角膜内皮移植联合超声乳化白内障吸除及人工晶状体置换手术的疗效评价

Objective To evaluate the effect and explore the complications of Descemet-stripping The effect of Descemet-stripping automated endothelial keratoplasty combined with phacoemulcification cataract surgery or lens exchange

目的 探讨角膜后弹力层剥除自动角膜刀取材内皮移植术（DSAEK）联合超声乳化白内障吸除及人工晶状体置换手术治疗角膜内皮失代偿并有白内障或人工晶状体异常患者的疗效和并发症情况.方法 回顾性临床自身对照研究.对2007年12月至2008年12月在北京大学第三医院就诊的各种原因引起的角膜内皮失代偿合并有晶状体异常的患者18例（20只眼）分别行DSAEK联合超声乳化白内障吸除人工晶状体植入手术5例（7只眼）、DSAEK联合前房型人工晶状体取出与前段玻璃体切除及后房型人工晶状体悬吊术7例（7只眼）或DSAEK联合前段玻璃体切除及后房型人工晶状体悬吊术6例（6只眼）.术后观察视力、角膜透明性的恢复、植片厚度、角膜内皮细胞丢失、植片的脱位率及排斥反应发生情况.采用治疗前后均数比较t检验.结果 术后18例患者眼部刺激症状均消除,角膜水肿全部消退,术前和术后的角膜厚度分别为859μm、553 μm,差异有统计学意义（t=5.303,P＜0.01）;术前供体角膜内皮细胞密度为2987个/mm2,术后3个月角膜内皮细胞密度为1803个/mm2,内皮细胞丢失率为41%.术后除去患有眼底病变的患者9只眼,其余患者视力均有大幅度的提高,视力恢复到0.8以上的有6只眼,在眼底正常的患者中占55%（6/11）.术后前房人工晶状体眼炎症反应最重,其余患者反应轻微;术后有6只眼植片脱位（30%,6/20）、术后5例出现眼压升高、1例发生植片排斥反应,均为前房人工晶状体眼的患者.结论 DSAEK联合超声乳化白内障吸除及人工晶状体置换手术对于治疗角膜内皮失代偿并有晶状体或人工晶状体异常患者是一种较安全、有效的手术方法.前房人工晶状体眼行DSAEK术后并发症较多,对虬膜、房角结构异常的患者行角膜内皮移植手术应谨慎.

automated endothelial keratoplasty （DSAEK） combined with phacoemulcification cataract surgery or lens exchange in corneal endothelial dysftnction eyes with lens disorders. Methods Retrospective case series.Eighteen consecutive cases （20 eyes） were performed DSAEK combined with lens surgery from December 2007 to December 2008 in Department of Ophthalmology, Peking University Third Hospital. Five cases （7 eyes） were performed DSAEK combined with phacoemulcification and intraocular lens （IOL） insertion.Seven cases were combined with anterior chamber IOL extraction, anterior vitrectomy and posterior chamber IOL insertion. Six aphakia cases were performed with DSAEK combined with anterior vitrectomy and sclera fixation posterior chamber IOL insertion. Postoperatively, the visual acuity, corneal transparency, central corneal thickness （CCT）, endothelial cell density （ECD） and complications were observed during the follow-up. Results The irritation was disappeared in all of patients. All of the corneas became transparent.The preoperative and postoperative mean CCT of the recipient beds was 859 μm and 553 μm respectively. T value was 5.303 （ t = 5.303, P 〈 0.01 ）. It was extremely significant difference. The mean ECD of the donors was 2987 cells/mm2. The ECD was 1803 cells/mm2 in three months postoperatively. The rate of endothelial cells loss was 41%. The visual acuity improved significantly except 9 eyes which had fundus disorders. Six eyes were better than 0.8. It was 55% in normal retinal function patients （6/11）. The inflammatory reaction of the anterior chamber IOL eyes was most serious. Six eyes underwent graft dislocation. Five cases underwent high intraocular pressure. One case occurred graft rejection.These complications occurred in anterior chamber IOL eyes. Conclusions DSAEK combined with phacoemulcification cataract surgery or lens exchange is a safe and effective surgical treatment for corneal endothelial dysfunction with lens disorders. More complications occur in anterior chamber IOL eyes. DSAEK should be cautiously chosen in abnormal iris and chamber angle structural eyes.