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- 疑难性角膜屈光手术分析
- 作者:李莹|发布时间:2009-07-03|浏览量:1328次
李莹 张潇 罗岩 陈秉钧 丁欣 艾凤荣
中国医学科学院 北京协和医学院 北京协和医院眼科 北京协和医院眼科李莹
通讯作者:李莹 liyingpumch@sohu.com
【摘要】目的 分析疑难性准分子激光角膜屈光手术的原因、分类、方案设计及治疗效果。设计 前瞻性病例系列。研究对象 非常规疑难准分子激光屈光性角膜手术患者47眼。方法 分析患者进行屈光手术的原因、方案设计及治疗效果。除视力(裸眼、矫正、小孔视力)、屈光度(散瞳和显然验光)、主视眼、角膜厚度、角膜地形图、像差检查等常规术前检查外,还要依据患者情况进行相应的特殊检查,包括角膜多点厚度、角膜曲率时间变化、眩光仪、对比敏感度、眼肌功能、VEP五项等检查。手术前对患者进行个性化手术设计以及可能的预后评估。主要指标 治疗前角膜厚度、视力、角膜地形图变化、屈光度、手术次数。 结果 疑难角膜屈光手术的界定:除最佳矫正视力小于0.8,还伴有角膜形态、结构异常或屈光参差、弱视等异常,或曾进行过屈光角膜手术但效果不满意,最佳矫正视力低于0.5,需再次进行角膜屈光手术的一类患者。疑难角膜屈光手术分类:(1)根据角膜屈光手术史分为:手术原性屈光状态异常性、手术原性角膜结构异常性;(2)根据角膜情况分为:角膜结构异常性、角膜曲率异常性;(3)根据双眼屈光状态差异分为:高度近视伴弱视性、屈光参差性疑难角膜屈光手术。治疗方法:个性化设计手术,地形图引导手术,各种角膜屈光手术(EP-LASIK+ PTK,EP-LASIK,LASIK,LASEK,PRK)(摘要尽量用中文)等。治疗效果:所有患者达到预期最佳矫正视力,其中超过预期矫正视力2行以上者为51.1%(24眼),超过3行以上者为23.4%(11眼)。预期性:实际矫正度在预期矫正度±0.5D之间者45眼。患者对手术效果满意,随访2年以上未出现异常情况。疑难角膜屈光手术也需围绕安全、慎重和个性化原则。无论选择那种手术方式,一定要以角膜创伤最小、近期和远期角膜状态稳定考虑,慎重选择准分子激光手术。再次手术设计需综合分析患者的个人情况设计手术方案。结论 界定疑难屈光性角膜手术的原因、适应证,严格分析患者屈光状态、角膜病变情况,进行合理的手术设计和时机选择,可以为眼部情况复杂的非常规的患者带来安全、有效、可预测性强的角膜屈光手术,为患者带来良好的屈光矫正和最佳生活视力。
Difficult excimer laser keratorefractive surgery LI Ying, ZHANG Xiao, LUO Yan, CHEN Bing-jun, DING Xin, AI Feng-rong. Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
Correspondence author: LI Ying, Email: liyingpumch@sohu.com
【Abstract】 Objective To analyze the causes, classification, operation design, and therapeutic effect of difficult excimer laser keratorefractive surgery. Design Retrospective case series. Participants Patients (47 eyes) who have received difficult corneal refractive surgeries (DCRS). Methods The causes, classification, operation design, and therapeutic effect of those patients were studied. Routine pre-operation examinations included visual acuity (uncorrected, corrected, pin hole), diopter (mydriasis, normal pupil), dominate eye, corneal thickness, corneal topography, wavefront aberration, and so on. There were some specific examinations according to conditions of different patients, including multipoint corneal thickness, time-related keratometry (TK), glare, contrast sensitivity, function of muscular apparatus, VEP, and so on. Customized operation was designed and possible prognosis was estimated before operation. Main Outcome Measures Preoperative corneal thickness, visual acuity, changes of corneal topography, diopter, and number of operations. Results The concept of DCRS included: patients needed keratorefractive surgery, whose best corrected visual acuity was lower than 0.8, with abnormalities of corneal morphology and structure, anisometropia, amblyopia, or previous keratorefractive surgery of unsatisfactory result. Classification of DCRS were based on: ① history of keratorefractive surgery: operation- originated refractive state abnormality and operation- originated corneal structure abnormality; ② cornea condition: corneal structure abnormality and corneal curvature abnormality; ③ binocular refractive state: high myopia with amblyopia, anisometropia. Treatment included customized ablation, topography guided ablation, EP-LASIK+ PTK,EP-LASIK,LASIK,LASEK,PRK, and so on. Therapeutic effect: all the patients achieved expected best corrected visual acuity, 51.1% of them (24 eyes) were 2 lines better than expected, and 23.4% (11 eyes) were 3 lines better. Among 47 eyes, actual correction of 45 eyes was within ±0.5D of expected correction. There were not any abnormalities in the follow up for more than 2 years. The principle of DCRS was also safety, caution and individualization. No matter what kind of operation, the goal was minimal corneal trauma and stability of cornea for present and long-time. Conclusion With clear identification of the causes and indications, strict analysis of the refractive state and keratopathy conditions, reasonable design of the operation and selection of the opportunity, patients with complicated conditions could receive safe, effective and predictable keratorefractive surgeries. These patients could receive satisfactory refractive correction and best life visual acuity.
【Key words】excimer laser; corneal, keratorefractive surgery
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