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目的分析疑难性准分子激光角膜屈光手术的原因、分类、方案设计及治疗效果。设计回顾性病例系列。研究对象非常规疑难性准分子激光屈光性角膜手术患者47眼。方法分析患者进行屈光手术的原因、方案设计及治疗效果。除视力(裸眼、矫正、小孔视力)、屈光度(散瞳和显然验光)、主视眼、角膜厚度、角膜地形图、像差检查等常规术前检查外,还要依据患者情况进行相应的特殊检查,包括角膜多点厚度、角膜曲率时间变化、眩光仪、对比敏感度、眼肌功能、VEP等检查。手术前对患者进行个性化手术设计以及可能的预后评估。主要指标治疗前角膜厚度、视力、角膜地形图变化、屈光度、手术次数。结果疑难角膜屈光手术的界定:除最佳矫正视力小于0.8,还伴有角膜形态、结构异常或屈光参差、弱视等异常,或曾行屈光角膜手术但效果不佳,最佳矫正视力低于0.5,需再次进行角膜屈光手术的患者。疑难角膜屈光手术分类:(1)根据角膜屈光手术史分为手术原性屈光状态异常性、手术原性角膜结构异常性;(2)根据角膜情况分为角膜结构异常性、角膜曲率异常性;(3)根据双眼屈光状态差异分为高度近视伴弱视性、屈光参差性疑难角膜屈光手术。治疗方法:个性化设计手术,地形图引导手术,角膜屈光手术方式包括准分子激光角膜屈光手术(PRK)、上皮下准分子激光角膜磨镶术(Epi-LASIK)、准分子激光角膜表层磨镶术(LASEK)、准分子激光原位角膜磨镶术(LASIK)、治疗性角膜屈光手术(PTK)以及联合手术等。治疗效果:所有患者达到预期最佳矫正视力,其中超过预期矫正视力2行以上者为51.1%(24眼),超过3行以上者为23.4%(11眼)。预期性:实际矫正度在预期矫正度±0.5 D之间者45眼。患者对手术效果满意,随访2年以上未出现异常情况。结论界定疑难屈光性角膜手术的原因、适应证,严格分析患者屈光状态、角膜病变情况,进行合理的手术设计和时机选择,可为眼部情况复杂的非常规患者提供安全、有效、可预测性强的角膜屈光手术,为患者带来良好的屈光矫正和最佳生活视力。
Objective To analyze the causes, classification, design and treatment of difficult excimer laser corneal refractive surgery. Design retrospective case series. 47 patients with unconventional excimer laser refractive corneal surgery. Methods Analysis of the reasons for refractive surgery, program design and treatment effect. In addition to routine visual examination (naked eye, correction, pinhole vision), diopter (mydriasis and apparently optometry), the dominant eye, corneal thickness, corneal topography, aberrations and other routine preoperative examination, but also according to the patient’s situation corresponding Special examination, including multi-point corneal thickness, changes in corneal curvature, glare, contrast sensitivity, ocular muscle function, VEP and other tests. Patients were given a personalized surgery design and a possible prognostic assessment before surgery. The main indicators of corneal thickness before treatment, visual acuity, corneal topography changes, refraction, number of operations. Results difficult corneal refractive surgery definition: In addition to the best corrected visual acuity of less than 0.8, but also associated with corneal morphology, structural abnormalities or anisometropia, amblyopia and other abnormalities, or had refractive corneal surgery but the effect is not good, the best corrected visual acuity Less than 0.5, need to re-corneal refractive surgery patients. Difficult corneal refractive surgery classification: (1) according to the history of corneal refractive surgery is divided into surgical abnormalities of refractive status, surgical abnormalities of corneal structure; (2) According to the cornea is divided into corneal structural abnormalities, corneal curvature Abnormalities; (3) According to differences in binocular refractive state is divided into high myopia with amblyopia, anisometropia difficult corneal refractive surgery. Treatment methods: personalized design surgery, topography guided surgery, corneal refractive surgery including excimer laser keratomileusis (PRK), subepithelial laser keratomileusis (Epi-LASIK), excimer laser corneal surface LASEK, LASIK, PTK and combined surgery. Therapeutic effect: All patients reached the expected best corrected visual acuity, of which 51.1% (24 eyes) were more than 2 lines expected vision correction and 23.4% (11 eyes) were more than 3 lines. Expected: Actual corrections ranged from ± 0.5 D to 45 expected. Patients were satisfied with the operation results, no abnormalities were observed after more than 2 years of follow-up. Conclusion Defining the causes and indications of refractory corneal refractive surgery, analyzing the patients’ refractive status and corneal disease strictly, making proper surgical design and timing selection can provide a safe and effective method for unconventional patients with complicated eye conditions Predictive corneal refractive surgery, patients with good refractive correction and the best life vision.