编者按：角膜损伤是失明的主要原因之一，影响了无数患者及其家人的生活质量。探寻角膜损伤更优治疗方法是众心所向，ARVO2023的Champalimaud Vision Award就授予了在角膜病治疗领域做出突出贡献的两位顶尖专家——Claes Dohlman教授和Gerrit Melles教授。《国际眼科时讯》有幸邀请到“板层角膜移植术之父”Gerrit Melles教授进行专访，Gerrit Melles教授分享了他在角膜移植手术方面的一些思考，并为年轻医生如何精进手术技术提供了宝贵建议。

前弹力层移植技术是如何诞生的？

Gerrit Melles教授：每位角膜外科医生都很熟悉极端圆锥角膜病例，根据我的经验，对于这样的患者，进行穿透性角膜移植术（PK）或深板层角膜移植术（DALK）是一条通往灾难的道路。我的思想转折点是一个19岁的女孩儿带来的，我为她做了DALK手术，但是术后患者角膜并发缝合反应，并出现了部分角膜溶解等情况。教科书将圆锥角膜认定为一种非炎症性疾病，但我并不认同这样的观点，我认为眼表面只是在等待对任何类型的触发（如缝合线、移植物等）做出反应。就是在那时（大约2010年），我将一个孤立的供体前弹力层植入受体的角膜基质袋内，产生大约8个屈光度的角膜扁平化，阻止了病变继续发展。作为传统技术的替代方案，这种手术方法效果很好，其目的不是恢复角膜曲率，而是允许患者长期持续配戴隐形眼镜。事实上，这些患者都习惯于配戴隐形眼镜，在进行PK或DALK手术后，大多数情况下都需要患者配戴隐形眼镜。

I guess every corneal surgeon is familiar with these cases of extreme keratoconus, and performing a penetrating keratoplasty or deep anterior lamellar keratoplasty is in my experience just a road to disaster. A turning point for me was a 19-year old girl in whom I did a DALK, which was then complicated with suture-reaction, a partial melt, etc. The textbooks claim that keratoconus is a non-inflammatory disease, but I tend to disagree in the sense that the ocular surface is just waiting to respond to any type of trigger (eg sutures, the graft, etc.). It was at that point (around 2010) that I thought to start with an isolated donor Bowman layer for implantation within a stromal pocket. This produced about 8 diopters of corneal flattening, it stopped progression, and it worked out well for us as an alternative to conventional techniques. The goal was not to restore the corneal curvature, but to allow continued contact lens wear in the long term. Virtually all of these patients are used to wearing contact lenses and after PK or DALK, most often a contact lens is required anyway.

前弹力层嵌体移植术治疗进展性圆锥角膜的效果如何？

Gerrit Melles教授：前弹力层嵌体移植（BLIT=在受体基质袋内）和前弹力层高嵌体移植（BLOT=位于宿主内皮下方）之间的区别并非广为人知。从临床角度来看，BLIT确实表现良好，但从外科角度来看，当宿主角膜形成非常薄的圆锥时，手术可能会变得相当有挑战性，因此有很大的术中操作风险。出于这个原因，我们开始研究BLOT，几乎可以避免/消除所有术中并发症。因此，对我们来说，这已成为晚期圆锥角膜的首选治疗方法。由于手术的目的是使角膜保持长期稳定、让患者长期配戴隐形眼镜，所以患者教育这方面的工作非常重要。另外，无论是在短期内，还是在长期内（因为圆锥角膜患者往往相对年轻），医生必须权衡PK和DALK可能带来的所有并发症。

The difference between a Bowman layer inlay transplantation (BLIT = within a recipient stromal pocket) and an onlay (BLOT = positioned underneath the host endothelium) is not always understood. BLIT did perform well from a clinical point of view, but from a surgical perspective, it may become rather challenging, when the host cornea has a really thin cone, so there is a substantial risk of intraoperative performation. For that reason, we started working on BLOT, in which virtually all intraoperative complications are avoided / eliminated. So for us this has become the treatment of choice in advanced keratoconus. Patient education is important, since the purpose of the surgery is long term stabilization and contact lens wear. You have to weigh this against all complications that potentially come with PK and DALK, in the short term, but also over the years (since KC patients tend to be relatively young).

如何更好地掌握DMEK手术的学习曲线？

Gerrit Melles教授：多年来，我们一直在鹿特丹开设wetlab课程，并编写了一本关于后弹力层角膜内皮移植术（DMEK）的教科书，在经过大量的尝试和失败后，我们总结了最有效的做法。如今，大多数角膜外科医生身边可能都会有同事进行DMEK手术。我希望大家可以通过查阅现有信息以及观看其他外科医生手术的方式来精进DMEK手术技术。在荷兰，人们很重视生活质量，因此我们会尽量为患者进行DMEK手术，成功的DMEK手术的并发症的发生风险相对较低，患者获得20/20 BCVA的情况非常常见。

Over the years, we have been giving wetlab courses in Rotterdam and we have written a textbook on DMEK, in which we basically summarized what worked best for us after a lot of trial and error. These days, most corneal surgeons will probably have some colleague nearby who is performing DMEK. If you read the information available and watch other surgeons do the surgery, it would be my hope it all works out when starting with DMEK. In The Netherlands, we value a life without worries, so we try to successfully do the DMEK surgery and once completed, the risk of complications is relatively low and a 20/20 BCVA is quite common.

小结

Gerrit Melles教授从不盲从认可某一观点，坚持从实践中汲取经验，以患者需求为根本目的，在此基础上不断完善、创新手术技术。正因具有这样的可贵品质，Gerrit Melles教授从未给自己的探索设限，不断迸发新的技术改良想法，进而造福更多角膜病患者，这种严谨治医、创新进取的态度值得年轻眼科医生学习。

Gerrit Melles教授

荷兰眼科创新研究所、鹿特丹Melles角膜诊所和Amnitrans EyeBank鹿特丹的创始人

Gerrit Melles教授积极参与眼科手术技术的研究和开发，发明了多项先进的板层角膜移植技术。除了率先将特定染色溶液用于眼科手术外，他还开发了多种仪器和医疗设备。2023年除了获得ARVO颁发的Champalimaud Vision Award以外，Gerrit Melles教授还入选了The Ophthalmologist 2023年度“世界最具影响力眼科人物100强”榜单。