【摘要】目的：评价应用干燥保存角膜片对554例严重感染性角膜溃疡行治疗性角膜移植手术的效果。方法：选自我院角膜病组197608/200012期间应用干燥保存角膜片对严重感染性角膜溃疡行治疗性角膜移植手术共计554例，本组病例统计分类为真菌性（238例）、单疱病毒性（170例）、细菌性（70例）及混合感染性（76例）角膜溃疡4种，分析临床应用效果。结果：本组手术治疗严重感染性角膜溃疡平均有效率88.8%，其中真菌性角膜溃疡81.5%，单疱病毒性角膜溃疡98.2%，细菌性角膜溃疡97.1%，混合感染性角膜溃疡82.9%。结论：无水氯化钙硅胶干燥长期保存的角膜片为临床随时提供角膜材料，是一项简单易行、便于推广应用的方法；在临床治疗过程中尽快、尽早查明感染病原体，可避免盲目性；对严重感染性角膜溃疡，治疗性角膜移植可直接清除病灶、较快地控制炎症、缩短治疗过程,达到保存眼球及恢复部分有用视力，为下一步光学性角膜移植创造条件。
【关键词】 感染性角膜溃疡；治疗性角膜移植；干燥脱水法；保存；角膜片
Application of donor corneas by dry preservation in treatment for infective corneal ulcer
WenXue Yang, Jie Wu, XiuPing Zhu, Ting Ma, Yong Yin, XianNing Liu
Department of Ophthalmology, the First Hospital of Xian City (Xian Ophthalmology Hospital, Shaanxi Provincial Ophthalmology Institute), Xian 710002, Shaanxi Province, China
Correspondecen to: WenXue Yang.Department of Ophthalmology, the First Hospital of Xian City (Xian Ophthalmology Hospital, Shaanxi Provincial Ophthalmology Institute), Xian 710002, Shaanxi Province, [email protected]
AbstractAIM: To evaluate the clinical effects of therapeutic keratoplasty using donor corneas of dry preservation for 554 cases of severe infective corneal ulcer.METHODS: From August 1976 to December 2000, 554 cases of severe infective corneal ulcer were treated in our hospital with therapeutic keratoplasty using donor corneas by dry preservation. These patients were divided into fungus corneal ulcer group (238 cases), herpes simplex corneal ulcer group (170 cases), bacterial corneal ulcer group (70 cases) and mixed infective corneal ulcer group (76 cases), clinical effects were analyzed through statistical means.RESULTS: The average effective rate of therapeutic keratoplasty in treatment for severe infective corneal ulcer was 88.8% in this study. The effective rates in the fungus corneal ulcer group, the herpes simplex corneal ulcer group, the bacterial corneal ulcer group and the mixed infective corneal ulcer group were 81.5%, 98.2%, 97.1%, 82.9% respectively.CONCLUSION: 1) The longtime dry preservation of corneas in waterfree calcium chloridesilica gel is able to supply corneal materials whenever necessary. Therefore it is an easy, simple and practical method. 2) It is essential to find out the pathogens early and rapidly in order to avoid aimless clinical work. 3) As for the treatment of serious corneal ulcer, therapeutic keratoplasty can clear infective foci, control the process of inflammation, shorten the period of treatment, and keep eyeballs and recover partial useful vision, all of which created conditions for optical corneal transplantation.
KEYWORDS: infective corneal ulcer; therapeutic keratoplasty; dehydration; preservation; donor cornea
引言
我院角膜病组从1976年开始采用西安市眼库无水氯化钙—硅胶干燥法[1,2]保存的角膜及角巩膜片进行治疗性角膜移植术。总结197608/200012期间应用干燥保存角膜片对严重感染性角膜溃疡行治疗性角膜移植手术共计554例，现将临床应用效果分析如下。
1对象和方法
1.1对象
选自197608/200012我院角膜病组住院患者共554例（554眼），男341例，女213例；农民315例，工人124例，干部61例，其他职业54例，年龄2mo～77岁。就诊前病程最短5d，最长45d。本组病例统计分类为真菌性（238例）、单疱病毒性（170例）、细菌性（70例）及混合感染性（76例）角膜溃疡4种， 共计554例。诱因主要包括各种农作物、劳动锐器划伤；火药炸伤、铁水及石灰烧伤；去角膜异物后；白内障人工晶状体术后大泡性角膜病变；上呼吸道感染史；反复单疱病毒性角膜炎感染史等。
1.2方法
1.2.1角膜材料来源及保存方法
采用无水氯化钙硅胶干燥法长期保存的角膜材料，均按眼库所制定的供眼采集医学标准进行选择[3]。 供体年龄1mo～50岁，眼球摘除时间夏季6h内，冬季12～24h内。角膜植片制备时间自眼球摘除后3d内不等（4℃湿房保存）。保存时间平均8a，最长15a。 使用时先检查保存瓶内兰色硅胶有无变色，如变为红色弃之不用。保存角膜片及角巩膜片复水后无裂纹、破裂，可供临床使用。
1.2.2实验室检测
角膜病灶区组织刮片检测病原体。采用我院研究所建立的真菌、细菌及单疱病毒快速检测法进行，并能同时检测棘阿米巴病原体。以100g/L氢氧化钾湿片法或丫啶橙荧光片染色查到真菌菌丝孢子，或检测到棘阿米巴包囊，单疱病毒单克隆抗体间接免疫荧光法(IFA)检测单纯疱疹病毒(HSV1)；Gram染色鉴别G+菌或G 菌，细菌培养获得药敏实验结果。
1.2.3手术指征及方法
病原体真菌、单疱病毒、细菌及混合感染所致的角膜溃疡，药物治疗5～7d无效(尤其真菌感染)，且病变进一步加重者尽快手术清除病灶。角膜溃疡炎性浸润局限于前2/3角膜基质，行板层角膜移植去除病灶。丝状真菌感染所致的角膜溃疡行穿透性角膜移植去除病灶。角膜溃疡并发后弹力层膨出/穿孔者急诊进行修补手术。按板层及穿透性角膜移植术常规施行。板层/深板层角膜移植术中注意点：手术范围超出溃疡边缘约1～2mm；分层剖切病灶时，最终植床表面最好为正常角膜组织；真菌感染辅以2%～4%碘酊或虹膜恢复器热烧灼创面。穿透性角膜移植术中注意点：植孔超过溃疡边缘约1mm；有前房积脓者术中仔细冲洗房角，去除虹膜表面膜样物。对术中取样材料及时送检，指导术后用药。
1.2.4临床疗效评价
有效：原发病变（灶）控制，术后植片透明或半透明，植片植床愈合良好，治疗目的达到。无效：原发病变（灶）术后未控制、或排斥反应不能控制，植片部分或全部混浊，溶解。
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