【摘要】目的:探讨大龄近视患者LASEK的疗效、特殊性以及需要加以关注和完善的问题。方法:对53例101眼大龄（年龄≥40岁）近视患者行LASEK治疗，并对术前和预矫屈光度以及手术疗效进行统计分析。结果:手术前屈光度（等量球镜）无轻度近视（D≤3.00）的患者；中度近视（3.00﹤D≤6.00）17眼，占16.8%；高度近视（ 6.00﹤D≤10.00）31眼，占30.7 %；超高度近视（D﹥10.00）53眼，占52.5%。手术后0.5a裸眼视力：0.3～1.2，平均： 0.81±0.32，其中裸眼视力≥0.5者77眼，占76.2%，术后裸眼视力≥1.0者24眼，占23.8%。因角膜厚度问题，为保证手术安全8例12眼（11.9%）手术前预矫屈光度适当减低。不同时期均出现了不同程度的Haze。4例8眼（7.9%）术后出现不同程度的角膜内皮水肿。结论:行LASEK的大龄近视患者以高度、超高度近视患者为主，术前角膜厚度的测量和预矫正屈光度的确定是手术安全性的关键；激光切削直径的选择对视觉质量有重要影响；另外，角膜内皮功能检查是否应该作为大龄近视患者LASEK术前的常规检查值得关注。
【关键词】 准分子激光上皮下角膜磨镶术；近视眼；大龄患者
Clinical analysis of excimer laser epithelial keratomileusis for the correction of myopia in older patients
XueBin Hu,Ping Jiang,ChunJian Mo,LiHua Chen
1The Optometric Center, the First Clinical School of Medical Sciences, Three Gorges University, Yichang 443003, Hubei Province, China;2The Optometric Center, Yichang Central Peoples Hospital, Yichang 443003, Hubei Province, China
Correspondence to:XueBin Hu.1The Optometric Centor, the First Clinical School of Medical Sciences, Three Gorges University, Yichang 443003, Hubei Province, China;2The Optometric Center, Yichang Central Peoples Hospital, Yichang 443003, Hubei Province, China. [email protected]
AbstractAIM: To study the curative effects and the particularity of excimer laser epithelial keratomileusis for correction of myopia of older patients.METHODS: Fiftythree myopic patients (101 eyes) with the age of 40 years or older were treated with LASEK. The preoperative refraction, the refractive diopter supposed to be corrected, and the curative effects were analyzed.RESULTS: No patients had the preoperative refraction ≤3.00D, 3.00﹤D≤6.00 in 16.8% of patients, 6.00﹤D≤10.00 in 30.7% of patients, D﹥10.00 in 52.5% of patients. After half a year, the preoperative uncorrected visual acuity was: 0.31.2, average: 0.81±0.32. The preoperative uncorrected visual acuity≥0.5 accounted for 76.2% of cases, ≥1.0 accounted for 23.8% of the cases. In light of corneal thickness, the refractive diopter supposed to be corrected was lower than the preoperative refractive diopter in 11.9% of cases. At different time, it appeared varied degree of Haze in partial cases, and 8 eyes, 7.9% appeared the varied degree of corneal endothelial edema.CONCLUSION: Most of 40 years of age or older patients treated with LASEK are high or super high myopic patients. To obtain better curative effects, it is important to measure corneal thickness carefully and to choose the refractive diopter supposed to be corrected and the diameter of the ablation zone. Whether the check of corneal endothelium function should be a routine is worth paying attention before LASEK surgery is performed in older myopic patients.
KEYWORDS: excimer laser epithelial keratomileusis; myopia; older patients
引言
准分子激光上皮下角膜磨镶术（excimer laser epithelial keratomileusis, LASEK）治疗近视眼于1999年由意大利医生Camellin首先提出[1]。因其特有的安全性和有效性在临床上逐渐被采用。我院自200405开始使用该术式并取得了良好的效果，其中的大龄患者具有一定特殊性且未见相关报道，现将我们的治疗结果报告如下。
1对象和方法
1.1对象
200408/200608在我院接受LASEK治疗的大龄（年龄≥40岁）近视患者共53例101眼，其中男23例43眼，女30例58眼，年龄40～52（平均44.41±3.85）岁；手术前近视度数5.50～16.00 D，平均（11.00±4.10）D，散光度数0.00～6.00 D,平均（1.15±1.26）D，并根据患者的年龄（调节力）、度数（安全角膜厚度）、职业习惯和激光机的性能等综合因素适当加减预矫屈光度；术前矫正视力0.5～1.5，平均0.91±0.18。
1.2方法
术前包括远、近裸眼和最佳矫正视力，裂隙灯显微镜，直接和间接检眼镜散瞳检查，常态和暗室瞳孔直径，非接触眼压，主、客观验光，角膜地形图，角膜厚度和眼轴测量。常规术前准备后，滴4g/L奥布卡因3～5次表面麻醉,用环形角膜上皮锯(内径8.0或8.5mm)以入射瞳孔中心为圆心按压角膜,切开角膜上皮,蒂部位于12点为中心20弧度范围内,环形酒精槽(内径8.5或9.0mm)以角膜上皮切开痕迹贴于角膜表面,注入分析纯酒精配制的200mL/L酒精浸泡15～33s,吸血海棉吸净酒精,BSS充分冲洗眼表,用角膜上皮铲沿切开上皮环痕边缘掀起形成上皮瓣,堆积于10～12点处,按设定程序激光切削，准分子激光采用美国Summit之3.5.1版本（大光斑）或鹰视准分子激光系统（小光斑）,切削完毕后,角膜基质床置以0.2g/L丝裂霉素Ｃ棉片,棉片大小与切削光区一致,时间与激光发射时间相当。BSS充分冲洗后,复位角膜上皮瓣,吸干水分,术眼置0～1.00D软性角膜接触镜，术毕。术后常规使用3g/L氧氟沙星滴眼液、酮咯酸氨丁三醇滴眼液和1g/L艾氟龙滴眼液。术后4～6d摘除角膜接触镜。角膜上皮下浑浊（Haze）分级和角膜水肿程度分级美国FDA的Haze分级标准[2]：0级，角膜完全透明；1级，可疑的角膜混浊，仅通过裂隙灯显微镜仔细检查发现；2级，轻度的角膜混浊，比较容易通过裂隙灯显微镜检查发现；3级，中度的角膜混浊，影响观察前房及虹膜结构；4级，重度的角膜混浊，明显的不透明。角膜水肿程度的分级标准[3]：1级为角膜局限性薄雾状水肿，角膜内皮面光滑，虹膜纹理尚清晰可见；2级为角膜浅灰色水肿，角膜内皮面粗糙，虹膜纹理模糊；3级为角膜弥满性灰白色水肿，角膜内皮面呈龟裂状，虹膜纹理不清；4级为角膜乳白色水肿，眼内结构视不清。
2结果
手术前屈光度（等量球镜）无轻度近视（D≤3.00）的患者；中度近视（3.00﹤D≤6.00）17眼，占16.8%；高度近视（ 6.00﹤D≤10.00）31眼，占30.7 %；超高度近视（D﹥10.00）53眼，占52.5%。手术后0.5a裸眼视力：0.3～1.2，平均：0.81±0.32，其中裸眼视力≥0.5者77眼，占76.2%，术后裸眼视力≥1.0者24眼，占23.8%。因角膜厚度问题，为保证手术安全8例12眼（11.9%）手术前预矫屈光度适当减低。Haze的发生情况：1mo时0级83眼，1级18眼；3mo时0级60眼，1级14眼，2级20眼，≥3级7眼；6mo时0级66眼，1级16眼，2级14眼，≥3级5眼；12mo时0级86眼，1级6眼，2级5眼，≥3级4眼。12mo以上的资料统计不全。4例8眼（7.9%）术后出现不同程度的角膜内皮水肿。角膜水肿分级：术后1d时1级2眼；2级4眼；3级2眼。3d内消退的有4眼；1wk内消退的有2眼；2wk内消退的有2眼。1级和2级角膜水肿视力恢复基本正常，3级者视力恢复短期出现延迟，半年后视力变化趋于稳定。
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