深层巩膜切除联合激光小梁灼滤术治疗开角型青光眼

Treatment of open angle glaucoma with deep sclerectomy combined with laser trabecular puncture

目的 观察深层巩膜切除联合激光小梁灼滤术治疗开角型青光眼的临床疗效。方法对 32例 (32只眼 )中、晚期开角型青光眼患者施行深层巩膜切除术 ,暴露Schlemm管外壁及残存的小梁网菲薄角膜缘组织 ,采取半导体激光器眼内用导光纤维 ,紧靠巩膜突前方小梁网角膜缘区域 ,直视下激光热灼击开 2或 3个圆形滤孔 ,滤孔直径 5 0 0 μm ,房水缓缓溢出。巩膜瓣缝合 1或 2针。术后观察患者眼压、眼内反应、滤过泡形态、前房角镜及超声生物显微镜 (UBM)检查结果。随访时间 4～ 2 4个月 ,平均 (7 94± 6 2 0 )个月。结果 32只眼术后早期前房形成良好 ,视力稳定。最终随访患者平均眼压 (14 86± 4 15 )mmHg(1mmHg =0 133kPa) ,明显低于术前 (2 9 6 8± 5 76 )mmHg ,差异有非常显著意义 (t=7 4 15 ,P <0 0 0 1)。术后 32只眼均形成明显弥散性滤过泡 ;随访期间 ,2 7只眼有功能性滤过泡 ,5只眼于术后 2～ 3个月功能性滤过泡消失。 2只眼术中虹膜轻微灼伤 ,出现前房一过性色素脱失和房水混浊 ;角膜与晶状体无激光性损伤。 2只眼术后眼压偏高 ,局部应用抗青光眼药物后眼压控制正常。结论 深层巩膜切除联合激光小梁灼滤术能有效降低眼压 ,无穿透性小梁切除术常见的严重并发症 ,是治疗开角型青光眼的有效术式之一。

Objective To study the effect of deep sclerectomy combined with laser trabecular puncture for the treatment of open angle glaucoma (OAG). Methods Deep sclerectomy was performed in 32 eyes of 32 patients with moderate to advanced stages of OAG. After the exposure of external wall of Schlemm′s canal and the remaining trabecula, the intraocular optic fiber of diode laser photocoagulator was directed to the trabecula-limbus near the anterior edge of the scleral spur. Two or three punctures, approximately 0.5 mm in diameter, were performed with laser beam under direct visualization until aqueous humor was extravasated slowly. The scleral flap was closed with one or two sutures. Postoperative observation included intraocular pressure (IOP), intraocular tissue reaction, the appearance of filtering bleb, gonioscopy and ultrasound biomicroscopy. The follow-up period was 4 to 24 months (7.94±6.20) months. Results The anterior chamber was recovered shortly after the operation and the visual acuity remained the same in all eyes. At the end of follow-up period, the postoperative IOP (14.86±4.15) mm Hg was lower than the preoperative IOP (29.68±5.76) mm Hg, the difference was statistically significant ( t =7.415, P <0.001). Diffuse and obvious filtering blebs were found in all eyes after the operation, including 27 functional blebs and 5 blebs that disappeared 2 to 3 months later. Iris was burned slightly in 2 cases, pigment was released and appeared in the anterior chamber temporarily. No laser injury occurred in the cornea and the lens. High IOP was found in 2 cases after long-term follow-up and could be controlled by antiglaucoma medication. Conclusions Deep sclerectomy with laser trabecular puncture can effectively reduce the IOP, without the occurrence of serious complications that commonly seen after the trabeculectomy. It is an effective surgical method for the treatment of OAG.