非穿透小梁切除术联合丝裂霉素Ｃ及羊膜植入术治疗难治性青少年开
【关键词】 切除。
摘要：目的：证明非穿透小梁切除术联合丝裂霉素Ｃ及羊膜植入术是治疗常规手术失败后的青少年开角型青光眼的一种安全有效的手术方法。方法：对15例（15眼）曾按常规手术失败的青少年开角性青光眼患者施行非穿透性小梁手术，术中使用丝裂霉素并联合羊膜移植，术后观察视力眼压滤泡及并发症。术后随访（9.2±3.5）个月。结果：术后1年，1眼较术前视力提高，14眼视力无改变，未发现视力下降者；患者术前平均眼压（30.18±4.38）mmHg，术后2周（11.25±2.58）mmHg，1月为（13.18±2.38）mmHg，3月为（14.27±2.55）mmHg，6月为（13.18±2.38）mmHg，1年时为（15.33±3.01）mmHg，术后各时段眼压与术前相比，差异均有显著意义（P0.01）；术后2周11眼（73.3%）为Ⅰ型功能性滤过泡、4眼（26.7%）为Ⅱ型功能性滤过泡，1眼在3月时滤过泡有轻度包裹，经用针轻挑滤过泡包膜内壁后恢复为Ⅰ型滤过泡，随访1年，15眼仍为Ⅰ、Ⅱ型功能性滤过泡；术后9眼无任何反应，5眼前房水轻度闪辉，术后3～5d消失，1眼前房轻度积血，术后6d吸收。未发生浅前房脉络膜脱离眼内炎及滤过泡渗漏等并发症。结论：非穿透小梁切除术联合丝裂霉素Ｃ及羊膜植入术治疗常规手术失败的青少年开角型青光眼是一种安全有效的方法。
关键词：非穿透小梁切除术；难治性；青少年开角型青光眼；丝裂霉素Ｃ；羊膜。
Non—penetrating Trabecular Surgery with Mitomycin—C and Amniotic Membrane Implant Treat the Refractory Juvenile Open Angle Glaucoma。
LI Qiang,WAN Peng—xia。
(Department of Ophthalmology, The People’s Hospital, Huadu District ofGuangzhou, Guangdong Guangzhou 510800,China)。
Abstract： Objective： To prove the safety and effectiveness of non—penetrating trabecular surgery with Mitomycin—C and amniotic membrane implant in treating the refractory juvenile open angle glaucoma that have failed in the routine surgery. Method： Non—penetrating trabecular surgery with Mitomycin—C and amniotic membrane implant was performed on the 15 patients (15 eyes) who have had failed in the routine surgery. Visual acuity, intraocular pressure (IOP), filtering bleb and complications were observed. The post operation follow—up period is (9.2±3.5) months. Results： One year after the operation, 1 eye with better visual acuity than that of preoperation,14 eyes have no change, no eye was found with worse visual acuity than before. Preoperative mean IOP was (30.18±4.38)mmHg, the mean IOP on post—operative 2nd week, 1st, 3rd, 6th month, and 1st year was (11.25±2.58)mmHg, (13.18±2.38)mmHg, (14.27±2.55)mmHg, (13.18±2.38)mmHg, (15.33±3.01)mmHg, the post—operative mean IOPs in every period comparing with that of pre—operation have significant difference. 2 weeks after the operation, 11 eyes (73.3%) with type I functional filtering bleb, 4 eyes (26.7%) with type II functional filtering bleb. 1 eyes with slightly encapsulated bleb 3 months after the operation , and the bleb turn back to type I after broke it’s capsule wall with a needle . 1 year after the operation , 15 eyes still with type I or II functional filtering bleb. After the operation, 9 eyes had no complications. 5 eyes with light aqueous flare which disappeared after 3～5 days. 1 eye with light hyphema, and it was absorbed in the 6th day after the operation. There were no other complications, such as shallow anterior chamber, choroidal detachment, endophthalmitis, filtering bleb leak and so on. Conclusion：Non—penetrating trabecular surgery with Mitomycin—C and amniotic membrane implant is a safe and effective method of treating the refractory juvenile open angle glaucoma that has failed in the routine surgery.
Key words：Non—penetrating trabecular surgery；Refractory；Juvenile open angle glaucoma； Mitomycin—C；Amniotic membrane 青少年型青光眼(ＪＯＡＧ)是指3岁以后至成人早期发病的先天性青光眼,其中绝大部分为开角,仅有约8.98%为闭角［1］。该病是需要手术治疗的疾病。传统的小梁切除术因为儿童筋膜囊厚增生活跃,伤口愈合迅速,巩膜硬度较低,水眼的巩膜较薄及多次手术瘢痕导致手术失败［2］。我们自2001年1月至2003年6月采用非穿透小梁切除术联合丝裂霉素Ｃ及羊膜植入术治疗传统的小梁切除术后失败的青少年开角型青光眼取得了满意的效果。
1 资料和方法。
1.1 临床资料：本组病例共15例（15眼），均为我院2001年1月至2003年6月收治的青少年开角性青光眼，都经历过一次常规抗青光眼术失败并有完整病历记录的先天性青光眼儿童,用药物难以控制眼压并有进行性视神经损害。其中男9例，女6例，年龄3.5～11岁，平均6.3岁。患者术前平均眼压（30.18±4.38）mmHg，术后随访（9.2±3.5）个月。
1.2 治疗方法。
1.2.1 羊膜的制备和处理：羊膜取自剖宫产孕妇的胎盘。产前母体血清学检查排除人免疫缺陷病毒、乙肝炎病毒、丙肝炎病毒、衣原体及梅毒。取材均在无菌操作下完成,将胎盘用生理盐水冲洗干净,再用无菌Ｅａｒｌｅ平衡盐溶液(含青霉素５０ｍｇ／ｍｌ、链霉素５０ｍｇ／ｍｌ、新霉素１００ｍｇ／ｍｌ、二性霉素２．５ｍｇ／ｍｌ)冲洗,然后从绒毛膜彻底钝性分离羊膜,将分离的羊膜上皮面向上平铺于硝酸纤维素膜上,并剪成8ｃｍ×8ｃｍ大小,置于含ＤＭＥＭ:甘油培养液(体积比１:１)的无菌玻璃瓶中,于—８０℃冷藏保存。
1.2.2 手术方法：常规在上方结膜下浸润麻醉,做以上穹窿部为基底的结膜瓣及以上方角膜缘为基底的巩膜瓣,约6ｍｍ×6ｍｍ,厚度约为1/3巩膜厚度,向前剖切至透明角膜内2ｍｍ;用3mm×4mm棉片浸含0.2mg/ml丝裂霉素C后,置巩膜瓣下3min,去除棉片,立即用200mlBSS液冲洗。在浅层巩膜瓣内1ｍｍ做另一深层巩膜瓣,约5ｍｍ×5ｍｍ。剖切深层巩膜瓣深度应仅保留一层菲薄的睫状体前巩膜组织,可透见其下黑色的睫状体组织,沿此层向前剖切至透明角膜内1ｍｍ,同时分离此深层巩膜瓣连同Schlemm管外壁及与之相连的小梁组织,暴露内部小梁,并可见房水外渗,用Venns剪剪除深层巩膜瓣,形成减压房。将羊膜解冻，取出后用含庆大霉素的生理盐水液漂洗2～3次，剪成6mm×7mm植片，将上皮面向上植入此减压房，复位浅层巩膜瓣，使羊膜在巩膜瓣的双侧和上方各露出约1.5～2mm,10～0尼龙线固定于巩膜上，缝合巩膜2针。连续分层缝合球结膜，结膜下注射庆大霉素2万U及地塞米松2.5mg。
2 结果。
2.1 滤过泡：术后2周11眼（73.3%）为Ⅰ型功能性滤过泡，4眼（26.7%）为Ⅱ型功能性滤过泡，1眼在3月时滤过泡有轻度包裹，经用针轻挑滤过泡包膜内壁后恢复为Ⅰ型滤过泡，随访1年，15眼仍为Ⅰ、Ⅱ型功能性滤过泡。