手术治疗结角膜肿瘤的临床分析
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摘要
目的:探讨手术治疗结角膜肿瘤的临床疗效。
方法:收集我院2000年3月-2008年9月手术治疗结角膜肿瘤患者68例(68眼)进行回顾性分析。其中结膜囊肿20例(20眼,占29.3%),结角膜皮样瘤14例(14眼,占20.6%),结膜色素痣5例、结角膜色素痣2例(共7眼,占10.3%),结膜皮样脂肪瘤7例(7眼,占10.3%),结膜乳头状瘤2例、结角膜乳头状瘤4例(共6眼,8.8%),结膜血管瘤4例(4眼,占5.9%),结角膜鳞状细胞癌4例(4眼,占5.9%),结角膜上皮内上皮癌(Bowen’s病)3例(3眼,占4.4%),结角膜恶性黑色素瘤1例(1眼,占1.5%),结角膜神经鞘瘤1例(1眼,占1.5%),结角膜恶性淋巴瘤1例(1眼,占1.5%)。根据眼表肿瘤的性质及部位的不同采取了不同手术方法,其中单纯手术切除肿瘤36例(36眼,占52.9%);肿瘤切除联合板层角膜移植术25例(25眼,占36.8%);肿瘤切除联合羊膜移植术6例(6眼,占8.8%);眶内容剜除术1例(1眼,占1.5%)。随访3-36个月。观察肿瘤的治愈率、复发率、术后视力及并发症等情况。
结果:(1)肿瘤治愈率为100%。(2)肿瘤复发率为0。(3)视力不配合者4眼(5.9%),视力不变者36眼(52.9%),视力提高者27眼(39.7%),视力下降者1眼(1.5%)。(4)术后角膜植片水肿3例(4.4%),角膜植床植片层间积血2例(2.9%),角膜移植排斥反应1例(1.5%),角膜新生血管1例(1.5%),内斜视1例(1.5%)。
结论:(1)手术治疗结角膜肿瘤是一种有效方法,有助于彻底清除病变,降低复发率。(2)根据肿瘤的大小、性质、部位的不同,适当选择不同的手术方式。(3)早期发现、早期诊断、早期治疗,手术创伤小,术后反应轻,可提高手术成功率。
Objective: Because of conjunctival and corneal exceptional location, directly in contact with the outside world, long-term by sunlight, wind stimulation, inflammation and other etiological factor, tumor happene liability. This study focused on the clinical efficacy of surgicaltherapy of conjunctival and corneal neoplasia.
Methods:From Mar.2000 to Sep.2008,68 cases (68eyes) of surg- icaltherapy of conjunctival and corneal neoplasia inpatients in our hospital were retrospectively analyzed. 20 cases of conjunctival cyst (20eyes,29.3%), 14 cases of corneal dermoid tumor (14eyes,20.6%), 5 cases of conjunctival nevi and 2 cases of conjunctival-corneal nevi (7eyes,10.3%),7 cases of conjunctival dermolipoma (7eyes,10.3%), 2 cases of conjunctival papilloma and 4 cases of conjunctival-corneal papilloma (6eyes,8.8%), 4 cases of conjunctival angioma (4eyes,5.9%), 4 cases of conjunctival and corneal squamous cells carcinoma (4eyes,5.9%),3 cases of conjunctival and corneal intraepithelial epithelioma (Bowen’s disease)(3eyes,4.4%), 1 case of conjunctival and corneal malignant melanoma (1 eye,1.5%), 1 case of conjunctival and corneal schwannoma (1 eye,1.5%), 1 case of malignant lymphoma (1 eye,1.5%). According to the nature and location of ocular surface of the tumor,the different modus of surgery were taken.Include 36 cases of simply surgical resection of tumor (36eyes,52.9%); 25 cases of tumor resection and lamellar keratoplasty (25eyes,36.8%) ; 6 cases of tumor resection and amniotic membrane transplantation (6eyes,8.8%); 1 case of exenteration of orbit (1 eye,1.5%). Follow up 3-36 months. Observation of tumor cure rate, relapse rate, postoperative visual acuity and complications.
Results: (1) Tumor cure rate was 100%. (2) Tumor recurrence rate was 0. (3) 4 months to 3 years old children who cannot check visual acuity have 4 eyes (5.9%); visual acuity unchanged have 36 eyes(52.9%)with lesions invading conjunctival or corneal of not more than 1mm;visual acuity improved have 27 eyes (39.7%),due to invasion corneal were taken lamellar corneal transplantation or amniotic membrane transplantation;visual acuity decreased has 1 eye(1.5%)with the orbital enucleation.(4) 3 cases of corneal grafts edema may be due to preoperative corneal graft preservation time so long that corneal epithelial barrier function decline , also may be due to not protect the corneal epithelium or a large number of interlamellar hematocele. Observing the situation of the corneal graft edema, identify its causes then to take measures. 2 cases of graft interlamellar hematocele, interlamellar hematocele was in the bed floor has deep neovascularization of residual cases, a small number of interlamellar hematocele can be self-absorbed, slightly more of the layers may be granted after hematocele compression bandage, with hemostatic and systemic steroids. 1 case of rejection, due to the tumor has larger and deeper, invaded cornea about 4mm, and there are more vessels surrounding the tumor,postoperative have a little of vessels invading cornea. After antirejection therapy with systemic and local hormone graft is transparency. 1 case of corneal neovascularization, normal corneal has the angiogenesis dynamic balance between promoting and inhibition factor.If the balance would be destroyed the neovascularization has accur.Given hormone and cyclosporine A inhibit angiogenesis.1 case of esotropia, a larger tumor invasive rectus, the medial rectus injury easier during surgical resection, postoperative strabismus happen, given the drug of alleviating inflammation and edema therapy and functional exercise decreases gradient.
Conclusion: 1.Today with the development and refreshment of ophthalmologic technology, there are a lot of methods to treat ocular surface tumor.However, surgical treatment of conjunctival and corneal tumor is an effective way which can removal the lesion thoroughly.
2. Simple surgical resection refer to small conjunctival tumor. Simple excision is the earliest treatment method,which is simple, low-cost, applicable to small conjunctival tumor. Some of the tumors recur easily after excision due to the characteristics,so we must remove the lesions completely.
3.Lamellar keratoplasty refer to large conjunctival and corneal tumors, postoperative ocular surface appearance will be improved well. Conjunctival and corneal tumor spread to the corneal scope larger and deeper, the excision will destroy the limbal to lead to the lack of the limbal stem cells, with the result that appears corneal neovascularization, chronic inflammation, fibrous tissue ingrowth and corneal opacity, also destroy the tear film to lead to corneal drying. Lamellar keratoplasty in the treatment of conjunctival and corneal tumor can repair the limbal stem cells and reconstruct the ocular surface, also can remove the tumor thoroughly, recover the corneal formation, help to reduce the postoperative astigmatism, have more obvious effect for larger conjunctival and corneal tumor especially. Completely remove the tumor and the tumor beneath the turbidity zone, so that corneal bed transparent, exposing the normal sclera, surgery to avoid penetrating bed, the implant equal to the aperture, thickness of the graft equal to the bed. It can be knotted suture,also be continuous suture.
4. When do not have fresh corneal material, tumor resection and amniotic membrane transplantation is a good way to treat conjunctival and corneal tumors, which can reconstruct ocular surface available. Amniotic membrane is translucent organization, that has a certain tenacity and no vessels, no nerves, no lymphatic. Amniotic membrane can be wound healing easily ,reduce scarring and neovascularization, prevent symblepharon, also has the function of the anti-causative organism. Because of their lack of immunogenicity, hardly in the post-transplant rejection happened. When conjunctival and corneal tumor is larger and have no fresh corneal material that can be used fresh amniotic membrane transplantation in place of lamellar keratoplasty for the treatment of ocular surface tumor.Amniotic membrane used in the transplantation come from the abdominal delivery women's placenta. Fresh amniotic membrane shoule be preserved at 4℃and used in 6 hours.
5.When malignant tumor invade intraocular or intraorbital tissue, the ophthalmectomy or exenteration of orbit should be taken. Malignant tumor can threat to life, it is the main purpose of surgical treatment that it is removed completely in order to reduce the recurrence and metastasis as soon as possible. If the tumor has violated intraorbital tissue, the ophthalmectomy had not cleaned the tumor completely, we must adopt to the exenteration of orbit with postoperative radiotherapy and chemotherapy.
方法:收集我院2000年3月-2008年9月手术治疗结角膜肿瘤患者68例(68眼)进行回顾性分析。其中结膜囊肿20例(20眼,占29.3%),结角膜皮样瘤14例(14眼,占20.6%),结膜色素痣5例、结角膜色素痣2例(共7眼,占10.3%),结膜皮样脂肪瘤7例(7眼,占10.3%),结膜乳头状瘤2例、结角膜乳头状瘤4例(共6眼,8.8%),结膜血管瘤4例(4眼,占5.9%),结角膜鳞状细胞癌4例(4眼,占5.9%),结角膜上皮内上皮癌(Bowen’s病)3例(3眼,占4.4%),结角膜恶性黑色素瘤1例(1眼,占1.5%),结角膜神经鞘瘤1例(1眼,占1.5%),结角膜恶性淋巴瘤1例(1眼,占1.5%)。根据眼表肿瘤的性质及部位的不同采取了不同手术方法,其中单纯手术切除肿瘤36例(36眼,占52.9%);肿瘤切除联合板层角膜移植术25例(25眼,占36.8%);肿瘤切除联合羊膜移植术6例(6眼,占8.8%);眶内容剜除术1例(1眼,占1.5%)。随访3-36个月。观察肿瘤的治愈率、复发率、术后视力及并发症等情况。
结果:(1)肿瘤治愈率为100%。(2)肿瘤复发率为0。(3)视力不配合者4眼(5.9%),视力不变者36眼(52.9%),视力提高者27眼(39.7%),视力下降者1眼(1.5%)。(4)术后角膜植片水肿3例(4.4%),角膜植床植片层间积血2例(2.9%),角膜移植排斥反应1例(1.5%),角膜新生血管1例(1.5%),内斜视1例(1.5%)。
结论:(1)手术治疗结角膜肿瘤是一种有效方法,有助于彻底清除病变,降低复发率。(2)根据肿瘤的大小、性质、部位的不同,适当选择不同的手术方式。(3)早期发现、早期诊断、早期治疗,手术创伤小,术后反应轻,可提高手术成功率。
Objective: Because of conjunctival and corneal exceptional location, directly in contact with the outside world, long-term by sunlight, wind stimulation, inflammation and other etiological factor, tumor happene liability. This study focused on the clinical efficacy of surgicaltherapy of conjunctival and corneal neoplasia.
Methods:From Mar.2000 to Sep.2008,68 cases (68eyes) of surg- icaltherapy of conjunctival and corneal neoplasia inpatients in our hospital were retrospectively analyzed. 20 cases of conjunctival cyst (20eyes,29.3%), 14 cases of corneal dermoid tumor (14eyes,20.6%), 5 cases of conjunctival nevi and 2 cases of conjunctival-corneal nevi (7eyes,10.3%),7 cases of conjunctival dermolipoma (7eyes,10.3%), 2 cases of conjunctival papilloma and 4 cases of conjunctival-corneal papilloma (6eyes,8.8%), 4 cases of conjunctival angioma (4eyes,5.9%), 4 cases of conjunctival and corneal squamous cells carcinoma (4eyes,5.9%),3 cases of conjunctival and corneal intraepithelial epithelioma (Bowen’s disease)(3eyes,4.4%), 1 case of conjunctival and corneal malignant melanoma (1 eye,1.5%), 1 case of conjunctival and corneal schwannoma (1 eye,1.5%), 1 case of malignant lymphoma (1 eye,1.5%). According to the nature and location of ocular surface of the tumor,the different modus of surgery were taken.Include 36 cases of simply surgical resection of tumor (36eyes,52.9%); 25 cases of tumor resection and lamellar keratoplasty (25eyes,36.8%) ; 6 cases of tumor resection and amniotic membrane transplantation (6eyes,8.8%); 1 case of exenteration of orbit (1 eye,1.5%). Follow up 3-36 months. Observation of tumor cure rate, relapse rate, postoperative visual acuity and complications.
Results: (1) Tumor cure rate was 100%. (2) Tumor recurrence rate was 0. (3) 4 months to 3 years old children who cannot check visual acuity have 4 eyes (5.9%); visual acuity unchanged have 36 eyes(52.9%)with lesions invading conjunctival or corneal of not more than 1mm;visual acuity improved have 27 eyes (39.7%),due to invasion corneal were taken lamellar corneal transplantation or amniotic membrane transplantation;visual acuity decreased has 1 eye(1.5%)with the orbital enucleation.(4) 3 cases of corneal grafts edema may be due to preoperative corneal graft preservation time so long that corneal epithelial barrier function decline , also may be due to not protect the corneal epithelium or a large number of interlamellar hematocele. Observing the situation of the corneal graft edema, identify its causes then to take measures. 2 cases of graft interlamellar hematocele, interlamellar hematocele was in the bed floor has deep neovascularization of residual cases, a small number of interlamellar hematocele can be self-absorbed, slightly more of the layers may be granted after hematocele compression bandage, with hemostatic and systemic steroids. 1 case of rejection, due to the tumor has larger and deeper, invaded cornea about 4mm, and there are more vessels surrounding the tumor,postoperative have a little of vessels invading cornea. After antirejection therapy with systemic and local hormone graft is transparency. 1 case of corneal neovascularization, normal corneal has the angiogenesis dynamic balance between promoting and inhibition factor.If the balance would be destroyed the neovascularization has accur.Given hormone and cyclosporine A inhibit angiogenesis.1 case of esotropia, a larger tumor invasive rectus, the medial rectus injury easier during surgical resection, postoperative strabismus happen, given the drug of alleviating inflammation and edema therapy and functional exercise decreases gradient.
Conclusion: 1.Today with the development and refreshment of ophthalmologic technology, there are a lot of methods to treat ocular surface tumor.However, surgical treatment of conjunctival and corneal tumor is an effective way which can removal the lesion thoroughly.
2. Simple surgical resection refer to small conjunctival tumor. Simple excision is the earliest treatment method,which is simple, low-cost, applicable to small conjunctival tumor. Some of the tumors recur easily after excision due to the characteristics,so we must remove the lesions completely.
3.Lamellar keratoplasty refer to large conjunctival and corneal tumors, postoperative ocular surface appearance will be improved well. Conjunctival and corneal tumor spread to the corneal scope larger and deeper, the excision will destroy the limbal to lead to the lack of the limbal stem cells, with the result that appears corneal neovascularization, chronic inflammation, fibrous tissue ingrowth and corneal opacity, also destroy the tear film to lead to corneal drying. Lamellar keratoplasty in the treatment of conjunctival and corneal tumor can repair the limbal stem cells and reconstruct the ocular surface, also can remove the tumor thoroughly, recover the corneal formation, help to reduce the postoperative astigmatism, have more obvious effect for larger conjunctival and corneal tumor especially. Completely remove the tumor and the tumor beneath the turbidity zone, so that corneal bed transparent, exposing the normal sclera, surgery to avoid penetrating bed, the implant equal to the aperture, thickness of the graft equal to the bed. It can be knotted suture,also be continuous suture.
4. When do not have fresh corneal material, tumor resection and amniotic membrane transplantation is a good way to treat conjunctival and corneal tumors, which can reconstruct ocular surface available. Amniotic membrane is translucent organization, that has a certain tenacity and no vessels, no nerves, no lymphatic. Amniotic membrane can be wound healing easily ,reduce scarring and neovascularization, prevent symblepharon, also has the function of the anti-causative organism. Because of their lack of immunogenicity, hardly in the post-transplant rejection happened. When conjunctival and corneal tumor is larger and have no fresh corneal material that can be used fresh amniotic membrane transplantation in place of lamellar keratoplasty for the treatment of ocular surface tumor.Amniotic membrane used in the transplantation come from the abdominal delivery women's placenta. Fresh amniotic membrane shoule be preserved at 4℃and used in 6 hours.
5.When malignant tumor invade intraocular or intraorbital tissue, the ophthalmectomy or exenteration of orbit should be taken. Malignant tumor can threat to life, it is the main purpose of surgical treatment that it is removed completely in order to reduce the recurrence and metastasis as soon as possible. If the tumor has violated intraorbital tissue, the ophthalmectomy had not cleaned the tumor completely, we must adopt to the exenteration of orbit with postoperative radiotherapy and chemotherapy.
引文
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[2]Santos A, Gomez-Leal A. Lesions of the lacrimal caruncle. Clinicopathologic features. Ophthalmology 1994;101:943-949.
[3]陈家祺,孙明霞等.“非接触技术”切除联合带角膜缘的板层角膜移植术治疗角结膜恶性黑色素瘤,中华眼科杂志,2006,142(1):23.
[4]Sjo NC, Heegaard S, Prause JU,etal: Human papillomavirus in conjunctival papilloma. Br J Ophthalmol 2001;85:785–787.
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