【摘要】 目的：评价氩激光周边虹膜成形术治疗原发性闭角型青光眼急性发作期疗效及随访3a疗效的稳定性。方法：原发性闭角型青光眼第1次急性发作患者23例23眼，局部予以10g/L毛果芸香碱滴眼液及5g/L噻吗心安滴眼液各1滴后，行氩激光周边虹膜成形术，眼压控制稳定后5～7d行激光周边虹膜切开术。观察氩激光周边虹膜成形术治疗前及治疗后2h;1，6，12，24，36mo眼压;观察相应时间点房角变化;术后1，6，12，24，36mo行暗室加俯卧激发试验。结果：氩激光周边虹膜成形术前平均眼压为69.43±8.22mmHg，术后2h眼压为15.74±3.09mmHg，1a随访期间患者未发生高眼压，2，3a部分患者眼压升高;术前所有23眼前房角镜检查可见前房角关闭，术后2h所有23眼静态前房角镜检查前房角增宽，小梁网可见范围增宽，1a随访期间房角无明显变化，2a随访3眼房角较前窄，3a随访又有3眼房角变窄;所有患者术后1，6，12mo行暗室加俯卧激发试验均为阴性，24mo时2眼阳性，36mo时又有4眼阳性。结论：氩激光周边虹膜成形术治疗原发性闭角型青光眼急性发作期(不联合使用全身降眼压药物治疗)可迅速、有效、安全降低眼压，重新开放房角，随访1a疗效稳定，随访3a部分患者进展为慢性闭角型青光眼。
【关键词】 闭角型青光眼;氩激光;虹膜成形术;随访
Followup study for immediate argon laser peripheral iridoplasty as treatment of acute attack of primary angleclosure glaucoma
KeHao Zhao, Ping Chen
Department of Ophthalmology, Beijing Shijingshan Hospital, Beijing 100043, China
Abstract AIM: To study the efficacy and persistency of argon laser peripheral iridoplasty (ALPI) as a firstline treatment of acute primary angleclosure glaucoma (PACG).
METHODS: Twentythree patients with acute PACG were recruited into the study. Each patient received topical pilocarpine (10g/L), timolol (5g/L), and immediate ALPI as primary treatment. The intraocular pressures (IOPs) 2 hours, 1 month, 6, 12, 24, 36 months after ALPI were documented. The angle of anterior chamber were documented at each followup time. Dark room, prone provocative tests were done in the followup.RESULTS: The mean IOP of this group patients was reduced from 69.43±8.22mmHg before ALPI to 15.74±3.09mmHg 2 hours after ALPI. Some patients had ocular hypertension in the followup.The anterior chamber angle was widened on goniscope and the trabecular meshwork could be visualized widely in static state after ALPI, but the anterior chamber angle was narrowed on goniscope in some other patients in the followup. Dark room, prone provocative tests were positive in part of patients in the followup.CONCLUSION: ALPI, without adjunctive systemic carbonic anhydrase inhibitors and hyperosmotic agents, appeared to be effective and safe in controlling the IOP in acute PACG; part of patients developed chronic angleclosure glaucoma in the 3 years followup.
KEYWORDS: angleclosure glaucoma; argon laser; iridoplasty; followup
Zhao KH,Chen P. Followup study for immediate argon laser peripheral iridoplasty as treatment of acute attack of primary angleclosure glaucoma. Int J Ophthalmol (Guoji Yanke Zazhi) 2010;10(8):15451547
0引言
急性闭角型青光眼传统的治疗方法是局部及全身联合应用降眼压药物，待眼压被控制，角膜恢复透明后，下一步治疗为激光周边虹膜切开术，以阻止再次急性发作或进展为慢性闭角型青光眼。然而药物治疗可能对相当一部分急性闭角型青光眼无效，不能有效降低这部分患者眼压。即使药物治疗有效，但它可能花费几个小时或几天时间才能使眼压降低至安全及无症状水平。急性闭角型青光眼眼压得以控制后下一治疗目标为预防青光眼再次急性发作，阻止进展为慢性闭角型青光眼。以往治疗为眼压控制后行激光周边虹膜切开术。一项研究表明，原发性急性闭角型青光眼传统药物治疗控制眼压后行激光周边虹膜切开术，术后平均随访50.3mo，58.1%进展为慢性闭角型青光眼[1]。因此，有待寻求一种更为理想的治疗方法。我们对就诊于我院原发性闭角型青光眼急性发作期患者行激光虹膜成形术(不联合使用全身降眼压药物治疗)控制发作期眼压，重新开放前房角，待眼压控制后行激光周边虹膜切开术，以阻止再次急性发作或进展为慢性闭角型青光眼，所有病例术后随访3a，现将结果报告如下。
1对象和方法
1.1对象 自200601/200701期间就诊于我院原发性急性闭角型青光眼第一次急性发作连续病例23例23眼，男5例5眼，女18例18眼，年龄48～77(平均64.7±8.0)岁。剔除标准：就诊之前已行抗青光眼药物治疗病例;因屈光间质混浊无法行周边虹膜成形术患者;单眼患者。所有纳入病例就诊时间为4～78(平均13.5±12.6)h。
1.2方法 术前准备：纳入眼滴10g/L毛果芸香碱滴眼液及5g/L噻吗心安滴眼液各1滴;纳入病例不给予任何全身降眼压药物治疗;术前纳入眼滴眼科用表面麻醉剂1滴，所有氩激光周边虹膜成形术均由同一术者操作。手术方法：应用LUMENIS Ultima 2000 SE型眼科用氩激光治疗机，放置Abraham角膜接触镜，进行虹膜根部360°光凝。光斑直径500μm，尽量靠近虹膜周边部，2个光凝斑之间间隔1.5个光斑直径距离。能量300～400mW，治疗时随时调整能量，以虹膜出现收缩反应为宜，忌产生气泡及色素逸出。持续时间0.5s，360°范围光凝30点左右。术后处理：术眼滴10g/L毛果芸香碱滴眼液、5g/L噻吗心安滴眼及典必殊滴眼液各1滴;以后滴10g/L毛果芸香碱滴眼液、典必殊滴眼液,4次/d,持续5～7d进而行激光虹膜切开术。观察指标：应用Schiotz压陷式眼压计测量术前及术后2h;1，6，12，24，36mo眼压;静态及动态前房角镜检查观察相应时间点前房角变化;术后1，6，12，24，36mo行暗室加俯卧激发试验。
2结果
2.1判断标准 疗效成功判定标准：随访期间眼压未升高;静态前房角镜检查小梁网可见范围>180°，前房角无进行性粘连;暗室加俯卧试验阴性。
2.2眼压 氩激光周边虹膜成形术前平均眼压为69.43±8.22(56～85)mmHg。术后2h平均眼压为15.74±3.09mmHg，所有23眼眼压均下降到<21mmHg。术后1a内所有纳入眼眼压均<21mmHg，术后2a，3眼眼压为21～40mmHg，术后3a又有3眼眼压为21～40mmHg。
2.3房角 术前所有23眼各方房角均呈不同程度关闭状态，静态前房角镜检查小梁网可见范围均<90°;术后2h所有23眼静态前房角镜检查前房角增宽，小梁网可见范围增宽，均>180°;术后1,6,12mo静态前房角镜检查小梁网可见范围与术后2h相比无明显变化，动态前房角镜检查各方房角无进行性粘连，术后24mo,3眼静态房角镜示前房角变窄，小梁网可见范围<180°，动态检查示虹膜根部前粘连，术后36mo,又发现3眼静态房角镜示前房角变窄，小梁网可见范围<180°，动态检查示虹膜根部前粘连。
2.4暗室加俯卧激发试验 术后1,6,12,24,36mo行暗室加俯卧激发试验，激发时间为2h，激发后较激发前眼压升高>8mmHg为阳性，术后1，6，12mo结果均为阴性，术后24mo，2眼结果阳性，术后36mo，又出现4眼阳性。
2.5手术并发症 (1)氩激光虹膜成形术并发症：术后轻度炎症反应，随访中1～4d消失，难以区分是由手术所致或是青光眼急性发作所致。(2)激光周边虹膜切开术并发症：术后部分患者一过性眼压增高，临时予以降眼压药物均于4h内恢复正常。
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