晶状体超声乳化术联合房角镜直视下房角分离术治疗晚期原发性闭角型青光眼

Phacoemulsification combined with goniosynechialysis under gonioscopy in the treatment of advanced primary angle-closure glaucoma

目的观察晶状体超声乳化术联合房角镜直视下房角分离术治疗晚期原发性闭角型青光眼(PACG)的疗效。方法回顾性收集2019年1月到2020年7月于本院收治的17例(25眼)晚期PACG患者。所有患者入院后均行晶状体超声乳化术+人工晶状体植入+术中房角镜直视下房角粘连分离术。术后随访6~24(15.64±4.35)个月。观察患者术中、术后并发症发生情况,比较术前及术后眼压、视力、用药情况。1例患者术后眼压失控,再次给予复合式小梁切除术,此患者除并发症发生情况以外其他资料未纳入统计。结果16例(24眼)患者术后眼压为(15.53±5.13)mmHg(1 kPa=7.5 mmHg),比术前用药下眼压(24.85±10.64)mmHg明显降低,差异有统计学意义(t=4.100,P=0.000)。术后用药种类和滴数均比术前明显减少,差异均有统计学意义(Z=-2.917,P=0.004;Z=-3.338,P=0.001)。术后16例(24眼)患者最佳矫正视力为(0.05±0.00)logMAR,较术前(0.28±0.41)logMAR有明显提高,差异有统计学意义(t=2.985,P=0.008)。17例(25眼)患者并发症发生或手术失败共有4例(4眼)1例患者术中发生房水迷流,经睫状体扁平部穿刺放液后完成手术;2例患者术后发生恶性青光眼,给予YAG激光虹膜周边切除加后囊膜切开术;1例患者术后眼压失控再次行复合式小梁切除术。logistic回归分析4例发生并发症或手术失败患者的危险因素,结果显示年龄≤50岁、眼轴长度<22 mm、晶状体厚度<4.5 mm、晶状体混浊程度较轻是发生并发症或手术失败的危险因素。结论晶状体超声乳化术+人工晶状体植入+房角镜直视下房角分离术治疗晚期PACG有效,但对年轻、短眼轴、晶状体厚度较薄及晶状体混浊较轻的患者应慎重选择。

Objective To observe the effect of phacoemulsification combined with goniosynechialysis under gonioscopy in the treatment of advanced primary angle-closure glaucoma(PACG).Methods A total of 17 patients(25 eyes)with advanced PACG admitted to our hospital from January 2019 to July 2020 and surgically treated with phacoemulsification+intraocular lens implantation+intraoperative goniosynechialysis under the direct vision of gonioscopy were retrospectively analyzed.Patients were followed up for an average of 6-24(15.64±4.35)months.The intraoperative and postoperative complications were recorded,and the preoperative and postoperative intraocular pressure(IOP),visual vision,and medication were compared.IOP of 1 patient was uncontrolled after surgery,and the patient was re-treated with trabeculectomy.Therefore,the patient’s complications were analyzed while the remaining variables were excluded.Results Compared with preoperative IOP with the medication,the postoperative IOP of 16 patients(24 eyes)was significantly reduced(15.53±5.13)mmHg(1 kPa=7.5 mmHg)vs.(24.85±10.64)mmHg(t=4.10,P=0.000).The types of postoperative medications and drips were significantly reduced compared with those of preoperative medications(Z=-2.917,P=0.004;Z=-3.338,P=0.001).The best corrected visual acuity of 24 eyes after operation was significantly higher than that of preoperative level(0.05±0.00)logMAR vs.(0.28±0.41)logMAR(t=2.985,P=0.008).Treatment failure occurred in 4 patients(4 eyes),including 1 patient had intraoperative aqueous vagus flow and the surgery was completed after puncture and drainage of the flat part of the ciliary body;2 patients developed postoperative malignant glaucoma and were treated with YAG laser peripheral iris plus posterior capsulotomy;1 patient was retreated with trabeculectomy due to uncontrolled IOP.logistic regression analysis was used to analyze the risk factors for complications or surgical failure in the 4 patients.It is found that the age≤50 years,axial length<22 mm,lens thickness<4.5 mm,and mild lens opacity were risk factors for complications or surgical failure.Conclusion Phacoemulsification+intraocular lens implantation+intraoperative goniosynechialysis under the direct vision of gonioscopy is effective for the treatment of advanced PACG.However,this procedure should be cautiously selected in young patients with short axial length,thin lens thickness and light lens opacity.