圆钝超声乳化针头在白内障超声乳化吸除术中的应用
研究生李帅飞
导师陈彬川教授
眼科学
河南郑州 450014
摘 要
linearization背景和目的
historical白内障是我国乃至全世界首位致盲性眼病，至今药物治疗尚不能有效阻止或逆转晶状体混浊，因此，手术治疗仍然是各种白内障的主要治疗手段，且是唯一有效手段。自1967年Kelman首次推出白内障超声乳化吸除术后，伴随超声乳化仪的不断改进和提高，临床手术技术也不断得到发展和完善，目前白内障超声乳化吸除术以其手术切口小、时间短和术后散光小、视力恢复良好等诸多优点受到白内障手术医师的广泛青睐，是目前白内障治疗的主流手术。
白内障超声乳化吸除术后带来视觉质量提高的同时，手术相关并发症仍不容轻视，提高手术效率和安全性一直备受关注。超声乳化针头作为超声能量释放的终端和抽吸作用的起始，在白内障超声乳化吸除术中意义重大。多项研究表明，白内障超声乳化吸除术中手术器械碰触晶状体后囊膜是其破裂的主要危险因素，即使经验丰富的白内障术者仍不能完全避免术中超声乳化针头及辅助器械碰触晶状体后囊膜。白内障超声乳化吸除术中锋利超声乳化针头可获得良好的手术效率，但同时增加晶状体后囊膜破裂的风险。有学者提出将超声乳化针头尖端打磨圆钝以降低晶状体后囊膜破裂的风险，甚至实现超声乳化针头进行晶状体后囊膜抛光。
采用圆钝超声乳化针头进行白内障超声乳化是否能够确实有效地保护晶状体后囊膜，是否能够高效率完成手术且不增加角膜水肿、虹膜损伤等手术风险，目前尚无相关随机对照研究，且国内更是缺少圆钝超声乳化针头的相关报道，本文旨在通过前瞻性临床研究探讨圆钝超声乳化针头在白内障超声乳化吸除术
中对手术效率和安全性的影响。
资料和方法
收集2014年10月至2015年12
北大青鸟上海
关性白内障并行白内障超声乳化吸除术的患者342例（406眼）。根据Emery核硬度分级标准将术眼分为非硬核组（Ⅲ级及以下）和硬核组（Ⅳ级及以上），两组术眼分别随机分为圆钝针头组（圆钝超声乳化针头）和锋利针头组（锋利超声乳化针头）并使用相应超声乳化针头进行手术。统计患者年龄、性别等基线资料，记录术前及术后1天、1月、3月时最佳矫正视力，术前及术后1天中央角膜厚度（使用ZEISS光学相干断层扫描仪测量），手术总时间（制作侧切口至水密封完成）、平均超声能量、累积超声时间、有效超声时间、灌注液使用量及晶状体后囊膜破裂例数。
结果
1. 非硬核组及硬核组中，两超声乳化针头组的患者年龄、性别等基本信息均无统计学差异（P均＞0.05）。
a christmas carol2. 406眼白内障超声乳化吸除术中均无爆发性脉络膜上腔出血、角膜后弹力层脱离、虹膜脱出及虹膜损伤发生，其中晶状体后囊膜破裂17眼，但未发生晶状体核坠入玻璃体腔、继发视网膜脱离等严重并发症。
3. 总体晶状体后囊膜破裂率为
4.18%，非硬核组和硬核组分别为3.79%、
5.17%。非硬核组中圆钝针头组的后囊破裂率（1.42%）明显小于锋利针头组（
6.52%），且差异具有统计学意义（P=0.035），硬核组中圆钝针头组的后囊破裂率（1.78%）亦小于锋利针头组（9.26%），但差异无统计学意义（P=0.225）。
4. 17眼晶状体后囊膜破裂的中，11眼（64.71%）于晶状体超声乳化结束时发现，6眼（3
5.29%）于I/A注吸皮质或晶状体后囊膜抛光时发生。超声乳化阶段与I/A阶段，晶状体后囊膜破裂率分别为2.71%、1.48%，前者略高于后者，但两者差异无统计学差异（χ2=1.502，P=0.220）。
5. 非硬核组中，两超声乳化针头组组术中指标均无统计学差异（P均＞0.05），硬核组中，圆钝针头组较锋利针头组使用更多的平均超声能量（42.2%±5.1%，38.9%±
solange6.4%，P=0.004）及有效超声时间（15.53s±3.47s，13.34s±3.18s，P=0.001），其余术中指标均无统计学差异（P均＞0.05）。
6. 术后1天、1月、3月视力改善率分别为78.95%~85.31%、86.44%~91.84%、89.47%~93.88%，术后视力改善率低者主要集中在硬核组，非硬核组术后视力改
善率相对较高。此外，非硬核组与硬核组中，两超声乳化针头组在术后各时间点视力改善率之间均无统计学差异（P＞0.05）。
7. 非硬核组中两超声乳化针头组中央角膜厚度增加量无统计学差异（78.5um±50.6um，71.6um±53.3um，P=0.263），硬核组中圆钝针头组中央角膜厚度增加量（220.8um±36.3um）大于锋利针头组（198.4um±53.1um）差异具有统计学意义（P=0.011）。
8. 中央角膜厚度增加量与有效超声时间呈正相关，Pearson相关系数r=0.746，P=0.000，并由散点图获得回归方程Y=11.67X+44.99，R2=0.556。
结论
1. 圆钝超声乳化针头是白内障超声乳化吸除术中安全、可靠的选择；
2. 圆钝超声乳化针头可减少晶状体后囊膜破裂的发生；
3. 非硬核白内障手术中，圆钝超声乳化针头不影响手术效率，亦不增加角膜内皮细胞的损伤；
4. 硬核白内障手术中，圆钝超声乳化针头增加了超声能量和有效超声时间，术后角膜水肿更重，但并未引起大泡性角膜病变；
5. 晶状体后囊膜破裂的发生率，硬核较非硬核白内障手术高，超声乳化阶段最高，I/A注吸阶段次之；
6. 超声能量是引起角膜内皮细胞损伤不可忽视的因素，角膜水肿程度与超声能量的使用呈正相关关系。
关键词
白内障/外科学；白内障超声乳化吸除术；超声乳化针头
Clinical application of phacoemulsification with
a round blunt phaco tip
By Shuaifei Li
Supervisor: Prof. Binchuan Chen
经费支出Department of Ophthalmology
The Second Clinical College of Zhengzhou University
Zhengzhou, Henan, 450014, China
Abstract
闻官兵收河南河北Background And Objectives
Cataract, the leading cau of blindness in our country and even the whole world, can’t be treated by drugs but surgery. The cataract surgery improved with the development of techniques and technologies, and phacoemulsification performed through a smaller incision with shorter time, less surgery-induced astigmatism and better visual rehabilitation has become the main choice of cataract surgeon since it was firstly introduced by Kelman in 1967.
divisional
Phacoemulsification can bring visual quality improved, and at the same time, surgical complications should not be ignored. The phaco tip is significant in phacoemulsification becau it is the point for relea of ultrasound energy and the initiation of aspiration. Studies have shown that the surgical instruments touching the posterior capsule is the main risk factor for rupture, and even experienced cataract surgery can not completely avoid the phaco tip or surgical instruments touching the posterior capsule. The sharp phaco tip can get a good surgical efficiency, but increa the risk of posterior capsular rupture. Some rearchers have propod rounded blunt phaco tip to reduce the risk of posterior capsular rupture, and even safely polish the posterior capsule.
There is no relevant randomized controlled study about whether the rounded blunt phaco tip can effe
ctively protect the posterior capsule without increasing the risk of corneal edema, iris injury and other surgical complications, especially in the domestic ophthalmic field. We design the study to determine the influence of rounded blunt phaco tip on efficiency and safety in conventional phacoemulsification prospectively.
Participants And Methods
This study enrolled 406 eyes of 342 nile cataract patients who had undergone phacoemulsification between October 2014 and December 2015 in the Second Affiliated Hospital of Zhengzhou University. The total of eyes were divided into 2 groups according to its nuclear hardness, and phacoemulsification in each group was performed with round blunt phaco tips or standard phaco tips randomly. Clinical characteristics such as age and x were recorded before the surgery. The best corrected vision were collected preoperatively and postoperatively at 1 day，1 month and 3 months. Intraoperative parameters included surgical time (ST), average ultrasound energy (A VE), accumulative phaco time (APT), effective phaco time (EPT), estimated fluid u (EFU). The ca of posterior capsule rupture was recorded. The central corneal thickness (CCT) were evaluated preoperatively and postoperatively at 1 day using OCT (ZEISS).
Results
1. Clinical characteristics such as age and x were similar in both tip groups of each nuclear hardness group (all P＞0.05).
2. All of the surgeries were successfully completed without explosive choroidal hemorrhage, detachment of descemet's membrane and iris injury, in which 17 cas occurred posterior capsule rupture without fragments felling into vitreous cavity and condary retinal detachment and other rious complications.
3. The overall incidence of posterior capsule rupture was
apply什么意思4.18%, with 3.79% in non-hard nuclear group and大声说英语
5.17% in hard nuclear group respectively. In non-hard nuclear group, the incidence of posterior capsule rupture was 1.42% and
6.52% with round blunt phaco tips or standard phaco tips respectively (P=0.035). In hard nuclear group, the incidence of posterior capsule rupture was 1.78% and 9.26% with round
