作者：杨锦，李 冰，杨付合 作者单位：1中国山西省太原市，山西医科大学眼科；2中国山西省太原市，山西省眼科医院；3中国山西省运城市眼科医院
【摘要】 目的：观察羊膜填塞法联合配戴软性角膜接触镜治疗角膜溃疡性穿孔的临床效果，了解此方法的有效性、安全性和局限性。 方法：对11例(11眼)感染性角膜溃疡穿孔的患者采用羊膜填塞治疗。其中，真菌性角膜溃疡穿孔3眼，病毒性角膜溃疡穿孔2眼，细菌性角膜溃疡穿孔5眼，单疱病毒性合并细菌感染者1眼。溃疡穿孔范围0.5～2mm。用羊膜填塞穿孔、用另一羊膜覆盖于整个角膜表面，配戴软性角膜接触镜。 结果：术后1d,11例患者前房均形成，穿孔区密闭良好，随访期间前房深度正常。手术后6wk有完好上皮覆盖，穿孔区角膜厚度逐渐增加,溃疡周边炎症反应减退。术后5mo溃疡瘢痕愈合，溃疡区的角膜厚度稳定。11眼术后视力均有不同程度提高。随访期间未出现复发及严重的并发症。 结论：羊膜填塞法联合配戴软性角膜接触镜治疗<2mm的角膜溃疡性穿孔是有效、安全的，但此方法术后角膜溃疡是瘢痕愈合，适用于穿孔区非角膜中央的患者。
【关键词】 角膜溃疡穿孔；羊膜填塞；软性角膜接触镜
Observation of clinical therapeutic effect of amniotic plugging associated with soft corneal contact lens to treat cornea ulcer perforation
Jin Yang1, Bing Li2, FuHe Yang3
1Department of Ophthalmology, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China; 2 Shanxi Eye Hospital, Taiyuan 030002, Shanxi Province, China; 3 Yuncheng Eye Hospital, Yuncheng 044000, Shanxi Province, China
AbstractAIM: To know the effectively, safety and limitations of amniotic plugging associated with soft corneal contact lens by observing its therapeutic effect among patients with cornea ulcer perforation.
METHODS: Eleven cases (11 eyes) with infected corneal ulcer perforation were treated by amniotic plugging, in which, 3 eyes were with fungus corneal ulcer perforation, 2 eyes with virus corneal ulcer perforation, 5 eyes with bacterial corneal ulcer perforation and 1 eye with herpes simplex associated with bacterial corneal ulcer perforation. The ranges of ulcer perforation was between 0.5 and 2mm. An amnion was used to stuff perforations, and another amnion was covered on the surface of entire corneal. Soft contact lens was worn eventually.
RESULTS: One day after operation, all 11 patients anterior chambers were well formed, perforation area closed tightly, and anterior chambers depth were normal during the period of followup. Six weeks later, perfect epithelium covered; in perforation area the corneal thickness increased gradually; inflammatory reaction around ulcer disappeared. Five months later, the ulcers scar healed, and the corneal thickness was stable. All of their vision had improved with different degrees. Recurrence and sever complications didnt happen during the period.
CONCLUSION: Its effective and safe to cure corneal ulcer perforations whose width is less than 2mm by employing amniotic plugging associated with soft corneal contact lens, but it's healed scarred lastly. So the method is suitable to the patients with ulcer area out of the center.
KEYWORDS: cornea ulcer with perforation; amniotic plugging; soft corneal contact lens
Yang J, Li B, Yang FH. Observation of clinical therapeutic effect of amniotic plugging associated with soft corneal contact lens to treat cornea ulcer perforation. Int J Ophthalmol(Guoji Yanke Zazhi) 2008;8(11):23282329
0引言
临床上由于感染引起的角膜溃疡性穿孔是很多见的，治疗有穿透性角膜移植术、板层角膜移植术、结膜瓣遮盖术、羊膜覆盖术、手术缝合等方法。为寻求一种简单易行、经济实用、在穿透性角膜移植材料缺乏的情况下，我院采用羊膜填塞法联合配戴软性角膜接触镜治疗感染性角膜溃疡穿孔11例取得较满意效果，现报告如下。
1对象和方法
1.1对象 角膜溃疡穿孔患者11例（11眼），其中右眼4例，左眼7例，年龄43～70岁，11例穿孔中，真菌性角膜溃疡穿孔3眼，病毒性角膜溃疡穿孔2眼，细菌性角膜溃疡穿孔5眼，单疱病毒性合并细菌感染者1眼。术前视力：手动～0.04者5眼，0.05～0.1者3眼，0.2～0.4者3眼。穿孔偏鼻侧的1眼，偏颞侧4眼，偏上方2眼，偏下方4眼。穿孔大小均在0.5～2mm，穿孔周边有不同程度的浸润病灶，药物控制炎症后均表现为无前房、低眼压和虹膜嵌顿。
1.2方法 选取同期住院健康剖宫产产妇，产前筛查病毒性肝炎HBsAg阴性、无人免疫缺陷病毒、巨细胞病毒和梅素螺旋体等感染。（1）用生理盐水冲洗干净胎盘表面的血迹。（2）用含抗生素的无菌生理盐水浸泡胎盘5～10min(抗生素混合液中含有50mg/L青霉素、50mg/L链霉素、2.5mg/L两性霉素B)。（3）将羊膜从绒毛膜分离出来，上皮面朝上放在有盖的容器内，用甘油脱水24h后更换甘油为保存液[1]，在4℃冰箱内保存。（1）切除溃疡面坏死组织：手术在显微镜下操作，确定溃疡范围。球后麻醉，用手术刀片尽量切除穿孔周围的炎性坏死组织，刮除角膜溃疡区坏死组织充分暴露溃疡面下健康角膜。（2）羊膜塞的制作：取羊膜浸泡在含2000U/mL妥布霉素的生理盐水中复水0.5h。将羊膜数次折叠，依据穿孔大小卷成羊膜塞。(3)羊膜填塞：用30号穿刺针从正常角膜缘进入前房，注入透明质酸钠形成前房，同时对嵌顿和粘连的虹膜用针头进行还纳分离。用穿刺针阻挡羊膜进入前房，把羊膜塞填塞于穿孔区至角膜全层，松紧适度，剪除多余羊膜，使羊膜塞表面平于角膜上皮层。(4)手术缝合：缝线采用10 0尼龙线，将羊膜塞对位缝合于角膜基质上，经角膜缘注入生理盐水检查呈水密性确定前房形成良好。再另取单层羊膜覆盖于角膜表面，拉紧固定于球结膜。术后用3g/L泰利必妥眼膏贝复舒眼膏加压包盖1d，第2d术眼配戴软性角膜接触镜，并根据原发病灶的病因对症用药，开放点眼。根据前房炎症反应程度给予散瞳及结膜下注射地塞米松。术后及随访需观察有无羊膜脱落、炎症反应、前房深度、虹膜粘连、视力变化等。根据羊膜覆盖角膜愈合情况摘除软镜。
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