【摘要】： 目的探索利用飛秒激光的光致破裂效應(yīng)實(shí)施微創(chuàng)性鞏膜造瘺術(shù)的可行性,并尋求適宜的激光參數(shù)和切割方式。 方法飛秒激光(800nm/50fs／1kHz)經(jīng)0.1數(shù)值孔徑(numerical aperture, NA)的物鏡聚焦后掃描離體兔眼水合鞏膜。通過(guò)計(jì)算機(jī)控制的精密三維平臺(tái)的移動(dòng),嘗試應(yīng)用不同脈沖能量和曝光時(shí)間的飛秒激光對(duì)鞏膜片的多種切割方式。應(yīng)用掃描電鏡對(duì)飛秒激光作用后的鞏膜組織進(jìn)行形態(tài)學(xué)觀察和測(cè)量。 結(jié)果飛秒激光能夠在離體兔眼鞏膜上完成包括線性切割,柱形孔隙和矩形空腔在內(nèi)的三種切口。當(dāng)脈沖能量在37.5-150μJ的范圍內(nèi)變化時(shí),飛秒激光以0.025-0.1mm/s的速度線性掃描鞏膜后均能在鞏膜表面產(chǎn)生光致破裂效應(yīng)。而當(dāng)脈沖能量低于31.25μJ,功率密度低于4.06×1014 W／cm2的閾值水平時(shí),受飛秒激光輻射的鞏膜組織在掃描電鏡下不會(huì)產(chǎn)生任何形態(tài)學(xué)改變。飛秒激光在鞏膜表面產(chǎn)生的線性切口深度與激光的脈沖能量以及曝光時(shí)間呈正相關(guān)。掃描電鏡顯示飛秒激光在鞏膜表面產(chǎn)生的切口具有精確的幾何形狀并且切口邊緣光滑整齊,切口周?chē)M織未見(jiàn)明顯的附帶損傷。 結(jié)論飛秒激光對(duì)離體兔眼鞏膜高精度、微創(chuàng)傷的光致破裂效應(yīng),預(yù)示了它在抗青光眼的鞏膜造瘺術(shù)中有著潛在的應(yīng)用價(jià)值。 目的探索飛秒激光經(jīng)外路鞏膜造瘺的可行性,評(píng)價(jià)手術(shù)的有效性和安全性。 方法對(duì)20只青紫藍(lán)兔右眼后房注射α-糜蛋白酶,制備兔慢性高眼壓模型。將兔隨機(jī)分為實(shí)驗(yàn)組和對(duì)照組,每組10只兔。實(shí)驗(yàn)組右眼行飛秒激光鞏膜造瘺術(shù),對(duì)照組右眼不做手術(shù)治療。飛秒激光脈寬50fs,波長(zhǎng)800nm,重復(fù)頻率1kHz,脈沖能量0.4mJ。觀察術(shù)后1個(gè)月內(nèi)濾過(guò)泡形態(tài)、眼壓及并發(fā)癥情況,組間眼壓比較采用重復(fù)測(cè)量方差分析。分別于術(shù)后第3、7、14、30天對(duì)濾過(guò)道組織進(jìn)行光鏡觀察,術(shù)后14天對(duì)濾過(guò)道組織進(jìn)行掃描電鏡觀察。 結(jié)果10只兔眼鞏膜均被飛秒激光一次性穿透性切除,激光作用時(shí)間為15s-16s,鞏膜切口約2mm×1mm2。術(shù)后第1、3、7、14、21、30天,實(shí)驗(yàn)組和對(duì)照組眼壓比較,差異具有統(tǒng)計(jì)學(xué)意義(F=117.46,39.96,15.17,11.62,15.31,11.10；P0.01)。除2眼因激光在切穿鞏膜時(shí)損傷虹膜根部導(dǎo)致前房出血外,未見(jiàn)其他明顯的手術(shù)并發(fā)癥。術(shù)后第1天所有實(shí)驗(yàn)眼均有濾過(guò)泡形成,到第3天濾過(guò)泡隆起度最高。隨后濾過(guò)泡逐漸縮小,泡壁增厚,第3周時(shí)濾過(guò)泡逐漸扁平消失。病理學(xué)檢查顯示飛秒激光鞏膜造瘺的切口光滑銳利,對(duì)周?chē)M織的附帶損傷小,術(shù)后濾過(guò)道的修復(fù)反應(yīng)主要表現(xiàn)為成纖維細(xì)胞的輕度增生和薄層疏松膠原纖維的形成。 結(jié)論飛秒激光經(jīng)外路鞏膜造瘺術(shù)簡(jiǎn)便快捷,安全有效,有可能成為治療青光眼的一種新的手術(shù)方法。 目的比較經(jīng)外路飛秒激光鞏膜造瘺術(shù)和機(jī)械刀鞏膜造瘺術(shù)的手術(shù)效果和濾過(guò)道創(chuàng)傷修復(fù)反應(yīng),探討飛秒激光鞏膜造瘺術(shù)的有效性和優(yōu)越性。 方法實(shí)驗(yàn)研究。20只青紫藍(lán)兔隨機(jī)分為兩組,每組各10只兔。一組右眼行飛秒激光鞏膜造瘺術(shù),另一組右眼行機(jī)械刀鞏膜造瘺術(shù),左眼作為非手術(shù)對(duì)照眼。觀察術(shù)后1個(gè)月內(nèi)濾過(guò)泡表現(xiàn)、眼壓變化及手術(shù)并發(fā)癥情況。另有6只兔,隨機(jī)選擇右眼行飛秒激光鞏膜造瘺術(shù),左眼行機(jī)械刀鞏膜造瘺術(shù),術(shù)后第14天處死,采用HE染色、Masson三色染色、免疫組化和掃描電鏡技術(shù),觀察濾過(guò)道的創(chuàng)傷修復(fù)反應(yīng)。飛秒激光脈寬50fs,波長(zhǎng)800nm,重復(fù)頻率1kHz,脈沖能量0.4mJ。本研究中的等級(jí)資料和分類(lèi)計(jì)數(shù)資料采用兩獨(dú)立樣本非參數(shù)檢驗(yàn),手術(shù)成功率的比較采用Kaplan-Meier法。 結(jié)果16只兔眼鞏膜均被飛秒激光一次性穿透性切除,激光作用時(shí)間為15s-16s。飛秒激光組19%(3／16)的術(shù)眼因激光誤傷虹膜導(dǎo)致前房少量出血,50%(8／16)的術(shù)眼手術(shù)區(qū)周邊角膜出現(xiàn)水腫混濁。飛秒激光鞏膜造瘺術(shù)后功能性濾過(guò)泡的生存時(shí)間以及眼壓下降的持續(xù)時(shí)間均較機(jī)械刀組明顯延長(zhǎng),差異有統(tǒng)計(jì)學(xué)意義(Mann-WhitneyU值=24.000,20.000；P=0.025,0.016)。飛秒激光組的手術(shù)成功率明顯高于機(jī)械刀組,差異有統(tǒng)計(jì)學(xué)意義(χ2=7.785,P=0.005)。病理學(xué)檢查顯示術(shù)后第14天,機(jī)械刀組的鞏膜切口及結(jié)膜下間隙已被致密的纖維結(jié)締組織完全阻塞,而飛秒激光組的濾過(guò)道則基本保持通暢,結(jié)膜下仍見(jiàn)大范圍濾過(guò)間隙存在。術(shù)后第14天,飛秒激光組濾過(guò)道內(nèi)新生膠原纖維量、成纖維細(xì)胞量和新生血管量均少于機(jī)械刀組,差異均有統(tǒng)計(jì)學(xué)意義(Mann-WhitneyU值=7.000,5.500,2.500；P=0.036,0.045,0.013)。 結(jié)論飛秒激光鞏膜造瘺術(shù)有可能成為一種安全有效,方便快捷的新型微創(chuàng)性抗青光眼手術(shù)方式。
[Abstract]:Objective To explore the feasibility of minimally invasive scleral fistula with femtosecond laser photorupture effect, and to find suitable laser parameters and cutting methods.
Methods Femtosecond laser (800 nm/50 fs/1 kHz) was focused by 0.1 numerical aperture (NA) objective lens and then scanned the hydration sclera of rabbit eyes in vitro. The sclera tissue after second laser treatment was observed and measured.
Results Femtosecond laser can perform three kinds of incisions including linear incision, cylindrical cavity and rectangular cavity on the sclera of rabbits in vitro. When the pulse energy changes in the range of 37.5-150 uJ, the sclera can be linearly scanned by femtosecond laser at the speed of 0.025-0.1 mm/s and the sclera surface can produce photorupture effect when the pulse energy is low. The scleral tissue irradiated by femtosecond laser has no morphological changes under scanning electron microscope when the power density is below the threshold level of 4.06 *1014 W/cm 2 at 31.25 uJ. The linear incision depth produced by femtosecond laser on the scleral surface is positively correlated with the laser pulse energy and exposure time. The scleral incision has precise geometry and smooth edge, and there is no obvious incidental damage to the surrounding tissue.
Conclusion Femtosecond laser has high precision and micro-traumatic photorupture effect on isolated rabbit sclera, which indicates that it has potential application value in anti-glaucoma scleral fistula.
Objective to explore the feasibility of femtosecond laser through external scleral fistulas and evaluate the effectiveness and safety of the operation.
Methods Twenty rabbits were injected with alpha-chymotrypsin into the posterior chamber of the right eye and divided into experimental group and control group randomly, 10 rabbits in each group. The morphology of filtering blebs, intraocular pressure and complications were observed one month after operation. The intraocular pressure between groups was compared by repeated analysis of variance.
Results The sclera of all 10 rabbits were resected by femtosecond laser. The duration of laser treatment was 15s-16s, and the scleral incision was about 2mm *1mm 2. The intraocular pressure of the experimental group and the control group was significantly different (F = 117.46, 39.96, 15.17, 11.62, 15.31, 11.10; P 0.01). There were no significant surgical complications except for anterior chamber hemorrhage at the iris root. On the first day after operation, all the experimental eyes had bleb formation, and the bleb swelling was the highest on the third day. The repairing reaction of the filter passage was mainly manifested by mild proliferation of fibroblasts and formation of thin-layer loose collagen fibers.
Conclusion Femtosecond laser sclerostomy is a simple, rapid, safe and effective method for the treatment of glaucoma.
Objective To compare the effect of external femtosecond laser sclerostomy with mechanical scalpel sclerostomy and repair reaction of filtering tract wound, and to explore the effectiveness and superiority of femtosecond laser sclerostomy.
Methods Twenty blue and blue rabbits were randomly divided into two groups, 10 rabbits in each group. One group underwent femtosecond laser sclerostomy on the right eye, the other underwent mechanical scalpel sclerostomy on the right eye, and the other underwent non-operative control on the left eye. Femtosecond laser sclerostomy was performed on the left eye and mechanical scalpel sclerostomy was performed on the 14th day after operation. HE staining, Masson trichrome staining, immunohistochemistry and scanning electron microscopy were used to observe the wound healing response of the filter passage. Two independent sample nonparametric tests were used to count data. Kaplan-Meier method was used to compare the success rate of operation.
Results The sclera of all the 16 rabbits were resected by femtosecond laser for 15s-16s. In the femtosecond laser group, 19% (3/16) of the eyes suffered from a small amount of bleeding in the anterior chamber and edema and turbidity in the cornea around the operation area of 50% (8/16) of the eyes. The survival time of the functional filtering blebs after femtosecond laser scleral fistulation. The duration of IOP decrease was significantly longer in the femtosecond laser group than in the mechanical knife group (Mann-Whitney U = 24.000,20.000; P = 0.025,0.016). The success rate in the femtosecond laser group was significantly higher than that in the mechanical knife group (2 = 7.785, P = 0.005). Pathological examination showed sclerectomy in the mechanical knife group on the 14th day after surgery. The oral cavity and subconjunctival space were completely blocked by dense fibrous connective tissue, while the filtering passage of femtosecond laser group remained unobstructed, and large-scale subconjunctival filtering space was still found. Academic significance (Mann-WhitneyU value =7.000,5.500,2.500; P=0.036,0.045,0.013).
Conclusion Femtosecond laser sclerostomy may be a safe, effective, convenient and new minimally invasive surgery for glaucoma.
【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2010
【分類(lèi)號(hào)】：R779.6

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