【摘要】 目的：探讨双手微小切口白内障超声乳化吸除术在治疗硅油填充眼并发性白内障的临床疗效及安全性。方法：选取200710/200811收治的病例完整的硅油填充眼并发性白内障患者的31例（31眼），随机分成两组，分别采用两种不同的手术方式。A组16例(16眼)行双手微小切口白内障超声乳化吸除术，B组15例(15眼)行常规的超声乳化吸除术，分别于术前、术后1wk；1，3mo行视力、角膜地形图检查。结果：所有术眼在手术过程中前房稳定，未见切口热灼伤，术后2眼角膜轻度水肿，均在术后1wk内缓解。两组术后均随访3mo以上，未发现有视网膜脱离复发。术后1wk A组最佳矫正视力高于B组，两组间比较，有显著性差异(P<0.05)；术后角膜地形图曲率和散光simk值手术前后比较，B组术后1wk角膜地形图散光与术前相比有显著性差异(P<0.05)。结论：双手微小切口白内障超声乳化吸除术在治疗硅油填充眼并发性白内障时安全有效，临床上值得推广。
【关键词】 微小切口；超声乳化吸除术；硅油；并发性白内障；角膜地形图
Bimanual microphacoemulsification at the treatment of cataract associated with the use of silicon oil
Jing Li, XiaoHui Zhao, YiQiao Xing
Department of Ophthalmology, Peoples Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
Abstract AIM: To evaluate the safety and clinical effect of bimanual icrophacoemulsification at the treatment of cataract associated with the use of silicon oil.METHODS: Thirtyone patients (31 eyes) with cataract associated with the use of silicon oil between October 2007 and November 2008 were randomly divided into two groups. In group A, 16 eyes were treated with bimanual microphacoemulsification, and in group B, 15 eyes were treated with regular phacoemulsification. Their visual acuity, complications, curvature and astigmatism of cornea topography were examined preoperatively, 1 week, 1 month and 3 months after the surgery.RESULTS: The formation of the anterior chamber was successfully maintained in every case. None of the cases showed heat injury from the incision, After surgery, corneal mild edema were found in 2 eyes and relieved within 1 week. There was no recurrence of retinal detachment during the 3month followingup. The best corrected visual acuity in group A was better than that in group B 1 week after surgery, with a statistical significance (P<0.05). No significant changes were found in curvature and astigmatism of cornea topography at 1, 3 months after operation (P>0.05). But there was a significant difference of astigmatism of cornea topography in group B 1 week after surgery compared with preoperative (P<0.05).CONCLUSION: Bimanual microphacoemulsification is a feasible, safe and effective surgery method for the cataract patients associated with the use of silicon oil, it is worth promoting.
KEYWORDS: microincision; phacoemulsification; silicon oil; complicated cataract; cornea topography
0引言
复杂性玻璃体视网膜手术常常需要眼内硅油填充，但是由于硅油长期接触晶状体后囊，晶状体代谢受到干扰，引起营养障碍，随访6mo内白内障的发生率几乎达到100%[1]。白内障的存在使患者残存的视力进一步受到影响，并影响患者眼底情况的观察和诊治。对硅油填充眼并发性白内障进行手术治疗是进一步改善视力的必要手段。然而，硅油填充眼白内障手术困难多、风险大，其手术方式的选择是临床上备受关注的问题。200710/200811我们将采用双手微小切口白内障超声乳化术治疗硅油填充眼并发性白内障的患者与同期常规超声乳化治疗组的患者进行对比分析，探讨该术式对患者角膜形态和屈光状态的影响。
1对象和方法
1.1对象
选取200710/200811间收治的病例完整的硅油填充眼并发性白内障患者的31例（31眼），男18例，女13例，年龄18～65(平均42±3.2)岁，31眼在本次白内障手术以前已经做过1～2次玻璃体切割术，并且联合硅油填充。视网膜脱离手术后随访期间视网膜复位。硅油在眼内填充时间2mo～1a，平均4mo。手术前后常规检查视力、眼底、眼压等。晶状体核硬度按LOCS II分级法为II～IV级，眼压均在10～21mmHg之间。所有病例均在术前予光学相干生物测量仪(IOLMaster)[2]测量眼轴，并结合健侧眼情况确定所需人工晶状体的度数。所有病例均无硅油溢入前房、角膜变性、硅油乳化及眼压高等病变发生。使用博士伦公司生产的Milleniun超声乳化仪，采用个体化控制软件(customized control software，CCS)爆破模式进行手术，其常规参数设置为：能量上限40%～45%，负压180mmHg，脉冲次数70～100次/s，灌注瓶高110～130cm。
1.2方法
将31例(31眼)患者随机分成两组，分别采用两种不同的手术方式。A组16例(16眼)行双手微小切口白内障超声乳化吸除术，其中男8例，女8例；B组15例(15眼)行常规的超声乳化吸除术，其中男9例，女6例，患者取仰卧位，常规消毒铺巾，倍诺喜(4g/L盐酸奥布卡因)表面麻醉。双手微小切口白内障超声乳化吸除术组(A组)：用19G的MVR刀在术眼的右上方作1.4mm透明角膜切口，左上方作1.2mm透明角膜辅助切口，前房注入黏弹剂，连续环形撕囊，水分离及水分层，自主切口伸入去除硅胶套的外径为0.9mm的钛金属乳化针头，自辅助切口伸入外径为1.1mm的灌注式劈核器，用乳化劈核法超声乳化吸除晶状体核，用注吸分离式双手IA系统吸除晶状体皮质，扩大切口至2.0mm，植入Acrismart一体式折叠人工晶状体。常规的超声乳化吸除术组(B组)：做颞侧透明角膜切口，于2∶00位做角膜缘辅助切口。前房注入粘弹剂，连续环形撕囊或开罐式截囊，充分水分离，行超声乳化，抽吸残余皮质，前房再次注入粘弹剂，囊袋内植入人工晶状体。术后常规滴用碘必殊眼药水并适当予托吡卡胺眼药水点眼活动瞳孔。随访>3mo，分别于术后1wk；1，3mo行视力、角膜地形图检查。
统计学分析：应用SPSS 13.0统计软件对两样本均数行t检验。
2结果
2.1术后视力
所有患者均顺利完成手术，术后1wk A组最佳矫正视力高于B组，两组之间比较，有显著性差异(P<0.05)；而术后1mo和3mo的视力比较差异无显著性（表1）。
2.2手术并发症
所有术眼在手术过程中均前房稳定，无后囊破裂、硅油溢入前房，未见切口热灼伤、晶状体皮质残留，术中无虹膜脱出，眼内出血等并发症，术后两组中各有2眼角膜轻度水肿，均在术后1wk内缓解；术后随访未发现有视网膜脱离复发。
2.3角膜地形图
角膜地形图曲率和散光手术前后比较，A组角膜地形图曲率和散光与术前相比无显著性差异；B组术后1wk角膜地形图散光与术前相比有显著性差异(t=3.99，P<0.05)，而术后1，3mo差异无显著性(t=1.41，0.39，P>0.05)（表2）。表1 两组患者手术前后最佳矫正视力眼（略）表2 术前和术后1wk；1，3mo角膜地形图变化（略）
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