Huang Ting, Wang Yujuan, Gao Na, Wang Tao, Ji Jianping, Chen Jiaqi
From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
Cornea. 2009 Feb;28(2):157-62. doi: 10.1097/ICO.0b013e3181859fa0.
To determine the efficacy and postoperative complications of complex deep lamellar endothelial keratoplasty (DLEK) when used for the management of complex bullous keratopathy with severe vision loss.
Twelve consecutive eyes with severe bullous keratopathy and other associated intraocular abnormalities underwent complex DLEK which was combined with other intraocular surgeries such as vitrectomy, intraocular lens removal, and secondary intraocular lens implantation. An air bubble was used in 9 eyes and an air and C3F8 gas bubble in 3 eyes for tissue support. Prospective data of best spectacle-corrected visual acuity, corneal astigmatism, and curvature were collected on all 12 eyes preoperatively and at 6, 9, and 12 months postoperatively. Average donor endothelial cell density was recorded preoperatively and at 9 months postoperatively.
Preoperatively, severe visual loss was recorded at hand motions (n = 3), count fingers (n = 7), and 20/400 (n = 2). Best spectacle-corrected visual acuity improved in 83% of eyes with vision of 20/67 or better in 42% (5/12) and 20/100 or better in 66% (8/12) of eyes at 12 months postoperatively. Vision was not improved in three eyes due to coexistent retinal disease. Four aphakic eyes underwent secondary intraocular lens implantation later at 4-6 months after DLEK, and best spectacle-corrected visual acuity was increased from count fingers to 20/200 or better. At 12 months postoperatively, average corneal astigmatism and curvature were 2.3 +/- 0.5 diopters and 44.0 +/- 0.9 diopters, respectively. Average central corneal thickness at 12 months postoperatively (541.3 +/- 26.7 microm) was significantly thinner than that before surgery (673.8 +/- 77.5 microm, P < 0.01). Preoperative average donor endothelial cell density was 2685.1 +/- 193.9 cells/mm. At 9 months postoperatively, average endothelial cell density was 1920.1 +/- 94.0 cells/mm (27.3% of endothelial cell loss) in eyes with primary surgery and 1866.3 +/- 92.8 cells/mm (33.9% of endothelial cell loss) in eyes with secondary surgery. Postoperative complications usually occurred within 3 months of surgery. After surgery, 3 eyes showed narrow gaps between the border of the graft and the host. Epithelial bullae in these areas recurred in 2 eyes but disappeared within 3 months. There was one graft dislocation in this series, no pupillary block cases, and no primary graft failures.
In cases of complex bullous keratopathy with severe vision loss, DLEK combined with other intraocular surgeries is a feasible and effective procedure to significantly improve visual acuity to a functional level in most patients. DLEK can be used successfully in eyes with aphakia and other anterior segment abnormalities without a high risk of graft dislocation or failure. Mild postoperative complications usually occurred early after DLEK and did not affect visual outcomes and graft survival if managed appropriately.
确定复杂深板层内皮角膜移植术(DLEK)用于治疗伴有严重视力丧失的复杂大泡性角膜病变的疗效及术后并发症。
连续12只患有严重大泡性角膜病变及其他相关眼内异常的眼睛接受了复杂DLEK手术,该手术与玻璃体切除术、人工晶状体摘除术及二期人工晶状体植入术等其他眼内手术联合进行。9只眼使用了气泡,3只眼使用了空气和C3F8混合气泡以提供组织支撑。收集了所有12只眼术前及术后6个月、9个月和12个月时最佳矫正视力、角膜散光和曲率的前瞻性数据。术前及术后9个月记录平均供体内皮细胞密度。
术前,严重视力丧失的情况为:手动视力(n = 3)、数指视力(n = 7)和20/400视力(n = 2)。术后12个月时,83%的患眼最佳矫正视力得到改善,42%(5/12)的患眼视力达到20/67或更好,66%(8/12)的患眼视力达到20/100或更好。3只眼因并存视网膜疾病视力未改善。4只无晶状体眼在DLEK术后4 - 6个月接受了二期人工晶状体植入,最佳矫正视力从数指提高到20/200或更好。术后12个月时,平均角膜散光和曲率分别为2.3±0.5屈光度和44.0±0.9屈光度。术后12个月时平均中央角膜厚度(541.3±26.7微米)显著薄于术前(673.8±77.5微米,P < 0.01)。术前平均供体内皮细胞密度为2685.1±193.9个细胞/平方毫米。术后9个月时,一期手术患眼的平均内皮细胞密度为1920.1±94.0个细胞/平方毫米(内皮细胞损失27.3%),二期手术患眼的平均内皮细胞密度为1866.3±92.8个细胞/平方毫米(内皮细胞损失33.9%)。术后并发症通常发生在术后3个月内。术后,3只患眼的植片与宿主边缘之间出现狭窄间隙。其中2只眼这些区域的上皮大泡复发,但在3个月内消失。本系列中有1例植片脱位,无瞳孔阻滞病例,也无原发性植片失败病例。
对于伴有严重视力丧失的复杂大泡性角膜病变病例,DLEK联合其他眼内手术是一种可行且有效的手术方法,可使大多数患者的视力显著提高到功能水平。DLEK可成功用于无晶状体眼及其他眼前节异常的眼睛,且植片脱位或失败风险不高。术后轻度并发症通常在DLEK术后早期出现,若处理得当,不影响视力结果和植片存活。