本文選題：青光眼白內(nèi)障聯(lián)合手術(shù) + 晶狀體前囊膜��； 參考：《天津醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的 1.觀察自體晶狀體前囊膜作為植入物應(yīng)用于兔眼超聲乳化聯(lián)合小梁切除術(shù)中抗濾過道瘢痕化的效果。 2.比較自體晶狀體前囊膜與絲裂霉素C應(yīng)用于青光眼白內(nèi)障聯(lián)合手術(shù)的臨床效果,評價晶狀體前囊膜的安全性和有效性。 方法 1.動物實(shí)驗(yàn)：對20只新西蘭白兔實(shí)施超聲乳化聯(lián)合小梁切除術(shù)。隨機(jī)分為兩組,每組各10只兔(20只眼),第1組：隨機(jī)選取1只眼做超聲乳化+小梁切除術(shù)(簡稱Trab組),另1只眼做超聲乳化小梁切除術(shù)并輔助應(yīng)用晶狀體前囊膜(簡稱ALC組)；第2組：隨機(jī)選取1只眼做超聲乳化小梁切除術(shù)聯(lián)合應(yīng)用絲裂霉素C(簡稱MMC組)；另1只眼做超聲乳化小梁切除術(shù)并輔助應(yīng)用晶狀體前囊膜。第3、7、14、21、28天觀察并比較三種不同術(shù)式手術(shù)后眼前節(jié)反應(yīng)、濾過泡形態(tài)及功能、眼壓情況,并于上述5個時間點(diǎn)兩組中各隨機(jī)處死1只兔制作病理切片,光學(xué)顯微鏡下觀察各組濾過道情況。 2.臨床研究：選擇2010年5月至2011年3月在天津醫(yī)科大學(xué)眼科中心確診的青光眼合并白內(nèi)障的住院患者共60例(60只眼),行二切口白內(nèi)障超聲乳化吸出、后房型折疊式人工晶狀體植入及小梁切除術(shù),采用隨機(jī)的方法,分為ALC組和MMC組,術(shù)中ALC組29例(29只眼)鞏膜瓣下植入自體晶狀體前囊膜,MMC組31例(31只眼)應(yīng)用絲裂霉素。術(shù)后1、3、6、12月隨訪,觀察兩組患者的眼壓、最佳矯正視力、濾過泡形態(tài)、術(shù)后并發(fā)癥等情況,并定期行超聲生物顯微鏡及視野檢查,對觀察結(jié)果進(jìn)行分析比較。采用SPSS16.0統(tǒng)計學(xué)軟件進(jìn)行數(shù)據(jù)處理,以P0.05作為差異有統(tǒng)計學(xué)意義。 結(jié)果 1.動物實(shí)驗(yàn)：(1)眼前節(jié)反應(yīng)：3種術(shù)式術(shù)后第1、5天,結(jié)膜充血差異無統(tǒng)計學(xué)意義(χ2=0.784,0.232,P值均0.05)；角膜混濁差異無統(tǒng)計學(xué)意義(χ2=1.200,3.442,P值均0.05)；術(shù)后第1、3、7、14天前房炎性反應(yīng)差異無統(tǒng)計學(xué)意義(χ2=3.599,3.200,3.388,2.133,P值均0.05),所有眼均未發(fā)現(xiàn)囊膜對兔眼的刺激體征；(2)濾過泡情況：術(shù)后第21天,3種術(shù)式術(shù)后功能性濾過泡所占比例分別為14.3%(1/7)、92.9%(12/14)、85.7%(6/7),差異有統(tǒng)計學(xué)意義(χ2=13.077,P0.05),結(jié)合所占比例值,可以認(rèn)為ALC組和MMC組的功能性濾過泡數(shù)多于Trab組,其他觀察時間3組之間差異無統(tǒng)計學(xué)意義；(3)眼壓：3種術(shù)式術(shù)后眼壓早期下降,后逐漸升高,術(shù)后第14、21天眼壓差異有統(tǒng)計學(xué)意義(χ2=14.377,10.279,P值均0.05),其他觀察時間3組之間差異無統(tǒng)計學(xué)意義；(4)組織病理學(xué)：術(shù)后7天除Trab組有1眼近端部分濾過道關(guān)閉外,ALC組和MMC組濾過道均開放,ALC組可見囊膜組織結(jié)構(gòu)完整,邊緣清楚,與周圍組織分界明顯,未見炎癥細(xì)胞侵入；術(shù)后28天Trab組濾過道完全被瘢痕組織阻塞,MMC組濾過道遠(yuǎn)端閉合,近端小部分開放,ALC組濾過道完全開放,囊膜邊緣變鈍,未見淋巴細(xì)胞浸潤。 2.臨床研究：(1)眼壓：術(shù)后1年時,ALC組眼壓從術(shù)前(22.28±10.81mmHg)下降至(12.24±2.91mmHg),差異有統(tǒng)計學(xué)意義(t=4.851,P0.05); MMC組眼壓從術(shù)前(26.50±12.69mmHg)下降至(11.15±2.87mmHg),差異有統(tǒng)計學(xué)意義(t=6.701,P0.05)。組間各時間點(diǎn)眼壓下降程度無統(tǒng)計學(xué)差異；(2)最佳矯正視力：術(shù)后1年時,兩組患者視力較術(shù)前提高,差異均有統(tǒng)計學(xué)意義(tALc=-5.294, P0.05; tMMc=-4.027, P0.05),兩組之間視力差異無統(tǒng)計學(xué)意義(t=-0.022,P0.05)；(3)濾過泡形態(tài)：術(shù)后1年時,ALC組Ⅰ、Ⅱ型濾過泡分別有4眼、21眼,即功能性濾過泡占86.2%(25/29),Ⅲ型濾過泡4眼；MMC組Ⅰ、Ⅱ型濾過泡分別有5眼、24眼,即功能性濾過泡占93.5%(29/31),Ⅲ型濾過泡2眼,兩組均未出現(xiàn)Ⅳ型濾過泡,兩組濾過泡差異無統(tǒng)計學(xué)意義(χ2=0.912,P0.05)；(4)手術(shù)成功率與抗青光眼藥物使用情況：術(shù)后1年時,ALC組手術(shù)成功率為86.2%(25/29),MMC組為93.5%(29/31),兩組間差異無統(tǒng)計學(xué)意義(χ2=0.897,P0.05)。術(shù)前ALC組患者平均使2.45種抗青光眼藥物,MMC組為2.61種；術(shù)后1年時,ALC組減少至0.14種,MMC組為0.06種,術(shù)前術(shù)后比較差異有統(tǒng)計學(xué)意義(tALc=13.970, tMMC=14.772, P0.05);(5)并發(fā)癥：兩組患者術(shù)后并發(fā)癥在術(shù)后2周內(nèi)消退或緩解,ALC組未出現(xiàn)嚴(yán)重排斥反應(yīng)；(6)視野：術(shù)后1年時,兩組患者的平均視野缺損值、平均模式標(biāo)準(zhǔn)差的變化與術(shù)前相比均無統(tǒng)計學(xué)差異,即術(shù)后視野均保持穩(wěn)定；(7)超聲生物顯微鏡檢查：兩組患者術(shù)后3個月均可見清晰的濾過間隙,濾過道內(nèi)外口通暢,而ALC組部分患者可見鞏膜瓣下晶狀體前囊膜的強(qiáng)回聲,為晶狀體前囊膜。 結(jié)論 1.動物實(shí)驗(yàn)：超聲乳化小梁切除術(shù)中應(yīng)用晶狀體前囊膜與絲裂霉素相比,兩者在眼前節(jié)反應(yīng)及降眼壓效果方面無明顯差異,但組織病理學(xué)結(jié)果表明植入晶狀體前囊膜維持濾過道開放的時間長于應(yīng)用絲裂霉素,兩者均明顯優(yōu)于單純小梁切除術(shù)后的降眼壓效果及濾過道瘢痕化程度。 2.臨床研究：晶狀體前囊膜應(yīng)用于青光眼白內(nèi)障聯(lián)合術(shù)中能有效防止濾過泡瘢痕化,控制眼壓、提高視力、穩(wěn)定視野,與傳統(tǒng)應(yīng)用絲裂霉素C的療效相當(dāng),方法安全有效。
[Abstract]:objective
1. to observe the effect of autologous lens anterior capsule as an implant in the treatment of rabbit eye phacoemulsification combined with trabeculectomy.
2. compare the clinical effect of the anterior capsule of autologous lens and mitomycin C in the combined operation of glaucoma and cataract, and evaluate the safety and effectiveness of the anterior lens capsule.
Method
1. animal experiments: 20 New Zealand white rabbits were treated with phacoemulsification combined with trabeculectomy. They were randomly divided into two groups, 10 rabbits in each group (20 eyes) and first groups: 1 eyes were randomly selected to do phacoemulsification and trabeculectomy (Trab group), the other 1 eyes were excised by phacoemulsification and assisted with the anterior capsule (ALC group); second Group: 1 eyes were randomly selected to do phacoemulsification and trabeculectomy combined with mitomycin C (MMC group); the other 1 eyes were treated with phacoemulsification and assisted with the anterior capsule membrane. On day 3,7,14,21,28, the anterior segment reaction, the morphology and function of filter bubble, the intraocular pressure, and the 5 of the three different surgical procedures were compared. At each time point, 1 rabbits were randomly executed in two groups to make pathological sections, and the filter passages were observed under light microscope.
2. clinical study: 60 cases (60 eyes) of hospitalized patients with glaucoma diagnosed in Ophthalmological Center of Tianjin Medical University from May 2010 to March 2011 were selected with two incision phacoemulsification, posterior chamber foldable intraocular lens implantation and trabeculectomy, and were randomly divided into group ALC and group MMC, ALC The anterior capsule of autologous lens was implanted under the scleral flap in 29 cases (29 eyes), and 31 cases (31 eyes) in group MMC were treated with mitomycin. The intraocular pressure of the two groups, the best corrected visual acuity, the form of filtering bleb and the postoperative complications were observed in the group of 31 (31 eyes), and the observation results were analyzed and compared. Data was processed with SPSS16.0 statistical software, and P0.05 as the difference was statistically significant.
Result
1. animal experiments: (1) anterior segment reaction: there was no significant difference in conjunctival hyperemia (x 2=0.784,0.232, P value 0.05) on day 1,5 after 3 surgical operations, and there was no statistically significant difference in corneal opacity (x 2=1.200,3.442, P value 0.05), and there was no statistical significance (x 2=3.599,3.200,3.388,2.133, P value 0) before the operation (0). .05), all eyes did not find the stimulation of the capsule to the rabbit eye; (2) the filter bubble situation: twenty-first days after the operation, the proportion of the 3 functional filtration blebs was 14.3% (1/7), 92.9% (12/14), 85.7% (6/7), the difference was statistically significant (x 2=13.077, P0.05), combined with the proportional value, the functional filter bubbles of the ALC group and MMC group could be considered. Number more than Trab group, other observation time between the 3 groups had no statistical significance; (3) intraocular pressure: 3 kinds of postoperative intraocular pressure decreased early, then gradually increased, postoperative 14,21 day intraocular pressure difference was statistically significant (x 2=14.377,10.279, P value is 0.05), the other observation time between the 3 groups had no statistical significance; (4) histopathology: 7 after the operation 7 In group Trab, 1 eyes were close to the proximal part of the filter, ALC and MMC were open, and the ALC group showed that the membrane structure was complete, the edge was clear, and the boundary was clear, and no inflammatory cells were intruded. The Trab group was completely blocked by scar tissue on the 28 day after the operation, and the distal end of the MMC group was closed, the proximal part of the filter was open, ALC The filtering passages were completely open, and the edges of the membranes were blunt and there was no lymphocytic infiltration.
2. clinical study: (1) intraocular pressure: at 1 years after operation, intraocular pressure in group ALC decreased from (22.28 + 10.81mmHg) to (12.24 + 2.91mmHg), and the difference was statistically significant (t=4.851, P0.05), and in group MMC, intraocular pressure dropped from (26.50 + 12.69mmHg) to (11.15 + 2.87mmHg), and the difference was statistically significant (t=6.701, P0.05). The degree of IOP decline at each time point between groups was not unified. Study difference; (2) best corrected visual acuity: 1 years after operation, the visual acuity of the two groups was higher than before the operation, the difference was statistically significant (tALc=-5.294, P0.05; tMMc=-4.027, P0.05), and there was no statistical difference between the two groups (t=-0.022, P0.05); (3) the form of filtering bleb: 1 years after the operation, ALC group I, type II filter bubbles were 4 eyes and 21 eyes respectively, that is, Functional filtration blebs accounted for 86.2% (25/29) and type III filter bubbles in 4 eyes; group I and type II filter bubbles were 5 eyes, 24 eyes, 93.5% (29/31), 2 eyes of type III filter bubbles, two groups without type IV filter bubbles, and two groups of filter bubbles in two groups (x 2=0.912, P0.05), and (4) the success rate of operation and the use of anti glaucoma drugs (4). 1 years after operation, the success rate of group ALC was 86.2% (25/29) and 93.5% (29/31) in group MMC. There was no statistical difference between the two groups (2=0.897, P0.05). Before operation, there were 2.45 kinds of anti glaucoma drugs in group ALC and 2.61 in MMC group; 1 years after the operation, the ALC group decreased to 0.14, and the MMC group was 0.06. The difference was statistically significant before and after the operation. TALc=13.970, tMMC=14.772, P0.05); (5) complications: two groups of postoperative complications were subsided or remission within 2 weeks after operation, and group ALC had no serious rejection; (6) the average visual field defect value of the patients in the 1 year after operation, and the average pattern standard deviation was not statistically different from that before the operation, that is, the postoperative visual field was maintained. Stability; (7) ultrasound biomicroscopy: two groups of patients showed clear filtration space at 3 months after 3 months of operation, and the inside and outside of the filter were unobstructed, while the anterior capsule of the scleral flap was strongly echoed by the scleral flap, which was the anterior capsule of the lens.
conclusion
1. animal experiments: there was no significant difference between the anterior capsule and mitomycin in the anterior capsule reaction and the effect of the intraocular pressure in the phacoemulsification of the trabeculectomy, but the histopathological results showed that the time of the implantation of the anterior capsule to maintain the filter was longer than that of mitomycin. Both of them were obviously superior to the simple trabeculae. The effect of lowering intraocular pressure and scar degree of filtering passage after resection were observed.
2. clinical study: the application of the anterior capsule of the lens to the combined operation of glaucoma and cataract can effectively prevent the scarring of filter bubbles, control the intraocular pressure, improve the vision and stabilize the field of vision, which is quite effective with the traditional application of mitomycin C, and the method is safe and effective.

【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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本文編號：1852707