多层羊膜联合结膜瓣覆盖治疗周边溃疡性角膜炎分析

Multilayer amniotic membrane combined with conjunctival flap for treatment of peripheral ulcerative keratitis

目的应用多层羊膜移植联合结膜瓣覆盖的手术方法治疗近穿孔的周边溃疡性角膜炎，从而探讨该手术方法的临床价值。方法自2008—2011年收集的21例（21只眼）周边溃疡性角膜炎近穿孔病例，其周边凹槽样角膜溶解，厚度约1／3—1／4CT，术前血液风湿系列检查所有患者显示异常，其中类风湿因子（RF）均超出正常值3～5倍，部分患者抗链球菌溶血素O定量测定（ASO）或超敏C反应蛋白测定高于正常值，抗环瓜氨酸多肽（ccp）抗体正常。术前药物控制角膜创面合并的混合感染；术中尽可能清除角膜溃疡局部坏死组织及角膜周边部免疫复合物沉积处，将营养液冷冻法保存羊膜组织片，复水后分层贴附于溃疡表面，上皮面向上，缝线间断固定，溃疡较深处再以羊膜条填塞其中，将自体带蒂转位的结膜瓣覆盖于羊膜表面，间断固定。术后结合局部感染情况给予糖皮质激素眼水、眼膏点眼，同时根据内科会诊意见全身使用糖皮质激素治疗相关性自身免疫性疾病。结果术后10～14d，18例患者周边溃疡性角膜炎近穿孔区有新生血管长入，术后1-2月角膜创面愈合；仅3例患者术后1．5月角膜创面再次出现部分结膜、角膜缘组织的溶解，即行第二次同术式手术，二次术后2月角膜创面全部愈合。患者随诊中仅1例患者在术后1年时，在距原手术区1个钟点位处出现新的周边溃疡性角膜炎溃疡病灶。结论周边溃疡性角膜炎是一种与自身免疫相关性眼病。在角膜供体材料匮乏的今天，多层羊膜联合结膜瓣覆盖为治疗周边溃疡性角膜炎近穿孔病例提供了一种有效的手术治疗方式。

Objective To observe the effect of multilayer amniotic membrane transplantation combined with conjunctival flap in the treatment of peripheral ulcerative keratitis in flesh perforation, so as to explore the clinical value of surgical methods. Methods A piece of preserved amniotic membrane tissue from Xi＇ an Eye bank before surgery was prepared. Twentyne cases （21 eyes） of peripheral ulcerative keratitis with fresh perforation were collected in our hospital from 2008-2011, those dissolved in the surrounding with groove-like, corneal thickness of about 1/3-1/4 CT, the thinnest part was only the Descemet＇s membrane. All patients showed abnormal series of rheumatoid blood test before surgery, including rheumatoid factor （RF） was 3-5 times above the normal; in some patients anti-streptolysin 0 quantitative analysis （ASO） or super-sensitivity C-reactive protein were higher than normal; however, the value of anti-cyclic citrullinated peptide （ccp） antibody was normal. The cases were diagnosed as peripheral ulcerative keratitis. Medications were used to treat the corneal infections before the operation. The ulcerated necrotic tissue and peripheral immune corn-plex deposition were removed, then the multilayer amniotic membrane was put on, with autologous pedicle conjunctival flap transposition in the amniotic membrane surface, intermittent fixed. Glucocor- ticoids drops and ointment were admitted locally, while systemic administration of immunosuppres- sive drugs was given according to medical consultation with autoimmune diseases. Results On 10-14 days postoperatively, 18 patients with peripheral ulcerative keratitis nearly perforated area were become into a neovascularization, corneal wound healed after 1-2 months; only 3 patients recurred with the dissolution of limbal tissue after 1,5 months, which received the second same surgical procedure, corneal wound healed after 2 months. All the eases were followed up, only 1 patient developed a new peripheral ulcerative keratitis ulcer lesions near the surgical areal year after surgery. Conclusions Peripheral ulcerative keratitis is an eye disease associated with autoimmunity. In the lack of corneal donor material, multi-layer amniotic membrane combined with conjunctival flap is an effective method to treat peripheral ulcerative keratitis with fresh perforation.