【摘要】目的：探讨使用改良小梁切除术联合MMC治疗NVG的疗效。方法：在经典现代小梁切除术基础上，改良行上穹窿为基底的角膜缘处结膜切口、做巩膜瓣5.0mm×4.5mm、巩膜瓣行MMC处理、透明角膜缘连同小梁区切除3.3mm×2。0mm、虹膜剪除前灼凝表面新生血管。结果：9例（9眼）NVG患者术后眼胀痛，头痛等症状消失，眼压保持良好。1例随访4a，3例随访3a，3例随访2a，眼压均稳定在15.88~23.78mmHg。2例失随访。结论：NVG采用改良小梁切除术联合MMC治疗效果较好。
【关键词】 新生血管性青光眼；改良小梁切除术；丝裂霉素C
Treatment of modified trabeculectomy with MMC for neovascular glaucoma
YanXian Li,Jun Yuan,Bei Li,Jiao Zhang
1Department of Ophthalmology, Sichuan Fire Armed Police Corps Hospital, Chengdu 610072, Sichuan Province, China;2 Department of Ophthalmology, the Second Peoples Hospital of Guangyuan, Guangyuan 628017,Sichuan Province,China;3 Department of Ophthalmology, No.416 Hospital, Chengdu 610051, Sichuan Province, China
Correspondence to: YanXian Li. Department of Ophthalmology, Sichuan Fire Armed Police Corps Hospital, Chengdu 610072, Sichuan Province, China. yanxian800 @sohu.com
AbstractAIM: To investigate the clinical effect of treatment of modified trabeculectomy with MMC for late neovascular glaucoma. METHODS: Bular conjunctives were at the base of vault incised. Then the operation was continued with a 5.0mm×4.5mm incision in corneoscleral limbus and 3。3mm×2。0mm in trabecula. Neovascular vessels on iris were electrocoagulated before iridectomy. Cotton slice with MMC was inserted into the incision on sclera; sclera and conjunctival flaps were sutured. Both eyes of the patient were dressed for three days.RESULTS: This modified trabeculectomy was successful in 9 eyes of 9 patients, of whom 1 was followed up for 4 years, 3 for 3 years, 3 for 2 years and 2 dropped out. It was found that their headache and pain in eyes disappeared and their eye pressure returned to normal (15.8823。78mmHg).CONCLUSION: Modified trabeculectomy is an effective treatment for late neovascular glaucoma.
KEYWORDS: neovascular glaucoma; modified trabeculectomy; MMC
0引言
新生血管性青光眼(neovascular glaucoma，NVG)是一种临床疗效极差的难治性青光眼，尤其是顽固性高眼压，除视力严重受损外，常伴有剧烈的眼胀痛和头痛。我们施行了改良小梁切除术联合MMC治疗NVG，以期重建房水循环路径，减轻患者的痛苦症状，收到较好效果。
1对象和方法
1.1对象
9例（9眼）中，男5例，女4例；右眼5例，左眼4例。年龄53~67（平均58）岁。病程8mo~2a，平均1a。5例（5眼）继发于视网膜中央静脉阻塞，2例（2眼）继发于糖尿病视网膜病变，2例（2眼）原因不明。视力:LP0.03。9例（9眼）瞳孔区均有不同范围的虹膜后粘连和不同程度的瞳孔散大，虹膜表面新生血管明显。7眼周边虹膜大部前粘连、房角大部分关闭，尚未关闭的房角处新生血管明显,另外2眼房角完全关闭。眼压53.61~66.23（平均58.01）mmHg。患者均有剧烈眼胀痛及同侧头痛。
1.2方法
1.2.1术前用药
术前30min根据患者情况，按1~2g/kg给予200g/L甘露醇快速静滴，联合口服乙酰唑胺及碳酸氢钠片各0.5g，必要时按1~2mL/kg增服500g/L甘油，设法使眼压控制在35mmHg左右；术前30min肌注止血敏0.5g，口服地塞米松0.75~1.5mg，吲哚美辛25mg或布洛芬0.2g。糖尿病患者，将血糖控制在安全范围实施手术，由于手术加用地塞米松，注意适当增加抗血糖药量。
1.2.2手术方法
手术在显微镜下完成。做上穹窿为基底的角膜缘处结膜切口，再行5.0mm×4.5mm浅层巩膜瓣。将浸有0.4g/L浓度的丝裂霉素C（MMC）棉片，剪成4mm×4mm大小嵌于巩膜瓣内2.5~3min后取出，用大量BSS液冲洗该巩膜瓣区及周围组织。将巩膜瓣连续分离至角膜缘内1.0~1.5mm，由平行角巩膜缘做3.3mm长的深层角膜基床切口，作为切除小梁组织的前缘切口，并于该切口两端向后，平行角巩缘做连同小梁区在内的2mm宽的切口，作为切除小梁组织的后缘切口。虹膜根部剪除前，灼凝虹膜切除区表面新生血管。虹膜切除区若遇渗血，于该处注射适量粘弹剂止血，或用1~2滴立止血注射液滴于渗血处至血止。10个0尼龙线轻度错位间断缝合巩膜瓣2针。结膜切口两端，电凝紧密对合或10个0尼龙线紧密缝合、结扎。
1.2.3术后处理
全身常规给予口服小剂量糖皮质激素和非甾体抗炎药1wk。云南白药口服3~5d，必要时联合其他止血药静滴或肌注，以加强止血。对高血压、糖尿病等原发病，密切监控血压、血糖，注意调节其相关病的用药量。眼部除按小梁切除术的术后常规处理外，特别强调双眼包扎3~4d待前房相对稳定。
2结果
2.1观察指标
术后随访时间2~4(平均3)a，均以术后2a检查结果为准，其中以自觉症状﹑前房出血﹑眼压﹑视力及虹膜新生血管情况为主要观察指标。
2.2自觉症状
9例(9眼)术后高眼压的痛苦症状及体征当日全部消失。
2.3前房出血
术后次日换药，有7眼前房出血。1眼限于虹膜切除区，丝网状积血；2眼虹膜切除区周围的虹膜表面散在积血；2 眼前房下部积血，占1／5液平面。这些积血均于2~3d后自行吸收。2眼虹膜切除区至瞳孔区薄血覆盖，3~4d后自行吸收。
2.4眼压
9例(9眼)术后4~28d眼压保持在10.2～17。30(平均12.23)mmHg。3例随访2a，3例随访3a，1例随访4a，眼压均稳定在15.88~23.78(平均21.89)mmHg。2例6mo后失随访。表1 术前及术后术眼疗效情况眼（略）注：2例术后失随访
2.5视力
随访病例6mo内与入院时相比，无1例下降，其中4例较术前略有增进，但均未脱盲。2例术后1~2a视力有下降趋势。
2.6虹膜新生血管
随访病例中，未见虹膜表面新生血管较术前明显增多情形。
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