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[ESCRS2014]白内障手术并发症浅析
——文森山大学医院Peter Barry教授专访

白内障  作者:  P.Barry  2014/9/24 17:24:00
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内容概要:《国际眼科时讯》:飞秒激光辅助白内障手术的禁忌症有哪些?

  <International Ophthalmology>: International What are the contraindications for femtosecond laser-assisted cataract surgery?
Dr Barry: Our main symposium is devoted to femtosecond laser surgery tomorrow and I have a specific presentation during that symposium of the preliminary results of the study of femto laser which the ESCRS has conducted over the past year. In this study, we have recruited patients from twenty-odd surgeons, mostly from Europe but also from Australia, and asked them to send us their consecutive Femto cases over a period of time and then entered those patients into the EUREQUO (European Registry for Quality Outcomes in Cataract and Refractive Surgery) database because it includes the fields that we used to identify quality outcomes in cataract and refractive surgery. There will be some additional subset fields for femto in terms of femto-related specific complications with respect to the rhexis or incisions or the fragmentation procedure but the bulk of the information will be entered into the EUREQUO fields so that we then compare those femto patients to randomly selected patients in the EUREQUO database who had their phaco surgery done at approximately the same time. We will look at them according to the benchmark outcomes that are in EUREQUO which are post-operatively: visual acuity, surgically-induced astigmatism, precision of biometry or the biometry prediction error and the occurrence of complications comprising torn capsules, vitreous loss, dropped nucleus, corneal edema post-operatively, uveitis requiring treatment and elevated intraocular pressure. Those are the key measurements that are in EUREQUO and we will match those femto patients with phaco patients and do a compare-and-contrast to see if on those benchmarkings, if there is a meaningful difference between the two surgical approaches. So that preliminary report is taking place tomorrow and I will be able to answer the question fully after that presentation has been made.

  《国际眼科时讯》:飞秒激光辅助白内障手术的禁忌症有哪些?
Dr Barry:我们明天研讨会的主要内容是飞秒激光手术,而且会中我将就近几年在ESCRS指导下飞秒激光的初步研究结果做专题报道。在这个研究中,我们通过20多名外科医生收集病人资料,医生们大多来自欧洲,也有的来自澳大利亚。我们让医生连续将他们在一段时间内的飞秒病人信息发送给我们,并将这些病人信息输入EUREQUO(欧洲白内障和屈光手术质量结果登记处)数据库,因为这个数据库中有我们用于对白内障和屈光手术术后质量鉴定的版块。在那里面,有一些附加的、针对飞秒手术的、名为“飞秒相关特定并发症”的亚版块,这些并发症与破裂、切开、粉碎操作有关,但大多数信息还是会输入EUREQUO版块,以便于将在大致同一时间内行飞秒手术的病人和EUREQUO数据库中随机选取的行超声乳化手术的病人作比较。我们将按照EUREQUO制定的术后标准进行评估:视力、术源性散光、生物统计学精度或生物统计学预测误差、并发症发生率,如囊破裂、玻璃体丢失、晶体核脱落、术后角膜水肿、需要治疗的虹膜炎、眼压升高等。这些都是EUREQUO的关键测量内容。我们将飞秒和超乳病人关联后进行比较比对,以了解按照这些标准两种手术方法是否存在存在明显的差别。因此,明天是个初步结果的报告,我将在会后回答您这个问题。

 <International Ophthalmology>: How do you reduce the incidence of macular edema after cataract surgery?
Dr Barry: That too is the subject of an ongoing ESCRS trial of diabetic and non-diabetic patients where the lead investigator is Rudy Nuijts from Maastricht with four or five participating clinics from the Netherlands. Other participating clinics are from Germany, Portugal, France and other European locations. They are hoping to treat 1100 non-diabetic and 300 diabetic patients utilizing different steroid and non-steroidal prophylactic measures with the endpoint being central OCT thickness and in the diabetic group to use intravitreal injection of Avastin as a beneficial effect in the diabetic group. It will compare and contrast drop treatments, intravitreal injections and subconjunctival steroids.

  《国际眼科时讯》:您是如何降低白内障术后黄斑水肿发生率的呢?
Dr Barry:这也是ESCRS针对糖尿病和非糖尿病病人正在进行的另一项研究。它的首席研究者是来自马斯特里赫特的Rudy Nuijts和四、五家荷兰的合作诊所。其他的合作诊所分别来自德国、葡萄牙、法国和其他欧洲国家。他们希望通过不同的甾体和非甾体方法分别对1100名非糖尿病病人和300名糖尿病进行治疗,以中央OCT厚度为治疗终点。糖尿病组使用玻璃体腔注射Avastin作为有益干扰。该研究将对滴眼治疗、玻璃体腔注射治疗和结膜下激素注射治疗进行比较比对。

 <International Ophthalmology>: Could you talk about the progress in the treatment of presbyopia in the near future?
Dr Barry: I think the pioneering surgical members will look on the treatment of presbyopia as the Holy Grail. My view is fairly conservative. I have an apprehension that the treatment of presbyopia becomes confused with clear lens extraction. It is an enormous shift to be removing clear lenses and implanting intraocular lenses in 45-50 year olds when we simply don’t know ultimately what long-term complicating factors there might be. We in the Society are a little concerned at the moment and are planning a major symposium next year in Barcelona on the exponential increase in recent years of spontaneous late dislocation of intraocular lenses into the vitreous cavity. We know from the past that this was primarily something that was associated with pseudoexfoliation being the biggest risk factor, high myopia, previous vitreoretinal surgery, retinitis pigmentosa and trauma. These would be the five things that come to most ophthalmologists’ minds as risk factors for late onset of dislocation. But that may well change in the future if we are operating on patients who are progressively younger. The Swedish cataract registry is showing a very disturbing exponential increase over the last five years in late onset dislocation occurring six to eight years afterwards in patients in whom the surgery was reported as uncomplicated and in whom the eyes were considered normal. So it is a long-term worry that we have to seriously start thinking about.

  《国际眼科时讯》:您能否就将来老视的治疗进展谈一下呢?
Dr Barry:我认为,手术治疗老视是外科大夫梦寐以求的事情。我的观点相当保守。我对通过取出透明晶体治疗近视的方法表示担忧。在我们不知道可能会出现哪些长期并发症的情况下,对45-50岁老年人取出透明晶体并植入眼内人工晶体,这是一个巨大的转变。我们学会目前对此并不关心,但同时也计划明年在巴塞罗那就近几年眼内人工晶体自发性脱入玻璃体腔发生率呈指数增长的问题举办一次重要的研讨会。从过去的经验我们得知,除假性剥脱是最大的危险因素;高度近视、玻璃体视网膜手术史,色素性视网膜炎和创伤都与之有关。这是与后期晶体脱位有关的、让眼科医生高度警惕的五个因素。然而,如果将来随着我们需手术病人的年轻化,这种情况将大大好转。瑞典白内障登记机构数据显示,在过去的5年里,术前检查正常、手术过程简单的病人,其术后6-8年的晚期晶体脱位率呈指数上升。因此,我们必须对这个长期风险做慎重思考。


 
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