活体共焦显微镜对结膜滤过泡在细胞水平的研究

In vivo confocal microscopy study of filtering blebs at the cellular level

目的应用活体共焦显微镜对小梁切除术后结膜滤过泡的组织病理学改变进行细胞水平的观察，研究结膜滤过泡形成的影响因素并进一步探讨滤过性手术的滤过机制。方法对小梁切除术后3周至510周的59例患者共86只眼行裂隙灯、眼压及活体共焦显微镜检查。将受试眼的滤过泡分为两种类型：①功能性滤过泡型（43只眼）；②非功能性滤过泡型（43只眼）。根据术中是否使用过MMC再将各型滤过泡分为Normal组与MMC组。对各组滤过泡中微囊泡的大小、数量、结缔组织的密度进行统计学分析。结果功能性滤过泡中含有大量透明的微囊泡，上皮下存在比较疏松的结缔组织；而非功能性滤过泡中没有或仅有少许透明度较低的微囊泡，结缔组织极致密；功能性滤过泡中出现新生血管的比例远远小于非功能性滤过泡。与Normal组相比较术中联合应用MMC的功能性滤过泡中含有大量直径较大、壁薄的微囊泡，其上皮下结缔组织较疏松，各层组织内均可见大量高反光颗粒；而术中联合应用MMC的非功能性滤过泡仅结缔组织比Normal组疏松。结论活体共焦显微镜检查能对结膜滤过泡进行诊断成像，是一种与来自离体组织学检查结果完全吻合的新的活体检查方法，对将来提高滤过性手术的成功率具有直接的指导作用。

Objective To demonstrate the factors which influence the formation of filtering bleb and filtering mechanisms after filtering surgery, and histological changes of filtering bleb after Trabeculectomy were analyzed at the cellular level using a new generation in vivo confocal microscope. Methods Eighty-six eyes of 59 patients were examined 3 to 510 weeks after trabeculectomy.The patients were examined clinically by slit-lamp, Goldmann applanation tonometry and in vivo confocal microscopy（Heidelberg Retina Tomograph Ⅲ/Rostock Cornea Module, HRTⅢ/RCM, Germany）.Eyes were classified into 2 groups： （1）functioning blebs （43 eyes）, which included functioning blebs after application of mitomycin C （ 18 eyes ）. （2）nonfunctioning blebs （43 eyes）, which included nonfunctioning blebs after application of mitomycin C （7 eyes）. Results All functioning blebs had numerous intraepithelial optically-empty microcysts,whereas all nonfunctioning blebs had none or few.Subepithelial connective tissue was widely spaced in all functioning blebs, whereas the tissue was dense in nonfunctioning blebs.Conversely, new blood vessels were seen in 72.1% of nonfunctioning blebs, whereas new blood vessels were seen in just 11.6% of functioning blebs.Functioning blebs with mitomycin C had numerous microcysts and loosely arranged subepithelial connective tissue as compared with nonfimctioning blebs.There were massive hyper-reflective microdots in all of the filtering bleb layers. Conclusions In vivo laser scanning confocal microscopy study of blebs is an original method that agrees well with ex vivo histologic examination.The number of microcysts and the density of the subepithelial connective tissue observed with in vivo confocal microscopy are correlated with bleb function.By providing details of the structures of filtering blebs at the cellular level, in vivo confocal microscopy provide specific treatments to enhance success rates of their surgical procedures.