本文選題：青光眼 + ECT　； 參考：《天津醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的 1.探討兔眼小梁切除術(shù)聯(lián)合鞏膜床電凝術(shù)(改良術(shù)式ECT)的降眼壓作用,探討鞏膜床電凝是否存在抗瘢痕化作用。 2.聯(lián)合電凝術(shù)的改良前三聯(lián)手術(shù)治療青光眼白內(nèi)障的臨床研究,與傳統(tǒng)MMC的前三聯(lián)手術(shù)對照,探討小梁切除術(shù)聯(lián)合鞏膜床電凝術(shù)的臨床效果。 方法 1.新西蘭白兔12只(12眼),體重2.0-2.5kg,隨機分為兩組分別行小梁切除+ECT(ECT組)、小梁切除+MMC (0.2mg/ml,2min)(MMC組),另取新西蘭白兔3只(3眼)行單純小梁切除術(shù)(Trab組)。ECT組、MMC組兩組術(shù)后定期觀察眼壓、眼前節(jié)變化、并發(fā)癥發(fā)生情況；三組定期各隨機處死1只實驗兔,制作術(shù)區(qū)濾過道病理切片。 2.選擇2010年6月至2011年7月在天津醫(yī)科大學(xué)眼科中心住院的青光眼合并白內(nèi)障患者,隨機行超聲乳化白內(nèi)障吸除+IOL植入+小梁切除+ECT (ECT組)、超聲乳化白內(nèi)障吸除+IOL植入+小梁切除+MMC (MMC組)。比較術(shù)前術(shù)后視力、眼壓、眼前節(jié)形態(tài)、眼底、UBM、視野及并發(fā)癥發(fā)生情況等指標(biāo)。分析與傳統(tǒng)術(shù)式相比,改良前三聯(lián)手術(shù)的實用性及安全性。采用SPSS16.0統(tǒng)計軟件對相關(guān)數(shù)據(jù)進行統(tǒng)計學(xué)分析。 結(jié)果 1.動物實驗中,ECT組與傳統(tǒng)MMC組兔眼術(shù)后3d內(nèi),所有術(shù)眼均有不同程度的結(jié)膜充血,7d內(nèi)充血全部消退,1d、7d各組結(jié)膜充血差異無顯著性(x2=0.556,0.78,P值均0.05)。手術(shù)后第1、2天兩組前房反應(yīng)較重,所有兔術(shù)眼前房水混濁程度(++),7d后兩組前房反應(yīng)均消失。術(shù)后早期大多為功能性濾過泡,隨著時間的推移,濾過泡均有不同程度瘢痕化,術(shù)后第14天,兩組功能性濾過泡所占比例均為66.7%(4／6),差異無統(tǒng)計學(xué)意義。ECT組及MMC組在做周邊虹膜切除術(shù)時各有1例前房出血,均于術(shù)后第3天吸收。MMC組術(shù)后1天有2例前房纖維素滲出,于術(shù)后7天內(nèi)吸收。 2.動物實驗中,ECT組與傳統(tǒng)MMC組術(shù)后1d、3d、7d眼壓均較術(shù)前下降,下降程度有統(tǒng)計學(xué)差異(tECT=0.000、0.000、0.001,tMMc=0.000、0.000、0.011,P均0.05),而第14d、28d兩組眼壓與術(shù)前比較無統(tǒng)計學(xué)差別(tECT=0.39、0.728,tMMC=0.084、0.908,P均0.05)；ECT組與傳統(tǒng)MMC組之間各時間點眼壓水平均無統(tǒng)計學(xué)意義(P0.05)。 3.動物實驗中,術(shù)后7天所有兔術(shù)眼結(jié)膜下組織疏松且輕度水腫,鞏膜瘺道間隙可見,濾過道內(nèi)較多成纖維細(xì)胞及少數(shù)炎癥細(xì)胞浸潤,除單純Trab組有較薄纖維結(jié)締組織阻塞濾過道外,ECT組和MMC組濾過道均開放。術(shù)后14天三組濾過通道不同程度關(guān)閉。術(shù)后28天,周圍大量膠原纖維沉積,三組均呈現(xiàn)瘢痕樣改變。 4.臨床研究中,術(shù)后1年隨訪時ECT組功能性濾過泡占89.7%(26／29),MMC組功能性濾過泡占93.3%(28／30),差異無統(tǒng)計學(xué)意義(x2=0.056,P=0.813)。兩組均各有7眼BCVA20／30,無統(tǒng)計學(xué)差異(Mann-Whitney U檢驗t,Z=-1.000,P=0.710)。ECT組5眼輕度角膜水腫,1眼術(shù)后早期前房有滲出；MMC組6眼角膜輕度水腫,1眼前房少量積血,1眼傷口滲漏,均在1周內(nèi)自愈。 5.臨床研究中,ECT組術(shù)后眼壓14.6±2.2mmHg,較術(shù)前27.0±6.2mmHg有統(tǒng)計學(xué)差異(t=13.675,P=0.000)；MMC組術(shù)后眼壓14.2±3.7mmHg,較術(shù)前28.6±7.1mmHg,差別有統(tǒng)計學(xué)差異(t=0.655,P=0.000)。各組術(shù)后眼壓較術(shù)前均有明顯下降(P=0.000),但兩組眼壓下降程度無明顯統(tǒng)計學(xué)差異(t=0.655,P=0.109)。隨訪12個月,兩組術(shù)前、術(shù)后MD值與PSD值差異無統(tǒng)計學(xué)意義(ECT組tMD=1.417,PMD=0.171,tPSD=0.553,PPSD=0.586；MMC組tMD=1.665,PMD=0.110,tPSD=-1.390,PPSD=0.178),表明術(shù)后視野保持穩(wěn)定。 6.臨床研究中兩組內(nèi)所有患者術(shù)后3,6,12月均能通過UBM觀察到濾過道。 結(jié)論 1.動物實驗研究電凝聯(lián)合小梁切除術(shù)與傳統(tǒng)MMC小梁切除切除術(shù)術(shù)后眼壓變化無統(tǒng)計學(xué)差異、術(shù)后并發(fā)癥少且14d內(nèi)病理切片顯示兩組均尚存濾過間隙,較單純小梁切除術(shù)明顯延緩了濾過道瘢痕化進程。 2.臨床研究聯(lián)合電凝的改良前三聯(lián)手術(shù)與傳統(tǒng)MMC前三聯(lián)手術(shù)術(shù)后1年內(nèi)降眼壓效果相當(dāng),且術(shù)后并發(fā)癥少、操作簡單易于基層醫(yī)院推廣。其長期的治療效果仍有待于多中心、大樣本的臨床研究考察。 3.本研究的結(jié)果是令人鼓舞的,但也存在不足,仍需深一步細(xì)胞或基因水平的研究證實電凝抗瘢痕化的機理。并且,本研究的隨訪時間還需延長,以驗證改良術(shù)式是否存在長期保持濾過通路的效果。
[Abstract]:objective
1. to explore the anti cicatricial effect of scleral bed electrocoagulation on rabbit eye trabeculectomy combined with scleral bed electrocoagulation (modified ECT).
2. clinical study of combined triple electrocoagulation for glaucoma and cataract. Compared with the traditional triple operation of MMC, we explored the clinical effect of trabeculectomy combined with scleral bed electrocoagulation.
Method
1. 12 New Zealand white rabbits (12 eyes), weighing 2.0-2.5kg, were randomly divided into two groups respectively underwent trabeculectomy with +ECT (group ECT), trabeculectomy +MMC (0.2mg/ml, 2min) (MMC group), another 3 New Zealand white rabbits (3 eyes) underwent trabeculectomy (group Trab).ECT group MMC, two groups of regular postoperative intraocular pressure, anterior segment changes, the occurrence of complications; three groups of the regular 1 experimental rabbits were making area filtration road sections.
2. June 2010 to July 2011 in patients with glaucoma complicated with cataract hospitalized in Ophthalmological Center of Tianjin Medical University, were underwent phacoemulsification and +IOL implantation and trabeculectomy with +ECT (group ECT), phacoemulsification and +IOL implantation and trabeculectomy with +MMC (group MMC). Compared with visual acuity before and after surgery, intraocular pressure, anterior segment morphology, fundus, UBM, vision and complications were measured. Compared with the traditional technique, practicability and safety of the modified triple operation. Before the relevant data were statistically analyzed by SPSS16.0 statistical software.
Result
1. animal experiment, the ECT group and the traditional group MMC rabbits in 3D after the surgery, all patients had different degrees of eye conjunctival hyperemia, congestion in 7d 1D, 7d were all faded, conjunctival congestion had no significant difference (x2=0.556,0.78, P 0.05). The 1,2 day after operation in two groups was higher than the anterior chamber all the rabbits, anterior chamber water turbidity, 7d (+ +) two groups after anterior chamber reaction disappeared. Early postoperative mostly functional blebs, with the passage of time, the bleb had different degree of scarring, fourteenth days after operation, two groups of functional bleb proportion was 66.7% (4 / 6), there was no significant difference between.ECT group and MMC group in peripheral iridectomy when each had 1 cases of hyphema, were absorbed in third days after operation in.MMC group after 1 days there were 2 cases of anterior chamber fibrin exudation, 7 days after the operation and absorption.
2. animal experiment, the ECT group and the traditional group MMC after 1D, 3D, 7d, intraocular pressure decreased, there were significant differences in degree of decline (tECT=0.000,0.000,0.001, tMMc=0.000,0.000,0.011, P 0.05), and the 14d, 28d two group compared with the preoperative IOP had no statistical difference (tECT= 0.39,0.728, tMMC=0.084,0.908, P 0.05); between the ECT group and the traditional group MMC intraocular pressure level at each time point were not statistically significant (P0.05).
3. animal experiment, 7 days after operation all postoperative subconjunctival tissue loose and mild edema, scleral fistula clearance visible, filtering channel in more fibroblasts and few inflammatory cell infiltration, in addition to the pure Trab group had thinner fibrous connective tissue blocking filtration outside, ECT group and MMC group were filtering are open to the public. 14 days after the three groups of filtering channels different degree closed. After 28 days, around a large number of collagen deposition, three groups showed a scar like changes.
4. clinical studies, 1 years of follow-up after operation group ECT functional bleb accounted for 89.7% (26 / 29), MMC group of functional bleb accounted for 93.3% (28 / 30), the difference was not statistically significant (x2=0.056, P=0.813). The two groups each have 7 eyes BCVA20 / 30, no significant difference (Mann-Whitney U test T, Z=-1.000, P=0.710).ECT group of 5 eyes with mild corneal edema, 1 eyes of early postoperative anterior chamber exudative MMC group; 6 slight corneal edema in 1 eyes, 1 eyes a few real blood, wound leakage, all in 1 weeks to heal.
5. clinical studies, ECT group of postoperative IOP was 14.6 + 2.2mmHg, 27 + 6.2mmHg compared with preoperative had statistically significant difference (t=13.675, P=0.000); group MMC IOP was 14.2 + 3.7mmHg, 28.6 + 7.1mmHg compared with preoperative, the difference was statistically significant (t=0.655, P=0.000). The postoperative intraocular pressure before surgery were significantly decreased (P=0.000), but the two groups of intraocular pressure decreased with no statistical difference (t=0.655, P=0.109). After 12 months of follow-up, the two groups before surgery, postoperative MD and PSD values had no significant difference (ECT group tMD=1.417, PMD=0.171, tPSD=0.553, PPSD=0.586; group MMC tMD= 1.665, PMD=0.110, tPSD=-1.390, PPSD=0.178) that, to maintain the stability of vision after surgery.
In 6. clinical studies, all patients in two groups were able to observe the filter through UBM 3,6,12 months after operation.
conclusion
1. animal experimental study on electrocoagulation combined with trabeculectomy and traditional MMC trabeculectomy resection after intraocular pressure had no statistical difference, less postoperative complications and 14d pathological examination showed that two groups were still filtration gap, compared with simple trabeculectomy significantly delayed the scarring process.
2. the improved triple surgery combined with electrocoagulation in the clinical research is equivalent to the intraocular pressure reduction in 1 years after the traditional MMC triple surgery. There are fewer postoperative complications and easy operation. It is easy to promote in primary hospitals. Its long-term therapeutic effect needs to be investigated in a multicenter, large sample clinical study.
3., the results of this study are encouraging, but there are still some shortcomings. Further research on cell or gene level is needed to confirm the mechanism of electric coagulation against scarring. Moreover, the follow-up time of this study needs to be extended to verify whether there is a long-term maintenance effect of filtration pathway.

【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R779.6

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