【摘要】：目的 擬創(chuàng)建一種全新的口唇粘膜移植重建眼表的手術(shù)技術(shù),重建疤痕期眼表角膜緣功能,矯正瞼球粘連,并行二期光學(xué)性角膜移植。通過臨床病例隨訪分析及手術(shù)標(biāo)本的實(shí)驗(yàn)室研究,評(píng)估手術(shù)療效并探討術(shù)后眼表上皮細(xì)胞的形態(tài)和性質(zhì)。方法研究對(duì)象為2011年8月至2014年3月期間在我院眼科住院接受口唇粘膜移植眼表重建手術(shù)的疤痕期眼表疾病患者。對(duì)患者主觀不適癥狀(包括畏光、疼痛、干眼)、視力、瞼球粘連程度、新生血管程度及角膜混濁度進(jìn)行等級(jí)評(píng)分并進(jìn)行術(shù)前術(shù)后比較,評(píng)估手術(shù)療效。對(duì)部分眼表成功重建的病例行二期光學(xué)性角膜移植手術(shù),觀察術(shù)后的視力、眼表上皮、新生血管以及植片情況等。同時(shí)通過眼表印記細(xì)胞、二期角膜移植手術(shù)標(biāo)本的組織病理切片、免疫組織化學(xué)染色和掃描電鏡等實(shí)驗(yàn)室技術(shù),對(duì)術(shù)后眼表上皮細(xì)胞的形態(tài)和性質(zhì)進(jìn)行探討和研究。結(jié)果1.第一部分結(jié)果共計(jì)88例患者(89眼)被納入研究,平均年齡42.7±12.40歲,其中男性77人(86.5%)。病因包括化學(xué)燒傷47眼(52.8%),熱燒傷33眼(37.1%),爆炸傷3眼(3.4%),Steven-Johnson綜合征3眼(3.4%)和多發(fā)胬肉3眼(3.4%)。平均隨訪355.9±233.8天,最長達(dá)847天,43.8%的病例隨訪超過1年。其中52眼(58.4%)施行了全周口唇粘膜移植,37眼(41.6%)行部分范圍的口唇粘膜移植,5例病人因剩余角膜基質(zhì)過薄聯(lián)合了深板層角膜移植術(shù)或板層角膜移植術(shù),所有病例術(shù)后粘膜植片生長良好。術(shù)后20眼并發(fā)羊膜下積血,平均31.89±19.90天完全吸收,未見其他術(shù)中及術(shù)后并發(fā)癥及不良事件,口唇切口約9天愈合,患者無不適主訴及并發(fā)癥。術(shù)后74眼(83.1%)主觀不適癥狀較術(shù)前改善,術(shù)后評(píng)分1.02±0.64較術(shù)前2.24±1.09明顯下降(P0.01),其中畏光、疼痛、干眼的改善率分別為84.7%、76.4%、 69.1%；43眼(48.3%)視力較術(shù)前提高；84眼(94.3%)角膜新生血管程度下降,血管深度和范圍分別較術(shù)前下降1.48±0.83和0.99±0.87個(gè)等級(jí)(P0.01)；術(shù)前瞼球粘連眼(57眼)術(shù)后皆得到改善,瞼球粘連程度較術(shù)前平均下降1.44±0.69個(gè)等級(jí)(P0.01),長期隨訪過程僅5眼(8.8%)有局部復(fù)發(fā)；25眼(28.9%)角膜混濁度較術(shù)前下降。粘膜移植術(shù)后,88眼(98.9%)上皮化完成,平均需時(shí)29.95±61.13天,其中12眼(14.6%)術(shù)后早期出現(xiàn)小范圍反復(fù)持續(xù)性上皮缺損(PED),經(jīng)過輔助治療恢復(fù)穩(wěn)定無并發(fā)癥,1眼(1.1%)持續(xù)存在PED至末次隨訪(501天)并發(fā)局部基質(zhì)浸潤。相關(guān)性分析示上皮化完成時(shí)間與以下因素相關(guān)：術(shù)前眼表不適癥狀(r=0.336,P0.01)、術(shù)前PED(r=0.364,P0.01)、角膜混濁程度(r=0.331,P0.01)及角膜緣干細(xì)胞缺失范圍(r=0.375,p0.01)。2.第二部分結(jié)果口唇粘膜移植術(shù)后15眼接受了姚氏法全植床深板層角膜移植(Yao's-DLK),4眼接受了穿透性角膜移植(PKP),平均隨訪305.1±152.4天。所有病例植片生長良好,內(nèi)皮細(xì)胞密度監(jiān)測平穩(wěn),未見排斥反應(yīng)。術(shù)后角膜混濁度、新生血管程度較一期術(shù)后進(jìn)一步降低。其中16眼(84.2%)視力較術(shù)前提高,13眼(68.4%)由術(shù)前的手動(dòng)或指數(shù)提高至0.05及以上,8眼(42.1%)至0.2及以上。術(shù)后早期有7眼(36.8%)上皮出現(xiàn)小范圍上皮持續(xù)缺損(PED),輔助治療后6眼上皮恢復(fù)穩(wěn)定,1眼持續(xù)缺損至末次隨訪(461天),其中4眼并發(fā)局部基質(zhì)浸潤混濁,有3眼對(duì)視力產(chǎn)生影響。DLK術(shù)中并發(fā)癥有后彈力層小穿孔至術(shù)后雙前房1眼,術(shù)后1月自行恢復(fù)；PKP術(shù)后并發(fā)癥有激素性青光眼1眼,改用低濃度激素后好轉(zhuǎn)；并發(fā)性白內(nèi)障1眼,隨訪病情穩(wěn)定。3.第三部分結(jié)果眼表印記細(xì)胞學(xué)檢查示口唇粘膜移植術(shù)后眼表上皮形態(tài)學(xué)上皆不同于三種上皮(口唇粘膜上皮、角膜上皮和結(jié)膜上皮)。術(shù)后眼表不同部位的細(xì)胞大小、形態(tài)、排列、層數(shù)、染色、核質(zhì)比等皆不同,角膜中央部位的細(xì)胞較周邊部位分化更好,術(shù)后時(shí)間越長,眼表細(xì)胞分化越好。手術(shù)標(biāo)本石蠟切片HE染色示術(shù)后上皮的層數(shù)多于正常角膜但少于口唇粘膜,周邊上皮較厚,中央上皮較薄。部分移植的病例上皮分化較全周移植的好,上皮更接近正常角膜。掃描電鏡結(jié)果示口唇粘膜移植術(shù)后眼表上皮的超微機(jī)構(gòu)皆不同于三種上皮；中央部位上皮微絨毛分化較周邊部位更明顯,部分移植的病例較全周移植更接近角膜上皮。免疫組織化學(xué)染色結(jié)果示新生上皮來源于口唇粘膜,但兼具角膜上皮和口唇粘膜上皮的部分特性,且有著豐富的上皮干細(xì)胞層。結(jié)論 本課題設(shè)計(jì)的口唇粘膜移植手術(shù)能有效的重建疤痕期眼表并成功施行二期光學(xué)性角膜移植；直接移植的自體口唇粘膜上皮在眼表可出現(xiàn)細(xì)胞轉(zhuǎn)分化,轉(zhuǎn)分化后的上皮細(xì)胞具備部分角膜上皮的特性。因此,口唇粘膜組織是較為理想的角膜緣上皮替代性組織。
[Abstract]:Objective To establish a new surgical technique for reconstruction of ocular surface by lip mucosa transplantation, to reconstruct the limbal function of ocular surface, to correct blepharoplasty and to perform secondary optical keratoplasty. Methods Patients with ocular surface diseases in scar stage who underwent lip mucosa transplantation for ocular surface reconstruction in our ophthalmology department from August 2011 to March 2014 were evaluated for subjective discomfort symptoms (including photophobia, pain, dry eyes), visual acuity, degree of symblepharon adhesion, degree of neovascularization and corneal opacity. The visual acuity, ocular surface epithelium, neovascularization and grafting were observed in some cases of successful ocular surface reconstruction. The ocular surface imprinted cells, histopathological sections of secondary corneal transplantation specimens, immunohistochemical staining and scanning electron microscopy were used. Results 1. Results A total of 88 patients (89 eyes) with an average age of 42.7 (+ 12.40 years) were included in the study, including 77 males (86.5%). The etiology included chemical burns in 47 eyes (52.8%), heat burns in 33 eyes (37.1%), explosive injuries in 3 eyes (3.4%) and explosive injuries in 3 eyes (Steven-Johnson). Three eyes (3.4%) with syndrome and three eyes (3.4%) with multiple pterygium were followed up for an average of 355.9 (+ 233.8) days, up to 847 days. 43.8% of the patients were followed up for more than one year. Among them, 52 eyes (58.4%) underwent full-cycle lip mucosa transplantation, 37 eyes (41.6%) underwent partial lip mucosa transplantation, and 5 patients underwent deep lamellar keratoplasty or lamellar keratoplasty because of the thin residual corneal stroma. After corneal lamellar transplantation, the grafts grew well in all cases. Subamniotic hemorrhage was found in 20 eyes (31.89 The improvement rates of photophobia, pain and dry eye were 84.7%, 76.4% and 69.1%, 43 eyes (48.3%) had improved vision, 84 eyes (94.3%) had decreased degree of corneal neovascularization, and the depth and scope of blood vessels were 1.48 + 0.83 and 0.99 + 0.87 grades (P 0.01), respectively. After mucosal transplantation, the epithelialization was completed in 88 eyes (98.9%) with an average time of 29.95 [61.13 days] and 12 eyes (14.6%) with early postoperative recurrence. Small-scale recurrent persistent epithelial defect (PED) occurred in the first stage. No complications occurred after adjuvant treatment. One eye (1.1%) had persistent PED and local matrix infiltration during the last follow-up (501 days). Correlation analysis showed that the completion time of epithelialization was related to the following factors: preoperative ocular surface discomfort symptoms (r = 0.336, P 0.01), preoperative PED (r = 0.364, P 0.01), angle. Membrane opacity (r = 0.331, P 0.01) and limbal stem cell loss (r = 0.375, P 0.01). 2. Results In the second part, 15 eyes received Yao's Full-Bed Deep lamellar keratoplasty (Yao's-DLK) and 4 eyes received penetrating keratoplasty (PKP), with an average follow-up of 305.1 (+ 152.4 days). Postoperative corneal opacity and neovascularization were further reduced. Visual acuity of 16 eyes (84.2%) was improved, 13 eyes (68.4%) were improved from preoperative manual or index to 0.05 or more, 8 eyes (42.1%) to 0.2 or more. Small epithelial areas persisted in 7 eyes (36.8%) in the early postoperative period. Defects (PED) were found in 6 eyes after adjuvant therapy, and 1 eye was persistent defect until the last follow-up (461 days). Four of them were complicated with local matrix infiltration and turbidity. Three eyes had visual impairment. The third part of the results showed that the morphology of the ocular surface epithelium was different from that of the three kinds of epithelium (lip mucosa epithelium, corneal epithelium and conjunctival epithelium). The number of layers, staining and the ratio of nucleus to cytoplasm were different. The cells in the central part of cornea differentiated better than those in the peripheral part. The longer the operation time, the better the differentiation of ocular surface cells. Scanning electron microscopy showed that the ultrastructure of the ocular surface epithelium was different from the three kinds of epithelium after oral mucosa transplantation. The microvilli differentiation of the central epithelium was more obvious than that of the peripheral epithelium, and some of the transplanted cases were closer to the corneal epithelium than that of the whole-week transplantation. Conclusion The lip mucosa transplantation designed in this study can effectively reconstruct the ocular surface in the scar stage and successfully perform the second-stage optical keratoplasty. Cell transdifferentiation can occur on the ocular surface, and the differentiated epithelial cells possess some characteristics of corneal epithelium.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R779.6

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1 祝遠(yuǎn)方;口唇粘膜移植眼表重建的臨床療效及其術(shù)后上皮特性的研究[D];浙江大學(xué);2014年

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