【摘要】 目的：观察在泪道内窥镜下泪道阻塞及治疗前后的形态对比以判断预后,指导手术。
方法：我们200702/11选择了52例（71眼）泪道阻塞患者，应用微型泪道内窥镜直视下动态观察泪道粘膜形态及狭窄部位，以环钻和/或激光解除阻塞，并逆行植入硅胶管，拔管后随访0.5a。
结果：52例（71眼）泪道阻塞患者经治疗后，治愈67眼，治愈率达94％,再次检查发现2眼泪道内壁有纤维附着,2眼泪总管阻塞。
结论：在泪道内窥镜下，直接观察泪道细小病变，并进行有针对性地环钻、激光术治疗，避免了手术对正常组织的损伤及假道形成，并可彻底清除阻塞物，防止再阻塞发生，是理想的治疗方法。
【关键词】 内窥镜 泪道阻塞 微型环钻 YAG激光
Application of endoscopy in dacryagogatresia
Li Yuan, XiaoJun Zhang, SuMin Shen
Department of Ophthalmology, the Second Affiliated Hospital, Nanjing Medical University, Nanjing 210011, Jiangsu Province, China
Abstract
AIM: To observe the obstruction and the shape before and after treatment under endoscopy, in order to judge prognosis and guide surgery.
METHODS: Fiftytwo cases (71 eyes) with dacryagogatresia from February to November, 2007 in our hospital were selected. Microminiature endoscope was used to observe morphology of lacrimal mucosal and narrow parts. Central drilling and/or laser lifting was used to dredge obstruction. and the silicone was implanted reversely. The followedup time was 6 months after extubation.
RESULTS: After treatment, 67 eyes (94%) were cured. Two eyes revealed a fiber wall attachment at lacrimal passage， and two eyes had lacrimal duct obstruction.
CONCLUSION: Under lacrimal endoscope, we can directly observe lacrimal small lesions, perform microdrilling/laser treatment in a targeted manner, avoid normal tissue injury and forming a false passage, completely clear the obstruction and prevent further obstruction. Lacrimal endoscope is an ideal treatment.
KEYWORDS: endoscopy; dacryagogatresia; microminiature; drilling; laser
0引言
泪道阻塞是眼科临床常见疾病,常伴有溢泪症状, 如并发感染、溢脓，可给患者生活带来不便,而且是眼部潜在的感染源,可引起眼部感染,如角膜溃疡、眼内炎等严重并发症而致盲。目前,可采用泪道激光、探通、逆行插管等多种方法治疗，创伤小，术后恢复快。但术中无法看到阻塞部位及情况，仅凭医生感觉、经验判断来完成手术过程，可产生假道、不必要损伤，影响手术远期效果。我们采用微型泪道内窥镜直视下观察泪道阻塞状况，并根据观察选择环钻或激光有针对性地进行治疗，现总结报告如下。
1对象和方法
1.1对象 200702/11门诊泪道阻塞患者52例（71眼），男19例（25眼），女33例（46眼），年龄17～80（平均41.4）岁，病程6mo～35a。19眼曾行泪道探通或挂线治疗，7眼曾行YAG激光治疗，1眼曾行YAG激光+硅胶管植入术;泪小管阻塞3例，泪总管阻塞5例（9眼），鼻泪管阻塞47例（62眼）。
1.2方法 患侧鼻腔术前3d滴用10g/L呋麻液,术前中鼻道填塞10g/L地卡因+10g/L麻黄素棉片。常规消毒、铺巾、暴露泪囊区,倍诺喜表麻及20g/L利多卡因2mL筛前神经及眶下神经阻滞麻醉。先冲洗泪道,使泪道洁净。扩张泪小点,将直径1.1mm德国进口（Poly Diagnost）带有三通道微型泪道内窥镜（一个管道放置直径为0.5mm的内窥镜，一个管道可放置直径为0.4mm的微型电钻，一个管道为灌注道）缓慢顺泪道方向插入,持续小水流冲洗(以便内窥镜能获得清晰的图像),在监视屏直视下再沿着泪小管的方向前进,当到达泪囊的外壁时,将内窥镜转向后下(与泪道探通术相同)，顺鼻泪管的方向继续前进直到下鼻甲的下方。边插入边进行检查,看到异常情况则立即记录病变的位置、性质及长度,如果有狭窄或阻塞,如位于泪总管，则用YAG激光打通，如位于鼻泪管即用直径0.4mm微型电钻将其切除，并彻底清除泪道壁纤维组织，使成为直径3～4mm的光滑管道。切除成功后,常规逆行在泪道内放置硅胶管,一般留置3～6mo。术后处理:酌情口服抗生素，10g/L的呋麻滴鼻液滴鼻，抗生素眼药水点眼，术后1mo内需冲洗泪道3～15次不等，必要时加抗菌药。硅胶管留置3mo。术后观察：术后1wk;1,2,3mo冲洗泪道。3～6mo后拔管。6mo后，冲洗泪道并以直径0.8mm两通道泪道内窥镜同上插入检查鼻泪管有无粘连、瘢痕形成、狭窄、阻塞，并记录图像。疗效评价：治愈：泪道冲洗通畅，溢泪症状消失，无粘脓性分泌物，泪道内窥镜下检查无疤痕性狭窄和阻塞；好转：泪道冲洗通而不畅，溢泪症状减轻，无粘脓性分泌物，泪道内窥镜下检查见鼻泪管有疤痕性狭窄；无效：泪道冲洗不通。
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