眼视光学杂志 2000年第4期第2卷 屈光手术
作者：高晓唯 胡裕坤 李晓虹
单位：解放军空军乌鲁木齐医院眼科中心,解放军空军眼科中心,新疆 乌鲁木齐 830011
关键词：散光；治疗；激光角膜原位磨镶术；治疗应用；近视；治疗
［摘 要］ 目的:研究准分子激光角膜原位磨镶术(LASIK)在治疗近视性散光中的作用。方法:采用LASIK术以线形扫描切削方式治疗580例(906眼)近视性散光患者,散光度数-1.00～-6.00DC(近视度数在-6.00DS以内)。低度散光组:-1.00～1.50DC(312眼),中度散光组:-1.75～2.50DC(340眼),高度散光组:-2.75～-6.00D(254眼)。随访时间一年。结果:术后平均散光度从术前的-2.15±0.8DC下降为-0.31±0.5DC(范围-1.15～-2.50DC)。低度散光组:术后一年时平均残余散光度为-0.20±0.50DC,散光度在±0.50DC以内者为94%。中度散光组:平均残余散光度为-0.40±0.60DC,散光度在±0.50DC和±1.00DC以内者分别为84%和90%。高度散光组:平均残余散光度为-0.87±1.06DC,散光度在±0.50DC和±1.00DC以内者分别为45%和78%。结论：使用线性扫描切削模式的LASIK术可有效地矫治近视性散光,尤其散光度在-1.00～-2.50DC时,完全矫治率在89%以上。对手术技巧、扫描方式和程序的不断改进可进一步提高手术的预测性和准确性。
［中图分类号］ R778.3 ［文献标识码］ A
［文章编号］ 1008-1801(2000)04-0207-03
Excimer laser in situ keratomileusis for treatment of astigmatism
GAO Xiao-wei，HU Yu-kun，LI Xiao-hong.
(Air Force Ophthalmic Center,Air Force Urmuqi Hospital,Urmuqi 830011)
Abstract： Objective：To study the efficacy of excimer Laser in situ keratomileusis for the treatment of myopic astigmatism.Methods：Ablations were performed with LASIK using a linear scanning-spot astigmatic module. 906 eyes of 580 astigmatic patients who received LASIK were studied. The patients were divided into 3 groups according to preoperative astigmatic diopters (group A:-1.00～-1.50DC,312 eyes，group B:-1.75～-2.50DC,340 eyes，group C:-2.75～-6.00DC,254 eyes). The average follow-up period was 12 months.Results：The average refractive cylinder was 2.15±0.8D preoperation, and had the average of -0.31±0.50D. residual astigmatism postoperation. In group A: the mean residual astigmatism was -0.20±0.50DC and 94% of eyes were ＜±0.50DC. In group B the mean residual astigmatism was -0.40±-0.60DC, and 84% and 90% of eyes was the ranges of ±0.50DC～±1.00DC. In group C: the mean residual astigmatism was -0.87±1.06DC, the 45% and 78% of eyes was in the ranges of ±0.50DC～±1.00DC.Conclusion：The results indicate that LASIK using a linear scanning-spot astigmatic module can treat astigmatism in the range of -1.00～-6.00Dc. The success rate can be 89% for the astigmatism of -1.00～2.50DC. Some modification of the surgical techniques and scanning mode may help to improve predictability and stability of outcome.
Key words： astigmatism/therapy; excimer laser in situ keratomilensis(LASIK)/therpeutic use; myopia/therapy
准分子激光角膜原位磨镶术（LASIK ）已经成为屈光手术的研究重点之一,其治疗近视，尤其是高度近视的优点已日渐凸现［1］。散光的治疗作为屈光手术中的一个难点是否能用LASIK进行治疗及效果如何，未有定论,已有一些国外学者对此进行了探索［2］, 其结果与前景令人鼓舞。如何增加这种方法的预测性和稳定性,已成为屈光手术的新课题。我科自1997年以来对这项手术进行前瞻性研究,以评价其效果。现将结果报告如下。
1 资料和方法
1.1 病例选择 选择散光度-1.00～-6.00DC,近视屈光度＜-6.00DS,散光度在2年内基本稳定,最佳矫正视力在0.5以上者580例(906眼),年龄18～48岁。所有患者均经检查排除任何显性或潜在的圆锥角膜,且无各种严重眼疾,身体健康。患者按散光度不同随机分组。低度散光组:-1.00～1.50DC(312眼),中度散光组:-1.75～-2.50DC(340眼),高度散光组:-2.75～-6.00DC(254眼),平均为-3.80±1.65D。
1.2 手术方法 ①采用美国Chiron Vision公司的KERACOR 117型准分子激光机和H230型自动微型板层角膜刀。②手术步骤与LASIK方法一致［3］。激光切削时先行散光治疗,切削模式采用线形扫描,长径为13.5mm,横径为4mm～4.5mm,切削后角膜中央4mm～4.5mm 区带内散光被矫正。
1.3 术前检查 所有患者均进行视力、屈光度、眼前节、眼底、眼压、角膜厚度和角膜地形图检查。术前3天滴用托百士眼液。
1.4 术后随访 于术后1天、7天，1、3、6、12、18月进行随访，平均随访12个月。随访时观察裸眼视力、矫正视力、屈光、裂隙灯、眼压和角膜地形图。
1.5 统计学方法 计量资料采用配对t检验及组间t检验,率比较用卡方检验,表3～5采用方差分析。运算以统计软件SPSS完成。
2.1 术后裸眼视力的变化，见表1。
表1 各组术后裸眼视力在不同时间的百分率 (%)
Tab.1 Percent of postoperative uncorrected visual
acuity among groups within different time (%)
| groups |
numbers of
eyes |
1 month |
3 months |
6 months |
12 months |
| 0.5～1.0 |
＞1.0 |
0.5～1.0 |
＞1.0 |
0.5～1.0 |
＞1.0 |
0.5～1.0 |
＞1.0 |
| low astigmatism |
312 |
29(9) |
283(91) |
19(6) |
293(94) |
31(10) |
281(90) |
29(9) |
283(91) |
| moderate
astigmatism |
340 |
48(14) |
292(86) |
65(19) |
275(81) |
68(20) |
272(80) |
65(19) |
275(81) |
| high astigmatism |
254 |
81(32) |
173(68) |
91(36) |
163(64) |
102(40) |
152(60) |
112(44) |
198(56) |
Comparision among groups:P＜0.012.2 术后各组12个月的残留散光度比较，见表2。
表2 各组术后12个月残留散光度比较
Tab.2 Comparision of residual astigmatism
among groups 12 months after surgery
| groups |
±0.50DC |
±1.00DC |
| eyes |
percent(%) |
eyes |
percent(%) |
| low astigmatism |
293 |
94.34 |
307 |
98.39 |
| moderat astigmatism |
285 |
84.88 |
306 |
90.76 |
| high astigmatism |
114 |
45.73 |
198 |
78.40 |
| total |
692 |
76.37 |
811 |
89.51 |
| P |
＜0.01 |
＜0.01 |
2 结果2.3 术后各组角膜地形图的改变，见表3、4、5。
表3 LASIK术前后各组角膜地形图中央4mm曲率平均值 (D, ±s)
Tab.3 The mean of corneal topography central curvature(4mm)
among groups before and after surgery (D,±s)
| groups |
presurgery |
postsurgery |
| 1 month |
3 months |
6 months |
12 months |
| low astigmatism |
44.12±0.61 |
40.05±1.67 |
40.55±1.04 |
41.02±0.78 |
41.08±0.64 |
| moderate astigmatism |
43.72±0.54 |
38.23±2.06 |
39.08±1.64 |
39.88±0.64 |
39.90±0.80 |
| high astigmatism |
43.89±0.71 |
36.77±2.54 |
37.12±2.64 |
38.09±1.55 |
38.64±0.94 |
| P |
＞0.05 |
＜0.01 |
＜0.05 |
＜0.01 |
＜0.01 |
表4 手术后各组角膜地形图SAI比较 (±s)
Tab.4 Comparision of corneal topography SAI among
groups before and after surgery (±s)
| groups |
presurgery |
postsurgery |
| 1 month |
3 months |
6 months |
12 months |
| low astigmatism |
0.39±0.20 |
0.69±0.58 |
0.49±0.51 |
0.46±0.55 |
0.41±0.48 |
| moderate astigmatism |
0.41±0.18 |
0.78±0.72 |
0.48±0.62 |
0.41±0.51 |
0.42±0.46 |
| high astigmatism |
0.38±0.23 |
0.86±0.81 |
0.56±0.74 |
0.52±0.60 |
0.51±0.45 |
| P |
＞0.05 |
＞0.05 |
＞0.05 |
＞0.05 |
＞0.05 |
表5 手术前后各组角膜地形图SRI比较 (±s)
Tab.5 Comparision of corneal topography SRI among groups
before and after surgery (±s)
| groups |
presurgery |
postsurgery |
| 1 month |
3 months |
6 months |
12 months |
| low astigmatism |
0.41±0.31 |
0.85±0.45 |
0.51±0.54 |
0.40±0.31 |
0.41±0.28 |
| moderate astigmatism |
0.42±0.28 |
0.90±0.61 |
0.53±0.49 |
0.45±0.35 |
0.39±0.36 |
| high astigmatism |
0.39±0.35 |
0.91±0.66 |
0.60±0.50 |
0.52±0.40 |
0.46±0.40 |
| P |
＞0.05 |
＞0.05 |
＞0.05 |
＞0.05 |
＞0.05 |
术后角膜地形图显示角膜中央4mm 图内曲率较术前减少量与单纯近视眼矫正不同,散光度数发生叠加,但中央曲率减少的幅度可大于二者之和,随着时间的推移又有减少(表3),在术前图与术后图重叠相减后的地形图(Differential map)中可以清楚地看到散光被矫正的轴向与度数。手术后SAI和SRI均较术前明显增高,然后逐渐减少,术后6～8个月时与术前值接近(表4、5)。
2.4 术后并发症 发生于LASIK治疗近视的并发症在治疗散光时均可发生。①角膜地形图观察,切削偏中心0.6mm以上为21只眼(2.18%),术后散光轴位发生变化,部分残留散光,其中2眼矫正视力下降2排。术后3个月时均显示散光欠矫，经二次手术后治愈。②术后3个月时检查出现其它轴位上的散光且接受散光镜片矫正者35例(3.67%)均发生在高度散光组,提示高度散光者散光矫正质量不够理想。
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