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LASIK 术后行白内障超声乳化摘除联合多焦点散光矫正型人工晶状体植入术一例

Toric multifocal intraocular lens implantation in a post-LASIK cataract patient: a case report

来源期刊: 眼科学报 | 2023年12月 第38卷 第12期 867-873 发布时间:2023-11-15 收稿时间:2024/3/5 17:32:03 阅读量:2714
作者:
关键词:
白内障手术LASIK术后多焦点散光矫正型人工晶状体角膜散光人工晶状体屈光度计算
cataract surgery post-LASIK toric multifocal intraocular lens corneal astigmatism intraocular lens power calculation
DOI:
10.12419/2308300001
该文报道一例激光原位角膜磨镶(laser-assisted in situ keratectomy,LASIK)术后行白内障超声乳化摘除联合多焦点散光矫正型人工晶状体植入术的病例。该患者为42岁女性患者,20年前外院行双眼LASIK手术,现因右眼视物模糊1年就诊。术前IOLMaster检查患者右眼眼轴长度29.66 mm,前房深度3.18 mm,晶状体厚度4.75 mm,白到白距离11.6 mm,前表面及全角膜散光分别为1.01 D@67 °及0.91 D@56 °。Pentacam角膜地形图15 °范围模拟角膜屈光力得到的角膜散光为1.2 D@58.1 °,为规则领结型。患者眼底检查未见明显异常,因其脱镜意愿强烈,植入双焦点散光矫正型IOL(德国Zeiss公司AT LISA toric 909M)。根据Barrett True-K Toric公式测量的后表面散光计算结果进行手术规划,选择+17 D球镜1.5 D柱镜Zeiss 909M IOL,植入轴位55 °。术后1个月患者裸眼远视力0.8,35 cm裸眼近视力1.0,最佳矫正远视力–0.25 DS/–0.5 DC×120 °至1.0,患者满意。提示经过详细的术前评估及规划,并与患者充分沟通,多焦点散光矫正型人工晶状体可以在部分适合的LASIK术后患者中取得良好效果。
It is reported a case of cataract phacoemulsification combined with toric multifocal intraocular lens (IOL) implantation after LASIK surgery in this article. A 42 year-old female patient who underwent bilateral LASIK surgery in other hospital 20 years ago. She visited our hospital due to blurred vision in her right eye for one year. The preoperative IOL Master examination results showed an axial length of 29.66 mm, anterior chamber depth of 3.18 mm, lens thickness of 4.75 mm, white to white distance of 11.6 mm, and anterior surface and total corneal astigmatism of 1.01 D @ 67 ° and 0.91 D @ 56 °, respectively in right eye. The corneal astigmatism measured by Pentacam using 15°range simulated keratometry is 1.2 D@ 58.1 °, which is a regular bow tie shape.No obvious abnormalities was found in the patient's fundus examination. Due to her strong desire to get rid of the glassesa toric bifocal IOL (AT LISA Toric 909M, Zeiss, Germany) was implanted.Based onthe IOL power calculation results of Barrett True-K Toric formula with measured posterior corneal astigmatism, an IOL with Sph 17.0 D/Cyl1.5 D/A 55°was chosen. One month after surgery, the patient's uncorrected distance visual acuity was 20/25, 35 cm uncorrected near visual acuity was 20/20, and the best corrected distance visual acuity was 20/20 with a prescription of –0.25 DS/–0.5 DC × 120 °. The patient was satisfied with the outcome. After detailed preoperative evaluation and design, and sufficient communication with patients, toric multifocal IOL implantation can achieve good results in some apropriated for the patients after LASIK surgery.
现代白内障手术已经进入屈光性白内障手术时代,患者对脱镜及视觉质量的需求与日俱增。虽然角膜屈光术后的患者常伴有长眼轴、角膜形态及生物力学较常规患者有显著改变,但随着白内障诊疗技术的发展,通过术前详细的眼部条件评估,精确的生物测量,选择合适的人工晶状体(intraocular lens,IOL)计算公式,并与患者充分沟通,功能性IOL可以在这类患者中可以取得良好疗效。该文报道一例激光原位角膜磨镶(laser-assisted in situ keratectomy,LASIK)术后行白内障超声乳化摘除联合多焦点散光矫正型IOL植入术的病例,供各位同道参考。

1 临床资料

患者女性,42岁,因右眼视物模糊1年于2023年5月16日至复旦大学附属眼耳鼻喉科医院就诊。眼科检查:裸眼视力右眼0.1,左眼0.8,矫正视力右眼–2.00 DS/–1.25 DC×140 °至0.3,左眼为–0.50 DS/–0.50 DC×60 °至1.0,左眼为主视眼。眼压:右眼11.2 mmHg(1 mmHg=0.133 kPa),左眼12.3 mmHg。裂隙灯显微镜检查右眼角膜中央透明,周边可见角膜切削印迹,前房中等深度,房水闪辉(–),瞳孔圆,对光反应(+),晶状体核性混浊(C1N3P1),眼底豹纹样高度近视改变;左眼晶状体尚透明,余同右眼。患者20年前于外院行LASIK术,自述LASIK术后双眼裸眼视力均可达1.0,具体资料不详。结合患者既往病史及眼科检查,临床诊断:右眼并发性白内障,双眼LASIK术后。
患者拟实施右眼白内障超声乳化摘除联合IOL植入术。术前进行了全面的眼部生物测量及角膜屈光状态评估。IOLMaster报告示患者右眼眼轴长度29.66 mm,前房深度3.18 mm,晶状体厚度4.75 mm,白到白距离11.6 mm,前表面角膜屈光力K1为35.23 D@157°,K2为36.24 D@67°,后表面角膜屈光力PK1为–5.48D@1°,PK2为–5.92D@91°,全角膜屈光力TK1为34.37D@146°,TK2为35.28D@56°,前表面及全角膜散光分别为1.01D@67°及0.91D@56°。Pentacam角膜地形图如图1所示,15°范围模拟角膜屈光力得到的角膜散光为1.2D@58.1°,为规则领结型。各区域角膜散光大小及轴位如表1所示,患者在3 mm角膜区域范围内角膜散光大小及轴位基本稳定,且与IOLMaster散光大小相差不大,轴位差异在15 °以内,考虑切口导致的术源性散光(surgical induced astigmatism,SIA),可植入散光矫正型IOL。患者脱镜意愿强烈,其右眼视网膜光学相干断层扫描(optical coherence tomography,OCT)黄斑中心凹未见明显异常,超广角眼底照相视网膜周边部未见明显裂孔,4 mm角膜总高阶像差为0.296 μm,α角0.29 mm,κ角0.37 mm,经与患者充分沟通后,考虑植入双焦点散光矫正型IOL(德国Zeiss公司AT LISA toric 909M)。
图1 患者右眼Pentacam角膜地形图
Figure 1 Pentacam topography of the patient's right eye

表1 患者右眼Pentacam各区域角膜散光大小及轴位

Table 1 Corneal astigmatism distribution of the patient's right eye in Pentacam

图2 Barrett True-K Toric公式计算IOL度数结果
Figure 2 IOL power calculation results using Barrett True-K Toric formula
(A)估算的角膜后表面散光计算结果;(B)测量的角膜后表面散光计算结果。
(A) Result with predicted posterior corneal astigmatism; (B) Result with measured posterior corneal astigmatism.
将IOLMaster测量数据代入在线的Barrett True-K Toric公式计算,利用估算的后表面散光及测量的后表面散光计算结果分别如图2A、B所示,目标屈光度为–0.5 D,两种计算方式IOL度数均为+17 D球镜及1.5 D柱镜,IOL的等效球镜为+17.75 D,仅植入轴位略有差异。利用美国白内障与屈光手术学会(American Society of Cataract and Refractive Surgery,ASCRS)网站多公式计算模式再次确认目标屈光度为–0.5 D时的IOL等效球镜,为+17.17~+17.81 D,平均17.49 D。最终根据Barrett True-K Toric公式测量的后表面散光计算结果进行手术规划,选择+17 D球镜1.5 D柱镜Zeiss 909M IOL,植入轴位55 °。
术后1 d,患者右眼裸眼远视力0.8,35 cm裸眼近视力0.8,最佳矫正远视力–0.5 DC×115 °至1.0,眼压12.3 mmHg,角膜切口对合良好,瓣缘处未见异常,前房中深,瞳孔圆,对光反应(+),IOL居中,轴位在54 °。术后1个月患者裸眼远视力0.8,35 cm裸眼近视力1.0,最佳矫正远视力–0.25 DS/–0.5 DC×120 °至1.0,IOL居中,轴位55 °(图3),患者夜间稍有眩光症状,无其他不适主诉,患者满意。
图3 患者术后1个月右眼OPD ScanIII无赤光后照法图像
Figure 3 Retrobulbar illumination photography of the patient's right eye one month postoperatively.

2 讨论

现代白内障手术已进入屈光手术时代,患者追求的不仅是术后远视力,对脱镜及全程视力的需求也与日俱增。尤其是既往接受过角膜屈光手术的患者,往往具有更强烈的脱镜意愿[1-2],但由于这些患者高度近视居多,加之既往进行过角膜切削,精准的生物测量及IOL计算存在一定困难[3-5],为功能性IOL的植入带来一定的局限性[6-8]。既往鲜少有LASIK术后患者植入多焦点散光矫正型IOL的病例报道,在本例手术前,笔者主要进行了以下几方面问题的思考和分析。
对于LASIK术后患者能否植入多焦点IOL,既往有较多研究表明LASIK术后患者植入多焦点IOL与单焦点IOL相比,远视力相当,但可以获得较好的近视力效果[9-10],84%的患者术后屈光误差在±1 D以内[3],但不可避免地存在对比敏感度下降及眩光、光晕、夜间开车困难等不良视觉症状的增加[10-11]。《中国多焦点人工晶状体临床应用专家共识(2019年)》也指出LASIK术后虽不作为多焦点IOL植入绝对禁忌证,但需告知患者术后将承受的对比敏感度明显降低导致视觉质量较差的风险,且需对患者的相关指标进行评估[12]。本例患者具有强烈的脱镜意愿,4 mm角膜总高阶像差为0.296 μm,<0.3 μm,α角0.29 mm、κ角0.37 mm,均<0.5 mm,暗室下自然瞳孔直径为5.2 mm,经与患者充分沟通,理解术后可能存在的风险,因此考虑植入多焦点IOL。
但值得注意的是,本例患者不论IOL Master还是Pentacam角膜地形图报告,角膜散光均>1.0 D,考虑160 °切口导致的SIA,术后预计的残留散光更大,对于预计术后散光≥1.0 D又有全程视力需求的患者,应考虑散光矫正型多焦点IOL[12]。既往有研究表明,角膜屈光术后白内障患者植入散光矫正型IOL有47%~84%的患者术后残留散光≤0.5 D[13-14],术前对角膜散光进行精确评估及筛选适应证,术后疗效更佳。Wang及Koch教授在眼科权威《Ophthalmology》期刊发表专家述评[3],推荐角膜屈光术后植入散光矫正型IOL的适应证包括:1)中央3 mm区域角膜散光为规则领结型;2)2种生物测量仪测量的散光差异≤0.75 D;3)2种生物测量仪测量的散光轴位差异≤15 °。本例患者IOL Master与Pentacam测量的角膜散光差异为0.19 D,轴位差异为8.9 °,3 mm范围角膜散光规则稳定,因此可以考虑植入多焦点散光矫正型IOL。
对于植入何种类型多焦点散光矫正型IOL,术后的囊袋稳定性是重要考量指标。术后IOL旋转每增加1 °,散光矫正能力将下降3.3%[15]。既往笔者研究表明,高度近视者囊袋大[16],平板型相比二襻型多焦点及散光矫正型IOL在高度近视眼中更稳定,不容易偏心、旋转[17-18],且与眼轴长度无明显相关性。但对于白到白距离及眼前节深度较大的高度近视患者,即使应用平板散光矫正型IOL,术后发生旋转的风险也较高[19]。本例患者虽为高度近视,但白到白距离<11.8 mm,眼前节深度<8.0 mm,考虑使用平板多焦点散光矫正型IOL术后稳定性较好。既往有文献表明,植入张力环可增加部分长眼轴患者(≥25.5 mm)植入散光矫正型IOL的旋转稳定性[20],虽然有研究提示,对白到白距离≥11.6 mm、晶状体厚度≥4.5 mm的患者植入散光矫正型IOL时建议植入张力环[21],但本例患者术中未发现悬韧带松弛。按照笔者既往研究及临床实践经验,平板散光矫正型IOL在与本例患者生物测量参数类似的高度近视眼中稳定性较好,考虑张力环远期对于悬韧带的压力,故未在本例患者中植入张力环。而在白到白距离增加>13 mm的患者中即便植入张力环也有较大的旋转风险,此类患者不建议使用散光矫正型IOL。
对于LASIK术后患者植入多焦点散光矫正型IOL,取得良好效果的前提是精准的IOL度数计算。多焦点矫正型IOL的度数既要考虑等效球镜,又要考虑柱镜计算的准确性。随着现代白内障诊疗技术的发展,LASIK术后IOL等效球镜的计算方法不断更新,其准确性也随之提升。针对本病例无屈光术前病史,IOL等效球镜度数的计算公式可分为:1)利用角膜前表面数据的Haigis-L、Shammas、Potvin-Hill Pentacam、Wang-Koch-Maloney及使用估算后表面曲率(predicted PCA)的Barrett True-K Toric的公式;2)利用前后表面散光的RTVue OCT相关计算公式及使用实测角膜后表面曲率(measured PCA)的Barrett True-K Toric公式;3)利用术中像差(optiwave refractive analysis,ORA)的计算公式等[3]。为了使用方便,ASCRS网站提供多种公式计算结果及平均值,研究表明利用ASCRS网站计算的IOL度数平均值,术后屈光误差在±0.5 D范围内的比例为45%~72%,平均绝对误差为0.45~0.84 D,绝对误差的中位数为0.28~0.35 D,计算结果较为准确[11]。笔者既往的一项网状荟萃分析显示Barrett True-K Toric、OCT及ORA公式是近视屈光术后最准确的3个公式[5],另一项研究也表明Barrett True-K Toric公式与ASCRS平均值对于术后屈光度预测的准确性相当[22],因此推荐采用这两种方法进行计算,本例患者使用这两种方法计算的IOL等效球镜结果相近。此外,既往笔者研究还发现,LASIK手术对角膜偏心切削会影响其白内障术后屈光度预测准确性,偏心切削越大,越容易产生近视误差[23]。根据Pentacam角膜地形图,本例患者LASIK手术对角膜的切削比较居中,因此术后屈光误差的可能性也相对较小。
对于本例患者多焦点散光矫正型IOL柱镜度数的计算,目前可以较简便使用的计算方法为Zeiss公司Z CALC在线IOL计算器(https://zcalc.meditec.zeiss.com)及Barrett True-K Toric计算公式[24-25],因Z CALC非针对屈光术后患者设计,其IOL等效球镜计算结果与Barrett True-K Toric计算公式及ASCRS平均值计算结果相差较大,因此选择Barrrett True-K Toric计算公式。本例患者后表面散光大小IOLMaser700测量为–0.44 D@91 °,Pentacam为–0.5 D@84.8 °,与常规后表面散光0.3 D相比较大,因此最终采用了Barrrett True-K Toric实测后表面散光的计算方法。因患者既往高度近视,相对年轻,对近视力要求较高,因此设定目标屈光度为–0.5 D,术后患者屈光度与预期相符,效果理想。
本例LASIK术后行白内障超声乳化摘除联合双焦点散光矫正型IOL植入术,提示通过术前详细的眼部条件评估、精确的生物测量、选择合适的IOL计算公式及类型,并与患者充分沟通利弊,在满足多焦点散光矫正型IOL筛选条件的角膜屈光术后患者中可以取得良好疗效。

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1、国家自然科学基金(81900838)。
This work was supported by the National Natural Science Foundation of China(81900838).()
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