful glaucoma filtration surgery

Purpose

To investigate the changes in choroidal thickness (CT), axial length (AL), and ocular perfusion pressure (OPP) accompanying intraocular pressure (IOP) reduction after trabeculectomy.

Methods

Thirty-nine eyes of 39 patients with primary open-angle glaucoma uncontrolled by medical therapy were included in this prospective and interventional study. All patients underwent a fornix-based trabeculectomy. The CT was measured by enhanced depth imaging-optical coherence tomography. IOP, AL, and systolic/diastolic blood pressure were also measured, and OPP was calculated. All measurements were performed at baseline and 1 month after surgery.

Results

The mean IOP was 25.0±5.8 mm Hg at baseline and 11.7±2.6 mm Hg after trabeculectomy (P<0.001), and the mean subfoveal CT was 295±84 mm Hg at baseline and 331±82 mm Hg after trabeculectomy (P<0.001). The mean AL was 23.64±0.98 mm at baseline and 23.54±0.96 mm after trabeculectomy (P<0.001), whereas the mean OPP was 38.8±6.2 mm Hg preoperatively, and 51.1±7.3 mm Hg postoperatively (P<0.001). The change in CT negatively correlated with the change in IOP (r=−0.785, P<0.001) and AL (r=−0.693, P<0.001), whereas it positively correlated with the change in OPP (r=0.418, P=0.008).

Conclusion

These results suggest that the large IOP decrease following trabeculectomy causes choroidal thickening. In addition, CT changes are associated with IOP and AL reduction as well as OPP increase.     

丝裂霉素C对青光眼小梁切除术后眼内压和眼血流的影响

目的：：分析丝裂霉素C对青光眼小梁切除术后眼内压和眼血流的影响,探讨其有效性和安全性。方法：将103例青光眼患者随机分为两组,均给予青光眼小梁切除术,观察组在术中行丝裂霉素C抗瘢痕治疗;术后完成6~12 mo随访,对比两组患者的临床眼压控制疗效、并发症发生率及视网膜中央动脉血流动力学指标。结果：观察组临床疗效优于对照组(P<0.05);两组患者的总并发症发生率无统计学差异(P>0.05),但并发症类型有所区别,观察组多发生低眼压和畏光症状,对照组多发生瘢痕性阻塞。治疗前,两组患者的眼压动力学指标无统计学差异(P>0.05);治疗后1mo,观察组收缩期峰速( peak systolic velocity,PSV)与舒张末期血流速度( end diastolic velocity, EDV )明显低于对照组,阻力指数( resistance index,RI)与搏动指数( pulsatility index,PI)明显高于对照组,差异有统计学意义(P<0.05);治疗后6mo,观察组PSV与EDV明显高于对照组,RI与PI明显低于对照组,差异有统计学意义(P<0.05)。结论：丝裂霉素C对青光眼小梁切除术患者的术后不良影响时间较短,其长期疗效安全、可靠。     

体位改变对开角型青光眼小梁切除术后眼压波动的影响

目的:研究体位改变对开角型青光眼小梁切除术后眼压波动的影响,并探讨这一影响对预测预后的价值。方法:选择51例62眼原发性开角型青光眼患者为研究对象。以Perkins压平眼压计检测患者坐位(初坐位)眼压后,要求患者平卧25min,检测眼压,继而要求患者行坐位(终坐位),持续15min,检测眼压。按眼压极差是否≥5mm Hg将其划分为高波动组和低波动组。统计视野进展情况(以AGIS得分评价)、HPA分期,评价眼压极差与其相关性。每3mo复查,持续1a,评价眼压极差与AGIS得分变化趋势。结果:初坐位眼压18.1±2.2mm Hg,同一体位多时点眼压无显著差异(P>0.05),眼压极差4.1±1.5mm Hg;低波动组AGIS视野稳定者及HPA早期者显著多于高波动组(P<0.001;P<0.05),眼压极差与AGIS显著正相关(r=0.412,P<0.001);随时间延长,视野进展人数上升,眼压极差上升,且任意时刻两者间均呈显著正相关(P<0.01)。结论:小梁切除术后患者体位改变下眼压波动与视野进展程度有关,可通过检测眼压波动简单预测患者预后,从而调整眼压控制方案。     

雷公藤甲素防治青光眼术后滤过泡纤维化的可行性分析

青光眼滤过术是目前青光眼的主要治疗手段,滤过泡纤维化是导致治疗失败的主要原因。滤过泡纤维化是一种临床常见的纤维增生性病变,与成纤维细胞活化增殖及产生大量胶原蛋白等细胞外基质（ECM）有关。目前临床上防治滤过泡纤维化的药物主要是5-氟尿嘧啶（5-FU）和丝裂霉素C（MMC）,它们虽也有一定疗效,但存在着不同程度的副作用而限制了临床使用。雷公藤甲素（TPL）是中药雷公藤的主要活性成分,具有免疫抑制、抗炎、抗肿瘤、抗生育等多种药理作用。系统综述近十年发表的相关文献,我们认为TPL可能具有防治青光眼术后滤过泡纤维化的功效,这与其具有的三方面作用有关：（1）抑制成纤维细胞活化增殖及胶原蛋白合成;（2）减轻创伤后炎症反应,从而抑制术后纤维瘢痕形成;（3）对视网膜神经节细胞（RGCs）有一定的保护作用。TPL抗滤过泡纤维化作用机制可能与其抑制TGF-β/Smad、NF-κB及PI3K/AKT通路有关。本文对TPL防治青光眼术后滤过泡纤维化的可行性进行了充分的分析,对于我们开发新的抗滤过泡纤维化药物及拓展TPL的临床应用具有一定的指导意义。