49例穿透性角膜移植术临床分析
摘要
目的总结自2005年1月至2006年12月间在我院行穿透性角膜移植术后定期随访的49例患者的临床资料,分析PKP的原因、疗效及并发症。
方法对49例穿透性角膜移植进行回顾性研究。
结果
病因:感染性角膜炎33例(67.35%),外伤及其所致角膜白斑6例(12.24%),第一次用冷冻保存的角膜行穿透性角膜移植术后原发性角膜内皮失代偿3例(6.12%),移植片排斥2例(4.08%),角膜变性和营养不良2例(4.08%),大泡性角膜病变1例(2.04%),圆锥角膜1例(2.04%),虹膜角膜内皮综合征1例(2.04%)。
疗效:植片透明愈合41眼(83.67%),植片混浊8眼(16.32%);视力:手动2例(4.08%),指数6例(12.24%),0.1～0.3,23例(46.94%),0.4～0.8,18例(36.73%)。
并发症:免疫排斥反应19例(38.78%),浅前房3例(6.12%),继发性青光眼1例(2.04%)。
结论穿透性角膜移植术是治疗角膜病的重要手段,防治免疫排斥反应是手术成功的关键。
Objective To evaluate the epidemiologic characteristics of patients who received
penetrating keratoplasty (PKP) in our hospital from Jan.2005 to Dec.2006, and study the
main causes, effects and complications of penetrating keratoplasty.
Methods Retrospective analysis of 49 cases of penetrating keratoplasty.
Results
Causes: infectious keratitis 33 cases(67.35%), ocular trauma and correlative corneal
leucoma 6 cases(12.24%), primary corneal endothelial decompensation after the first
penetrating keratoplasty with chilled corneas 3 cases(6.12%), grafts rejection 2 cases(4.08%),
degeneration and dystrophy 2 cases(4.08%), bullous keratopathy 1 cases(2.04%),
keratoconus 1 cases(2.04%), iridocorneal endothelial syndrome 1 cases(2.04%).
Effects: grafts are transparent in 41 eyes(83.67%), turbid in 8 eyes(16.32%). Visual acuity:
hand move 2 cases(4.08%), finger count 6 cases (12.24%), 0.1～0.3 23 cases(46.94%),
0.4～0.8 18 cases(36.73%).
Complications: immune rejection 19 cases(38.78%), shallow anterior chamber 3
cases(6.12%), secondary glaucoma 1 cases(2.04%).
Conclusion penetrating keratoplasty is an effective means for disorders of cornea.
Prevention and treatment of immune rejections are the key to the success of operations.
方法对49例穿透性角膜移植进行回顾性研究。
结果
病因:感染性角膜炎33例(67.35%),外伤及其所致角膜白斑6例(12.24%),第一次用冷冻保存的角膜行穿透性角膜移植术后原发性角膜内皮失代偿3例(6.12%),移植片排斥2例(4.08%),角膜变性和营养不良2例(4.08%),大泡性角膜病变1例(2.04%),圆锥角膜1例(2.04%),虹膜角膜内皮综合征1例(2.04%)。
疗效:植片透明愈合41眼(83.67%),植片混浊8眼(16.32%);视力:手动2例(4.08%),指数6例(12.24%),0.1～0.3,23例(46.94%),0.4～0.8,18例(36.73%)。
并发症:免疫排斥反应19例(38.78%),浅前房3例(6.12%),继发性青光眼1例(2.04%)。
结论穿透性角膜移植术是治疗角膜病的重要手段,防治免疫排斥反应是手术成功的关键。
Objective To evaluate the epidemiologic characteristics of patients who received
penetrating keratoplasty (PKP) in our hospital from Jan.2005 to Dec.2006, and study the
main causes, effects and complications of penetrating keratoplasty.
Methods Retrospective analysis of 49 cases of penetrating keratoplasty.
Results
Causes: infectious keratitis 33 cases(67.35%), ocular trauma and correlative corneal
leucoma 6 cases(12.24%), primary corneal endothelial decompensation after the first
penetrating keratoplasty with chilled corneas 3 cases(6.12%), grafts rejection 2 cases(4.08%),
degeneration and dystrophy 2 cases(4.08%), bullous keratopathy 1 cases(2.04%),
keratoconus 1 cases(2.04%), iridocorneal endothelial syndrome 1 cases(2.04%).
Effects: grafts are transparent in 41 eyes(83.67%), turbid in 8 eyes(16.32%). Visual acuity:
hand move 2 cases(4.08%), finger count 6 cases (12.24%), 0.1～0.3 23 cases(46.94%),
0.4～0.8 18 cases(36.73%).
Complications: immune rejection 19 cases(38.78%), shallow anterior chamber 3
cases(6.12%), secondary glaucoma 1 cases(2.04%).
Conclusion penetrating keratoplasty is an effective means for disorders of cornea.
Prevention and treatment of immune rejections are the key to the success of operations.
引文
1．李凤鸣，主编．眼科全书[M]．北京：人民卫生出版社，1996．
2. Smithe RE, Mcdonald HR, Nesbum AB, et al. Penetrating keratoplasty: changing indications, 1947 to 1978[J]. Arch Ophthalmol, 1980, 98(7): 1226-1229.
3. Mohamadi P, Mcdonal JM, Irvine JI, et al. Changing indications for penetrating keratoplasty, 1984-1988[J]. Am J Ophthalmol, 1989, 107(5): 550-552.
4. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000[J]. Cornea, 2002, 21(2): 148-151.
5. Dobbins KR, Price FW Jr, Whitson WE. Trends in the indication for penetrating keratoplasty in the Midwestern united states[J]. Cornea, 2000, 19(6): 813-816.
6. Randleman JB, Song CD, Palay DA. Indications for and outcomes of penetrating keratoplasty performed by resident surgeons[J]. Am J Ophthalmol, 2003, 136(1): 68-75.
7．谢立信，王富华，史伟云．1997至2002年山东省眼科研究所穿透性角膜移植术的原因分析[J]．中华眼科杂志，2006，42(8)：704-708．
8．李绍伟，谢立信，晋秀明，等．严重真菌性角膜炎患者就诊史调查分析[J]．中华眼科杂志，2003，39：274-277．
9．林跃生，张建华，陈家祺，等．高危角膜移植48眼临床分析[J]．临床眼科杂志，1999，7(2)：93-95．
10. Frucht-Pery J, Shtibel H, Solomon A, et al. Thirty years of penetrating keratoplasty in Istael[J]. Cornea, 1997, 16: 16-20.
11. Legeais JM, Parc C, d' Hermies F, et al. Nineteen years of penetrating keratoplasty in the Hotel-Dieu Hospital in Paris[J]. Cornea, 2001, 20: 603-606.
12．谢立信，崔彦，董晓光，等．穿透性角膜移植432例流行病学报告[J]．眼科研究，1997， 15：243-245．
13．孙秉基，赵东卿，张郑民，等．角膜移植适应症的变迁[J]．眼科研究，1993，11：19-22．
14. Liu E, Slomovic AR. Indications for penetrating keratoplasty and associated procedures, 1989-1995[J]. Cornea, 1997, 16: 623-629.
15. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000[J]. Cornea, 2002,21:148-151.
16. Cursifen C, Kuchle M, Naumann GOH. Changing indications for penetrating keratoplasty: histopathology of 1,250 corneal buttons[J]. Cornea, 1998,17:468-470.
17. Obata H, Ishida K, Marao M, et al. Corneal endothelial cell damage in penetrating keratoplasty[J]. Jpn J Ophthalmol, 1992, 96:346-351.
18. Brightbill FS. Corneal Surgery St.Louis[M], Mosby, 1986, 428-439.
19. Inoue K, Amano S, Osbika T, et al. Risk factors for corneal graft failure and rejection in penetrating keratoplasty [J]. Acta Ophthalmol Scand, 2001,79:251-255.
20. Boisjoly HM, Bernard PM, Dube I, et al.Effect of factors unrelated to tissue matching on corneal transplant endothelial rejection[J]. Am J Ophthalmol, 1989,107:647-654.
21. Bourne WM. Reduction of endothelial cell loss during phakic penetrating keratoplasty[J].Am J Ophthalmol, 1980, 89:787-790.
22. Maguire MG, Stark WJ, Gottsch JD, et al. Risk factors for corneal graft failure and rejection in collaborative corneal transplantation studies[J]. Ophthalmology, 1994,101:1536-1547.
23. Cavanagh HD, Leveible AS. Extended wear contact lenses in patients with corneal grafts and aphakia[J]. Ophthalmology, 1982, 89:643-650.
24. Smolin G, Biswel IR. Corneal graft rejection associated with anterior iris adhension: Case report[J]. Ann Ophthalmol, 1972,10:1603-1604.
25. Tragakis MP, Brown SI. The significance of anterior synechiae after corneal transplantation[J]. Am J Ophthalmol, 1972,74:233-240.
26. Mayer RF. Corneal allograft rejection in bilateral penetrating keratoplasty: clinical and laboratory studies[J]. Trans Am Ophthalmol Soc, 1986, 84:664-742.
27. Foulks GN. Glaucoma associated with penetrating keratoplasty[J]. Ophthalmology, 1987,94:871-874.
28. Williams KA, Roder D, Esterman A, et al. Factors predictive of corneal graft survival[J].Ophthalmology, 1992, 99:403-414.
29. Yamagami S, Suzuki Y, Tsuru T. Risk factors for graft failure in penetrating keratoplasty[J]. Acta Ophthalmol, 1996, 74: 584-588.
30．赵伟，王正华．角膜缘上皮移植和选择性联合羊膜移植治疗化学伤后眼表疾患[J]．中国实用眼科杂志，2001，19(4)：305-306．
31．孙秉基，徐锦堂，主编．角膜病的理论基础与临床[M]．北京：科学技术文献出版社， 1994，395-397．
32．史伟云，谢立信．高危角膜移植[J]．眼科新进展，1999，19(1)：1-3．
33. Nishi M, Herbort CP, Malsuhara M, et al. Effects of the immunosuppressant FK-506 on a penetrating keratoplasty rejection model in the rat[J]. Invest Ophthalmol Vis Sci, 1993, 34(8): 2477-2486.
34．刘家琦，李凤鸣，主编．实用眼科学[M]，第二版．北京：人民卫生出版社，2003，775-776．
1．陈慰峰，主编．医学免疫学[M]，第三版．北京：人民卫生出版社，2002．
2. Hegde S, Beauregard C, Mayhew E, et al. CD4(+) T-cell-mediated mechanisms of corneal allograft rejection: role of Fas-induced apoptosis[J]. Transplantation. 2005, 79(1): 23-31.
3．史伟云，谢立信．CD4和CD8基因敲除鼠行穿透性角膜移植术后免疫排斥特征的研究[J]．中华眼科杂志，2005，41(4)：350-354．
4. He YG, Ross J, Niederkorn JY. Promotion of murine orthotopic corneal allografl survival by systemic administration of anti-CD4 monoclonal antibody[J]. Invest Ophthalmol Vis Sci, 1991, 32: 2723-2728.
5. Joo CK, Pepose JS, Stuart PM. Y-cell mediated responses in a murine model of orthotopic corneal transplantation[J]. Invest Ophthalmol Vis Sci, 1995, 36: 1530-1540.
6. Linsley PS, Brady W, Grosmaire L, et al. Binding of the B cell activation antigen B7 to CD28 costimulates T cell proliferation and interleukin 2 mRNA accumulation[J]. J Exp Med, 1991, 173: 721-730.
7．钟敬祥，朱春玲，徐锦堂，等．角膜移植患者外周血中T细胞CD28分子的表达及其意义[J]．眼科新进展，2005，25(2)：130-131．
8．白浪，陆晓和，周瑾，等．CD86在大鼠角膜移植排斥反应中的表达及意义[J]．第一军医大学学报，2004，24(5)：533-535．
9．余洪华，陆晓和，姚建兵，等．CD80与CD86在角膜移植排斥反应中作用的实验研究[J]．实用医学杂志，2005，21(8)：787-789．
10. Kagawa F, Horl J, Kamiya K, et al. Inhibition of murine corneal allograft rejection by treatment with antibodies to CD80 and CD86[J]. Exp Eye Res, 2002, 74(1): 131-139.
11. Mastellar EL, Chuang E, Schwaetz JC. Structure analysis of CTLA-4 function in vivo[J]. J Immunol, 2000, 164: 5319-5327.
12. Richard M. Comer, William J. King, Navid Ardjomand, et al. Effect of Administration of CTLA4-Ig as Protein or cDNA on Corneal Allograft Survival[J]. Investigative Ophthalmology and Visual Science, 2002, 43: 1095-1103.
13. Ying Qian, Florence Boisgerault, Gilles Benichou. Blockade of CD40-CD154 Costimulatory Pathway Promotes Survival of Allogeneic Corneal Transplants[J]. Investigative Ophthalmology and Visual Science, 2001, 42:987-994.
14. Tang A, Judge TA, Turka LA. Blockade of CD40-CD40 ligand pathway induces tolerance in mudne contact hypersensitivity[J]. Eur J Immunol, 1997,27: 3143-3150.
15. Navid Ardjomand, James C. McAlister, Nicola J. Rogers, et al. Modulation of Costimulation by CD28 and CD154 Alters the Kinetics and Cellular Characteristics of Corneal Allograft Rejection[J]. Investigative Ophthalmology and Visual Science, 2003, 44: 3899-3905.
16．钟敬祥，徐锦堂，刘莲，等．角膜移植患者外周血T细胞及其亚群CD25分子表达研究[J]．中华现代眼科学杂志，2004，1(2)：129-131．
17．吴静，徐锦堂．转化生长因子—β1对异体角膜上皮所诱导的CD69^+及CD25^+表达的影响[J]．中华眼科杂志，2000，36(1)：24-26．
18. Bachmaler K, Krawczyk C, Koziradzki I, et al. Negative regulation of lymphocyte activation and autoimmunity by the molecular adaptor CbI-b[J]. Nature, 2000, 403(13): 211.
19. Castellanos MS, Munoz C, Montoya MC, et al. Expression of the leukocyte early activation antigen CD69 is regulated by the transcription factor AP-1[J]. J Immunol., 1997, 159(11): 5463-5473.
20. Craston R, Koh M, Mc Dermott A, et al. Temporal dynamics of CD69 expression on lymphoid cells[J]. J Immunol Methods, 1997, 209(1): 37-45.
2. Smithe RE, Mcdonald HR, Nesbum AB, et al. Penetrating keratoplasty: changing indications, 1947 to 1978[J]. Arch Ophthalmol, 1980, 98(7): 1226-1229.
3. Mohamadi P, Mcdonal JM, Irvine JI, et al. Changing indications for penetrating keratoplasty, 1984-1988[J]. Am J Ophthalmol, 1989, 107(5): 550-552.
4. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000[J]. Cornea, 2002, 21(2): 148-151.
5. Dobbins KR, Price FW Jr, Whitson WE. Trends in the indication for penetrating keratoplasty in the Midwestern united states[J]. Cornea, 2000, 19(6): 813-816.
6. Randleman JB, Song CD, Palay DA. Indications for and outcomes of penetrating keratoplasty performed by resident surgeons[J]. Am J Ophthalmol, 2003, 136(1): 68-75.
7．谢立信，王富华，史伟云．1997至2002年山东省眼科研究所穿透性角膜移植术的原因分析[J]．中华眼科杂志，2006，42(8)：704-708．
8．李绍伟，谢立信，晋秀明，等．严重真菌性角膜炎患者就诊史调查分析[J]．中华眼科杂志，2003，39：274-277．
9．林跃生，张建华，陈家祺，等．高危角膜移植48眼临床分析[J]．临床眼科杂志，1999，7(2)：93-95．
10. Frucht-Pery J, Shtibel H, Solomon A, et al. Thirty years of penetrating keratoplasty in Istael[J]. Cornea, 1997, 16: 16-20.
11. Legeais JM, Parc C, d' Hermies F, et al. Nineteen years of penetrating keratoplasty in the Hotel-Dieu Hospital in Paris[J]. Cornea, 2001, 20: 603-606.
12．谢立信，崔彦，董晓光，等．穿透性角膜移植432例流行病学报告[J]．眼科研究，1997， 15：243-245．
13．孙秉基，赵东卿，张郑民，等．角膜移植适应症的变迁[J]．眼科研究，1993，11：19-22．
14. Liu E, Slomovic AR. Indications for penetrating keratoplasty and associated procedures, 1989-1995[J]. Cornea, 1997, 16: 623-629.
15. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000[J]. Cornea, 2002,21:148-151.
16. Cursifen C, Kuchle M, Naumann GOH. Changing indications for penetrating keratoplasty: histopathology of 1,250 corneal buttons[J]. Cornea, 1998,17:468-470.
17. Obata H, Ishida K, Marao M, et al. Corneal endothelial cell damage in penetrating keratoplasty[J]. Jpn J Ophthalmol, 1992, 96:346-351.
18. Brightbill FS. Corneal Surgery St.Louis[M], Mosby, 1986, 428-439.
19. Inoue K, Amano S, Osbika T, et al. Risk factors for corneal graft failure and rejection in penetrating keratoplasty [J]. Acta Ophthalmol Scand, 2001,79:251-255.
20. Boisjoly HM, Bernard PM, Dube I, et al.Effect of factors unrelated to tissue matching on corneal transplant endothelial rejection[J]. Am J Ophthalmol, 1989,107:647-654.
21. Bourne WM. Reduction of endothelial cell loss during phakic penetrating keratoplasty[J].Am J Ophthalmol, 1980, 89:787-790.
22. Maguire MG, Stark WJ, Gottsch JD, et al. Risk factors for corneal graft failure and rejection in collaborative corneal transplantation studies[J]. Ophthalmology, 1994,101:1536-1547.
23. Cavanagh HD, Leveible AS. Extended wear contact lenses in patients with corneal grafts and aphakia[J]. Ophthalmology, 1982, 89:643-650.
24. Smolin G, Biswel IR. Corneal graft rejection associated with anterior iris adhension: Case report[J]. Ann Ophthalmol, 1972,10:1603-1604.
25. Tragakis MP, Brown SI. The significance of anterior synechiae after corneal transplantation[J]. Am J Ophthalmol, 1972,74:233-240.
26. Mayer RF. Corneal allograft rejection in bilateral penetrating keratoplasty: clinical and laboratory studies[J]. Trans Am Ophthalmol Soc, 1986, 84:664-742.
27. Foulks GN. Glaucoma associated with penetrating keratoplasty[J]. Ophthalmology, 1987,94:871-874.
28. Williams KA, Roder D, Esterman A, et al. Factors predictive of corneal graft survival[J].Ophthalmology, 1992, 99:403-414.
29. Yamagami S, Suzuki Y, Tsuru T. Risk factors for graft failure in penetrating keratoplasty[J]. Acta Ophthalmol, 1996, 74: 584-588.
30．赵伟，王正华．角膜缘上皮移植和选择性联合羊膜移植治疗化学伤后眼表疾患[J]．中国实用眼科杂志，2001，19(4)：305-306．
31．孙秉基，徐锦堂，主编．角膜病的理论基础与临床[M]．北京：科学技术文献出版社， 1994，395-397．
32．史伟云，谢立信．高危角膜移植[J]．眼科新进展，1999，19(1)：1-3．
33. Nishi M, Herbort CP, Malsuhara M, et al. Effects of the immunosuppressant FK-506 on a penetrating keratoplasty rejection model in the rat[J]. Invest Ophthalmol Vis Sci, 1993, 34(8): 2477-2486.
34．刘家琦，李凤鸣，主编．实用眼科学[M]，第二版．北京：人民卫生出版社，2003，775-776．
1．陈慰峰，主编．医学免疫学[M]，第三版．北京：人民卫生出版社，2002．
2. Hegde S, Beauregard C, Mayhew E, et al. CD4(+) T-cell-mediated mechanisms of corneal allograft rejection: role of Fas-induced apoptosis[J]. Transplantation. 2005, 79(1): 23-31.
3．史伟云，谢立信．CD4和CD8基因敲除鼠行穿透性角膜移植术后免疫排斥特征的研究[J]．中华眼科杂志，2005，41(4)：350-354．
4. He YG, Ross J, Niederkorn JY. Promotion of murine orthotopic corneal allografl survival by systemic administration of anti-CD4 monoclonal antibody[J]. Invest Ophthalmol Vis Sci, 1991, 32: 2723-2728.
5. Joo CK, Pepose JS, Stuart PM. Y-cell mediated responses in a murine model of orthotopic corneal transplantation[J]. Invest Ophthalmol Vis Sci, 1995, 36: 1530-1540.
6. Linsley PS, Brady W, Grosmaire L, et al. Binding of the B cell activation antigen B7 to CD28 costimulates T cell proliferation and interleukin 2 mRNA accumulation[J]. J Exp Med, 1991, 173: 721-730.
7．钟敬祥，朱春玲，徐锦堂，等．角膜移植患者外周血中T细胞CD28分子的表达及其意义[J]．眼科新进展，2005，25(2)：130-131．
8．白浪，陆晓和，周瑾，等．CD86在大鼠角膜移植排斥反应中的表达及意义[J]．第一军医大学学报，2004，24(5)：533-535．
9．余洪华，陆晓和，姚建兵，等．CD80与CD86在角膜移植排斥反应中作用的实验研究[J]．实用医学杂志，2005，21(8)：787-789．
10. Kagawa F, Horl J, Kamiya K, et al. Inhibition of murine corneal allograft rejection by treatment with antibodies to CD80 and CD86[J]. Exp Eye Res, 2002, 74(1): 131-139.
11. Mastellar EL, Chuang E, Schwaetz JC. Structure analysis of CTLA-4 function in vivo[J]. J Immunol, 2000, 164: 5319-5327.
12. Richard M. Comer, William J. King, Navid Ardjomand, et al. Effect of Administration of CTLA4-Ig as Protein or cDNA on Corneal Allograft Survival[J]. Investigative Ophthalmology and Visual Science, 2002, 43: 1095-1103.
13. Ying Qian, Florence Boisgerault, Gilles Benichou. Blockade of CD40-CD154 Costimulatory Pathway Promotes Survival of Allogeneic Corneal Transplants[J]. Investigative Ophthalmology and Visual Science, 2001, 42:987-994.
14. Tang A, Judge TA, Turka LA. Blockade of CD40-CD40 ligand pathway induces tolerance in mudne contact hypersensitivity[J]. Eur J Immunol, 1997,27: 3143-3150.
15. Navid Ardjomand, James C. McAlister, Nicola J. Rogers, et al. Modulation of Costimulation by CD28 and CD154 Alters the Kinetics and Cellular Characteristics of Corneal Allograft Rejection[J]. Investigative Ophthalmology and Visual Science, 2003, 44: 3899-3905.
16．钟敬祥，徐锦堂，刘莲，等．角膜移植患者外周血T细胞及其亚群CD25分子表达研究[J]．中华现代眼科学杂志，2004，1(2)：129-131．
17．吴静，徐锦堂．转化生长因子—β1对异体角膜上皮所诱导的CD69^+及CD25^+表达的影响[J]．中华眼科杂志，2000，36(1)：24-26．
18. Bachmaler K, Krawczyk C, Koziradzki I, et al. Negative regulation of lymphocyte activation and autoimmunity by the molecular adaptor CbI-b[J]. Nature, 2000, 403(13): 211.
19. Castellanos MS, Munoz C, Montoya MC, et al. Expression of the leukocyte early activation antigen CD69 is regulated by the transcription factor AP-1[J]. J Immunol., 1997, 159(11): 5463-5473.
20. Craston R, Koh M, Mc Dermott A, et al. Temporal dynamics of CD69 expression on lymphoid cells[J]. J Immunol Methods, 1997, 209(1): 37-45.
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