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1、角膜穿通伤合并外伤性白内障最佳手术时机及手术方式的探讨余晓锐1* 王学珍2 1*山西省大同市第三人民医院眼科 山西大同 0370062 山西省大同大学医学院眼科 山西大同 037009【摘要】 目的：探讨角膜穿通伤合并外伤性白内障手术时机及超声乳化合并人工晶体植入手术的优点。方法：将45例(45眼)角膜穿通伤合并外伤性白内障患者随机分为A、B两组，A组20例，期行角巩膜伤清创缝合术的同时行外伤性白内障囊外摘除联合人工晶状体植入术；B组25例，行角巩膜伤清创缝合术后15-60天期再行外伤性白内障超声乳化联合人工晶状体植入术。观察两组病人术后视力及并发症。结果：术后随访15年，术后1年时矫正视力0
2、.5者，期植入者7眼，期植入者12眼; 矫正视力0.8者，期植入者6眼，期植入者8眼; 其余12例视力0.050.5，期植入者7例，期植入者5例; 差异均无显著性(P0.05)。A组术后继发青光眼4例、脉络膜脱离3例，睫状体脱离2例，治疗病程较长；B组术前发生青光眼3例、脉络膜脱离2例，睫状体脱离3例，但较A组为轻，经保守治疗后期行外伤性白内障超声乳化联合人工晶状体植入术时一并行小梁切除术，术后眼压仍轻微高者1例，经药物控制治愈，病程较A组为短。A组术后角膜水肿、虹膜炎症反应、后囊膜混浊等的发生率均高于B组。结论：角膜穿孔伤伴外伤性白内障手术治疗效果满意，但以伤后1560天内行白内障超声乳化联
3、合人工晶状体植入术，效果更好，安全可靠，术后并发症少，远期效果好；同时在此期间也可以观察外伤性青光眼、脉络膜脱离、睫状体脱离、视网膜脱离等并发伤、并发症的发生并在期手术前或手术时对症治疗。【关键词】 角膜穿通伤 外伤性白内障 手术时机 超声乳化 前部玻璃体切割术 人工晶体植入 并发症 Investigate the Best Timing and Way of Penetrating Corneal Laceration and Traumatic Cataract SurgeryYU Xiao-rui*, WANG Xue-zhen*Ophthalmology Department of D
4、atong No.3 Peoples Hospital in Shan Xi Province,Datong,037006,China.AbstractObjective:Penetratingcorneal laceration and traumatic cataract phacoemulsification time and intraocular lens implantation combined advantages. Methods: 45 cases (45 eyes) of corneal penetrating injury with traumatic cataract
5、 were randomly divided into A, B groups, A group of 20 patients, Phase corneoscleral wound debridement surgery simultaneously traumatic cataract extraction and intraocular lens implantation; B group of 20 patients, After corneoscleral wound debridement 15-60 days Operate phaseSurgery of traumatic ca
6、taract phacoemulsification and intraocular lens implantation; Observed postoperative complications and 作者简介：余晓锐，女，副主任医师，山西省大同市第三人民医院眼科，Tel：13008081638 Email：visual acuity. Results: Patients were followed up 1 to 5 years; After one year,Corrected visual acuity was 0.5, Phase was 7 eyes, Phase was 12
7、eyes; Corrected visual acuity was 0.8, Phase was 6 eyes, Phase was 8 eyes; The Others 12 case visual acuity was 0.05 0.5, Phase was 7 eyes, Phase was 5 eyes; There was no significant difference(P0.05). Complications of A group inclouded four cases of secondary glaucoma ,3 cases of choroidal detachme
8、nt ,2 cases of ciliary body detachment, and longer treatment duration. The patients in group B occurred preoperative 3 cases of glaucoma,2 cases of choroidal detachment ,3 cases of ciliary body detachment，However, lighter than the A group，andafter conservative treatment in phaseOperate traumatic cat
9、aract phacoemulsification and intraocular lens implantation simultaneously trabeculectomy , IOP was still slightly higher in 1 case, Cured by the drug control, the course was shorter than group A. A group of corneal edema, iris inflammation, such as posterior capsule opacification incidence rate was
10、 higher than the B group. Conclusion：Traumatic corneal cataract surgery have satisfactory results, But 15 to 60 days after injury, cataract phacoemulsification and intraocular lens implantation isbetter,safe and reliable, has less postoperative complications and long-term good effect; Also can obser
11、ve traumatic glaucoma, choroidal detachment, ciliary body detachment, retinal detachment complicated by injuries, complications during this period, And in stage surgical symptomatic treatment can be do before or during surgery.Key words Corneal penetrating injury Traumatic cataract Timing of operati
12、on Phacoemulsification Anterior vitrectomy Intraocular lens implantation Complication我院从2005年6月2009年6月共收治的45例角膜穿通伤合并外伤性白内障患者，随机分为A、B两组：A组采用期植入人工晶体，B组采用期植入人工晶体，现对两种手术时机及手术方式选择的优缺点进行了总结分析，报告如下。1 资料与方法1.1.1 一般资料 收集的45例角膜穿通伤合并外伤性白内障患者，男36例，女9例，年龄2150岁，平均33.6岁，受伤时间1天2天。受伤原因：小刀刺伤10例，玻璃划伤18例，地砖釉碎片划伤5例，鞭炮爆伤
13、3例，铁丝溅起刺伤3例，挫裂伤6例。就诊时患者视力为光感FC/眼前。45例角巩膜穿通伤长度为321mm不等。伤口虹膜嵌顿42例；合并晶状体嵌顿8例；伴前房和玻璃体积血6例；玻璃体大量溢出10例；全部虹膜、晶状体及大量玻璃体脱失者2例；脉络膜部分脱离者6例；前房均消失；术前经CT检查有3例眼内异物。将45例患者随机分为A、B两组；A组20例，采用期行角巩膜伤清创缝合术的同时行外伤性白内障摘除联合人工晶状体植入术，时间为伤后1h2天；B组25例，在行角巩膜伤清创缝合术后1560天再行期外伤性白内障超声乳化联合人工晶状体植入术。眼内异物均在期清创缝合术时取出。1.1.2眼球穿通伤诊断标准分级及本文纳
14、入标准：1级是眼球穿通伤仅合并患眼虹膜嵌顿；2级是眼球穿通伤合并晶状体或多种损害；3级是眼球穿通伤合并球内异物；4级是眼球穿通伤合并多种损害，眼内容物大量溢出。（本文所有病例对：1有较严重眼后段伤害者除外；2对于不能除外感染可能或玻璃体视网膜难以评价者除外。） A、B两组患者严重程度分级统计表如下：表一 A、B两组患者严重程度分级统计表严重程度A组B组1级032级17153级124级25合计2025 1.2 手术方法 手术均在显微镜下操作；受伤眼局部皮肤用生理盐水洗净血迹，再用络合碘消毒，铺无菌巾，作球后或球周麻醉；上开睑器，将粘有络合碘的棉球置于眼球上方约2cm，用生理盐水冲洗该络合碘棉球，
15、其水液冲洗结膜囊二到三次，再用庆大霉素及生理盐水混合液冲洗角膜伤口；将嵌顿的虹膜能还纳的还纳，受伤时间太长虹膜脱出太多或已经有坏死的就要剪除；用10-0不可吸收缝线间断板层缝合角巩膜伤口，并将缝线头转埋于角巩膜间；眼内异物均在期清创缝合术时取出。1.2.1如果是A组患者：接下来将前房注入透明质酸钠以恢复前房深度；在上方角膜缘处重新切口，娩出晶体核，吸出残留皮质，囊袋内植入人工晶体；如后囊有微小破损，则将晶体植于周边完整的囊膜上；如果后囊破损范围较大则将人工晶体悬吊于睫状沟；如果术中发生玻璃体溢出则应用前部玻璃体切割术；1.2.2如果是B组患者：在缝合好角巩膜伤口后前房注入无菌空气泡，球侧注射“2%利多卡因+妥布霉素20mg+地塞米松3mg”涂眼药膏包扎术眼。观察病情变化，如眼压高者给予降眼压药物控制；有脉络膜脱离者给予保守或巩膜切口放液治疗等对症治疗。期植入人工晶状体一般根据晶状体损害程度、皮质性炎症反应的有无及轻重在伤口缝合后1560天进行，如果晶状体囊膜破裂，皮质溢出明显对眼部的刺激较大则手术时间就要提前在1520天之内进行；反之如果晶状体囊膜没有破裂或破裂口很小皮质溢出不明显对眼部的刺激较小则手术时间适当延长在2060天之内进行。因为在角巩膜伤口缝合后1560天角巩膜伤口已接近愈合或愈合，所采用的方法为作清
