【摘要】 目的 观察1.4 mm双手微切口白内障超声乳化联合人工晶状体植入术的临床效果，并与传统同轴超声乳化手术进行比较。方法 年龄相关性白内障患者48例(56眼)，年龄55～75岁，晶状体混浊分级为Ⅱ~Ⅲ级，随机分为2组，每组28眼。Ⅰ组行1.4 mm双手微切口冷超声乳化联合Acri.Smart人工晶状体植入术，Ⅱ组行传统同轴超声乳化人工晶状体植入术。术中记录超声乳化时间和能量。术后第1天、第1周和第1个月观察随访，记录术后的散光改变、裸眼视力和手术并发症，术后1个月同时检查最佳矫正视力。采用卡方检验和t检验对所得数据进行分析。结果 术中，Ⅰ组平均超声乳化时间为(0.75±0.63)min，超声乳化能量为9.6%(Ⅲ级核)和11.6%(Ⅳ级核);Ⅱ组平均超声乳化时间为(1.15±0.56)min，超声乳化能量为12.5%(Ⅲ级核)和20.4%(Ⅳ级核);两组比较，Ⅰ组超声时间更短，超声能量更少，差异均有统计学意义(P<0.05)。视力变化：术后第1天、第1周和第1个月，Ⅰ组裸眼视力≥0.5的分别占82.14%、92.86%和100%，Ⅱ组裸眼视力≥0.5的分别占53.57%、71.43%和96.43%;术后第1天、第1周，Ⅰ组视力≥0.5者均多于Ⅱ组，两组差异有统计学意义(P<0.05)，术后第1个月两组最佳矫正视力≥0.8者均占92.86%，无差异。角膜散光变化：术前与术后比较，两组角膜散光均有不同程度改变;术后第1天，Ⅱ组角膜散光大于Ⅰ组(P<0.05)，术后第1周和第1个月，两组角膜散光差异无统计学意义(P>0.05)。结论 双手冷超乳联合Acri.Smart人工晶状体植入可以使白内障手术切口缩小至1.4 mm，手术源性散光更小，前房密闭稳定，手术安全可靠。

　　【关键词】 双手法;微切口白内障超声乳化;人工晶状体植入;视力;角膜散光

　　Clinical application of 1.4 mm bimanual microphacoemulsification with IOL implantation

　　ZHOU Binbing， LIN Min， ZHU Yudong， et al.

　　Department of Ophthalmology， the First Affiliated Hospital of Guangdong Pharmacy University， Guangzhou China， 510080

　　[Abstract] Objective To investigate the clinical outcomes of bimanual microphacoemulsification with implantation and compare it to traditional phacoemulsification in cataract surgery. Methods Forty-eight eyes of 56 patients with age-related cataract were randomly divided into two groups. The age range was 55~75 years. There were 28 eyes in each group. Group Ⅰ underwent 1.4 mm bimanual cold phacoemulsification while group Ⅱ underwent traditional phaco. Phaco power and time were recorded for each procedure. Follow-up exams were performed on 1 day， 1 week and 1 month after surgery. Preoperative and postoperative astigmatism changes， postoperative visual acuity and complications were assessed for the two groups. Statistical analysis was done with a ?字2 test and t-test. Results The average phaco time(EPT) for group Ⅰ was (0.75±0.63)min， and average power(AP) was 9.6% for a relatively soft nucleus (grade Ⅲ) and 11.6% for a grade Ⅳ nucleus; the EPT for group Ⅱ was (1.15±0.56)min， AP was 12.5% for a grade Ⅲ nucleus and 20.4% for a grade Ⅳ nucleus. A statistically significant difference was found in EPT and AP between the two groups (P<0.05). On the first day， first week and first month after surgery， a visual acuity of 0.5 or better was attained for 82.14%， 92.86% and 100% of patients in group Ⅰ， respectively， and for 53.57%， 71.43% and 96.43% of patients in group Ⅱ， respectively. A visual acuity of 0.8 or better was attained in 92.86% in each group. A statistically significant difference was found between preoperative measurements and 1 day and 1 week postoperatively， but no statistically significant difference was found at 1 month postoperatively. There were statistically significant differences between preoperative and postoperative astigmatism changes in both groups. There was a statistically significant difference in astigmatism between the two groups 1 day postoperatively (P<0.05)， but there was no statistically significant difference after one week and one month (P>0.05). Conclusion Bimanual cold phacoemulsification with Acri.Smart IOL implantation can decrease the incision to 1.4 mm， resulting in a smaller change in corneal astigmatism， and the anterior chamber is obturated and stable during the operation. It is a safe and reliable operation.

　　[Key words]bimanual; microincision phacoemulsification; lens， intraocular， implantation; visual acuity; corneal astigmatism

　　1998年，Agarwal等[1]首次采用无套超声乳化头和灌注劈核器在普通脉冲模式下进行双手白内障吸除术，其目的是使切口更小，损伤更少，散光更轻，手术更快，视力恢复更佳。2006年，我科应用白星技术(White Star)行双手法微切口冷超声乳化白内障联合超强弹性人工晶状体(德国Acri.Smart46s)植入术，并与3.2 mm常规超声乳化术进行了对比研究。现将临床结果报告如下。

　　1 资料和方法

　　1.1 一般资料

　　收集我院2005年12月至2008年12月年龄相关性白内障患者48例(56眼)，年龄55～75岁，平均69.5岁，男25例(32眼)，女23例(24眼)。核硬度按LOCS Ⅲ晶状体混浊分类体系分Ⅱ～Ⅳ级。眼部检查排除角膜白斑、青光眼、糖尿病性视网膜病变、年龄相关性黄斑病变等。随机分为2组：Ⅰ组25例(28眼)，男17眼，女11眼，年龄55~70岁，平均68.5岁，其中Ⅱ级核2眼，Ⅲ级核17眼，Ⅳ级核9眼，行1.4 mm双手法微切口冷超声乳化联合人工晶状体植入术;Ⅱ组23例(28眼)，男15眼，女13眼，年龄57~75岁，平均70.5岁，其中Ⅱ级核3眼，Ⅲ级核16眼，Ⅳ级核9眼，行3.2 mm常规超声乳化联合人工晶状体植入术。

　　1.2 仪器和设备

　　Sovereign超声乳化仪(美国AMO公司)，TOPCON角膜曲率计(日本TOPCON公司)，角膜地形图仪CT-1000(日本SHIN-NIPPON)。为配合手术切口大小，我们采用了两种人工晶状体：Ⅰ组植入Smart46s人工晶状体(德国Acri.Tec公司)，Ⅱ组植入单焦折叠人工晶状体(美国AMO)。

　　1.3 手术方法

　　Ⅰ组表面麻醉后在11点钟位置用1.4 mm角膜穿刺刀做1.4 mm透明角膜隧道。前房内注入其胜黏弹剂。在2点钟位置做1.2 mm透明角膜切口，行5 mm直径连续环行撕囊，用BSS(平衡盐溶液)行水分离、水分层并旋转核。应用Sovereign system系统的白星模式(White Star mode)进行双手超声乳化。将没有外套管的超声乳化针头通过第1个直径1.4 mm的切口插入前房，同时将Duet系统的超微切口灌注手柄(Micro Surgical Technologies，美国)通过左手切口插入前房。先用对冲挤压法将晶状体核一分为二，再采用劈核法将剩余的核分为3~4块，依次乳化吸除。用双手注吸器械行剩余皮质的抽吸，将核碎块清除之后，将超声乳化针头换为抽吸针头来清除残余皮质并抛光后囊。如果切口下方的皮质不好清理，将双手注吸手柄交换位置就可以更容易到达切口下方的囊袋穹隆部。囊袋及前房内注入黏弹剂后，用15°穿刺刀扩大切口至1.6 mm，用Acri.Shooter推注器将Smart46s折叠人工晶状体植入到囊袋内，调整好人工晶状体位置，用双手注吸术将眼内黏弹剂抽吸干净，行前后囊抛光，BSS液形成前房后切口自闭。

　　Ⅱ组表面麻醉后在11点钟位置做3.2 mm透明角膜隧道切口。前房注入其胜黏弹剂。2点钟位置用15°穿刺刀做透明角膜侧切口，行4~5 mm直径的连续环行撕囊和常规水分离、水分层，核旋转。应用Sovereign系统在不启动白星模式下进行传统超声乳化手术，并植入AMO单焦折叠人工晶状体。

　　1.4 冷超声乳化参数设置

　　阻塞状态下的参数设置为：超声能量上限60%，负压350 mmHg，流量25 ml/min。非阻塞状态下的参数设置为：超声能量上限50%，流量35 ml/min，进入阻塞状态的负压阈值为150 mmHg。灌注液瓶高度为110 cm。

　　1.5 观察项目

　　记录术中超声乳化时间和超声乳化能量，观察前房稳定性、术后角膜及切口情况，房水闪辉。观察术后第1天、第1周和第1个月的视力及角膜散光变化。

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