晶状体悬韧带异常致急性继发性闭角型青光眼的临床特点及其治疗方法的探讨

Clinical features and treatment of acute secondary angle-closure glaucoma caused by abnormal ciliary zonule

关键词:  悬韧带  晶状体  松弛  青光眼  闭角型  继发性  前房深度

Key words:  zonule  lens  relaxation  glaucoma  angle-closure  secondary  anterior chamber depth

摘要:

目的　探讨晶状体悬韧带异常导致的急性继发性闭角型青光眼的临床特点及手术治疗方式的选择。方法　回顾性分析2016年4月至2018年5月沈阳市第四人民医院眼科收治的晶状体悬韧带异常导致临床表现为双眼前房深度不对称的急性继发性闭角型青光眼25例(25眼)（晶状体不全脱位15例，晶状体悬韧带松弛10例）。根据晶状体悬韧带松弛及断裂程度和范围，分别行晶状体超声乳化吸出＋前房角分离＋人工晶状体囊袋内植入术（A组）、囊袋拉钩辅助晶状体超声乳化吸除＋前房角分离＋囊袋张力环植入+人工晶状体囊袋内植入术（B组）、囊袋拉钩辅助晶状体超声乳化吸除＋前部玻璃体切除+人工晶状体睫状沟悬吊缝合固定术（C组）。术后3个月随访观察最佳矫正视力、眼压、前房深度以及前房角开放程度、手术并发症等。结果　A、B、C组术前平均最佳矫正视力(BCVA) (LogMAR)分别为2.10±0.70、2.65±0.40和 2.40±0.80, 术后分别为0.24±0.13、0.36±0.13和0.59±0.29, 各组手术前后比较，差异有统计学意义（P均< 0.05）;术前平均眼压分别为(50.18±7.58)、(51.75±4.79)和(48.25±1.26)mmHg, 术后降低至(12.82±1.85)、(16.50±1.29)和(13.25±1.70)mmHg, 差异有显著统计学意义（P均<0.01）; 术前平均CACD分别为 (1.20±0.14)、(1.19±0.05)和(1.15±0.07)mm, 术后加深至(3.29±0.24)、(3.43±0.24)和(3.64±0.06)mm, 差异有显著统计学意义（P均< 0.01）。术前平均AOD500分别为 (0.020±0.007)、(0.024±0.007)和(0.025±0.005)mm, 术后增大至(0.531±0.055)、(0.569±0.032)和(0.594±0.009)mm, 差异有显著统计学意义（P均<0.01）。术后A组中3眼3个月随访时出现后发性白内障，行YAG激光后囊膜切开术，B、C组各l眼随访3个月时发现IOL轻度偏位。结论　晶状体悬韧带异常导致的急性继发性闭角型青光眼患者的临床表现与急性原发性闭角型青光眼极其相似，双眼前房深度不对称为其临床特点，必须加以鉴别。根据晶状体悬韧带松弛及断裂程度范围选择个体化的手术治疗方式，均可获得良好的临床疗效。

Abstract:

Objective To investigate the clinical features and treatment options of acute secondary angle-closure glaucoma. Methods A retrospective analysis was performed on 25 cases (25 eyes) (15 cases of subluxation of lens, 10 cases of relaxation of ciliary zonule) of acute secondary angle-closure glaucoma caused by abnaormal ciliary zonule, which were characterized by binocular asymmetry of anterior chamber depth, in the Department of Ophthalmology at Shenyang Fourth People's Hospital from April 2016 to May 2018. According to the extent of relaxation and fracture of tciliary zonule, the patients were divided into A, B and C groups. The phacoemulsification+goniosynechialysis+intraocular lens implantation were performed in group A; capsular hook assisted phacoemulsification+goniosynechialysis+[JP]capsular tension ring implantation+intraocular lens implantation in group B; and capsular hook assisted phacoemulsification + anterior vitrectomy+intraocular lens ciliary sulcus suture fixation in group C. The best corrected visual acuity, intraocular pressure, anterior chamber depth, anterior chamber angle opening degree and surgical complications were compared at 3 months after surgery. Results The mean best corrected visual acuity (BCVA) (LogMAR) in groups A, B and C were 2.10±0.70, 2.65±0.40 and 2.40±0.80, respectively before surgery, and increased to 0.24±0.13, 0.36±0.13 and 0.59±0.29 after surgery. The differences were statistically significant (P<0.05). The mean intraocular pressure were (50.18±7.58), (51.75±4.79) and (48.25±1.26) mmHg, respectively before surgery and decreased to (12.82±1.85), (16.50±1.29) and (13.25±1.70) mmHg after surgery, the differences were statistically significant (P<0.01). The mean CACD were (1.20±0.14), (1.19±0.05) and (1.15±0.07) mm, respectively before surgery and increased to (3.29±0.24), (3.43±0.24) and (3.64±0.06) mm after surgery, the differences were statistically significant (P<0.01). The average AOD500 were (0.020±0.007), (0.024±0.007), and (0.025±0.005) mm before surgery and increased to (0.531±0.055), (0.569±0.032), and (0.594±0.009) mm after surgery, the differences were statistically significant (P<0.01). Posterior capsular opacity occurred in 3 eyes in group A at 3 months follow-up, and YAG laser posterior capsulotomy was performed. IOL mild deviation occurred in 1 eyes in groups B and C, respectively at 3 months follow-up. Conclusion Clinical manifestations of acute secondary angle-closure glaucoma caused by abnormal ciliary zonule are characterized by binocular asymmetrical anterior chamber depth, very similar to those of acute primary angle-closure glaucoma and must be differentiated. According to the extent of relaxation and fracture of ciliary zonule, individualized surgical treatment can be used to obtain excellent clinical results.