作者：唐广贤,田爱军,王晓冰,卢文胜,周永志,吕建华 作者单位：054001）中国河北省邢台市眼科医院
【摘要】 目的：探讨Ahmed青光眼阀植入联合视网膜光凝或冷凝术对新生血管性青光眼治疗的临床效果。
【关键词】 新生血管性青光眼；青光眼阀；视网膜光凝；视网膜冷凝
Ahmed glaucoma valve implantation combined with retinal photocoagulation or cryocoagulation for the treatment of neovascular glaucoma GuangXian Tang, AiJun Tian, XiaoBing Wang, WenSheng Lu, YongZhi Zhou, JianHua Lü Xingtai Ophthalmic Hospital, Xingtai 054001,Hebei Province, China Abstract AIM: To investigate the therapeutic effect of Ahmed glaucoma valve implantation combined with retinal photocoagulation or cryocoagulation for the treatment of neovascular glaucoma. METHODS: Fiftysix cases(58 eyes) with neovascular glaucoma were involved in this study. In them, 25 cases(25 eyes) sufferred from central retinal vein occlusion(CRVO); 21 cases(23 eyes) with diabetic retinopathy; 5 cases(5 eyes) with retinal vasculitis; 4 cases(4 eyes) with carotid artery stenosis; one eye with branch retinal vein occlusion. All cases underwent Ahmed glaucoma valve implantation combined with retinal photocoagulation or cryocoagulation;47 eyes underwent panretinal photocoagulation before and after surgery; 11 eyes underwent peripheral retinal cryocoagulation during surgery. The mean followup time was 18.0±6.2 months. The changes of visual acuity and IOP and complications were observed before and after operation.The results were statistically analyzed. RESULTS: Visual acuity: The visual acuity of 43 eyes were improved at different degrees after surgery, and 15 eyes had no change. The visual acuities were not worsened in any eyes. IOP: The mean IOP decreased from 49.56±8.25mmHg to 17.86±5.25mmHg 6 months after surgery, and the success rate was 85%; the mean IOP decreased from 50.25±7.18mmHg to 18.80±6.81mmHg 12 months after surgery,and the success rate was 78%; There were 19 eyes which were followed up over 24 months. The mean IOP decreased from 51.05±8.10mmHg to 20.12±7.01mmHg, and the success rate was 74%. There were significant differences in IOP reduction before and after surgery. Its complications included hemorrhage in anterior chamber, delaying the formation of anterior chamber, drainage tube endostoma occlusion, drainage plate coated by fiber. All recovered after treatment. CONCLUSION: Ahmed glaucoma valve implantation combined with retinal photocoagulation or cryocoagulation seems to be a safe and effective method for the treatment of neovascular glaucoma.
KEYWORDS: neovascular glaucoma; glaucoma valve; retinal photocoagulation;retina cryocoagulation
方法：选取4a来住院的新生血管性青光眼56例58眼，其中视网膜中央静脉阻塞25例25眼，糖尿病性视网膜病变21例23眼，视网膜血管炎5例5眼，颈动脉狭窄4例4眼，视网膜分支静脉阻塞1例1眼，平均年龄50.6岁，均行Ahmed青光眼阀植入联合视网膜光凝或冷凝治疗，其中47眼于手术前后行全视网膜光凝，11眼于手术中联合周边视网膜冷凝术，平均随访18.0±6.2mo，观察手术前后视力和眼压的变化以及术后并发症的情况，结果进行统计学分析。 结果：视力：术后43眼有不同程度地提高，15眼无变化，无视力下降者。眼压：随访6mo时眼压由术前49.56±8.25mmHg降至17.86±5.25mmHg，总成功率为85%；随访12mo时，眼压由术前50.25±7.18mmHg降至18.80±6.81mmHg，总成功率为78%； 24mo以上随访19眼，眼压由术前51.05±8.10mmHg降至20.12±7.01mmHg，总成功率为74%，手术前后眼压比较差异有非常显著性。并发症主要有前房出血、前房延缓形成、引流管内口堵塞、引流盘纤维包裹，经术后处理均得到了恢复。 结论：Ahmed青光眼阀植入联合视网膜光凝或冷凝是治疗新生血管性青光眼安全有效的方法之一。0引言
新生血管性青光眼( neovascular glaucoma,NVG)是一种难治性青光眼，由于其眼压难以控制，常规手术成功率低，因而常导致患眼剧痛,视力丧失。随着人民生活水平的提高，糖尿病、高血压等病的发病率有逐年增高趋势，NVG发病率也逐年增高，严重影响了这些患者的生活质量。近年来，我们应用Ahmed青光眼阀植入联合视网膜光凝或冷凝对新生血管性青光眼进行治疗，取得了较好的临床效果，现报告如下。
1对象和方法
1.1对象 连续性选取200402/200803间在我科收治的新生血管性青光眼患者56例58眼，女23例23眼，男33例35眼，其中视网膜中央静脉阻塞25例25眼，糖尿病性视网膜病变21例23眼，视网膜血管炎5例5眼，颈动脉狭窄4例4眼，视网膜分支静脉阻塞1例1眼，平均年龄50.6±6.2岁。术前视力光感～0.01者11眼，0.02～0.1者26眼，0.1以上17眼，无光感者4眼；术前平均眼压50.86±6.65mmHg（为未用药时的最高眼压），所有患者均有明显眼部症状，其中16眼和31眼分别于手术前和手术后接受了全视网膜光凝（panretinal photocoagulation,PRP）治疗，11眼由于屈光间质混浊、瞳孔后粘连，难以施行光凝治疗而于术中施行了周边视网膜冷凝术。
1.2方法 手术选择颞上象限，对于接受视网膜光凝或术后能够施行视网膜光凝的47眼施行单纯的引流管植入手术。应用20g/L利多卡因注射液行术侧球周麻醉或球结膜下浸润麻醉，做以穹窿部为基底的结膜瓣，牵引固定直肌，完全分离球结膜和筋膜，暴露巩膜赤道部，取Ahmed减压阀用生理盐水试冲通畅后，将引流盘置于两直肌间的巩膜面。引流管指向角膜，引流盘的前缘以50尼龙线缝合固定于距角膜缘后10mm的浅层巩膜上。修剪引流管，使其斜面向上，在引流管进入前房的相应位置用7号针头做角膜缘前房穿刺，方向与虹膜面平行，并稍有水平偏斜使其形成小的角度，将引流管与虹膜面平行进入前房2～3mm，用约4mm×4mm的异体巩膜瓣覆盖在角膜缘附近的引流管上，80可吸收缝线缝合4针，关闭结膜切口，结膜下注射妥布霉素2万U、地塞米松2.5mg。联合周边视网膜冷凝术的11眼，沿角膜缘行结膜360°剪开并分离做上下内外四条直肌牵引缝线，用国产眼科冷冻机以直径2mm的冷凝头、温度为80°，各象限于直肌附着点部位向后开始冷冻，分3排，冷冻8～10个点，每点冷凝6s，冷凝时冷冻头应垂直于巩膜并中度加压避免重复冷冻。然后再行颞上象限的引流管植入手术。 随访时间:3～42(平均18±6.2)mo。
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