白内障防盲行动中年轻医师的手术技能培养

眼科手术医师的技能培训多采用住院医师培训模式,其培训周期长、间断、技能重复训练率低、手术技能不稳定。我们探索的小切口白内障手术培训模式具备集中,实践性强,短时重复训练率高的特点。视频理论教学使学员对手术有整体连续性的认识;手术技巧训练顺序的合理安排使学员在保障手术安全性的条件下得到充分训练;PBL教学法有助于培养具有独立能力的手术者,安全控制机制的建立保障了患者手术安全性,也提高了学员的手术自信。     

Impact of Ocular Residual Astigmatism on Visual Outcomes of Myopic Astigmatism Correction after Small Incision Lenticule Extraction

Objective: To calculate ocular residual astigmatism (ORA) by vector analysis and to evaluate the impact of ocular residual astigmatism on refractive and visual outcomes after correction of myopic astigmatism by small incision lenticule extraction (SMILE). Methods: In this prospective case-series study, 115 eyes with myopic astigmatism were treated with SMILE from Jauary 2019 to August 2019 atRefractive Center of Ophthalmology Department, Shengjing Hospital, China Medical University. ORA was calculated by vector analysis and patients were divided into two groups according to the magnitude of ORA: high ORA group (ORA≥1.00 D) with 42 eyes and low ORA group (ORA<1.00 D) with 73 eyes. The follow-up period was 3 months after the operation. Uncorrected visual acuity (UCVA) and pythagorean length were measured and compared after the operation. The following measurements were compared: refractive outcomes, total higher order aberrations (tHOAs), vertical trefoil, vertical coma, horizontal coma, oblique trefoil, oblique quadrafoil, oblique secondary astigmatism, spherical aberration, vertical secondary astigmatism, and vertical quadrafoil. Contrast sensitivity was compared between the high and low ORA groups under either 85 cd/m2 or 3 cd/m2 illumination from 1.5 c/d to 18 c/d. The data were analyzed by an independent-samples t test and Mann-Whitney U test to compare the differences between the two groups. Results: Three months postoperatively, refractive outcomes showed that postoperative residual astigmatism in the high ORA group was significantly higher than in the low ORA group (t=3.293, P=0.001). Vector analysis showed that the error vector (EV), absolute error of angle (absolute EA) and index of success (SI) were higher in the high ORA group (t=-3.235, P=0.001; t=-2.326, P=0.020; t=-2.587, P=0.010). After SMILE，all cases had achieved a desirable visual acuity: high ORA group: -0.15±0.05, low ORA group: -0.15±0.05. There were no statistically significant differences in visual acuity, pythagorean length, tHOAs, vertical trefoil, vertical coma, horizontal coma, oblique trefoil, oblique quadrafoil, oblique secondary astigmatism, spherical aberration, vertical secondary astigmatism, or vertical quadrafoil between the two groups. An obvious difference was found in contrast sensitivity, which showed a higher contrast sensitivity at a spatial frequency of 18 c/d with 85 cd/m2 in the low ORA group than in the high ORA group (t=-2.877, P=0.005), but this tendency was not present at 3 cd/m2 . Conclusions: Ocular residual astigmatism impacts the precision of SMILE in correcting myopic astigmatism. This leads to a tendency of more residual astigmatism in refractive outcomes, and reduces contrast sensitivity at high spatial frequencies. However, it does not affect the outcome of obtaining good visual quality in both visual acuity and higher order aberrations.     

Merits of conjunctival frill incision in reducing trabeculectomy-induced astigmatism and patient discomfort

Purpose:To compare results of a novel “conjunctival frill/smile incision” on surgically induced astigmatism (SIA) and patient discomfort vs conventional trabeculectomy in the initial postoperative period.Methods:Sixty trabeculectomy cases were subjected to either conjunctival frill incision, performed 1.5–2.0 mm from the limbus (study group) or conventional fornix-based conjunctival flap (control group). Corneal astigmatism and suture-induced discomfort were assessed by keratometry and a self-devised patient questionnaire, respectively.Results:Both groups generated a “with the rule” SIA, which was 1.77 vs 2.42 at 1 week and reduced to 1.27 vs 1.8 in the study vs control group, after removal of sutures – both scleral flap releasable and conjunctival at 1 month. Patient discomfort score revealed enhanced comfort in 37% of patients (study group) vs 17% (control group) during the early postoperative period. After 1 month of surgery, good comfort was regained in all cases.Conclusion:This novel suturing technique results in reduced SIA, patient discomfort during the 1^st month after trabeculectomy.     

飞秒激光小切口透镜取出术治疗屈光不正后的角膜形态变化研究进展

飞秒激光小切口透镜取出术（small incision lenticule extraction,SMILE）作为目前最前沿的治疗屈光不正的激光手术方式,因其耗时短、并发症少、疗效好等优势而被广泛应用。SMILE在我国的开展已超过5 a,有很多针对其术后角膜形态变化的研究以检验手术的可靠性。本文将对SMILE术后的角膜形态变化进行综述。     

微切口超声乳化术对糖尿病合并白内障患者眼表的影响

目的：探讨白内障超声乳化手术中2.2及3.0mm透明角膜切口对2型糖尿病患者术后泪膜功能及眼表的影响。
　　方法：收集2015-01/10在我院接受超声乳化术的2型糖尿病患者150例150眼。按照随机数字表,将其分为两组,A组微切口组(75例75眼)行2.2mm透明角膜微切口白内障超声乳化术, B 组小切口组(75例75眼)行常规3.0 mm透明角膜切口白内障超声乳化术,两组资料的人口统计学特征差异无统计学意义。观察并比较两组患者术前及术后1wk,1、3、6mo的眼表疾病指数( ocular surface disease index,OSDI)、角膜知觉、泪膜破裂时间( break-up time,BUT)和基础泪液分泌试验( Schirmer’s Ⅰtest,SⅠt)指标的变化。
　　结果：术后1wk,1、3mo,两组患者的 OSDI 评分均高于术前,且B组的OSDI评分明显高于A组,差异有统计学意义(均P<0.05);两组患者的角膜知觉均较术前降低,且B组的角膜知觉明显低于A组,差异具有统计学意义(均P<0.05);两组患者的SⅠt均低于术前,且B组的SⅠt明显低于A组,差异具有统计学意义(均 P<0.05)。术后1wk,1mo,两组患者的BUT均低于术前,且B组的BUT明显低于A组,差异具有统计学意义(均 P<0.05)。术后6mo,A组患者的OSDI、角膜知觉、BUT和SⅠt与术前相比差异不明显,无统计学意义(均P>0.05);B组患者的OSDI评分和角膜知觉与术前相比差异明显,具有统计学意义(均P<0.05);BUT和SⅠt与术前相比差异不明显,无统计学意义(均P>0.05)。
　　结论：2.2mm透明角膜微切口对眼表及泪膜的影响较小,对并发白内障的2型糖尿病患者尤为适用。     

SMILE术后1个月患者瞳孔中心和角膜顶点实际角膜基质透镜厚度与预计厚度的差异

目的　探讨飞秒激光小切口角膜基质透镜取出术（SMILE）术后1个月患者瞳孔中心和角膜顶点实际角膜基质透镜厚度与预计厚度的差异。方法　选取2021年1月至4月在西安高新医院眼科屈光门诊行SMILE的患者66例（132眼）作为研究对象。分别于术前和术后1个月应用眼前节三维成像分析系统Pentacam测量患者瞳孔中心角膜厚度和角膜顶点厚度,检测患者视力及等效球镜度。将术前Pentacam检查结果作为“A图”,术后1个月检查结果作为“B图”,（A图－B图）数据即可得出每个坐标的角膜厚度差值,角膜厚度差值中瞳孔中心的差值(ΔCT_p)和角膜顶点的差值(ΔCT_v)即为实际角膜基质透镜厚度。角膜基质透镜厚度误差（E）=预计角膜基质透镜厚度-实际角膜基质透镜厚度,其中预计角膜基质透镜厚度为VisuMax飞秒激光手术设计软件预计的角膜厚度（LT）,瞳孔中心角膜基质透镜厚度误差E_p=LT_p-ΔCT_p;角膜顶点角膜基质透镜厚度误差E_v=LT_v-ΔCT_v。分析实际角膜基质透镜厚度与预计厚度的关系。结果　术后1个月所有患者均无角膜水肿及炎症反应发生,眼压正常;132眼患者裸眼视力均达到或超过术前最佳矫正视力。术后1个月132眼患者等效球镜度范围为-0.50 ~+0.50 D。患者ΔCT_p为43~133（86.83±16.81）μm,明显低于LT_p［55~130（96.89±15.92）μm］,差异有统计学意义（t=-17.71,P<0.01）。患者ΔCT_v为43~131（86.95±16.66）μm,明显低于LT_v［55~130（96.89±15.92）μm］,差异有统计学意义（t=-17.65,P<0.01）。患者E_p为-7~28（10.07±6.53）μm,E_v为-7~27（9.95±6.48）μm。实际角膜基质透镜厚度随着预计厚度的增加而增加。LT_p每增加1 μm,ΔCT_p增加0.97 μm ［y=-7.5+0.97x（R²=0.85,P<0.01）,x为LT_p,y为ΔCT_p］; LT_v每增加1 μm,ΔCT_v增加0.96 μm［y=-6.54+0.96x（R²=0.85,P<0.01）,x为LT_v,y为ΔCT_v］。结论　SMILE手术实际制作的角膜基质透镜厚度明显低于预计厚度,实际厚度与预计厚度呈线性关系;角膜顶点位置的检测结果与VisuMax手术设计软件所预计的角膜基质透镜厚度更接近。     

有限切开腱周内缝合法治疗新鲜闭合性跟腱断裂

目的探讨新鲜闭合性跟腱断裂有限切开腱周内缝合术的初步临床应用结果。方法对27例新鲜闭合性跟腱断裂患者采用有限切开腱周内缝合术修复跟腱。采用Amer-Lindholm疗效评定标准进行功能评价。结果平均随访32个月,无感染及跟腱再断裂,腓肠神经支配区皮肤感觉正常。功能评定：优23便（85．2％）,良4例（14．8％）。结论有限切开腱周内缝合法治疗新鲜闭合性跟腱断裂,能有效保护断端血运,创伤小,再断裂及感染机会少,功能恢复好,是治疗新鲜闭合性跟腱断裂的又一选择。     

腕管镜及改良小切口松解法治疗糖尿病腕管综合征的疗效分析

目的 探讨腕管镜腕管松解术和改良小切口腕管松解术治疗糖尿病腕管综合征的临床疗效和安全性差异.方法 回顾性分析腕管综合征合并糖尿病患者86例,其中43例患者行双孔道腕管镜腕管松解术(A组),43例患者行改良小切口腕管松解术(B组),随访10 ～ 24个月,统计两组患者的手术时间、住院时间、恢复工作时间、术后并发症和临床疗效.结果 A组和B组患者的优良率分别为93.02％和90.70％,两组的优良率比较差异无统计学意义(P＞0.05);A组患者的住院时间[(5.5±2.7)vs(6.8±2.9)d]及术后恢复工作时间[(19.3±3.1)vs(21.5±3.3)d]少于B组,差异有统计学意义(P＜0.05),而两组患者的手术时间、术后并发症发生率比较均差异无统计学意义(P＞0.05).结论 腕管镜腕管松解法和改良小切口腕管松解法均是治疗糖尿病腕管综合征的有效且安全的手术方法,腕管镜腕管减压术患者住院时间短、术后恢复快,对于机体修补能力较差的糖尿病患者更为适合.     

熟三七粉对妇科术后恢复的疗效影响

目的：观察熟三七粉对妇科术后伤口愈合及贫血恢复效果的影响。方法：按病例入选标准选择86例进行过妇科手术的患者,并依照病情程度作为控制因素随机分观察组43例,对照组43例。2组均施行手术,同时观察组术后加服熟三七粉,连服4周。连续治疗4周后,观察2组治疗后患者的刀口Ⅰ期愈合情况及治疗前后患者的外周血象变化情况。结果：观察组刀口Ⅰ期愈合率95.35%,对照组Ⅰ期愈合率65.12%,2组比较有统计学意义(P<0.05)。观察组患者的外周血象情况较治疗前明显好转;与对照组比较,观察组患者的红细胞(RBC)、血红蛋白(HGB)水平均有显著性升高,且差异具有统计学意义(P<0.05或P<0.01)。观察组治疗后总有效率为72.1%,明显高于对照组的37.2%,2组比较有统计学意义（P<0.05）。结论：熟三七粉对妇科术后患者的刀口Ⅰ期愈合情况及外周血象变化情况有明显的改善作用,能有效改善患者贫血状况,值得在临床推广。     

Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score–matched study

Anastomotic leakage (AL) after colorectal surgery is a serious complication. This study aimed to evaluate the effectiveness of the EEA™ circular stapler, a new triple-row circular stapler (TCS), relative to a conventional, double-row circular stapler (DCS).A total of 285 patients who underwent anastomosis with the double stapling technique at the Tokyo Medical University Hospital between 2017 and 2021 were included in this nonrandomized clinical trial with historical controls using a propensity score (PS) analysis. The primary endpoint was the risk of AL.We performed a 1:2 PS matching analysis. Before case matching, AL occurred in 15 (7.4%) and 2 (2.4%) patients in the DCS and TCS groups, respectively, with no significant difference (P = .17). After case matching, AL occurred in 13 patients (11.6%) and 1 patient (1.8%) in the DCS and TCS groups, respectively, revealing a significant difference (P = .04). Cox models were created by applying PS to adjust for group differences via regression adjustment. Odds ratios for AL in the DCS group versus the TCS group were 0.31 (95% confidence interval [CI]: 0.07–1.38) in the entire cohort, 0.15 (95% CI: 0.02–0.64) in the regression adjustment cohort, and 0.14 (95% CI: 0.02–1.09) in the 1:2 PS-matched cohort.PS analysis of clinical data suggested that the use of TCS contributes to a reduced risk of AL after colorectal anastomosis CTwith the double stapling technique.