眼烧伤后重度睑球粘连眼表重建的临床研究

Ocular surface reconstruction for severe symblepharon resulting from eye burns

目的探讨新鲜供体带角膜缘板层角膜移植(LKP)联合带角膜缘干细胞自体球结膜移植和羊膜移植治疗眼烧伤后重度睑球粘连的眼表重建效果。方法选择1998年2月至2003年2月我院收治的眼烧伤后重度睑球粘连患者26例(26只眼)。根据视功能受损程度将睑球粘连分为4度,其中Ⅲ度19只眼、Ⅳ度7只眼。手术方法:(1)分离睑球粘连,保留假性胬肉;(2)利用新鲜供体行带角巩膜缘的部分LKP(19只眼)或全LKP(7只眼);(3)取带角膜缘组织自体球结膜瓣移植于粘连最重的创面;(4)假性胬肉后徙,部分替代球结膜,联合羊膜移植重建结膜囊。术后随访8～36个月,观察结膜囊情况、眼球活动、角膜植片免疫排斥反应情况以及羊膜和假性胬肉的转归。结果除1只眼因睑裂闭合不全行永久性睑裂缝合术外,其余25只眼的眼表情况均得到不同程度改善。(1)睑球粘连:17只眼(65%)第一次手术后粘连完全分离,复视消失;8只眼(31%)在单纯羊膜覆盖的创面区复发条带状睑球粘连,其中5只眼经再次手术粘连完全解除,3只眼残余Ⅰ度粘连。(2)羊膜在术后1周开始自溶,3个月时完全消失;保留的假性胬肉术后1～3个月充血消退,逐渐变薄,相应区域无睑球粘连复发。(3)角膜情况:6只眼角膜植片发生免疫排斥反应,其中3只眼治疗后植片恢复透明,2只眼因植片混浊行二次LKP。结论新鲜供体带角膜缘LKP联合带角膜缘干细胞自体球结膜移植和羊膜移植是治疗眼烧伤后重度睑球粘连的有效方法,假性胬肉可部分替代球结膜重建结膜囊,羊膜移植在重度睑球粘连的治疗中仅发挥暂时支持创面促进眼表恢复的作用。

Objective To evaluate the efficacy of lamellar keratoplasty （LKP） using fresh graft with limbus, combined with conjunctival limbal autograft transplantation （CLAT） and amniotic membrane transplantation （AMT）, in treating severe symblepharon resulting from eye burns. Methods Patients with severe symblepharon visited our hospital between February 1998 and February 2003 were divided into 4 degrees based on impairment of visual function. Pseudopterygium was partially dissected after separation of conjunctival adhesion, the corneal lesion was covered with partial （17 eyes） or total （9 eyes） lamellar corneal graft. Autologous limbal graft was placed onto the most seriously damaged limbus. Then the preserved pseudopterygium was receded with AMT to reconstruct fomix. All cases were followed up for 8 months to 3 years. Eye movement, diplopia, development of corneal grafts, preserved pseudopterygium and transplanted amniotic membrane were observed. Results 25 eyes, except that 1 eye because of irreformable lagophthalmos, got considerable improvement. Conjunctival adhesion was completely relieved and diplopia disappeared in 17 eyes. Adhesion recurred in the area covered only with amniotic membrane in 8 eyes, and 5 of them were completely relieved after one or two adhesion excisions combined with autologous conjunctival transplantation. Mild adhesion still remained in 3 eyes. Amniotic membrane began autolyzing at 1 week and completely disappeared 3 months after operation. Pseudopterygium began thinning at 1 to 3 months. Immune rejection occured in 6 eyes, and 2 of them had second LKP. Conclusions LKP using fresh graft with limbus, combined with CLAT and AMT, is an ideal treatment for severe symblepharon resulting from eye burns. Pseudopterygium can partly substitute conjunctiva to reconstruct fomix. Amniotic membrane facilitates ocular surface reconstruction by temporary protection of lesions. （Chin J Ophthalraol, 2005,41 ： 791-795 ）