在白内障手术中旋转人工晶状体以防止后囊混浊
Summary
本协议描述了在囊外白内障手术中通过旋转人工晶状体去除残留的上皮细胞，而无需额外的工具来防止后囊混浊。
Abstract
后囊混浊（PCO）是囊外白内障手术常见的术后并发症，由晶状体上皮细胞的增殖和迁移引起，可显着影响长期视觉效果。PCO最有效的治疗方法是掺钕钇铝石榴石（Nd：YAG）激光囊切开术;然而，这种治疗与后节并发症有关，并可能破坏包膜袋的稳定性，影响三焦点或复曲面人工晶状体（IOL）的位置和功能。近年来，外科手术、人工晶状体设计和药学的进步降低了PCO的发生率，集中在抑制增殖性晶状体上皮细胞（LECs）上。该协议旨在超声乳化和人工晶状体植入期间更彻底地清除 LEC。前几个步骤，包括透明角膜切口、连续圆形囊溢、水解、水化描写和超声乳化术，作为常规手术完成。将人工晶状体放入囊袋后，使用冲洗/抽吸尖端或钩子将人工晶状体旋转至少 360°，对后囊施加轻微应力。在人工晶状体旋转后，原本透明的荚膜袋中出现了一些残留物。然后，使用灌溉/抽吸系统完全清除这些材料和粘弹性。在接受这种方法的患者中，手术后观察到清晰的后囊。这种旋转人工晶状体的方法是一种简单、有效且安全的方法，可以通过清除残留的 LEC 来预防 PCO，无需额外的工具或技能即可进行。
Introduction
白内障是全世界最常见的失明原因，其特征是晶状体混浊。治疗白内障的唯一方法是通过去除不透明的晶状体进行手术干预，从而恢复高视觉质量。然而，在手术后 2-5 年内，20%-40% 的患者会出现视觉质量的继发性下降，称为后囊混浊 （PCO）1。本文介绍了一种通过旋转人工晶状体（IOL）来预防PCO来进一步去除白内障手术中残留的晶状体上皮细胞（LECs）的方法。
PCO是由LEC引起的过程，在白内障手术后不可避免地留在包膜袋中，然后开始增殖和迁移2。在超声乳化过程中，前囊中连续的曲线囊溢出产生囊袋，其包括前囊的一部分、赤道囊和整个后囊2,3。在大多数患者中，将人工晶状体植入包膜袋中。透明的囊袋，尤其是后囊，允许光线透射到眼睛，这对于良好的术后视觉质量是必要的4。一部分 LEC 通常仍附着在包膜袋上。作为对手术创伤的反应和对人工晶状体的异物反应，残留的上皮细胞开始增殖并首先占据前囊的剩余部分，然后是所有可用的表面，包括人工晶状体的表面，最重要的是，先前无细胞的后囊4。随后，细胞继续分裂，最终覆盖整个后囊并影响视觉轴。以下变化，包括纤维化和再生形式5，可能导致严重的视力障碍6。
影响视力的PCO可以通过后囊囊切开术进行治疗，通常通过掺钕钇铝石榴石（Nd：YAG）激光，有时通过外科手术4。最近的研究报告，术后 3 年治疗 PCO 的 Nd：YAG 囊切开术的发生率在 5% 至 20% 之间7,8。然而，该手术会破坏正常的后囊形态并使后囊起皱，从而可能影响人工晶状体的位置，不利于人工晶状体的长期视觉结果，尤其是多灶性人工晶状体和复曲面人工晶状体6。外科手术、人工晶状体设计、LEC 增殖的药理学抑制和诱导 LEC 细胞凋亡方面的进展已被证实可用于预防 PCO，其中大部分针对 LEC9。
LEC通常以单层形式1分布在前晶状体囊的内侧。分布在赤道晶状体周围区域的LEC是分裂的自然部位，称为发芽区，而在前囊10,11上也观察到分裂细胞。还表明，赤道细胞可以在后囊中增殖和迁移12。囊袋中的残留 LEC 负责 PCO。如果在白内障手术期间尽可能清除萌发区的LEC，则术后发生PCO的可能性就会降低。据了解，常规超声乳化术不包括去除赤道LEC的程序。在印度的一项研究中，作者提出，通过囊袋中的Sinskey钩13旋转IOL会降低PCO和Nd：YAG囊切开率。
在这里，我们介绍了一种方法，即使用囊袋中的冲洗/抽吸（I / A）尖端旋转IOL，以防止白内障手术中的PCO。该方法的基本原理依赖于人工晶状体和囊袋（尤其是赤道区域）之间的机械接触，以去除残留的 LEC。与使用Nd：YAG囊切开术治疗PCO相比，预防PCO可保持后囊的完整性和人工晶状体的正确位置。此外，这种方法具有成本效益，不需要额外的工具，适用于白内障超声乳化术和人工晶状体植入术。与在phaco系统6,14的抛光模式下使用I / A尖端进行的前囊抛光不同，IOL的旋转是在人工晶状体植入后进行的，并且应该进一步去除可见的晶状体物质（皮层）和细胞。
Protocol
Representative Results
Discussion
这种方法有一些好处。首先，胶囊袋内残留LEC进一步减少，尤其是赤道地区，合理降低PCO发生的可能性;其次，PCO的可能性降低意味着Nd：YAG激光治疗率较低，从而提供了保持胶囊袋完整性和有效镜片位置和功能的机会。第三，这种方法可以在白内障手术中使用可用的仪器来实现，而无需额外的准备。为了达到预防PCO的目的，有必要首先了解其生物过程。猕猴周围的前LEC具有原位生长的特征?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
本文由北京海淀创新与转型项目HDCXZHKC2021212资助。
Materials
| 20 G Sideport MVR Knife | BVI | 378231 | To make corneal incision |
| 3.2 mm Slit Blade | BVI | 378232 | To make corneal incision |
| Balanced salt solution | Xingqi | H19991142 | Compound electrolyte intraocular irrigating solution |
| Centurion vision system | Alcon Laboratories | 8065753057 | The Centurion Vision System is indicated for emulsification, separation, irrigation, and aspiration of cataracts, residual cortical material and lens epithelial cells, vitreous aspiration and cutting associated with anterior vitrectomy, bipolar coagulation, and intraocular lens injection. |
| Compound tropicamide eye drops | Xingqi | Zhuobian | To dilate the pupils before the surgery |
| Disposable sterile irrigator | WEGO | 100038404339 | To complete hydrodissection and hydrodelineation |
| Fenzl lens insertion hook and manipulator | Belleif | IF-8100 | IOL positioning hook |
| Levofloxacin eye drops | Santen | Cravit | To prevent ocular infection before the surgery |
| Mini-flared Kelman tip 30DG | Alcon Laboratories | 8065750852 | To complete phacoemulsification |
| One piece intraocular Lens | Zeiss | AT TORBI 709M | Intraocular lens |
| Oxybuprocaine hydrochloride | Santen | Benoxil | Topical anesthesia |
| Phaco handpiece | Alcon Laboratories | 8065751761 | To complete phacoemulsification |
| Sinskey hook | Belleif | IF-8013 | For chop |
| Ultraflow II I/A tip | Alcon Laboratories | 8065751795 | To complete irrigation and aspiration |
| Utrata capsulorhexis forceps | Belleif | IF-3003C | To complete continuous circular capsulorhexis |
| Viscoelastics/Medical sodium hyaluronate gel | Bausch&lomb | iviz | Maintaining the anterior chamber and capsular bag |
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