翼状胬肉显微手术方法及其疗效观察

Study on microsurgical procedures for pterygium operation and its therapeutic effects

目的探讨翼状胬肉显微手术方法及其疗效，在手术显微镜下观察翼状胬肉与角巩膜的病理关系及其术后复发情况和视力变化。方法选择超过瞳孔缘的41例（46只眼）原发性翼状胬肉患者，在手术显微镜下采用多种方法剖切，观察翼状胬肉组织与角膜的病理关系。将翼状胬肉头部分为头顶部、疏松部及粘连部3个部分；头顶部是翼状胬肉头部顶端的致密、坚硬的半透明组织，与角膜粘连紧密；粘连部为角巩膜缘前界前平行于角膜缘的带状区，与角膜粘连紧密；疏松部为头顶部和粘连部之间的翼状胬肉组织，易与角膜分离；翼状胬肉颈部和体部易与角巩膜缘和巩膜分离。测量翼状胬肉头部及其3个分部的数据。做广泛的变性球筋膜切除和自体结膜瓣转位移植，术后随访时间为12．0—50．2个月，中位数为22．4个月，观察患者术前、后视力改变和术后复发情况。结果翼状胬肉头部总长（6．3±0．4）mm，头顶部长约（1．7±0．4）mm；粘连部长约（0．9±0．1）mm；疏松部长约（3．6±0．4）mm。患者术前裸眼视力为指数／眼前至0．7，中位数为0．3；术后1个月裸眼视力为指数／眼前至1．5，中位数为0．7（秩和检验u=5．435，P〈0．01）。5例（5只眼）患者术后复发，复发率为11％（5／46）。结论原发性翼状胬肉与角巩膜的病理关系具有规律性，为翼状胬肉显微手术方法的选择提供了客观依据；广泛变性球筋膜切除联合自体结膜瓣转位移植方法，术后复发率低，视力提高显著。

Objective To study the microsurgical procedures for the treatment of large primary pterygium and their therapeutic effects. To observe the recurrence rate, the changes of visual acuity after microsurgery and the pathological relationships between pterygium and cornea/sclera under the surgical microscope. Methods Forty-six eyes of forty-one patients with pterygium which invading the cornea over the pupil border were included. Pterygium was dissected by various methods under surgical microscope. The pathological relationship between the pterygium and cornea/sclera was observed. The lengths of the pterygium head and its three parts were measured. Degenerative Tenon＇s capsule was removed totally and the wound was covered by rotated conjunctival flaps. These patients were followed-up for 12.0-50.2 months （median： 22.4 months ）. Changes in visual acuity and recurrence rate after operation were observed. Results The average length of the total pterygium heads was （6.3±0.4） mm. The head was divided into three parts： the apical, loose and adhesive parts. The apical part was located at the top of the pterygium head with a length of （ 1.7±0.4） mm. The tissue of apical part was compact, hard, translucent and adhered to the cornea tissue. The adhesive part was a band in front of the anterior border of the limbus and paralleled to the limbus. The width of adhesive part was （0.9±0.1 ） mm and was tightly adhered to the cornea. The loose part lied between the apical and the adhesive part. The length of which was （ 3.6±0.4） mm and could be separated from the cornea easily. The neck and the body parts of pterygium could be separated easily from the limbus and sclera. Non-corrected visual acuity averaged 0.3 （ ranged from finger count to 0. 7 ） before the operation and averaged 0. 7 （ ranged from finger count to 1. 5 ） 1 month postoperatively （ Wilcoxon signed rank test u = 5. 435, P 〈 0.01 ）. Pterygium relapsed in 5 eyes with a recurrence rate of 11% （5/46）. Conclusions There is a regular pathological relationship between the pterygium and the cornea/sclera under surgical microscope, which is fundamental for the microsurgery of the pterygium. Extensively degenerated Tenon＇s capsule should be removed totally and the defect should be covered by rotated conjunctival flaps. The recurrence rate is low and the visual acuity increases significantly after the operation.