【摘要】 目的：评价及探讨矫治超高度近视眼的各类屈光手术的有效性、稳定性和安全性。
方法：随机选择临床中观察到的超高度近视患者行各类屈光手术者108眼，近视范围10.00～24.50D,术前屈光度平均为(12.25±1.53)D,散光平均为(1.52±0.55)D;手术方式的选择:(1)I组52眼，行LASIK术：(2)II组23眼,行透明晶状体超声乳化摘除加后房型人工晶状体植入术。(3)III组33眼行有晶状体眼虹膜固定型人工晶状体植入术。术后随访观察平均6mo，主要观察术后裸眼视力、最佳矫正视力、屈光度、眼压及眼前段、眼底情况。
结果：三组术后裸眼视力均比术前提高,术后裸眼视力≥0.5者分别是42眼(80.8%),20眼(87.0%),28眼(84.8%),术后屈光度分别为（2.10±2.38）D，(1.75±1.33)D，（0.83±1.16)D,主要并发症I组术后6mo黄斑出血1眼，II组术后15mo视网膜脱离1眼，III组平均角膜内皮细胞丢失率为4.5%。
结论：对于超高度近视,晶状体性屈光手术效果优于LASIK术。对超高度近视行屈光手术，要根据患者年龄，眼部情况，手术医师的技术等，选择安全、有效、稳定性好的手术。
【关键词】 高度近视/外科手术 角膜磨镶术 激光原位 晶状体/外科手术
Selection of refractive surgery in high myopia
Yang Yang,Yang He, Dick H.Burkhard
Deppartment of Ophthalmology, Kunming Yanan Hospital, Kunming 650051, Yunnan Province, China;Department of Opthalomology, Johannes GutenbergUniversity, Mainz, Germany
Abstract
AIM: To compare and evaluate the efficacy, safety and stability of the selection of corneal or lens refractive surgery in high myopia.
METHODS: The results of treating 108 eyes in high myopia were analyzed retrospectively. The mean preoperative spherical equivalent and astigmatis was (12.25±1.53)D and (1.52±0.55)D. Fiftytwo eyes treated with LASIK were as group 1. Twentythree eyes in group 2 were treated with clear lens extraction and intraocular lens (IOL) implantation. Thirtythree eyes in group 3 were treated with phakic IOL for high myopia. The followup time was 6 months. Postoperative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), diopter, intraocular pressure (IOP) and the condition of anterior segment and fundus were observed.
RESULTS: The UCVA improved in all cases postoperatively, including 42 eyes (80.8%), 20 eyes (87.0%), and 28 eyes (84.8%) of group 1, 2 and 3 achieving>0.5, respectively. The mean postoperative shpherical equivalent and astigmatism was (2.10±2.38), (1.75±1.33)D, and (0.83±1.16)D, respectively. Complication of macular hemorrhage was found in group 1 after 6 months, retinal detachment presented in group 2 after 15 months. The average loss rate of corneal endothelial cell in group 3 was 4.5%.
CONCLUSION: Treating with IOL and phakic IOL implantation is better than with LASIK for high myopia. The selection of refractive surgery in patients with high myopia should be based on age, condition of lens, degree of myopia, doctors level and so on.
KEYWORDS: high myopia/surgery; keratomileusis; laser in situ/methods; lens; crystalline/surgery
0引言
近视眼的屈光性手术是当前眼科界发展最快的前沿领域之一，种类繁多，更新较快[1]。对于手术类型的选择，临床中尚无统一标准，200307/200510，我们对超高度近视行各类屈光性手术的患者进行了系统性长期随访观察，现将结果报告如下。
1对象和方法
1.1对象 选择临床中观察到的高度近视患者行各类屈光手术者108眼，男39眼，女69眼；年龄：18～50岁；手术范围为近视10.00～24.00D,术前屈光度平均(12.25±1.53)D,平均散光 (2.52±0.55)D;手术方式的选择:（1）I组18～50岁,屈光度稳定2a以上,矫正视力≥0.5,有足够角膜厚度(切削完成后基质层厚度>250μm)者，屈光度10.00～14.00D者52眼，采用德国Wavelight公司的 ALLEGRETTO型鹰视准分子激光系统联合法国M2自动角膜板层切削刀进行常规LASIK术：光学切削区6mm，角膜瓣厚度130～160μm。（2）II组年龄40～50岁，伴随有晶状体混浊趋势者，屈光度(10.00～18.00D)者23眼,行超声乳化加后房型人工晶状体植入术;超声乳化机为美国AMO公司的Sovereign,人工晶状体型号为AMO公司的Ar40折叠晶状体。（3）III组年龄18～40岁,屈光度在12.50D～24.00D,平均为(17.22±1.20)D,散光度数0～2.50D,平均散光度数(1.27±0.40),因角膜厚度较薄,矫正视力>0.3,前房深度>3.2mm，角膜内皮细胞计数>2500个/mm2者33眼,行有晶状体眼虹膜固定型人工晶状体植入术（AMO公司的Verisyse人工晶状体）。
1.2方法 以上各类屈光手术后随访观察3～18mo，平均6mo以上，主要观察术后裸眼视力、最佳矫正视力、屈光度、眼压、眼角膜及眼前段、眼底情况。
统计学处理：采用列联表χ2 检验，P<0.05为差异有统计学意义。
2结果
2.1术后视力 术后裸眼视力均较术前提高。各组术后不同时间裸眼视力分布情况(表1)。
2.2术后屈光度 术后屈光度(表2)。
2.3术后并发症 I组3mo后有屈光回退27眼,占56.2%；1眼术后6mo发生黄斑出血,视力0.2;II组中1眼术后15mo发生视网膜脱离,行视网膜复位术后视力至0.4。此2眼导致最佳矫正视力较术前下降2行以上（1.8%）。
2.4患者的主观感觉及满意度 I组患者术后早期有较高满意度，术后1mo内感觉视远清楚而视近模糊，30%夜间有眩光，50%有干眼症状，术后3mo部分患者出现不同程度远视力下降；II组术后也有较高满意度，但视近模糊欠清；III组患者有很高的满意度，术后1mo视力均达到或高于术前矫正视力。
2.5术后眼压及角膜内皮细胞计数 III组中有2眼术后2d眼压高于21mmHg,给甘露醇静脉滴注250mL后眼压降至正常，术后12mo III组患者眼压至18mmHg以下；平均角膜内皮细胞计数丢失率为4.5%。
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