小梁切除术中以角膜缘为基底和以穹窿为基底结膜瓣的比较

小梁切除术自1968年由Caims等引入后已广泛应用于青光眼的治疗.该手术的目的在于降低眼压,保护视功能.为了提高小梁切除术的手术成功率,降低术后并发症,其手术方式不断改进.目前小梁切除术的结膜瓣有两种类型,以角膜缘为基底的结膜瓣和以穹窿为基底的结膜瓣.两种结膜瓣各有其特点和优势,但在降眼压效果上两种结膜瓣是否同样有效,相关并发症是否存在差别,选择哪种结膜瓣更安全,到目前为止尚无定论.本文就小梁切除术两种结膜瓣的术中优势、术后效果及并发症情况作一综述.     

Two-site phacotrabeculectomy with intraoperative mitomycin-C: fornix- versus limbus-based conjunctival opening in fellow eyes

To prospectively compare the influence of fornix-based and limbus-based conjunctival flaps on the final outcome and complications of 2-site phacotrabeculectomy with mitomycin-C in fellow eyes of patients with bilateral open-angle glaucoma (OAG).Glaucoma Unit, Department of Ophthalmology, University of Crete, Crete, Greece.Twenty-two patients with bilateral primary OAG and 8 patients with bilateral exfoliative glaucoma had 2-site phacotrabeculectomy in both eyes. Eyes were randomly assigned to the fornix-based flap or limbus-based flap group by the use of random tables.The intraocular pressure (IOP) decreased significantly in both groups (P <.01); however, there was no statistically significant difference between the groups in the amount of IOP decrease or the number of postoperative antiglaucoma medications after a 1-year follow-up. Faster improvement in visual acuity was observed in the fornix-based group during the first week. The mean time of surgery was 3.5 minutes less in the fornix-based group. An increased incidence of fibrin exudation, pupillary membrane formation, and capsule opacification was found in eyes with exfoliative glaucoma. The early bleb leakage was 3 times more frequent in the fornix-based group.The type of conjunctival flap in a 2-site phacotrabeculectomy did not seem to influence the final outcome. The main advantage of the fornix-based conjunctival flap is the shorter surgical time and the relatively faster improvement in vision postoperatively. The main disadvantage is more frequent early bleb leakage.     

Limbal- vs fornix-based conjunctival trabeculectomy flaps

We studied 20 patients with uncontrolled symmetric glaucoma who had undergone bilateral trabeculectomy after having received the same medical or laser treatment to both eyes. In each patient, the techniques and suture material used in the two eyes were identical, and the surgeon was the same. The only variable was the type of conjunctival flap used: one eye received a limbal-based flap and the other a fornix-based flap. These patients were followed up from three to 13 months (median, 8.5 months). There was no difference between the two groups in postoperative anterior chamber depth, intraocular pressure control, occurrence of hyphema, size and shape of the bleb, or the rate of complications. The fornix- and limbal-based conjunctival flaps in trabeculectomy were found to yield comparable results in terms of safety and short-term efficacy of pressure control.     

Limbus-based versus fornix-based conjunctival flap in glaucoma filtering surgery.

Eighteen consecutive patients suffering from the same type of glaucoma in both eyes were treated with bilateral trabeculectomy. Surgery with both fornix-based and limbus-based flap was performed on each patient, one procedure in each eye. Pre- and postoperative intraocular pressure, morphology of the fistulation bleb, anterior chamber depth and need for additional treatment were recorded. Half a year after surgery, the fornix-based flap procedure was superior (p < 0.05) concerning high success rate, little additional therapy and good morphology of the bleb.     

Limbal-based vs fornix-based conjunctival flaps in combined extracapsular cataract surgery and glaucoma filtering procedure

Extracapsular cataract extractions and posterior chamber intraocular lens implantations combined with glaucoma filtering procedures were done in 47 eyes of 43 consecutive patients who had coexisting cataract and glaucoma. A limbal-based conjunctival flap was used in 22 patients and a fornix-based flap was used in 25 patients; the surgical technique was otherwise identical in all patients. Patients were followed up for a minimum of six months (mean, 18 months). Long-term intraocular pressure control and visual acuity were similar in the two groups, although the limbal-based group had significantly better early postoperative intraocular pressure control. Because control of intraocular pressure during the early postoperative period is a principal benefit of combined cataract and glaucoma surgery, we prefer the limbal-based conjunctival flap.     

Penetrating keratoplasty in eyes treated with conjunctival flaps

PURPOSE: To analyze the results of corneal transplants in severely inflamed eyes previously treated with conjunctival flaps. METHODS: In the period 1984-1996, seven homoplastic penetrating keratoplasties (PKs) and one rotating autokeratoplasty were performed on a series of 47 eyes of 46 patients treated with partial or total conjunctival flaps. Two of these PKs were combined with an extracapsular cataract extraction, and the rotating autograft was combined with an extracapsular cataract extraction and intraocular lens implantation. Patient ages ranged between 25 and 52 years (three men and five women), and the follow-up period was 3 to 15 years. The recipient corneal buttons were studied histopathologically. RESULTS: The eight graftings remained transparent; two cases developed glaucoma that was controlled with medication, and one had a rejection episode, which disappeared with medical treatment. All patients reached a postoperative vision between 20/70 and 20/30. CONCLUSION: Therapeutic conjunctival flaps improve the conditions of the recipient bed for transplant in severely inflamed eyes.     

Cystic bleb formation and related complications in limbus- versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin C

OBJECTIVE: Comparison of fornix- and limbus-based conjunctival flaps with respect to cystic bleb-related complications of trabeculectomy with high-dose mitomycin C (MMC) in pediatric and young adult glaucoma. DESIGN: Retrospective nonrandomized comparative interventional case series. PARTICIPANTS: Thirty-seven patients. METHODS: Identification of patients aged <30 years from operating theater records from 1995 and 1996 of the Moorfields Pediatric Glaucoma Service who had trabeculectomy with an MMC concentration of >/=0.4 mg/ml. Over a 2-year period, 37 consecutive operations matching these criteria were performed by a single surgeon: 20 with a limbus-based flap and 17 with a fornix-based flap. Except for the conjunctival incision and associated alteration in antimetabolite application and wound closure, the surgical technique was not significantly different between the groups. MAIN OUTCOME MEASURES: Bleb evolution and complications. RESULTS: The age at time of surgery, MMC concentration, history of one or more previous surgeries, and follow-up were similar in the 2 groups. The risk of cystic bleb formation was greater in the limbus-based flap group (90% in the limbus-based group vs. 29% in the fornix-based group; P<0.001). Late hypotony and bleb-related ocular infection were more common in the limbus-based flap group (P<0.05) and occurred earlier. There were four episodes of bleb-related infection (20%) in the limbus-based group (three of these [15%] were bleb-related endophthalmitis) and none in the fornix-based group. CONCLUSIONS: In pediatric and young adult trabeculectomy with high doses of MMC, limbus-based flaps may be more likely to develop serious bleb-related complications and may develop these earlier than fornix-based flaps. The higher rates of complications could be attributable to the differences in bleb morphology, with limbus-based flap cases more likely to develop cystic blebs.     

Fornix- vs. limbus-based flaps in combined phacoemulsification and trabeculectomy

We studied prospectively the results of limbus-versus fornix-based flaps in patients undergoing combined trabeculectomy and phacoemulsification. We found no significant difference at six months postoperatively in the level of intraocular pressure between the limbus-(16.1 ± 4.1 mm Hg) and fornix- (14.0 ± 3.4 mm Hg, p = 0.161) based groups, or in the number of glaucoma medications (p = 0.0750). The highest intraocular pressure recorded within the first postoperative month was similar between groups (18.4 ± 6.9 mm Hg for limbus and 18.5 ± 5.5 mm Hg for fornix, p > 0.900). Postoperative bleb height, extent, and vascularity, as well as chamber depth were statistically similar between groups (p > 0.05). Postoperative complications were similar between groups. This study indicates that both fornix- and limbus-based flaps may be used safely and effectively when performing a trabeculectomy combined with phacoemulsification.     

Improved suture for fornix-based conjunctival flap in filtering surgery

Major problems in the early postoperative phase in filtering surgery are hypotony, flattening of the anterior chamber and choroidal detachment. We describe a new suture technique for the closure of the conjunctiva in goniotrephination with a fornix-based conjunctival flap which is helpful in reducing these complications. After dissecting the conjunctiva from the limbus, a shallow groove is cut directly behind the former conjunctival insertion. At the end of the operation the conjunctiva is sutured into this groove using a running 10.0 nylon suture in a meander-like fashion. A very tight wound closure results. We used this technique in 104 consecutive goniotrephinations. We found a low incidence of only mild external fistulation, hypotony, flattening of the anterior chamber and choroidal detachment. Astigmatism induced by the operation was-1.2+±1.2D, usually with the rule.     

Limbus-based flap versus fornix-based flap in goniotrepanation

In a prospective, randomized study 61 eyes in which goniotrepanation had been performed using fornix-based or limbus-based conjunctival flaps were followed up for 4 to 18 months. No differences were found in the results of filtration, nor in the form and frequency of filtering blebs or the frequency of complications. In view of the easier technique and better visualization, the present authors prefer the fornix-based flap.     

Comparative results of limbal based versus fornix based conjunctival flaps for trabeculectomy.

Among 100 cases of primary glaucomas, 50 cases were operated for trabeculectomy by making fornix based flap and 50 cases were operated by fashioning limbal based conjunctival flap. Operative and post operative complications were studied thoroughly in the two groups. All the cases were followed up for six months to one year to assess control of intra ocular pressure, nature and functioning of filtering bleb, field changes and visual status in the two groups. It was found that the fornix based flap is much superior and carries various advantages over the limbal based flap. The operative and post operative complications are minimum in the fornix based flap as compared to the limbal based flap.     

单眼多焦点人工晶状体植入术眼与对侧透明晶状体眼的视功能对照研究

目的 评价不同年龄的单眼白内障患者植入ReSTOR多焦点人工晶状体(MIOL)后的视功能状况及患者的主观满意度.方法 前瞻性对照研究.研究对象为行超声乳化白内障吸除联合ReSTOR MIOL植入的单眼白内障患者24例,按年龄分为2组:老视组,年龄≥45岁,17例;非老视组,年龄＜45岁,7例.研究参数:裸眼及远矫正状态下的远(4 m)、中(80cm,60 cm)、近视力,对比敏感度和问卷调查.统计学方法采用秩和检验.结果 老视组患者ReSTOR MIOL植入眼近视力优于对侧透明晶状体眼(Z=2.864,Z=2.911;=0.004),远视力、中距离视力及对比敏感度与对侧透明晶状体眼相比较,差异无统计学意义(Z=0.183～1.417,P=0.855～0.156);主观满意度为7～10分,70.6%(12/17)的患者满意度9分以上,双眼脱镜率58.8%(10/17).非老视组患者ReSTOR MIOL植入眼近视力及中距离视力均低于对侧透明晶状体眼(Z=2.197～2.371;=0.028～0.018),MIOL植入眼的对比敏感度普遍低于对侧眼,其中夜晚眩光(3 cd/m2+28 Lux)低频(1.5 c/d)对比敏感度,差异有统计学意义(Z=1.997,P=0.046);主观满意度为6～9分,14.3%(1/7)的患者满意度9分以上,双眼脱镜率85.7%(6/7).结论 伴有老视的单眼白内障患者,MIOL植入眼近视力优于对侧透明晶状体眼,远、中距离视力及对比敏感度差异不明显,主观满意度较高,因此较适合植入ReSTORMIOL;不伴有老视的年轻的单眼白内障患者,MIOL植入眼近、中距离视力均低于对侧透明晶状体眼,远视力差异不明显,主观满意度偏低(与老视患者相比较),因此可以植入ReSTOR MIOL,但是术前需要与患者进行更加详细的沟通.     

复发性角膜缘型结膜鳞状上皮乳头状瘤1例及文献回顾

结膜乳头状瘤是结膜上皮组织呈乳头状增生的良性肿瘤,根据发病部位可分为结膜型和角膜缘型。结膜型多见,好发于儿童或青少年;角膜缘型少见,好发于中老年人,过度增生有演变成鳞状上皮细胞癌的可能。结膜乳头状瘤发病原因与人乳头状瘤病毒(HPV)感染有关,而HPV在结膜鳞状上皮细胞癌的发生过程中也起着重要作用。因此对结膜乳头状瘤患者进行常规HPV检测对于治疗和随访是非常重要的。手术切除是结膜乳头状瘤基本的治疗方法,但单纯手术切除复发率高,目前采用多种方法防治复发,包括冷冻及电灼、细胞毒药物及干扰素的应用。我们报道了成功应用多种方法综合治疗1例复发性角膜缘型鳞状上皮乳头状瘤的病例。     

Phacotrabeculectomy versus two-stage operation: a matched study

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and safety of phacoemulsification and foldable intraocular lens, combined with trabeculectomy (phacotrabeculectomy) in patients with coexisting cataract and glaucoma. PATIENTS AND METHODS: A total of 53 consecutive eyes which underwent phacotrabeculectomy and posterior chamber intraocular lens (PCIOL) were matched and compared with 53 eyes that had trabeculectomy followed by phacoemulsification and posterior chamber intraocular lens (mean interval 3.2 month). The 2 groups were first matched by diagnostic group and subsequently for the closest possible match with other successive variables, including age, gender, race and preoperative glaucoma medications. Mean intraocular pressure (IOP) reduction, visual acuity, antiglaucoma medications, and surgical success as well as complications were compared in both groups. RESULTS: Mean IOP reduction was 14.5+/-4.1 mmHg in the two-stage group compared to 15.1+/-3.9 in the phacotrabeculectomy group at 6 months follow-up (P<0.1) and 13.8+/-3.9 and 14.6+/-3.7 respectively at 1 year (P<0.1).Visual acuity and complications were comparable. CONCLUSION: Phacotrabeculectomy provides IOP control statistically comparable to two-stage surgery with earlier visual rehabilitation.