部分环状板层角膜移植治疗蚕蚀性角膜溃疡

Clinical effect of using a ring＇shaped donor cornea in partial lamellar keratoplasty for Mooren^sulcer

目的观察部分环状板层角膜移植治疗早期药物治疗无效的进展性蚕蚀性角膜溃疡的临床疗效。方法回顾性系列病例研究。10例（11眼）常规给予局部及全身免疫抑制剂和对症治疗1周及以上、病灶不断扩散的蚕蚀性角膜溃疡患者，行部分环状板层角膜移植手术，角膜供体选自部分穿透性角膜移植术后残留的环形供体角膜。手术方法：采用7．75-8．00mm的环钻在角膜中央压痕，在彻底切除病灶后，覆盖与病灶范围相同的供体角膜。随访6-36个月，观察患者的视力、角膜植片愈合时间及是否复发等。采用重复测量方差分析比较手术前后视力变化。结果患者裸眼视力术后1个月平均提高（1．36±1．21）行，术后3个月平均提高（1．72±1．47）行，术后6个月平均提高（1．86±2．04）行：最佳矫正视力术后1个月平均提高（0．46±0．93）行，术后3个月平均提高（0．73±1．10）行，术后6个月平均提高（1．55±1．75）行。手术前后裸眼视力（F=5．630，P〈0．05）与最佳矫正视力忙5．925，P〈0．05）差异均有统计学意义。术后患者角膜植片上皮平均愈合时间为（7．00±5．31）d；1例患者术后角膜植片上皮愈合不良，行羊膜移植术后20d愈合；1例患者术后19个月复发，行二次部分板层角膜移植。所有患者随访期间未发生免疫排斥反应等并发症。结论使用环形供体角膜的部分板层角膜移植能有效控制早期药物治疗无效的蚕蚀性角膜溃疡的发展，保存视轴区透明角膜，术后视觉效果良好，同时节约角膜供体材料。

Objective To evaluate the clinical effect of using a ring-shaped donor cornea in partial lamellar keratoplasty for early-stage Mooren＇s ulcer. Methods It was a retrospective case series study. Partial lamellar keratoplasty was performed on 11 eyes with Mooren＇s ulcer. The patients were treated for symptoms for a week or more. A residual ring-shaped section of a donor cornea was used after partial penetrating keratoplasty. A trephine （7.75-8.00 mm） was used to mark the central cornea. An ophthalmic knife was used to deepen the trephine groove to an extent dictated by the size of the lesion in order to excise the lesion adequately. If corneal perforation appeared before or during the operation, it was repaired using a very thin layer of lamellar cornea larger than the perforation and sutured to the perforation hole with 10-0 sutures. Then a ring-shaped donor graft was used to repair the lesion area. Visual acuity, condition of the lesion, and complications were monitored for 6-36 months. Repeated measures analysis of variance were used. Results Compared to pre-surgery, uncorrected visual acuity improved by a mean of 1.36±1.21 Snellen chart lines at 1 month, 1.72± 1.47 lines at 3 months and 1.86±2.04 lines at 6 months. Best spectacle-corrected visual acuity improved by a mean of 0.46±0.93 Snellen chart lines at 1 month, 0.73±1.10 lines at 3 months and 1.55±1.75 lines at 6 months. There were significant difference before and after surgery at uncorrected visual acuity （F=5.630, P〈0.05） and best spectacle-corrected visual acuity （F=5.925, P〈0.05）. One patient had graft epithelial defect and was cured with an amniotic membrane transplant after 20 days. One patient had a recurrence after 19 months and was cured with a second lamellar keratoplasty. Norejections were detected. Conclusion A ring-shaped donor cornea in partial lamellar keratoplasty for Mooren＇s ulcer is a useful option when medical treatment fails. It cannot only control the development of the disease, but also preserve the visual axis of the clear cornea and to a large extent save the donor cornea.