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未行准分子激光角膜屈光手术的原因分析

Analysis of reasons for not performing laser refractive keratomileusis in refractive surgery candidates

来源期刊: 眼科学报 | 2018年3月 第33卷 第1期 15-19 发布时间: 收稿时间:2024/10/10 15:56:22 阅读量:113
作者:
关键词:
准分子激光角膜屈光手术术前检查适应证
laser refractive keratomileusis preoperative examination indications
DOI:
10.3978/j.issn.1000-4432.2018.03.05
收稿时间:
2018–02–07 
修订日期:
 
接收日期:
 

目的:分析有意愿接受准分子激光角膜屈光手术治疗近视的患者在术前检查后未行手术的原因。方法:选取20151月至20176月在安徽医科大学附属第一医院眼科激光中心检查的近视患者,分析其中未行激光手术的原因。结果:2 875例患者准备接受准分子激光角膜屈光手术,其中821(28.6%)检查后未进行手术,男462(56.3%),女359(43.7%),年龄18~51(23.69±5.85)岁。821例中社会心理因素影响484(59.0%),角膜薄或角膜厚度不足182(22.2%),超高度近视(>10.00 D)100(12.2%),高眼压19(2.3%),弱视13(1.6%),角膜曲率异常11(1.3%),眼底病变7(0.9%),角膜变性3(0.4%),其他2(0.2%)结论:近视治疗术前检查后未进行准分子激光角膜屈光手术的原因多种多样,其中社会心理因素及角膜厚度不足是最主要的原因。术前详细检查,严格掌握手术适应证和禁忌证以及充分医患沟通是手术安全的保障。

Objective: To analyze the reasons for not performing laser refractive keratomileusis surgery among refractive surgery candidates under regular preoperative examination. Methods: The patients with myopia examined in the Center of Ophthalmology in the First Affiliated Hospital of Anhui Medical University Laser between January 2015 and June 2017 were selected, the reasons for not performing laser refractive keraomileusis after regular preoperative examination were analyzed. Results: A total of 2 875 patients requested refractive surgery and 2 054 (71.4%) of them received refractive surgery. Among 821 (28.6%) patients who did not get laser refractive keratomileusis, 462 (56.3%) were male and 359 (43.7%) were female, aged 1851 years (range, 23.69±5.85 years). The most common reason for not offering refractive surgery were social psychological factors (59.0%), low central corneal thickness (22.2%), high myopia (12.2%), high intraocular pressure (2.3%), poor corrected visual acuity (1.6%), corneal topography anomaly (1.3%), retinal disease (0.9%), corneal (0.4%) and other diseases (0.2%). Conclusion: Reasons for not performing refractive surgery are quite diverse. Social psychological factors and inadequate corneal thickness were the most common reasons in the present study. Careful preoperative examination, strictly mastering indications and contraindications and full doctor-patient communication should be done for the safety of surgery.

 准分子激光角膜屈光手术具有安全、有效性和预测性好的特点,是当前应用最普遍的矫正屈光不正的技术之一,帮助许多屈光不正的患者摘掉眼镜,获得良好的裸眼视力。但并非所有屈光不正的患者都适合激光屈光手术矫正,如角膜疾病患者、角膜薄等,因此手术的适应证和禁忌证的把握至关重要。选择适当的患者及全面的术前筛查与评估是术后完美视觉的重要保证。同时屈光手术作为可选择性手术,人们对手术效果、手术费用和并发症的担忧也使部分人持怀疑、观望和比较的态度。本研究拟分析安徽医科大学附属第一医院2015120176月未行准分子激光角膜屈光手术的原因。

1 资料与方法

1.1 一般资料

 2015120176月共有2 875例屈光不正患者在安徽医科大学附属第一医院眼科激光中心接受术前全面检查,欲行准分子激光角膜屈光手术治疗近视,经检查有 821 例未行手术,其中男462(56.3%), 女359(43.7%),年龄18~51(23.69±5.85)岁。等值球镜为−0.75~28.00 D,散光为−0.50~5.50 D

1.2 方法

 术前详细询问所有患者的病史及家族史,排除全身性疾病。了解其摘除眼镜的愿望。对所有近期戴软性角膜接触镜者停戴2周以上,硬性角膜接触镜者停戴4周以上。术前检查包括:裸眼视力和最佳矫正视力,散瞳验光,非接触眼压计测量眼压,Orbscan-II角膜地形图,A超角膜测厚及眼轴测量,常规裂隙灯显微镜检查眼前段,散瞳后间接眼底镜检查眼底,必要时行三面镜检查、视野、光学相干断层扫描仪(optical coherence tomographyOCT)B超等。

2 结果

 821 例未行准分子激光角膜屈光手术的患者中,社会心理因素影响484(59%),角膜薄或角膜厚度不足的182(22.2%),超高度近视(>10.00 D)100(12.2%)。社会心理因素中,因视力低下不能进入职业350(72%),手术费用原因82(17%,表1)

1 未行角膜激光屈光手术原因

Table 1 Reasons for not performing excimer laser corneal refractive surgery

原因

例数(%)

社会心理因素

484 (59.0)

升学、入伍和入职( 视力低 下,不能进入职业)

350 (72.3)

手术费用

82 (16.9)

担心风险

39 (8.0)

其他

13 (2.7)

角膜厚度不足

182 (22.2)

超高度近视>10.00 D

100 (12.2)

高眼压

19 (2.3)

弱视

13 (1.5)

角膜曲率异常

11 (1.3)

眼底病变

7 (0.9)

角膜病变

3 (0.4)

其他

2 (0.2)

3 讨论

 随着信息化、城镇化建设,我国近视的患病率逐年上升[1]。角膜屈光手术方式也呈现多元化的趋势,但准分子激光角膜屈光手术仍是目前矫正屈光不正的主流手术方式,其包括角膜刀制瓣或飞秒激光制瓣两种。随着手术技术和设备的日趋完善,越来越多的屈光不正患者摘除眼镜,获得了良好的裸眼视力[2]。但仍有部分患者术后出现眼干、暗适应差、虚影等不适,因此对准分子激光角膜屈光手术要理性选择,慎重实施,严格掌握其适应证和禁忌证。

根据统计资料显示分析:部分患者是以升学、入伍和入职因视力低下而不能进入职业而选择手术,希望手术能帮助顺利通过体检,当此目的因其它因素而未达成时,往往放弃手术。在未手术的患者中,此类因素共有350例,占社会心理因素的72%,所占比例较大。部分患者是因手术费用,目前有多家眼科机构能开展激光屈光手术,手术费用也有差别,部分医疗机构以各种打折优惠吸引患者,而在综合医院眼科没有这些政策,以致有些患者检查后仍想比较等待,此类原因未进行手术者82例,占社会心理因素的17%。另外有部分患者及家属担心手术风险,其对手术期望值较高,对手术同意书上的风险和并发症不认同,要求完美,经医生分析解释后仍不能理解和接受,持怀疑态度,最终未能手术者3 9例,占社会心理因素的8%。此外有13例患者检查后坚持做全飞秒手术,目前我院暂无此设备,因此放弃手术,占社会心理因素3%。本研究中未行准分子激光角膜屈光手术的原因主要是社会心理因素,主观因素占大部分,这与周育锋等[3]的调查结果相似。与以往的检查后未行激光角膜屈光手术的报道不同,候英芳等[4]报道思想有顾虑期望值高未手术的占24.7%;孙平等[5]报道心理精神因素影响未手术的占9.6%;霍银平等[6]报道未手术原因心理因素占26.19%;戚晓圆[7]报道思想顾虑大期望值过高未手术的占13.43%。荆翠红[8]报道因对手术存在顾虑而未手术的原因占19.71%

 高度近视、角膜厚度不足是客观制约角膜屈光手术的一大原因。准分子激光屈光性角膜手术通过对角膜切削而改变屈光力,同时术后角膜厚度相应变薄,故角膜厚度对手术的选择和切削量的深度、直径等手术设计都有决定性作用[9]。一般认为角膜厚度<490 μ m时不应当施行角膜屈光手术,术后角膜基底的剩余厚度应>250 μ m,最好是>300 μ m,而且角膜剩余厚度应不少于原角膜厚度一半[10]。对于角膜偏薄的患者,可以选择飞秒制瓣。虽然角膜刀制瓣厚度理论可达90 μ m,但实际根据术中负压吸引时间长短,角膜瓣的厚度会有些偏差。而飞秒制瓣厚度非常精确,根据术前设计的厚度,非常精确。但对于角膜厚度和近视不匹配、角膜薄和近视度数偏高的患者,不建议行角膜激光手术,可考虑有晶体眼人工晶体植入手术。

 术前筛查圆锥角膜或疑似圆锥角膜是角膜屈光手术的安全保障。角膜屈光术后的严重并发症之一是继发圆锥角膜,其发生原因与术前即存在隐形圆锥角膜有关[11-12]。本组病例疑似圆锥角膜11(1.3%)。应用Orbscan II眼前节分析系统(美国Bausch & Lomb)能较早发现角膜形态异常,特别是角膜后表面形态异常,角膜后表面作为抵抗眼内压的第一道屏障,其受眼内压的影响较角膜前表面更明显,因此早期圆锥角膜的后表面形态变化也早于前表面形态变化[13-14]。圆锥角膜初步诊断:1)角膜前表面Diff值≥0.025 mm2)角膜后表面Diff值≥0.050 mm3)角膜最薄点≤460 μ m,双眼相差≥20 μ m。对可疑圆锥角膜诊断标准:1 )角膜前表面Diff值≥0.020 mm2 )角膜后表面Diff值≥0.040 mm3 )角膜最薄点≤500 μ m,双眼相差 ≥ 10 μ m [15]。本组有 7 例角膜后表面Diff 0.040 mm,均未实施手术。

 本组视网膜病变7(0.9%)。近视眼特别是高度近视眼常具有眼轴病理性增长,脉络膜毛细血管层变薄,导致缺血缺氧,营养代谢障碍,从而引起视网膜及脉络膜弥漫性萎缩,周边视网膜变性及裂孔形成,同时伴有玻璃体变性及后脱离等,易导致孔源性视网膜脱离的发生伴有不同程度的眼底退行性改变,其发生率为0.7%~6.0%[16]。在LASIKSBK制作角膜瓣时眼压瞬间提高达约65 mmHg(1 mmHg=0.133 kPa),这种变化对玻璃体可能造成牵拉作用,导致原有眼底疾病进一步发展。飞秒制瓣时眼压升高约35 mmHg,对眼底的扰动较小,虽然目前研究[17]表明角膜屈光手术并不增加近视患者视网膜脱离的发生率,但术前仍须散瞳查眼底,如发现干孔,建议眼底激光光凝治疗,光凝后1~3个月,待激光光斑色素反应良好时再考虑行准分子手术,并建议行飞秒制瓣。

 近视眼的青光眼患病率是正常人群的2~3[18],高度近视发生开角型青光眼的比例为正常人的6~8[19]。而且屈光术后皮质类固醇激素,可能加重术前高眼压,损害视功能。对于角膜厚度<550 μ m,眼压测量>21 mmHg[20]的近视患者建议其进一步进行视野、视盘OCT等检查,对不能确诊青光眼的建议其定期观察随访,定期复查眼压、视野、OCT等。本组有19例术前发现高眼压,暂时不做手术,观察随访。5例确诊为开角型青光眼,并给予相应治疗。

 综上所述,准分子激光角膜屈光手术具有高度的选择性,术前检查后未手术的原因既有主观因素,也有客观原因,且主观因素占主要原因。术前主动恰当的沟通,了解患者的需求,消除疑虑,同时严格掌握手术适应证和禁忌证,保障手术安全,提高术后满意度。本研究只是在大学附属医院展开,大样本多中心的研究可能进一步完善原因分析。

 

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