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中华眼科医学杂志(电子版) ›› 2024, Vol. 14 ›› Issue (03) : 155 -159. doi: 10.3877/cma.j.issn.2095-2007.2024.03.005

病例报告

角膜内皮移植联合白内障手术1例
李诗文1, 董贺1,†(), 于亮1, 刘起明1, 于贺1, 纪莉莉1   
  1. 1. 116091　大连市第三人民医院眼科
  • 收稿日期:2024-05-28 出版日期:2024-06-28
  • 通信作者: 董贺
  • 基金资助:
    辽宁省自然科学基金指导计划项目(201602210); 大连市第三人民医院科研启动专项基金计划项目(2021ky001)

One case of corneal endothelial transplantation combined with cataract surgery

Shiwen Li, He Dong†(), Liang Yu   

  • Received:2024-05-28 Published:2024-06-28
  • Corresponding author: He Dong
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李诗文, 董贺, 于亮, 刘起明, 于贺, 纪莉莉. 角膜内皮移植联合白内障手术1例[J]. 中华眼科医学杂志(电子版), 2024, 14(03): 155-159.

Shiwen Li, He Dong, Liang Yu. One case of corneal endothelial transplantation combined with cataract surgery[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2024, 14(03): 155-159.

患者，女性，59岁。2023年10月因左眼视物不清加重就诊。自诉2年前有角膜内皮炎病史，近年来视物不清逐渐严重。患者全身状态佳，否认高血压和糖尿病病史，无药物过敏史。患者右眼视力0.6，最佳矫正视力0.8；左眼视力指数/20 cm，矫正视力不提高，光感光定位正常。双眼眼压正常，左眼角膜全层水肿，角膜上皮大泡样改变，基质混浊，全周新生血管长入基质层，后弹力层皱褶(＋)，双眼晶状体混浊，右眼眼底未见明显异常，左眼眼底窥不入。Spectralis型光学相干断层扫描(德国海德堡公司生产)眼前节成像显示，左眼角膜全层水肿增厚，上皮下大泡形成。HRT3型共聚焦显微镜(德国海德堡公司生产)检查结果显示左眼角膜上皮细胞水肿增大，细胞间隙增宽，细胞间水泡样改变，暗区中可见圆顶状亮点的赘生物。SP－3000P型角膜内皮镜(日本TOPCON株式会社生产)检查结果显示角膜内皮细胞标准偏差和变异系数均异常，可见蜂巢样暗区。见图1A～图1G。根据患者的病史、查体及辅助检查结果，诊断为左眼角膜内皮失代偿，双眼老年性白内障。经专家组讨论，给予患者行一期角膜内皮移植联合白内障手术治疗，且在内皮移植术前，在角膜水肿的情况下先行白内障手术操作。参照对侧健眼人工晶状体屈光度测算结果，选择单焦点人工晶状体。术前给予患者复方托比卡胺(沈阳兴齐眼药股份有限公司生产)麻痹睫状肌，制作角膜内皮植片。使用自动板层刀(法国Moria公司生产)系统和负压控制系统垂直于供体角膜表面旋转制作前部深板层角膜片，厚度约400 μm，剥除前部深板层角膜片，沿角巩膜缘外1～2 mm环形剪下供体后板层角膜片，将内皮面朝上置于专用的角膜刻切枕上，以环钻钻取带有部分后基质的内皮植片，标记基质面。术中先刮除病变的角膜上皮以增加视野的清晰度，3：00时钟位角膜缘处做侧切口，前房注入过滤空气后注入吲哚菁绿注射液(丹东医创药业有限责任公司生产)染色晶状体前囊，行白内障超声乳化吸除联合后房型人工晶状体植入术。角膜内皮移植采用后弹力层剥离自动内皮角膜移植术，7.5 mm环钻在术眼角膜上皮定位，亚甲蓝注射液(江苏济川制药有限公司生产)标记出需要剥除的后弹力层范围，穿刺刀扩大主切口至5 mm宽，前房内注入黏弹剂，于角膜缘做辅助切口，用后弹力层剥除钩沿标记环钻刮除后弹力层及内皮细胞层，角膜内皮植片内皮面朝下放于植入器，10－0尼龙线缝合标记角膜植片，在缝线辅助下将角膜植片植入前房，前房内注入无菌空气形成前房。使植片和植床紧密相贴，术中见双环征，即为注气成功。使用虹膜恢复器在角膜表面推压以排净植片与植床之间多余的液体和气体，促使植片与植床的紧密贴附。术毕，给予妥布霉素地塞米松眼膏(美国Alcon公司生产)涂术眼，嘱患者仰卧位24 h。术后第1 d，术眼视力眼前光感，光定位准确，术眼结膜充血水肿，角膜水肿，角膜植片与植床贴敷良好，颞上方角膜缝线在位，前房上方可见圆形气泡，前房深度正常，人工晶状体正位。术后1周，术眼视力恢复至0.3，前房气泡消失。术后1～6个月，术眼视力波动于0.5～0.6，角膜水肿消退，人工晶状体在位，光学相干断层扫描成像提示角膜植片与植床贴敷良好。见图2A～图2G。

图1　角膜内皮失代偿联合老年性白内障患者术前左眼的眼部表现　图1A和图1B示左眼裂隙灯显微镜下眼前节照彩色照相(×16)，可见左眼角膜全层水肿，角膜上皮大泡样改变，基质混浊，全周新生血管长入基质层，后弹力层皱褶(＋)；图1C和图1D示光学相干断层扫描成像，可见左眼角膜全层增厚，上皮下大泡形成；图1E示共聚焦显微镜下3D捕捉成像(×800)，可见左眼上皮细胞水肿增大，细胞间隙增宽，细胞间水泡样改变，暗区中可见圆顶状亮点的赘生物；图1F示角膜内皮镜下角膜内皮细胞成像(×180)，角膜内皮细胞标准偏差和变异系数均异常，可见蜂巢样暗区　 图2　角膜内皮失代偿联合老年性白内障患者术后不同时期左眼的眼部表现　图2A示患者术后1 d左眼裂隙灯显微镜下眼前节彩色照相(×16)，可见结膜充血水肿，角膜水肿，角膜植片与植床贴敷良好，颞上方角膜缝线在位，前房上方可见圆形气泡，前房深度正常，人工晶状体正位；图2B示患者术后1 d时的光学相干断层扫描成像，可见角膜内皮植片和植床贴敷良好；图2C示患者术后7 d时的左眼裂隙灯显微镜下眼前节彩色照相(×16)，可见前房气泡消失；图2D示患者术后30 d时的左眼裂隙灯显微镜下眼前节照彩色照相(×16)，可见角膜植片透明，角膜水肿消退；图2E和2F示患者术后6个月时的裂隙灯显微镜下眼前节照彩色照相(×16)，可见角膜水肿消退，人工晶状体在位；图2G示术后6个月时的光学相干断层扫描成像，可见角膜植片与植床贴敷良好
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