板层角膜移植治疗周边部角膜溃疡穿孔

Lamenar keratoplasty for treatment of peripheral corneal perforation

目的探讨不同形状的板层角膜移植术（LKP）治疗周边部角膜溃疡穿孔的适应证、疗效及并发症。方法采用非随机回顾性系列病例研究。选择2003年1月至2006年6月在中山眼科中心住院的40例（42只眼）周边部角膜溃疡穿孔患者，根据溃疡和穿孔区的大小和形状，分别采用半月形LKP（14只眼）、新月形LKP（11只眼）、双凸面形LKP（7只眼）、指环状LKP（5只眼）及全LKP（5只眼）治疗。术后随访3～21个月，观察患者术后视力、角膜透明度、角膜散光及并发症，分析原发病的种类和复发情况。结果周边部角膜溃疡穿孔的原发病主要有Terrien边缘性角膜变性（15只眼，35．7％），蚕食性角膜溃疡（13只眼，31．0％），单纯疱疹病毒性角膜炎（5只眼，11．9％），眼部化学烧伤或热烧伤（4只眼，9．5％）及周边部角膜扩张性病变（3只眼，7．1％）等。LKP后34只眼（81．0％）板层植片与植床贴合良好，角膜透明。术前13只眼（31．0％）视力为0．1以下，术后仅3只眼（7．1％）视力为低于0．1。术后27只眼（64．3％）视力提高，9只眼（21．4％）最佳矫正视力大于或等于0．5。术后3个月角膜散光为（7．23±1．22）D，术后6—9个月（已拆线）角膜散光减少为（3．72±1．76）D。术后并发症主要为双前房（8只眼，19．1％），继发性青光眼（8只眼，19．1％）等。结论LKP治疗周边部角膜溃疡穿孔，可有效修复穿孔，挽救眼球。采用不同形状的LKP可避免损伤过多的正常角膜，制作与植床高度匹配的植片可减轻术后严重角膜散光，从而使大多数患者改善或保存了视力。

Objective To explore the indications, efficacy, and complications of different types of lamellar keratoplasty （LKP） for peripheral corneal perforation. Methods In our nonrandomized retrospective case series, 40 cases （42 eyes） with peripheral corneal perforation at Zhongshan Ophthalmic Center between January 2003 and June 2006 underwent semi lunar LKP （ 14 eyes）, crescent LKP （ 11 eyes）, biconvex LKP （7 eyes） , ring-shaped LKP （5 eyes）, and total LKP （5 eyes）. The selection of various procedures was based on the size and shape of corneal ulceration and perforation. Postoperative visual acuity （VA）, corneal clarity, astigmatism, and complications were studied during a follow-up of 3 to 21 months. The initial causes and recurrence for peripheral corneal perforation were analyzed. Results The initial causes of corneal perforation were mostly Terrien＇s marginal degeneration （35.7%）, Mooren＇s ulcer （31.0%）, herpes simplex keratitis （11.9%）, chemical/thermal bums （9.5%）, and corneal ecstatic diseases （7. 1% ）. The lamellar graft attached to the host well and was transparent in 34 eyes （81.0%） following LKP. VA less than 0. 1 were presented in 13 eyes （31.0%） preoperatively and in 3 eyes （7.1%） postoperatively. VA in 27 eyes （64. 3% ） improved after LKP, and best-corrected VA in nine eyes （21.4%） was 0.5 or better. The mean corneal astigmatism was （7.23 ± 1.22） D three months postoperatively, and this decreased to （3.72 ± 1.76 ） D in six to nine months postoperatively when sutures were removed. The postoperative complications included graft-host interface effusion （ 8 eyes, 19. 1% ）, secondary glaucoma （8 eyes, 19. 1% ） and reoccurrence of primary diseases, including Mooren＇s ulcer （3 eyes, 23.1% ） and herpes simplex keratitis （ 1 eye, 20. 0% ）. Conclusions LKP is effective to restore the integrity of the eyes with peripheral corneal perforation. Choosing the appropriate type of LKP based on different shape of corneal perforations can remove the corneal lesion and spare the normal tissue to the maximum. Moreover, the well-matched graft configuration can reduce the postoperative astigmatism, helping restore or improve the vision in most cases.