重新开放房角在重症急性闭角型青光眼治疗中的临床意义

Clinical significance of reopening anterior chamber angle for severe acute angle-closure glaucoma

目的:探讨360°"最大程度"房角关闭的重症急性闭角型青光眼,通过"双穿刺"、联合超声乳化加房角分离手术,能否重新开放房角,开放的范围和眼压变化。方法:回顾性系列病例研究。2008-11/2015-11收住我院病例完整的重症急性闭角型青光眼患者33眼,均为最大量药物治疗无效的患者。入院后行"双穿刺"手术短时间降低眼内压(术前和术后7d查房角),7～14d后行超声乳化联合房角分离手术治疗(术中检查房角),比较两次手术前后患者眼压、房角变化,观察手术并发症。随访时间为6～24mo。结果:"双穿刺"术前眼压为53.4±10.7mm Hg(1mm Hg=0.133k Pa),"双穿刺"手术后32眼眼压正常(其中2眼激光打孔后眼压正常),平均眼压为16.9±13.2mm Hg。1眼眼压仍高。双穿刺术前、术后眼压比较差异有统计学意义(t=9.21,P<0.001)。超声乳化术后1wk眼压为16.7±4.8mm Hg。双穿刺术后与超声乳化术后眼压比较差异无统计学意义(t=0.38,P>0.05)。1眼术后眼压异常,术后30d后正常。双穿刺术后房角的检查结果为:房角开放均值(131.8±111.3)°。术后7～14d 32眼行超声乳化联合房角分离术,1眼行超乳联合小梁切除手术,房角开放手术治疗有效率为32/33(97%)。术中房角开放均值(228.6±108.3)°,术后3mo房角开放均值(234.6±107.2)°。双穿刺术后与超声乳化术中房角开放度数比较差异有统计学意义(t=4.52,P<0.001),超声乳化术后3mo房角均值大于术中房角,差异无统计学意义(t=0.46,P>0.05)。没有严重并发症发生。结论:"最大程度"房角关闭的重症急性闭角型青光眼,可以通过"双穿刺"联合晶状体摘除手术逐步开放房角、降低眼压。开放房角可以作为重症急性闭角型青光眼的选择。

AIM： To explore whether the drainage angle could be reopened by surgery in patients with severe acute angle-closure glaucoma at “the greatest degree” of angle closure, and to study the treatment methods, such as double-paracentesis, phacoemulsification combined with goniosychialysis, and the effectiveness. METHODS： Retrospective observational case series. From November 2008, to November 2015, there were 33 patients with severe acute angle-closure glaucoma and 360° angle closure. Drug treatment showed no effect on them, so initial double-paracentesis（anterior chamber paracentesis combined with vitreous paracentesis）was applied. Then, either phacoemulsification combined with goniosychialysis or trabeculectomy surgery was performed after 7-14d, which was chosen based on the result of gonioscope during the surgery. The intraocular pressure, angle changes, and complications were observed. The follow-up period was 6mo to 3a. RESULTS： Of 33 participants enrolled, 32 had normal intraocular pressure after “double-paracentesis”（2 had normal intraocular pressure after laser peripheral iridotomy）. The mean intraocular pressure was significantly reduced from 53.4±10.7mmHg to 16.9±13.2mmHg（t=9.21,P〈0.001）by applying “double-paracentesis”, and 1 still had higher intraocular pressure. The mean intraocular pressure（16.7±4.8mmHg）was 0.2mmHg lower after phacoemulsification than after “double-paracentesis” while there was no significant difference（t=0.38,P〉0.05）. One patient had abnormal intraocular pressure until 30d after phacoemulsification. Every participant had 360° angle closed before “double-paracentesis”, 32 patients had opened angle（mean 131.8°±111.3°）after “double-paracentesis” and mean（228.6°±108.3°）during phacoemulsification, and mean（234.6°±107.2°）at 3mo after phacoemulsification. There was a significant difference between the post-paracentesis and intraoperative values（t=4.52, P〈0.001）. There was no difference between the intraoperative and postoperative values（t=0.46, P〉0.05）. No patients had serious adverse events. CONCLUSION： For the “maximum degree” angle closure of severe acute angle-closure glaucoma, “double-paracentesis” combined with phacoemulsification can be chosen to open the angle gradually, and reduce intraocular pressure in vast majority of patients.