玻璃体切割术后晶状体改变的临床研究
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摘要
现代玻璃体切割术已成为玻璃体视网膜疾病的常用治疗方法,挽救了不少复杂的玻璃体视网膜疾病患者的视力。为了保持生理性光学系统的完整和减少术后并发症的发生,尽可能保留透明晶体已成为人们的共识。然而玻璃体切割术后晶体混浊的发生和加重相当多见。其发生的确切机制尚不明了。影响因素有:玻璃体腔内填充物对晶状体的直接影响,玻璃体切割术后的葡萄膜炎反应,病人的年龄、血糖水平等。由于术后晶状体无法保留其透明性,混浊加重因而影响病人术后视力的提高,因此有些医生于术中便摘除晶状体,这样做法是否有肯定性还需要进一步探讨。在这种情况下众多学者将眼光投到如何用药物防治玻璃体切割术后并发性白内障的发生,例如调整玻璃体切割手术中使用的灌注液的成分及浓度以期对晶状体代谢的影响最小;向玻璃体腔内植入各种药物的缓释剂型(抗氧化、抗增殖);寻找新的对晶状体影响小的眼内填充物。但这些研究归根结底要依赖于对玻璃体切割术后并发性白内障的可能原因的研究,循其发生原因找其解决办法,国内外多数学者也均意识到这一点,而将眼光投至对玻璃体切割术后并发性白内障的临床分析和实验研究上。本文以2001年5月-2003年10月于我院行玻璃体切割手术的病人为研究对象,将所研究的对象分为﹤50岁一组,≥50岁一组,按玻璃体切割术后并发性白内障的类型进一步分组(后囊膜混浊型、核性、皮质性),明确何种类型白内障的发生率高;本文也评价不同年龄组病人的术后并发性白内障的发生率以及不同眼内填充物组(注入18%C3F8气体、硅油、BSS平衡液)的术后并发性白内障的发生率,进一步探讨玻璃体切割术后并发性白内障的发生机制,以求获得防治玻璃体切割术后并发性白内障的方法。我们观察了103例(103眼)连续的因增殖性玻璃体视网膜病变或玻璃体积血而于我院行玻璃体切割手术的病人,病人均为有晶状体眼,以前没有眼部手术史,没
    
    
    有已知的其他眼病,糖尿病患者及双眼增殖性玻璃体视网膜病变或玻璃体积血的不包括在内,并且病人双眼晶状体混浊程度一致,使得同一个病人双眼晶状体有可比性及至少6个月的随访期限。103例病人中有一例为14岁儿童,术后因全身其他系统疾病使用皮质类固醇激素而被剔除在外,有两例因无法保证6个月的随访期限而不被包括在内。剩余100例(100眼)病人中50岁以上共53人(含50岁),50岁以下47人,男56人,女44人。病人均由我科有熟练技能的教授行玻璃体切割手术,均为单纯玻璃体切割而未同时行环扎手术,术中均以BSS为眼内灌注液,灌注液高度为50厘米,其中玻璃体切割眼内硅油注入术的29眼,玻璃体切割眼内18%C3F8注入术的48眼,玻璃体切割术以BSS平衡液填充玻璃体腔的23眼。术后晶体混浊程度的判定以“晶状体混浊程度分级系统Ⅲ(LOCSⅢ)”,LOCSⅢ分级系统是目前国际上最佳的晶状体混浊程度判定标准,是客观的分级标准。依据于这一系统,我们对术后病人的晶状体情况通过裂隙灯以45度角斜照法以及将焦点集中于晶体核中心法来拍摄照片,并将所获得的照片同标准的照片进行对比。所获得的数据结果使用SPSS统计软件,各组间采用假设检验(两个样本率的比较和多个样本率的比较),P﹤0.05为有显著性差异,P﹤0.01为有非常显著性差异。
    研究结果表明50岁以上病人玻璃体切割术后并发性白内障的发生率为73.58%,其中核性白内障的发生率为50.94%,皮质性白内障的发生率为50.94%,后囊膜性白内障的发生率为22.64%;50岁以下病人玻璃体切割术后并发性白内障的发生率为42.55%。其中核性白内障的发生率为10.64%,皮质性白内障的发生率为10.64%,后囊膜性白内障的发生率为31.91%。50岁以上病人术后并发性白内障的发生率明显高于50岁以下病人,二者差异有显著性(P﹤0.05);玻璃体切割术后核性白内障与皮质性白内障往往伴行。玻璃体切割术后玻璃体腔内填充18%C3F8气体术后并发性白内障的发生率为52.08%,填充硅油术后并发性白内障的发生率为
    
    
    82.76%,填充BSS平衡液术后并发性白内障的发生率为43.48%。填充硅油组术后并发性白内障的发生率明显高于另两组,差异有显著性(P﹤0.05)。
    48例玻璃体腔填充18%C3F8气体的患者有25例发生白内障,可大体上分为三种类型:一过性白内障(可逆性白内障),有14例。特征为后囊膜羽毛状混浊,或鳞状空泡聚集,可局部也可累及全部晶体后囊下。白内障出现的时间从术后翌日起,术后10~25天,随着气体的减少,晶体混浊渐消失;不可逆性白内障,有9例。特点为白内障出现或加重的时间多在术后1~2周,形态不同于一过性白内障,更不随气体减少而消失;静止性白内障,有2例。特点为晶体后囊下点、片状混浊,不随气体减少而减轻;29例注入硅油的患者中有19例于术后3个月内行玻璃体腔硅油取出术,随访至6个月,其中有5例晶状体一直保持透明性,2例白内障继续进展至6个月时晶状体重度混浊,无法窥清眼底,其余12例病人晶状体轻度混浊,在硅油取出后晶状体混浊程度不再继续进展;有10例患者于术后3个月以后行硅油取出,这组病人白内障严重程度较前一组加重,其中有5例病人随访至6个月时晶状体重度混浊,其余5例病人晶状体中度混浊,硅油取出
Pars plana vitrectomy methods are used to treat various types of posterior diseases, and surgery is often required in phakic as well as in aphakic and pseudophakic eyes. Serious posterior segment complications are infrequent, and the most common postoperative complication is later progressive lens opacity. To keep the patient’s eyesight, we must try to keep the crystalline lens clear. But it is very common that the lens lose it’s clarity after operation. The mechanism can not be confirmed at the moment. We studied an expanded series of these patients with a follow-up of 6 months in order to evaluate the incidence of postoperative cataract in patients of different ages and in groups of eyes in which different compositions of intraocular replacements were used. Such as : 18% perfluoropropane(18%C3F8) gas, silicon and BSS fluid.
    The patients were from the number two hospital of JiLin university who were in hospital from 2001-5 to 2003-10.We reviewed 103 consecutive records of posterior segment diseases in phakic eyes, which had been treated by vitrectomy. The patients had no history of previous ocular surgery and no known other ocular diseases. Only patients with an intact crystalline lens in both eyes were included, thereby permitting comparison between both lenses of the same
    
    
    patient. One 14-year-old boy was excluded because of long-term high-dose corticosteroid therapy for a separate systemic condition. The patient developed posterior subcapsular cataracts in both eyes because of the corticosteroids, thereby masking any possible effect of vitrectomy. Two other patients were excluded because the minimum of six months of follow-up could not be obtained. Thus, the study population was 100 patients(100 eyes). We divided the 100 patients into two groups:≥50 years old (53 persons) and <50 years old (47 persons).During the operation BSS were used as irrigating fluid. There were 29 patients who used silicon as the intraocular replacement,48 patients used 18%C3F8,23 patients used BSS fluid. Postoperative lens status was determined using the Lens Opacities Classification System Ⅲ (LOCSⅢ).The LOCSⅢ system has been shown to have excellent intra-observer agreement and to give results comparable to objective lens grading systems. Under this system, color slit-lamp photographs with the slit beam oriented at 450 and the camera focused on the center of the lens were taken by trained photographs.
    Of the patients aged 50 or above 50 years old the rate of occurrence of cataract formation after pars plana vitrectomy is 73.58%,of the patients under 50 years old the rate of which is 42.55% (P﹤0.05).The rate of occurrence of cataract formation in patients who use 18%C3F8, silicon and BSS fluid to replace the vitreous after pars plana
    
    
    vitrectomy is 52.08%, 82.76% and 43.48% respectively( P﹤0.05).
    The result showed that cataract formation after pars plana vitrectomy was relate to the patients’ ages. The older the patients were, the higher the rate of occurrence of cataract formation. The style of the postoperation cataract was related to the patients’ ages and the composition of the intraocular replacements. If the patients was older than 50, it was easy to suffer from nuclear sclerotic cataract after vitrectomy. However posterior subcapsular cataract was often seen in patients who used 18%C3F8 as intraocular replacement after pars plana vitrectomy. Cataract formation after vitrectomy was also relate to diseases after operation, such as high intraocular pressure, uveitis et al. Cataract formation after vitrectomy was also relate to the operation itself. There were at least three possible mechanisms proposed: intraoperative light toxicity, intraoperative oxidation of lens proteins, and surgery-induced changes of the lens’biochemical microenvironment.
    Conclusion: Cataract formation after vitrectomy was relate to the patients’ages and the composition of the intraocular replacements. Using silicon as intraocular replacement after pars plana vitrectomy tends to develope lens opacity mostly. Diseases after th
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