手法扩张后不同瞳孔直径对瞳孔闭锁并发性白内障疗效的影响

Influence of manual enlarging pupil to different diameters on clinical outcome of pupil atresia complicated cataract

背景瞳孔闭锁增加了白内障超声乳化手术的难度，瞳孔扩张不当容易产生诸多并发症，探索合适的瞳孔扩张直径和方法对提高手术疗效十分重要。目的评价手法扩张瞳孔术对瞳孔闭锁并发性白内障患者术后瞳孔功能的影响。方法收集2006年5月至2012年5月在山东省眼科研究所诊治的陈旧性葡萄膜炎致瞳孔闭锁或膜闭并发性白内障患者30例38眼，对患眼行手法扩张瞳孑L术治疗瞳孑L闭锁并发性白内障。按照患眼术中瞳孔扩张的大小分为瞳孔扩大≥6．0mm组15眼和瞳孔扩大4．5～5．5mm组23眼，同时行白内障超声乳化摘出联合人工晶状体（IOL）植人术。手术中首先撕除瞳孔区机化膜，然后应用23G眼科显微剪对瞳孔领的机化纤维条带做均匀锯齿状剪开，左右手虹膜拉钩多点扩张瞳孔。手术后局部与全身应用糖皮质激素药物和非甾体类抗炎药物，局部应用扩张瞳孔药物。术后随访3个月，分析不同瞳孔直径对术眼视力、并发症、畏光症状、眼压等情况的影响。结果瞳孔扩大≥6．0mm组手术中扩张瞳孑L至（6．9±0．4）mm，瞳孔扩大4．5～5．5mm组扩张瞳孔至（5．1±0．3）mm，两组差异有统计学意义（t=16．100，P=0．000）。术后3个月瞳孔扩大≥6．0mm组瞳孔直径为（4．9±0．4）NINl，瞳孔缘有不同程度的撕裂口；瞳孔扩大4．5～5．5mm组瞳孔直径为（3．5±0．5）mm，瞳孔缘撕裂口少见，2个组瞳孔直径的差异有统计学意义（t=9．820，P=0．000）。瞳孔扩大≥6．0mm组瞳孔对光反射迟钝或消失者11眼，明显高于瞳孔扩大4．5～5．5mm组的6眼，差异有统计学意义（x2=8．200，P=0．005）。瞳孔扩大≥6．0mm组主观畏光感为2～3级者12眼，瞳孔扩大4．5～5．5mm组者仅2眼，差异有统计学意义（H=19．840，P=0．000）。瞳孔扩大≥6．0mm组术中虹膜出血者7眼，明显高于瞳孑L扩大4．5～5．5mm组的3眼，差异有统计学意义（x2=5．290，P=0．030）。术后3个月2个组患眼的视力均有不同程度的提高。结论陈旧性葡萄膜炎瞳孔闭锁并发性白内障患眼手术中可采用均匀松解、扩张瞳孔的方法，瞳孔扩张直径不超过5．5mm时可获得满意的近似生理性瞳孔，提高患者的视觉质量。

Background Pupil atresia increases the difficulty of cataract surgery. The improper enlarging pupil will lead to many complications. The appropriate method of pupil dilation is very important to improve the postoperative effect. Objective This study was to evaluate the pupillary function after manually enlarged pupil to different sizes for pupil atresia complicated cataract. Methods A retrospective case-controlled study was designed. Thirty-eight eyes of 30 cases suffered from pupil atresia complicated cataract induced by chronic uveitis were enrolled in Shandong Eye Institute from May 2006 to May 2012. The eyes underwent pupil forming and phaeoemulsification and assigned to the pupil enlarged to ≥ 6.0 mm group （15 eyes） and 4.5-5.5 mm group （23 eyes）. The fibrosis membrane at pupil zone was removed, and the fibrosis strip at pupil collar was cut evenly by 23G intraocular mieroscissors as zigzag shape. Then the pupil was enlarged in multipoint by a pair of left and right iris hook from the main and lateral incisions. The pupils of 15 eyes in the pupil enlarged to /〉6.0 mm group were dilated above 6.0 mm and 23 pupils in the 4.5-5.5 mm group were dilated to 4.5-5.5 mm and followed by routine phacoemulsifieation and foldable intraocular lens implantation. Topical and systemic eortieosteroids and nonsteroidal anti-inflammatory drugs combined topical mydriatie were applied before and after operation. The pupil diameter,light reflex and photophobia symptom in postoperation were compared between the two groups. The visual acuity before and after operation and intra-and post-operative complications were recorded. This study was approved by Ethic Committee of Shandong Eye Hospital,and written informed consent was obtined from each patient befnre operation. Results The pupil diameter in the pupil enlarged to ≥6.0 nun group was dilated to （6.9±0.4）mm and that of the 4.5-5.5 mm was dilated to （5. 1 ±0. 3 ）mm intraoperatively, with a statistical significance between them （t = 16. 100, P = 0. 000 ）. Three months later,the pupil diameter in the pupil enlarged to 6.0 mm group was （4.9±0.4）mm, with different degrees of lacerated pupillary margins, and that in the pupil enlarged to 4.5-5.5 mm group was （3.5±0. 5）mm, with rare lacerated pupiltary margins, showing a statistically significant difference （ t = 9. 820, P = 0. 000 ）. The unresponsive or obtuse light reflex in the pupil enlarged to 〉16. 0 mm group was significantly higher than in the pupil enlarged to 4.5- 5.5 mm group（ 11 eyes vs. 6 eyes） （X2 = 8. 200, P = 0. 005 ）. The subjective photophobia symptom of 2-3 grades in the pupil enlarged to ≥6.0 mm group was in 12 eyes,which was higher than that in the pupil enlarged to 4.5-5.5 mm group （2 eyes） （H= 19. 840,P--0. 000）. The iris haemorrhage were seen in 3 eyes in the pupil enlarged to 4.5- 5.5 mm group and 7 eyes in the pupil enlarged to ≥6.0 mm group （X2 =5. 290 ,P=0. 030）. The visual acuities of the operated eyes in the two groups improved at different degrees. Conclusions Approximate physiological pupil and good visual quality can been obtained by manual releasing and enlarging pupil to less than 5.5 mm evenly during the surgery fur pupil atresia complicated cataract induced by chronic uveitis.