【摘要】 目的：观察羊膜联合Ahmed青光眼减压阀植入术在治疗新生血管性青光眼的疗效和并发症。方法：200801/200909行羊膜联合Ahmed青光眼减压阀植入术25例25眼和单纯Ahmed青光眼减压阀植入术23例23眼的年龄和病因基本匹配的两组患者进行回顾性比较分析。结果：羊膜联合Ahmed青光眼减压阀植入术组出院时成功率96%，术后3mo成功率88%，术后12mo成功率83%。单纯Ahmed青光眼减压阀植入术组出院时成功率91%，术后3mo成功率59%，术后12mo成功率55%。两组中远期效果比较经过χ2检验差异有统计学意义(P<0.05)。结论：羊膜联合Ahmed青光眼减压阀植入术能较安全、有效的治疗新生血管性青光眼，特别是在中远期疗效上优于单纯减压阀植入术。
【关键词】 青光眼减压阀;新生血管性青光眼;生物羊膜
Observation on the effect of biological amnion combined with Ahmed glaucoma valve implantation on neovascular glaucoma
QingZhu Nie, ZhiLi Liu, KongYang Yu,Qian Sha,DianWen Gao
Foundation item: Liaoning Provincial Science and Technology Plan Project, China(No.2009225021)
Department of Ophthalmology, the Affiliated Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China;Department of Ophthalmology, Zhuanghe Hospital, Dalian 116400, Liaoning Province, China;Heilongjiang Eye Hospital, Harbin 150001, Heilongjiang Province, China
Abstract AIM: To observe the longterm effect and complication of biological amnion combined with Ahmed glaucoma valve implantation on neovascular glaucoma.METHODS: This was a retrospective observational case series. Patients with neovascular glaucoma underwent either of the two procedures from Jan. 2008 Sept. 2009. Twentyfive cases 25 eyes underwent biological amnion combined with Ahmed glaucoma valve implantation,while twentythree cases 23 eyes underwent Ahmed glaucoma valve implantation.RESULTS: The success rate of biological amnion combined with Ahmed glaucoma valve implantation was 96% at the time of discharge from hospital and 88% 3 months later, 83% 12 months later; while the rate of Ahmed glaucoma valve implantation were 91% at the time of discharge from hospital and 59% 3 months later, 55% 12 months later. The longterm effects of the two groups had statistical difference (P<0.05).CONCLUSION: It is considered the biological amnion combined with Ahmed glaucoma valve implantation surgery may be effective and safe for treating neovascular glaucoma .
KEYWORDS: glaucoma valve; neovascular glaucoma; biological amnion
0 引言
新生血管性青光眼(neovascular glaucoma, NVG)是一种特别难治的顽固性青光眼，常规的滤过性手术治疗常常难以建立有效的滤过通道，是眼科临床治疗最为棘手的难题之一。近年来国内外开展了青光眼减压阀引流植入物手术治疗NVG。Ahmed(ahmed glancoma valve, AVG)青光眼阀作为一种单向压力敏感阀，以其术后并发症较其他引流物少,成功率高等优点，经常被眼科医师选用[1,2]。但不容忽视的是青光眼减压阀术后并发症尤其是中远期并发症如Ahmed阀盘周围局部纤维化及炎症反应、甚至瘢痕化是导致手术失败,眼压不降的常见原因。如何抑制局部纤维细胞增生,减少瘢痕形成是青光眼手术成功的关键。我科200801/200909行羊膜联合减压阀植入术和单纯减压阀植入术治疗的年龄和病因基本匹配的NVG患者进行了回顾性比较分析，旨在探讨羊膜联合减压阀植入术及单纯减压阀植入术治疗的早期和中远期疗效。
1 对象和方法
1.1 对象
羊膜联合Ahmed青光眼减压阀植入术组25例25眼，男16例，女9例;右眼14例，左眼11例;年龄26～75(平均50.2)岁;病因：视网膜静脉阻塞13眼，糖尿病7眼，视网膜色素变性2眼，眼外伤3眼;视力：无光感11眼，光感5眼，手动/眼前6眼，0.1者3眼。入院时眼压32.8～76.6(平均56.0±8.9)mmHg。所使用的减压阀均为Ahmed青光眼阀，羊膜为生物羊膜。单纯Ahmed青光眼减压阀植入术组23例23眼，男15例，女8例;右眼10例，左眼13例;年龄23～76(平均49.7)岁;病因：视网膜静脉阻塞11眼，糖尿病6眼，视网膜色素变性3眼，眼外伤3眼;视力：无光感9眼，光感6眼，手动/眼前4眼，0.1者4眼。入院时眼压31.8～75.7(平均54.3±10.6)mmHg。所使用的减压阀均为Ahmed青光眼阀。所有患者术前均见明显的虹膜新生血管，房角广泛粘连关闭。术前经最大耐量的降眼压药物治疗，眼压不能得到控制。
1.2 方法
羊膜联合Ahmed青光眼减压阀植入术前200g/L甘露醇静点;尼目克司50mg，口服;尽可能降低眼压。用20g/L利多卡因与7.5g/L布比卡因按3∶2比例混合液常规球后阻滞麻醉。于颞上象限上、外直肌间沿角膜缘做以穹窿部为基底的结膜瓣，分离筋膜暴露巩膜至赤道部稍后方。将25mm×25mm大小的羊膜片剪为两等份，将其中一份羊膜片上皮面朝上，展铺于赤道部稍后方的巩膜表面，Ahmed青光眼阀冲洗通畅后，将Ahmed青光眼阀的引流盘置于两条直肌间羊膜表面，使其前缘距角膜缘10～12mm，用50尼龙线固定于巩膜2针。置另一份羊膜片上皮面朝下于AVG引流盘表面。做角膜缘为基底1/2的巩膜瓣，用7号注射针头在巩膜瓣下角膜缘做前房穿刺。将AVG引流管修剪适当长度和角度，于前房穿刺口深入前房2～3mm引流管前端与虹膜平行。100尼龙线密闭缝合巩膜瓣及结膜瓣，颞下区结膜下注射地塞米松2mg，典必殊眼膏涂眼。单纯Ahmed青光眼减压阀植入术除未置羊膜外余步骤同上。手术完全成功：6mmHg≤眼压≤21mmHg，不用抗青光眼药物;部分成功：6mmHg≤眼压≤21mmHg，加用局部抗青光眼药物或无视功能眼，眼压>21mmHg,但由高眼压引起的症状完全缓解;失败：需进一步抗青光眼手术，或是长期低眼压(<6mmHg),或发生严重的并发症或原有视功能丧失。
统计学分析：采用SPSS 16.0统计学软件进行统计分析，计量资料所有数据均以±s表示。两组间测量指标的均数比较采用独立样本t检验。两组间测量指标率的比较采用χ2检验。P<0.05为差异有统计学意义。
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