[准分子激光非机械性角膜环钻术后的免疫移植反应]

[Immunologic transplant reactions after non-mechanical corneal trepanation with the excimer laser].

作者信息

Seitz B, Langenbucher A, Kus M M, Küchle M, Naumann G O

机构信息

Augenklinik mit Poliklinik, Universität Erlangen-Nürnberg.

出版信息

Ophthalmologe. 1998 Sep;95(9):607-18. doi: 10.1007/s003470050323.

DOI:10.1007/s003470050323

PMID:9793382

Abstract

BACKGROUND

Nonmechanical trephination has been established as the standard procedure in penetrating keratoplasty (PK) for avascular corneal diseases at our institution. The purpose of this study was to analyze the incidence and reversibility of immunologic graft reactions after nonmechanical trephination and to detect potentially causative factors.

PATIENTS AND METHODS

Out of a total series of 400 nonmechanical PKs, 286 consecutive procedures with sufficient follow-up performed between 07/1989 and 09/1997 were included in the study (104 x keratoconus, 78 x Fuchs' dystrophies, 31 x bullous keratopathies, 28 x ulcers, 25 x avascular scars, 12 x stromal dystrophies, 4 x buphthalmos, 4 x others; 202 x PK only, 84 x combined procedures; 276 first PK). The age of the 138 females and 148 males at the time of surgery ranged from 16 to 89 (mean 55 +/- 19) years. The recipient and donor trephinations were performed from the epithelial side using an 193-mm excimer laser (MEL50 or MEL60, Aesculap-Meditec, 1.5 x 1.5 mm spot mode, 16-24 mJ/pulse, repetition rate 30 or 25/s; metal masks). The shape of the recipient trephination was either circular with four or eight "orientation teeth" (n = 251; 5.0-8.0 mm diameter) or elliptical (n = 35, 6.0 x 7.0 to 7.5 x 8.5 mm diameter). In 62% of procedures fresh or short-term-preserved donor tissue was used, and in 38% of procedures the donor tissue was organ-culture-preserved.

RESULTS

During a mean follow-up of 22 +/- 18 months (maximum 7.7 years), 10 acute diffuse (3 irreversible; 1.0%) and 3 chronic focal endothelial graft reactions occurred (4.5%) not earlier than 4 months and not later than 35 months after PK. Elective procedures (3.5%) resulted in significantly (P = 0.01) less reactions than acute corneal ulcers (14.3%). After 1, 2 and 3 years, the cumulative reaction rates (Kaplan-Meier values) were 1.3%, 6.3% and 13.9% in elective procedures, none of which, however, occurred after 26 elliptical trephinations. With fresh or short-term-preserved donor tissue (4.2%), graft reactions did not happen more frequently but earlier (12 +/- 6 months) than with organ-culture-preserved donor tissue (2.2%, 30 +/- 6 months). In patients with keratoconus (4.9%), reactions occurred more frequently (P = 0.05, LogRank) and earlier than in patients with Fuchs' dystrophy (1.3%).

CONCLUSIONS

In addition to well-established optical advantages, nonmechanical trephination seems to have no immunologic drawbacks.

摘要

背景

在我们机构，非机械性环钻术已成为穿透性角膜移植术（PK）治疗无血管性角膜疾病的标准手术方法。本研究的目的是分析非机械性环钻术后免疫性移植反应的发生率和可逆性，并检测潜在的致病因素。

患者与方法

在总共400例非机械性PK手术中，纳入了1989年7月至1997年9月间连续进行且随访充分的286例手术（圆锥角膜104例，富克斯营养不良78例，大泡性角膜病变31例，溃疡28例，无血管性瘢痕25例，基质营养不良12例，牛眼4例，其他4例；单纯PK手术202例，联合手术84例；初次PK手术276例）。138名女性和148名男性手术时年龄在16至89岁之间（平均55±19岁）。使用193毫米准分子激光（MEL50或MEL60，蛇牌-美迪泰克，光斑模式1.5×1.5毫米，能量16 - 24毫焦/脉冲，重复频率30或25次/秒；金属掩膜）从上皮侧进行受体和供体环钻。受体环钻的形状要么是带有四个或八个“定位齿”的圆形（n = 251；直径5.0 - 8.0毫米），要么是椭圆形（n = 35，直径6.0×7.0至7.5×8.5毫米）。62%的手术使用新鲜或短期保存的供体组织，38%的手术使用器官培养保存的供体组织。

结果

在平均22±18个月（最长7.7年）的随访期间，PK术后4个月至35个月内发生了10例急性弥漫性（3例不可逆；1.0%）和3例慢性局灶性内皮移植反应（4.5%）。择期手术（3.5%）导致的反应明显（P = 0.01）少于急性角膜溃疡（14.3%）。1年、2年和3年后，择期手术的累积反应率（Kaplan - Meier值）分别为1.3%、6.3%和13.9%，然而，26例椭圆形环钻术后均未发生反应。使用新鲜或短期保存的供体组织时（4.2%），移植反应发生频率并不更高，但比使用器官培养保存的供体组织（2.2%，30±6个月）更早（12±6个月）出现。圆锥角膜患者（4.9%）的反应发生频率高于（P = 0.05，对数秩检验）富克斯营养不良患者（1.3%），且出现更早。