目的:探讨超声乳化白内障吸除联合房角分离术(Phaco-GSL)治疗闭角型青光眼(ACG)合并白内障疗效及对房角宽度的影响。方法:将我院眼科收治的90例ACG合并白内障患者随机分为Phaco-GSL组和Phaco组,各45例,Phaco组接受Phaco + 人工晶状体植入(IOL)术,Phaco-GSL组接受Phaco + IOL + GSL,比较两组手术前后眼压、降眼压药种类、房角宽度、最佳矫正视力及并发症。结果:两组术后1 d和术后1、3个月眼压均低于术前(P < 0.05),术后1个月眼压低于术后1 d (P < 0.05);Phaco-GSL组术后1 d眼压低于Phaco组(P < 0.05),两组术前及术后1、3个月眼压比较,无显著差异(P > 0.05);两组术前、术后降眼压药种类无显著差异(P > 0.05);Phaco-GSL组手术前后眼压差值及降眼压药种类差值均高于Phaco组(P < 0.05);两组术后1个月房角均较术前明显增宽(P < 0.05),Phaco-GSL组房角开放情况优于Phaco组(P < 0.05);两组术后3个月最佳矫正视力均明显提高(P < 0.05),两组术前、术后3个月最佳矫正视力比较,无显著差异(P > 0.05);Phaco-GSL组术后出现角膜水肿11例(24.44%),前房微出血2例(4.44%);Phaco组术后出现角膜水肿10例(22.22%);两组均未出现视网膜脱落、后囊破裂等并发症。结论:Phaco-GSL治疗ACG合并白内障疗效确切,能有效降低眼压、开放房角,并改善患者是功能。 Objective: To explore the efficacy of phacoemulsification combined with goniosynechialysis (Pha-co-GSL) on angle-closure glaucoma (ACG) with cataract and its effects on angle of anterior chamber. Methods: 90 patients with ACG and cataract admitted to ophthalmology department of our hospital were randomly divided into Phaco-GSL group and Phaco group, with 45 cases in each group. Phaco group was given Phaco + intraocular lens implantation (IOL), and Phaco-GSL group was given Phaco + IOL + GSL. The intraocular pressure, types of ocular hypotensive agents, angle of anterior chamber, best corrected visual acuity and complications were compared between the two groups before and after surgery. Results: The intraocular pressure in the two groups at 1 d, a month and 3 months after surgery was lower than that before surgery (P < 0.05), and the intraocular pressure at 1 month after surgery was lower than that at 1 d after surgery (P < 0.05). The intraocular pressure in Phaco-GSL group at 1 d after surgery was lower than that in Phaco group (P < 0.05), and there was no significant difference in intraocular pressure between the two groups before surgery and at 1 month and 3 months after surgery (P > 0.05). There were no significant differences in the types of ocular hypotensive agents before and after surgery (P > 0.05). The intraocular pressure difference and difference of types of ocular hypotensive agents before and after surgery in Phaco-GSL group were higher than those in Phaco group (P < 0.05). The angle of anterior chamber in the two groups was significantly wider than that before surgery (P < 0.05), and the angle opening in Phaco-GSL group was better than that in Phaco group (P < 0.05). The visual acuity in the two groups was significantly improved at 3 months after surgery (P < 0.05), and there was no significant difference in the best corrected visual acuity between the two groups before surgery and at 3 months after surgery (P > 0.05). There were 11 cases (24.44%) of corneal edema and 2 cases (4.44%) of anterior chamber microbleeds in Phaco-GSL group. There were 10 cases (22.22%) of corneal edema after surgery in Phaco group. There were no complications such as retinal detachment and posterior capsule rupture in the two groups. Conclusions: Phaco-GSL has exact efficacy in the treatment of ACG with cataract, and it can effectively reduce intraocular pressure, open angle, and improve the function of patients.
李珂
濮阳市安阳地区医院,河南 濮阳
收稿日期:2019年10月23日;录用日期:2019年11月8日;发布日期:2019年11月15日
目的:探讨超声乳化白内障吸除联合房角分离术(Phaco-GSL)治疗闭角型青光眼(ACG)合并白内障疗效及对房角宽度的影响。方法:将我院眼科收治的90例ACG合并白内障患者随机分为Phaco-GSL组和Phaco组,各45例,Phaco组接受Phaco + 人工晶状体植入(IOL)术,Phaco-GSL组接受Phaco + IOL + GSL,比较两组手术前后眼压、降眼压药种类、房角宽度、最佳矫正视力及并发症。结果:两组术后1 d和术后1、3个月眼压均低于术前(P < 0.05),术后1个月眼压低于术后1 d (P < 0.05);Phaco-GSL组术后1 d眼压低于Phaco组(P < 0.05),两组术前及术后1、3个月眼压比较,无显著差异(P > 0.05);两组术前、术后降眼压药种类无显著差异(P > 0.05);Phaco-GSL组手术前后眼压差值及降眼压药种类差值均高于Phaco组(P < 0.05);两组术后1个月房角均较术前明显增宽(P < 0.05),Phaco-GSL组房角开放情况优于Phaco组(P < 0.05);两组术后3个月最佳矫正视力均明显提高(P < 0.05),两组术前、术后3个月最佳矫正视力比较,无显著差异(P > 0.05);Phaco-GSL组术后出现角膜水肿11例(24.44%),前房微出血2例(4.44%);Phaco组术后出现角膜水肿10例(22.22%);两组均未出现视网膜脱落、后囊破裂等并发症。结论:Phaco-GSL治疗ACG合并白内障疗效确切,能有效降低眼压、开放房角,并改善患者是功能。
关键词 :超声乳化白内障吸除术,房角分离术,闭角型青光眼,白内障
Copyright © 2019 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
青光眼、白内障是目前全球范围内排名最前的两种致盲性眼病,西方国家的青光眼患者以开角型青光眼为主,我国90%的原发性青光眼患者为闭角型青光眼(angle-closure glaucoma, ACG),且好发于中老年人 [
选取2016年5月~2018年5月我院眼科收治的90例ACG合并白内障患者为研究对象,纳入标准:① 符合ACG、白内障的诊断标准 [
Phaco组接受Phaco+人工晶状体植入(IOL)术,Phaco-GSL组接受Phaco + IOL + GSL,具体如下:
两组患者术前均完善相关检查,给予降眼压药控制眼压(控制在21 mmHg以下),盐酸左洋佛沙星滴眼液滴眼,术前1 d停止使用缩瞳剂,术前半小时用美多丽散瞳。用0.4%奥布卡因行表面麻醉,于11点位角膜缘内透明角膜处作3.2 mm宽角膜隧道切口,2点钟角膜缘作1 mm透明角膜侧切口,前房内注入粘弹剂,用撕囊镊进行连续环形撕囊,直径5~5.5 mm,然后水分离将囊、皮质粘连完全分层,超声乳化吸出,清除皮质,行抛光,然后再次注入粘弹剂,囊袋内植入IOL。Phaco组植入IOL后彻底抽吸前房、IOL后面及囊袋内的粘弹剂,机化膜及色素等残留物质,检查切口闭合情况良好后结束手术。Phaco-GSL组则接着进行GSL,在12点位房角粘连处注入透明质酸钠,进行钝性分离,用人工晶状体定位钩后压虹膜根部,彻底抽吸出前房好囊袋内的透明质酸钠、积血块、机化膜、色素等残留物质,然后对透明角膜切口进行水化处理,检查切口闭合无漏水,结束手术。
分别于术前、术后1d和术后1、3个月用眼压计测量两组患者患眼眼压,并记录手术前后所用降眼压药种类,计算手术前后眼压差值及降眼压药种类差值;术前和术后1个月行前房角镜检查测量房角宽度,测量术前和术后3个月的最佳矫正视力,并观察术后并发症情况。
所有采用SPSS19.0软件进行统计学分析,计量数据以均数±标准差( x ¯ ± s )表示,组间比较采用成组t检验,多时间点比较采用重复测量方差分析,若有差异,采用LSD-t检验进行组内两两比较;计数数据以[n(%)]表示,组间比较行χ2检验,等级资料采用秩和检验,P < 0.05表示差异有统计学意义。
两组术后1 d和术后1、3个月眼压均低于术前(P < 0.05),术后1个月眼压低于术后1 d (P < 0.05);Phaco-GSL组术后1 d眼压低于Phaco组(P < 0.05),两组术前及术后1、3个月眼压比较,无显著差异(P > 0.05)。见表1。
组别 | n | 术前 | 术后1 d | 术后1个月 | 术后3个月 | 统计值 | P值 |
---|---|---|---|---|---|---|---|
Phaco-GSL组 | 45 | 25.81 ± 3.25 | 19.33 ± 2.38① | 16.32 ± 1.97①② | 16.24 ± 1.95①② | F组间 = 164.485 | 0.000 |
Phaco组 | 45 | 24.94 ± 3.17 | 20.58 ± 2.47① | 16.75 ± 2.01①② | 16.68 ± 2.03①② | F时间 = 133.627 | 0.000 |
t值 | 1.285 | 2.445 | 1.025 | 1.049 | F组间*时间 = 21.501 | 0.000 | |
P值 | 0.202 | 0.017 | 0.308 | 0.297 |
表1. 两组不同时间眼压比较( x ¯ ± s , mmHg)
注:与术前比较,①P < 0.05;与术后1 d比较,②P < 0.05;与术后1个月比较,③P < 0.05。
两组术前、术后降眼压药种类无显著差异(P > 0.05)。见表2。
组别 | n | 术前 | 术后 | t值 | P值 |
---|---|---|---|---|---|
Phaco-GSL组 | 45 | 2.29 ± 0.78 | 0.69 ± 0.21 | 21.683 | 0.000 |
Phaco组 | 45 | 2.13 ± 0.65 | 0.73 ± 0.24 | 21.104 | 0.000 |
t值 | 1.057 | 0.841 | |||
P值 | 0.293 | 0.402 |
表2. 两组术前和术后降眼压药种类比较( x ¯ ± s )
Phaco-GSL组手术前后眼压差值及降眼压药种类差值均高于Phaco组(P < 0.05)。见表3。
组别 | n | 眼压差值(mmHg) | 降眼压药种类差值 |
---|---|---|---|
Phaco-GSL组 | 45 | 9.57 ± 1.03 | 1.60 ± 0.47 |
Phaco组 | 45 | 8.26 ± 0.89 | 1.40 ± 0.43 |
t值 | 6.456 | 2.106 | |
P值 | 0.000 | 0.038 |
表3. 两组手术前后眼压差值及降眼压药种类差值比较
两组术后1个月房角均较术前明显增宽(P < 0.05),Phaco-GSL组房角开放情况优于Phaco组(P < 0.05)。见表4。
组别 | n | 术前 | 术后1个月 | Z值 | P值 | ||||
---|---|---|---|---|---|---|---|---|---|
房角完全开放 | 房角关闭<180˚ | 房角关闭≥180˚ | 房角完全开放 | 房角关闭<180˚ | 房角关闭≥180˚ | ||||
Phaco-GSL组 | 45 | 0 | 6 | 39 | 23 | 14 | 17 | 6.785 | 0.000 |
Phaco组 | 45 | 0 | 10 | 35 | 0 | 28 | 17 | 3.815 | 0.000 |
Z值 | 1.091 | 4.559 | |||||||
P值 | 0.275 | 0.000 |
表4. 两组术后前后房角宽度比较
两组术后3个月最佳矫正视力均明显提高(P < 0.05),两组术前、术后3个月最佳矫正视力比较,无显著差异(P > 0.05)。见表5。
组别 | n | 术前 | 术后3个月 | Z值 | P值 | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|
<0.1 | 0.1~0.2 | 0.25~0.4 | >0.4 | <0.1 | 0.1~0.2 | 0.25~0.4 | >0.4 | ||||
Phaco-GSL组 | 45 | 17 | 22 | 6 | 0 | 2 | 14 | 12 | 17 | 31.625 | 0.000 |
Phaco组 | 45 | 15 | 25 | 5 | 0 | 5 | 16 | 13 | 13 | 21.281 | 0.000 |
Z值 | 0.050 | 1.468 | |||||||||
P值 | 0.823 | 0.226 |
表5. 两组手术前后最佳矫正视力比较
Phaco-GSL组术后出现角膜水肿11例(24.44%),前房微出血2例(4.44%);Phaco组术后出现角膜水肿10例(22.22%);两组均未出现视网膜脱落、后囊破裂等并发症。
瞳孔阻滞是ACG发病的主要诱因,而晶状体膨胀是导致瞳孔阻滞的重要因素,白内障往往会成为ACG的发病原因,患者晶状体吸水膨胀,厚度增加,晶状体与虹膜接触面积增大,导致虹膜前移,前房角变浅,加重瞳孔阻滞,引发ACG [
邓里等 [
本研究结果显示,两组术后1 d和术后1、3个月眼压均低于术前,两组术后3个月最佳矫正视力均明显提高,说明无论是Phaco + IOL + GSL还是Phaco + IOL都能显著降低眼压,提升患者视力,但两种手术方案在提升视力方面并无显著差异。两组术前、术后降眼压药种类无显著差异,Phaco-GSL组手术前后眼压差值及降眼压药种类差值均高于Phaco组,说明Phaco + IOL + GSL的降眼压效果优于Phaco + IOL。两组术后1个月房角均较术前明显增宽,Phaco-GSL组房角开放情况优于Phaco组;提示Phaco + IOL + GSL更有助于粘连关闭的房角重新开放。值得注意的是,晶状体核较硬、术中有效超声乳化时间较长者手术可能出现角膜水肿,术中用人工晶状体定位钩后压虹膜根部分离房角时可能会引起前房出血,术中应重视消毒,先做角膜缘内侧切口,缓慢放出适量房水,前房内注入透明质酸钠,部分减轻角膜水肿,便于手术操作 [
综上所述,Phaco-GSL治疗ACG合并白内障疗效确切,能有效降低眼压、开放房角,并改善患者是功能,值得临床推广。
李 珂. 超声乳化白内障吸除联合房角分离术治疗闭角型青光眼合并白内障疗效及对房角宽度的影响Efficacy of Phacoemulsification Combined with Goniosynechialysis on Angle-Closure Glaucoma with Cataract and Its Effects on the Angle of Anterior Chamber[J]. 护理学, 2019, 08(06): 397-403. https://doi.org/10.12677/NS.2019.86073