复合式小梁切除术治疗难治性青光眼疗效分析

Clinical analysis of compound trabeculectomy for refractory glaucoma

目的观察复合式小梁切除术治疗难治性青光眼的临床疗效。方法对42例(50眼)难治性青光眼患者施行复合式小梁切除术,其中青少年型发育性青光眼6例(10眼),眼钝挫伤继发青光眼5例(5眼),无晶状体眼青光眼3例(3眼),滤过手术失败的青光眼10例(14眼),葡萄膜炎继发青光眼10例(10眼),新生血管性青光眼8例(8眼)。术中使用0.33g.L-1丝裂霉素C抑制滤过区瘢痕形成,巩膜瓣可调整缝线及前房注水成形控制术后早期浅前房,以获得功能性滤过泡和理想的眼压控制。葡萄膜炎继发青光眼术后按病因抗炎治疗。新生血管性青光眼8例(8眼)患者中由视网膜中央静脉阻塞引起的4例(4眼),由糖尿病视网膜病变引起的3例(3眼),术后均行视网膜光凝治疗,由长期高眼压引起的1例(1眼)。结果术后1周平均眼压为(10.07±2.38)mmHg(1kPa=7.5mmHg),术后6个月平均眼压为(14.30±2.73)mmHg,与术前用药后眼压(35.00±5.58)mmHg相比,差异均有统计学意义(均为P<0.05)。随访6～24个月,手术成功率为92%,其中完全成功45眼(90%),条件成功1眼(2%),失败4眼(8%)。术后6个月滤过泡中Ⅰ型4眼(8%),Ⅱ型42眼(84%),Ⅲ型3眼(6%),Ⅳ型1眼(2%),其中Ⅰ型、Ⅱ型为功能性滤过泡;最佳矫正视力提高2行及以上5眼,不变44眼,减退2行1眼;患者视野扩大者5眼,其余视野基本保持不变,未见明显减退。术中前房出血8例8眼,经应用药物后3-5d吸收;术后渗出性反应3眼,用药后消退;脉络膜脱离1眼,用药后恢复。无滤过泡渗漏、持续性低眼压、黄斑水肿发生。结论复合式小梁切除术治疗难治性青光眼成功率高,并发症少,应辅以早期眼球按摩,并进一步针对病因治疗,可取得较好疗效。

Objective To investigate the clinical efficacy of compound trabeculectomy for refractory glaucoma.Methods A total of 42 refractory glaucoma patients（50 eyes）,who were taking compound trabeculectomy,were enrolled,in which were 6 cases（10 eyes） with juvenile developmental glaucoma,5 cases（5 eyes） with secondary glaucoma by ocular contusion,3 cases（3 eyes） with aphakic glaucoma,10 cases（14 eyes） with glaucoma by the failure of filtration surgery,10 cases（10 eyes） with secondary glaucoma by uveitis and 8 cases（8 eyes） with neovascular glaucoma.For achieving functional filtering blebs and ideal intraocular pressure,0.33 g·L^-1 mitomycin C was used to inhibit scar formation at filtration areas,adjustable suture at sclera flap and anterior chamber injection were used to control shallow of anterior chamber at postoperative early time.Patients with secondary glaucoma by uveitis were treated with anti-inflammatory treatment according to etiopathogenesis.For 8 cases（8 eyes） with neovascular glaucoma,there were 4 cases（4 eyes） by central retinal vein occlusion,3 cases（3 eyes） by diabetic retinopathy and 1 case（1 eye） by high intraocular pressure with a long time;The former two types were treated with laser retinal photocoagulation postoperatively.Results The average intraocular pressure were （10.07±2.38）mmHg（1 kPa=7.5 mmHg）,（14.30±2.73）mmHg at postoperative 1 week,6 months,which had statistical difference compared with（35.00±5.58） mmHg preoperatively and after taking drugs（both P〈0.05）.All patients were followed up for 6 months to 24 months.The operative successful rate was 92%,in which 45 eyes（90%） were with complete success,1 eye（2%） with success at certain condition and 4 eyes（8%） with failure.Filtering blebs of 4 eyes（8%） were in type Ⅰ,42 eyes（84%） in typeⅡ,3 eyes（6%） in type Ⅲ and 1 eye（2%） in type Ⅳ;The type Ⅰ and type Ⅱ were functional filtering blebs.Best corrected visual acuity improved be and more than 2 lines was in 5 eyes,unchanged in 4 eyes and decreased 2 lines in 1 eye.Visual field enlarged in 5 eyes,unchanged or be without obvious decrease in others.Hyphema was in 8 cases（8 eyes） postoperatively,and absorbed after drug treatment for 3 days to 5 days.There were 3 eyes with exudative reaction,and resolved after drug treatment;There was 1 eye with detachment of choroid,and recovered after drug treatment.There was not filtering blebs leakage,persistent hypertension or macular edema.Conclusions Compound trabeculectomy is with high successful rate and less complications for refractory glaucoma.It should be combined with early eyeball massage and taking treatment according to etiopathogene for achieving better curative efficacy.