经巩膜睫状体光凝术治疗近穿孔角膜溃疡继发青光眼的探讨

Trans-scleral cyclophotocoagulation to treat secondary glaucoma in nearly perforated corneal ulcer

目的探讨应用经巩膜睫状体光凝术(TSCP)治疗近穿孔角膜溃疡(1/2CT^2/3CT)继发青光眼的疗效和安全性。方法选择近穿孔并继发青光眼的角膜溃疡26例(26只眼),平均眼压36.5±8.7(22~65)mmHg,采用culight SLx半导体激光器(波长为810 nm,使用G探头),对A组:治疗组14例(16只眼)近穿孔并继发青光眼的角膜溃疡患者进行TSCP治疗(有2只眼接受2次治疗),并同时刮除溃疡表面分泌物及坏死组织,并送检确定病原学诊断,后用4%碘酒烧灼溃疡区。观察患者术后溃疡区深度、直径(眼前节光学相干扫描),患者眼压变化、视力及并发症情况,术后随访12个月;B组:对照组10例(10只眼),患者不同意接受TSCP治疗,应用降眼压药物降低眼压,余治疗均同治疗组。结果治疗组16只近穿孔并继发青光眼的角膜溃疡患眼,术后不用降眼压药物,1周眼压平均为(25.9±11.2)mm Hg,术后1个月眼压平均为(20.5±8.5)mm Hg,术后3个月眼压平均为(17.6±11.6)mm Hg,有2只眼行2次TSCP治疗,此后眼压平稳,术后12个月眼压平均为(17.8±10.4)mm Hg,术前、术后的眼压差异有统计学意义(P<0.01)。患者术后视力较术前略增高,差异无统计学意义(P>0.01)。治疗结束时角膜溃疡深度平均为(15.5±9.5)μm,较术前(376.4±6.4)μm明显减轻,差异有统计学意义(P<0.01)。治疗组术后次日有前房渗出、前房出血、结膜下出血、结膜充血等并发症,术后1周症状明显消退;术后末次随访时视网膜脱离1只眼,其它患者术后均未出现视网膜脱离、脉络膜上腔出血、眼内炎或交感性眼炎等并发症,12个月随访时3例患者行穿透性角膜移植手术,术后视力提高明显,所有患者角膜感染得到有效控制,均未出现角膜溃疡穿孔。而对照组,在观察期间,有1只眼出现角膜溃疡穿孔。结论 TSCP能有效地降低感染性角膜溃疡的眼压,从而降低角膜溃疡穿孔的发生率,减少角膜局部用药的种类及数量,感染得到有效控制,无明显严重并发症。TSCP是一种辅助治疗感染性角膜溃疡继发性青光眼安全而有效的治疗方法之一。

Objective To investigate the curative effect and safety of trans-scleral cyclophotocoagulation （TSCP） in the treatment of seeondary glaucoma in nearly perforated corneal ulcer （ 1/2CT -2/3CT）. Methods 26 eyes with seeondary glaucoma due to corneal ulcer were included in this study. Average intraocular pressure （ IOP ） was 36. 5 ＋ 8. 7 （ range 22 - 65 ） mm Hg. Among these 26 eyes, 16 were treated with TSCP （ 2 eyes were treated twice ） after thorough debridement. Another 10 eyes were treated with topical lOP-lowering medications after debridement because of unwilling to consent for laser treatment. Ulcer area, depth （ measured by SD-OCT ） , IOP, visual acuity and complications were followed for 12 months. Results IOPwas25.9±11.2, 20.5 ＋8.5, and 17.6±11.6 mmHgat 1 week, 1 month and3 monthsin patients treated with TSCP. These IOP levels were significantly lower than pre-treatment IOP （ P 〈0. 01 ）. Visual acuity slightly improved but was not significant. At the end of the treatment, average corneal ulcers depth was 15.5 ±9.5 μm, significantly reduced when compared to preoperative depth （376. 4 ±6. 4μm; P 〈 0. 01 ）. Complications included anterior chamber exudation, hyphema, subconjunctival hemorrhage, conjunctival hyperemia, but most complications subsided in 1 week. Retinal detachment occurred in 1 patient. By the end of follow-up, corneal infection has been effectively controlled in all patients, and there was no corneal ulcer. In control group, there was a patient with recurred corneal ulcer. Conclusions TSCP can effectively reduce IOP in infectious corneal ulcer, therefore reducing the risk of corneal perforation. TSCP reduces the types and amount of topical anti-glancoma eye drops that were needed. Infection has been effectively controlled and there was no serious complication. TSCP is a safe and effective treatment for secondary glaucoma due to infectious corneal ulcer.