【作者】 崔靖；

【导师】 贺忠江； 闫一鸣；

【作者基本信息】 天津医科大学 ， 眼科学， 2010， 博士

【摘要】 目的：本文为研究一种新的手术方式,在传统的小梁切除手术中,将M形巩膜瓣支架植入巩膜瓣下,形成一个能储存房水的缓冲腔隙,同时在巩膜瓣下平坦部咬切深层巩膜窗口,在借助支架保持原滤道引流的基础上增加葡萄膜巩膜通道房水引流,称“滤道成形联合睫状体上腔开窗术”。验证PMMA材料制成的巩膜瓣支架植入巩膜瓣下的可行性、安全性和有效性,并获得房水引流到葡萄膜巩膜通道的证据。此外要证实本支架无诱发纤维化的负面作用。方法：选用25只大白兔,用作自身对照法比较滤道成形联合睫状体上腔开窗术(实验组)和单纯小梁切除术组(对照组)的术后效果。经过2个月的系统观察,获得了不同时期的眼压、前房形态、滤过泡形态、UBM活体检查、放射学检查、病理光镜和免疫组化检查资料。结果：1.未发现任何毒、负作用和不良反应。2.眼压变化的差异：实验组术后1W、1M和2M眼压值与术前比较均有显著性差异(P(0.05),对照组术后1W和1M眼压与术前比较也有显著性差异(P<0.05),但对照组术后2M时眼压与术前比较已无显著性差异(P>0.05)。3.实验组和对照组术后1d前房深度不同程度变浅,术后2d、3d、1W前房深度恢复到术前4CT水平的分别为8例／11例；17例／16例；23例／24例,无显著差异,无浅前房。4.实验组和对照组术后1W、2W、1M、2M功能性滤过泡比例分别为100%／100%；90.0%／35.0%；33.3%／6.7%；40.0%／0%。5. UBM检查显示术后1M,实验组可见房水滤过通道仍存在；对照组可见房水滤过间隙消失,巩膜瓣粘连。6.术后1M,两组取平坦部巩膜部位做放射性r计数检查,结果显示实验组和对照组单位组织放射性计数之间有显著性差异(P(0.05)7.病理结果显示术后1M实验组可见支架存在的间隙,肉芽组织逐渐成熟,逐渐纤维化,可见少量胶原组织。对照组手术区组织纤维化明显,逐渐被纤维组织修复。术后2M实验组可见支架存在的间隙,手术区纤维细胞增多,胶原增多。对照组手术区胶原增多,纤维化明显。8.免疫组化结果显示实验组与对照组在术后1W、2W、1M和2M时PCNA阳性细胞计数之间比较没有显著差异(均是P>0.05)。结论：1.本文在正常兔眼自身对照的研究结果证实,滤道成形联合睫状体上腔开窗术降眼压效果好,作用持久,无明显并发症,未引起过度组织增生,具有安全性高、使用性强,操作简单等优点。2.实验组与对照组术后成纤维细胞的增殖和瘢痕形成过程相似,实验组没有出现过度的组织增生反应。说明本实验新术式安全有效,不会引起过多的纤维化。3.实验组和对照组术后眼压均有明显下降,实验组下降幅度明显大于传统小梁切除组。4.通过两组滤过形态和功能性滤过泡的比例以及UBM检查证实,实验组的巩膜瓣支架对滤过泡有“成形”作用,从而增强并延长了降眼压效果。5.实验组手术将葡萄膜巩膜通道切开,房水进入葡萄膜巩膜间隙引流,揭示葡萄膜巩膜引流是实验组术后房水的主要引流途径。小梁切除术后房水主要是从球结膜滤过,很少能透过致密的全层巩膜进入脉络膜。更多还原

【Abstract】 Objective:To study a new surgical method, we implanted M-shaped frame under the scleral flap, and open a window at Pars plana to increase aqueous outflow, named "Filering Pathway Plasty and Supraciliary Spaces Opening Surgery". The purpose of the study is to verify the feasibility, safety and efficacy of PMMA scleral flap frame under the scleral flap, and verify the feasibility of the uveal scleral aqueous drainage.Methods:Twenty-five rabbits were selected. Filering pathway plasty and supraciliary spaces opening surgery group was the experimental group and the trabeculectomy group was the control group. After 2 months of systematic observation, we obtained IOP, anterior chamber, bleb morphology, UBM, radiology, pathology and immunohistochemistry data in different periods.Results:1. Did not find any negative effects and adverse reactions.2. There were significant difference between the IOP values of 1 week,1 month and 2 months after surgery of the experimental groups and the preoperative IOP (P<0.05). There were significant differences between the IOP value of 1 week and 1 month after surgery of the control group and the preoperative IOP (P<0.05), but there was no significant difference between the IOP values of 2 month after surgery of the control groups and the preoperative IOP (P> 0.05).3. One day after surgery, the anterior chambers of the experimental group and control group were shallowing.2 days after surgery,8 cases of the experimental group returned to preoperative levels of 4CT and 11 cases of the control group returned to preoperative levels of 4CT.3 days after surgery,17 cases of the experimental group returned to preoperative levels of 4CT and 16 cases of the control group returned to preoperative levels of 4CT.1 week after surgery,23 cases of the experimental group returned to preoperative levels of 4CT and 24 cases of the control group returned to preoperative levels of 4CT.4. One week after surgery, the proportions of functional filtering bleb were 100%of the experimental group and control group.2 weeks after surgery, the proportion of functional filtering bleb was 90%of the experimental group and it was 35%of the control group.1 month after surgery, the proportion of functional filtering blebs was 33.3%of the experimental group and it was 6.7%of the control group.2 month after surgery, the proportion of functional filtering blebs was 40%of the experimental group and it was 0%of the control group.5. One week after surgery, UBM examination showed M-shaped frame hyperechoic, aqueous filtration gap, and black low-echo areas in the experimental group, and showed the water filtration gap and black low-echo area in the control group.2 weeks after surgery, UBM showed frame hyperechoic and aqueous filtration area in the experimental group and showed water filtration channel narrowed and black low echo area in the control group.1 month after surgery, UBM showed water filtration channel and black low-echo areas in the experimental group and showed no water filtration gap and the scleral flap adhesion in the control group.6. One month after surgery, radiation r count test results showed there was significant difference between that the experimental group and control group.7. One week after surgery, pathology results showed tissue edema, little new blood vessels. Fibroblast proliferation and inflammatory cell infiltration were seen. Intrascleral hemorrhage and edema can be seen at the operating area in control group, and a small amount of new blood vessels, more fibroblasts and inflammatory cells.2 weeks after surgery, inflammatory cells decreased, fibroblast cells gradually shift to the fiber cells, Neovascularization increased in the experimental group. Angiogenesis increased, fibroblast cells increased gradually to the fiber cell transformation, surgical areas of inflammatory cells decreased in the control group.1 month after surgery, fibroblast cells gradually transformed into fiber cells, gradually fibrosis, showing that a small amount of collagen in experimental group. In control group, significant areas of tissue fibrosis, fibrous tissue is gradually repaired.2 months after surgery, collagen cells and collagen increased in experimental group and collagen increased fibrosis in control group. 8. Immunohistochemistry showed that there were no significant differences of the PCNA-positive cell counts between the experimental group and the control group 1 week,2 weeks,1 month and 2 months after surgery (P> 0.05).Conclusions:1. Filering Pathway Plasty and Supraciliary Spaces Opening Surgery is safe and easy to operate.2. The fibroblast proliferation and scar formation process is similar in experimental group and control group. There is no excessive tissue reaction in the experimental group.3. IOPs of two groups are decreased, and IOP of experimental group is much significant decreased.4. Scleral flap frame might lengthen the filtration foam molding time and extend the aqueous drainage.5. The higher r counts in experimental group means the uveal scleral drainage of aqueous humor is the main drainage channel of the experimental group.更多还原