缝线植入Schlemm管开口部成形联合小梁切除术治疗原发性闭角型青光眼临床疗效观察

The evaluation of the clinical results of the opening of Schlemm′s canalizationwith suture implantation and trabeculectomy for primary angle-closure glaucoma

目的探讨缝线植入Schlemm管开口部成形联合小梁切除术治疗原发性闭角型青光眼患者的有效性和安全性。方法对33例41眼原发性闭角型青光眼患者施行了缝线植入Schlemm管开口部成形联合小梁切除术。手术方法是做二层巩膜瓣并切除深层巩膜瓣,剪除Schlemm管外壁,并从管断端口分别植入Schlemm管内6-0尼龙线,穿透性小梁切除及相应虹膜剪除,水密缝合浅层巩膜瓣。术后观察眼压、前房形成、眼内炎性反应、视力、术后并发症以及滤过泡形成等情况。结果随访6m～48m,平均(24.98±14.41)m。术后末次随访平均眼压(16.35±4.88)mmHg(1mmHg=0.133kPa),较术前平均眼压(24.17±12.85)mmHg,差异有非常显著意义(t=3.674,P=0.001)。33例41眼原发性闭角型青光眼患者术后随访眼压经局部降眼压药物治疗,眼压≥22mmHg者3例3眼占7.32%,有效率达92.68%。术前与术后不同时间随访平均眼压值比较,经配对t检验法分析结果显示差异有显著意义。对15例19眼术后随访≥36m青光眼患者,术前、术后眼压差值(12.66±12.72)mmHg,术后眼压与术前眼压比较,差异有非常显著的意义(t=3.446,P=0.005)。41眼青光眼患者中术后形成滤过泡9例10眼占24.39%,其中眼压≥22mmHg者2眼占20%。术后有滤过泡与无滤过泡青光眼患者术前与术后末次随访平均眼压差值的均值比较,经成组t检验法分析结果显示无显著性意义(t=-1.824,P=0.076)。1例双眼术后均出现前房形成迟缓,经阿托品眼药水散瞳后前房形成良好。除8眼术后第1天前房形成不良外,余例术后第1天均前房形成良好。有12眼(29.27%)术后出现前房积血。术后一过性眼压升高(眼压≥22mmHg)4眼。术后一过性低眼压(眼压≤6mmHg)10眼。术后随访早期(术后1m内)一过性眼压升高2眼。术后2眼出现前房内纤维蛋白渗出,其他病例术后均无明显的前房炎性反应。术后均无脉络膜脱离等并发症发生。结论缝线植入Schlemm管开口部成形联合小梁切除术治疗原发性闭角型青光眼降眼压效果肯定、安全,术后并发症少,适应症广,术后管理容易,为一种具有良好应用前景的抗青光眼新手术。

Objective To evaluate the therapeutic effects and safety of trabeculectomy combined with Schlemm＇s canal suture implantation in patients with primary angle -closure glaucoma （PACG）. Methods Trabeculectomy combined with Schlemm＇s canal suture implantation was performed on 33 cases （41 eyes） with PACG. The surgeries were done as follow. Two scleral flaps were made and the deeper one was dissected. The outer wall of Schlemm＇s canal was cut away. A 6 -0 nylon was implanted between the two cut of the canal. Penetrating trabeculectomy was performed and then peripheral iridectomy was achieved. Superficial scleral flap was sutured. Intraocular pressure, formation of the anterior chamber, inflammatory reaction, visual acuity, complications and filtering bleb＇s situation were examined postoperatively. Results Mean follow - up was （24. 98 ± 14. 41 ） months （range 6 -48 months）. Statistically significant difference was found between preoperative and postoperative IOP （24. 17 ± 12. 85 VS 16. 35 ±4. 88, t =3. 674, P =0. 001 ）. Postoperative IOPwas greater than 22mmHg in 3 of 41 eyes （7.32%） with antiglaucoma medication. The lOPs at each visit were significant different. Statistically significant difference was found between preoperative and postoperative lOP in 15 cases （ 19 eyes） who were followed more than 36 months （t =3.446, P =0. 005）. Filtering blebs were formed in 9 cases （ 10 eyes）, including 2 eyes （20%） with lOP greater than 22 mmHg. There was no significant difference in change of preoperative and postoperative IOP in patients with or without filtering blebs by t - test （ t = - 1. 824, P =0. 076）. Anterior chamber formed slowly in 1 case （2 eyes） , and then was recovered by mydriatic drug （ Atropin drops）. Anterior chamber formed well one day after operation except for 8 eyes. Hyphema was formed in 12 eyes （29. 27% ）. Hypertonia oculi （IOP≥22mmHg） and hypotonia oculi （IOP≤6mmHg） appeared occasionally in 4 eyes and 10 eyes respectively. There were 2 eyes with temporary hypertonia oculi in the forepart of fellow - up （ one month after operation）. Except for 2 eyes with fibrinous exudate, inflammatory reaction in anterior chamber didn＇t appear in other cases. Postoperatively there were no choroidal detachment and other complications in any case. Condltsions The control of lOP appears to be good after the surgery of trabeculectomy combined with Schlemm＇s canal suture implantation. It＇s a new anti - glaucoma surgery method with fewer postoperative complications, wide indications and bright prospect.