飞秒激光辅助超声乳化白内障吸除联合张力环及人工晶状体植入术治疗晶状体不全脱位的临床观察

doi:10.3877/cma.j.issn.2095-2007.2019.03.002

目的

观察飞秒激光辅助超声乳化白内障吸除联合张力环及人工晶状体植入术在晶状体不全脱位(SL)治疗中的安全性与有效性。

方法

收集2017年10月至2019年3月就诊于广州爱尔眼科医院的SL患者22例(26只眼)的病例资料。其中，男性患者18例(21只眼)，女性患者5例(5只眼)；年龄5~65岁，平均(45.8±18.2)岁；外伤性的SL 14例(14只眼)、马凡综合征SL 5例(9只眼)及自发性(原因不明)的SL 3例(3只眼)。按SL程度分，本研究中11只眼脱位轻度，7只眼脱位中度，8只眼脱位重度。采用飞秒激光辅助超声乳化白内障吸除联合张力环及人工晶状体植入术治疗SL，观察并记录术中和术后并发症的情况；检查术后视力、眼压；观察并记录囊袋的稳定性和人工晶状体的居中情况。手术前后患者的最佳矫正视力采用眼数和百分比进行描述；术前、术后的比较采用Wilcoxon检验。

结果

本研究纳入的22例(26只眼)患者的手术均顺利，人工晶状体成功植入囊袋内。术中并发症主要有球结膜下出血(20/26只眼)、激光前囊膜未完全切开(5/26只眼)和瞳孔缩小(4/26只眼)。术后无黄斑水肿、眼内炎及视网膜脱离等并发症。本研究中26只眼术后视力均有不同程度的提高。其中，术前最佳矫正视力≥0.5者为2只眼；术后最佳矫正视力≥0.5者为14只眼。术前最佳矫正视力0.3~0.5者为2只眼；术后最佳矫正视力0.3~0.5者为8只眼。经Wilcoxon统计学检验，发现术前、术后最佳矫正视力的差异具有统计学意义(Z＝-4.46，P<0.05)。术后20例(24只眼)人工晶状体的居中性良好，2例(2只眼)人工晶状体发生轻度移位，3例(3只眼)人工晶状体出现前囊膜皱缩。

结论

飞秒激光辅助超声乳化白内障吸除联合张力环及人工晶状体植入术在SL治疗中是一种安全有效的方法，其不仅可提高撕囊的成功率，降低超声乳化手术难度，保持囊袋的稳定性，亦可减少术后并发症，临床效果良好。

关键词: 晶状体不全脱位, 飞秒激光, 超声乳化, 张力环

Objective

The aim of this study was to observe the safety and effectiveness of femtosecond laser-assisted with phacoemulsification surgery of cataracts combined with tension ring and intraocular lens implantation in the treatment of subluxated lens (SLs).

Methods

22 cases of 26 eyes with SL were enrolled in Guangzhou Aier Eye Hospital from October 2017 to March 2019, including 18 male (21 eyes), 5 female (5 eyes); the age range from 5-65, average age (45.8±18.2). Among of them, 14 cases of 14 eyes with traumatic lens subluxation, 5 cases of 9 eyes with Mafan syndromes, and 3 spontaneous cases of 3 eyes with unexplained reasons. According to the extent of zonular weakness, 11 eyes of them were mild; 7 eyes of them were medium, and 8 eyes of them were severe. The femtosecond laser-assisted with phacoemulsification surgery of cataracts combined with tension ring and intraocular lens implantation was used to perform, and intraoperative and postoperative complications were evaluated. Visual acuity and intraocular pressure after operation were recorded. The stability of capsular bag and intraocular len were assessed. The best corrected visual acuity (BCVA) before and after surgery was described by the number and percentage of eyes. Wilcoxon testing was used to compare preoperative and postoperative visual acuity.

Results

All the operations of 26 eyes were completed and SLs were implanted into capsular bag successfully. Intraoperative complications were mainly subconjunctival hemorrhage (20/26 eyes), incomplete capsulotomy (5/26 eyes) and contracted pupils (4/26 eyes). Postoperative complications such as macular edema, endophthalmitis and retinal detachment were not found. BCVA of 26 eyes after surgery was improved to some extent. Before the cataract surgery, the eyes with BCVA was ≥0.5, which had 2 patients; after cataract surgery, the eyes with BCVA was ≥0.5, which had 14 patients. Before cataract surgery, eyes with BCVA was between 0.3 and 0.5, which had 2 patients; after cataract surgery, eyes with BCVA was between 0.3 and 0.5, which had 8 patients. Compared with that before cataract surgery, the postoperative of BCVA was significantly improved (Z=-4.46, P<0.05). 24 SLs were stably centered; two intraocular lens were slightly displaced; and 3 eyes had anterior capsular contraction.

Conclusion

Femto second laser-assisted cataract surgery is an effective and safe approach for patients with SLs. This approach have shown the good clinical effect, including the increase in the successful rate of capsulorhexis, the decrease in the difficulty of phacoemulsification, and perioperative complications through preserving the stability of the capsular bag.

Key words: Subluxated lens, Femtosecond laser, Phacoemulsification, Capsular tension ring

图1 术中光学相干断层扫描监测下飞秒激光前囊膜切开、预劈核及主侧切口标记图和术中完成操作的彩色照像图A示前囊膜切开、预劈核范围预劈核模式及切口定位图像；图B示光学相干断层扫描监测下的飞秒激光前囊膜切开设定图；图C示光学相干断层扫描监测下飞秒激光劈核的直径与作用深度示意图；图1D示飞秒激光辅助下完成的前囊膜切开、预劈核及主侧切口制作；图E示囊袋拉钩辅助下的囊袋；图F示注射式张力环植入；图G示改良的单钩张力环悬吊植入

表1 术眼术前、术后最佳矫正视力的对比[%(眼数/总眼数)]

组别	<0.1	0.1~0.3	0.3~0.5	>0.5
术前	69.23(18/26)	15.38(4/26)	7.69(2/26)	7.69(2/26)
术后	3.85(1/26)	11.54(3/26)	30.77(8/26)	53.85(14/26)
Z值	-4.46
P值	<0.05

表1 术眼术前、术后最佳矫正视力的对比[%(眼数/总眼数)]

组别	<0.1	0.1~0.3	0.3~0.5	>0.5
术前	69.23(18/26)	15.38(4/26)	7.69(2/26)	7.69(2/26)
术后	3.85(1/26)	11.54(3/26)	30.77(8/26)	53.85(14/26)
Z值	-4.46
P值	<0.05

[1]	Dureau P. Pathophysiology of zonular diseases[J]．Curr Opin Ophthalmol, 2008, 19(1): 27-30.
[2]	蒋永祥，卢奕. 晶状体不全脱位的手术治疗进展[J]. 中国眼耳鼻喉科杂志，2017, 17(2) ：88-91.
[3]	Hoffman RS, Snyder ME, Devgan U, et al. Management of the subluxated crystalline lens[J]. J Cataract Refract Surg, 2013, 39(12): 1904-1915.
[4]	Martínez-Gutiérrez JD, Mencía-Gutiérrez E, Gracia-García-Miguel T, et al. Classical familial homocystinuria in an adult presenting as an isolated lens subluxation[J]. Int Ophthalmol, 2011, 31(3): 227-232.
[5]	Schmidt D, Shin YS, Auw-Haedrich C, et al. Congenital ocular malformations (lens subluxation, pupillary displacement, cataract, myopia) and clas sic galactosaemia associated with Q188R and/or G1391A mutations[J]. Acta Ophthalmol, 2011, 89(5): 489-494.
[6]	Neuhann TM. Hereditary ectopia lentis[J]. Klin Monbl Augenheilkd, 2015, 232(3): 259-265.
[7]	González-Casta OC, Castro J, Alvarez-Sánchez M. Subluxation of the lens: etiology and results of treatment [J]. Arch Soc Esp Oftalmol, 2006, 81(8): 471-478.
[8]	Pathak-Ray V. Subluxated spherophakic lens: Zonules still not relinquished[J]. Indian J Ophthalmol, 2019, 67(7)：1204-1206.
[9]	Simon MA, Origlieri CA, Dinallo AM, et al. New management strategies for ectopia lentis[J]. J Pediatr Ophthalmol Strabismus, 2015, 52(5): 269-281.
[10]	Varga B. The results of my operations improving visual acuity of ectopia lentis[J]. Ophthalmologica, 1971, 162(2): 98-110.
[11]	Morrison D, Sternberg P, Donahue S. Anterior chamber intraocular lens (ACIOL) placement after pars plana lensectomy in pediatric Marfan′s yndrome[J]. J AAPOS, 2005, 9(3): 240-242.
[12]	Hakin KN, Jacobs M, Rosen P, et al. Management of the subluxed crystalline lens[J]. Ophthalmology, 1992, 99(4): 542-545.
[13]	Jarrett WH. Dislocation of the lens: A study of 166 hospitalized cases[J]. Arch Ophthalmol, 1967, 78(3): 289-296.
[14]	Sellyei LJ, Barraquer J. Surgery of the ectopic lens[J]. Ann Ophthalmol, 1973, 5(10): 1127-1133.
[15]	Kim WS. Transscleral intraocular lens fixation with preservation of the anterior vitreous face in patients wi th marfan syndrome and ectopia lentis[J]. Cornea, 2010, 29 (S1): S20-S24.
[16]	Dureau P, de Laage DMP, Edelson C, et al. Iris fixation of foldable intraocular lenses for ectopia lentis in children[J]. J Cataract Refract Surg, 2006, 32(7): 1109-1114.
[17]	金创，陈浩宇，夏红和，等. 外伤性晶状体半脱位行Ⅰ期与Ⅱ期人工晶状体睫状沟缝线固定术的疗效比较[J]. 眼科学报，2018, 33(1)：27-31.
[18]	Titiyal JS, Kaur M, Rathi A, et al. Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in ante rior chamber[J]. Indian J Ophthalmol, 2019, 67(1): 155-157.
[19]	Rosenthal KJ. Technique to avoid cortical entrapment in early insertion of capsular tension rings[J]. J Cataract Refract Surg, 2017, 43(4): 577.
[20]	Agarwal A, Jacob S. Current and effective advantages of femto phacoemulsification[J]. Curr Opin Ophthalmol, 2017, 28(1): 49-57.
[21]	Weber CH, Cionni RJ. All about capsular tension rings[J]. Curr Opin Ophthalmol, 2015, 26(1): 10-15.
[22]	Taravella MJ, Meghpara B, Frank G, et al. Femtosecond laser-assisted cataract surgery in complex cases[J]. J Cataract Refract Surg, 2016, 42(6): 813-816.
[23]	Gavri M, Mateescu R, Belicioiu R, et al. Is laser assisted capsulotomy better than standard CCC？[J]. Rom J Ophthalmol, 2017, 61(1): 18-22.
[24]	Chee SP, Wong MH, Jap A. Management of severely subluxated cataracts using femtosecond laser-assisted cataract surgery[J]. Am J Ophthalmol, 2017, 173: 7-15.
[25]	Li B, Wang Y, Malvankar-Mehta MS, et al. Surgical indications, outcomes, and complications with the use of a modified capsular tension ring du ring cataract surgery[J]. J Cataract Refract Surg, 2016, 42(11): 1642-1648.
[26]	Hasanee K, Butler M, Ahmed II. Capsular tension rings and related devices: current concepts[J]. Curr Opin Ophthalmol, 2006, 17(1): 31-41.
[27]	Grewal DS, Schultz T, Basti S, et al. Femtosecond laser-assisted cataract surgery——current status and future directions[J]. Surv Ophthalmol, 2016, 61(2): 103-131.
[28]	Zhang F. Femtosecond laser-assisted cataract surgery versus conventional cataract surgery comparison[J]. J Cataract Refract Surg, 2019, 45(1): 21-27.
[29]	陈佳惠，景清荷，缪爱珠，等. 飞秒激光联合Cionni张力环植入治疗外伤性晶状体不全脱位的有效性和安全性[J]. 国际眼科杂志，2017, 17(7)：1323-1326.
[30]	Morris B, Cheema RA. Phacoemulsification using iris-hooks for capsular support in high myopic patient with subluxated lens and secondary angle closure glaucoma[J]. Indian J Ophthalmol, 2006, 54(4): 267-269.
[31]	Santoro S, Sannace C, Cascella MC, et al. Subluxated lens: phacoemulsification with iris hooks[J]. J Cataract Refract Surg, 2003, 29(12): 2269-2273.
[32]	Sethi HS, Mayuresh NP, Gupta VS. Intraoperative intracameral pilocarpine after capsular tension ring and capsule/iris hook insertion in pediatric eyes with subluxated cataract[J]. J Cataract Refract Surg, 2016, 42(2): 190-193.
[33]	Blecher MH, Kirk MR. Surgical strategies for the management of zonular compromise[J]. Curr Opin Ophthalmol, 2008, 19(1): 31-35.
[34]	Goldman JM, Karp CL. Adjunct devices for managing challenging cases in cataract surgery: pupil expansion and stabilization of the capsular bag[J]. Curr Opin Ophthalmol, 2007, 18(1): 44-51.
[35]	Khokhar S, Gupta S, Nayak B, et al. Capsular hook-assisted implantation of modified capsular tension ring[EB/OL]. [2019-03-23]． URL
[36]	Biglan AW, Cheng KP, Davis JS, et al. Secondary intraocular lens implantation after cataract surgery in children[J]. Am J Ophthalmol, 1997, 123(2): 224-234.
[37]	Buttanri IB, Sevim MS, Esen D, et al. Modified capsular tension ring implantation in eyes with traumatic cataract and loss of zonular support[J]. J Cataract Refract Surg, 2012, 38(3): 431-436.
[38]	Marques DM, Marques FF, Cionni RJ, et al. Evaluation of the modified capsular tension ring in cases of traumatic lens subluxation[J]. Arq Bras Oftalmol, 2007, 70(5): 746-751.
[39]	Konradsen T, Kugelberg M, Zetterstrom C. Visual outcomes and complications in surgery for ectopia lentis in children[J]. J Cataract Refract Surg, 2007, 33(5): 819-824.
[40]	何守志. 晶状体病学[M]. 2版. 北京：人民卫生出版社，2014：67-69.
[41]	Vasavada V, Vasavada VA, Hoffman RO, et al. Intraoperative performance and postoperative outcomes of endocapsular ring implantation in pediatric eyes[J]. J Cataract Refract Surg, 2008, 34(9): 1499-1508.
[42]	Cionni RJ, Osher RH. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation[J]. J Cataract Refract Surg, 1998, 24(10): 1299-1306.

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Clinical observation of femtosecond laser-assisted with phacoemulsification surgery of cataracts combined with tension ring and intraocular lens implantation in the treatment of subluxated lens

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Clinical observation of femtosecond laser-assisted with phacoemulsification surgery of cataracts combined with tension ring and intraocular lens implantation in the treatment of subluxated lens