鼻内镜下Hasner瓣切除术治疗低位鼻泪管阻塞的临床研究

doi:10.3877/cma.j.issn.2095-2007.2020.01.002

目的

探讨Hasner瓣切除术用于低位鼻泪管阻塞患者治疗的临床效果。

方法

收集2016年10月至2019年1月于首都医科大学附属北京同仁医院北京同仁眼科中心进行Hasner瓣切除术患者31例(31只眼)的病例资料。其中，男性3例，女性28例；年龄17~79岁，平均年龄(41.8±15.5)岁。观察术前与术后溢泪症状、泪河高度(TMH)及泪道冲洗检查结果的情况。采用配对样本t检验比较同一患眼术前与术后TMH值的变化、不同观察时间点TMH差值的变化；采用Wilcoxon符号秩和检验比较术前与术后泪道的冲洗检查结果。

结果

患眼Hasner瓣切除术后90%无溢泪，10%溢泪有所减轻。术前患眼染色前TMH值为(0.62±0.32)mm，术后患眼染色前TMH值为(0.30±0.10)mm，差异有统计学意义(t＝5.25, P<0.05)。患眼术前与术后在染色后0 min和染色后5 min的TMH值变化明显，差异有统计学意义(t＝2.31，5.45；P<0.05)；而健眼术前与术后在染色前、染色后0 min及染色后5 min的TMH值变化，差异无统计学意义(t＝0.40，-0.25，0.25；P>0.05)。健眼术前染色后0 min与染色前的TMH差值为(0.17±0.17)mm；术前染色后0 min与染色后5 min的TMH差值为(0.12±0.19)mm。患眼术前染色后0 min与染色前的TMH差值为(0.02±0.27)mm；术前染色后0 min与染色后5 min的TMH差值为(-0.14±0.28)mm。患眼术前与术后在不同观察时间点的TMH差值均有统计学意义(t＝-3.90，-4.69；P<0.05)。健眼术前与术后在不同观察时间点的TMH差值均无统计学意义(t＝-0.13，-0.61；P>0.05)。术前患眼的泪道冲洗检查结果为1或者2者占96%；术后患眼的冲洗检查结果为6者占90.4%，差异有统计学意义(Z＝-4.02，P<0.05)。

结论

Hasner瓣切除术用于低位鼻泪管阻塞患者的治疗有较好的治疗效果，术后患者的泪道通畅程度能显著得到改善。

关键词: Hasner瓣, 鼻泪管阻塞, 泪河高度, 泪道冲洗

Objective

The aim of this study was to evaluate the efficacy of Hasner valvulotomy for inferior nasolacrimal duct obstruction.

Methods

The study group recruited 31 patients (31 eyes) who underwent Hasner valvulotomy in Beijing Tongren Eye Center, Beijing Tongren Hospital affiliated with Capital Medical University from October 2016 to January 2019 were analyzed. Among of them, there were 3 males, and 28 females; their ages were the range from 17 to 79 with the average age of (41.8±15.5) years-old. To evaluate efficacy of operation, tearing symptoms, tear meniscus height (TMH) and lacrimal passage irrigation were observed. Paired Sample t test and Wilcoxon Signed-Rank Test were conducted to compare TMH, D-value of TMH and lacrimal passage irrigation before and after operation.

Results

90% of affected eyes had no symptoms of tearing, and 10% had reduced symptoms of tearing after operations. In affected eyes, the preoperative TMH was (0.62±0.32) mm; the postoperative TMH was (0.30±0.10) mm with significant statistical differences (t=5.25, P<0.05). There were significant statistical differences between preoperative and postoperative TMH at the dyeing for 0 min and 5 min in the affected eyes(t=2.31, 5.45; P<0.05). However, there were non-significant differences between preoperative and postoperative TMH before dyeing, at dyeing for 0 min and 5 min in the healthy eyes (t=0.40, -0.25, 0.25; P>0.05). In the healthy eyes, the D-value of preoperative TMH between before dyeing and at dyeing for 0 min was (0.17±0.17) mm; that of the preoperative TMH between the dyeing for 0 min and 5 min was (0.12±0.19) mm. In the affected eyes, the D-value of the preoperative TMH between before dyeing and at dyeing for 0 min was (0.02±0.27) mm; that of the preoperative TMH between the dyeing for 0 min and 5 min was (-0.14±0.28) mm. The D-value of preoperative and postoperative TMH between different times in the affected eyes was significant statistical different (t=-3.90, -4.69; P<0.05). The D-value of preoperative and postoperative TMH between different times in the healthy eyes was non-significant statistical different (t=-0.13, -0.61; P>0.05). The lacrimal passage irrigation before operation in affceted eyes was 1 or 2 accouting for 96%; the postoperative lacrimal passage irrigation was 6 accoutng for 88.4% with significant statistical differences (Z=-4.02, P<0.05).

Conclusions

Hasner valvulotomy is effective for patients with inferior nasolacrimal duct obstruction and there was a great improvement of their lacrimal passage irrigations.

Key words: Hasner valvulotomy, Nasolacrimal duct obstruction, Tear meniscus height, Lacrimal passage irrigation

图1 Hasner瓣切除术术前与术后的泪道磁共振成像图　图A示术前泪道冠状位造影图；图B示术前泪道水平位造影图；图C示术前泪道矢状位造影图，Hasner瓣显示为圆弧状界面，向下鼻道内突起，鼻泪管下口有造影剂潴留(箭头处)；图D示术后泪道冠状位造影图；图E示术后泪道水平位造影图；图F示术后泪道矢状位造影图，右侧造影剂(箭头处)进入下鼻道内

图2 鼻内镜下Hasner瓣切除术及术后换药过程的彩色照像　图A~J示Hasner瓣切除术手术过程。图A示泪道探针支撑H瓣；图B示针状电极定位，从隆起前上方开始；图C示切割模式下开始破膜；图D示沿隆起前缘由上至下切开；图E示切开处可见白色脓液流出(箭头处)；图F示显露出泪道探针，探针支撑下显示鼻泪管下口外侧壁正常粘膜(星号处)；图G示分别自上下泪点插入带侧槽的探针(箭头处)；图H示自下鼻道下方钩出人工泪管；图I示人工泪管于前鼻孔打结后，线结外剪断硅胶管；图J示下鼻道人工泪管安置妥当，纳吸棉填塞下鼻道。图K示术后2个月鼻泪管下口显示良好，人工泪管(箭头处)在位，活动度良好；图L示拔管后可见气泡(箭头处)位于鼻泪管下口处，冲洗泪道通畅

表1 患者Hasner瓣切除术前与术后各观察时间点泪河高度的比较(±s，mm)

治疗时间	患眼			健眼
治疗时间	染色前	染色后0 min	染色后5 min	染色前	染色后0 min	染色后5 min
术前	0.62±0.32	0.65±0.27	0.79±0.40	0.29±0.17	0.47±0.19	0.35±0.15
术后	0.30±0.10	0.51±0.16	0.35±0.11	0.27±0.07	0.48±0.19	0.32±0.10
t值	5.25	2.31	5.45	0.40	-0.25	0.25
P值	<0.05	<0.05	<0.05	>0.05	>0.05	>0.05

表1 患者Hasner瓣切除术前与术后各观察时间点泪河高度的比较(±s，mm)

治疗时间	患眼			健眼
治疗时间	染色前	染色后0 min	染色后5 min	染色前	染色后0 min	染色后5 min
术前	0.62±0.32	0.65±0.27	0.79±0.40	0.29±0.17	0.47±0.19	0.35±0.15
术后	0.30±0.10	0.51±0.16	0.35±0.11	0.27±0.07	0.48±0.19	0.32±0.10
t值	5.25	2.31	5.45	0.40	-0.25	0.25
P值	<0.05	<0.05	<0.05	>0.05	>0.05	>0.05

表2 患者Hasner瓣切除术前与术后不同观察时间点泪河高度差值的比较(±s，mm)

治疗时间	患眼		健眼
治疗时间	染色后0 min-染色前	染色后0 min -染色后5 min	染色后0 min -染色前	染色后0 min -染色后5 min
术前	0.02±0.27	-0.14±0.28	0.17±0.17	0.12±0.19
术后	0.20±0.10	0.16±0.11	0.21±0.14	0.16±0.17
t值	-3.90	-4.69	-0.13	-0.61
P值	<0.05	<0.05	>0.05	>0.05

表2 患者Hasner瓣切除术前与术后不同观察时间点泪河高度差值的比较(±s，mm)

治疗时间	患眼		健眼
治疗时间	染色后0 min-染色前	染色后0 min -染色后5 min	染色后0 min -染色前	染色后0 min -染色后5 min
术前	0.02±0.27	-0.14±0.28	0.17±0.17	0.12±0.19
术后	0.20±0.10	0.16±0.11	0.21±0.14	0.16±0.17
t值	-3.90	-4.69	-0.13	-0.61
P值	<0.05	<0.05	>0.05	>0.05

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Efficacy of endonasal Hasner valvulotomy for inferior nasolacrimal duct obstruction

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Efficacy of endonasal Hasner valvulotomy for inferior nasolacrimal duct obstruction