TVG手术房角镜直视下房角分离联合白内障超声乳化手术对药物治疗无效的原发性闭角型青光眼合并白内障患者的临床疗效观察

Analysis of the Clinical Effect of PhacoemulsificationCombined with Goniosynechialysis on Uncontroled Primary Angle-Closure Glaucoma under the Guide of TVG Goniscope

摘要: 目的：评价TVG手术房角镜直视下房角分离联合白内障超声乳化吸除术(phacoemulsification and goniosynechialysis, Phaco-GSL)对药物治疗无效的原发性闭角型青光眼(primary angle-closure glau-coma, PACG)合并白内障的临床疗效。方法：药物治疗无效的PACG合并白内障患者45例病人45只眼，周边虹膜前粘连(peripheral anterior synechiae, PAS)范围 ≥ 180˚，行Phaco-GSL术，比较手术前及术后各随访时间点(1周、1月、3月、6月)前房参数、眼压、视盘OCT、视力、视野及手术并发症等指标的变化。结果：术后6个月裸眼视力、最佳远距矫正视力得到显著提高(P < 0.01)，中央前房深度(anterior chamber depth, ACD)加深(P < 0.01)，周边各方向房角显著增宽，PAS范围明显减小，眼压显著降低(P < 0.01)。术后1周、1月视网膜神经纤维层平均厚度和术前相比显著增厚(P < 0.05)，术后3月、6月视网膜神经纤维层平均厚度和术前相比未见明显变化。术后各随访时间点(1周、1月、3月、6月)视野参数MD、PSD和术前相比未见明显变化。45眼均未发生前房变浅、脉络膜脱离、恶性青光眼、人工晶体脱位等严重并发症。3眼发生少量前房出血，其中2眼对术后效果无影响，1眼术后眼压未降至正常，后给予2种降眼压药物治疗，术后6月PAS范围较术前减少105˚，分离的PAS再次部分粘连，药物治疗眼压控制在23 mmHg左右。2眼术后发生前房渗出，分别发生在术后1周和术后2周。2眼发生角膜上皮损伤。结论：TVG手术房角镜直视下行房角分离联合白内障超声乳化吸除术可以有效加深前房的深度，开放粘连的房角，降低眼压并提高视力，是一种安全有效的治疗药物控制无效的PACG合并白内障的方法。

Abstract: Purposes: To evaluate the clinical effect of phacoemulsification combined with goniosynechialysis on uncontroled primary angle-closure glaucoma under the guide of TVG goniscope. Methods: 45 eyes of 45 patients with PACG and cataract did not respond to drug treatment, and the peripheral anterior synechiae (PAS) range was ≥180˚. Phaco-GSL surgery was performed, and the follow-up time points before and after surgery were compared (1 week, 1 month, 3 months, 6 months): changes in anterior chamber parameters, intraocular pressure, OCT of the optic disc, vision, visual field and surgical complications. Results: The visual acuity and the best distance corrected acuity were significantly improved at 6 months after operation, the central anterior chamber depth (ACD) was deepened, the peripheral angles were significantly widened in the peripheral directions, the PAS range was significantly reduced, and the intraocular pressure significantly reduced. The av-erage thickness of the retinal nerve fiber layer at 1 week and 1 month after operation was signifi-cantly thicker than that before operation, and the average thickness of the retinal nerve fiber layer at 3 and 6 months after operation was not significantly different from that before operation. The visual field parameters MD and PSD at each follow-up time point (1 week, 1 month, 3 months, and 6 months) showed no significant changes compared with those before surgery. No serious complications such as shallow anterior chamber, choroid detachment, malignant glaucoma, and intraocular lens dislocation occurred in 45 eyes. A small amount of anterior chamber hemorrhage occurred in 3 eyes, 2 of which had no effect on the postoperative effect, and the IOP did not fall to normal in 1 eye. Later, two intraocular pressure-lowering drugs were given. The PAS range in June was 105 lower than before, the separated PAS was partially adhered again, and the intraocular pressure of the drug treatment was controlled at about 23 mmHg. Anterior chamber exudation occurred in 2 eyes after 1 week and 2 weeks after operation. Corneal epithelial damage occurred in 2 eyes. Conclusion: TVG gonioscopy with direct angle separation and cataract phacoemulsification can effectively deepen the depth of the anterior chamber, open the adhering angle of the chamber, reduce intraocular pressure and improve vision.