青光眼患者手术中房水逆流的处理及其相关因素

Treatment and correlation factors of aqueous misdirection during surgery on glaucoma patients

目的探讨青光眼患者行青光眼或白内障手术中发生房水逆流的应急处理措施及其相关因素。设计回顾性病例系列。研究对象术中发生房水逆流的闭角型青光眼患者126例(132眼),术中未发生房水逆流的闭角型青光眼及老年性白内障患者各100例(100眼)作为对照。方法发生房水逆流的青光眼患者术中采取睫状体平部玻璃体水囊抽吸术或前部玻璃体切割切术治疗。对观察组及对照组的眼压等参数进行比较及Logistic回归分析。主要指标术前最高眼压(HIOP)、术前最大量药物治疗后眼压(IOP)、前房深度(ACD)、晶状体厚度(LENS)、眼轴长(AXL)、平均角膜曲率(K)、用SRK-T公式矫正至-0.5D以内的人工晶状体屈光度(IOLD)。结果术中发生房水逆流的闭角型青光眼93.18%(123/132)的眼术中采取睫状体扁平部玻璃体水囊抽吸术、6.8%(9/132)术中采用前部玻璃体切割术作为紧急处理措施。术后并发症包括浅前房20眼(恶性青光眼7眼、脉络膜脱离9眼、迟发性局限性脉络膜上腔出血4眼)、玻璃体少量积血1眼。观察组与两个对照组(术中未发生房水逆流的闭角型青光眼组及白内障组)的各观察指标(HIOP、IOP、ACD、LENS、AXL、K、IOLD)差异均有统计学意义(P均<0.01)。观察组与闭角型青光眼对照组的IOP、ACD、AXL、IOLD均有统计学差异(P均<0.01),观察组与白内障对照组各观察指标均有统计学差异(P均<0.01)。Logistic回归分析显示,IOP、ACD、IOLD为术中发生房水逆流的危险因素(r=0.085、-1.868、0.352,P均<0.01)。结论玻璃体水囊抽吸术或前部玻璃体切割术为闭角型青光眼患者行青光眼或白内障手术中发生房水逆流时积极有效的应急措施。术前眼压高、前房浅、人工晶状体矫正度数较大时应高度警惕术中房水逆流发生。(眼科,2008,17:16-19)

Objective To investigate the emergency treatment and correlation factors of aqueous misdirection during glaucoma and cataract surgery in glaucoma patients. Design Retrospective case series. Participants 126 cases （132 eyes） of angle-closure glaucoma patients with aqueous misdirection during surgery, 100 cases （100 eyes） of angle-closure glaucoma patients without aqueous misdirection during surgery and 100 cases （100 eyes） of senile cataract patients. Methods We performed pars plana vitreous water-bag aspiration or anterior vitrectomy on glaucoma patients with aqueous misdirection during surgery. All the factors in observation group and control groups were compared and analyzed by logistic regression. Main Outcome Measures Preoperative highest intraocular pressure （HIOP）, intraocular pressure after maximum dose （IOP）, anterior chamber depth （ACD）, lens thickness （LENS）, axial length （AXL）, mean keratometry （K）, intraocular lens diopter within -0.5D corrected by SRK-T formula （IOLD）. Results Among all the 132 angle-closure glaucoma eyes whose posterior chamber pressures were increased during surgery, we performed pars plana vitreous water-bag aspiration in 123 eyes （93.18%）, and anterior vitrectomy in 9 eyes （6.8%）. Postoperative complications included shallow anterior chamber in 20 eyes （7 eyes with malignant glaucoma, 9 eyes with choroidal detachment, 4 eyes with delayed local suprachorodal hemorrhage）, and vitreous local hemorrhage in 1 eye. Means of all the observation indexes on three groups showed significant difference （all P〈0.01）. IOP, ACD, AXL, IOLD between observation group and angle-closure glaucoma control group showed significant difference （all P〈0.01）, all the observation indexes between observation group and cataract group showed significant difference （all P〈0.01）. Logistic regression analysis revealed that IOP, ACD, IOLD were risk factors for aqueous misdirection during surgery （r=0.085, -1.868,0.352, P=0.000）. Conclusions Vitreous water-bag aspiration or anterior vitrectomy is the active and effective emergent option when aqueous misdirection during surgery in glaucoma patients. Sharp vigilance should be kept for aqueous misdirection during surgery when preoperational high ocular pressure, shallow anterior chamber or high-corrected intraocular lens diopter happens.