【摘要】 目的：探讨多层新鲜羊膜移植术治疗结膜囊狭窄的临床疗效。方法：对52例（52眼）结膜囊狭窄、无法安装义眼的患者行结膜囊成形术，根据结膜囊狭窄的不同程度分为3组。将2～3层新鲜羊膜上皮面朝上移植于结膜缺损区，上下睑缘褥式缝合。每周打开眼睑并用荧光素试纸染色，观察结膜上皮生长情况。术后3mo拆除上下眼睑缝线，定制合适的义眼。结果：术后随访12mo。术后4wk 51眼羊膜表面全部被结膜上皮覆盖，有1眼发生羊膜上皮融解，结膜上皮未愈。术后3mo Ⅰ度结膜囊狭窄（A组）15眼全部治愈；Ⅱ度结膜囊狭窄（B组）17眼中15眼治愈，2眼好转；Ⅲ度结膜囊狭窄（C组）20眼中16眼治愈，3眼好转，1眼无效。Ⅲ度结膜囊狭窄患者手术成功率与Ⅰ度、Ⅱ度结膜囊狭窄患者比较，其差异无显著性意义(P>0.05)。结论：多层新鲜羊膜移植联合结膜囊成形术是治疗结膜囊狭窄的有效方法，同样适用于重度结膜囊狭窄。
【关键词】 羊膜；移植术；结膜囊；狭窄
Clinical study on fresh multilayer amniotic membrane transplantation combined with conjunctival reconstruction for treatment of conjunctival sac stenosis
XinSheng Zeng, YanYi Peng, YuPing Guan
Department of Ophthalmology, the Affiliated Hospital of Guilin Medical College, Guilin 541001, Guangxi Zhuang Autonomous Region, China
Correspondence to: XinSheng Zeng. Department of Ophthalmology, the Affiliated Hospital of Guilin Medical College, Guilin 541001,Guangxi Zhuang Autonomous Region, China. [email protected]
Abstract AIM: To observe the therapeutic effect of fresh multilayer amniotic membrane transplantation combined with conjunctival reconstruction for treatment of conjunctival sac stenosis.METHODS: Fiftytwo patients (52 eyes) suffered from conjuctival sac stenosis were treated with fresh multilayer amniotic membrane transplantation. The superior and lower eyelid was closed with mattress suture. The eyelids were opened and stained with fluorescein test paper every week in order to observe the growth of conjunctival epithelium. Stitches were removed three months after surgery and the suitable prosthesis was made.RESULTS: Conjunctival epithelium migrated to the surface of the amniotic membrane and covered it completely in 51 cases four weeks after surgery. Amniotic membrane was dissolved and conjunctival epithelium could not cover the defect area in one case. Three months after surgery,15 eyes of degree Ⅰ cojunctival sac constriction （group A） were all cured. In degree Ⅱ cojunctival sac constriction （group B）,15 eyes were cured and two eyes were improved. In degree Ⅲ cojunctival sac constriction （group C）,16 eyes were cured, 3 eyes were improved and 1 eye failed. There was no statistical difference of success rate between three groups.CONCLUSION: Fresh multilayer amniotic membrane transplantation combined with conjunctival reconstruction is effective for treatment of conjunctival sac stenosis of degree Ⅰ, Ⅱand Ⅲ.
KEYWORDS: amnion; transplantation; conjunctival sac; stenosis
前言
各种原因行眼球摘除术患者，术后由于长期未配戴义眼，导致结膜囊收缩变浅、变窄。另外，有些眼外伤患者结膜亦受到广泛损伤，产生瘢痕，使结膜囊狭窄。这些患者行义眼安装后会滑出或不能装入，需行结膜囊成形术。我们采用多层新鲜羊膜移植联合结膜囊成形术矫治结膜囊狭窄，取得了满意的疗效，现报告如下。
1对象和方法
1.1对象
200309/200609我院收治的结膜囊狭窄患者52例（52眼），其中男32例（32眼），女20例（20眼），年龄3～51（平均29）岁。病程2mo～21a,平均12a。患者眼球摘除的原因：眼肿瘤7例，眼化学性烧伤13例，机械伤23例，眼内炎6例，原因不明3例。结膜囊狭窄程度分为：（1）Ⅰ度（15例）：结膜囊狭窄约1/3，上下穹隆变浅；Ⅱ度（17例）：结膜囊狭窄缩小约1/3，上下穹隆明显变浅；Ⅲ度（20例）：结膜囊缩小为正常大小的1/3，上下穹隆消失，结膜囊底部垂直径小于10mm。
1.2方法
1.2.1新鲜羊膜制备
取HBsAg、衣原体、AIDS等阴性无传染性疾病的健康孕妇剖宫产胎盘，无菌条件下用林格氏液冲洗干净，置于含链霉素8×104U/L，青霉素8×104U/L，二性霉素B 2.5mg/L的生理盐水中浸泡20min，分离羊膜，去除绒毛膜，上皮面向上铺置于手术面膜纸上，羊膜片剪成5cm×5cm大小。
1.2.2手术方法
采用表面麻醉加局部浸润麻醉。结膜囊中间水平剪开球结膜，结膜下潜行向上下穹隆分离，为避免损伤提上睑肌，上穹隆中间1/3部分到眶缘，内侧分离至内眦深部，外侧至眶外缘，彻底剪除结膜下瘢痕组织，直至结膜软化。将结膜向上下穹隆推移后徙，自下穹隆结膜面进针，皮肤面出针，深达眶骨膜，缝3对褥式缝线，结膜囊内垫橡皮管，皮肤面垫小棉卷；同样方法上穹隆缝3对褥式缝线。结扎缝线，加深上下穹隆部。暴露结膜缺损创面，充分止血。将2～3层羊膜上皮面朝上平铺于结膜缺损区，结膜囊为轻度、中度狭窄用双层羊膜，如为重度狭窄则用三层羊膜，根据创面大小剪去多余的羊膜（羊膜面积大于结膜缺损范围约30%），折叠的羊膜边缘用80可吸收线间断缝合固定。将羊膜边缘嵌入结膜与筋膜之间，80可吸收线间断缝合羊膜与结膜边缘，每针均穿过深部组织，植片中央多处间断缝合，排尽羊膜和筋膜之间的空气和渗液，使羊膜组织充分与植床相贴。结膜囊内涂地塞米松妥布霉素眼膏，植入眼膜，上下睑缘褥式缝合，活结结扎缝线，内外眦留一定空隙，以便引流分泌物。术眼加压包扎。术后全身应用抗菌素、激素3d。术后5d换药，局部滴含有激素的抗菌药物眼液。每周打开眼睑并用荧光素试纸染色，观察结膜上皮生长情况，3wk后拆眼睑褥式缝线。术后2mo拆除上下眼睑缝线，术后3mo配戴合适的义眼。术后3mo观察手术眼结膜囊的大小。（1）结膜囊无狭窄，能放置正常大小义眼片为治愈；（2）结膜囊狭窄Ⅰ度，能放置较小义眼片为好转；（3）结膜囊狭窄Ⅱ度或Ⅲ度为无效。
统计学处理：采用SPSS11.5统计软件包，行χ2及Fishers检验检验，P<0.05为显著性检验水准。
2结果
术后4wk 52眼羊膜表面全部被结膜上皮覆盖，有1眼发生羊膜上皮融解，结膜上皮未愈。术后3mo Ⅰ度结膜囊狭窄15眼全部治愈；Ⅱ度结膜囊狭窄17眼中15眼治愈，2眼好转；20眼Ⅲ度结膜囊中16眼治愈，3眼好转，1眼无效。Ⅲ度结膜囊狭窄患者手术成功率与Ⅰ度、Ⅱ度结膜囊狭窄患者比较，其差异无显著性意义(P>0.05，表1)。表1不同结膜囊狭窄程度患者术后疗效比较（略）
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