高危穿透性角膜移植术后白内障摘除手术的临床观察

Cataract extraction and intraocular lens implantation after high-risk penetrating keratoplasty

目的 探讨高危穿透性角膜移植术 (PKP)后白内障患者白内障摘除手术的疗效 ,并分析手术时机和手术切口的选择。方法 对 2 5例 (2 6只眼 )高危PKP术后白内障患者行超声乳化白内障吸除术和 (或 )人工晶状体植入术 ,术前进行相应的围手术期处理 ,根据角膜植床、植片和眼内情况确定手术时机 ,并选择手术切口。比较手术前、后术眼的视力、角膜曲率、角膜内皮细胞 (CEC)密度 ,观察术后并发症。术后随访时间 3～ 33个月。结果 术后 3个月裸眼视力≥ 0 5者 2 7% (7/ 2 6 ) ,最佳矫正视力≥ 0 5者 4 6 % (12 / 2 6 ) ,屈光度数在± 2 0 0D之内者 5 4 % (14 / 2 6 ) ;平均角膜散光度数术前为 (5 70± 3 90 )D ,术后 3个月为 (4 70± 3 0 0 )D ,差异无显著意义 (t=1 4 71,P =0 15 4 ) ;平均CEC密度术前为 (1883± 6 2 5 )个 /mm2 ,术后 3个月为 (176 0± 6 2 9)个 /mm2 ,差异无显著意义(t=1 934,P =0 0 6 5 ) ,平均CEC损失率为 6 5 % ;术中无出现并发症者 ,术后 7个月 1只眼 (4% )出现慢性免疫排斥反应 ,2 5只眼 (96 % )角膜植片保持透明。结论 对于高危PKP术后白内障患者 ,只要根据角膜移植术式、植床及瞳孔等情况 ,注意围手术期治疗 ,选择适当的手术时机和切口 ,注意术中操作 。

Objective To study the indication and incision of phacoemulsification and intraocular lens (IOL) implantation after high-risk penetrating keratoplasty (PKP) and to evaluate the clinical results. Methods Twenty-six eyes of 25 patients who underwent high-risk PKP were treated with phacoemulsification and IOL implantation. The high-risk reasons included chemical burn of cornea, severe infective corneal perforation, total keratoplasty, diameter of the corneal graft larger than 8.5 mm, secondary keratoplasty and PKP combined with cataract extraction and anterior segment vitrectomy. Systemic and local steroid administration was given and surgical indication and incision were chosen according to the condition of the eyes. The mean interval time between PKP and IOL implantation was 11 months. Visual acuity, refractive status, central corneal endothelial cell density before and after IOL implantation (3 months) and allograft rejection were recorded. The mean follow-up after IOL placement was 17 months. Results Uncorrected visual acuity was 50/100 or better in 7 (27%) eyes and corrected visual acuity was 50/100 or better in 12 (46%) eyes. Fourteen (54%) eyes had refractive errors within 2 diopters. The mean refractive cylinders before and after IOL implantation were 5.70 D and 4.70 D, respectively (paired t test, t =1.471, P =0.154). The endothelial cell density before and after IOL implantation was 1 883 cells/mm 2 and 1 760 cells/mm 2, respectively ( t =1.934, P =0.065) and the rate of endothelial cell loss was 6.5%. Only one graft rejection (4%) occurred 7 months after IOL implantation (anterior chamber IOL). Conclusion It is safe and effective to perform phacoemulsification and IOL implantation after high-risk PKP when paying attention to the perioperative treatment and selecting the surgical indication and the position of the incision.