不同大小角膜微切口超声乳化白内障摘出术对术后角膜愈合过程的影响

Effect of phacoemulsification with different corneal micro-incision sizes on postoperative corneal healing

目的观察不同大小角膜微切口超声乳化白内障摘出术对术后角膜愈合过程的影响。方法采用前瞻性非随机对照临床研究,选取2016年5月至2017年5月在延边大学附属医院眼科行超声乳化白内障摘出联合人工晶状体植入术的年龄相关性白内障患者76例76眼,按照透明角膜切口大小的不同分为2.2 mm切口组37例37眼和1.8 mm切口组39例39眼。术中测量并比较2个组累积释放能量(CDE)和有效超声乳化时间。术前和术后第1天、第1周及第1个月,采用眼前节光相干断层扫描仪(AS-OCT)测量并比较2个组角膜切口结构和角膜厚度;采用Pentacam眼前节分析仪测量并比较2个组角膜内皮细胞数量、中央角膜厚度(CCT)、直径3.0 mm范围角膜体积(CV3)和直径10.0 mm范围角膜体积(CV10)。结果2个组间角膜内皮细胞数量、CCT、CV3、CV10、角膜切口外口处角膜厚度总体比较差异均无统计学意义(F组别=0.788、0.706、3.692、4.341、4.182,均P>0.05);手术前后不同时间点上述各参数总体比较差异均有统计学意义(F时间=17.717、67.356、17.577、13.559、80.076,均P<0.01)。术后1个月2个组角膜内皮细胞数量较术前明显减少,差异均有统计学意义(均P<0.05)。术后1 d,2个组CCT、CV3、CV10、角膜切口外口处平均角膜厚度均较术前明显增加,差异均有统计学意义(均P<0.05);术后1周、1个月CCT、CV3、CV10、角膜切口外口处平均角膜厚度与术前比较差异均无统计学意义(均P>0.05)。术后1个月,1.8 mm切口组术眼角膜切口内口哆开和角膜内皮错位的发生率分别为12.8%(5/39)和5.1%(2/39),高于2.2 mm切口组的0.0%(0/37)和2.7%(1/37),2个组比较差异均有统计学意义(χ^(2)=5.078,P=0.024;χ^(2)=0.295,P=0.590)。术后1 d,1.8 mm切口组角膜切口内口角膜厚度明显较2.2 mm切口组增厚,差异有统计学意义(P=0.042);2.2 mm切口组和1.8 mm切口组角膜切口内口角膜厚度与CDE均呈正相关(r=0.231,P=0.025;r=0.347,P=0.003)。结论与2.2 mm角膜切口相比,1.8 mm角膜切口的超声乳化白内障摘出术后角膜切口内口哆开、角膜内皮错位发生率以及角膜切口内口处角膜水肿程度较高,且恢复较慢。

Objective To investigate the effect of phacoemulsification using different corneal micro-incision sizes on the postoperative corneal healing.Methods A non-random controlled study was performed.Seventy-six patients(76 eyes)with age-related cataract who underwent phacoemulsification and cataract extraction combined with intraocular lens(IOL)implantation in Yanbian University Hospital from May 2016 to May 2017 were enrolled.The subjects were divided into 2.2 mm incision group(37 eyes)and 1.8 mm incision group(39 eyes)according to corneal incision size.The intraoperative cumulative dissipated energy(CDE)and ultrasound time of the two groups were measured and compared.The corneal incision structure and corneal thickness of operative eyes were measured by anterior segment optical coherence tomography before surgery and at postoperative 1 day,1 week and 1 month.The corneal endothelial cells count,the central corneal thickness(CCT),and the corneal volume in the central corneal diameters of 3.0 mm(CV3)and 10.0 mm(CV10)were measured by Pentacam.This study adhered to the Declaration of Helsinki.The study protocol was approved by the Ethics Committee of the Yanbian University Hospital(No.2015153),and written informed consent was obtained from all subjects before surgery.Results There were statistically significant differences in the corneal endothelial cells count,CCT,CV3,CV10,and corneal thickness at epithelial side of the incision between pre-operation and post-operation in each group(Ftime=17.717,67.356,17.577,13.559,80.076;all at P<0.01).But there was no statistically significant difference in the indexes between the two groups(Fgroup=0.788,0.706,3.692,4.341,4.182;all at P>0.05).The number of corneal endothelial cells in the two groups was gradually decreased after surgery,and was significantly reduced at one month after surgery in comparison with the pre-operation,and the differences were statistically significant(both at P<0.05).At 1 day after surgery,the CCT,CV3,CV10,and corneal thickness at epithelial side of the incision in the two groups were increased significantly in comparison with the pre-operation and the differences were statistically significant(all at P<0.05),and the differences were not statistically significant between preoperative and postoperative 1 week or 1 month(all at P>0.05).With time going by,the indexes were back to normal gradually.The incidence of endothelial gaping and dislocation at the corneal incision in the 1.8 mm incision group was 12.8%(5/39)and 5.1%(2/39),which were significantly higher than 0.0%(0/37)and 2.7%(1/37)in the 2.2 mm incision group,and the differences were statistically significant(χ^(2)=5.078,P=0.024;χ^(2)=0.295,P=0.590).At 1 day after surgery,corneal thickness at the endothelial side in the 1.8 mm incision group was significantly thicker than that in the 2.2 mm incision group,and the difference was statistically significant(P=0.042),and the corneal thickness at endothelial side of the incision was positively correlated with CDE in the two groups(r=0.231,P=0.025;r=0.347,P=0.003).Conclusions Compared with 2.2 mm incision,1.8 mm corneal incision results in higher incidence of endothelial gaping and dislocation at the corneal incision,greater corneal thickness at endothelial side of the incision and slower recovery.