Trans-PRK联合预防性快速CXL矫正薄角膜或角膜形态欠规则屈光不正的疗效及安全性

Efficacy and safety of transepithelial photorefractive keratectomy combined with accelerated corneal cross-linking for refractive error in thin or irregular cornea

目的评估经上皮准分子激光屈光性角膜切削术(Trans-PRK)联合预防性快速角膜交联术(CXL)矫正薄角膜或角膜形态欠规则(除外圆锥角膜)屈光不正的疗效及安全性。方法采用系列病例观察研究方法,纳入2017年8月至2018年7月于包头朝聚眼科医院诊断为薄角膜或角膜形态欠规则并行Trans-PRK联合预防性CXL手术的近视患者55例55眼,所有患者均取右眼数据进行分析。术前、术后1周及术后1、3、6、12个月采用国际标准视力表检测术眼裸眼远视力(UDVA);采用电脑验光和综合验光检测屈光度。术前及术后3、6、12个月采用Pentacam眼前节分析仪检查角膜形态;术前及术后1、3、6、12个月采用非接触式眼压计测量眼压。记录术后并发症发生情况。结果术前、术后1周及术后1、3、6和12个月术眼UDVA(LogMAR视力)分别为0.52(0.55,0.78)、0.22(0.12,0.17)、0.10(0.04,0.07)、0.00(-0.04,-0.16)、-0.08(-0.05,-0.03)、-0.08(-0.06,-0.04),总体比较差异有统计学意义(Z=249.44,P<0.001),其中术后各时间点UDVA均较术前提高,术后3、6和12个月术眼UDVA较术后1周和1个月明显改善,差异均有统计学意义(均P<0.001)。术眼术后各时间点球镜度较术前均明显下降,术后1、3、6和12个月术眼球镜度低于术后1周,术后12个月术眼球镜度低于术后3和6个月,差异均有统计学意义(均P<0.001)。术后1、3、6和12个月术眼柱镜度低于术前和术后1周,差异均有统计学意义(均P<0.05)。术眼术后等效球镜度随时间延长逐渐下降,趋于正视状态;术后各时间点术眼等效球镜度低于术前,术后1、3、6和12个月术眼等效球镜度低于术后1周,术后12个月低于术后3和6个月,差异均有统计学意义(均P<0.001)。术后3、6及12个月术眼角膜K1值、K2值均明显低于术前,差异均有统计学意义(均P<0.001),术后3个月角膜K1值、K2值趋于稳定。术后3、6、12个月术眼眼压均显著低于术前,术后6和12个月术眼眼压低于术后1和3个月,差异均有统计学意义(均P<0.001)。术后1周1眼出现0.5级角膜上皮下雾状混浊,于术后1个月角膜自行恢复透明。结论Trans-PRK联合预防性快速CXL手术矫治合并薄角膜或角膜形态欠规则的(除外圆锥角膜)屈光不正眼具有良好的有效性、稳定性及安全性。

Objective To evaluate the efficacy and safety of transepithelial photorefractive keratectomy(Trans-PRK)combined with accelerated corneal cross-linking(CXL)for refractive error in patients with thin or irregular corneas,excluding keratoconus.Methods An observational case series study was performed.Fifty-five right eyes of 55 myopic patients diagnosed with thin or irregular corneas,who underwent Trans-PRK combined with prophylactic CXL surgery,were included at Baotou Chaoju Eye Ophthalmic Hospital from August 2017 to July 2018.Uncorrected distance visual acuity(UDVA)of the operated eye was measured using international standard visual acuity charts,and refractive diopters were measured by computer and comprehensive refraction before surgery and at 1 week,1,3,6,and 12 months after surgery.Corneal morphology was assessed with the Pentacam anterior segment analyzer before surgery and at 3,6,and 12 months after surgery.Intraocular pressure(IOP)was measured with a non-contact tonometer before surgery and at 1,3,6,and 12 months after surgery.The incidence of postoperative complications was recorded.This study adhered to the Declaration of Helsinki.The study protocol was approved by the Ethics Committee of Baotou Chaoju Ophthalmic Hospital(No.btcj-u-1).Written informed consent was obtained from each subject.Results Preoperative,1-week,1-,3-,6-,and 12-month postoperative UDVA(LogMAR)were 0.52(0.55,0.78),0.22(0.12,0.17),0.10(0.04,0.07),0.00(-0.04,-0.16),-0.08(-0.05,-0.03)and-0.08(-0.06,-0.04),respectively,showing a statistically significant overall difference(Z=249.44,P<0.001).UDVA at each postoperative time point was improved compared to preoperative,and UDVA at 3,6,and 12 months postoperatively was significantly improved compared to 1 week and 1 month postoperatively(all at P<0.001).The spherical diopter at each postoperative time point decreased significantly compared to preoperative,with the spherical diopter at 1,3,6,and 12 months postoperatively being lower than that at 1 week postoperatively,and the 12-month postoperative spherical diopter being lower than that at 3 and 6 months postoperatively,showing statistically significant differences(all at P<0.001).The cylindrical degree at 1,3,6,and 12 months postoperatively was lower than that at preoperative and 1 week postoperatively,with statistically significant differences(all at P<0.05).After the operation,the spherical equivalent of the operated eye gradually decreased with time,tending toward emmetropia.The spherical equivalent at each postoperative time point decreased compared to preoperative,with the spherical equivalent at 1,3,6,and 12 months postoperatively being lower than that at 1 week postoperatively,and the spherical equivalent at 12 months postoperatively being lower than that at 3 and 6 months postoperatively,showing statistically significant differences(all at P<0.001).The corneal K1 and K2 values at 3,6,and 12 months postoperatively were significantly lower than preoperatively(all at P<0.001),and the corneal K1 and K2 values at 3 months postoperatively tended to stabilize.The IOP of the operated eye at 3,6,and 12 months postoperatively was significantly lower than preoperatively,and the IOP at 6 and 12 months postoperatively was lower than that at 1 and 3 months postoperatively,with statistically significant differences(all at P<0.001).One eye developed grade 0.5 corneal haze at 1 week postoperatively,which spontaneously resolved to transparency at 1 month postoperatively.Conclusions Trans-PRK combined with accelerated CXL has good efficacy,stability and safety for refractive error patients with thin or irregular corneas,except for keratoconus.