本文關(guān)鍵詞：全植床深板層角膜移植術(shù)治療不同時期圓錐角膜的臨床療效分析　出處：《浙江大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 圓錐角膜 不同時期 全植床深板層角膜移植術(shù) 臨床療效分析

【摘要】：目的:評估全植床深板層角膜移植術(shù)(Full-bed deep lamellar keratoplasty,簡FB-DLKP)治療不同時期圓錐角膜的療效,分析不同時期圓錐角膜患者FB-DLKP術(shù)前術(shù)后各項指標的差異,包術(shù)前術(shù)后裸眼視力、最佳矯正視力、角膜厚度、散光、內(nèi)皮細胞密度、術(shù)中情況、術(shù)后并發(fā)癥等,并對其臨床療效進行評估。方法:回顧性研究數(shù)據(jù)分析2013年1月至2015年12月于我院行FBDLK的圓錐角膜患者共53人、56眼,并完整隨訪12個月的患者,根據(jù)Amsler-Krumeich的圓錐角膜分期標準將病例進行分期,將Ⅱ期及Ⅲ期分為A組,Ⅳ期為B組。觀察每一期病例的手術(shù)過程,比較各期之內(nèi)以及各期之間術(shù)前、術(shù)后1月、6月、12月隨訪時視力(裸眼視力及最佳矯正視力,對視力進行統(tǒng)計學(xué)分析時轉(zhuǎn)換為LogMAR視力)、內(nèi)皮細胞密度、角膜厚度的變化情況、術(shù)前及術(shù)后6月、12月散光變化、植片存活情況、術(shù)中情況、術(shù)后并發(fā)癥等。非正態(tài)分布的數(shù)據(jù)用中位數(shù)[四分位距]表示,各時期組內(nèi)的各隨訪使用配對非參數(shù)檢驗,如Wilcoxon符號秩檢驗、符號檢驗,各時期組間使用獨立樣本的非參數(shù)檢驗,如秩和檢驗。對于正態(tài)分布或近正態(tài)分布的數(shù)據(jù)用均數(shù)±標準差表示,用配對t檢驗進行統(tǒng)計學(xué)分析。結(jié)果:納入標準的共53人,56眼,左眼26例,右眼30例,其中男性35人,女性18人,患者年齡分布為14-41歲,平均年齡為22.68±7.17歲。滿足II期及III期的共有18眼,滿足IV期的有38眼。分析統(tǒng)計以上隨訪數(shù)據(jù)結(jié)果如下:術(shù)前B組有3眼(5.4%)為急性水腫后疤痕累及后彈力膜,但術(shù)中未發(fā)現(xiàn)疤痕重新裂開,術(shù)中2例(3.6%,A組B組各1例)發(fā)現(xiàn)厚彈力膜面微穿孔,并有少量房水涌出,予前房注氣。A組(II期及III期)術(shù)后1、6、12的裸眼視力分別為:0.75[0.54,0.90]、0.56[0.34,0.82]、0.52[0.40,0.67],有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。B組(IV期)術(shù)后1、6、12的裸眼視力分別為:0.56[0.40,0.90]、0.52[0.40,0.60]、0.40[0.22,0.60],有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。A組與B組之間比較術(shù)后各個隨訪時間點的裸眼視力統(tǒng)計學(xué)上無顯著性差異(秩和檢驗,P0.05)。A組術(shù)后1、6、12的BCVA分別為:0.34[0.24,0.40]、0.26[0.22,0.40]、0.26[0.11,0.35],有顯著性差異(Wilcoxon符號秩檢驗,P0.05),B組術(shù)后1、6、12的BCVA分別為:0.26[0.22,0.40]、0.22[0.15,0.30]、0.22[0.11,0.28],有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。B組與A組之間比較術(shù)后各個隨訪時間點的BCVA,二者無顯著性差異(秩和檢驗,P0.05)。術(shù)前A組和B組角膜厚度分別為:411[360,436]μm、357[319.75,371],有顯著性差異(秩和檢驗,P0.05)。術(shù)后A組各個隨訪時間點角膜厚度分別為 515[498.25,531.25]μm、467[458.5,493.25]μm、464[445.75、471]μm,有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。術(shù)后B組期各個隨訪時間點角膜厚度分別為539.5[515.5,566.5]μm、479.5[458.25,503.75]μm、467[449,504.75]μm,有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。術(shù)后各個隨訪時間點A組和B組角膜厚度相互比較均無顯著性差異(秩和檢驗,P0.05)。術(shù)前各組內(nèi)皮細胞數(shù)分別為:2322[2287,2587]cells/mm~2、2516.5[2326.50,2612.25]cells/mm~2,二者無顯著性差異(秩和檢驗,P0.05)。術(shù)后A組各個隨訪時間點內(nèi)皮細胞數(shù)分別為:2224.5[2013,2314.5]cells/mm~2、2253.5[2070.25,2311.5]cells/mm~2、2210[1850.5,2288.5]cells/mm~2,術(shù)后6月與術(shù)后1月比較無顯著性差異(Wilcoxon符號秩檢驗,P0.05),術(shù)后6月與術(shù)后12月比較有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。術(shù)后B組各個隨訪時間點內(nèi)皮細胞數(shù)分別為2217[2013.5,2374]cells/mm~2、2166,5[1990,2311.5]cells/mm~2、2084.5[1870,2259]cells/mm~2,有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。術(shù)后A組與B組各個隨訪時間點內(nèi)皮細胞數(shù)相互比較無顯著性差異(秩和檢驗,P0.05)。術(shù)前A組與B組散光分別為:4.33[3.12,5.87]D、8.21[4.50,12.01]D,有顯著性差異(秩和檢驗,P0.05)。術(shù)后A組6月、12月的散光分別為:5.16[2.76,9.67]D、3.67[3.06,6.13]D,有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。術(shù)后B組6月、12月的散光分別為:5.21[3.61,7.44]D、3.71[1.99,5.21]D,有顯著性差異(Wilcoxon符號秩檢驗,P0.05)。A組與B組術(shù)后散光各個隨訪時間點之間相互比較無顯著性差異(秩和檢驗,P0.05)。不同時期的圓錐角膜術(shù)后植片存活率100%,植片排斥率0%,術(shù)后一過性高眼壓、繼發(fā)性青光眼、并發(fā)性白內(nèi)障等并發(fā)癥發(fā)生率為0,僅有1眼(1.8%B組)于術(shù)后第1天1針縫線脫開,予及時縫合。結(jié)論:綜上所述全植床深板層角膜移植術(shù)在治療不同時期圓錐角膜術(shù)后各個隨訪時間的裸眼視力以及矯正視力都較術(shù)前明顯提高。不同時期患者術(shù)后內(nèi)皮細胞數(shù)較FB-DLKP術(shù)后內(nèi)皮細胞較術(shù)前有所減少,但是術(shù)后長期隨訪內(nèi)皮細胞數(shù)丟失逐漸減少并趨于相對穩(wěn)定,且殘留的內(nèi)皮細胞數(shù)保持在可以維持角膜透明的數(shù)量范圍內(nèi)。不同時期患者FB-DLKP術(shù)后角膜植片厚度均較術(shù)前明顯增加。不同時期患者術(shù)后角膜散光均較術(shù)前有明顯減少。不同時期患者術(shù)后一過性高眼壓、繼發(fā)性青光眼、并發(fā)性白內(nèi)障等并發(fā)癥發(fā)生率低。不同時期圓錐角膜患者之間相互比較可以發(fā)現(xiàn)Ⅳ期的患者術(shù)后裸眼視力、角膜厚度、內(nèi)皮細胞數(shù)、散光與Ⅱ期及Ⅲ期相比無明顯差異。盡管術(shù)前Ⅳ期的角膜厚度均較Ⅱ期及Ⅲ期薄、曲率、散光大,但是FB-DLKP術(shù)后Ⅳ期患者各項隨訪指標均較Ⅱ期及Ⅲ期無明顯差異,說明FB-DLKP治療圓錐角膜Ⅳ期的預(yù)后與Ⅱ期及Ⅲ期無顯著性差異,Ⅳ期術(shù)后的各項指標均可以達到Ⅱ期及Ⅲ期水平。并且FB-DLKP最大的優(yōu)點是無排斥反應(yīng),術(shù)后無需終生使用抗排斥藥物,因手術(shù)無需新鮮角膜,大大增加了角膜供體來源。所以FB-DLKP手術(shù)是目前治療圓錐角膜最有效也是最優(yōu)化的方案之一。
[Abstract]:Objective: To evaluate the graft bed deep lamellar keratoplasty (Full-bed deep lamellar keratoplasty, FB-DLKP) curative effect in the treatment of keratoconus in different periods, the differences of different period of keratoconus FB-DLKP preoperative and postoperative indexes, package of preoperative and postoperative uncorrected visual acuity, best corrected visual acuity, astigmatism, corneal thickness, endothelial cell density, intraoperative and postoperative complications, and to evaluate its clinical curative effect. Methods: a retrospective study on the data analysis of January 2013 to December 2015 in our hospital FBDLK patients with keratoconus were 53 people, 56 eyes, and 12 months of follow-up of patients with keratoconus, according to the Amsler-Krumeich criteria were stage II and III will be divided into A group, B group IV. To observe the operation process of each phase of the case, the comparison between the period and the period before and after surgery in January, June, December (follow-up vision uncorrected and best corrected visual acuity, the statistical analysis on the visual conversion for LogMAR vision), endothelial cell density, corneal thickness changes, preoperative in June December, and postoperative astigmatism, graft survival, intraoperative and postoperative complications. The data of non normal distribution were expressed by median [four minute distance]. Each group was followed by paired nonparametric tests, such as Wilcoxon signed rank test and symbol test. Each group used independent sample nonparametric tests, such as rank sum test. The data of normal distribution or near normal distribution were expressed with mean standard deviation, and the statistical analysis was carried out by paired t test. Results: a total of 53 patients, 56 eyes, 26 left eyes and 30 right eyes were included in the study, including 35 males and 18 females. The age of the patients was 14-41 years, with an average age of 22.68 + 7.17 years. A total of 18 eyes were met in phase II and III, and 38 eyes were met in IV phase. Statistical analysis of follow-up data above results are as follows: preoperative B group have 3 eyes (5.4%) for acute edema after scar involving Descemet's membrane, but were not found to scar dehiscence, 2 cases during operation (3.6% A group, B group with 1 cases in each group) found thick elastic membrane surface micro perforation, and a small amount of real water gushed out, to the anterior chamber gas injection. In group A (stage II and III), 1, 6 and 12 of uncorrected visual acuity were 0.75[0.54,0.90], 0.56[0.34,0.82] and 0.52[0.40,0.67], respectively, with significant difference (Wilcoxon signed rank test, P0.05). Group B (stage IV) had 1, 6, 12 naked eyes after operation: 0.56[0.40,0.90], 0.52[0.40,0.60] and 0.40[0.22,0.60], respectively, with significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in the visual acuity between the A group and the B group at each follow-up time point (rank sum test, P0.05). Group A after 1, 6 and 12 BCVA respectively: 0.34[0.24,0.40], 0.26[0.22,0.40], 0.26[0.11,0.35], there was significant difference (Wilcoxon signed rank test, P0.05), group B after 1, 6 and 12 BCVA respectively: 0.26[0.22,0.40], 0.22[0.15,0.30], 0.22[0.11,0.28], there was significant difference (Wilcoxon signed rank test, P0.05). Between group B and group A, there was no significant difference between the two groups (rank sum test, P0.05) at each follow-up time point of BCVA. The corneal thickness of group A and group B before operation were 411[360436] mu m and 357[319.75371], and there were significant differences (rank and test, P0.05). The corneal thickness at each follow-up time in group A was 515[498.25531.25] mu m, 467[458.5493.25] m, 464[445.75 and 471] m respectively, showing significant difference (Wilcoxon signed rank test, P0.05). The corneal thickness at each follow-up time in group B was 539.5[515.5566.5] m, 479.5[458.25503.75] m and 467[449504.75] m, respectively. There was significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in corneal thickness between the A group and the B group after the operation (rank sum test, P0.05). The number of endothelial cells in each group was 2322[22872587]cells/mm~2 and 2516.5[2326.502612.25]cells/mm~2 before operation, and there was no significant difference between the two groups (rank and test, P0.05). The postoperative A group each follow-up time point, the number of endothelial cells were 2224.5[20132314.5]cells/mm~2, 2253.5[2070.252311.5]cells/mm~2, 2210[1850.52288.5]cells/mm~2, after June and January after the operation showed no significant difference (Wilcoxon signed rank test, P0.05), after June and December after the operation had significant difference (Wilcoxon signed rank test, P0.05). The number of endothelial cells at each follow-up time in group B was 2217[2013.52374]cells/mm~2, 2166,5[19902311.5]cells/mm~2 and 2084.5[18702259]cells/mm~2, respectively, with significant difference (Wilcoxon signed rank test, P0.05). There was no significant difference in the number of endothelial cells between the A group and the B group after the operation (rank sum test, P0.05). Before operation, the astigmatism in group A and group B were respectively 4.33[3.12,5.87]D and 8.21[4.50,12.01]D, and there were significant differences (rank and test, P0.05). After the operation, the astigmatism of group A in June and December were 5.16[2.76,9.67]D and 3.67[3.06,6.13]D, and there were significant differences (Wilcoxon sign rank test, P0.05). After the operation, the astigmatism of group B in June and December were 5.21[3.61,7.44]D and 3.71[1.99,5.21]D, and there were significant differences (Wilcoxon sign rank test, P0.05). There was no significant difference between group A and group B after the follow-up time points of astigmatism (rank sum test, P0.05). The survival rate of keratoconus at different stages was 100%, the graft rejection rate was 0%. The incidence of postoperative complications such as transient intraocular hypertension, secondary glaucoma and complicated cataract was 0. Only 1 eyes (group 1.8%B) were removed from the 1 needle stitch on the first day after operation, and then sutured in time. Conclusion: In conclusion, the whole bed deep lamellar keratoplasty is effective in the treatment of keratoconus. Endothelial cells in different periods decreased compared with those after FB-DLKP, but the number of endothelial cells decreased gradually and tended to be relative after long-term follow-up.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R779.65

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