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关于手术时机的选择,我们认为碱烧伤后越早进行羊膜移植手术治疗效果越好，特别是在1wk内进行手术可以明显减少和阻止并发症的发生。早期行羊膜移植手术有利于抑制更多炎性细胞的浸润，缩短炎症时间，减少炎症范围。Ⅲ度以上的烧伤应尽早作羊膜移植，否则会给受损器官和组织带来难以挽回的恶果，因为烧伤后引起的一系列病理生理过程一旦发生，大多数难以逆转，特别是角膜缘上皮基底层的一部分处于休克状态的干细胞，拖延手术时机，无异于会将濒临绝境的干细胞获救的一线生机完全熄灭。如角膜缘广泛损害或者角膜菲薄，甚至合并睑球粘连，则应同时联合部分或全部板层角膜移植及角膜缘干细胞移植重建眼表[15,16]。本组病例中术后1wk内手术10例12眼，4眼视力>0.1，5眼视力在0.05～0.1，无新生血管生长，3眼角膜透明，角膜血管化者均是伤后2wk后才施行手术。因此，我们认为烧伤后时间越短手术的效果就越好。角膜穿孔或即将穿孔时行角膜移植,结果多数植片由于排斥反应和血管化或继续溶解而导致手术失败[15]，有学者认为此时应先行羊膜移植，待眼表稳定后再决定行二期角膜移植术。研究表明，羊膜移植术能有效的降低角膜在急性烧伤期的炎性反应，防止角膜溃疡及穿孔，减少角膜新生血管形成，为成功的角膜移植建立更好的条件[17]。羊膜移植在治疗急性中度眼表烧伤方面虽然具有明显优势，但在重度烧伤方面却并非如此[18]。对于Ⅳ度以上重症热伤，结膜上皮缺损范围较大，尤其是对应巩膜缺血性坏死患者，羊膜移植仅适于作为一期手术方法。单纯羊膜移植对大部分眼表严重疾患具有良好的治疗作用, 但对角膜缘干细胞完全缺失的患者治疗效果不是很理想。印迹细胞学研究[19],对于角巩膜缘完全遭到破坏的患者，行单纯羊膜移植治疗后, 结膜及角膜上皮表型全部结膜化,对于此类患者应把羊膜移植看作是眼表重建的第一步, 把它作为一种底物附着层来清除角、结膜瘢痕组织,抑制纤维化的同时联合自体或异体角膜缘干细胞移植, 提供干细胞来源重建健康眼表。
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