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Ahmed青光眼阀治疗新生血管性青光眼术后浅前房的预防

时间:2017-07-22 20:00:12 来源: 代写硕士论文

                  作者:方爱武 瞿佳 孙传宾 侯立杰 

【摘要】  目的 探讨Ahmed青光眼阀(AGV)置入术治疗新生血管性青光眼(NVG)术后浅前房的预防方法。 方法 对观察组31例(31眼)NVG行AGV前房置入术,术中预制旁刺口、前房注射粘弹剂及可吸收缝线结扎引流管,观察术后浅前房等并发症的发生率及手术效果,并与12例(12眼)按常规方法行AGV前房置入术者(对照组)进行比较。 结果 术后Ⅱ级以上浅前房的发生率:观察组为4/31,对照组为6/12,两组差异有统计学意义(P<0.05);观察组平均随访时间(12.29±11.18)个月,最后随访眼压平均为(23.45±12.04)mmHg,不用降眼压药,6mmHg≤最后随访眼压≤21mmHg 17例,完全成功率为54.84%,予局部应用降眼压药,眼压≤21mmHg 6例,相对成功率为19.35%,总成功率为74.19%;对照组:平均随访时间(11.08±8.08)个月,最后随访眼压平均为(27.81±12.04)mmHg,不用降眼压药,最后随访眼压≤21mmHg 6例,占50.00%,予局部应用降眼压药,眼压≤21mmHg 2例,相对成功率为12.67%,总成功率为66.67%。 结论 Ahmed青光眼阀前房置入术术中预制旁刺口、应用透明质酸钠及可吸收缝线结扎引流管等综合措施可预防NVG术后浅前房的发生及由浅前房引起的一系列并发症。

【关键词】  青光眼 Ahmed青光眼阀

  【Abstract】  Objective  To investigate effective ways for precaution of shallow of anterior chamber after implantation of ahmed glaucoma valve(AGV) to treat neovascular glaucoma . Methods  In treating group ,31 eyes of 31 patients with NVG were treated with AGV implant placement in anterior chamber with intraoperative paracentesis, partial ligation of a silicone tube of AGV and injection visco-elastic material were performed on 31 eyes of 31 patients. And a conventional AGV implant placement were performed in 12 eyes of 12 patients as control group . The main outcome measure was the rate of early postoperative shallow anterior chamber and the postoperative intraocular pressure (IOP). And the outcome was compared between the two groups. Success was defined as an intraocular pressure of 21 mm Hg or less. Results  Early postoperative grade 2 shallow anterior chamber occurred in 4 patients (4eyes)in the ligation group and in 6 patients (6 eyes) in control group(t=4.75,P<0.05). For the ligation group, The follow-up periods were over 3 months. The intraocular pressure was reduced to 23.45 +/- 13.27 mm Hg at the most recent follow-up after surgery with a mean follow-up of 12.29 +/- 11.18 months (range,3 to 48 months). there were 17eyes (54.84%) that were classified as complete successes, 6 eyes (19.35%) that were qualified successes, For the control group, at last follow-up (more than 3 months)intraocular pressure was reduced to 27.81 +/-12.04mmHg,there were 6 eyes (50.00%) classified as complete successes, 2 eye (16.67%) that were qualified successes normal. Conclusions  The technique including intraoperative paracentesis , partial ligation of silicone tube of AGV and injection visco-elastic material with neovascular glaucoma undergoing AGV implantation may prevent early postoperative shallow anterior chamber and other complications induced from shallow anterior chamber .

  【Key word】  glaucoma  ahmed glaucoma valve(AGV)   

  低眼压、浅前房是前房引流物置入术后早期最常见的并发症[1],采用限制性前房引流物可减少上述并发症的频率和严重性,但不能完全避免它的发生[2,3]。而在治疗新生血管性青光眼(NVG)时,术后浅前房的发生率更高,为减少限制性前房引流物术后浅前房的发生及由浅前房引起的一系列并发症,作者在应用属于限制性前房引流物之一的Ahmed青光眼阀(AGV)治疗NVG时,采取术中预制旁刺口、应用粘弹剂及可吸收缝线(8-0Vicryl)结扎引流管等综合方法,观察其效果,现报告如下。

  1  资料与方法

  1.1  一般资料     

  2000年5月至2005年6月收住本院的42例(43眼)NVG患者,NVG的诊断标准为眼压高且虹膜面有新生血管;引起NVG的病因有糖尿病22例(23眼),视网膜中央静脉阻塞12例(12眼),Coats病4例(4眼),视网膜静脉周围炎3例(3眼),眼外伤1例(1眼);所有患者均接受最大限度的降眼压药物治疗, 其中4 眼曾行玻璃体手术,为硅油眼。分观察组和对照组,其中1例患者,1眼归入对照组,另1眼归入观察组。观察组31例31眼,其中男18例,女13例;右16眼,左15眼;年龄 11~84岁。术前眼压38.3~60.0mmHg。术前矫正视力:10眼NLP,7眼LP,7眼HM, 2眼CF,1眼0.05,2眼0.1,1眼0.25,1眼0.6;术后随访3~48个月。对照组12例(12眼):男6例,女6例;右7眼,左5眼;年龄 32~75岁。术前眼压40.7~69.0mmHg。术前矫正视力:8眼NLP,1眼LP,1眼HM,1眼CF, 1眼0.1;术后随访3~36个月。

  1.2  AGV特点     

  AGV是一种限制性前房引流物。该引流盘设计有两层弹性硅酮薄膜,在前部内此膜被围封成一单向压力敏感活瓣作用,通过文丘里(Venturi)效应,当压力达到8~12mmHg时,两层硅酮膜分开,允许房水通过阀门[2,4],而该阀门关闭压为5~6mmHg[4]。

  1.3  手术方法 

  观察组:(1)在颞上或颞下象限,做以穹隆部为基底的结膜瓣,距角膜缘8mm以后球结膜下放置0.4mg/ml的丝裂霉素C(MMC)5min。(2)AGV冲洗通畅后,用8-0Vicryl可吸收缝线做管外环绕松懈缝线结扎。(3)用5-0尼龙线将引流盘的前缘固定于距角膜缘8~10mm,相邻两条直肌之间的赤道部巩膜上。(4)3点或5点方位的透明角膜上做一前房穿刺口,必要时放液降眼压或前房注射透明质酸钠维持眼压和前房深度。(5)顺着引流管的方向,用国产7号针头平行虹膜面,在相应的角膜缘前界穿刺入前房,将引流管断端修剪成斜面向上45°,沿穿刺道置入前房内2~3mm。(6)用6mm×4mm以上的异体巩膜覆盖引流管的角膜缘部,并用10-0的尼龙线间断缝合;8-0Vicryl缝线原位缝合结膜瓣。(7)必要时前房注射透明质酸钠维持眼压和前房深度。对照组:按常规方法行AGV前房置入术,术中未预制旁刺口、应用粘弹剂及采取可松懈缝线结扎引流管等综合方法预防浅前房。

  1.4  术后处理和随访 

  (1)术后常规抗炎等治疗。(2)术后6h左右测眼压一次,如眼压高,应用降眼压药,必要时于原角膜旁刺口处放液。术后1~7d,每天裂隙灯显微镜、检眼镜检查及测眼压。术后出现低眼压、浅前房者予1%阿托品散瞳,静滴地塞米松等。(3)术后2周后,眼压高>21mmHg,可限期拆除可松懈缝线。

  1.5  手术成功标准 

  成功:(1)完全成功:不用降眼压药,6mmHg≤最后随访眼压≤21mmHg;(2)相对成功:局部用降眼压药,6mmHg≤最后随访眼压≤21mmHg[13]。

  1.6  统计学处理 

  采用SPSS 11.0软件对结果进行分析。

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