結(jié)膜松弛癥定量定位切除術(shù)的臨床療效觀察

1、結(jié)膜松弛癥定量定位切除術(shù)的臨床療效觀察         11-03-04 11:52:00     編輯：studa20           作者：李青松，張興儒，鄭一仁，項(xiàng)敏泓，周歡明，張振永，張桂麗【摘要】  目的：為了尋求安全、簡(jiǎn)便、經(jīng)濟(jì)、有效切除結(jié)膜松弛癥的手術(shù)方法，評(píng)價(jià)結(jié)膜松弛癥定量定位切除術(shù)和新月形切除術(shù)的臨床療效。方法：采用前瞻性隨機(jī)分組對(duì)照研究方法，將

2、200801/200905在上海中醫(yī)藥大學(xué)附屬普陀醫(yī)院眼科按照結(jié)膜松弛癥診斷標(biāo)準(zhǔn)入選手術(shù)治療患者30例30眼按患者入選編號(hào)末位數(shù)的奇偶數(shù)隨機(jī)分為兩組。奇數(shù)組行結(jié)膜定量定位切除術(shù)15例15眼；偶數(shù)組行結(jié)膜新月形切除術(shù)手術(shù)15例15眼。手術(shù)后第2，4，8wk分別隨訪患者癥狀改善程度，裂隙燈觀察結(jié)膜松弛癥變化情況，測(cè)量淚河、BUT，氯霉素眼液嘗味試驗(yàn)。結(jié)果：結(jié)膜松弛癥定量定位切除儀和結(jié)膜新月形切除術(shù)組術(shù)后4wk，兩組癥狀改善有效率均為87%，無差異。結(jié)膜定量定位切除術(shù)松弛結(jié)膜完全消除，占87%；結(jié)膜新月形切除術(shù)組松弛結(jié)膜完全消除，占73%，差異無統(tǒng)計(jì)學(xué)意義（20.833，P0.361）。結(jié)膜定量定位

3、切除術(shù)后4wk淚河恢復(fù)正常者，占87%，BUT10s者，占73%，氯霉素眼液嘗味試驗(yàn)陽性者，占53%。結(jié)膜新月形切除術(shù)后4wk淚河恢復(fù)正常者，占73%（20.833，P0.361）， BUT10s者，占67%（20.159，P0.690），氯霉素眼液嘗味試驗(yàn)陽性者，占60%（20.136，P0.713），差異均無統(tǒng)計(jì)學(xué)意義。結(jié)論：結(jié)膜松弛癥定量定位切除術(shù)安全、簡(jiǎn)便、準(zhǔn)確、有效，更適合手術(shù)經(jīng)驗(yàn)不足的醫(yī)師開展。 【關(guān)鍵詞】  結(jié)膜松弛癥；定量定位切除術(shù)；外科手術(shù)AbstractAIM: To find a safe, simple resection and costeffective

4、method for the surgical treatment of conjunctivochalasis through a prospective study with randomized comparison observation on the efficacy of treatment device for conjunctivochalasis oriented and quantitative resection.METHODS: Thirty conjunctivochalasis patients 30 eyes with standard diagnosis cri

5、teria in department of Ophthalmology of the Affiliated Putuo Hospital of Shanghai University of Traditional Chinese Medicine from Jan. 2008 to May. 2009 were recruited. Patients were randomly grouped according to the odd or even of the last number of the coding. 15 patients(15 eyes) in odd group rec

6、eived oriented resection and 15 patients(15 eyes) in even group received crescented resection.The improvement degrees of symptom release were observed 2,4 and 6 weeks after operation and tears river, BUT and Tasting of chloramphenicol test essay were tested. RESULTS: The efficacy of symptom release

7、in week 4 was 87% in patient group receiving oriented and quantitative resection with conjunctivochalasis treatment device. The cure rate of conjunctivochalasis in patient group receiving oriented and quantitative resection with conjunctivochalasis treatment device was 87% while 73% in patient group

8、 receiving crescented resection. Theres no significant difference（2=0.833， P=0.361）. In patient group receiving oriented and quantitative resection with conjunctivochalasis treatment device, 87% patients were with recovery of tears river in week 4, 73% patients with BUT10 seconds, 53% patient with T

9、asting of chloramphenicol test essay positive. In patient group receiving crescented resection, 73% patients were with recovery of tears river in week 4 （2 0.833， P0.361）, 67% patients with BUT10 seconds （20.159， P0.690）, 60% patient with Tasting of chloramphenicol test essay positive （20.136， P0.71

10、3）. Theres no significant difference.CONCLUSION: Both operation by conjunctivochalasis treatment device for oriented and quantitative resection and conjunctivochalasis crescented resection are effective while operation by conjunctivochalasis treatment device for oriented and quantitative resection i

11、s more simple and accurate, its more suitable for physician with less operation experience.    KEYWORDS: conjunctivochalasis；conjunctivochalasis oriented and quantitative resection; surgical operation0引言        結(jié)膜松弛癥(conjunctivochalasis,CCh)是年齡相關(guān)性老年人

12、常見眼病1,2，隨著人口老齡化加快，患者日趨增多?；颊咧髟V眼部干澀、異物感、淚溢，嚴(yán)重病例伴有刺痛、灼痛感，角膜潰瘍或結(jié)膜下出血等，影響眼視覺和生活質(zhì)量35。結(jié)膜松弛癥手術(shù)治療主要方法是結(jié)膜新月形切除術(shù)，手術(shù)切除松弛結(jié)膜組織時(shí)因球結(jié)膜移動(dòng)性強(qiáng)，切除量和位置難于準(zhǔn)確。切除量少了容易復(fù)發(fā)；切除量多了切口容易裂開、造成下穹隆縮窄及眼球運(yùn)動(dòng)障礙、傷口感染等并發(fā)癥發(fā)生的危險(xiǎn)68。為了尋求安全、有效、經(jīng)濟(jì)、簡(jiǎn)便治療結(jié)膜松弛癥的手術(shù)方法，優(yōu)化治療方案，最大限度地減少手術(shù)治療的副作用，力求以最小的損傷取得最佳療效。200801/200905前瞻性臨床隨機(jī)分組對(duì)比評(píng)價(jià)結(jié)膜松弛癥定量定位切除術(shù)和新月形切除術(shù)的臨床

13、療效。    1對(duì)象和方法    1.1對(duì)象    1.1.1臨床表現(xiàn) 按結(jié)膜松弛癥診斷標(biāo)準(zhǔn)1，9入選的病例中，結(jié)膜松弛癥引起的干澀、異物感、淚溢、視物模糊、視疲勞、疼痛等癥狀明顯；裂隙燈顯微鏡檢查球結(jié)膜過度松弛成皺褶堆積在下瞼緣、內(nèi)、外眥部之間，影響淚河，堵塞淚小點(diǎn)；結(jié)膜松弛癥分級(jí)級(jí)9，經(jīng)規(guī)范藥物等保守方法治療3mo無明顯效果，有下例3種情況之一者手術(shù)治療。結(jié)膜松弛明顯堵塞淚小點(diǎn)引起淚溢的患者：（1）球結(jié)膜松弛或/和半月皺襞松弛堵塞淚小點(diǎn)。（2）淚小點(diǎn)大小、位置無異常，沖洗淚道通暢。（3）用氯

14、霉素眼液（受試者坐位，頭略后仰）滴眼后10min內(nèi)，嘗味試驗(yàn)陰性。通過眼位或下瞼緣位置改變解除結(jié)膜松弛對(duì)淚小點(diǎn)的阻塞后，嘗味試驗(yàn)陽性。結(jié)膜松弛明顯堆積在下瞼緣上，患者癥狀明顯：（1）結(jié)膜松弛明顯堆積在下瞼緣上，結(jié)膜松弛癥分級(jí)級(jí)。（2）患者主訴干澀、異物感、淚溢、視物模糊、視疲勞、疼痛等癥狀明顯。（3）評(píng)估結(jié)膜松弛癥手術(shù)能夠改善患者部分癥狀，知情同意。（4）淚道系統(tǒng)阻塞的患者要告知手術(shù)后淚溢不能改善，獲得患者知情同意者。結(jié)膜松弛癥引起角膜潰瘍、結(jié)膜下出血、眼瞼不能閉合等問題：（1）結(jié)膜松弛癥分級(jí)級(jí)。（2）結(jié)膜松弛癥引起角膜潰瘍、結(jié)膜下出血。（3）結(jié)膜松弛癥引起眼瞼裂不能完全閉合者。 &

15、#160;  1.2對(duì)象 結(jié)膜松弛癥手術(shù)治療患者30例，男14例，女16例，年齡72.8±7.4歲，按照結(jié)膜松弛癥分級(jí)標(biāo)準(zhǔn)9級(jí)1例、級(jí)20例、級(jí)9例。按患者入選編號(hào)末位數(shù)的奇偶數(shù)隨機(jī)分為兩組，奇數(shù)組行結(jié)膜定量定位切除術(shù)和偶數(shù)組行結(jié)膜新月形切除術(shù)。手術(shù)均由同一位醫(yī)師主刀完成。結(jié)膜松弛癥分級(jí)輕重比較（21.074，P0.584）；兩組年齡大小比較差異無統(tǒng)計(jì)學(xué)意義（t0.888，P0.415，表）。表1  結(jié)膜松弛癥分級(jí)與手術(shù)治療年齡（略）    1.3方法 結(jié)膜定量定位切除術(shù)：用5g/L愛爾卡因在結(jié)膜囊內(nèi)表面麻醉后，開

16、瞼器開瞼，在眼表結(jié)膜囊中放置結(jié)膜松弛癥定量定位切除儀（圖1），中央圓孔與角膜相對(duì)應(yīng)，調(diào)整結(jié)膜松弛癥定量定位切除儀位置使300，900位對(duì)應(yīng)外眥、淚阜（角膜緣300，900位），按手術(shù)前在裂隙燈下設(shè)計(jì)的切除象限位置，術(shù)者從結(jié)膜松弛癥定量定位切除儀切口線上的2個(gè)圓孔中用2個(gè)眼科顯微鑷輕柔拉出松弛結(jié)膜，一邊拉出松弛結(jié)膜一邊透過透明的定量定位切除儀觀察，直到松弛結(jié)膜完全拉出，結(jié)膜表面平復(fù)，而又不牽拉結(jié)膜造成切除過多。將切口線中拉出的松弛結(jié)膜向角膜緣一側(cè)定量定位切除儀面上展平，通過上面的刻度描述計(jì)算切除的松弛結(jié)膜位置和數(shù)量。用眼科顯微剪剪除切口線上的松弛結(jié)膜，取出結(jié)膜松弛癥定量定位切除儀，100尼龍縫線

17、連續(xù)縫合結(jié)膜，結(jié)束后用慶大霉素稀釋液沖洗結(jié)膜囊，涂泰利必妥眼膏包眼。術(shù)后第1d術(shù)眼開始用貝復(fù)舒滴眼液和氧氟沙星滴眼液1wk。術(shù)后7d拆線。拆除縫線后人工淚液滴眼2wk。結(jié)膜新月形切除術(shù)：用5g/L愛爾卡因在結(jié)膜囊內(nèi)表面麻醉后，開瞼器開瞼，用眼顯微無齒鑷夾提松弛結(jié)膜，估計(jì)切除范圍。在距角膜緣45mm的下方球結(jié)膜部位按角膜緣弧度半月形切除松弛的結(jié)膜，100尼龍縫線連續(xù)縫合結(jié)膜，結(jié)束后用慶大霉素稀釋液沖洗結(jié)膜囊，涂泰利必妥眼膏包眼。術(shù)后第1d術(shù)眼開始用貝復(fù)舒滴眼液和氧氟沙星滴眼液1wk。術(shù)后7d拆線。拆除縫線后人工淚液滴眼2wk。        統(tǒng)計(jì)學(xué)分析：采用SAS 6.0統(tǒng)計(jì)軟件包進(jìn)行2及t檢驗(yàn)，P<0.05為差異有統(tǒng)計(jì)學(xué)意義。    2結(jié)果    2.1效評(píng)價(jià) 自覺癥狀改善評(píng)價(jià): 手術(shù)后第2，4，8wk分別采用填表式詢問患者手術(shù)后自覺癥狀改善程度。干澀、異物感、淚溢等癥狀完全控制者為治愈；明顯減少者為改善；不改善者為無效。結(jié)