發(fā)布時(shí)間：2018-06-08 19:09

  本文選題：飛秒激光白內(nèi)障 + 超聲乳化手術(shù)飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障�。� 參考：《天津醫(yī)科大學(xué)》2016年博士論文

【摘要】：目的:觀察飛秒激光白內(nèi)障超聲乳化手術(shù)對(duì)角膜內(nèi)皮細(xì)胞、超聲能量的使用、術(shù)中眼壓及房水中炎性因子(IL-1β,IL-6及PGE2)濃度的影響,并觀察術(shù)中術(shù)后并發(fā)癥、系統(tǒng)性評(píng)價(jià)該新技術(shù)臨床應(yīng)用的安全性及有效性。觀察飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障超聲乳化手術(shù)矯正角膜散光的臨床效果,并利用Holladay-Cravy-Koch formula修正用于術(shù)前計(jì)算角膜松解切口弧長(zhǎng)及軸位的參考表(nomogram)。方法:前瞻性研究。在山西省眼科醫(yī)院行白內(nèi)障超聲乳化吸除聯(lián)合人工晶體植入術(shù)的老年性白內(nèi)障患者87例(114眼)分為2組,飛秒激光超聲乳化手術(shù)組(FLACS組)44例(60眼),2.2mm同軸微切口白內(nèi)障超聲乳化手術(shù)組(傳統(tǒng)組)43例(54眼)。對(duì)比兩種手術(shù)方式對(duì)術(shù)后早期遠(yuǎn)視力,中央角膜厚度,角膜內(nèi)皮細(xì)胞計(jì)數(shù),超聲能量的使用情況及術(shù)中術(shù)后并發(fā)癥。收集42名老年性白內(nèi)障患者前房水100微升,其中27例(27只眼)患者進(jìn)行飛秒激光白內(nèi)障手術(shù),在飛秒激光操作之后,打開(kāi)側(cè)切口,抽取100微升前房水。15例(15只眼)患者在進(jìn)行傳統(tǒng)白內(nèi)障超聲乳化手術(shù)之前,抽取100微升前房水。用酶聯(lián)免疫吸附實(shí)驗(yàn)對(duì)比觀察兩組前房水中IL-1β、IL-6、及PGE2的濃度。收集2014年2月至2014年6月在山西省眼科醫(yī)院白內(nèi)障科就診的32例預(yù)行飛秒激光白內(nèi)障超聲乳化手術(shù)的老年性白內(nèi)障患者(39眼),在手術(shù)開(kāi)始前使用手持回彈式眼壓計(jì)iCare測(cè)量基線眼壓并記錄解除負(fù)壓吸引環(huán)及角膜接觸鏡后30秒、1分鐘、2分鐘、3分鐘、5分鐘及10分鐘的眼壓。每個(gè)時(shí)間點(diǎn)測(cè)量三次,取平均值用于數(shù)據(jù)分析。飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障超聲乳化手術(shù)矯正角膜散光的臨床觀察,收集2014年12月至2015年7月在山西省眼科醫(yī)院白內(nèi)障科就診,預(yù)行飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障超聲乳化手術(shù),角膜散光為0.7 D~3D之間的老年性白內(nèi)障患者38例(48眼),記錄裸眼視力,矯正視力。進(jìn)行前節(jié)oct、iolmaster及角膜地形圖orbscanⅡ檢查。術(shù)后1天、1周、1個(gè)月、3個(gè)月進(jìn)行隨訪,檢查裸眼遠(yuǎn)視力,最佳矯正視力,屈光度。術(shù)后1個(gè)月及3個(gè)月復(fù)查角膜地形圖orbscanⅡ查角膜曲率,前節(jié)oct查穿透性角膜松解切口深度。術(shù)前應(yīng)用amolridonnenfeld參考表(nomogram)在線計(jì)算角膜松解切口位置及弧長(zhǎng)。利用飛秒激光制作一對(duì)直徑為8mm穿透性角膜松解切口在白內(nèi)障手術(shù)的同時(shí)矯正角膜散光。散光的評(píng)估采用alpins向量分析法,計(jì)算目標(biāo)矯正散光向量、手術(shù)矯正散光向量、誤差向量、誤差率、矯正率、誤差值、誤差角及方向偏移,并繪制double-angleplots散點(diǎn)圖顯示術(shù)前及術(shù)后角膜散光的分布。同時(shí)應(yīng)用holladay-cravy-kochformula計(jì)算wtw-atw,顯示松解切口對(duì)角膜散光造成的總體變化(neteffect),修正參考表。結(jié)果:飛秒激光白內(nèi)障超聲乳化手術(shù)(lensx設(shè)備)使超聲能量的使用顯著減少,超聲時(shí)間較傳統(tǒng)組減少29.69%,累計(jì)釋放能量較傳統(tǒng)組減少48.89%。flacs組術(shù)后早期中央角膜厚度的恢復(fù)早于傳統(tǒng)組。前囊膜切開(kāi)過(guò)程中,4眼(6.67%)前囊膜片未完全游離,需要用撕囊鑷輔助撕開(kāi),其中3眼(5%)手工完整撕開(kāi)前囊膜,1眼(1.67%)發(fā)生小的撕裂,但未累及赤道部,所有病例未發(fā)生后囊膜破裂并發(fā)癥。4例(6.67%)在激光后出現(xiàn)瞳孔縮小。飛秒激光白內(nèi)障超聲乳化手術(shù)的飛秒激光操作,會(huì)導(dǎo)致房水中il-1β、il-6及pge2濃度顯著升高(p0.01),但三種因子的濃度與患者年齡、白內(nèi)障核硬度、負(fù)壓吸引時(shí)間和飛秒激光發(fā)射時(shí)長(zhǎng)無(wú)關(guān)。飛秒激光白內(nèi)障超聲乳化手術(shù)在移除負(fù)壓吸引環(huán)后30秒、1分鐘、2分鐘、3分鐘、5分鐘及10分鐘,眼壓分別為21.61mmhg、17.34mmhg、16.80mmhg、17.20mmhg、17.13mmhg及17.86mmhg。與基線相比,2分鐘的眼壓值低于基線水平,差異有統(tǒng)計(jì)學(xué)意義(p0.05)。各個(gè)觀察時(shí)間點(diǎn)的眼壓與負(fù)壓吸引時(shí)間及飛秒激光發(fā)射時(shí)長(zhǎng)均無(wú)相關(guān)性(p0.05)。飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障超聲乳化手術(shù)術(shù)后1個(gè)月及3個(gè)月角膜散光由術(shù)前1.42±0.43d下降至0.79±0.39d及0.78±0.38d。術(shù)后3個(gè)月,角膜散光≤1.0D的比例由術(shù)前16%升高至87%,≤0.5D的患者由術(shù)前2%上升至50%,術(shù)后1至3個(gè)月散光值穩(wěn)定。術(shù)后1個(gè)月及3個(gè)月平均手術(shù)矯正散光向量(SIA)為1.14±0.63 D及1.05±0.56 D。SIA與目標(biāo)校正散光向量(TIA)呈正相關(guān),但SIA小于TIA,表現(xiàn)為欠矯。術(shù)后1個(gè)月及3個(gè)月誤差值(EM)分別為0.30±0.50 D及0.42±0.46 D;矯正率(CI)為0.78±0.38及0.72±0.32,小于理想值1,兩指標(biāo)均表示欠矯。誤差向量(DV)表示術(shù)后散光,較術(shù)前有明顯下降。術(shù)后1個(gè)月及3個(gè)月誤差率(ER)的結(jié)果為0.60±0.34及0.57±0.32。術(shù)后1個(gè)月,AE的平均值為1.67±29.84°(-80.78°~89.77°);術(shù)后3個(gè)月時(shí),AE的平均值為2.14±18.24°(-41.80°~47.73°)。術(shù)后逆規(guī)散光(ATR)組SIA值為1.25±0.58D大于順規(guī)散光(WTR)組0.86±0.50 D,ATR組的DV、ER及ME值均小于WTR組,顯示ATR組術(shù)后散光誤差率及誤差值更小。ATR組的CI為0.83±0.25高于WTR組的0.57±0.30,顯示ATR的矯正率接近80%,而WTR組的矯正率接近60%,ATR組的矯正率更高。LenSx飛秒激光平臺(tái)制作深度達(dá)90%的穿透性角膜松解切口,術(shù)后1個(gè)月及3個(gè)月時(shí),深度為78.6%及78.9%,切口深度并未達(dá)到理想的90%。結(jié)論:飛秒激光白內(nèi)障超聲乳化手術(shù)與傳統(tǒng)2.2mm同軸微切口白內(nèi)障超聲乳化手術(shù)相比,其使用的超聲能量顯著減少,術(shù)后早期角膜組織恢復(fù)更快。該手術(shù)飛秒激光操作可使房水中IL-1β、IL-6及PGE2濃度升高。負(fù)壓吸引導(dǎo)致眼壓波動(dòng)。飛秒激光穿透性角膜松解切口聯(lián)合白內(nèi)障超聲乳化手術(shù)矯正角膜中低度散光安全有效。
[Abstract]:Objective: To observe the effects of femtosecond laser cataract phacoemulsification on the corneal endothelial cells, the use of ultrasonic energy, intraoperative intraocular pressure and the concentration of inflammatory factors (IL-1, IL-6 and PGE2) in aqueous humor, and observe the postoperative complications, and systematically evaluate the safety and effectiveness of the new technique in the clinical application of this new technique. The clinical effect of incision combined with cataract phacoemulsification to correct corneal astigmatism and the reference table (nomogram) modified by Holladay-Cravy-Koch formula for preoperative calculation of the arc length and axis of corneal loosening incision. Method: prospective study in Shanxi ophthalmic hospital with phacoemulsification and intraocular lens implantation 87 cases (114 eyes) of senile cataract were divided into 2 groups, 44 cases (60 eyes) with femtosecond laser phacoemulsification group (group FLACS), 43 cases (54 eyes) with 2.2mm coaxial micro incision phacoemulsification group (traditional group). Comparison of two surgical methods for early postoperative far vision, central corneal thickness, corneal endothelial cell count, and ultrasonic energy use 42 patients with senile cataract were collected by 100 micro elevation of anterior chamber water, of which 27 cases (27 eyes) underwent femtosecond laser cataract surgery. After the femtosecond laser operation, the side incision was opened, and 100 micro elevation anterior chamber water (15 eyes) was extracted.15 (15 eyes) before the traditional cataract phacoemulsification, and before the traditional cataract phacoemulsification, 100 l l l l was extracted. Aqueous enzyme linked immunosorbent assay (ELISA) was used to compare the concentration of IL-1 beta, IL-6, and PGE2 in two groups of anterior chamber water. 32 cases of senile cataract (39 eyes) were collected from February 2014 to June 2014 at the cataract Department of Shanxi ophthalmology hospital, which was treated with femtosecond laser cataract phacoemulsification, and the handheld rebound type of intraocular pressure was used before the operation. ICare measured baseline intraocular pressure and recorded 30 seconds, 1 minutes, 2 minutes, 3 minutes, 5 minutes and 10 minutes of intraocular pressure after negative pressure suction ring and corneal contact lens. Measure three times at each time point for data analysis. Clinical observation of corneal astigmatism corrected by femtosecond laser penetrating keratoplasty incision combined with white obstacle phacoemulsification From December 2014 to July 2015, the treatment of cataract in the Shanxi ophthalmological hospital was collected. Femtosecond laser penetrating keratoplasty combined with cataract phacoemulsification and 38 cases of senile cataract (48 eyes) with corneal astigmatism between 0.7 D~3D were collected. The naked eye vision and corrected visual acuity were recorded. The anterior segment OCT, IOLMaster and corneal topographic map were performed. Orbscan II examination. Follow up 1 days, 1 weeks, 1 months, 3 months, examination of naked eye vision, best corrected visual acuity, diopter. Corneal topography of corneal topography was examined by Orbscan II in 1 months and 3 months after operation. The depth of penetrating keratoplasty in anterior segment was examined by OCT, and corneal loosening was calculated online by amolridonnenfeld reference table (nomogram) before operation. The position of the incision and the arc length. Using the femtosecond laser to make a pair of 8mm penetrating keratoplasty incision to correct corneal astigmatism at the same time in cataract surgery. The evaluation of astigmatism by alpins vector analysis is used to correct astigmatism vector, correct astigmatism vector, error rate, correction rate, error value, error angle and direction. The distribution of corneal astigmatism before and after double-angleplots was plotted and the distribution of corneal astigmatism before and after the operation was plotted. At the same time, the holladay-cravy-kochformula calculation of wtw-atw was used to show the overall changes in corneal astigmatism (NetEffect) and corrected reference table. Results: the ultrasonic energy of femtosecond laser phacoemulsification (lensx equipment) was made. With significant reduction, the time of ultrasound was reduced by 29.69% than that in the traditional group. The cumulative release of energy was earlier than that in the traditional group. The early recovery of central corneal thickness in the 48.89%.flacs group was earlier than that in the traditional group. In the process of anterior capsule incision, 4 eyes (6.67%) were not completely free, and tearing tweezers were needed to tear open the anterior capsule, and 3 eyes (5%) were manually tearing the anterior capsule, 1 The eyes (1.67%) had small tear, but did not involve the equator, all cases did not have posterior capsule rupture..4 cases (6.67%) appeared to decrease the pupil after laser. Femtosecond laser cataract operation of femtosecond laser phacoemulsification could lead to a significant increase in the concentration of IL-1 beta, IL-6 and PGE2 in aqueous humor (P0.01), but the concentration of three factors and the year of the patient Age, cataract nuclear hardness, negative pressure attraction time and duration of femtosecond laser emission. Femtosecond laser cataract phacoemulsification, 30 seconds, 1 minutes, 2 minutes, 3 minutes, 5 minutes and 10 minutes after the removal of negative pressure suction ring, and intraocular pressure of 21.61mmhg, 17.34mmhg, 16.80mmhg, 17.20mmhg, 17.13mmhg and 17.86mmhg. respectively to the baseline, 2 minutes of intraocular pressure The difference was statistically significant below the baseline level (P0.05). There was no correlation between the intraocular pressure of the observation time and the duration of the negative pressure and the duration of the femtosecond laser emission (P0.05). The corneal astigmatism of the femtosecond laser penetrating keratoplasty combined with cataract phacoemulsification decreased from 1.42 + 0.43d to 0.79 + 0. in the 1 and 3 months after the cataract phacoemulsification. At 3 months after 39d and 0.78 + 0.38d., the proportion of corneal astigmatism less than 1.0D increased from 16% to 87% before operation, and the patients with less than 0.5D increased from 2% to 50% before operation and 1 to 3 months after operation. The average corrected astigmatism vector (SIA) was 1.14 + 0.63 D and 1.05 + D.SIA with target correction astigmatism vector (TIA) in 1 and 3 months postoperatively. IA was less than TIA and was under correction. The 1 month and 3 month error values (EM) were 0.30 + 0.50 D and 0.42 + 0.46 D, respectively, the correction rate (CI) was 0.78 + and 0.72 + 0.32, less than 1 of the ideal value, and two index were all under correction. The error vector (DV) indicated the postoperative astigmatism. The average value of AE was 1.67 + 29.84 degrees (-80.78 [~89.77]) at 1 months after 34 and 0.57 + 0.32.. The average value of AE was 2.14 + 18.24 degrees (-41.80 / ~47.73) at 3 months after operation. The SIA value of the reverse optical astigmatism (ATR) group after operation was 1.25 + 0.58D greater than 0.86 + 0.50 D. The CI of.ATR group was 0.83 + 0.25 higher than that of group WTR, 0.57 + 0.30, which showed that the correction rate of ATR was close to 80%, and the correction rate of WTR group was close to 60%. The correction rate of group ATR was higher than that of.LenSx femtosecond laser platform making penetrating keratoplasty with 90% depth of 90%. The depth was 78.6% and 78.9% at 1 and 3 months postoperatively, and the depth of incision was not in depth. The ideal 90%. conclusion: femtosecond laser cataract phacoemulsification, compared with the traditional 2.2mm coaxial micro incision phacoemulsification, has a significant reduction in ultrasonic energy and faster corneal tissue recovery. The operation of femtosecond laser operation can increase the concentration of IL-1 beta, IL-6 and PGE2 in aqueous humor. Negative pressure attraction leads to intraocular pressure. Conclusion: femtosecond laser penetrating keratoplasty combined with phacoemulsification for corneal astigmatism is safe and effective.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R779.6

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