作者：陈梅珠，王云鹏，陈国苍
作者单位：（350025）中国福建省福州市，南京军区福州总医院眼科
【摘要】目的：对穿透性角膜移植术后白内障进行超声乳化吸除术，分析其对角膜移植片内皮细胞的影响因素。方法：单纯穿透性角膜移植术后11眼，未出现排斥反应7眼，排斥反应控制后3mo以上3眼，角膜缝线已拆除。术前裸眼视力光感～0.1，术前及术后均检测角膜植片中央内皮细胞计数，晶状体核III～IV级。手术方式为超声乳化吸除联合人工晶状体植入术，术中平均超声能量14.82%±0.47%，流速26mL/min，负压180～200mmHg（U/S Power），200～210mmHg(U/S Pulse)。超声时间1.5～2.5(1.95±0.47)min。术后常规抗生素及激素眼液点眼。结果：术后最佳矫正视力0.2～0.5，均较术前提高。术后2～3d，角膜植片少许内皮皱褶，术后4d角膜恢复透明。术前术后角膜移植片中央部位内皮细胞计数分别为：607～1998(1248.09±408.52）个/mm2和601～1899(1184.36±373.92）个/mm2，术后内皮细胞丢失率为5.11%，与术前比较采用配对t检验得t=3.6418，P<0.05，有统计学意义。随访3mo以上，角膜植片保持透明，内皮细胞稳定。未发现大泡样角膜病变。结论：穿透性角膜移植术后白内障，超声乳化术式安全有效。
【关键词】 角膜移植；白内障；超声乳化；角膜内皮
Phacoemulsification with intraocular lens implantation in treatment for cataract after penetrating keratoplasty
MeiZhu Chen, YunPeng Wang, GuoCang Chen
Department of Ophthalmology, Fuzhou General Hospital of Nanjing Military Command of Chinese PLA, Fuzhou 350025, Fujian Province, China
Correspondence to: MeiZhu Chen. Department of Ophthalmology, Fuzhou General Hospital of Nanjing Military Command of Chinese PLA, Fuzhou 350025, Fujian Province, China. [email protected]
Abstract AIM: To analyze the influencing factors of phacoemulsification, which was performed for cataract after penetrating keratoplasty (PKP), to endothelial cells of corneal graft.METHODS: A total of 11 eyes had cataract after simple penetrating keratoplasty, 7 eyes of which did not have immune rejection, 3 eyes of which were found immune rejections but were controlled after treatment for over 3 months. Preoperative naked visual acuity was light perception to 0.1. The number of central endothelial cells of corneal graft was counted before and after the operation. The hardness of lens nucleus was III to IV grade. Corneoscleral tunnellike incision was chosen under peribulbar anesthesia. Phacoemulsification was performed and injectable AMO Sensar intraocular lens was implanted in the capsular pocket. The procedure was smooth in all patients. Ultrasonic time lasted for 1.52.5 minutes (1.95±0.47 minutes). The average U/S power was 14.82±0.47%; aspiration rate 26mL/min, negative pressure 180200 mmHg (U/S Power) and 200210 mmHg (U/S Pulse). Conventional antibiotic and steroid eyedrops were topically used after the operation.RESULTS: The postoperative best corrected vision was 0.20.5, improved than before the operation. At 4 days after the operation, corneas recovered to transparency. Endothelial cells density before and after the cataract surgery was 6071998/mm2(1248.09±408.52/mm2) and 6011899/mm2(1184.36±373.92/mm2). The endothelial cell loss rate was 5.11%. There was statistically significant difference between preoperative and postoperative results (t=3.6418,P<0.05). The corneal grafts were transparent and endothelial cells were stable during more than three months of followup. No bullous keratopathy was found.CONCLUSION: Phacoemulsification is safe and effective for cataract after PKP.
KEYWORDS: keratoplasty; cataract; phacoemulsification; corneal endothelium
引言
白内障超声乳化吸除术已成为目前治疗白内障最常规的手术，2004年以来我们对穿透性角膜移植（penetrating keratoplasty，PKP）术后白内障进行超声乳化吸除人工晶状体植入术，术后随访3mo～3a，观察角膜内皮细胞计数和视力，发现治疗效果满意，角膜植片透明，未出现大泡样角膜病变。现分析如下。
1对象和方法
1.1对象
共11眼穿透性角膜移植术后2～5a，年龄45～59岁，均为单眼。角膜拆线后1～3mo待眼部充血完全缓解后进行白内障手术。未出现排斥反应7眼，余3眼出现排斥反应，治疗后病情控制3mo以上，余1例为排斥反应控制不到2mo，因患者渴望复明强烈要求白内障手术。术前裸眼视力光感～0.1，光定位确切。术前角膜移植片中央部位内皮细胞计数：607～1998(1248.09±408.52）个/mm2，晶状体核III～IV级。为防手术刺激或诱发排斥反应，术前术后均加强局部激素用量，增加点眼次数。
1.2方法
球周麻醉，采用角巩膜缘隧道切口宽3.5mm，3例部分虹膜后粘连致瞳孔变形，术中用粘弹剂针头分离粘连的虹膜。3例晶状体完全白色混浊，应用胎盘蓝染色，环形撕囊。采用最简单的stop and chop法，超乳头的斜面朝下，不直对着角膜内皮面。后囊膜均完整，AMO推注式Sensar人工晶状体植入囊袋内。超声乳化参数：美国Alcon公司Legacy 2000型超声乳化仪，超声能量设置为40%～50%，术中平均超声能量12%～21%（14.82%±0.47％），流速26～30mL/min，负压180～200mmHg（U/S Power），200～210mmHg(U/S pulse)。超声时间1.5～2.5（1.95±0.47）min。由同一术者完成手术，术程顺利。术后局部抗生素眼液和激素眼液点眼，碘必殊眼膏睡前涂眼，术后1wk内每晚睡前托吡卡胺活动瞳孔。有2例术前内皮细胞计数分别为607个/mm2、677个/mm2者，术后3d内予以iv 500g/L葡萄糖40mL+2.0g维生素C。
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