Four-year experience with argon laser trabecular surgery in uncontrolled open-angle glaucoma

Eighty-two phakic eyes with uncontrolled open-angle glaucoma underwent 360 degrees argon laser trabecular surgery. There was a 77% success rate with a mean follow-up of 24 months in the successful group. A glaucoma diagnosis of exfoliation syndrome or open-angle glaucoma, an age greater than 60, and a baseline pressure of less than 26 mmHg were each associated with an increased success rate. The mean pressure change in the treated eye reached its maximum at two months, with a 9.7 mmHg decrease, and the pressure lowering effect slowly decreased with time to a 5.9 mmHg decrease at 42 months. It increased again at 48 months. Failure occurred within two years in 18 of the 19 eyes, and the remaining eye failed at 36 months. Long-term tonographic data shows significant improvement in outflow through 30 months. Argon laser trabecular surgery continues to enjoy an excellent risk-vs-benefit ratio, but its use should still be limited to patients with uncontrolled open-angle glaucoma on maximum medical therapy who are surgical candidates.     

Neodymium:YAG laser trabeculopuncture in juvenile open-angle glaucoma

The authors performed neodymium:YAG (Nd:YAG) laser trabeculopuncture (YLT) in eight eyes of six patients with uncontrolled juvenile open-angle glaucoma. Two methods of treatment were evaluated: either two confluent trabeculotomies, each 1 clock hour in extent; or focal treatment in four quadrants. In six eyes (75%), the intraocular pressure (IOP) was controlled (less than or equal to 19 mmHg) after a mean follow-up period of 6 +/- 2 months. All successful treatments were associated with blood reflux from the site of trabeculopuncture into the anterior chamber at the time of the procedure. Energy levels required for a single trabeculotomy (1 clock hour in extent) and for one focal trabeculopuncture, were 156 +/- 59 mJ and 42 +/- 24 mJ, respectively. The clinical results suggested that confluent trabeculotomy may be superior to focal treatment. No major complications were encountered with either treatment. The authors propose the use of YLT in uncontrolled juvenile glaucoma before surgically invasive goniotomy or filtration operations.     

一期粘弹剂小管切开术治疗青少年开角型青光眼

目的 评价一期粘弹剂小管切开术治疗药物难控性青少年开角型青光眼(juvenile openangle glaucoma,JOAG)的有效性和安全性.方法 研究17例JOAG患者的18眼,其JOAG患者经连续药物治疗未能有效控制病情,故一期行粘弹剂小管切开术,此前无相关手术史及激光治疗史.手术大体成功的判断标准为:术后眼内压(intraocular pressure,IOP)≤20mmHg,与用药和不用药时的基线IOP相比:IOP下降30%;无视盘凹陷进行性加深;无视野进行性受损.当再不需要药物治疗时,认为手术完全成功.未达到以上标准,需要手术矫正或进一步行前房穿刺的病例视为治疗失败.患者术后平均随访时间为(15±7.64)m.结果 术前平均IOP为(29.56±12.72)mmHg,术后平均IOP为(16.08±9.19)mmHg,两者之间存在着显著的统计学差异(t=16.20,P＜0.001).术后随访(12～18)m,15眼(83.3%)获得大体成功.10例(55.6%)为完全成功.3例(16.7%)失败.术中、术后均未发生严重的并发症,有2例(11.1%)自发出现了少量可吸收的前房出血.2例(11.1%)出现小梁网-狄氏膜的微小穿孔,另外1例(5.6%)因小梁网-狄氏膜穿孔伴虹膜脱出而需行虹膜周边切除术.结论 对于药物难控性JOAG,一期粘弹剂小管切开术是一种安全有效降低IOP的治疗方法,是一种合理的、可代替传统术式的治疗方法.     

Nd:YAG激光房角穿刺治疗非穿透性小梁手术后高眼压

目的观察评估Nd:YAG激光行房角穿刺治疗非穿透性小梁手术后眼压控制不理想的原发性开角型青光眼患者的临床疗效。方法选取非穿透性小梁手术后眼压控制不理想(不用降眼压药物眼压>21mmHg,1kPa=7.5mmHg)的原发性开角型青光眼患者35例(38眼)为研究对象,硝酸毛果芸香碱缩瞳后,在激光房角镜下原手术部位行Nd:YAG激光房角穿刺,观察激光前及激光后1h、1d、1周、1个月、3个月、6个月、12个月、18个月、2a时的眼压、滤过泡、房角及前房反应情况。结果激光前及激光后1h、1d、1周、1个月、3个月、6个月、12个月、18个月、2a的眼压分别为(25.0±3.4)mmHg、(12.5±3.4)mm-Hg、(12.0±3.2)mmHg、(13.1±3.0)mmHg、(14.0±3.1)mmHg、(14.1±2.7)mmHg、(14.3±2.9)mmHg、(15.3±2.6)mmHg、(16.2±2.8)mmHg、(16.0±3.0)mmHg,激光后各时间点眼压均较激光前下降,差异均有统计学意义(均为P<0.01)。其中10眼激光后眼压、滤过泡无明显改善,28眼滤过泡形成或原滤过泡面积、隆起度增大;激光后发生浅前房2眼(5.3%),虹膜周边前粘连2眼(5.3%),无前房出血、脉络膜脱离等并发症发生。结论 Nd:YAG激光房角穿刺能够安全有效地改善非穿透性小梁手术后小梁网-狄氏膜的房水低滤过状态,是非穿透性小梁手术后高眼压治疗的有效方法。     

非穿透性小梁手术治疗青少年开角型青光眼

目的探讨非穿透性小梁手术（NPTS）联合透明质酸钠生物胶（SK胶）植入治疗青少年开角型青光眼的临床疗效。方法对12例（22眼）青少年开角型青光眼采用非穿透性小梁手术联合SK胶植入,术中应用抗代谢药物。术后观察视力、眼压、滤过泡、眼底杯/盘、视野及手术并发症。随访36～44个月,并在末次随访时行超声生物显微镜（UBM）检查。结果手术1周及随访末次平均眼压分别为（10.27±1.38）mmHg,（16.18±7.69）mmHg,与术前平均眼压（29.38±12.56）mmHg相比,差异均有统计学意义（分别为t=6.65,P〈0.01和t=2.71,P〈0.01）。术后22眼均形成显著弥散滤过泡,末次随访时10眼（45.50%）可见扁平稍弥散滤过泡,12眼（54.50%）手术区瘢痕形成,未见滤过泡;视力提高2行及以上者5眼,不变者17眼,无视力下降。眼底杯/盘减小者6眼,不变者16眼;视野改善者6眼,不变者16眼,无视野损害进行性加重。结论非穿透性小梁手术联合透明质酸钠生物胶植入治疗青少年开角型青光眼疗效确切,并发症少,可作为青少年开角型青光眼的首选术式。     

选择性激光小梁成形术治疗原发性开角型青光眼的一年疗效观察

目的研究选择性激光小梁成形术(SLT)治疗原发性开角型青光眼的安全性和有效性。设计回顾性病例系列。研究对象47例62眼早期原发性开角性青光眼患者。方法所有患者应用Q开关、倍频532 nm、Nd:YAG激光器(Selecta Duet型)行SLT治疗,范围下方房角180度,50个点,单脉冲能量0．5～1．4mJ。激光手术前后抗青光眼药物保持不变。随访12个月。主要指标眼压与并发症。结果在62眼中有72．5%眼压控制。SLT术前平均眼压(24．3±3．7)mmHg,手术后12个月的平均眼压(19．1±3．9)mmHg,眼压的下降差异有统计学意义(P＜0．001)。所有病例在手术后1小时均出现轻度前房炎症反应,3天后消失。结论SLT治疗早期原发性开角型青光眼随访一年是安全有效的。(眼科,2007,16:37-39)     

激光小梁成形术前后对原发性开角型青光眼患者昼夜眼压变化影响

目的 评价选择性激光小梁成形术(Selective laser Trabeculoplasty SLT)对原发性开角型青光眼(primary open-angle glaucoma,POAG)昼夜眼压的影响.方法 POAG患者40例76只眼.倍频Q-开关532nm Nd YAG激光,3ns单脉冲,光斑直径400μm,激光击射下方180°范围小梁组织,能量0.53～0.89mJ,点数60～100点.气动眼压计测量术前及术后12周昼夜眼压,两组数值比较采用配对t检验.结果 术前平均眼压(21.6±2.87)mmHg(1mmHg=0.133KPa),术后平均眼压(18.7±1.36)mmHg,两组比较P＜0.05(t=7.69);手术前后6am点术眼眼压降低最明显,为6.9 mmHg.术前眼压高峰出现在6am,波谷最低在10pm,昼夜眼压波动6.4 mmHg;术后眼压高峰移至12时,最低在22时,昼夜眼压波动3.2 mmHg.结论 SLT治疗原发性开角型青光眼安全、可靠,可有效降低POAG患者的平均眼内压,降低昼夜眼压波动.     

选择性激光小梁成形术治疗开角型青光眼的研究进展

选择性激光小梁成形术（selective laser trabeculoplasty,SLT）采用倍频Q开关Nd：YAG激光,选择性作用于色素小梁网,而对邻近无色素小梁网不产生热损伤和凝固性破坏,目前对其作用机制的研究多集中于细胞因子的作用和后基因水平的改变.在SLT问世之初主要应用于原发性开角型青光眼的治疗,随着对其研究的深入,近年来SLT又被证明对其他类型的开角型青光眼也是安全有效的.在传统治疗参数的基础上,有学者认为低能量激光可以取得更好的疗效.目前已证实的影响SLT的降压效果的因素为基线眼压,基线眼压越高,效果越好.SLT术后常见的并发症包括一过性眼压升高、前房炎性反应以及结膜充血等.SLT的治疗能量与范围的选择、是否能替代传统的药物治疗而作为原发性开角型青光眼患者的初始治疗方法及其与药物配合治疗的最佳方案等问题仍需进一步研究探讨.     

倍频Nd∶YAG激光联合YAG激光治疗闭角型青光眼

目的:观察倍频Nd∶YAG激光联合YAG激光行周边虹膜切除术治疗急性闭角型青光眼的疗效及并发症。方法:本组共105例,其中临床前期91眼,先兆期32眼,间歇期46眼,均先使用倍频Nd∶YAG激光在拟行周边虹膜切孔处分层射击,最后用YAG激光穿透造孔,随访12mo,观察疗效及并发症。结果:术后1～6h眼压暂时性升高,24h后眼压下降,虹膜周切孔均通畅,房角无粘连,3眼周切孔处局限性晶状体混浊。结论:倍频Nd∶YAG激光联合YAG激光行周边虹膜切除术是防止闭角型青光眼急性发作的安全有效的手术。     

The effect of argon laser trabeculoplasty on the medical control of primary open-angle glaucoma

Argon laser trabeculoplasty was performed in 33 eyes with primary open-angle glaucoma whose intraocular pressures were poorly controlled on medical therapy. Five eyes (three patients) were failures and underwent trabeculectomy within three months. The remaining 28 eyes were followed up for 18 months and received a complete examination at periodic intervals. Beginning three months after trabeculoplasty, an attempt was made to decrease medications in a prospective manner in order to determine the least treatment required to maintain a pressure of less than 22 mmHg. No medication could be discontinued in 39% of eyes, whereas 18% were "cured" by trabeculoplasty and required no further medical therapy for control. Nine of 14 eyes that had been treated with carbonic anhydrase inhibitors were controlled without these drugs after trabeculoplasty. In 57% of eyes, the miotic could be discontinued. A total of 82% of cases still required some medication for pressure control after laser trabeculoplasty.     

Photoablative filtration surgery with the excimer laser for primary open-angle glaucoma: a pilot study

We have performed ab-externo photoablative filtration surgery on 19 patients affected by uncontrolled primary open-angle glaucoma. All cases had wide open angles, were previously treated with argon laser trabeculoplasty and were considered good candidates for trabeculectomy. After topical and peribulbar anesthesia, a limbus-based conjunctival flap was dissected. Photoablation of a rectangular area at the limbus was performed with an argon fluoride excimer laser (193 nm), at 180mJxsq cm fluence. The beam was shaped in the appropriate fashion using a custom-made metal mask. Photoablation was continued until aqueous appeared percolating through the juxtacanalicular tissue at the bottom of the crater; a water-tight closure of conjunctiva was then performed. Postoperatively, the anterior chamber reaction was minimal; in no case a flat chamber or choroidal detachment was observed. In 18 of the 19 cases the IOP was significantly lowered, and a filtering bleb developed. Mean preoperative IOP was 26.4 (±7) mmHg. At a median follow-up of 9 months (range 4–15) the IOP is<18 mmHg on no medications in 16 (84%) of the eyes, with a mean value of 13.3 (±6) mmHg. Our short-term results support excimer laser photoablative filtration as a relatively safe and effective procedure for primary open-angle glaucoma.     

A review of argon and selective laser trabeculoplasty as primary treatments of open-angle glaucoma

It is generally accepted within the ophthalmic community that medical therapy is the preferred primary treatment in open-angle glaucoma, followed by laser trabeculoplasty if the medical therapy is unsuccessful, with surgery employed more as an end-stage option when these avenues have been exhausted. This review discusses the efficacy of argon laser trabeculoplasty, alone and in comparison with medical therapy as a primary treatment of glaucoma. It will also discuss the new laser technique, selective laser trabeculoplasty.     

Intraocular pressure the day of argon laser trabeculoplasty in primary open-angle glaucoma

Argon laser trabeculoplasty was performed in one eye of 57 phakic patients with primary open-angle glaucoma. The eyes received a mean of 78 +/- 7 treatments over 360 degrees to the anterior trabecular meshwork. The power was titrated to produce blanching without bubble formation. Increased intraocular pressure (range +1 to +22 mmHg) occurred in 30 of the 57 (53%) eyes 1 hour after treatment. Eight (14%) of these eyes had a clinically significant elevation defined by all of three criteria: (1) an intraocular pressure greater than 30 mmHg, (2) greater than a 30% increase over the mean prelaser intraocular pressure, and (3) greater than a 10 mmHg increase over the peak prelaser diurnal intraocular pressure curve. These eight patients received either oral glycerine or acetazolamide. A rebound increase in intraocular pressure requiring repeat medical treatment occurred in four of the eight eyes. Two additional eyes without a pressure elevation 1 hour after treatment showed a later elevation. This was first detected 4 hours postoperatively in one eye and 7 hours after treatment in another eye. The 1-hour postoperative measurement detected most patients with clinically significant increased intraocular pressure (8 of 10 eyes) but these required continued observation for rebound increases. Patients with advanced glaucomatous visual field loss should also be followed closely to detect late increases in intraocular pressure (2 of 10 eyes).     

非穿透性小梁切除加羊膜移植治疗开角型青光眼

目的观察非穿透性小梁手术(nonperforating trabecular surgery,NPTS)联合羊膜移植的治疗效果。方法对106例136眼开角型青光眼患者行NPTS联合羊膜植片瓣下植入术,术后观察视力、眼压、眼内反应、滤过泡及并发症,并做前房角镜检查。结果术后眼压控制成功率为97.1％,不需辅用降眼压药物;术后眼压≥21mmHg者2.9％,应用降眼压药物眼压控制正常,眼压控制总有效率100％。功能性滤过泡69.4％,无滤过泡但眼压正常者17.7％;无滤过泡应用降眼压药物眼压控制正常者2.9％。术后视力提高1—2行。4眼发生前房少量出血,在48～72h内吸收;23眼前房内有轻度闪光,2～4d消失;无浅前房、角膜水肿、脉络膜脱离等并发症的发生。结论 NPTS能建立良好的多途径的房水引流,达到降眼压的目的;羊膜可有效地防止滤过泡的瘢痕组织形成,使滤过区滤过通畅,并能有效的长期保留功能性滤过泡;NPTS联合羊膜植片瓣下植入术提高了眼压控制成功率,是一种安全有效的新的抗青光眼手术方法。     

非穿透性小梁切除联合小梁切开术治疗原发性开角型青光眼

目的观察非穿透性小梁切除联合小梁切开术治疗原发性开角型青光眼的临床效果。方法对10例12眼原发性开角型青光眼患者行非穿透性小梁切除联合小梁切开术,术中应用丝裂霉素C,术后观察视力、前房反应、眼压、滤过泡情况,随诊时间3月。结果10例12眼术前眼压(36.6±11.8)mmHg(1kPa=7.5mmHg),术后1d(6.2±2.8)mmHg,术后1周(7.3±3.7)mmHg,术后2周(9.6±4.2)mmHg,术后1月(12.7±4.7)mmHg,术后2月(11.5±4.2)mmHg,术后3月(12.2±4.4)mmHg。术后视力均达到或高于术前水平。12眼均有功能型滤泡。术中、术后均未出现浅前房及前房炎症反应。有1例术中少量前房出血,于术后1d全部吸收。结论非穿透性小梁切除联合小梁切开术能安全、有效地治疗原发性开角型青光眼,成功率高于单纯性非穿透性小梁手术。     

非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼

目的 评价非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼的临床效果。方法 16例(16眼)继发性开角型青光眼,行非穿透小梁手术联合羊膜植入术。术后观察眼压、滤过泡、眼内反应及视力等情况。随访6～24个月。结果 术后1、3、6、12和24个月的眼压(单位:mmHg)分别为:13.52±4.71、16.30±4.11、16.38±4.26、16.54±4.39和17.6±4.58,与术前眼压46.24±9.32相比,差异有非常显著性(P<0.01)。随访期间2眼眼压>21mmHg,其中一眼局部用药可控制,另一眼接受再次手术。75％眼可见显著弥散的滤过泡。无手术并发症发生。术后早期视力不稳定,1个月后有不同程度提高。结论 非穿透小梁手术联合羊膜植入治疗继发性开角型青光眼是一种理想的方法,比经典小梁切除术更优越。     

激光虹膜成形术联合YAG激光与传统小梁切除术治疗闭角型青光眼的疗效比较

目的：探讨激光虹膜成形术联合YAG激光治疗青光眼与传统小梁切除术治疗青光眼的临床效果。

方法：回顾性分析60例60眼闭角型青光眼患者临床资料,行激光虹膜成形术联合YAG激光虹膜切开术者纳入观察组(38例38眼),行传统小梁切除术者纳入对照组(22例22眼)。比较术前和术后1、3、12mo时,两组患者眼压(intraocular pressure,IOP)、房角开放距离(angle open distance,AOD500)、中央前房深度(anterior chamber depth,ACD)、角膜内皮细胞密度(corneal endothelial cell density,ECD)变化,分析术后12mo内两组患者并发症发生情况。

结果：术后1、3、12mo时,两组患者IOP水平均较术前有显著下降,且观察组明显低于同期对照组(P<0.05); 观察组患者AOD500、ACD水平均较治疗前有显著提升,且明显高于同期对照组(P<0.05); 观察组患者ECD水平与术前比较均无统计学意义(P>0.05),但明显高于同期对照组(P<0.05)。术后12mo内,观察组患者并发症总发生率明显低于对照组(P<0.05)。

结论：激光虹膜成形术联合YAG激光治疗青光眼可获得较为理想的治疗效果,其安全性较传统小梁切除术更佳,有利于患者预后眼功能恢复。     

Nd:YAG激光虹膜切除术治疗葡萄膜炎继发闭角型青光眼

目的 评价Nd：YAG激光虹膜切除术治疗葡萄膜炎继发闭角型青光眼的临床效果。方法 回顾性分析27例葡萄膜炎继发瞳孔阻滞闭角型青光眼经Nd：YAG激光虹膜切除术治疗的情况。随诊时间2月到4年。结果1)一次激光所有患眼均成功击穿虹膜。虽经术后积极抗炎治疗．12眼(44％)发生虹膜孔关闭。多次激光治疗后，最终89％的患眼获得了通畅的激光孔。2)在46次激光治疗中，击射点数为3～376点，激光能量为12～2077mJ。所用激光能量较原发闭角型青光眼高。3)75％的患眼激光治疗后眼压控制正常，6只眼(22％)眼压不能控制行滤过手术。4)激光手术的并发症主要是激光时虹膜的出血和暂时的眼压升高。5)术前有活动性炎症的患眼，发生激光孔闭合的比例更高。结论 Nd：YAG激光虹膜切除术是治疗葡萄膜炎继发闭角型青光眼的一种安全有效的方法。为提高手术的成功率，应在积极抗炎的同时，尽早行激光虹膜切除术。若激光后虹膜孔反复关闭，应考虑手术周边虹膜切除术。     

选择性激光小梁成形术治疗原发性青光眼

目的评价选择性激光小梁成形术治疗原发性开角型青光眼(primaryopenangleglaucome,POAG)及原发性闭角型青光眼(prionaryangleclosureglaucome,PACG)虹膜周切术后残余青光眼的疗效和安全性。方法前瞻性、非随机性选择局部用药眼压不能控制的原发性开角型青光眼患者(13例16眼),或已行周边虹膜切除或激光虹膜打孔术,房角大部开放而眼压高的原发性闭角型青光眼患者(22例32眼)。应用选择性激光小梁成形术治疗。观察患者术后6个月眼压的变化。结果两组患者的眼压在激光治疗后均有显著下降:POAG组由术前的(25.3±3.9)mmHg降低至术后6个月的(18.0±4.2)mmHg;PACG组由术前的(23.9±3.0)mmHg,降低至术后6个月的(18.8±3.8)mmHg(1kPa=7.5mmHg)。术后暂时的眼压升高为最常见的并发症。结论选择性激光小梁成形术不仅可用于原发性开角型青光眼的治疗,也可以作为治疗残余闭角型青光眼的一种安全有效的方法。