屈光性角膜手术十年回顾
中国协和医科大学北京协和医院眼科
[摘要] 目的 总结准分子激光屈光性角膜手术的十年临床效果。方法 对我院自1993年5月至2003年5月拟行屈光性角膜手术者近3万人，包括行PRK、LASEK及LASIK的患者26743人，44580只眼进行检查，应用数学模式建立数据库，进行数据统计分析。结果 10年手术患者男性14691只眼，女性29889只眼；年龄9~57岁，平均27.2岁；左眼22443眼，右眼22137眼。术前情况：裸眼视力0.10±0.07；矫正视力0.98±0.37，其中≥0.5 43794只眼，占98.2%，≥1.0 41066只眼，占92.1%，≥1.5 2218只眼，占5%；眼压15.76±7.25；屈光度 球镜 -0.75 ~-18.00D(–5.65±3.24D)，柱镜 -0.25~-5.00D(–0.051±0.77D)；角膜曲率（K）值 K1 43.94±3.57 K2 42.98±3.50。筛选圆锥角膜 占0.99%，亚临床圆锥角膜 占0.93%；眼底病变及视网膜周边变性 占0.39%，排除系统疾病及不适宜激光手术者。眼术后情况：裸眼视力0.98±0.34，其中≥0.5 44580只眼，占100%，≥1.0 44031只眼，占98.8%，≥1.5 4732只眼，占10.61%；矫正视力1.03±0.33；眼压14.87±7.06；屈光度 球镜 –0.001±0.058D，柱镜 –0.000±0.027D；K值 K1 38.07±9.83 K2 37.20±10.84。实际矫正度在预期矫正度±1.00范围内98.7%。临床、亚临床圆锥角膜及眼底病变者不手术；视网膜周边变性眼底激光1月后可进行手术，以LASEK为主。三种手术长期效果没有统计学差异。
PRK1周内基质细胞明显减少，10天、1个月基质细胞数目增加，3个月减少，6个月后逐渐恢复正常；LASIK各时间点角膜细胞变化差异很小，神经纤维在3~6个月恢复正常。术中和术后并发症发生率0.2%，因手术方法、时间而有差异。术后早期（6月内）主要是激素性高眼压、Haze或角膜混浊、眼干；中期（6月到3年）主要是屈光回退、眩光；远期（3年以上）主要是角膜混浊、屈光回退。PRK、LASEK及LASIK屈光回退分别为3.2%、2.9%、1.1%。PRK后主要为激素性高眼压、屈光回退、Haze和激素性青光眼，分别占5.3%、2.4%、2.5%、0.02%；LASEK后角膜上皮下混浊占1.5%，激素性高眼压占0.3%；LASIK后角膜瓣及瓣下混浊占0.18%，感染占0.016%，上皮下植入0.18%。术后均可出现眼干燥、眩光表现，分别为3%、1.5%，LASIK相对PRK及LASEK发病率高，95%患者1年左右明显好转。屈光度高、年龄大、术后激素用量不足是PRK后Haze的主要原因，术后激素用量大、时间长、患者未按医嘱用药是激素性高眼压或青光眼发生的主要原因。医源性因素、有脚手癣患者易发生感染。角膜瓣不全、薄厚不均、角膜瓣下异物是LASIK手术后角膜混浊的主要原因。结论 准分子激光屈光性角膜手术安全、有效，98.7%患者获得了良好的、预期的屈光矫正；完善的术前检查、熟练的手术技巧、严格的无菌操作、合理的术后用药是避免严重并发症的重要手段。
[关键词] 准分子激光；角膜；屈光性角膜手术；近视；并发症
通讯作者：李莹，Email: LYing6@sohu.com Tel: 010-65296352(9)
A decade retrospective study of keratorefractive laser surgery LI Ying, JIN Yu-Mei, WANG Zhong-Hai, SUN Yu-Min, LI Hai-Yan. Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences. Beijing 100730, China
Corresponding author: LI Ying, Email: lying6@sohu.com Tel: 010-65296352,65296359
【Abstract】 Objective To study retrospectively the clinical results of keratorefractive laser surgery for the past decade. Methods 44580 eyes of 26743 subjects who underwent keratorefractive laser surgery in our hospital were studied. The surgery include photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK) and laser-assisted sub-epithelial keratomileusis (LASEK). A database was established with applied mathematics mode and the data were statistically analyzed with SPSS 10.0 for windows. Results The patients ranged in age from 9 to 57 years (mean, 27.2 years). 14691 were male eyes, 29889 were female eyes; 22443 were left eyes and 22137 were right eyes. Before operation, the mean uncorrected visual acuity was 0.10±0.07; Corrected visual acuity 0.98±0.37. 43794 eyes (98.2%) had corrected visual acuity ≥0.5, 41066 eyes(92.1%) ≥1.0, 2218 eyes(5%)≥1.5. Patients had mean interlobular pressures of 15.76±7.25 mmHg preoperatively. Parents had preoperative spherical changes from -0.75D to -18.00 D (mean, –5.65±3.24D), cylinder changes from -0.25D to -5.00D (mean, –0.051±0.77D). The preoperative corneal curvature was: K1 43.94±3.57, K2 42.98±3.50. Patients with systemic or ocular contraindications were eliminated or treated before operation: keratinous 0.99%, subclinical keratoconus 0.93%, retinal disorders and peripheral retinal degeneration 0.39%. After operation, the mean uncorrected visual acuity was 0.98±0.34, 44580 eyes (100%) had uncorrected visual acuity ≥0.5, 44031 eyes(98.8%) ≥1.0, 4732 eyes(10.61%) ≥1.5. The mean corrected visual acuity was 1.03±0.33D. Patients had mean intraocular pressures of 14.87±7.06 mmHg postoperatively. Patients had postoperative spherical changes of –0.001±0.058D, cylinder changes of –0.000±0.027D. The postoperative corneal curvature was: K1 38.07±9.83 K2 37.20±10.84. 98.7% of the patients had a difference between the achieved and the attempted correction dopier less than 1.00D. Patients with keratinous, subclinical keratinous and retinal disorders were eliminated; patients with peripheral retinal degeneration were treated with argon laser 1 month before the keratorefractive laser surgery, mainly with LASEK. The stromal cells of patients with PRK underwent a marked reduction within a week postoperation and an increase in the 10 days and 1 month postoperation, but then a reduction in the third month and eventually recovered in the sixth month. There were no marked changes in the numbers of corneal stoma cells of patients with LASIK. The corneal neves recovered after 3 to 6 months post operation. The incidence of complications during or post operations was 0.2%, varying according to the surgery choice and the operation duration. The common complications of early time (within 6 months post operation) were: steroid ocular hypertension, Haze, corneal opacity and dry eye. The common complications of middle time (from 6 months to 3 years post operation) were: refraction regression, glaring. The long-term (more than 3 years post operation) complications were: corneal opacity, refractive regression. The incidences of refractive regression with PRK, LASEK and LASIK were 3.2%, 2.9%, 1.1%, respectively. The common complications of PRK were steroid ocular hypertension, refraction regression, Haze and steroid glaucoma, each accounted for 5.3%, 2.4%, 2.5%, 0.02%, respectively. The complications of LASEK were: Haze, 1.5%; steroid glaucoma, 0.3%. The complications of LASIK were: opacity of corneal flap or beneath corneal flap, 0.18%; infection, 0.016%, subepithelial implation, 0.18%. Dry eye and glaring occurred in all the three kinds of surgery, more in patients with LASIK than with PRK and LASEK, 95% of which recovered about 1 year later. High myopia, aging and steroid insufficiency postoperation are the main causes of Haze after PRK. Overdose of steroid, long duration of operation, bad compliance were the main causes of steroid ocular hypertension and glaucoma. Iatrogenic factors and concurrence of tine were risk factors for infection. Defect or unevenness of corneal flaps and foreign bodies beneath the flaps were the main cause of post operation cornral opacity. Conclusions Keratorefractive laser surgery is safe and effective for correction of refraction error, which contribute satisfying expected visual acuity for most patients. Severe complications might be avoided by thorough preoperational examination, well skill of operation, strict aseptic manipulation and proper post operation medication.
【Key words】 Excimer laser; cornea; keratorefractive laser surgery; myopia; complication
准分子激光屈光性角膜手术治疗屈光不正已经十年了，我院作为首先引进并应用这项技术的医院，十年里，先后进行了几次机器换代、升级，开展了PRK、LASIK及LASEK手术，治疗并使2万多患者得到了良好的视力矫正。应用数学模型，建立了数据库，对患者术后情况进行详细的随访、记录，保留完整的资料，获得了很多重要提示和治疗经验。总结如下。
资料和方法
一、临床对象：为我院眼科自1993年5月至2003年5月行屈光性角膜手术的患者26743人，44580只眼进行随诊。
二、研究方法
对就诊拟行屈光性角膜手术的患者进行检查，获得数据进行详细的数据库记录。将术前及术后1、3、10天，1、3、6、12月，2~10年随诊记录的眼部情况、并发症特点及治疗结果输入数据库。临床检查包括裸眼及矫正视力、屈光度、眼压、地形图、角膜情况、眼底、视野、共聚焦显微镜检查、视敏度和眩光测试、泪膜和泪液分泌情况等，个别病例还进行全身系统检查，如免疫学、内分泌检查。
以上数据应用数据库进行数据统计分析。同时用SPSS for Windows 1.0中的均数、百分数、配对T检验进行统计。P值小于0.05认为有显著差异。
结 果
一．患者一般资料
患者总数26743人，44580眼，其中男性14691只眼，女性29889只眼；年龄9~57岁，平均27.2岁；左眼22443眼，右眼22137眼。
屈光性角膜手术患者术前一般情况见表1。
表1 十年屈光性角膜手术患者一般情况
| * | 1Y | 2Y | 3Y | 4Y | 5Y | 6Y | 7Y | 8Y | 9Y | 10Y |
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