角膜移植治疗Terrien边缘角膜变性

Keratoplasty in the management of Terrien＇s marginal degeneration

目的探讨角膜移植治疗Terrien边缘角膜变性的临床效果与安全性。方法采用非随机回顾性系列病例研究。分析1995年1月至2004年12月期间在中山大学中山眼科中心行病灶切除联合角膜移植手术治疗的40例（48只眼）Terrien边缘角膜变性患者的临床资料，对其中9只眼进行手术前后的散瞳检影验光检查，对7只眼进行手术前后OrbscanⅡ角膜地形图检查。结果患者年龄（30±6）岁，术后随访时间为（7±6）年。手术前、后各参数采用（Q25，Q75）表示。息眼手术前裸眼视力为（0．05，0．4），最佳矫正视力为（0．1，0．5），手术后裸眼视力为（0．2，0．6），最佳矫正视力为（0．4，0．7）（Z=4．63，3．85；P均〈0．01）。息眼验光球镜度数的术前值为（-2．00D，-8．50D），术后值为（-1．25D，-4．75D）（Z=2．49，P=0．01）；柱镜度数的术前值为（2．50D，12．00D），术后值为（0．75D，4．25D）（Z=2．54，P=0．01）。术后OrbscanⅡ角膜地形图模拟角膜曲率、角膜散光度数、角膜直径3mm与5mm处的散光度数和屈光力度数均较术前有所下降，除角膜直径5mm处的散光度数改善外（Z=1．86，P=0．06），其余指标的改善差异均有统计学意义（P〈0．05）。手术并发症包括术中植床穿孔5只眼（10．4％）、术后角膜层间积液8只眼（16．7％）、角膜层间上皮植入4只眼（8．3％）、脉络膜脱离1只眼（2．1％）、术后植片排斥反应7只眼（14．6％）、复发3只眼（6．3％）。5只眼（10．4％）分别因层间积液、层间上皮植入及复发行二次手术治疗。结论病灶切除联合角膜移植是Terrien边缘角膜变性的优选治疗手段之一，可有效地保存或提高患眼视力。

Objective To evaluate the efficacy and safety of keratoplasty combined with corneal foci resection in the treatment of Terrien＇s marginal degeneration （TMD）. Methods In this nonrandomized retrospective case series, the records of 48 eyes from 40 patients with TMD who received keratoplasty from January 1995 to December 2005 in Zhongshan Ophthalmic Center were reviewed retrospectively. Orbscan topography examination was undertaken in 8 eyes of 8 patients and the refractive error of 9 eyes from 9 patients was tested before and after the operation. Results The mean age of the patients was （ 30 ± 6） years old. The mean follow up period was （7 ± 6） years. It took （ 3 ± 1 ） months postoperatively to obtain a stable visual acuity. Before operation, the naked eye and best corrected visual acuity （VA） （ Q25, Q75 ） were （0. 05,0. 4）, and （0. 1,0. 5）, respectively, while improved to （0. 2,0.6） and （0. 4,0.7） after operation, respectively （Z = 4. 63,3. 85, both P 〈 0. 01 ）. VA was improved in 39 eyes （81.3 % ）, remained at the same level in 4 eyes（8.3% ） ,decreased 1-2 lines in 3 eyes（6. 3% ） ,and decreased more than 2 lines in 2 eyes （4. 1% ） after the operation. The median spherical diopter and cylinder diopter were（ -2.00 D, -8.50 D） and（2. 50 D,12.00 D） before operation, while decreased to （ - 1. 25 D, -4.75 D） and（0. 75 D,4.25 D） after operation （ Z = 2.49,2. 54, P = 0.01,0. 01 ）. The improvement in Sim K＇ s astigmatism, astigmatism in 3 mm zone and mean power in 3 mm and 5 mm zone were reduced statistically significant after the operation （ P 〈 0. 05 ） ; with the exception of astigmatism in the 5 mm zone, which was not reduced significantly after the operation （ Z = 1.86, P = 0. 06 ） . The operative complications included corneal perforation during operation in 5 eyes（ 10. 4% ）, hydrops between graft and recipient interface in 8 eyes（ 16. 7% ）, epithelial in-growth in 4 eyes（8. 3% ）, choroidal detachment in 1 eye（2. 1% ）, graft rejection in 7 eyes（ 14. 6% ）, and recurrence in 3 eyes （6. 3% ）. Secondary surgery was required in 5 eyes （10. 4% ） for interface hydrops, epithelial in-growth and recurrence of TMD. Conclusions Keratoplasty combined with foci resection is effective and safe in the treatment of TMD. This procedure can preserve and improve the visual activity.