新型白内障手术联合巩膜电凝对于伤口愈合以及角膜散光影响的临床及病理研究
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摘要
非超乳不缝合白内障摘除人工晶状体植入术是先进的白内障手术技术。手术切口的位置、大小以及构型是影响术后角膜形态变化的主要因素。在新型白内障手术中，巩膜电凝作为一项常规步骤，具有止血，使局部巩膜组织产生粘连，加强切口密闭性，预防术后切口渗漏等作用。本研究临床部分应用角膜地形图仪对术前与术后不同时期巩膜隧道切口白内障手术联合巩膜电凝或者不电凝进行分析研究，观察术后3个月内巩膜电凝对角膜散光的影响及其规律。此外，通过动物实验，应用核仁组成区相关嗜银蛋白(AgNORs)表达成纤维细胞(Fb)增殖活性，分析电凝以及不电凝组于术后30天内不同时期伤口愈合的情况，观察巩膜电凝对于伤口愈合的病理改变过程。
本研究结果如下：
1．用直接相减法以及Jaffe矢量分析法分析白内障手术后各个时期巩膜电凝组与非电凝组散光，两组间没有统计学上显著的差别(P＞0.05)。但两组术后随着时间推移，手术源性散光逐渐减少，且巩膜电凝组平均手术源性散光小于非电凝组。
2．在散光轴向方面分析两组间的变化，术前巩膜电凝组与非电凝组角膜散光以逆规性为主，占全部病例的54.55％，术后一天顺规性散光比例增加，以后逆规性散光呈增长趋势，其比例数超过术前。术后散光轴向构成与术前有显著差异(P＜0.05)。
3．巩膜电凝组于手术后各个时期与非电凝组相比，100个成纤维细胞核内的平均棕黑色颗粒数目，没有明显的差别(P＞0.05)。核仁占细胞核的面积比具有统计学显著差异(P＜0.05)。手术后7天巩膜电凝组成纤维细胞核的平均光密度高于非电凝组
天津医科大学硕士研究生学位论文
一
p仍．05人其余各个时期各组间没有统计学上显著差别O川．05）
总之，在新型白内障手术中，巩膜电凝作为一项常规步骤，
具有止血，使局部巩膜组织产生粘连，切口密闭性加强，促进伤
口的愈合，预防术后切口渗漏，激活成纤维细胞，使手术切口早
日愈合。通过巩膜组织的收缩所产生的循规性散光抵消了由于不
缝合所引起的角膜逆规性散光。而且在我们的研究中，并没有发
现由于巩膜电凝所引起的不良炎性反应。
No phaco and non-stitch cataract surgery combined with IOL implantation is an advanced surgery skill .The main factors which affect the shape of the cornea are the structure, location, and length of the incision in the cataract surgery. Sclera cautery is one of the regular steps of the new type cataract surgery, which could stop the hemorrhage during the surgery, produce adhesion in the local surgery area, strengthen and stabilize the incision, and avoid exudates and hemorrhage. We apply computer-assisted corneal topography to study both groups during different period postoperatively, and discuss the effects and regularity of the postoperative astigmatism produced by sclera cautery within 3 month after the surgery. We also apply AgNORs to express the activity of fibroblast, which could analysis the healing process after the cataract surgery of both cautery group and the control group. The results were demonstrated as follows: 1. It had no statistic significance in both groups postoperatively when the surgica
lly induced astigmatism were analysesed by direct subtract and Jaff e method (P>0. 05). But the surgery induced astigmatism decreased step by step postoperatively, and the SIA in cautery group was even smaller than the control group.
2.In the axial analyses of the surgically induced astigmatism, against the rule astigmatism accounted for 54. 55% of all the patients in both groups. The number of with the rule patients increased 1 day postoperatively, but the number of against the rule patients became more and more
after on and surpassed the pre-operative patients. It had statistic significance when referred to axis changes (P<0.05).
3. The average number of black dots in 100 fibroblasts in sclera cautery group had no statistic significance as compared with the control group postoperatively (P>0. 05) The area percentage of nucleolus accounts for the whole cell nuclear had statistic significance when the tow group were compared (P<0.05). But the average optical density was higher in the sclera group when compared with the control group 7 days after the surgery. It had statistic significance (P<0. 05). But it had no statistic significance in any other periods in both groups (P>0.05).
In general, sclera cautery was one of the regular steps of the new type cataract surgery, which could stop the hemorrhage during the surgery, produce adhesion in the local surgery area, strengthen the incision, and avoid exudates and hemorrhage. It could activate the f ibroblast and improve the incision healing. The sclera cautery could subtract the against the rule astigmatism by producing the with the rule astigmatism. It was safe and effective in clinic, and no inflammatory responses were observed.
本研究结果如下：
1．用直接相减法以及Jaffe矢量分析法分析白内障手术后各个时期巩膜电凝组与非电凝组散光，两组间没有统计学上显著的差别(P＞0.05)。但两组术后随着时间推移，手术源性散光逐渐减少，且巩膜电凝组平均手术源性散光小于非电凝组。
2．在散光轴向方面分析两组间的变化，术前巩膜电凝组与非电凝组角膜散光以逆规性为主，占全部病例的54.55％，术后一天顺规性散光比例增加，以后逆规性散光呈增长趋势，其比例数超过术前。术后散光轴向构成与术前有显著差异(P＜0.05)。
3．巩膜电凝组于手术后各个时期与非电凝组相比，100个成纤维细胞核内的平均棕黑色颗粒数目，没有明显的差别(P＞0.05)。核仁占细胞核的面积比具有统计学显著差异(P＜0.05)。手术后7天巩膜电凝组成纤维细胞核的平均光密度高于非电凝组
天津医科大学硕士研究生学位论文
一
p仍．05人其余各个时期各组间没有统计学上显著差别O川．05）
总之，在新型白内障手术中，巩膜电凝作为一项常规步骤，
具有止血，使局部巩膜组织产生粘连，切口密闭性加强，促进伤
口的愈合，预防术后切口渗漏，激活成纤维细胞，使手术切口早
日愈合。通过巩膜组织的收缩所产生的循规性散光抵消了由于不
缝合所引起的角膜逆规性散光。而且在我们的研究中，并没有发
现由于巩膜电凝所引起的不良炎性反应。
No phaco and non-stitch cataract surgery combined with IOL implantation is an advanced surgery skill .The main factors which affect the shape of the cornea are the structure, location, and length of the incision in the cataract surgery. Sclera cautery is one of the regular steps of the new type cataract surgery, which could stop the hemorrhage during the surgery, produce adhesion in the local surgery area, strengthen and stabilize the incision, and avoid exudates and hemorrhage. We apply computer-assisted corneal topography to study both groups during different period postoperatively, and discuss the effects and regularity of the postoperative astigmatism produced by sclera cautery within 3 month after the surgery. We also apply AgNORs to express the activity of fibroblast, which could analysis the healing process after the cataract surgery of both cautery group and the control group. The results were demonstrated as follows: 1. It had no statistic significance in both groups postoperatively when the surgica
lly induced astigmatism were analysesed by direct subtract and Jaff e method (P>0. 05). But the surgery induced astigmatism decreased step by step postoperatively, and the SIA in cautery group was even smaller than the control group.
2.In the axial analyses of the surgically induced astigmatism, against the rule astigmatism accounted for 54. 55% of all the patients in both groups. The number of with the rule patients increased 1 day postoperatively, but the number of against the rule patients became more and more
after on and surpassed the pre-operative patients. It had statistic significance when referred to axis changes (P<0.05).
3. The average number of black dots in 100 fibroblasts in sclera cautery group had no statistic significance as compared with the control group postoperatively (P>0. 05) The area percentage of nucleolus accounts for the whole cell nuclear had statistic significance when the tow group were compared (P<0.05). But the average optical density was higher in the sclera group when compared with the control group 7 days after the surgery. It had statistic significance (P<0. 05). But it had no statistic significance in any other periods in both groups (P>0.05).
In general, sclera cautery was one of the regular steps of the new type cataract surgery, which could stop the hemorrhage during the surgery, produce adhesion in the local surgery area, strengthen the incision, and avoid exudates and hemorrhage. It could activate the f ibroblast and improve the incision healing. The sclera cautery could subtract the against the rule astigmatism by producing the with the rule astigmatism. It was safe and effective in clinic, and no inflammatory responses were observed.
引文
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3．史伟云，谢立信，李绍伟等。巩膜角膜切口的试验和临床研究。眼科研究，1998；16：266-268
4．阎亦农，郝继龙。小梁切除术后角膜曲率变化的观察。眼科研究 1998．VOL16，NO．4。295-7
5. Jone,-M,-E; Noblitt,-R-L; Boleyn,-K-L. et al. Effect of a superficial and a deep scleral pocket incision on the incidence of hyphema. J Cataract refract surg. 1992 SEP; 18(5): 495-9
6. Dick H B, Kohnen T, Jacobi F K, et al. Long-term endothelial cell loss following phacoemulsification through a temporal clear corneal incision. J cataract Refract Surg, 1996;22:63-71
7．南利，汤欣。两种巩膜隧道切口超声乳化白内障吸除手术的疗效比较。中华眼科杂志．2002．38(4)．-220-223
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9．倪卓。眼的解剖组织学及其临床应用，上海，上海医科医科大学出版社，1993，82
10．梁慷，卞征。水下电凝致翼状胬肉切除术后缺血性角巩膜坏死1例。眼外伤职业眼病杂志 1998，Vol20，No．6，615．
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12. Gimble HV;Sun R; De Broff BM. Effects of would architecture and suture technique on postoperative astigmatism. Opthalmic Surg Laser 1995 Nov-Dec; 26(6): 524-8
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17．汤欣，袁佳琴。角膜地形图仪和角膜曲率仪对正常角膜检测的对比分析。中国实用眼科杂志．1996．14(1)．-24-26
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19．林振德，陈家祺，李绍珍等。人工晶体植入术的早期角膜地形图改变。眼科研究1994，12：167
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21．张葵，李志辉，陆文秀。角膜地形图和角膜曲率计测量散光的研究。中华眼科杂志 1998，VOL．34，NO．6。448-50
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59．刘亦志，李绍珍。人工晶体植入术后早期角膜地形图的变化。中华眼科杂志，1996；1995，75：47
2．王嘉健，陆国生，徐格致等。4mm巩膜隧道自闭切口白内障超声乳化吸出术。中国实用眼科杂志1998；16：536-539
3．史伟云，谢立信，李绍伟等。巩膜角膜切口的试验和临床研究。眼科研究，1998；16：266-268
4．阎亦农，郝继龙。小梁切除术后角膜曲率变化的观察。眼科研究 1998．VOL16，NO．4。295-7
5. Jone,-M,-E; Noblitt,-R-L; Boleyn,-K-L. et al. Effect of a superficial and a deep scleral pocket incision on the incidence of hyphema. J Cataract refract surg. 1992 SEP; 18(5): 495-9
6. Dick H B, Kohnen T, Jacobi F K, et al. Long-term endothelial cell loss following phacoemulsification through a temporal clear corneal incision. J cataract Refract Surg, 1996;22:63-71
7．南利，汤欣。两种巩膜隧道切口超声乳化白内障吸除手术的疗效比较。中华眼科杂志．2002．38(4)．-220-223
8．廉景才，吕世荣，汪宝麟等。兔眼巩膜透热电凝术的实验研究。眼科研究 1991VOL19，No．2．85-7
9．倪卓。眼的解剖组织学及其临床应用，上海，上海医科医科大学出版社，1993，82
10．梁慷，卞征。水下电凝致翼状胬肉切除术后缺血性角巩膜坏死1例。眼外伤职业眼病杂志 1998，Vol20，No．6，615．
11 Mester,-U; Zuche, -M; Rauber,-M. Astigmatism after phacoemulsification with posterior chamber lens implantation: small incision technique with fibrin adhensive for would closer, J Cataract Refract
Surg. 1993, Sep; 19(5): 6169
12. Gimble HV;Sun R; De Broff BM. Effects of would architecture and suture technique on postoperative astigmatism. Opthalmic Surg Laser 1995 Nov-Dec; 26(6): 524-8
13. Masket,-S. One year postoperative astigmatic comparison of sutured and unsutured 4.0mm scleral pocket incision. J Cataract Refract Surg. 1993 Jul; 19(4):453-6
14．林松，汤欣。中老年人角膜屈光状态与年龄关系的研究。中国实用眼科杂志．1998．16(6)．-340-342
15．徐广第。眼科屈光学。军事医学出版社，1995；70-72。
16．姚晓明。角膜地形图分析。国外医学眼科学分册，1993；17：260-265
17．汤欣，袁佳琴。角膜地形图仪和角膜曲率仪对正常角膜检测的对比分析。中国实用眼科杂志．1996．14(1)．-24-26
18．王曼，齐亚卡尔，陆国生。白内障小切口术后的角膜地形图分析。中华眼科杂志1997，VOL．33，NO．4。280-282
19．林振德，陈家祺，李绍珍等。人工晶体植入术的早期角膜地形图改变。眼科研究1994，12：167
20. Johansen MD, Olsen T, Theodorsen F. The long-term course of the Surgically induced astigmatism after Scleral Tunnel incision. Eur J implant Ref Surg, 1994; 6:337-344.
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