角膜上皮瓣弃留对Epi-LASIK矫治近视影响的实验与临床研究
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摘要
机械法准分子激光角膜上皮瓣下磨镶术(Epi—LASIK)是目前最受欢迎的准分子激光表层切削术之一,特别适用于角膜较薄、角膜曲率较大、眼睛易受外伤的患者,因此大大拓展了准分子激光在治疗屈光不正领域的应用范围。同时此种手术方式不仅可以减少其他准分子激光表层切削术如PRK. LASEK等术后常见的角膜刺激症状重、角膜上皮下雾状浑浊(Haze)发生率高等缺点,还可以避免LASIK术中及术后各种并发症如游离瓣、不全角膜瓣、角膜上皮植入、医源性角膜扩张等,其治疗近视的安全性与有效性不断得到临床验证。传统Epi—LASIK术中保留完整的角膜上皮瓣,激光切削基质床后将角膜上皮瓣复位,也称为留瓣型Epi-LASIK(On—flap Epi—LASIK),而目前国内外有些医生手术过程中有意将角膜上皮瓣丢弃,称为弃瓣型Epi—LASIK(Off—flap Epi—LASIK).留瓣型Epi—LASIK与弃瓣型Epi—LASIK临床结果是否有差异及有何差异,目前国内外尚无定论。本研究通过动物实验与临床研究两方面对二者进行比较,即前者建立On—flap Epi—LASIK、Off—flap Epi—LASIK动物模型,旨在从病理组织学角度和分子生物学水平,比较两者术后角膜创伤愈合反应的异同,后者通过临床上对两种手术方式进行前瞻性研究,探讨两种手术方式术后临床结果异同,为屈光手术医生更合理地选择手术方式提供参考。
第一部分兔On—flap Epi—LASIK与Off—flap Epi—LASIK术后早期角膜愈合特点及其对角膜早期创伤炎症反应的影响
目的：研究对比兔On—flap Epi—LASIK与Off—flap Epi—LASIK术后早期角膜不同的愈合方式特点及其对角膜早期创伤愈合反应的影响。
方法：健康Albino纯种白兔34只(68只眼),将其中32只兔按不同取材时间1d、3d、5d、7d随机分为4组,每组8只兔,一眼行On—flap Epi—LASIK,另一眼行Off—fl ap Epi—LASIK手术,另2只兔(4只眼)作为空白对照。应用透射电子显微镜及光镜观察两种手术后角膜上皮愈合特点,免疫组化方法检测角膜基质细胞凋亡数量、角膜基质内碱性成纤维细胞生长因子(bFGF)及增殖蛋白Ki-67的表达情况。
结果：
1.角膜上皮愈合特点On—flap Epi—LASIK组,术后第1d角膜上皮瓣稍微变薄,基底膜与基质床较为紧密地贴合,少量的基底细胞水肿,角膜瓣表面细胞的微绒毛较正常组减少,提示上皮瓣活性尚可；术后第3d上皮瓣水肿达到高峰、线粒体高度肿大、核周间隙明显扩大；术后第5d开始上皮瓣水肿渐渐消退,上皮细胞微绒毛较前增多,至术后第7d开始可见外层的部分上皮细胞逐渐坏死脱落。Off—flap Epi—LASIK组,术后第1d可见切削区域被一层新生的角膜上皮覆盖；术后3-5d,新生上皮细胞逐渐增加至4-5层,上皮表面微绒毛渐增多,未见明显上皮细胞水肿；术后7d上皮层数约5-6层,完整的基底膜与角膜基质贴附良好,角膜基质纤维的排列较整齐。
2.角膜基质细胞的凋亡术后第1d,角膜基质细胞凋亡数目虽然On—flap Epi—LASIK比Off—flap Epi—LASIK稍多,但差异无统计学意义(t=1.326,P>0.05);术后第3d、5d时,On—flap Epi—LASIK比Off—flap Epi—LASIK凋亡数目多,差异均具有统计学意义(t=3.526、t=2.061,P均<0.05)；术后7d时,On—flap Epi—LAS IK组与Off—flap Epi—LASIK组均未见角膜基质凋亡细胞。
3.角膜基质bFGF表达术后第1d,On—flap Epi—LASIK、Off—flap Epi—LASIK角膜基质bFGF表达差异无统计学意义(t=-0.128,P>0.05)；3d、5d时,On—flap Epi—LASIK比Off—flap Epi-LASIK角膜基质bFGF表达稍弱,差异有统计学意义(t=-2.842、t=-2.478,P均<0.05)；第7d时,On—flap Epi—LASIK、Off—flap Epi—LASIK角膜基质bFGF表达差异无统计学意义(t=-0.086,P>0.05)。
4.角膜基质中增殖蛋白Ki-67的表达术后第1d、3d、5d时,On—flap Epi—LASIK组的角膜基质中Ki-67表达明显高于Off—flap Epi—LASIK组,两者差异均有统计学意义(t=2.732、t=3.341、t=2.965,P均<0.05)；术后第7d时,On—flap Epi-LASIK组的角膜基质中Ki-67表达虽然高于Off—flap Epi—LASIK组,但两者差异无统计学意义(t=1.284,P>0.05)。
结论：On-flap Epi-LASIK、Off-flap Epi-LASIK两种角膜表面切削术由于术中对角膜上皮的处理方式不同导致术后不同的上皮愈合方式,引起术后早期角膜创伤愈合反应程度的差异,Off-flap Epi-LASIK的反应程度轻于On-flap Epi-LASIK,提示Off-flap Epi-LASIK能减轻术后早期角膜刺激症状,同时也可能会减轻术后Haze的程度。
第二部分角膜上皮瓣弃留对Epi-LASIK矫治近视影响的临床研究
目的：通过Epi-LASIK手术矫正近视术中保留与去除角膜上皮瓣的临床研究,探讨两种手术方式对中低度及高度近视术后临床结果的异同,为临床中更合理地选择屈光手术方式提供参考。
方法：此研究共包括96例近视眼患者192只眼,根据近视度数分为A组(中低度近视组,56例)与B组(高度近视组,40例),患者双眼同时接受Epi-LASIK手术,征得患者同意后,其中一眼行保留角膜上皮瓣Epi-LASIK术(A1、B1留瓣组),一眼行丢弃角膜上皮瓣Epi-LAS IK术(A2、B2弃瓣组)。观察术后术眼疼痛及畏光、流泪等角膜刺激症状及上皮愈合时间,分别对比A1、A2组及B1、B2组术后1w、1mo及6mo视力、屈光度及1mo、6mo角膜上皮下雾状浑浊(Haze)程度。采用配对t检验对数据进行统计分析。
结果：
1.疼痛：术后第1d,Al与A2的疼痛指数对比及B1与B2的疼痛指数对比差异均无统计学意义(P>0.05)；术后第2、3、5d,A1与A2的疼痛指数对比及Bl与B2的疼痛指数对比差异均有统计学意义(P<0.05)。
2.畏光、流泪等角膜刺激症状：术后第1d,A1与A2的角膜刺激症状对比及B1与B2的角膜刺激症状对比差异均无统计学意义(P>0.05)；术后第2、3、5d,A1与A2的角膜刺激症状对比及B1与B2的角膜刺激症状对比差异均有统计学意义(P<0.05)。
3.角膜上皮愈合时间：A1组与A2组角膜愈合时间分别为(4.56±1.12)d、(3.02±0.63)d,两组间差异有统计学意义(P<0.05)； B1组与B2组角膜愈合时间分别为(4.92±1.38)d、(2.96±0.51)d,两组间差异有统计学意义(P<0.05)。
4.裸眼视力：术后1w,A1组视力差于A2组,两组间差异有统计学意义(P<0.05),B1组视力差于B2组,两组间差异有统计学意义(P<0.05)；术后1、6mo,A1组与A2组间视力差异无统计学意义(P>0.05),B1组与B2组间视力差异无统计学意义(P>0.05)。
5.术后等效球镜度及柱镜度对比：术后1mo.6mo时,A1组与A2组等效球镜度对比及B1组与B2组等效球镜度对比差异均无统计学意义(P>0.05)；术后1mo时,A1组与A2组等效柱镜度对比及B1组与B2组等效柱镜度对比差异均有统计学意义(P<0.05)；术后6mo时,A1组与A2组等效柱镜度对比及B1组与B2组等效柱镜度对比差异均无统计学意义(P>0.05)。
6.Haze:术后1、6mo时,A1组与A2组间haze差异均无统计学意义(P>0.05)；B1组与B2组间haze差异均有统计学意义(P<0.05)。
结论：
1.Epi—LASIK术后早期,对于中低度近视组和高度近视组,丢弃角膜上皮瓣都会减轻术眼疼痛及畏光、流泪等角膜刺激症状,缩短角膜上皮愈合时间,增加角膜的透明度,提高裸眼视力。
2.Epi—LASIK术后1、6个月,不管是高度近视组还是中低度近视组,丢弃角膜上皮瓣与保留角膜上皮瓣术后裸眼视力都逐渐提高,其对裸眼视力的影响无差异。
3.保留角膜上皮瓣Epi—LASIK与丢弃角膜上皮瓣Epi—LASIK术后Haze变化在中低度近视组与高度近视组是有差异的,对于中低度近视组,术后1、6个月留瓣组Haze与弃瓣组Haze程度基本相同,而对于高度近视组,留瓣组Haze明显轻于弃瓣组Haze.
There has been more and more interest in epipolis laser in situ keratomileusis(Epi-LASIK) for its many advantages such as applying to the patients whose cornea was thin, corneal curvature was comparatively large, eye easy was traumatic.As one of surface ablation modalities, Epi-LASIK was expanding the range of excimer laser in therapying ametropia. At the same time, in this operation corneal irritation symptoms and corneal haze were lessened apparently than in photorefractive keratectomy(PRK)and laser subepithelial keratomileusis(LASEK). Some complications related with laser in situ keratomileusis(LASIK) such as free flap,broken flap, corneal epithelium implantation, iatrogenic cornea extention,et al could be avoided in this operation, so it is safety and effectivity in Epi-LASIK therapying myopia. In On-flap Epi-LASIK, corneal epithelium flap was repositioned after laser remotioning corneal stroma, however, some doctors of in and outside the country discarded the corneal flap on purpose which called Off-flap Epi-LASIK. There were no final conclusions at international if there were differences and what differences of On-flap Epi-LASIK and Off-flap Epi-LASIK. In our study, animal experiment and clinical research were done to contrast this two modus operandi. Through setting up the animal models of on-flap Epi-LASIK and off-flap Epi-LASIK in histopathology and molecular biology to study the effects of different way of corneal epithelium wound healing and making prospective studies for this two operation, different clinical effectiveness was made to provide the basis for the selection of a suitable surface ablation modality in photorefractive corrections.
Part I To study the different way of corneal epithelium wound healing and the early inflammatory response of cornea on On-flap Epi-LASIK compared to Off-flap Epi-LASIK in rabbits
Objective:To evaluate the effect of different way of corneal epithelial wound healing and the early inflammatory response of cornea on On-flap Epi-LASIK compared to Off-flap Epi-LASIK in rabbits.
Methods:34healthy Albino white rabbits(68eyes)were used as experimental animals and32of them were randomly divided into4groups (1d、3d、5d、7d) with one eye for On-flap Epi-LASIK and the other eye for Off-flap Epi-LASIK and2of them without treatment were served as blank controls.The way of the corneal epithelium wound healing was observed at1,3,5,7days after surgery by light micrograph and transmission electron microphotograph after On-flap Epi-LASIK and Off-flap Epi-LASIK. The immunohistochemical technique was used to detect the number of the apoptotic cells in the corneal stroma and the expressions of both Basic fibroblast growth factor(bFGF) and proliferin Ki-67in the corneal stroma.
Results:
1. Different feature of the epithelial healing:Light micrograph and transmission electron microscopy demonstrated that at the first day after surgery the epithelial flap was getting a little thinner and the basement membrane of the corneal epithelium in On-flap Epi-LASIK specimens conjuncted with stroma tightly, the microvilli on the epithelial surface reduced, a small number of the basal cells showed edema. The above indicated that the cell viability of epithelial flap was still better in a proper way. At the third day after surgery, the edema of the epithelium flap in the On-flap Epi-LASIK specimens reached to peak. The perinuclear space was expanded and there was the edema of the chondriosome too. At the fifth day after the surgery,the edema of epithelium in the On-flap Epi-LASIK specimens resolved gradually and the microvilli on the epithelial increased than before. At the seventh day after surgery, some epithelial cells of outer layer necrosised and ablated gradually. At the first day after surgery, there was one layer of neogenesis corneal epithelium cell covered the filed of operation in Off-flap Epi-LASIK specimens. At the3to5days after the surgery, the new corneal epithelium increased layer by layer to4-5epithelial cell layers and the microvilli on the epithelial surface increased without obvious edema of epithelium. At the seventh day after the surgery the epithelium cells were5-6sheets and the epithelium cell accreted with the stroma well. The epithelium cell basilar membrane were both integrity. The alignment of the fiber in the corneal stroma is regularity.
2. Keratocyte apoptosis:At the first day after surgery, no difference in TUNEL positive cells were seen between specimens of On-flap Epi-LASIK and Off-flap Epi-LASIK(P>0.05);There was a significant difference for the more number keratocyte apoptosis in On-flap Epi-LASIK compared to Off-flap Epi-LASIK specimens at3、5days after surgery (p<0.05); At the seventh day after surgery, there was no TUNEL positive cells both in On-flap Epi-LASIK and Off-flap Epi-LASIK.
3. Expression of bFGF in the cornea:There was no statistically significant difference in the expression of bFGF in the corneal stroma between On-flap Epi-LASIK and Off-flap Epi-LASIK specimens at1、7days after surgery (P>0.05).But there was a significant increase in the expression of bFGF in the corneal stroma of Off-flap Epi-LASIK compared to On-flap Epi-LASIK specimens at3,5days after surgery (p<0.05).
4.Expression of Ki-67in the cornea:There was no statistically significant difference in the expression of Ki-67in the corneal stroma between On-flap Epi-LASIK and Off-flap Epi-LASIK specimens at7days after surgery (P>0.05). But there was a significant increase in the expression of Ki-67in the corneal stroma of On-flap Epi-LASIK compared to Off-flap Epi-LASIK specimens atl,3,5days after surgery (p<0.05).
Conclusions:There were the specific way of both the epithelium removal and epithelium healing in Off-flap Epi-LASIK comparing to On-flap Epi-LASIK.Therefore, Off-flap Epi-LASIK possibly has a potential advantage over On-flap Epi-LASIK in reducing inflammatory response and irritation symptoms in prophase and the forward incidence of corneal Haze after surface ablation laser refractive surgery.
PartⅡ Clinical study of removing or reserving the epithelial flap on myopia correction by Epi-LASIK
Objective:To compare the advantages and disadvantages on low-to-moderate myopia and high myopia of removing or reserving epithelial flap during epipolis laser in situ keratomileusis (Epi-LASIK) and to offer references in selecting refraction surgery styles.
Methods:A prospectively, double-masked and randomized study was performed on192eyes of96patients including112eyes of low-to-moderate myopia(A group) and80eyes of high myopia(B group). When getting the agreement of each patient, one eye underwent On-flap Epi-LASIK (A1、B1group) randomly and the other eye had Off-flap Epi-LASIK(A2、B2group). All eyes wore bandage contact lens after operation. Corneal irritation symptoms and time of corneal healing were observed after operation;Visual acuity, refractive and corneal haze were evaluated within6months postoperatively. The data was statistical analysis by paired t-test.
Results:
1. Pain:On post operative day1, the difference of subjective mean pain of group Al and group A2with group B1and group B2were not statistically significant (P>0.05);On post operative day2、3and5, the difference of group Al and group A2with group B1and group B2were statistically significant (P<0.05).
2. Corneal irritation symptoms:On post operative day1, the difference of corneal irritation symptoms of group A1and group A2with group B1and group B2were not statistically significant(P>0.05);On post operative day2、3and5, the difference of group Al and group A2with group B1and group B2were statistically significant (P<0.05).
3. Corneal epithelial healing time:The mean time of epithelial healing in groupAl and groupA2was4.56±1.12days and3.02±0.63days respectively, there was significant difference between two groups (P <0.05); The mean time of epithelial healing in groupBl and groupB2was4.92±1.38days and2.96±0.51days respectively, there was significant difference between two groups (P<0.05)
4. The uncorrected visual acuity (UCVA):The mean UCVA on post operative day7of groupAl was lower than groupA2and the difference was statistically significant (P<0.05); The mean UCVA on post operative day7of groupBl was lower than groupB2and the difference was statistically significant (P<0.05);The difference of UCVA of groupAl and groupA2at1st、6th month was not statistically significant (P>0.05); The difference of UCVA of groupB1and groupB2at1st、6th month was not statistically significant (P>0.05)
5. The mean spherical degree and the mean cylindrical degree:The difference of mean spherical degree of groupAl and groupA2with groupBl and groupB2at1st、6th month postoperatively was not statistically significant (P>0.05);The difference of mean cylindrical degree of groupAl and groupA2with groupBl and groupB2at1st month postoperatively was statistically significant (P<0.05);The difference of mean cylindrical degree of groupAl and groupA2with groupBl and groupB2at6th month postoperatively was not statistically significant (P>0.05)
6. Haze:On the developing of corneal haze after the operation, there were not statistical difference between groupAl and groupA2at the1st and6th month respectively (P>0.05), but there were statistical difference between groupBl and groupB2at the1st and6th month respectively (P<0.05).
Conclusions:
1.To both low-to-moderate myopia and high myopia,the Off-flap Epi-LASIK seem to reduce pain and other uncomfortable symptoms in early postopertative period and shorten the epithelial healing time and increase the cornea transparence with better UCVA.
2. To both low-to-moderate myopia and high myopia, the uncorrected visual acuity improved gradually at1st、6th month postoperatively whether removing or reserving the epithelial flap.
3. There were difference between low-to-moderate myopia and high myopia of corneal haze at1st、6th month postoperatively in On-flap Epi-LASIK and Off-flap Epi-LASIK. To low-to-moderate myopia, there was no difference of corneal haze at1st、6th month postoperatively in On-flap Epi-LASIK and Off-flap Epi-LASIK.But to high myopia,the corneal haze of On-flap Epi-LASIK was obviously slighter than that of Off-flap Epi-LASIK.
第一部分兔On—flap Epi—LASIK与Off—flap Epi—LASIK术后早期角膜愈合特点及其对角膜早期创伤炎症反应的影响
目的：研究对比兔On—flap Epi—LASIK与Off—flap Epi—LASIK术后早期角膜不同的愈合方式特点及其对角膜早期创伤愈合反应的影响。
方法：健康Albino纯种白兔34只(68只眼),将其中32只兔按不同取材时间1d、3d、5d、7d随机分为4组,每组8只兔,一眼行On—flap Epi—LASIK,另一眼行Off—fl ap Epi—LASIK手术,另2只兔(4只眼)作为空白对照。应用透射电子显微镜及光镜观察两种手术后角膜上皮愈合特点,免疫组化方法检测角膜基质细胞凋亡数量、角膜基质内碱性成纤维细胞生长因子(bFGF)及增殖蛋白Ki-67的表达情况。
结果：
1.角膜上皮愈合特点On—flap Epi—LASIK组,术后第1d角膜上皮瓣稍微变薄,基底膜与基质床较为紧密地贴合,少量的基底细胞水肿,角膜瓣表面细胞的微绒毛较正常组减少,提示上皮瓣活性尚可；术后第3d上皮瓣水肿达到高峰、线粒体高度肿大、核周间隙明显扩大；术后第5d开始上皮瓣水肿渐渐消退,上皮细胞微绒毛较前增多,至术后第7d开始可见外层的部分上皮细胞逐渐坏死脱落。Off—flap Epi—LASIK组,术后第1d可见切削区域被一层新生的角膜上皮覆盖；术后3-5d,新生上皮细胞逐渐增加至4-5层,上皮表面微绒毛渐增多,未见明显上皮细胞水肿；术后7d上皮层数约5-6层,完整的基底膜与角膜基质贴附良好,角膜基质纤维的排列较整齐。
2.角膜基质细胞的凋亡术后第1d,角膜基质细胞凋亡数目虽然On—flap Epi—LASIK比Off—flap Epi—LASIK稍多,但差异无统计学意义(t=1.326,P>0.05);术后第3d、5d时,On—flap Epi—LASIK比Off—flap Epi—LASIK凋亡数目多,差异均具有统计学意义(t=3.526、t=2.061,P均<0.05)；术后7d时,On—flap Epi—LAS IK组与Off—flap Epi—LASIK组均未见角膜基质凋亡细胞。
3.角膜基质bFGF表达术后第1d,On—flap Epi—LASIK、Off—flap Epi—LASIK角膜基质bFGF表达差异无统计学意义(t=-0.128,P>0.05)；3d、5d时,On—flap Epi—LASIK比Off—flap Epi-LASIK角膜基质bFGF表达稍弱,差异有统计学意义(t=-2.842、t=-2.478,P均<0.05)；第7d时,On—flap Epi—LASIK、Off—flap Epi—LASIK角膜基质bFGF表达差异无统计学意义(t=-0.086,P>0.05)。
4.角膜基质中增殖蛋白Ki-67的表达术后第1d、3d、5d时,On—flap Epi—LASIK组的角膜基质中Ki-67表达明显高于Off—flap Epi—LASIK组,两者差异均有统计学意义(t=2.732、t=3.341、t=2.965,P均<0.05)；术后第7d时,On—flap Epi-LASIK组的角膜基质中Ki-67表达虽然高于Off—flap Epi—LASIK组,但两者差异无统计学意义(t=1.284,P>0.05)。
结论：On-flap Epi-LASIK、Off-flap Epi-LASIK两种角膜表面切削术由于术中对角膜上皮的处理方式不同导致术后不同的上皮愈合方式,引起术后早期角膜创伤愈合反应程度的差异,Off-flap Epi-LASIK的反应程度轻于On-flap Epi-LASIK,提示Off-flap Epi-LASIK能减轻术后早期角膜刺激症状,同时也可能会减轻术后Haze的程度。
第二部分角膜上皮瓣弃留对Epi-LASIK矫治近视影响的临床研究
目的：通过Epi-LASIK手术矫正近视术中保留与去除角膜上皮瓣的临床研究,探讨两种手术方式对中低度及高度近视术后临床结果的异同,为临床中更合理地选择屈光手术方式提供参考。
方法：此研究共包括96例近视眼患者192只眼,根据近视度数分为A组(中低度近视组,56例)与B组(高度近视组,40例),患者双眼同时接受Epi-LASIK手术,征得患者同意后,其中一眼行保留角膜上皮瓣Epi-LASIK术(A1、B1留瓣组),一眼行丢弃角膜上皮瓣Epi-LAS IK术(A2、B2弃瓣组)。观察术后术眼疼痛及畏光、流泪等角膜刺激症状及上皮愈合时间,分别对比A1、A2组及B1、B2组术后1w、1mo及6mo视力、屈光度及1mo、6mo角膜上皮下雾状浑浊(Haze)程度。采用配对t检验对数据进行统计分析。
结果：
1.疼痛：术后第1d,Al与A2的疼痛指数对比及B1与B2的疼痛指数对比差异均无统计学意义(P>0.05)；术后第2、3、5d,A1与A2的疼痛指数对比及Bl与B2的疼痛指数对比差异均有统计学意义(P<0.05)。
2.畏光、流泪等角膜刺激症状：术后第1d,A1与A2的角膜刺激症状对比及B1与B2的角膜刺激症状对比差异均无统计学意义(P>0.05)；术后第2、3、5d,A1与A2的角膜刺激症状对比及B1与B2的角膜刺激症状对比差异均有统计学意义(P<0.05)。
3.角膜上皮愈合时间：A1组与A2组角膜愈合时间分别为(4.56±1.12)d、(3.02±0.63)d,两组间差异有统计学意义(P<0.05)； B1组与B2组角膜愈合时间分别为(4.92±1.38)d、(2.96±0.51)d,两组间差异有统计学意义(P<0.05)。
4.裸眼视力：术后1w,A1组视力差于A2组,两组间差异有统计学意义(P<0.05),B1组视力差于B2组,两组间差异有统计学意义(P<0.05)；术后1、6mo,A1组与A2组间视力差异无统计学意义(P>0.05),B1组与B2组间视力差异无统计学意义(P>0.05)。
5.术后等效球镜度及柱镜度对比：术后1mo.6mo时,A1组与A2组等效球镜度对比及B1组与B2组等效球镜度对比差异均无统计学意义(P>0.05)；术后1mo时,A1组与A2组等效柱镜度对比及B1组与B2组等效柱镜度对比差异均有统计学意义(P<0.05)；术后6mo时,A1组与A2组等效柱镜度对比及B1组与B2组等效柱镜度对比差异均无统计学意义(P>0.05)。
6.Haze:术后1、6mo时,A1组与A2组间haze差异均无统计学意义(P>0.05)；B1组与B2组间haze差异均有统计学意义(P<0.05)。
结论：
1.Epi—LASIK术后早期,对于中低度近视组和高度近视组,丢弃角膜上皮瓣都会减轻术眼疼痛及畏光、流泪等角膜刺激症状,缩短角膜上皮愈合时间,增加角膜的透明度,提高裸眼视力。
2.Epi—LASIK术后1、6个月,不管是高度近视组还是中低度近视组,丢弃角膜上皮瓣与保留角膜上皮瓣术后裸眼视力都逐渐提高,其对裸眼视力的影响无差异。
3.保留角膜上皮瓣Epi—LASIK与丢弃角膜上皮瓣Epi—LASIK术后Haze变化在中低度近视组与高度近视组是有差异的,对于中低度近视组,术后1、6个月留瓣组Haze与弃瓣组Haze程度基本相同,而对于高度近视组,留瓣组Haze明显轻于弃瓣组Haze.
There has been more and more interest in epipolis laser in situ keratomileusis(Epi-LASIK) for its many advantages such as applying to the patients whose cornea was thin, corneal curvature was comparatively large, eye easy was traumatic.As one of surface ablation modalities, Epi-LASIK was expanding the range of excimer laser in therapying ametropia. At the same time, in this operation corneal irritation symptoms and corneal haze were lessened apparently than in photorefractive keratectomy(PRK)and laser subepithelial keratomileusis(LASEK). Some complications related with laser in situ keratomileusis(LASIK) such as free flap,broken flap, corneal epithelium implantation, iatrogenic cornea extention,et al could be avoided in this operation, so it is safety and effectivity in Epi-LASIK therapying myopia. In On-flap Epi-LASIK, corneal epithelium flap was repositioned after laser remotioning corneal stroma, however, some doctors of in and outside the country discarded the corneal flap on purpose which called Off-flap Epi-LASIK. There were no final conclusions at international if there were differences and what differences of On-flap Epi-LASIK and Off-flap Epi-LASIK. In our study, animal experiment and clinical research were done to contrast this two modus operandi. Through setting up the animal models of on-flap Epi-LASIK and off-flap Epi-LASIK in histopathology and molecular biology to study the effects of different way of corneal epithelium wound healing and making prospective studies for this two operation, different clinical effectiveness was made to provide the basis for the selection of a suitable surface ablation modality in photorefractive corrections.
Part I To study the different way of corneal epithelium wound healing and the early inflammatory response of cornea on On-flap Epi-LASIK compared to Off-flap Epi-LASIK in rabbits
Objective:To evaluate the effect of different way of corneal epithelial wound healing and the early inflammatory response of cornea on On-flap Epi-LASIK compared to Off-flap Epi-LASIK in rabbits.
Methods:34healthy Albino white rabbits(68eyes)were used as experimental animals and32of them were randomly divided into4groups (1d、3d、5d、7d) with one eye for On-flap Epi-LASIK and the other eye for Off-flap Epi-LASIK and2of them without treatment were served as blank controls.The way of the corneal epithelium wound healing was observed at1,3,5,7days after surgery by light micrograph and transmission electron microphotograph after On-flap Epi-LASIK and Off-flap Epi-LASIK. The immunohistochemical technique was used to detect the number of the apoptotic cells in the corneal stroma and the expressions of both Basic fibroblast growth factor(bFGF) and proliferin Ki-67in the corneal stroma.
Results:
1. Different feature of the epithelial healing:Light micrograph and transmission electron microscopy demonstrated that at the first day after surgery the epithelial flap was getting a little thinner and the basement membrane of the corneal epithelium in On-flap Epi-LASIK specimens conjuncted with stroma tightly, the microvilli on the epithelial surface reduced, a small number of the basal cells showed edema. The above indicated that the cell viability of epithelial flap was still better in a proper way. At the third day after surgery, the edema of the epithelium flap in the On-flap Epi-LASIK specimens reached to peak. The perinuclear space was expanded and there was the edema of the chondriosome too. At the fifth day after the surgery,the edema of epithelium in the On-flap Epi-LASIK specimens resolved gradually and the microvilli on the epithelial increased than before. At the seventh day after surgery, some epithelial cells of outer layer necrosised and ablated gradually. At the first day after surgery, there was one layer of neogenesis corneal epithelium cell covered the filed of operation in Off-flap Epi-LASIK specimens. At the3to5days after the surgery, the new corneal epithelium increased layer by layer to4-5epithelial cell layers and the microvilli on the epithelial surface increased without obvious edema of epithelium. At the seventh day after the surgery the epithelium cells were5-6sheets and the epithelium cell accreted with the stroma well. The epithelium cell basilar membrane were both integrity. The alignment of the fiber in the corneal stroma is regularity.
2. Keratocyte apoptosis:At the first day after surgery, no difference in TUNEL positive cells were seen between specimens of On-flap Epi-LASIK and Off-flap Epi-LASIK(P>0.05);There was a significant difference for the more number keratocyte apoptosis in On-flap Epi-LASIK compared to Off-flap Epi-LASIK specimens at3、5days after surgery (p<0.05); At the seventh day after surgery, there was no TUNEL positive cells both in On-flap Epi-LASIK and Off-flap Epi-LASIK.
3. Expression of bFGF in the cornea:There was no statistically significant difference in the expression of bFGF in the corneal stroma between On-flap Epi-LASIK and Off-flap Epi-LASIK specimens at1、7days after surgery (P>0.05).But there was a significant increase in the expression of bFGF in the corneal stroma of Off-flap Epi-LASIK compared to On-flap Epi-LASIK specimens at3,5days after surgery (p<0.05).
4.Expression of Ki-67in the cornea:There was no statistically significant difference in the expression of Ki-67in the corneal stroma between On-flap Epi-LASIK and Off-flap Epi-LASIK specimens at7days after surgery (P>0.05). But there was a significant increase in the expression of Ki-67in the corneal stroma of On-flap Epi-LASIK compared to Off-flap Epi-LASIK specimens atl,3,5days after surgery (p<0.05).
Conclusions:There were the specific way of both the epithelium removal and epithelium healing in Off-flap Epi-LASIK comparing to On-flap Epi-LASIK.Therefore, Off-flap Epi-LASIK possibly has a potential advantage over On-flap Epi-LASIK in reducing inflammatory response and irritation symptoms in prophase and the forward incidence of corneal Haze after surface ablation laser refractive surgery.
PartⅡ Clinical study of removing or reserving the epithelial flap on myopia correction by Epi-LASIK
Objective:To compare the advantages and disadvantages on low-to-moderate myopia and high myopia of removing or reserving epithelial flap during epipolis laser in situ keratomileusis (Epi-LASIK) and to offer references in selecting refraction surgery styles.
Methods:A prospectively, double-masked and randomized study was performed on192eyes of96patients including112eyes of low-to-moderate myopia(A group) and80eyes of high myopia(B group). When getting the agreement of each patient, one eye underwent On-flap Epi-LASIK (A1、B1group) randomly and the other eye had Off-flap Epi-LASIK(A2、B2group). All eyes wore bandage contact lens after operation. Corneal irritation symptoms and time of corneal healing were observed after operation;Visual acuity, refractive and corneal haze were evaluated within6months postoperatively. The data was statistical analysis by paired t-test.
Results:
1. Pain:On post operative day1, the difference of subjective mean pain of group Al and group A2with group B1and group B2were not statistically significant (P>0.05);On post operative day2、3and5, the difference of group Al and group A2with group B1and group B2were statistically significant (P<0.05).
2. Corneal irritation symptoms:On post operative day1, the difference of corneal irritation symptoms of group A1and group A2with group B1and group B2were not statistically significant(P>0.05);On post operative day2、3and5, the difference of group Al and group A2with group B1and group B2were statistically significant (P<0.05).
3. Corneal epithelial healing time:The mean time of epithelial healing in groupAl and groupA2was4.56±1.12days and3.02±0.63days respectively, there was significant difference between two groups (P <0.05); The mean time of epithelial healing in groupBl and groupB2was4.92±1.38days and2.96±0.51days respectively, there was significant difference between two groups (P<0.05)
4. The uncorrected visual acuity (UCVA):The mean UCVA on post operative day7of groupAl was lower than groupA2and the difference was statistically significant (P<0.05); The mean UCVA on post operative day7of groupBl was lower than groupB2and the difference was statistically significant (P<0.05);The difference of UCVA of groupAl and groupA2at1st、6th month was not statistically significant (P>0.05); The difference of UCVA of groupB1and groupB2at1st、6th month was not statistically significant (P>0.05)
5. The mean spherical degree and the mean cylindrical degree:The difference of mean spherical degree of groupAl and groupA2with groupBl and groupB2at1st、6th month postoperatively was not statistically significant (P>0.05);The difference of mean cylindrical degree of groupAl and groupA2with groupBl and groupB2at1st month postoperatively was statistically significant (P<0.05);The difference of mean cylindrical degree of groupAl and groupA2with groupBl and groupB2at6th month postoperatively was not statistically significant (P>0.05)
6. Haze:On the developing of corneal haze after the operation, there were not statistical difference between groupAl and groupA2at the1st and6th month respectively (P>0.05), but there were statistical difference between groupBl and groupB2at the1st and6th month respectively (P<0.05).
Conclusions:
1.To both low-to-moderate myopia and high myopia,the Off-flap Epi-LASIK seem to reduce pain and other uncomfortable symptoms in early postopertative period and shorten the epithelial healing time and increase the cornea transparence with better UCVA.
2. To both low-to-moderate myopia and high myopia, the uncorrected visual acuity improved gradually at1st、6th month postoperatively whether removing or reserving the epithelial flap.
3. There were difference between low-to-moderate myopia and high myopia of corneal haze at1st、6th month postoperatively in On-flap Epi-LASIK and Off-flap Epi-LASIK. To low-to-moderate myopia, there was no difference of corneal haze at1st、6th month postoperatively in On-flap Epi-LASIK and Off-flap Epi-LASIK.But to high myopia,the corneal haze of On-flap Epi-LASIK was obviously slighter than that of Off-flap Epi-LASIK.
引文
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1. Sridhar MS, Rao SK, Vajpayee RB, et al. Complications of laser in situ Keratomileusis[J]. Indian J Ophthalmol 2002;50(4):265-282.
2. Dai J, Chu R, Zhou X, et al. One-year outcomes of Epi-LASIK for myopia[J]. J Refract Surg 2006;22(6):589-595.
3. Katsanevaki VJ, Kalyvianaki MI, Kavroulaki DS, et al. One year clinical results after Epi-LASIK for myopia[J]. Ophthalmology 2007;114(6):1111-1117.
4. Camellin M. Laser Epithelial keratomileusis for myopia[J].J Refract Surg 2003:19(6):666-670.
5.Azar DT, Ang RT, Lee JB, et al. Laser subepithelial keratomileusis:electron microscopy and visual outcomes of flap photorefractive keratectomy[J]. Curr Opin Ophthalmol 2001;12(4):323-328.
6.Rudolf A,Jaroslav R. Laser-assisted subepithelial keratectomy and photorefractive keratectomy for the correction of hyperopia, Results of a 2-year follow-up. J Cataract Refract Surg 2003,29(11):2105-14.
7.孙秉基,贺燚,主编。现代角膜移植及角膜激光手术。天津：天津科学技术出版社,1999.127.
8. Kim SY, Sah WJ, Lim YW, et al. Twenty Percent Alcohol Toxicity on Rabbit Corneal Epithelial Cells; electron microscopic study [J]. Cornea,2002,21 (4):388-392.
9. Rudolf A, Jaroslav R. Laser-assisted subepithelial keratectomy for myopia:Two-year follow-up [J]. J Caratact Refract Sury,2003,29(4): 661-668.
10. Panagopoulon S I,Pallikaris I G. Wavefront customized ablations with the WASCAAsclepion workstation[J]. Refract Surg,2001,17(8): 608-612.
11. Kalyvianaki M I, Katsanevaki V J, Kavroulaki D S, et al. Comparison of corneal sensitivity and tear function following epi-LASIK or laser in situ keratomileusis for myopia[J]. Am J Ophthalmol,2006,142 (4): 669-671.
12. Sharma N, Kaushal S, Jhanji V, et al. Comparative evaluation of 'flap-on'and'flap-off techniques of Epi-LASIK in low-to-moderate myopia[J]. Eye,2009,23(9):1786-1789.
13. Kalyvianaki MI, Kymionis GD, Kounis GA, et al. Comparison of Epi-LASIK and off-flap Epi-LASIK for the treatment of low and moderate myopia[J]. Ophthalmology 2008;115(12):2174-80.
14. Wang QM, Fu AC, Yu Y. et al. Clinical investigation of off-flap epi-LASIK for moderate to high myopia[J]. Invest Ophthalmol Vis Sci.2008 Jun;49(6):2390-2394.
15. Chen W L, Shen E P, Hsieh Y T, et al. Comparison of in vivo confocal microscopic findings between epi-LASIK procedures with different management of the epithelial flaps[J]. Invest Ophthalmol Vis Sci,2011,52(6):3640-3647.
16. Pallikaris IG, Kalyvianaki MI, Katsanevaki VJ, et al. Epi-LASIK:preliminary clinical results of an alternative surface ablation procedure[J].J Cataract Refract Surg,2005:31(5):879-885.
17.周行涛,褚仁远,王晓瑛,等.无痛性准分子激光角膜上皮瓣下磨镶术及微型角膜刀准分子激光角膜上皮瓣下磨镶术的临床研究[J].中华眼科杂志,2005：41(11)：977-980.
18.戴锦晖,陈冲达,褚仁远,等.机械法准分子激光角膜上皮瓣下磨镶术矫治高度近视[J],中华眼科杂志,2005;41(3)：211-215.
19. Fitzsimmons T D, Fgerlolm P, Harfstrand A, et al. Hyaluronic acid in the rabbit cornea after excimer laser superficial keratectomy [J]. Invest Ophthalmol Vis Sci,1992,33(11):3011-3016.
20.Michael J.Endl无瓣Epi-LASIK术后结果很有希望[J],眼外科新闻(OSN),2008,19(1)：8-9.
21.杨智,赵海鸥,梁莉,等Epi-LASIK术中上皮瓣去留的临床研究.临床眼科杂志,2009,17(1)：23-24.
22. Netto MV, Mohan RR, Sinha S, et al. Stromal haze, myofibroblasts, and surface irregularity after PRK[J].Exp Eye Res,2006;82(5):788-797.
1. Trokel SL, Srinivasan R, Braren B. Excimer laser surgery of the cornea. Am J Ophtholmol,1983,96(6):710-715.
2. Seiler T, Holschbach A, Derse M, Jean M, Genth U. Complications of myopia photorefractive keratectomy with the excimer laser. Ophtholmology,1994,101(1):153-160.
3. Pallikaris IG, Siganos DS. Excimer laser in situ keratomileusis and photorefractive keratectomy for the correction of high myopia. J Refract Corneal Surg,1994,10 (5):498-510.
4. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O, Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med,1990,10(5):463-468.
5.Knorz MC. Complications of refractive excimer laser surgery. Am J Ophthalmol,2006,103(3):192-198.
6. Wang MY, Maloney RK.Epithelial in growth after laser in situ keratomileusis[J]. Am J Ophthalmol,2000,129 (6):746-751.
7.Shah MN, Misra M, Wilhelmus KR,et al. Diffuse lamellar keratitis associated with epithelial defects after laser in situ keratomileusis[J].J Cataract RefractSurg,2000,26(9):1312-1318.
8.Ambrosio RJr, Wilson S.LASIK vs. LASEKvs. PRK:advantages and indications. Semin phthalmol,2003,18:2-10.
9. Camellin M. LASEK may offer the advantages of both LASIK and PRK. Ocu Surg News(International Edition),1999,10(3):14-15.
10. Kornilovsky IM. Clinical Results after Subepithelial Photorefractive Keratectomy(LASEK)[J]. J Refract Surg,2001,17(2S):S222-223.
11.Pallikaris IG, Katsanevaki VJ, Kalyvianaki MI,et al. Advances in subepthelial excimer refractive surgery techniques:Epi-LASIK[J]. Curr Opin Ophthalmol,2003,14(4):207-212.
12. Pallikaris IG, Naoumidi II, Kalyvianaki MI, et al. Epi-LASIK:Comparative Histolgical Evaluation of Mechanical and Alcohol-assisted Epithelial Separation[J]. J Cataract Refract Surg,2003,29(8):1496-1501.
13. Tychsen L, Packwood E, Berdy G. Correction of Large Amblyopi genIc Refractive Errors in Children Using the Excimer Laser[J].J AAPOS,2005,9 (3):224-233.
14.Sharma N,Kaushal S,Jhanji V,et al.Comparative evaluation of 'flap on' and 'flap off' techniques of Epi-LASIK in low-to-moderate myopi a. Eye,2009,23:1786-1789.
15. Wang QM, Fu AC, Yu Y, et al. Clinical investigation of off-flap epi-LASIK for moderate to high myopia. Invest Ophthalmol Vis Sci,2008,49:2390-2394.
16. Kalyvianaki MI, Kymionis GD, Kounis GA, et al. Comparison of Epi-LASIK and off-flap Epi-LASIK for the treatment of low and moderate myopia. Ophthalmology,2008,115:2174-2180.
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23. Stojanovic A, Nitter TA. Correlation between ultraviolet radiation level and the incidence of late-onset corneal haze after photorefractive keratectomy. J Cataract Refract Surg,2001,27:404-410.
24. Lipshitz I,Loewenstein A,Varssano D, et al. Late onset corneal haze after photorefractive keratectomy for moderate and high myopia. Ophthalmology,1997,104:369-374.
25. Pallikaris IQ, Kalyvianaki MI, Katsanevaki VJ. Epi-LASIK:Preliminary clinical results of an alternative surface ablation Procedure.J Cataract Refract Surg,2005,31:879-885.
26.戴锦晖,陈冲达,褚仁远,等.机械法准分子激光角膜上皮瓣下磨镶术矫治高度近视.中华眼科杂志,2005,41(3)：211-215.
27.王琦,袁满红.准分子激光屈光手术后Haze形成的相关因素分析[J].中国实用眼科杂志,2008,26(9)：888-891.
28.赵愈敏,袁南荣,袁志兰,卢善华.丝裂霉素C与地塞米松治疗PRK后角膜上皮下雾状混浊的对比实验研究[J].眼科新进展Yanke Xin jinzhan 2002; 22(2):88-90.
29. Carones F, Vigo L, Scandola E, Vacchini L. Evaluation of the prophylactic use of mitomycin-C to inhibit haze formation after photorefractive keratectomy. J Cataract Refract Surg,2002,28:2083-2095.
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2. Seiler T, Holschbach A, Derse M, Jean M, Genth U. Complications of myopia photorefractive keratectomy with the excimer laser. Ophtholmology,1994,101(1):153-60.
3. Pallikaris IG, Siganos DS. Excimer laser in situ keratomileusis and photorefractive keratectomy for the correction of high myopia. J Refract Corneal Surg,1994,10(5):498-510.
4. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O,Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med,1990,10(5):463-8.
5. Knorz MC.Complications of refractive excimer laser surgery.Am J Ophthalmol,2006,103(3):192-8.
6. Schallhorn SC, Amesbury EC, Tanzer DJ. Avoidance, recognition, and management of LASIK complications. Am J Ophthalmol,2006,141(4):733-9.
7. Camellin M. LASEK may offer the advantages of both LASIK and PRK. Ocu Surg News(International Edition),1999,10(3):14-5.
8. Pallikaris IG, Katsanevaki VJ, Kalyvianaki MI, et al. Advances in subepthelial excimer refractive surgery techniques:Epi-LASIK[J]. Curr Opin Ophthalmol,2003,14(4):207-12.
9. Pallikaris IG, Naoumidi Ⅱ, Kalyvianaki MI,et al. Epi-LASIK:comparative histological evaluation of mechanical and alcohol-assisted-epithelial separation. Cataract Refract Surg,2003,29 (4):1496-1501.
10.戴锦晖,陈冲达,褚仁远,等.机械法准分子激光角膜上皮瓣下磨镶术矫治高度近视.中华眼科杂志,2005,41：211-215.
11. Kalyvianaki MI, Kymionis GD,Kounis GA, et al. Comparison of Epi-LASIK and off-flap Epi-LASIK for the treatment of low and moderate myopia[J]. Ophthalmology.2008;115(12):2174-2180.
1. Netto MV, Mohan RR, Ambrosio R Jr, et al. Wound healing in the cornea:a review of refractive surgery complications and new prospects for therapy[J]. Cornea,2005,24(5):509-522.
2.陈冲达,周行涛,戴锦晖,等.微型角膜刀法与乙醇浸润法准分子激光上皮瓣下磨镶术对角膜基质细胞影响的实验研究.中华眼科杂志,2006,42(9)：796-801.
3. Jared schultz.表面手术最适合于薄角膜高度近视Ocular surgery News China Edition,2007,18(11):16.
4. Rudolf A, Jaroslav R. Laser-assisted subepithelial keratectomy for myopia:Two-year follow-up [J]. J Caratact Refract Surg,2003,29(4): 661-668.
5. Rudolf A, Jaroslav R. Laser-assisted subepithelial keratectomy and photorefractive keratectomy for the correction of hyperopia results of a 2-year follow-up [J]. J Caratact Refract Surg,2003,29(11): 2105-2114.
6. Azar DT, Ang RT. Laser subepithelial keratomileusis:evolution of alcohol assisted flap surface ablation.Int Ophthalmol Clin,2002,42:89-97.
7. Claringbold TV Ⅱ. Laser-assisted subepithelial keratectomy for the correction of myopia. J Cataract Refract Surg,2002,28:18-22.
8. Panagopoulon S I,Pallikaris I G. Wavefront customized ablations with the WASCAAsclepion workstation[J]. Refract Surg,2001,17(8): 608-612.
9.Pallikaris IG,Kalyvianaki MI, Katsanevaki VJ, et al.Epi-LASIK:preliminary clinical results of an alternative surface ablation procedure[J]. J Cataract Refract Surg,2005:31(5):879-885.
10.戴锦晖,陈冲达,褚仁远,等.机械法准分子激光角膜上皮瓣下磨镶术矫治高度近视.中华眼科杂志,2005,41：211-215.
11. Espana EM, Grueterich M, Mateo A, et al. Cleavage of corneal basement membrane components by ethanol exposure in laser-assisted subepithelial keratectomy[J]. J Cataract Refract surg,2003,9(6):1192-1197.
12. Lee JB, Seong GJ, Lee JH, et al. Comparison of laser epithelial keratomileusis and photorefractive keratectomy for low to moderate myopia. J Cataract Refract Surg,2001,27:565-570.
13. Mohan RR, Hutcheon AE, Choi R, et al. Apoptosis, necrosis, proliferation, and myofibroblast generation in the stroma following LASIK and PRK. Exp Eye Res,2003,76(1):71-87.
14. Shah S,Sebai Sarhan AR,Doyle SJ,et al. The epithelial flap for photorefractive keratectomy. Br J Ophthalmol,2001,85:393-396.
15.Jared Schultz表面手术最适合于薄角膜高度近视。眼外科新闻(OSN)2007；18(11)：16.
16. Michael J. Endl,无瓣epi-LASIK术后结果很有希望。眼外科新闻(OSN)2008；19(1)：8-9.
17.刘维锋,杜之渝,等。微型角膜刀法准分子激光角膜上皮瓣下磨镶术后兔角膜上皮瓣结构及活性的研究。中华眼科杂志,2007；43(7)：651-657.
18.杜之渝,陈颖,等。药物对Epi-LASIK术后上皮瓣活性影响的临床研究。中国实用眼科杂志,2007；25(9)：953-957.
19. Wilson SE,He YG, Weng J, et al. Epithelial injury induces kerotocyte apoptosis:hypothesized role for the interleukin-1 system in the modulation of corneal tissue organization and wound healing. Exp Eye Res,1996,62:325-327.
20.李镜海,肖瑛,主编.近视手术治疗学.北京：人民卫生出版社,2001：27.
21. Rieck P, David T, Hartmann C, et al. Basic fibroblast growth factor modulatescorneal wound healing after excimer laser keratomileusis in rabbits.Ger J Ophthalmol,1994,3:105.
22.戴超,刘翔EGF、bFGF对兔自体穿透角膜移植伤口愈合的影响.第三军医大学学报,2001,23：211-214.
23.Wilson SE, Mohan RR,Hong JW, et al. The wound healing response after laser in-situ keratomileusis and Photorefractive keratectomy. Arch Ophthalmol,2001,119:889-896.
24. W ilson SE. Analysis of the keratocyte apoptosis, keratocyte proliferation, and myofibroblast transformation responses after photorefractive keratectomy and laser in situ keratomileusis [J].Trans Am Ophthalmol Soc,2002,100:411-433.
25. Wilson SE, Mohan RR, Hutcheon AE, Mohan RR, Ambrosio R,Zie ske JD, et al. Effect of ectopic epithelial tissue within the stroma on keratocyte apoptosis, mitosis, and myofibroblast transformation[J]. Exp Eye Res,2003,76 (2):193-201.
26. Fini ME. Keratocyte and fibroblast phenotypes in the repairing cornea. Prog Retinal Eye Res,1999,18:591-551.
27. Jester JV, Petroll WM, Cavanagh HD.Corneal stromal wound healing in refractive surgery:the role of myofibroblast. Prog Retinal Eye Res,1999,18:311-356.
28. Tanioka H, Hieda 0, Kawasaki S, et al. Assessment of epithelial integrity and cell viability in epithelial flaps prepared with the epi-LASIK procedure. J Cataract Refract Surg,2007,33(7):1195-1200.
1. Sridhar MS, Rao SK, Vajpayee RB, et al. Complications of laser in situ Keratomileusis[J]. Indian J Ophthalmol 2002;50(4):265-282.
2. Dai J, Chu R, Zhou X, et al. One-year outcomes of Epi-LASIK for myopia[J]. J Refract Surg 2006;22(6):589-595.
3. Katsanevaki VJ, Kalyvianaki MI, Kavroulaki DS, et al. One year clinical results after Epi-LASIK for myopia[J]. Ophthalmology 2007;114(6):1111-1117.
4. Camellin M. Laser Epithelial keratomileusis for myopia[J].J Refract Surg 2003:19(6):666-670.
5.Azar DT, Ang RT, Lee JB, et al. Laser subepithelial keratomileusis:electron microscopy and visual outcomes of flap photorefractive keratectomy[J]. Curr Opin Ophthalmol 2001;12(4):323-328.
6.Rudolf A,Jaroslav R. Laser-assisted subepithelial keratectomy and photorefractive keratectomy for the correction of hyperopia, Results of a 2-year follow-up. J Cataract Refract Surg 2003,29(11):2105-14.
7.孙秉基,贺燚,主编。现代角膜移植及角膜激光手术。天津：天津科学技术出版社,1999.127.
8. Kim SY, Sah WJ, Lim YW, et al. Twenty Percent Alcohol Toxicity on Rabbit Corneal Epithelial Cells; electron microscopic study [J]. Cornea,2002,21 (4):388-392.
9. Rudolf A, Jaroslav R. Laser-assisted subepithelial keratectomy for myopia:Two-year follow-up [J]. J Caratact Refract Sury,2003,29(4): 661-668.
10. Panagopoulon S I,Pallikaris I G. Wavefront customized ablations with the WASCAAsclepion workstation[J]. Refract Surg,2001,17(8): 608-612.
11. Kalyvianaki M I, Katsanevaki V J, Kavroulaki D S, et al. Comparison of corneal sensitivity and tear function following epi-LASIK or laser in situ keratomileusis for myopia[J]. Am J Ophthalmol,2006,142 (4): 669-671.
12. Sharma N, Kaushal S, Jhanji V, et al. Comparative evaluation of 'flap-on'and'flap-off techniques of Epi-LASIK in low-to-moderate myopia[J]. Eye,2009,23(9):1786-1789.
13. Kalyvianaki MI, Kymionis GD, Kounis GA, et al. Comparison of Epi-LASIK and off-flap Epi-LASIK for the treatment of low and moderate myopia[J]. Ophthalmology 2008;115(12):2174-80.
14. Wang QM, Fu AC, Yu Y. et al. Clinical investigation of off-flap epi-LASIK for moderate to high myopia[J]. Invest Ophthalmol Vis Sci.2008 Jun;49(6):2390-2394.
15. Chen W L, Shen E P, Hsieh Y T, et al. Comparison of in vivo confocal microscopic findings between epi-LASIK procedures with different management of the epithelial flaps[J]. Invest Ophthalmol Vis Sci,2011,52(6):3640-3647.
16. Pallikaris IG, Kalyvianaki MI, Katsanevaki VJ, et al. Epi-LASIK:preliminary clinical results of an alternative surface ablation procedure[J].J Cataract Refract Surg,2005:31(5):879-885.
17.周行涛,褚仁远,王晓瑛,等.无痛性准分子激光角膜上皮瓣下磨镶术及微型角膜刀准分子激光角膜上皮瓣下磨镶术的临床研究[J].中华眼科杂志,2005：41(11)：977-980.
18.戴锦晖,陈冲达,褚仁远,等.机械法准分子激光角膜上皮瓣下磨镶术矫治高度近视[J],中华眼科杂志,2005;41(3)：211-215.
19. Fitzsimmons T D, Fgerlolm P, Harfstrand A, et al. Hyaluronic acid in the rabbit cornea after excimer laser superficial keratectomy [J]. Invest Ophthalmol Vis Sci,1992,33(11):3011-3016.
20.Michael J.Endl无瓣Epi-LASIK术后结果很有希望[J],眼外科新闻(OSN),2008,19(1)：8-9.
21.杨智,赵海鸥,梁莉,等Epi-LASIK术中上皮瓣去留的临床研究.临床眼科杂志,2009,17(1)：23-24.
22. Netto MV, Mohan RR, Sinha S, et al. Stromal haze, myofibroblasts, and surface irregularity after PRK[J].Exp Eye Res,2006;82(5):788-797.
1. Trokel SL, Srinivasan R, Braren B. Excimer laser surgery of the cornea. Am J Ophtholmol,1983,96(6):710-715.
2. Seiler T, Holschbach A, Derse M, Jean M, Genth U. Complications of myopia photorefractive keratectomy with the excimer laser. Ophtholmology,1994,101(1):153-160.
3. Pallikaris IG, Siganos DS. Excimer laser in situ keratomileusis and photorefractive keratectomy for the correction of high myopia. J Refract Corneal Surg,1994,10 (5):498-510.
4. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O, Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med,1990,10(5):463-468.
5.Knorz MC. Complications of refractive excimer laser surgery. Am J Ophthalmol,2006,103(3):192-198.
6. Wang MY, Maloney RK.Epithelial in growth after laser in situ keratomileusis[J]. Am J Ophthalmol,2000,129 (6):746-751.
7.Shah MN, Misra M, Wilhelmus KR,et al. Diffuse lamellar keratitis associated with epithelial defects after laser in situ keratomileusis[J].J Cataract RefractSurg,2000,26(9):1312-1318.
8.Ambrosio RJr, Wilson S.LASIK vs. LASEKvs. PRK:advantages and indications. Semin phthalmol,2003,18:2-10.
9. Camellin M. LASEK may offer the advantages of both LASIK and PRK. Ocu Surg News(International Edition),1999,10(3):14-15.
10. Kornilovsky IM. Clinical Results after Subepithelial Photorefractive Keratectomy(LASEK)[J]. J Refract Surg,2001,17(2S):S222-223.
11.Pallikaris IG, Katsanevaki VJ, Kalyvianaki MI,et al. Advances in subepthelial excimer refractive surgery techniques:Epi-LASIK[J]. Curr Opin Ophthalmol,2003,14(4):207-212.
12. Pallikaris IG, Naoumidi II, Kalyvianaki MI, et al. Epi-LASIK:Comparative Histolgical Evaluation of Mechanical and Alcohol-assisted Epithelial Separation[J]. J Cataract Refract Surg,2003,29(8):1496-1501.
13. Tychsen L, Packwood E, Berdy G. Correction of Large Amblyopi genIc Refractive Errors in Children Using the Excimer Laser[J].J AAPOS,2005,9 (3):224-233.
14.Sharma N,Kaushal S,Jhanji V,et al.Comparative evaluation of 'flap on' and 'flap off' techniques of Epi-LASIK in low-to-moderate myopi a. Eye,2009,23:1786-1789.
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