准分子激光原位角膜磨镶术后弥漫性层间角膜炎的临床分析

Clinical study of diffuse lamellar keratitis after laser in situ keratomileusis

目的探讨准分子激光原位角膜磨镶术后弥漫性层间角膜炎的临床综合分级标准，指导临床分级治疗。方法前瞻性系列病例研究。收集2004年12月至2005年5月于复旦大学附属眼耳鼻喉科医院就诊的准分子激光原位角膜磨镶术后弥漫性层间角膜炎患者29例（35只眼），根据角膜层间炎性细胞浸润程度和浸润范围制定分级标准，依照综合分级诊断，予以相应分级治疗方案。观察其治疗前和治疗后1d、3d、5d、7d、10d及1个月时临床症状、角膜浸润程度和范围、视力、屈光度数及眼压等情况。测得的小数视力转换为logMAR单位进行统计分析，配对t检验比较LASIK术前、DLK确诊时和治疗后1月的视力及屈光不正变化情况。以炎性细胞浸润程度、浸润范围和治疗方案作为研究因素，对炎性细胞浸润灶消退时间、视力、屈光不正及眼压变化情况进行方差分析或t检验。方差不齐时采用非参数检验方法Kruskal—Wallis检验。以P〈0．05作为差异有统计学意义。结果29例（35只眼）准分子激光原位角膜磨镶术后弥漫性层间角膜炎病例多为轻度，其中Ⅰ度30只眼，Ⅱ度3只眼，Ⅲ度和Ⅳ度各1只眼；20只眼侵及周边1区，11只眼侵及中周2区，4只眼侵及中央3区；19只眼为Ⅰ度1区。33只眼在术后1～3d内确诊。确诊时裸眼视力低于术前最佳矫正视力。经过相应分级糖皮质激素治疗，角膜瓣下炎性细胞浸润灶平均在（6．06±2．04）d内消退。随访至治疗后1个月，裸眼视力显著提高，达术前最佳矫正视力水平，30只眼最佳矫正视力优于或同术前。等效球镜平均为（-0．21±1．16）D。角膜体征、视力及屈光不正恢复程度在各分级弥漫性层间角膜炎之间，及在接受不同分级治疗方案的病例之间，差异均无统计学意义。无糖皮质激素性高眼压发生。结论弥漫性层间角膜炎的Ⅰ临床综合分级对糖皮质激素分级治疗准分子激光原位角膜磨镶术后弥漫性层间角膜炎具有治疗指导作用。

Objective To investigate a new clinical grading scale of diffuse lamellar keratitis （DLK） following laser in situ keratomileusis （LASIK） and to observe the clinic outcomes of eyes treated with corresponding classified therapy. Methods It was a prospective case-control study. Eyes that developed DLK after LASIK were diagnosed by a new criterion of clinical grading scale based on both severity and scope of inflammatory cells infiltrations in the corneal interface. Dose and frequency of topical or systemic corticosteroid were determined by the classified profiles according to each grade. Clinical symptoms, corneal inflammatory cells infiltrations, visual acuity, refractive error and intraocular pressure （IOP） were evaluated on 1, 3, 5, 7, 10 days and 1 month after diagnosis as well as at the time of diagnosis. Results Among the 35 eyes of 29 patients that developed DLK, mild inflammatory cells infiltrations were mostly seen. Thirty eyes had degree Ⅰ DLK and 3 had degree ⅡDLK. One eye had degree Ⅲ DLK and one had degree Ⅳ DLK. Inflammatory cells infiltrations in 20 eyes invaded peripheral zone （zone 1 ） and those in 11 eyes invaded mid-peripheral zone （zone 2）. Inflammatory cells infiltrates in 4 eyes invaded central zone （zone 3 ）. Nineteen eyes had degree Ⅰ zone 1 DLK. Thirty three eyes were diagnosed between the 1 st day and the 3rd day after surgery. Uncorrected visual acuity （ UCVA ） was worse thanpreoperative best spectacle corrected visual acuity （BSCVA）. Inflammatory cells infiltrations retreated within 6.06 ± 2.04 days after classified corticosteroid therapy. One month after the treatment, UCVA had improved to the level of preoperative BSCVA. BSCVA in 30 eyes were equal to or better than those before surgery. Spherical equivalent of the refractive error was （ -0. 21 ± 1.16）D. There was no statistic difference in the retreat time of inflammatory cells infiltrations, recovery of visual acuity and refractive error among the different grades of DLK or among the DLK treated with different therapy profiles. No eye suffered from high intraocular pressure during the treatments. Conclusions Clinical grading scale and corresponding classified therapy were proved to be effective in the treatment for DLK.