【摘要】目的：探讨小梁切除联合应用丝裂霉素C治疗青光眼再手术的远期疗效。方法：回顾性分析19例21眼常规小梁切除无功能滤过泡、眼压失控再次手术的病例资料，手术方式为再次小梁切除联合应用丝裂霉素C并术后随访1~3a。疗效判定标准 ：A 疗效好：眼压 ＜16 mmHg、视力≥0.3、视盘与视野损害无进展。B 疗效较好：不用或仅用局部抗青光眼药物眼压≤21 mmHg、视力0.1～0.25、视盘与视野损害无进展。C 疗效差：眼压失控、药物不能控制在正常范围或手术治疗。手术成功判定标准：A B项为手术成功标准。结果：随访1a以上19例21眼(100%)，随访3a以上16例（18眼）(76%)。术后平均眼压16.3±4.1 mmHg。较术前眼压35.8±5.32 mmHg明显降低.( P ≤0.001) 、11眼眼压控制在13±2.7 mmHg , 8眼局部应用抗青光眼一种药物眼压控制好, 较术前眼压难以控制有显著意义。检眼镜观察杯盘比值与视野检查,术前术后无显著差异。术后裸眼与矫正视力为0.02～0.5，视力满意（＞0.3）8眼（38%），17眼（0.1以上）保持有用视力（81%）。根据上述标准：疗效好8眼、疗效较好9眼、4眼疗效差。1a手术成功率86%。3a手术成功率76%。本组病例术后早期并发症：角膜上皮损害6眼，低眼压、浅前房发生9眼，其中滤过强与渗漏4眼，2眼脉络膜脱离,1眼发生睫状环阻塞性青光眼。3a随访晶状体浑浊加重5眼，2眼再一次出现眼压失控行抗青光眼联合手术。结论：小梁切除联合应用丝裂霉素C治疗青光眼手术成功率高，远期效果好，再次手术疗效满意。

   【关键词】  小梁切除　丝裂霉素C　青光眼再手术　随访研究

　　Long-term effect of trabeculectomy combined with MMC on repeated surgery for glaucoma

    Ping Ming , Bin Zhou, Ze-Rong Li

    Department of Ophthalmology, the Ninth People's Hospital of Chongqing,Chongqing 400700, China

     Abstract AIM:To evaluate the long-term effect of trabeculectomy combined with MMC on repeated surgery for Glaucoma. METHODS:This retrospective study included 19 cases(21 eyes) with Glaucoma patients for trabeculectomy and followed up for 1- 3 years . Definition of effect for surgery were determined as A Nice :Intraocular Pressure( IOP) ≤16 mmHg , visual acuity≥0.3 , Optic Nerve and vision field without advanced damage ; B Good : no antiglaucoma medication or only local medication of topical antiglaucoma drops， IOP≤21mmHg , visual acuity≥0.1-0.25 and optic Nerve and vision field without advanced damage; C No effect:IOP could not been controlled and also with antiglaucoma topical drops . Definition of successful surgery : A and B is successful .RESULTS: The study included 19 cases (21 eyes) with 100% patients who followed up for over one year, 16 cases (18 eyes) with 76% patients who followed up for over 3 years. After surgery , the average IOP was significantly lowered to 16.3±4.1mmHg from 35.8±5.32mmHg( P≤0.001) ,there were 11 cases which the IOP was 13±2.7mmHg , 8 cases which the IOP were controlled with topical antiglaucoma drops. There was no significantly difference in the cup-disc ratio (C/D) and the vision field . the visual acuity after surgery was 0.02-0.5. there were 8 eyes with 38% patients who had visual acuity>0.3 ,17 eyes with 81% patients who had visual acuity>0.1.Based on the criteria for successful surgery : A 8eyes, B 9 eyes, C 4 eyes. The successful rate of surgery was 86% at one year, 76% at three years. Among 21 eyes for early complication: there were 6 eyes with the corneal epithelial defect, 9 eyes with lower IOP and shallow anterior chamber, two eyes with choroidal detachment,1 eye with ciliary block glaucoma .After followed-up for three years ,there were 5 eyes with advanced cataract， 2 eyes were underwent cataract surgery combined with antiglaucoma because of uncontrolled IOP .
CONCLUSION: Trabeculectomy combined MMC has a high successful rate in treatment of glaucoma with good long-term effect, Observation from repeated surgery also showed satisfactory results.

    · KEYWORDS: trabeculectomy ; mitomycin; follow-up time ; repeated surgery for glaucoma

　　0引言

    小梁切除联合丝裂霉素C应用是现代治疗青光眼的主要术式，并取得好的手术效果，但对抗青光眼术后眼压失控病例的再手术的观察报道不多。我院自2001年以来采用此术式治疗青光眼再手术病例19例21眼。现将其追踪随访资料进行回顾性分析并报告如下。

    1对象和方法

    1.1对象 选取2002-04/2005-08的19例21眼在我院眼科手术的青光眼病例，符合以下标准。（1）首次抗青光眼术后眼压失控。（2）检查合作能按医嘱随访者。男8例8眼，女11例13眼，年龄28～61岁。开角型青光眼7眼，闭角型青光眼11眼，继发青光眼3眼。传统小梁切除术20眼、虹膜嵌顿术1眼。

    1.2方法 球后麻醉联合睑轮匝机麻醉。小梁切除按常规进行，MMC为术中一次性使用，浓度为0.2g/L。完成巩膜瓣后，用配制好的MMC溶液棉片置于分离好的巩膜瓣和结膜瓣下2～3min后取出，再用100～200mL生理盐水冲洗。术后常规结膜下注射抗炎药与激素。术后1mo始1次/1mo，6mo始1次/3mo，1a以后3mo至0.5a1次。检查项目包括眼压、滤过泡形态、眼底检查、视力与矫正。每0.5a检查视野。疗效判定标准：A 疗效好：眼压 ＜16mmHg、视力≥0.3、视盘与视野损害无进展。B 疗效较好：不用或仅用局部抗青光眼药物眼压≤21mmHg、视力0.1～0.25、视盘与视野损害无进展。C 疗效差：眼压失控、药物不能控制在正常范围或手术治疗、视力＜0.1。A B项为手术成功标准。

    统计学处理：应用显著性检验中的t 检验方法对术前术后眼压及视力进行数据分析。

    2结果

    2.1随访情况 患者19例随访观察1～3a以上。坚持1a随访19例21眼（100%）、3a以上16例18眼（76%）。随访最长时间达5a。

    2.2疗效 在21眼中8眼疗效好，眼压控制在13.7±2.1 mmHg、9眼疗效较好, 不用或仅用局部抗青光眼药物眼压≤21 mmHg、3眼出现并发症效果差。1a手术成功率86%。3a手术成功率76%。

    2.3手术后眼压 21眼中，术后眼压≤21mmHg18眼（86%），所有术眼术后平均眼压较术前显著降低（35.8±5.32，16.3±4.1，P ≤0.001）

    2.4滤过泡形态 在1a扁平弥散型17眼、微小囊泡型1眼、缺如型3眼。功能型滤过泡86%。3a微小囊泡型增加为10眼。

    2.5术后视力 术后最佳矫正视力为0.02～0.5，与术前比较：矫正视力≥0.3者8眼（38%）、0.1~0.25 者9眼（43%）、＜0.1者4眼（19%）。0.1以上视为有用视力（81%）、≥0.3者作为视力满意、＜0.1者作为低视力。术前、术后最佳矫正视力为P ≤0.001，差异具有显著性（表1）。

    2.6杯盘比值与视野 随访期15眼杯盘比值与视野无明显变化。

    2.7手术后并发症 角膜上皮损害6眼，低眼压、浅前房发生9眼，其中滤过过强3眼，渗漏1眼， 2眼脉络膜脱离。3a随访晶状体浑浊加重5眼，2眼再一次出现眼压失控行抗青光眼联合手术。除2例加重另做处理外，1眼于术后1mo眼压再次升高接受晶状体手术，均采取积极措施得以良好转归。3a随访晶状体浑浊加重5眼，2眼再1次出现眼压失控行抗青光眼联合手术。

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