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ENGLISH ABSTRACT
白内障术中房角镜指导下房角成形术治疗原发性闭角型青光眼合并白内障疗效评价
王瑾
牟大鹏
张烨
王悦
孙云晓
唐炘
王宁利
作者及单位信息
·
DOI： 10.3760/cma.j.cn115989-20221002-00465
Evaluation of clinical efficacy and safety on phacoemulsification combined with gonioscopy-assisted angle plasty for primary angle-closure glaucoma with cataract
Wang Jin
Mou Dapeng
Zhang Ye
Wang Yue
Sun Yunxiao
Tang Xin
Wang Ningli
Authors Info & Affiliations
Wang Jin
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Mou Dapeng
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Zhang Ye
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Wang Yue
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Sun Yunxiao
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Tang Xin
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
Wang Ningli
Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
·
DOI： 10.3760/cma.j.cn115989-20221002-00465
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摘要

目的评估超声乳化白内障吸除术中房角镜指导下房角成形术(Phaco-GAAP)治疗原发性闭角型青光眼(PACG)合并白内障的疗效及安全性。

方法采用系列病例观察研究方法，于2022年4月至2022年8月在首都医科大学附属北京同仁医院纳入PACG合并白内障患者22例25眼。所有患眼均接受Phaco-GAAP手术，术中先进行黏弹剂辅助下房角成形操作，再用房角镜观察并记录术眼360°房角周边前粘连(PAS)部位及范围，对未完全开放处的房角行二次房角成形操作，记录房角PAS范围。若2次房角成形后房角PAS范围依然>180°，则术中联合内窥镜下睫状体光凝术。分别于术后1 d、1周、1个月及3个月进行随访，主要效应指标包括眼压、房角PAS范围、降眼压药物使用数量和手术并发症，计算手术成功率。手术条件成功定义为术后联合药物应用眼压可控制到≤21 mmHg，完全成功定义为术后未使用降眼压药物眼压≤21 mmHg。术后1个月、3个月评估房角PAS范围。

结果25眼术前、Phaco-GAAP术中第1次和第2次房角成形后房角PAS范围分别为[270(225，360)°]、[165(110，215)°]和[100(35，175)°]，总体比较差异有统计学意义(χ2＝40.742，P<0.001)，其中术中第1次房角成形后PAS范围小于术前，第2次房角成形后PAS范围小于第1次房角成形后，差异均有统计学意义(均P<0.001)。2次房角成形后房角PAS范围≥180°的比例由48%下降到24%。随访末期完成房角镜检查的13眼术前、术毕、术后1个月及术后3个月房角PAS范围分别为[240(195，305)°]、[60(25，182.5)°]、[170(120，275)°]和[180(140，280)°]，总体比较差异有统计学意义(χ2＝23.631，P<0.001)，术后1个月、3个月术眼PAS范围明显小于术前，但均大于术毕时房角PAS范围，差异均有统计学意义(P＝0.004、0.004、0.011、0.003)。术眼手术前及术后1 d、1周、1个月和3个月眼压值分别为(40.19±17.23)、(15.80±7.98)、(13.89±5.09)、(12.80±3.79)和(13.24±2.78)mmHg(1 mmHg＝0.133 kPa)，总体比较差异有统计学意义(F＝44.031，P<0.001)，术后各时间点眼压均低于术前，差异均有统计学意义(均P<0.001)。术眼术毕与术前PAS范围呈正相关(rs＝0.409，P＝0.042)。所有术眼及术后各时间点抗青光眼药物使用均少于术前。术后1个月手术完全成功率和条件成功率均为95.8%，术后3个月手术完全成功率和条件成功率分别为95.8%和100%。术中主要并发症为局限性前房角出血，发生率为68%，未见其他严重并发症。

结论Phaco-GAAP术中可定量观察房角PAS范围并指导二次房角成形，是一种安全有效的治疗PACG合并白内障的手术方式。

原发性闭角型青光眼;房角成形术;周边前粘连;疗效;安全性
ABSTRACT

ObjectiveTo evaluate the efficacy and safety of phacoemulsification combined with gonioscopy-assisted angle plasty (Phaco-GAAP) for primary angle closure glaucoma (PACG) with cataract.

MethodsA case series study was carried out.Twenty-five eyes of 22 patients with PACG and cataract were enrolled in Beijing Tongren Hospital from April 2022 to August 2022.All of the patients received Phaco-GAAP surgery.During the operation, viscoelastic-assisted goniosynechialysis was performed at first, followed by a secondary angle plasty for residual peripheral anterior synechiae (PAS) based on the quantified assessment by gonioscopy, and the extent of PAS was recorded intraoperatively.The operated eyes were followed at 1 day, 1 week, 1 month and 3 months after surgery to evaluate intraocular pressure (IOP), PAS range, the number of anti-glaucoma drugs application, operation-related complications, and success rate.The qualified success rate was defined as medicine-controlled IOP ≤21 mmHg after surgery, and complete success rate was defined as IOP ≤21 mmHg without any anti-glaucoma medication.This study complied with the Declaration of Helsinki and was approved by the Ethics Committee of Beijing Tongren Hospital (TRECKY2021-136). Written informed consent was obtained from each patient prior to entering the research cohort.

ResultsThe extent of PAS was [270(225, 360)°], [165(110, 215)°] and [100(35, 175)°] at preoperation, first and secondary angle plasty, respectively, showing a significant difference among them (χ2 =40.742, P<0.001). The PAS range was significantly reduced at first angle plasty in comparison with preoperation and was significantly reduced at secondary angle plasty in comparison with at first angle plasty (both atP<0.001), and the proportion of the angle PAS range ≥180° decreased from 48% to 24% after second angle plasty.In 13 eyes finished gonioscopy, the PAS range was [240(195, 305)°], [60(25, 182.5)°], [170(120, 275)°]and [180(140, 280)°]at preoperation, at the end of operation, postoperative 1 month and 3 months, respectively, with a significant difference (χ2 =23.631, P<0.001). The PAS range was significantly smaller at postoperative 1 month, 3 months than that at preoperation (both atP=0.004) and larger than that at the end of operation (P=0.011, P=0.003). The IOP was (40.19±17.23), (15.80±7.98), (13.89±5.09), (12.80±3.79) and(13.24±2.78) mmHg before operation and 1 day, 1 week, 1 month and 3 months after operation, respectively, showing a significant difference (F=44.031, P<0.001), and the IOP was significantly reduced after operation (all atP<0.001). The PAS range at the end of operation was positively correlated with preoperation (rs=0.409, P=0.042). The complete and qualified success rates were 95.8%, 95.8% for postoperative 1 month, 95.8% and 100% for postoperative 3 months, respectively.The primary complication was intraoperative anterior chamber angle hemorrhage, with an incidence of 68%.

ConclusionsPhaco-GAAP can intraoperatively quantify PAS range and guide secondary angle plasty, therefore, it is an effective and safe surgical intervention for PACG with cataract.

Primary angle closure glaucoma;Gonioplasty;Periphery anterior synechiae;Outcome;Safety
Wang Ningli, Email: mocdef.3ab61.pivilgninw
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引用本文

王瑾,牟大鹏,张烨,等. 白内障术中房角镜指导下房角成形术治疗原发性闭角型青光眼合并白内障疗效评价[J]. 中华实验眼科杂志,2023,41(01)：47-53.

DOI:10.3760/cma.j.cn115989-20221002-00465

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超声乳化白内障吸除术联合房角分离术(phacoemulsification combined with goniosynechialysis，Phaco-GSL)或超声乳化白内障吸除术联合房角成形术(phacoemulsification combined with viscogonioplasty，Phaco-VGP)，是目前国内原发性闭角型青光眼(primary angle closure glaucoma，PACG)的首选手术治疗方案[ 1 ]。PACG的发病机制主要是房角关闭致房水排出受阻，引起眼压升高及视神经损害[ 2 ]。既往研究发现，单纯晶状体摘出手术可通过增宽房角改善房水排出[ 3 , 4 ]，但是其对于房角粘连范围超过180°的PACG患者来说，改善房角的狭窄或粘连作用十分有限[ 5 ]，同时长期周边虹膜前粘连(peripheral anterior synechiae，PAS)会造成小梁网组织的不可逆性损伤[ 6 , 7 ]。从理论上来讲，晶状体摘出术联合房角分离术(goniosynechialysis，GSL)或房角成形术可在改善房角结构基础上解除房水排出阻力，从而达到对因治疗的目的，进一步提高PACG的治疗效果。
GSL或房角成形术是2种不同的开放房角的抗青光眼手术。国际上将应用虹膜分离器或钝性器械(如黏弹剂针头、白内障劈核钩等)在房角镜辅助下机械压迫虹膜根部以开放房角的方法定义为GSL[ 8 ]，而将直接在房角处注射黏弹剂，利用黏弹剂的机械压迫作用分离房角的方法定义为房角成形术[ 9 ]。目前国内房角成形术的临床研究较少。国内外研究均显示，Phaco-GSL术后复发性PAS的发生率可达83.2%[ 10 ]，2022年一项回顾性研究显示补充的机械GSL后复发性PAS的发生率更高，可能与房角和/或小梁网组织的机械性损伤、前房易发生出血及较重的炎症反应等因素有关，且研究发现无论术前PAS的范围是否超过180°，都可通过黏弹剂充填实现房角成形，术后房角开放者达到半数以上[ 11 ]。然而如何在不增加手术难度和复杂性的基础上达到更有效的术中房角成形效果，并尽可能减轻因分离房角所造成的机械损伤，避免术后的广泛房角再粘连仍是眼科医师面临的挑战。
本研究团队首次提出了房角镜指导下房角成形术(gonio-assessed angle plasty，GAAP)方案，在白内障超声乳化摘出术联合人工晶状体(intraocular lens，IOL)植入术后先行黏弹剂辅助下房角成形，并且在无需调节显微镜及患者头位的情况下用房角镜评估360°房角开放状态，以对未完全开放的房角行补充房角成形。本研究拟对Phaco-GAAP治疗PACG合并白内障的疗效及安全性进行评估。
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参考文献
[1]
中华医学会眼科学分会青光眼学组．中国原发性闭角型青光眼诊治方案专家共识(2019年)[J]．中华眼科杂志， 2019，55(5):325-328. doi: 10.3760/cma.j.issn.0412-4081.2019.05.002 .
返回引文位置Google Scholar
百度学术
万方数据
[2]
Yanoff M , Jay SD . Ophthalmology[M]. 5th ed. Amsterdam：Elsevier， 2018∶1064.
返回引文位置
[3]
郑东健，王宁利，甄兆忠，等．原发性闭角型青光眼白内障术后房角形态的改变[J]．眼科， 2000，9(3):131-135. doi: 10.3969/j.issn.1004-4469.2000.03.001 .
返回引文位置Google Scholar
百度学术
万方数据
Zheng DJ , Wang NL , Zhen ZZ ，et al. The change of configuration about anterior chamber angle of primary angle-closure glaucoma before and after extraction of cataract[J]．Ophthalmol CHN， 2000，9(3):131-135. doi: 10.3969/j.issn.1004-4469.2000.03.001 .
Goto CitationGoogle Scholar
Baidu Scholar
Wanfang Data
[4]
梁远波，王宁利，乔利亚，等．对单纯白内障手术治疗合并白内障的闭角型青光眼的疗效评价[J]．中华眼科杂志， 2004，40(11):3. doi: 10.3760/j:issn:0412-4081.2004.11.002 .
返回引文位置Google Scholar
百度学术
万方数据
[5]
Krishnadas R ．Current management options in primary angle closure disease[J]．Indian J Ophthalmol， 2019，67(3):321-323. doi: 10.4103/ijo.IJO_1932_18 .
返回引文位置Google Scholar
百度学术
万方数据
[6]
Hamanaka T , Kasahara K , Takemura T ．Histopathology of thetrabecular meshwork and Schlemm's canal in primary angle-closure glaucoma[J]．Invest Ophthalmol Vis Sci， 2011，52(12):8849-8861. doi: 10.1167/iovs.11-7591 .
返回引文位置Google Scholar
百度学术
万方数据
[7]
Sihota R , Goyal A , Kaur J ，et al. Scanning electron microscopy of the trabecular meshwork：understanding the pathogenesis of primary angle closure glaucoma[J]．Indian J Ophthalmol， 2012，60(3):183-188. doi: 10.4103/0301-4738.95868 .
返回引文位置Google Scholar
百度学术
万方数据
[8]
Campbell DG , Vela A ．Modern goniosynechialysis for the treatment of synechial angle-closure glaucoma[J]．Ophthalmology， 1984，91(9):1052-1060. doi: 10.1016/s0161-6420(84)34195-1 .
返回引文位置Google Scholar
百度学术
万方数据
[9]
Varma D , Adams WE , Phelan PS ，et al. Viscogonioplasty in patients with chronic narrow angle glaucoma[J]．Br J Ophthalmol， 2006，90(5):648-649. doi: 10.1136/bjo.2005.087577 .
返回引文位置Google Scholar
百度学术
万方数据
[10]
Tian T , Li M , Pan Y ，et al. The effect of phacoemulsification plus goniosynechialysis in acute and chronic angle closure patients with extensive goniosynechiae[J/OL]．BMC Ophthalmol， 2019，19(1):65[2022-09-20]. http://pubmed.ncbi.nlm.nih.gov/30832600. doi: 10.1186/s12886-019-1070-9 .
返回引文位置Google Scholar
百度学术
万方数据
[11]
Wei L , Fu L , Nie L ，et al. Efficacy of combined phacoemulsification and goniosynechialysis in primary angle closure disease with different degrees of peripheral anterior synechiae[J]．J Glaucoma， 2022，31(7):540-546. doi: 10.1097/IJG.0000000000002050 .
返回引文位置Google Scholar
百度学术
万方数据
[12]
Foster PJ , Buhrmann R , Quigley HA ，et al. The definition and classification of glaucoma in prevalence surveys[J]．Br J Ophthalmol， 2002，86(2):238-242. doi: 10.1136/bjo.86.2.238 .
返回引文位置Google Scholar
百度学术
万方数据
[13]
Villavicencio JCI , Arbelaez NA , Lastra BR ，et al. Primary outcomes of patients with chronic angle-closure glaucoma treated with combined phacoemulsification，viscogoniosynechialysis，and endocyclophotocoagulation[J/OL]．J Ophthalmol， 2019，2019:6378489[2022-09-20]. https://pubmed.ncbi.nlm.nih.gov/31312531/. doi: 10.1155/2019/6378489 .
返回引文位置Google Scholar
百度学术
万方数据
[14]
Harasymowycz PJ , Papamatheakis DG , Ahmed I ，et al. Phacoemulsification and goniosynechialysis in the management of unresponsive primary angle closure[J]．J Glaucoma， 2005，14(3):186-189. doi: 10.1097/01.ijg.0000159131.38828.85 .
返回引文位置Google Scholar
百度学术
万方数据
[15]
Kameda T , Inoue T , Inatani M ，et al. Long-term efficacy of goniosynechialysis combined with phacoemulsification for primary angle closure[J]．Graefe's Arch Clin Exp Ophthalmol， 2013，251:825-830. doi: 10.1007/s00417-012-2091-8 .
返回引文位置Google Scholar
百度学术
万方数据
[16]
Husain R , Do T , Lai J ，et al. Efficacyof phacoemulsification alone vs phacoemulsification with goniosynechialysis in patients with primary angle-closure disease：a randomized clinical trial[J]．JAMA Ophthalmol， 2019，137(10):1107-1113. doi: 10.1001/jamaophthalmol.2019.2493 .
返回引文位置Google Scholar
百度学术
万方数据
[17]
Angmo D , Shakrawal J , Gupta B ，et al. Comparative evaluation of phacoemulsification alone versus phacoemulsification with goniosynechialysis in primary angle-closure glaucoma：a randomized controlled trial[J]．Ophthalmol Glaucoma， 2019，2(5):346-356. doi: 10.1016/j.ogla.2019.05.004 .
返回引文位置Google Scholar
百度学术
万方数据
[18]
Nie L , Pan W , Fang A ，et al. Combined phacoemulsification and goniosynechialysis under an endoscope for chronic primary angle-closure glaucoma[J/OL]．J Ophthalmol， 2018，2018:8160184[2022-09-22]. https://pubmed.ncbi.nlm.nih.gov/29576881/. doi: 10.1155/2018/8160184 .
返回引文位置Google Scholar
百度学术
万方数据
[19]
Teekhasaenee C , Ritch R ．Combined phacoemulsification and goniosynechialysis for uncontrolled chronic angle-closure glaucoma after acute angle-closureglaucoma[J]．Ophthalmology， 1999，106(4):669-674,. DOI：.
返回引文位置Google Scholar
百度学术
万方数据
[20]
陈瑶，程钢炜．房角粘连分离联合Phaco与单纯Phaco治疗小范围房角粘连的CPACG伴白内障疗效比较[J]．中华实验眼科杂志， 2021，39(10):885-891. doi: 10.3760/cma.j.cn115989-20201222-00857 .
返回引文位置Google Scholar
百度学术
万方数据
Chen Y , Cheng GW . A comparison study on goniosynechialysis+ phacoemulsification versus simple phacoemulsification for CPACG with PAS≤180° combined cataract[J]．Chin J Exp Ophthalmol， 2021，39(10):885-891. doi: 10.3760/cma.j.cn115989-20201222-00857 .
Goto CitationGoogle Scholar
Baidu Scholar
Wanfang Data
备注信息
A
王宁利，Email：mocdef.3ab61.pivilgninw
B

王瑾：参与选题、研究实施、数据收集和分析、论文撰写；牟大鹏、张烨、王悦、孙云晓、唐炘：参与研究实施、数据收集、论文修改；王宁利：参与选题、研究实施、论文智力性内容修改、最终定稿

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