Deep Anterior Lamellar Keratoplasty in the Early Phase of Learning Curve

前深層角膜移植的初期學習歷程

楊勝吉(Sheng-Chi Yang) ； 曾順輝(Sung-Huei Tseng)

《中華民國眼科醫學會雜誌》 49卷4期 (2010/12) Pp. 542-551

https://doi.org/10.30048/ACTASOS.201012.0005

摘要

目的：探討角膜移植醫師在前深層角膜移植手術的初期學習歷程。
設計：回溯性介入性病例分析。
方法：此研究分析角膜移植醫師，在前深層角膜移植初期的學習歷程。共16位病人（16隻眼睛）接受此手術，適應症包括圓錐角膜（8位病人），及中央角膜瘢痕，造成原因分別因戴隱形眼鏡引發綠膿桿菌角膜潰瘍後造成（4位病人），皰疹性病毒感染造成（l位），外傷性造成（3位）。術式則使用安華大水泡技術(Angwar's big-bubble)輔以小水泡技術(small-bubble technique)。我們記錄每位病人術中及術後併發症、角膜清晰度、最佳視力以及內皮細胞密度。術後追蹤8至33個月，平均15.8個月。
結果：病人平均年齡為32.1±16.9歲（最小17歲，最大77歲）。術中有五例發生微小角膜破裂，但是手術都能夠順利繼續進行而無需轉變成全層角膜移植。術後有四例發生後彈力層(Descemet membrane)剝離，在前房施打20%的SF6氣體或空氣變，剝離的後彈力層皆能重新復位。在本研究結束前，所有移植的角膜都維持清澈，無任何排斥或內皮失償的狀況。排除一例有弱視病人的視力外，其餘病人的術前最佳矯正視力(logMAR)平均為0.93±0.48，而術後進步至0.60±0.52。內皮細胞平均喪失率為14%，但在術中有微小角膜破裂的病人，則有較高的內皮細胞喪失率及發生後彈力層剝落的機會。
結論：在治療角膜基質疾病中，前深層角膜移植是全層移植外的另類有效選擇。雖然在初期的學習歷程中，發生術中微小角膜破裂及術後後彈力層剝離的機會不低，但適時並適當地處置仍將有不錯的手術成效。

並列摘要

Objective: To report the early experience of deep anterior lamellar keratoplasty (DALK).
Design: Retrospective interventional case series.
Methods: We retrospectively reviewed 16 patients (16 eyes) who had undergone DALK in a corneal transplant surgeon's early phase of DALK learning. Preoperative diagnosis included advanced keratoconus (8 eyes) and corneal stromal scars associated with previous contact lens-related keratitis (4 eyes), herpetic keratitis (1 eye), and trauma (3 eyes). DALK was performed by using Angwar's big-bubble technique, assisted by the small-bubble technique if required. Outcome measures included intraoperative and postoperative complications, graft clarity, postoperative best-corrected visual acuity (BCVA) and corneal endothelial cell density.
Results: The mean age of the patients was 32.1±16.9 years (range, 17 to 77 years). The mean postoperative follow-up period was 15.8 months, ranging from 8 to 33 months. Intraoperative microperforation occurred in 5 eyes; however, none required converting DALK to penetrating keratoplasty. Postoperatively, detachment of the Descemet membrane (DM) was observed in 4 patients, and all of them could be successfully reattached after intracameral injection of 20% SF6 or air. By the end of the study, all patients attained a clear graft without rejection or endothelial decompensation. Excluding one patient with amblyopia, the mean preoperative and postoperative BCVA (logMAR) for eyes with a minimum of 8 months of follow-up were 0.93±0.48 and 0.60±0.52, respectively. The mean endothelial cell loss was estimated to be 14%. Eyes with intraoperative microperforation tended to have a greater endothelial cell loss and a higher incidence of DM detachment.
Conclusion: DALK is a viable alternative to PK for corneal stromal disorders. Although the incidences of intraoperative microperforation and postoperative DM detachment were not low in the early phase of the learning curve, favorable outcome is possible with timely and appropriate management of these complications.

並列關鍵字

deep anterior lamellar keratoplasty ； learning curve ； microperforation ； Descemet membrane detachment