隐匿性巩膜破裂伤的临床特征

Clinical characteristics of occult scleral rupture

目的 探讨隐匿性巩膜破裂伤的临床特征及其治疗效果。方法 为回顾性系列病例研究。分析1996年11月至2006年11月间收治的、经手术探查证实的、资料完整的28例（28只眼）隐匿性巩膜破裂伤患者的临床资料。所有患者在手术探查证实存在巩膜破裂伤后均行I期修复手术，其中14例（14只眼）在随访中接受了Ⅱ期玻璃体手术。患者手术前和末次随访时最佳矫正视力的变化以及与预后相关性分别采用R×C表的X^2检验和Spearman秩相关分析。I期与Ⅱ期手术后视力改善情况比较采用Fisher精确检验。结果 患者中常见临床体征依次为球结膜水肿或球结膜下大量出血（100％）、玻璃体积血（89．3％）、前房积血（78．6％）、低眼压（75．0％）、眼球运动障碍（75．0％）、视力光感或光感以下（67．9％）、晶状体损伤或脱位（39．3％）、瞳孔变形或扩大（35．7％）、脉络膜出血或脱离（35．7％）以及视网膜脱离（32．1％）等。接受A或B超检查的23例患者中，10例显示为球后壁中断或球壁紊乱并伴有眼轴缩短（与对侧眼比较），5例显示球后壁中断或球壁紊乱，4例仅显示眼轴缩短。术前CT检查10例，提示5例为眼环中断或不清、同时伴眼内密度不均，3例仅表现眼环中断或眼环不清，2例仅显示眼内密度不均匀。末次随访时最佳矫正视力较治疗前明显改善（X^2=13．29，P〈0．05），其中视力增进者18例，无变化者9例，下降者1例。视力预后与治疗前视力明显相关（r=0．62，P〈0．05）。I期修复手术后视力增进者占21．4％（6／28），联合Ⅱ期玻璃体手术后视力增进者达85．7％（12／14）。结论 视力光感或光感以下、球结膜水肿或结膜下大量出血、低眼压、前房积血及眼球运动障碍为诊断隐匿性巩膜破裂伤的主要依据。晶状体损伤或脱位、玻璃体积血、视网膜脱离等眼内结构损害，可作为其诊断、指导治疗以及判断预后的重要参考指标。与A、B超及CT等检查相结合，可减少误诊和漏诊率。及时恰当的手术治疗，对改善患者视功能具有一定的价值。

Objective To evaluate the clinical characteristics and therapeutic efficacy of occult scleral rupture. Methods It was a retrospective case series. Clinical data of 28 patients （28 eyes ） with occult scleral rupture in recent 10 years was reviewed. All patients were performed with I-stage debridement and suturing surgery when the scleral ruptures were confirmed by operation search, and fourteen eyes of them were performed II -stage vitrectomy in following up periods. Results In 28 cases with occult scleral rupture, the major clinical signs included bulbar conjunctival edema and subconjunctival hemorrhage （100%）, vitreous hemorrhage （89. 3% ）, hyphema （78. 6% ）, ocular hypotension （75.0%）, limitation of ocular movement （75.0%）, reduction of visual acuity to light perception or less than light perception （67.9%）, impairment or dislocation of the lens （ 39. 3% ）, pupilla distortion or dilatation （ 35.7% ） , choroidal hemorrhage or detachment （ 35.7% ） and retinal detachment （ 32. 1% ）. In 23 patients their eyes were scanned by A/B-ultrasonography, the image of eyeball wall were found to be interrupted or disorder in 5 eyes and the ocular axis was shorten in 4 eyes. X-ray computed tomography（CT） were performed in 10 patients before operation. It was found interruption or unsharpness of ocular ring in 3 eyes, the unevenness of ocular density in 2 eyes, and both signs were seen in 5 eyes. Total 28 eyes, the visual acuity were improved in 18 eyes after operation, no change 9 eyes and decreased 1 eye. Visual acuity was significantly increased postoperation （ X^2 =13.29,P 〈 0.05 ）. The result showed that the visual acuity increased in 21.4% （6/28） of eyes with I -stage operation and 85.7% （12/14） of eyes with II -stage vitrectomy respectively. Conclusions The major sign of diagnosis of occult scleral rupture are visual acuity with light perception or less than light perception, bulbar conjunctival edema and subconjunctival hemorrhage, hyphema, ocular hypotension and limitation of ocular movement, etc after ocular trauma. The intraocular damage such as impairment or dislocation of the lens, vitreous hemorrhage, retinal detachment etc. , is regarded as the important references in the diagnosis, treatment and prognosis. The rates of misdiagnosis can reduce if auxiliary examinations of A or B-ultrasonography and CT are applied. The prompt and appropriate surgery play an important role in the recovery of visual function.