眼内窥镜下睫状体光凝对角膜植片存活的影响

Effect of endocydophotocoagulation on survival of corneal grafts

目的探讨对穿透性角膜移植术（PKP）后眼压升高且药物不能控制的患者，采用眼内窥镜直视下睫状体光凝术（ECP）进行治疗的疗效和对角膜植片存活的影响。方法选择2000年3月至2004年4月期间，于中山大学中山眼科中心就诊的34例（34只眼）PKP术后眼压升高且药物不能控制患者，在眼内窥镜直视下，行半导体激光睫状体光凝术（12例）或联合玻璃体切除术（22例）（ECP组）。选择26例（26只眼）患者作为对照，采用经巩膜面半导体激光睫状体光凝术（TCP）（TCP组）。术前、术后随访观察视力、眼压、植片透明度、内皮细胞密度及前房反应，超声活体显微镜（UBM）检查睫状突和房角情况，注意术后并发症等。结果ECP组术后3个月和6个月时，分别有13例（38．2％）和23例（67．7％）眼压低于21mmHg。TCP组术后3个月和6个月时，分别有10例（38．5％）和8例（30．8％）眼压低于21mmHg。两组之间术后眼压控制率比较，在3个月时差异无统计学意义（X^2=0．0003，P=0．986），但6个月时差异有统计学意义（X^2=8．024，P=0．005）。ECP组和TCP组术后植片内皮细胞密度分别为（1013±170）个／mm^2和（847±136）个/mm^2，差异有统计学意义（t=-0．009，P=0．033）。ECP组和TCP组术后分别有9例（26．5％）和21例（80．8％）出现反应性虹膜炎，两组之间比较差异有统计学意义（x^2=17．376，P=0．001）。结论ECP对降低PKP术后青光眼患者眼压的远期疗效优于TCP。ECP对角膜植片内皮细胞的损伤和引起术后葡萄膜炎的程度均较TCP轻，相对提高了PKP术后角膜植片的生存质量。

Objective To observe the effect of semiconductor （diode） laser endocyelophotocoagulation （ECP） on the survival of corneal grafts for patients with uncontrolled refractory glaucoma secondary to penetrating keratoplasty （PKP）. Methods Thirty-four eyes of 34 patients with refractory glaucoma were prospectively assigned to diode laser ECP in 12 eyes, and diode laser ECP with anterior vitrectomy in 22 eyes in Zhongshan Ophthalmic Center from March 2000 to April 2004 as ECP group. Twenty-six eyes of 26 patients were underwent trans-scleral cyclophotocoagulation （TCP） as TCP group. The preoperative and postoperative follow-up parameters evaluated included visual acuity （VA）, intraocular pressure （IOP）, corneal graft clearance, endothelial cell density （ECD）, anterior chamber inflammation, ciliary processes and chamber angle （viewed under ultrasonic biomieroseope, UBM）, and the postoperative complications were recorded as well. Results In ECP group, a mean of （ 2. 7 ± 1.3） glaucoma medications was used with mean preoperative IOP value of （ 40. 1 ± 9.6 ） mm Hg preoperatively. IOP was decreased （below 21 mm Hg） in 13 eyes （38.2%） 3 months postoperatively. Six months after ECP, decreased IOP （below 21 mm Hg） was obtained in 23 eyes （67.7%）. In TCP group, a mean of （2. 3 ± 1.5） glaucoma medications were administrated with mean preoperative IOP value of（41.4 ± 10. 4） mm Hg preoperatively. IOP was decreased （ below 21 mm Hg） in 10 eyes （ 38.5% ） 3 months postoperatively. Six months after TCP, decreased IOP （ below 21 mm Hg） was obtained in 8 eyes （30. 8% ）. The difference of IOP reduction between these two groups showed no statistical significance 3 months postoperatively （ X^2= 0. 0003, P = 0. 986 ）, but it was statistically significant after 6 months （ X^2 = 8. 024, P = 0. 005 ）. In ECP group,25 eyes had clear corneal grafts preoperatively, with mean ECD of（ 1353 ± 293 ） cells/mm^2. Postoperative mean ECD was （1013 ± 170）cells/mm^2. In TCP group, 20 eyes had clear corneal grafts preoperatively, with mean ECD of （ 1221 ± 191 ） cells/mm^2 . Postoperative mean ECD was （ 847 ± 136 ） cells/mm^2. The difference of ECD between ECP and TCP group was statistically significant （ t = - 0. 009, P = 0. 033 ）. Reactive no-specific inflammation in anterior chamber occurred in 9 eyes （26. 5% ） in ECP group and 21 eyes （ 80. 8% ） in TCP group, which showed statistical significance （ X^2 = 17. 376, P = 0. 001 ） . Conclusion： ECP proved more efficacious than TCP in controlling IOP in patients with pest-penetrating keratoplasty glaucoma in long-term observation. Compared with TCP, ECP shows less corneal graft endothelial cell loss, and comparatively mild post-ECP uveitis, which improves the survival of corneal grafts greatly.