【摘要】 目的：观察脐带静脉管在兔眼非穿透性小梁手术(nonpenitrating trabecular surgery, NPTS)中抗瘢痕化及其毒副作用。方法：对30只家兔双眼行NPTS，按照自身对照原则，术中一眼于深层巩膜切除处放置经醛化脐带静脉管组成实验组，另一眼不植入为对照组。术后观察眼压、滤过泡和眼局部反应，并做组织学及超声生物显微镜（UBM）检查。结果：术后1～5wk滤过泡存留例数实验组大于对照组（P<0.05）；术后3d及6wk以后两组差异无显著性。术前眼压两组差异无显著性，术后1～8wk实验组低于术前，对照组术后1～2wk眼压低于术前（P<0.05），术后1～8wk实验组平均眼压低于对照组（P<0.05）。对照组术后2wk减压房被纤维组织充填，滤过道关闭，实验组术后28wk房水减压房内仍可见脐带静脉管，与周围瘢痕组织不发生紧密粘连，滤过道仍存在。术后1～28wk UBM检查脐带静脉管未降解，减压房仍然存在。术后：前房出血2眼（两组各1例），高眼压1眼（对照组），其余两组在观察期内均无明显炎症反应，植入物未见裸露及被排出现象。 结论：醛化脐带静脉管可在家兔非穿透性小梁手术中防止滤过道粘连，维持巩膜间腔的存在，有效地降低眼压，无免疫排斥反应。
【关键词】 脐带静脉管；非穿透性小梁手术；青光眼
Experimental study on the application of human umbilical vein in nonpenitrating trabecular surgery
Lu Pan1, DianWen Gao2, Lei Shi2, QingZhu Nie2, GuangHui Song1
Foundation item: Science Research Fund of Education Department of Liaoning Province (No.202013128)
1Department of Ophthalmology, Minhang Center Hospital of Ruijin Hospital Group, Shanghai 201100, China; 2 Department of Ophthalmology, Shengjing Hospital Affiliated to China Medical University, Shenyang 110003, Liaoning Province, China
AbstractAIM: To experimentally evaluate the effects of human umbilical vein tube implant in nonpenitrating trabecular surgery (NPTS) and its toxic and side effects.
METHODS: Thirty rabbits underwent bilateral nonpenitrating trabecular surgery. An umbilical vein tube was sutured in the scleral bed in one eye, while the other eye served as the control. Intraocular pressure (IOP), filtering bleb, intraocular reactions, histological exams and ultrasound biomicroscopy (UBM) exams of the surgical area were performed postoperatively.
RESULTS: Three days after surgery, the bleb formation was similar in two groups. From the 1st to the 5th postoperative week, the number of existing functional bleb in the experimental group was significantly higher than that in the control group (P<0.05), and there was no statistical difference between the two groups after 6 weeks. Eyes in the experimental group showed longer postoperative IOPreduction periods than those in the control group (8 weeks vs 2 weeks). From the 1st to the 8th week after surgery, the decreasing of intraocular pressure in the experimental group was significantly greater than that in the control group (P<0.05). Histological observation showed that in the control group fibroblastic proceeded to completely fill with fibrin clots and fibroblasts by postoperative day 7. In the experimental group, the decompression space was detectable at all histology study periods. The implant can still be seen at the operative site up to week 28 postoperatively. In the postoperative 128 weeks, UBM exam showed that the implant was not degraded and the decompression space and still been seen. Mild hyphema occurred in 2 eyes and intraocular hypertension occurred in 1 eye postoperatively. No signs of significant inflammations were observed in other individuals of the two groups during the 28 weeks study, and no signs of foreignbody reaction were detected in all the eyes with umbilical vein implant.
CONCLUSION: The use of human umbilical vein in nonpenitrating trabecular surgery can prevent the adhesion of filtering channel and its well biocompatible with no toxity, and this study can provide experimental reference for the clinical use of biomembrane.
KEYWORDS: human umbilical vein; nonpenitrating trabecular surgery; glaucoma
Pan L, Gao DW, Shi L, et al. Experimental study on the application of human umbilical vein in nonpenitrating trabecular surgery. Int J
Ophthalmol(Guoji Yanke Zazhi)2008;8(11):22062209
0引言
近年来，非穿透性小梁手术(nonpenetrating trabecular surgery，NPTS)作为一种新型的抗青光眼手术正逐渐为眼科医生所认识和接受。与传统的小梁切除术相比，此类手术不穿透前房，术中切除深层角巩膜组织，形成减压房，同时保留了菲薄的葡萄膜小梁网组织,这样既可增加房水引流，有效地降低眼压，又可限制术后早期房水的过度外流，减少与滤过过强相关的并发症。显然，房水减压房的开放与否是影响降压效果主要因素，如果单纯切除深层角巩膜组织，由于术后纤维组织增生，往往导致眼压控制失败。为了维持减压房的存在，国内外学者或于术中切除深层角巩膜组织后放置了不同的植入材料，如胶原植入物[1]、网格状透明质酸钠凝胶[2]、羊膜[3]、Healon [4]、自体巩膜[5]、壳聚糖膜[6]等，或在术中应用丝裂霉素(MMC)、5氟尿嘧啶（5FU）[7]，有些取得了较为满意的效果，有些还在不断地探索中。我们通过动物实验，将脐带静脉管作为植入物，观察其在非穿透性小梁手术后维持减压房存在的作用如下。
1材料和方法
1.1材料 采用正常足月分娩的新生儿脐带，于生后4h内无菌采取，用生理盐水冲洗干净，再浸入生理盐水中置于4℃冰箱中12h。用林格氏液500mL(含肝素1000U)彻底冲洗脐带血管管腔内的血迹，在脐带静脉管内插入直径1mm的硬膜外麻醉导管，放于5g/L戊二醛溶液（pH 7.4）中，室温固定36h。剥离取出完整的脐静脉，拔掉麻醉导管，浸入750mL/L乙醇中保存1wk。取样做细菌、霉菌培养，若连续3次阴性，即封闭存放在4℃冰箱内（保存液为750mL/L乙醇）,供随时备用，使用前用生理盐水浸泡0.5h。制作的脐带静脉管内径2.0mm，外径3.0～4.0mm。纯种健康成年日本大耳白兔30只，雌雄不限，质量2.5～4.5kg，由中国医科大学附属二院动物室提供。实验前检查双眼，除外眼部疾患。
1.2方法 按自身对照原则，每只家兔双眼均行非穿透性小梁手术，随机选取一眼于术中植入脐带静脉管，组成实验组，对侧眼不植入组成对照组。术前2d常规用氯霉素滴眼液滴眼，2次/d。5g/L地卡因表面麻醉后，用schiфtz眼压计测量双眼压3次，取均值作基础眼压。846合剂（动物化学保定剂，兽医大学军事兽医研究所生产）0.2～0.3mL/kg im麻醉后，双眼行非穿透性小梁手术。手术均由相同两人完成，具体步骤如下：制作以上方穹窿为基底的结膜瓣，暴露巩膜，做约4mm×5mm大小、1/3巩膜厚度的舌形表层巩膜瓣，向前分离至透明角膜内1～2mm。在浅层巩膜瓣下的巩膜床中，于创缘内1mm勾划出边长为3mm三角形深层巩膜瓣切口，在两侧切口前端相当于角膜缘后方的巩膜突附近，探查、切开Schlemm管外壁，此时即可见房水溢出，以此作为剥离深层巩膜瓣的参考平面，从该瓣的顶端开始向前剖切。此层深度约为巩膜的2/3厚度，基底保留极薄一层巩膜，达Schlemm管后继续向前剖切达透明角膜内1mm。接着用显微镊子撕除Schlemm管内侧壁，此时可见大量房水渗出，而前房不变浅，随后切除此深层巩膜角膜瓣组织。将长约2mm的脐带静脉管管腔垂直于角膜缘方向置于实验眼深层巩膜床表面，位置尽量靠前，用10 0尼龙线将其固定于巩膜床上。对照眼不植入脐带静脉管。松驰间断缝合浅层巩膜瓣共4针，再缝合结膜瓣。双眼结膜下注射地塞米松2mg。术后1wk内每日点氯霉素滴眼液，涂四环素可的松眼膏，不拆除结膜图1兔NPTS术后眼压变化趋势
线。术后1wk内每日观察切口愈合情况、滤过情况及前房炎症反应。于局麻下(5g/L地卡因)每周测量1次眼压。术后每月进行术区UBM检查，观察植入物的吸收情况。将家兔随机分成6组，每组5只，分别于术后1，2，4，8，16,28wk用空气栓塞法处死，立即摘除眼球，石蜡切片，HE染色。观察植入物的代谢吸收及其周围间隙情况。
统计学处理：用美国SPSS 10.0统计软件对各组结果进行统计学分析,P<0.05为差异显著性界限;实验数据以平均数±标准差(±s)记录。比较两组术前与术后每期的差异采用两个独立样本t检验，比较实验组和对照组间眼压的差异采用配对样本t检验，比较术后实验组与对照组间滤过泡存留情况的差异用χ2检验法（n≥40）和Fisher χ2确切检验法(n<40)。
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