1CU可调节性后房型人工晶体植入患者Nd:YAG激光切囊术后的调节研究

Purpose: After initial encouraging results with the accommodative 1CU posterio r chamber lens (PCIOL), we investigated the rate, the postoperative time point o f posterior capsular opacification (PCO) necessitating YAG capsulotomy and the a ccommodative range after Nd: YAG capsulotomy in patients with 1CU-PCIOL. Patien ts and methods: This prosective clinical study included 65 patients who underwen t phacoemulsification and implantation of the accommodative 1CU-PCIOL with post operative follow-up from 3 to 24 months. Postoperative examination was performe d 3, 6 and 12 months after surgery, then before and 6 weeks after Nd: YAG capsul otomy. Measurements included: the best corrected distance visual acuity, distanc e refraction, near visual acuity (Birkhauser charts in 35 cm) obtained with be st distance correction, accommodative range measured by subjective near point wi th an accodommometer and defocusing with a visual acuity fall to 0.4. Results: B oth best corrected distance visual acuity (1.1±0.1) and near visual acuity with best distance correction (0.4±0.1) remained stable over the follow-up period until 12 months postoperatively. The accommodative range determined by near poin t was stable (mean 2.0±0.5 D). Also, the defocusing range remained stable over 12 months (1.8±0.4 D). A clinically relevant posterior c apsule opacification with a significant decrease of visual acuity (0.4±0.2) and a need for Nd: YAG capsulotomy was diagnosed in 12 patients between 15 and 22 ( mean 20±4, median 20) months postoperatively. All capsulotomies were performed without complication. Six weeks after capsulotomy, best corrected distance visua l acuity was improved (1.1±0.1), near visual acuity with best distance correcti on was 0.4±0.1 and the accommodative range determined by near point was 1.95±0 .6 D and by defocusing was 1.88±0.47 D. Six weeks after capsulotomy, measuremen ts of the accommodative range did not show any statistical difference to the 12 -month results before the occurrence of PCO (P >0.5). Conclusions: A clinically relevant PCO with a significant decrease of visual acuity necessitating Nd: YAG capsulotomy occurred mainly after 15 postoperative months in patients with 1CU. Our results indicate that Nd: YAG capsulotomy may not affect the accommodation ability of the 1CU. Nevertheless, long-term studies are needed to further analy ze the accommodative properties.

圆锥角膜行非机械性全层角膜移植术后拆除连续缝线导致的角膜功能和屈光度的改变情况

Purpose: To assess the changes in corneal power and refraction due to sequential suture removal after penetrating keratoplasty (PK). DESIGN: Retrospective consecutive case series. METHODS: SETTING: Clinical practice. STUDY POPULATION: We studied 67 phakic keratoconus eyes (central excimer laser trephination, primary keratoplasty, graft/recipient diameter 8.1/8.0 mm; double running suture) in this longitudinal study. MAIN OUTCOME MEASURES: Zeiss keratometry (equivalent power (KEQ), astigmatism (KAST)), corneal topography (equi-valent power (TEQ), astigmatism (TAST)) and subjective refractometry (spherical equivalent (SEQ), refractive cylinder (RAST)) were assessed with sutures in place (interval 1), with one suture out (interval 2), and with all sutures out (interval 3). OBSERVATION PROCEDURE: Corneal power and refraction was decomposed into vector components and the changes were derived between time stages. RESULTS: The mean follow-up period was 3.9 ±1.7 years. At interval 1, the axes of KAST/TAST/RAST were almost randomly distributed. At interval 2, the with/against the rule component of KAST/TAST/RAST decreased slightly and the oblique component increased significantly, so that the axes tended to have a preferred oblique direction. At interval 3, the with/against the rule component of KAST/TAST/RAST increased slightly and the oblique component decreased significantly, so that the with/against the rule component exceeded the oblique component by approximately 23%/28%/25%. Median KEQ/ TEQ/SEQ changed by 0.64/0.62/-1.11 diopters (interval 1 to interval 2) and by -0.85/-0.90/1.56 diopters (interval 2 to interval 3). CONCLUSIONS: As a result of removal of the first running suture, corneal astigmatismas well as the refractive cylinder tend to oblique axes. As a result of removal of the second running suture, the final corneal astigmatism and refractive cylinder tend to orientation axes with/against the rule.

假性剥脱综合征的角膜病变(PEX角膜病)行穿透性角膜移植术后的疗效

Purpose: Keratopathy in pseudoexfoliation syndrome (PEX- keratopathy) is a particular form of corneal endothelial decompensation, which requires a penetrating keratoplasty (PK) for visual rehabilitation at advanced states. The aim of this study was to evaluate the functional outcome and the development of intraocular pressure (IOP) after PK in patients with PEX- keratopathy depending on the presence of pre- exist- ing glaucoma. Patients and Methods: This retrospective study included 21 eyes of 21 patients (age 78.6± 7.5 years) with a mean postoperative follow- up of 1.8 ± 2.2 (median 2) years. The diagnosis of PEX- kerat- opathy was confirmed clinically as well as by electron microscopy. The recipient and donor trephinations were performed from the epithelial side using an 193 nm excimer laser (n=11) or mechanically (n=10). An iridotomy was performed routinely during PK. The postoperative treatment with topical steroid was standardized. Results: Preoperatively, a secondary open- angle glaucoma (SOAG) with optic nerve damage was diagnosed in 11 patients (52% ). Topical antiglaucomatous treatment was needed in 81 % of patients with SOAG. Six weeks postoperatively, patients with SOAG showed a higher prevalence of increased intraocular pressure (IOP) and/or antiglaucomatous treatment compared to patients without SOAG (45% vs. 20% ). Most of the mild- early intraocular pressure elevations were controlled in both groups during the follow- up. From one year post- PK, there was an increased need for topical antiglaucomatous treatment in both patient groups. In all eyes the IOP was controlled by topical antiglaucomatous treatment. Preoperatively, visual acuity was comparable in patients with and without SOAG (0.06 ± 0.09 vs.0.08 ± 0.1, P=0.7), but increased significantly more in patients without SOAG (0.38 ± 0.1, median 0.4) than in patients with SOAG (0.2 ± 0.1, median 0.2; P=0.01) after PK. Visual acuity remained stable in both groups throughout the follow- up period. During followup only one eye developed an episode of reversible endothelial graft rejection 18 months postoperatively. An irreversible graft failure was seen in none of the patients. Conclusion: The functional outcome after PK in PEX- keratopathy seems to be strongly associated with pre- existing SOAG. Patients without SOAG may expect good visual rehabilitation without persistent postoperative IOP increases. However, patients should be followed- up for a prolonged period of time, because from 1 year following PK the need for topical antiglaucomatous treatment increased significantly.

重复性角膜移植术矫正透明角膜植片的高度或不规则角膜移植术后散光

PURPOSE: To evaluate the functional results of repeat penetrating keratoplasty in clear corneal grafts with high/irregular postkeratoplasty astigmatism. DESIGN: Retrospective, longitudinal, single-center, consecutive clinical case series. METHODS: We studied 17 eyes (16 keratoconus, 1 Fuchs’dystrophy) of 16 patients (age, 54.9±12.6 years). They were treated with repeat PK, performed using the 193-nm Zeiss-MeditecMEL-60 excimer laser using round metal masks (diameter, 7.5-8.0 mm), and employing double running sutures. MAIN OUTCOME MEASURES: Subjective refractometry, standard keratometry, and corneal topography (Tomey TMS-1) were used to assess best-corrected visual acuity (BCVA), spherical equivalent (SEQ), keratometric and topographic central corneal power (CP), refractive, keratometric and topographic astigmatism, surface regularity index (SRI), surface asymmetry index (SAI), and potential visual acuity (PVA) preoperatively, before and after first suture removal (1.1 year), and after second suture removal (1.8 years). RESULTS: Visual acuity improved significantly (BCVA from 0.2-0.5, P=.04 or better) for all postoperative measurements. CP decreased significantly, but SEQ did not change. All measures of astigmatism and SRI and SAI values showed postoperative improvement with sutures in place; however, astigmatism increased signifi-cantly after second suture removal. CONCLUSIONS: With all-sutures-in, BCVA and astigmatism improve significantly after repeat PK for high/irregular astigmatism. However, to present significant increase in astigmatism, final suture removal should be postponed as long as possible in such eyes.

眼球转动对环面人工晶体轴向定位分析的影响:对环面人工晶体旋转稳定性的最佳评价法

Background:After the implantation of toric intraocular lenses(tIOLs)significant postoperative tIOL rotation angles were measured occasionally.We investigated the rotational stability of eyes during standardized photography and recommend two methods for an enhanced evaluation of tIOL rotation.Patients and Methods:1.The cyclororation of the eye was investigated using standard fundus photography.A sequence of two fundus photographic slides was taken in 550 phakic eyes of 275 consecutive patients with a time interval of at least 6 months.With characteristic markers on the fundus photograph,the axial orientation of the eyes was defined and the cyclorotation between the two slides of each eye was measured.2.Using bifocal photography(HRA II-Heidelberg Retina Angiograph),a sequence of anterior segment and fundus images was taken considering stable head position in 19 pairs of photographs of eyes with implanted tIOLs.The angle between reference fundus axis and tIOL axis was measured at both time stages(mean:after 3 months).The difference of the angle between bifocal-image samples was defined as the real tIOL rotation angle.3.Ten pairs of anterior segment photographs of eyes with a tIOL were investigated using the Axenfeld loop analysis.In each photograph,the angle between the axis connecting two Axenfeld loops and the tIOL axiswasmeasured.The difference of two angles of two photographs was defined as the rotational tIOL angle.Results:1.The mean absolute eye’ s rotation angle was 2.3± 1.7(range:0 to 11.5)in all 550 eyes.Only 9.1% of the eyes did not rotate.In 57.3% of the eyes a rotation of less than 3° and in 33.6% of more than or equal to 3 was detected.The eye’ s cyclorotation correlated(p < 0.04)with an age older than 39 years and higher astigmatism(> 1.5 D).Because of the significant amount of spontaneous globe rotation we developed the following enhanced methods to minimize measurement errors of tIOL rotation:2.Bifocal photography:Comparing the 19 HRA anterior segment images,the amount of mean tIOL rotation was 5.4± 4.8°(range:0-20.0°).Using the bifocal photography,the mean tIOL rotation was 1.9± 1.3°(range:0-5.0°).The overestimated rotation of the tIOL(only anterior segment tIOL comparison)correlated with higher amounts of the eye’ s cyclorotation(r=0.94;p=0.01)and higher corneal astigmatism(r=0.54;p=0.05).3.The simultaneous analysis of Axenfeld loops revealed significantly smaller amounts of tIOL rotation(2.3± 2.5° range:0-7.0°)in 10 pairs of anterior segment photographs in contrast to the single analysis of tIOL axis(5.5± 4.8° range:1-13.0° p=0.09).A reduction of up to 18.0° tIOL rotation measurement failure was possible in single cases by applying the bifocal photography or simultaneous Axenfeld loop analysis.Conclusions:Head inclination,head rotation,and incyclo-or excyclorotation of the eye may have a significant impact on the tIOL axis evaluation.Besides the bifocal photography the simultaneous Axenfeld loop analysis could be a promising alternative to the conventional axis evaluation of tIOLs.