角膜基质透镜联合生物工程角膜移植治疗感染性角膜溃疡伴穿孔的临床观察

Clinical Observation of Corneal Stromal Lenticules Combined with Bioengineered Corneal Transplantation for Treatment of Infectious Corneal Ulcer with Perforation

目的:观察分析角膜基质透镜联合生物工程角膜移植治疗感染性角膜溃疡伴穿孔的疗效及安全性。方法:回顾性系列病例研究。收集2021年1—12月于西安市人民医院眼科所有接受角膜基质透镜联合生物工程角膜移植的感染性角膜溃疡伴穿孔患者24例(24眼),其中细菌性角膜溃疡伴穿孔10眼,病毒性角膜溃疡伴穿孔9眼,真菌性角膜溃疡伴穿孔5眼。角膜溃疡灶均位于非瞳孔区,穿孔直径2~4(3.13±0.92)mm。观察患者视力、眼压、散光、植片厚度、感染复发情况、并发症及植片排斥反应等。随访6~18(13.2±2.2)个月。结果:所有手术均顺利完成,角膜植片厚度为485~561(518±33)μm。术前最佳矫正视力(BCVA)为光感~0.12,小于0.1者18眼,0.1~0.25者6眼;末次随诊时BCVA为0.02~0.8,小于0.1者5眼,0.1~0.25者9眼,0.3~0.5者7眼,大于0.5者3眼。末次随诊时的术后角膜散光为1.1~3.5(1.76±0.81)D。2眼术中还纳嵌顿虹膜时致前房出血,保留少量黏弹剂,前房积血分别于术后3、5 d完全吸收。所有患者于术后3~7 d均完成植片上皮化,生物工程植片逐渐变透亮。在院期间1例患者(术后2 d)出现轻度双前房,加压包扎3 d后消失。至末次随诊,未见原发感染复发者。2例原发病灶位于近角膜缘处的患者分别于术后2、5个月时出现了植片局部边缘水肿及新生血管长入,予以及时拆除局部缝线及加强使用糖皮质激素联合他克莫司点眼后植片逐渐透明;1例在术后6个月时因特殊原因停用所有眼药3周后,发生严重排斥反应,行结膜瓣覆盖术;其余患者植片、基质透镜垫片与植床均贴附紧密,愈合良好,透明度良好。结论:角膜基质透镜联合生物工程角膜移植是治疗非瞳孔区感染性角膜溃疡伴小穿孔的安全方法,不受限于供体角膜材料短缺且术后视力恢复较好。

Objective:To investigate the efficacy and safety of corneal stromal lenticules combined with bioengineered corneal transplantation in the treatment of infectious corneal ulcer with perforation.Methods:In this retrospective case series study.From January 2021 to December 2021,totally 24 patients(24 eyes)with infectious corneal ulcer and perforation who received corneal stromal lenticules combined with bioengineered corneal transplantation in Xi'an People's Hospital(Xi'an Fourth Hospital)were selected,including 10 eyes with bacterial corneal ulcer and perforation,9 eyes with viral corneal ulcer and 5 eyes with fungal corneal ulcer and perforation.The corneal ulcer area were all located in the non pupillary area,and the perforation diameter was 3.13±0.92(2-4)mm.The visual acuity,intraocular pressure,corneal astigmatism,infection recurrence,complications and graft rejection were observed.Results:All operations were successfully completed.The follow-up ranged from 13.2±2.2(6-18)months.The best corrected visual acuity before operation was light perception-0.12,of which 18 eyes were less than 0.1 and 6 eyes were 0.1-0.25.The last follow-up was 0.02-0.8,of which 5 eyes were less than 0.1,9 eyes were 0.1-0.25,7 eyes were 0.3-0.5,and 3 eyes were more than 0.5.Postoperative corneal astigmatism:1.76±0.81(1.1-3.5)D at the last follow-up.The graft thickness measured at the last follow-up was 518±33(485-561)μm.In 2 cases,the anterior chamber hemorrhage was caused when the incarcerated iris was returned during the operation,and a small amount of viscoelastic agent was retained.The anterior chamber hemorrhage was completely absorbed at 3 and 5 days after the operation,respectively.All patients completed epithelialization of the grafts at 3-7 days after operation,and the bioengineering grafts gradually became transparent.One patient developed mild double anterior chamber at the second day after operation which disappeared after 3 days of pressure bandaging.Up to the last follow-up,there was no recurrence of primary infection.Two patients with primary lesions near the corneal limbus developed edema and neovascularization at the local edges of the grafts at 2 months and 5 months after surgery.The local sutures were removed in time and the grafts were gradually transparent after intensive use of glucocorticoid and tacrolimus;one patient developed severe rejection after discontinuing all ophthalmic drugs for special reasons at 6 months after surgery,and underwent conjunctival flap covering surgery.In other patients,the implant,matrix lens gasket and the implant bed were closely attached,with great healing and good transparency.Conclusions:Corneal stromal lenticules combined with bioengineered corneal transplantation is a safe method for the treatment of infectious corneal ulcer with perforation,which is not limited by the shortage of donor corneal materials and have a good visual recovery after operation.