非穿透小梁手术失败原因与再次手术部位选择

目的　观察非穿透小梁手术联合透明质酸生物胶植入术治疗开角型青光眼的临床效果 ,探讨手术失败原因和再次手术部位的选择。方法　对 13例 ( 13只眼 )非穿透小梁手术联合透明质酸生物胶植入术失败且药物控制眼压不佳的开角型青光眼患者 ,行滤过道再通术。再次手术前行超声生物显微镜 (ultrsoundbiomicroscopy ,UBM)检查 ,观察房水外流阻力发生部位 ,并予以解除 ;术中局部应用丝裂霉素 ;术后定期随访眼压。结果　UBM检查发现非穿透小梁手术联合透明质酸生物胶植入术失败后 ,虽然滤过泡实性变 ,但浅层巩膜瓣下仍有液腔存在。其中 9例因结膜瓣及浅层巩膜瓣瘢痕化造成房水外流受阻 ,深层巩膜床无明显瘢痕 ;3例非穿透小梁网表面增殖膜形成 ,其中 1例原非穿透小梁手术区范围过窄 ;1例原非穿透小梁手术处有微穿孔 ,虹膜根部与小梁相贴。再通术后随访6～ 2 4个月 ,平均 ( 14 0± 5 8)个月。随访期末 ,10例不用任何降眼压药物 ,眼压 <2 1mmHg( 1mmHg=0 133kPa) ,平均 ( 14 1± 3 7)mmHg;1例局部应用降眼压药 ,眼压控制在 15mmHg左右 ;2例再通术后 6个月手术失败 ,最终改行小梁切除术。 2例出现术后并发症 ,其中 1例前房积血 2mm ,术后 5d吸收 ;1例撕除增殖膜时 ,小梁穿孔 ,再行小的虹膜根部切除。结论　结膜瓣

The failure causes of non-penetrating trabecular surgery and reoperation

OBJECTIVE: To study the failure causes of non-penetrating trabecular surgery (NPTS) with SKGeL (a hyaluronic acid biological gel) implant and the surgical method of reoperation. METHODS: Repeated operation with mitomycin (MMC) through the initial surgical site was performed on 13 failure cases (13 eyes) that had undergone NPTS with SKGeL implant. The blockage of filtration tract was removed and the anterior chamber was intact during the surgery. All of these cases were open-angle glaucoma. Before the repeated surgery ultrasound biomicroscopic (UBM) examination was performed on the primary filtering bleb, and the intraocular pressure (IOP) examination was followed after the repeated operation. RESULTS: The mean follow-up period was (14.0 +/- 5.8) months (6 to 24 months). The examination of UBM showed that the filtering bleb disappeared and there was a liquid chamber under the superficial scleral flap in every failure case. The filtration failure due to the scarring at conjunctiva-Tenon's capsule-superficial scleral flap interface in 9 cases, proliferative membrane formation on the trabecular surface in 3 cases, micro-penetration of the trabecula in 1 case. At the end of follow-up, the IOP of 10 cases was lower than 21 mmHg without medication, the mean IOP level was (14.1 +/- 3.7) mm Hg, the IOP of 1 cases was 15 mmHg with Betagen, another 2 cases failed again 6 months after the repeated surgery and underwent the trabeculectomy at last. The complications included hyphema in one case and micro-penetration of the tabecula in one case. CONCLUSIONS: The scarring at conjunctiva-Tenon's capsule-superficial scleral flap interface was the most important cause of NPTS with SKGeL implant failure. A repeated surgery with MMC through the initial surgical site may be a choice for the failure cases.