手术治疗翼状胬肉的临床分析
摘要
目的:
应用翼状胬肉单纯切除术、胬肉切除联合自体结膜移植术、胬肉切除联合自体角膜缘干细胞移植术、胬肉切除联合板层角膜移植术治疗翼状胬肉,分析各手术方法的临床疗效。探求好的手术方式以降低胬肉术后的复发率。
方法:
选择1994年1月至2006年1月因翼状胬肉住院病人158例164眼,依照采取不同手术方式分为四组:Ⅰ组:单纯胬肉切除术(25眼),Ⅱ组:胬肉切除联合自体结膜移植术(93眼),Ⅲ:胬肉切除联合自体角膜缘干细胞移植术(29眼),Ⅳ:胬肉切除联合异体板层角膜移植术(17眼)。并且依照胬肉分级法将病例另外分为三度,Ⅰ°(30眼)、Ⅱ°(80眼)、Ⅲ°(54眼)。随访6月至36个月。观察术后胬肉复发情况、角膜上皮修复时间及手术前后视力变化。统计分析各组手术效果的差异。
结果:
1.各组胬肉术后复发率比较:Ⅰ组10眼复发,复发率为40%;Ⅱ组11眼复发,复发率为11.83%;Ⅲ组1眼复发,复发率为3.45%;Ⅳ组1眼复发,复发率为5.88%.经统计学分析,Ⅰ组与其他组比差异有显著性。而其他三组之间复发率无显著性差异。
2.各级胬肉复发率的关系:Ⅰ°胬肉1眼复发,复发率为3.33%;Ⅱ°胬肉16眼复发,复发率为20%;Ⅲ°胬肉18眼复发,复发率为33.33%.统计结果:Ⅰ°与Ⅱ°、Ⅲ°比较差异有显著性。
3.各级胬肉术后视力情况的比较:Ⅰ°胬肉术后均在0.6以上,96.7%的视力在0.8以上,效果满意。而Ⅱ°与Ⅲ°胬肉分别有91.3%和98.1%的视力在0.6以下。
4.各组上皮修复时间比较:角膜缘干细胞移植组角膜上皮修复时间短于其他各组。有显著性差异。
结论:
1.胬肉切除联合结膜移植术、胬肉切除联合角膜缘干细胞移植术、胬肉切除联合板层角膜移植术是治疗翼状胬肉及降低术后复发率较好的方法。
2.翼状胬肉应及早治疗,治疗愈早,其术后复发率愈低,术后视力效果愈好。
3.胬肉切除联合角膜缘干细胞移植术治疗翼状胬肉对于角膜上皮修复来说是较好的手术方式。
Surgical treatment is still the main method for pterygium therapy.There are some methods which are accepted by most doctors: 1.simple excision of pterygium ,which is simple and easy for operating and was the main surgery of pterygium before.however, a high rate of recurrence can be as high as 30% -50%,so most of the operators haven,t taken it any more.2. Pterygium excision combined with Mc transplantation, which is a classic treatment of pterygium surgery.the recurrence rate of it is lower compared with simple Pterygium excision ,so it is widely used by Ophthalmology colleagues. 3. Pterygium excision combined with limbal autograft transplantation(LAT), which is a new type of surgery in recent years.The effect of this surgery is so affirmed,and the recurrence rate and complictions of it are lower and fewer than simple pterygium excision and Mc transplantation. As well as LAT is not very difficult surgical operation, it is becoming more acceptable for ophthalmologists. 4. Pterygium excision combined with lamellar keratoplasty, Which is applied to the relatively large size of many of the pterygium or recurrent pterygium,it is still a considered treatment method to use though it can be with a low recurrence rate and the result of it would be better .because the corneal material is scarcity,and high cost and the surgery is relative difficult.This paper retrospectively analyzed 158 cases of 164 patients admitted to the hospital because of pterygium from January 1994 to January 2006 .The eyes were divided into four groups according to the four different methods used for treating pterygium.We summed up the methods which can be with lower recurrence rate and promote visual acuities .Results : 1. Therecurrence rate in each group : the recurrence rate was 40% in group simple excision of pterygium,the recurrence rate was 11.83% in group Pterygium excision combined with Mc transplantation, the recurrence rate was 3.45% in group limbal stem cell transplantation, and the recurrence rate was 5.88% in group lamellar keratoplasty . The recurrence rate of the first group was significantly higher than the other three groups, and the difference was significant compared with the other three groups with statistical analysis. However there was no significant difference between the other three groups. we can conclude From this: Pterygium excision combined with Mc transplantation , Pterygium excision combined with limbal autograft transplantation(LAT),and Pterygium excision combined with lamellar keratoplasty are the better methods to reduce the recurrence rate of pterygium surgery. 2. The patients were divided into three degrees According to pterygium morphology and growth area.we found that the recurrence rate of these were3.33%,20%,33.33% from low to high Comparing with the postoperative recurrence rate. The recurrence rate of one-degree was significantly lower than two-degree and three-degree, and the difference was significant Through statistical analysis.we conclude that the sooner the pterygium is treated. the better the recover it is, and it should be treated in the early stage. 3. Comparing visual acuity of eyes of different periods after pterygium surgery ,we found that 96.7% of patients of one-degree with postoperative visual acuity of 0.8 or above, the results of which were satisfactory. And postoperative visual acuity of most of two-degree and three-degree eyes was as less than 0.6,and the percent of them were 91.3% and 98.1.So we get the conclution that Pterygium should be treated early. 4. Thecorneal Epithelial healing time of each group was: The mean time for the Group I was 8.50±1.20d,the mean time for the Group II was 7.73±0.77d,The mean time for the group III was 4.45±1.02d, and the mean time for the Group IV was 5.65±0.01d. the corneal Epithelial healing time of Group III was faster than the other three groups by statistical analysis (F=25.237, p <0.05).we can conclude that limbal autograft transplantation(LAT) is the best way for the growth of postoperative corneal epithelial cell. There are following understandings based on the clinical results of the pterygium surgery: 1.In order to reduce the recurrence rate of pterygium ,the Surgery should be done under the microscope for thoroughly eliminating of the pterygium corneoscleral.2. Because of the unique biological characteristics of limbal stem cells and lamellar corneal, it is better to use them for surgical treatment of pterygium and it should be extensivlly applicatied and still improvemented . However, the following attentions should be paid to the operation: (1) The hemostasis intraoperative should be in extenso and the blood under the plot should be removed thoroughly in order to facilitate the graft to stick better ,Providing a source of the growth of corneal epithelium postoperative and Promoting the recovery of epithelial. (2) The suture of the graft should be firm to avoid the Pleat and olisthesis of the graft. (3) The limbal should not be cut too deeply to avoid false pterygium and delayed healing .The Surgical operation should be careful in order not to harm rectus and cause scleral perforation. 3. Pterygium should be early treated . the pterygium of the second and third degree are Obviously congestive hypertrophy and deeply violat cornea,so the scope of the operation was larger ,and the bleeding was more , they were adverse for complete resection of the pterygium, and increased therecurrence rate. Moreover, the deep third degree pterygium has become a permanent corneal opacity, and made cornea not to be transparent, leading to the poor visual acuity postoperative. However, the first degree-and second-degree pterygium had advantage to the above, they had less violation of the cornea and made the surgery of pterygium easier after the use of drugs quiescent. We suggest that the surgery of pterygium should be taken earlier when they are in the firsr and second degree to reduce the damage to the cornea; and the surgery of pterygium should be taken in the quiescent stage to facilitate the surgical operation and reduce recurrence rate .
应用翼状胬肉单纯切除术、胬肉切除联合自体结膜移植术、胬肉切除联合自体角膜缘干细胞移植术、胬肉切除联合板层角膜移植术治疗翼状胬肉,分析各手术方法的临床疗效。探求好的手术方式以降低胬肉术后的复发率。
方法:
选择1994年1月至2006年1月因翼状胬肉住院病人158例164眼,依照采取不同手术方式分为四组:Ⅰ组:单纯胬肉切除术(25眼),Ⅱ组:胬肉切除联合自体结膜移植术(93眼),Ⅲ:胬肉切除联合自体角膜缘干细胞移植术(29眼),Ⅳ:胬肉切除联合异体板层角膜移植术(17眼)。并且依照胬肉分级法将病例另外分为三度,Ⅰ°(30眼)、Ⅱ°(80眼)、Ⅲ°(54眼)。随访6月至36个月。观察术后胬肉复发情况、角膜上皮修复时间及手术前后视力变化。统计分析各组手术效果的差异。
结果:
1.各组胬肉术后复发率比较:Ⅰ组10眼复发,复发率为40%;Ⅱ组11眼复发,复发率为11.83%;Ⅲ组1眼复发,复发率为3.45%;Ⅳ组1眼复发,复发率为5.88%.经统计学分析,Ⅰ组与其他组比差异有显著性。而其他三组之间复发率无显著性差异。
2.各级胬肉复发率的关系:Ⅰ°胬肉1眼复发,复发率为3.33%;Ⅱ°胬肉16眼复发,复发率为20%;Ⅲ°胬肉18眼复发,复发率为33.33%.统计结果:Ⅰ°与Ⅱ°、Ⅲ°比较差异有显著性。
3.各级胬肉术后视力情况的比较:Ⅰ°胬肉术后均在0.6以上,96.7%的视力在0.8以上,效果满意。而Ⅱ°与Ⅲ°胬肉分别有91.3%和98.1%的视力在0.6以下。
4.各组上皮修复时间比较:角膜缘干细胞移植组角膜上皮修复时间短于其他各组。有显著性差异。
结论:
1.胬肉切除联合结膜移植术、胬肉切除联合角膜缘干细胞移植术、胬肉切除联合板层角膜移植术是治疗翼状胬肉及降低术后复发率较好的方法。
2.翼状胬肉应及早治疗,治疗愈早,其术后复发率愈低,术后视力效果愈好。
3.胬肉切除联合角膜缘干细胞移植术治疗翼状胬肉对于角膜上皮修复来说是较好的手术方式。
Surgical treatment is still the main method for pterygium therapy.There are some methods which are accepted by most doctors: 1.simple excision of pterygium ,which is simple and easy for operating and was the main surgery of pterygium before.however, a high rate of recurrence can be as high as 30% -50%,so most of the operators haven,t taken it any more.2. Pterygium excision combined with Mc transplantation, which is a classic treatment of pterygium surgery.the recurrence rate of it is lower compared with simple Pterygium excision ,so it is widely used by Ophthalmology colleagues. 3. Pterygium excision combined with limbal autograft transplantation(LAT), which is a new type of surgery in recent years.The effect of this surgery is so affirmed,and the recurrence rate and complictions of it are lower and fewer than simple pterygium excision and Mc transplantation. As well as LAT is not very difficult surgical operation, it is becoming more acceptable for ophthalmologists. 4. Pterygium excision combined with lamellar keratoplasty, Which is applied to the relatively large size of many of the pterygium or recurrent pterygium,it is still a considered treatment method to use though it can be with a low recurrence rate and the result of it would be better .because the corneal material is scarcity,and high cost and the surgery is relative difficult.This paper retrospectively analyzed 158 cases of 164 patients admitted to the hospital because of pterygium from January 1994 to January 2006 .The eyes were divided into four groups according to the four different methods used for treating pterygium.We summed up the methods which can be with lower recurrence rate and promote visual acuities .Results : 1. Therecurrence rate in each group : the recurrence rate was 40% in group simple excision of pterygium,the recurrence rate was 11.83% in group Pterygium excision combined with Mc transplantation, the recurrence rate was 3.45% in group limbal stem cell transplantation, and the recurrence rate was 5.88% in group lamellar keratoplasty . The recurrence rate of the first group was significantly higher than the other three groups, and the difference was significant compared with the other three groups with statistical analysis. However there was no significant difference between the other three groups. we can conclude From this: Pterygium excision combined with Mc transplantation , Pterygium excision combined with limbal autograft transplantation(LAT),and Pterygium excision combined with lamellar keratoplasty are the better methods to reduce the recurrence rate of pterygium surgery. 2. The patients were divided into three degrees According to pterygium morphology and growth area.we found that the recurrence rate of these were3.33%,20%,33.33% from low to high Comparing with the postoperative recurrence rate. The recurrence rate of one-degree was significantly lower than two-degree and three-degree, and the difference was significant Through statistical analysis.we conclude that the sooner the pterygium is treated. the better the recover it is, and it should be treated in the early stage. 3. Comparing visual acuity of eyes of different periods after pterygium surgery ,we found that 96.7% of patients of one-degree with postoperative visual acuity of 0.8 or above, the results of which were satisfactory. And postoperative visual acuity of most of two-degree and three-degree eyes was as less than 0.6,and the percent of them were 91.3% and 98.1.So we get the conclution that Pterygium should be treated early. 4. Thecorneal Epithelial healing time of each group was: The mean time for the Group I was 8.50±1.20d,the mean time for the Group II was 7.73±0.77d,The mean time for the group III was 4.45±1.02d, and the mean time for the Group IV was 5.65±0.01d. the corneal Epithelial healing time of Group III was faster than the other three groups by statistical analysis (F=25.237, p <0.05).we can conclude that limbal autograft transplantation(LAT) is the best way for the growth of postoperative corneal epithelial cell. There are following understandings based on the clinical results of the pterygium surgery: 1.In order to reduce the recurrence rate of pterygium ,the Surgery should be done under the microscope for thoroughly eliminating of the pterygium corneoscleral.2. Because of the unique biological characteristics of limbal stem cells and lamellar corneal, it is better to use them for surgical treatment of pterygium and it should be extensivlly applicatied and still improvemented . However, the following attentions should be paid to the operation: (1) The hemostasis intraoperative should be in extenso and the blood under the plot should be removed thoroughly in order to facilitate the graft to stick better ,Providing a source of the growth of corneal epithelium postoperative and Promoting the recovery of epithelial. (2) The suture of the graft should be firm to avoid the Pleat and olisthesis of the graft. (3) The limbal should not be cut too deeply to avoid false pterygium and delayed healing .The Surgical operation should be careful in order not to harm rectus and cause scleral perforation. 3. Pterygium should be early treated . the pterygium of the second and third degree are Obviously congestive hypertrophy and deeply violat cornea,so the scope of the operation was larger ,and the bleeding was more , they were adverse for complete resection of the pterygium, and increased therecurrence rate. Moreover, the deep third degree pterygium has become a permanent corneal opacity, and made cornea not to be transparent, leading to the poor visual acuity postoperative. However, the first degree-and second-degree pterygium had advantage to the above, they had less violation of the cornea and made the surgery of pterygium easier after the use of drugs quiescent. We suggest that the surgery of pterygium should be taken earlier when they are in the firsr and second degree to reduce the damage to the cornea; and the surgery of pterygium should be taken in the quiescent stage to facilitate the surgical operation and reduce recurrence rate .
引文
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[16] 陈家祺,周世有,黄挺,等.新鲜羊膜移植治疗严重的急性炎症期及疤痕期眼表疾病的临床研究.中华眼科杂志,2000,36(1):13-17·
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[22] He YG, Alizadeh H, Kinoshita K, McCulley JP.Experimental transplantation of cultured human limbal and amniotic epithelial cells onto the corneal surface. Cornea. 1999 Sep;18(5):570-9.
[23] Dekaris I, Gabric N, Karaman Z, Mravicic I, Kastelan S. Limbal-conjunctival autograft transplantation for recurrent pterygium.Eur J Ophthalmol. 2002 May-Jun;12(3):177-82.
[24] Helal M, Messiha N, Amayem A, el-Maghraby A, Elsherif Z, Dabees M. Intraoperative mitomycin-C versus postoperative topical mitomycin-C drops for the treatment of pterygium. Ophthalmic Surg Lasers. 1996 Aug;27(8):674-8.
[25] Anduze AL. Merest sclera technique for primary pterygium surgery. Ophthalmic Surg. 1989 Dec;20(12):892-4.
[26] Wilson SE, Bourne WM. Conjunctival Z-plasty in the treatment of pterygium.Am J Ophthalmol. 1988 Sep 15;106(3):355-7.
[27] 孙景莹, 戎君, 染俊芳, 等.532 激光治疗翼状胬肉的临床观察 . 中国实用眼科杂志, 2005, 23( 2) : 179-181.
[28] Haik GM, Ellis GS, Nowell JF. The management of pterygia, with special reference to surgery combined with beta irradiation.Trans Am Acad Ophthalmol Otolaryngol. 1962 Nov-Dec;66:776-84
[29] Wan Norliza WM, Raihan IS, Azwa JA, Ibrahim M. Scleral melting 16 years after pterygium excision with topical Mitomycin C adjuvant therapy.Cont Lens Anterior Eye. 2006 Sep;29(4):165-7.
[30] 夏晓波.丝裂霉素C在青光眼滤过性手术中的应用.国外医学-眼科学分册,1995,1:18.
[31] 孙岩秀.5-Fu抑制后囊混浊及其角膜毒性的研究进展.中国实用眼科杂志,2000,18:72~74.
[32] Sebban A, Hirst LW. Pterygium recurrence rate at the Princess Alexandra Hospital.Aust N Z J Ophthalmol. 1991 Aug;19(3):203-6.
[33] 姜文浩.5- 氟尿嘧啶治疗人羊膜移植后翼状胬肉复发的临床研究.中国实用眼科杂志, 2007, 25(1):116-117.
[34] Singh G, Wilson MR, Foster CS. Mitomycin eye drops as treatment for pterygium.Ophthalmology. 1988 Jun;95(6):813-21.
[35] 罗舒娅.塞替派及丝裂霉素C在翼状胬肉切除术中的应用.眼科新进展, 2000,20(6):424-425.
[36] 李凤鸣主编.眼科全书.北京: 人民卫生出版社.1996, 1319-1326.
[37] Chayakul V. Prevention of recurrent pterygium by mitomycin-C.Fortschr. Ophthalmol. 1987;84(5):422-4.
[38] Bahrassa F, Datta R. Postoperative beta radiation treatment of pteryg- ium.Int J Radiat Oncol Biol Phys. 1983 May;9(5):679-84.
[39] Alaniz-Camino F. The use of postoperative beta radiation in the treatmentof pterygia.Ophthalmic Surg. 1982 Dec;13(12):1022-5.
[40] Yamada E. Radiation dosimetry with the 90Sr-applicator, and its prophylactic effect on the recurrence of pterygium and beta-radiation cataract.Nippon Ganka Gakkai Zasshi. 1969 Apr;73(4):438-45.
[41] Smitt MC, Donaldson SS. Radiation therapy for benign disease of the orbit.Semin Radiat Oncol. 1999 Apr;9(2):179-89.
[42] Monteiro-Grillo I, Gaspar L, Monteiro-Grillo M, Pires F, Ribeiro da Silva JM. Postoperative irradiation of primary or recurrent pterygium: results and sequelae.Int J Radiat Oncol Biol Phys. 2000 Oct 1;48(3):865-9.
[43] Willner J, Flentje M, Lieb W. Soft X-ray therapy of recurrent pterygium--an alternative to 90Sr eye applicators.Strahlenther Onkol. 2001 Aug;177(8):404-9.
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