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1、 前房型Ahmed房水引流物植入治疗难治性青光眼的并发症的预防及处理 作者：王海瑛，盛晓捷，孙艳，朱洪丽【摘要】 目的：探讨前房型Ahmed房水引流物植入术治疗难治性青光眼术中术后并发症的预防及处理，提高手术的成功率。方法：对2003/2005之间于我院行前房型Ahmed房水引流物植入后的20例难治性青光眼患者的术中术后并发症进行回顾性分析。结果：随访时间423mo。平均眼压水平由35.35.2mmHg（1mmHg=0.133kPa）降低至
2、 18.64.4mmHg，成功率为90%。 13例完全成功（65%），包括早期低眼压4例、浅前房6例、前房积血4例、引流管口阻塞3例、脉络膜脱离1例；5例条件成功者（25%）包括引流盘周纤维化4例、暴发性脉络膜出血1例，仍需辅以降眼压药物控制眼压；2例因持续性高眼压导致失败。结论：通过前房植入Ahmed房水引流物术中术后并发症复杂多发，但经过及时妥善的处理仍可达到理想的疗效。 【关键词】 并发症 难治性青光眼 Ahmed减压阀 前房 0引言 经前房 Ahmed青光眼减压阀（AGV）植入术
3、为适用于前房深度良好的难治性青光眼的经典术式，其操作简单，解剖结构清晰，宜于掌握。但AGV植入术中及术后早期易发生浅前房、低眼压等一系列并发症，如处理不当将导致角膜损伤、前房出血、甚至于手术失败。为提高手术成功率，我们对我院2003-12以来前房型AGV植入术后的患者术中术后并发症对症处理，并进行回顾性分析，比较其AGV植入手术前后眼压控制效果，分析如下。 1对象和方法 1.1对象 男13例女7例，共20眼。年龄4178（平均51. 6）岁，ECCE术后4例，ECCE+IOL植入术后7例，多次小梁切除后4例，新
4、生血管性青光眼4例，葡萄膜炎并发白内障青光眼1例，术前平均眼压35.35.2mmHg（1mmHg=0.133kPa）,降眼压药物控制无效，视力持续性下降。 1.2方法 常规球后麻醉后选择合适的象限两直肌间作一90范围的以穹隆为基底的结膜瓣，潜行分离筋膜和巩膜，达眼球赤道部后方；在赤道部巩膜表面，筋膜组织下放置0.4g/L MMC 35min，20mLNS冲洗；作5mm6mm以角膜缘为基底的巩膜瓣，相当于1/2巩膜全厚，达角巩膜缘内0.5mm；取Ahmed青光眼阀，自引流管开口注入生理盐水以证实阀门通畅。无任何阻力的情况下，将Ahmed青光眼阀的引
5、流盘置于两条直肌间巩膜表面，并骑跨于眼球赤道部，使引流管直接指向角膜巩膜瓣中心径线，于角膜缘后8mm用5-0尼龙线将引流盘前端两个固定孔与巩膜固定2针；注射器连7号针头行角巩膜缘穿刺。在角巩膜缘处引流管进入前房的相应位置，用盛有生理盐水的2mL注射器连7号针头行角巩膜缘穿刺，针尖平行于虹膜面进入前房，针头撤离前房前，注入少量生理盐水以加深前房；置入引流管前将其前端置于角膜面上预测长度，再将引流管修剪成能进入前房23mm的45斜面向上的合适长度，插入时用平镊夹住引流管小心地进入前房，确保引流管与虹膜面平行而不与虹膜和角膜内皮接触，并使引流管斜面朝向角膜内表面；将巩膜瓣覆盖引流管，或者用约4mm5
6、mm的异体巩膜覆盖在角膜缘附近引流管上，并于瓣两角及两腰上用10-0尼龙线间断原位缝合4针。10-0尼龙缝线固定引流管于巩膜，并暂时性结扎引流管根部，用10-0尼龙线同时原位缝合球结膜及筋膜。术后结膜下注射地塞米松2.5mg及 庆大霉素2万U。手术成功标准：完全成功：患者不用降眼压药物条件下眼压21mmHg；条件成功：患者局部应用降眼压药物点眼条件下，眼压21mmHg；失败：局部用药不能控制眼压，需进一步行抗青光眼手术。 2结果 随访时间423（平均10.2）mo。术前眼压均值35.35.2mmHg、术后眼压均值18.64
7、.4mmHg。总的成功率90%。术后视力提高2行或2行以上7眼，提高1行或不变8眼，5眼视力下降。并发症：13例完全成功（65%），包括早期低眼压4例、浅前房6例、前房积血4例、引流管口阻塞3例、脉络膜脱离1例；5例条件成功者（25%）包括引流盘周纤维化4例、暴发性脉络膜出血1例，仍需辅以降眼压药物控制眼压；2例因持续性高眼压导致失败。 3讨论 Ahmed减压阀（美国）由两部分组成：一是引流管，它将前房水引流到远端的引流盘处；二是引流盘，通过引流盘植入后在盘周围形成和引流盘表面积相同的纤维性储液间隙。房水通过引流管被引流到
8、这一储液间隙，再经该间隙的纤维壁到周围组织内被吸收，达到降低眼压的目的。它的独特之处是在引流盘的前部附加了具有物理学缩喉嘴作用的房水控制室，该室出口处有一用弹性硅胶制成的压力敏感活瓣，该活瓣在前房压力1.071.33kPa时开放，房水则以23L的速度缓慢流向引流盘。 前房型Ahmed青光眼减压阀（AGV）植入术成功率，与术中预防性措施及术后及时处理密切相关。前房型AGV植入术最常见和最严重的并发症之一是低眼压和浅前房2。其原因主要是引流过强，由于术后早期房水引流量较大，本组患者中6 例出现浅前房其前房形成迟缓，4例早期低眼压，可能与引流管位于前房，房水直接经
9、引流管快速排出，前房容积迅速减少有关；或可能是由于前房插入口处引流管周围的渗漏和/或睫状体功能抑制，因此，我们认为限制术后早期房水过量排出是术后早期低眼压、浅前房的关键2-6，为避免这种并发症，出现了一些改良的术式。本组中导管一期植入术部分病例应用可吸收缝线暂时性结扎导管根部法7，同时密缝巩膜瓣及导管褥式缝合固定。必要时行结膜修补。本组病例有1例脉络膜脱离，经药物保守治疗而治愈。一般认为脉络膜脱离的发生率与术后早期低眼压和血管扩张、血浆外渗有关2,8,9。1例暴发性脉络膜出血，术中及时发现当即行后巩膜切开引流，联合止血药物等，达到了保存视力的良好效果。本组病例除2例持续性高眼压以外，其余均得到
10、良好转归。 另外，为避免一些其他并发症，术中术后1我们均进行了妥善的处理。引流管进入前房时要平行于虹膜避免与角膜内皮及虹膜接触。我们采用术中即刻形成前房的方法，既可观察前房形成后引流管口位置，又便于观察早期引流状况。还可避免眼压骤降眼内出血及脉络膜脱离；术中引流管暂时性结扎，可避免早期低眼压、浅前房。前房型AGV术关键是术后形成一稳定的前房状态及造成一个洁净的前房环境，以防止出现前房并发症及造成引流管口阻塞。因此，术中操作轻柔准确及术后处理妥善均至关重要。引流管避开虹膜粗大血管区进入前房，术中即刻形成前房，术后应用止血剂及皮质类固醇激素及前列腺素抑制剂，对防
11、止低眼压血管扩张再出血及前房渗出有一定作用。 前房型AGV植入术术中首先要充分分离植入阀所在赤道部区域的球结膜及结膜下组织，使植入盘周围形成一足够的腔隙以便于形成具有渗漏作用的囊腔，达到更有效降压效果。为预防引流阀的盘周围组织机化包裹，在手术时，要在引流阀的盘周围放置MMC，以便进一步提高手术的成功率。尤其对于年轻患者或估计引流盘周纤维增殖较严重的病例10。 如发生引流管堵塞，我们可依据不同情况予以YAG激光击射导管口堵塞物或角膜缘前房穿刺拨除堵塞物，引流管冲洗等使导管重新开放、必要时，重新打开结膜瓣及部分巩膜瓣，取出引
12、流管前房端，清除引流管末端处堵塞物，并用平衡盐水经4号针头插入引流管口冲洗至引流盘周结膜隆起，再将引流管植入。 术后早期高眼压未形成引流盘周纤维包裹膜之前，提前量早期眼球按摩十分有益。通过眼球指压按摩或结膜下注射MMC或5-FU，或于术后及时在引流盘周围应用抗纤维增殖剂，如对侧眼结膜下注射5-FU等，以预防瘢痕增殖发生，大部分患者可获成功5。 当已经形成明显包裹的无滤过功能纤维膜时，有关处理的详细报道很少10,11，目前的处理方法包裹纤维膜切除联合MMC：重新打开结膜瓣，分离结膜与巩膜及结膜与引流盘周围的纤维包裹膜之间的瘢
13、痕组织，在结膜与包裹膜间放置0.4g/L MMC 35min，用20mL平衡盐水冲洗后切除引流盘表面的纤维包裹膜，暴露出完整的引流盘。切除时见房水持续外流、眼压下降、部分病例伴前房变浅，表示AGV的房水引流通畅，阀门处无粘连。术后尽早作眼球指压按摩。该补救性手术方法是一种简单有效的处理方法，可减少再次植入的额外费用支出及避免睫状体破坏性手术后眼球萎缩的风险12,13。 前房型AGV是针对患眼因外伤及某手术引起的结膜、巩膜瘢痕化，或新生血管性青光眼已无常规小梁切除术的条件，避开了眼前部易结瘢痕组织，用青光眼阀将房水引流至位于赤道部巩膜表面的引流盘周围形成一个疏
14、松蜂窝结缔组织囊腔，房水由此被动扩散或渗透入眶组织的细胞间隙被毛细血管和淋巴管吸收，形成永久性房水引流通道。因为眼后部的结膜筋膜对增加引流表面积具有很大潜力，并且较前部结膜能更有效地使房水被血管吸收，以及位于后部的引流囊腔远离了前部易结瘢痕区等原因，使此手术更具优点。如能及时有效地处理术中术后并发症，其成功率将有希望大大提高，真正为难治性青光眼患者带来福音。【参考文献】 1吴瑜瑜,王宁利.青光眼引流性植入物的研究进展,国外医学眼科学分册,1996;20:228-2322 Ayyala RS, Zurakowski D, Smith JA, Monshizadeh R, Netlan
15、d PA, Richards DW, Layden WE .A clinical study of the Ah med gLaucoma vale implant in advanced glaucoma. Ophthalmology ,1998;105:1968-19763 Mills RP, Reynods A, Emond MJ, Barlow WE,Leen MM. Long-term survival of Molteno glaucoma drainage devices. Ophthalmology ,1996;103:2994 Huang MC, Netland PA, Co
16、leman AL, Siegner SW, Moster MR, Hill RA .Intermediterm clinical experience with the Ahmed glaucoma valve implant. Am J Ophthalmol ,1999;127:27-335孟娜,任百超.青光眼房水引流装置的研究进展.国际眼科杂志,2005;5(4):715-7186 Roy S, Ravinet E, Mermond A. Baerveldt implant in refractory glaucoma: long-term results and factors infl
17、uencing outcome. Int Ophthalmol ,2001;24(2):93-1007王宁利,高汝龙.难治性青光眼中复杂病例的手术治疗.中国实用眼科杂志第,2000;18(6):346-3498李绍珍.眼科手术学.第2版.北京:人民卫生出版社,1997:501-5179骜昆,陶源,卜秀荣.青光眼阀植入术治疗难治性青光眼.航空航天医药,1998;9(2):3-610唐忻,张舒心,刘磊.引流植入物手术治疗难治性青光眼的探讨,中国实用眼科杂志,2000;18(2):89-9211 Fuller JR, Bevin TH, Molteno AC. Long-term follow-up
18、 of traumatic glaucoma treated with Molteno implants. Ophthal mology ,2001;108(10):1796-80012张舒心,孙丽.联合玻璃体切除术在治疗难治性青光眼的临床研究与探讨.眼科,2001;10(2):71-7513杨侠,董晓光.Ahmed青光眼阀治疗难治性青光眼的作用和现状.国际眼科杂志,2005;5(5):994-998/Porganization system and working mode, the selection of a number of municipal strengthening group
19、 to build innovation and strengthen the organization of the basic level organizations advanced model.(seven) the manual work of the Communist Youth League Organization published and League branch of manual work, to promote the use of two manuals in the citys organizations at various levels. The coun
20、ty committee, directly under the group (work) is under the jurisdiction of grassroots League and group (total) using branch ratio shall not be less than 70%.Three, to further strengthen the groups leadership and team building(a) to strengthen the leagues leadership at all levels of construction. Con
21、tinue to do a good job of municipal Party Committee Organization Department on the strengthening of the Communist Youth League cadres management opinions implementation. To promote the group counties (autonomous counties, cities) Commission and city directly under the group (workers) appointed to ca
22、rry out the Five team building activities. Improve the League Association Department working mechanism. Conscientiously fulfill the duties of CO, combined with the city group directly under (the) Committee of the general election and the adjustment, actively jointly with the unit where the party org
23、anization department good group leadership selection with the work. Do a good job in municipal Party committee assistant committee leadership and leading cadres of the annual assessment work, adhere to and improve the assistant secretary of the Communist Youth League talk system group To weave indiv
24、idual conversation and collective conversation, to strengthen the committees of all levels, the Standing Committee of the Standing Committee, the establishment of a sound system of central group learning, the system of investigation and study, the system of important issues and the reporting system.
25、(two) to strengthen the work of education and training of cadres to conscientiously implement the Central Committee. On the implementation of grassroots cadres training project and opinions on carrying out the mission municipal CYL Cadres training project implementation opinions, full implementation
26、 of the project of the City Youth League cadres training education. Focus on the county grassroots cadres and workers focused on training, the new school system vocational training League cadres, for the Municipal Organization Department jointly held the third session of the Communist Youth League s
27、ystem training cadres in party. Focusing on the construction of new socialist countryside, strengthening village cadres and rural construction team group member of the young team, the county organizations at various levels throughout the year is expected to train 100 00 rural grassroots cadres, plan
28、s to train 1000 village secretary of the village Party branch.(three) actively promote grassroots cadres election work. Under the unified leadership of the party organization, to strengthen grassroots organizations direct work, standardize the election work rules and procedures, in the designated ca
29、ndidate, open competition to democratically elected branch secretary at the same time, actively and steadily the development of Township, streets and other grassroots organizations in the direct election of the pilot work, on the basis of summarizing the experience and gradually expand the scope of
30、the pilot, and gradually formed a set of measures and cadres election system.(four) to strengthen the cadres testing exercise. To study the development of XX city from 2006 to 2008 cadres testing exercise planning. To select outstanding cadres to the central mission in Beijing, Shanghai, Guangzhou a
31、nd other central organs and sending work in developed areas. With the Central Committee the implementation of the western region and ethnic minorities cadres training plan . To carry out the eighth batch of municipal organs attachment cadre management, selection, training work. The outstanding cadre
32、s to start the National Development Bank XX branch testing exercise.(five) to strengthen the group construction. The main position to play the role of Youth League cadre education and training as the city, in accordance with the requirements of post training, further curriculum scientifically and ra
33、tionally, adopt arrangement menu course, basic theory includes group work, focus, hot and difficult issues, to enhance the content and practice; to strengthen the construction of teaching staff, the integration of teachers, establish a quality teacher training team, establish and implement course ev
34、aluation system; take delivery of training to the countryside, on-site training, and increase the rural grassroots cadres training efforts.Four, efforts to strengthen the work of young talent(a) to tenth XX young 54 medal in recognition of the publicity, and actively explore the XX youth service. 54
35、 Medal of institutionalization, standardization and socialization mechanism. Give full play to the XX award in recognition of 54 youth medal Association, Youth Award winner in the 54 chapter, investigation activities. Who won the Youth Service medal, dedication to the society to create conditions, b
36、uild the stage. During the 54, named in recognition of the tenth XX young 54 medal. The association of XX editing of young talent , the exchange of information and communication platform for the XX of outstanding young talents.(two) the establishment of municipal Party committee of young talent info
37、rmation database. In accordance with the feasible, effective, classification management, implement step by step principle, the establishment of municipal Party committee of youth talent database; guiding organizations at various levels generally established the young talent database, construction of
38、 city, county (directly under the Communist Youth League), grassroots organizations three young talent information database the relevant information collection system, and gradually establish the citys young people, the Communist Youth League youth talent information network, provide information pla
39、tform for young talent resource development.Five, take effective measures to strengthen the mission management(a) to strengthen the mission management work. Strengthen the dues collection and management, continue to adhere to the dues collection regularly reporting system, the annual comprehensive a
40、ward in recognition of the tour and the tour one vote veto system audit system. Do statistical work in the group. The group service award in recognition of the advanced units, standardization, promoting group management work institutionalized.(two) to strengthen the organization of research and info
41、rmation exchange efforts. Grassroots carry out research, efforts to form a number of theoretical results. Make full use of the network carrier, to explore the establishment of electronic group service system, promote the work of Communist Youth League information.Attachment 4:XX municipal Party Comm
42、ittee Propaganda Department of the Communist Youth League work pointsIn 2006, the Communist Youth League propaganda ideological work XX to Deng Xiaoping theory and the important thought of Three Represents as guidance, study and implement the partys sixteen and the spirit of the the fifth Plenary Se
43、ssion of the 16th CPC Central Committee implementation of the eight plenary session of the two committee, the citys cultural work conference, the Propaganda Department of the meeting and the the fourth Plenary Session of the 15th CPC Central Committee permanent mission spirit, closely around 11th Fi
44、ve-Year XX the goal of full implementation of Scientific Outlook on Development, emancipating the mind, seeking truth from facts, keep pace with the times, close to reality, close to life, close to the young, persevere grasp orientation, grasping deepening, grasping construction innovation, further
45、improve the groups propaganda and ideological work ability, unity To guide the majority of members of the youth to achieve the 11th Five-Year planning tasks, the overall construction of a well-off society, building a socialist harmonious society to make new contributions.One, adhere to the Three Rep
46、resents important thought and Scientific Outlook on Development education to guide the youth, to further strengthen the ideological and political education of youth(a) armed with youth science theory. Unremittingly with Deng Xiaoping theory and the important thought of Three Represents armed members
47、 of youth education, to promote the study and implement to expand the depth and breadth. To study and implement the important thought of Three Represents with the establishment and implementation of Scientific Outlook on Development combine with the implementation of the requirements of constructing
48、 socialist harmonious society with Scientific Outlook on Development, carry out education as an important part of the theory of armed youth in the new period, strengthen the establishment and implementation of Scientific Outlook on Development education, educate and guide the youth to fully understa
49、nd the great significance of establishment and implementation of Scientific Outlook on Development, in-depth understanding of the Scientific Outlook on Development era back The king, the practice foundation, basic connotation, historical status, spirit and practice requirements, a profound understanding of Scientific Outlook on D