30 周年 ~ 亚太白内障及屈光手术医师学会 (APACRS) 成立于 1987 年, 致力于在亚太地区传播白内障和屈光手术领域内的新知识, 新信息和新进展 30 年来,APACRS 通过和各个地区性组织联合举办年会以及发行出版物例如 EyeWorld 亚太版等活动, 已经发展成

Transcription

1 白内障手术实践指南

2 30 周年 ~ 亚太白内障及屈光手术医师学会 (APACRS) 成立于 1987 年, 致力于在亚太地区传播白内障和屈光手术领域内的新知识, 新信息和新进展 30 年来,APACRS 通过和各个地区性组织联合举办年会以及发行出版物例如 EyeWorld 亚太版等活动, 已经发展成为地区的领导论坛, 为全世界过半人口的白内障和屈光手术需求服务 亚太白内障及屈光手术医师学会 11 Third Hospital Avenue Singapore apacrs@apacrs.org

3 前言 内障手术是开展最广泛的手术 近年来, 白现代白内障摘除技术, 人工晶状体植入术以及各项研究发展突飞猛进, 白内障手术医生在患者选择 围手术期处理及手术操作时常常会面临大量令人困惑的选择 即使像我们这些在大型眼科中心, 有机会参加国际会议及医学继续教育课程的医生, 在作出选择时也会遇到困难, 那么在偏远农村地区的白内障医生呢? 初版白内障手术实践指南完成于 年, 至今已十余年, 亟待更新 恰逢 APACRS 30 周年大庆之际, 我们决定更新修订这套循证实践指南, 并且在亚洲地区进行推广 我们相信这对全亚洲白内障手术医生的白内障手术安排和具体操作会非常有用, 我们的患者也定会受益匪浅 杨南顺亚太白内障及屈光手术医师学会主席 在此, 我对白内障指南的编辑组表示由衷的感谢, 尤其是 Dr. Vaishali Vasavada, 感谢他们在其中所付出的诸多心血 同时感谢蔡司教育基金对于本指南出版的支持 希望您和您的患者都能从中获益 APACRS 实践指南

4 编辑组 主编 Dr. Vaishali Vasavada 顾问眼科医生 Raghudeep 眼科医院印度, 斋浦尔 审稿组 Prof. Graham Barrett 顾问眼科手术医生利亚 Lions 眼科研究所 Sir Charles Gairdner 医院科主任澳大利亚, 珀斯 Dr. Chan Wing Kwong 高级顾问眼科及视网膜专科手术医生访问高级顾问新加坡国立眼科中心新加坡 Prof. Hiroko Bissen-Miyajima 眼科主任, 教授东京牙科学院,Suidobashi 医院日本, 东京 Dr. Johan Hutauruk 眼科顾问及主任雅加达眼科中心主任印度尼西亚, 雅加达中区 Adj. Assoc Prof. Ronald Yeoh 医学主任及创始合伙人眼科及视网膜专科手术医生兼职高级顾问新加坡国立眼科中心新加坡 Dr. Abhay Vasavada 研究主任 Iladevi 白内障和 IOL 研究中心印度, 艾哈迈达巴德 Prof. Chee Soon Phaik 高级顾问白内障科主任新加坡国立眼科中心新加坡国立大学及 Duke-NUS 医学院教授新加坡 Prof. Hungwon Tchah 眼科主任 Ulsan 大学教授韩国, 首尔 Dr. Pannet Pangputhipong Mettapracharak 医院主任总干事医疗服务部, 泰国卫生部泰国, 曼谷 Prof. Yao Ke 浙江大学, 眼科研究所主任浙江大学医学院第二附属医院眼科主任中国, 杭州 APACRS 实践指南

5 目录 1. 引言 4 2. 证据分级和推荐等级 5 3. 总体推荐意见 6 4. 术前评估和决策 7 5. 培训和认证 手术预后评估推荐 参考文献 编辑组 致谢 45 意向声明 本实践指南 (PPP) 致力于为眼科医生提供最新的白内障手术方面的循证信息 最终, 每一位医生都要根据患者的临床特点以及现有的诊断和治疗手段治疗不同的患者个体 2017 亚太白内障及屈光手术医师学会 (APACRS) 版权所有 APACRS 实践指南

6 1 引言 1.1 白内障的流行病学 虽然全球公共和私人医疗保健有了很大的进步, 白内障仍然是主要的致盲病因 根据世界卫生组织 (WHO) 的数据, 白内障占全球盲的 33%, 亚洲不同国家的报告显示, 白内障和未矫正屈光不正是大多数国家两大最主要致盲因素 在西太平洋地区, 白内障仍然是视力损伤的主要原因 但是, 在日本和澳大利亚等国家, 年龄相关性黄斑病变 (AMD) 是最主要的致盲原因 1 因为定义的不同和检查技术的非标准化, 很难总结白内障的患病率, 但是新加坡 Tanjong Pagar 的调查报告显示,40 岁及以上华人白内障患病率为 35% 2 今后 5 年内,65 到 74 岁人群出现晶状体混浊的比例高达 20% 到 30% 美国国家健康和营养调查结果显示,45 到 74 岁人群 ( 以视力低于 6/9 为标准 ) 的患病率为 14.7% 3 目前, 白内障手术已经成为一种成功率和效价比都很高的手术, 能够提高患者的视力和生活质量 W H O 建议, 要很好地解决白内障盲的负担, 目标是每 100,000 人群中每年开展 350 例手术 随着医疗保健和生活方式的改变, 我们对于白内障的处理也发生了变化 不应该只将视力做为计划白内障手术的标准, 因为视力和视功能并不总是相关的 因此, 需要重新审视我们的手术指征 1.2 本指南的目的和目标读者 本指南的目的是透彻理解现有的同行评议证据和临床经验, 提供推荐实践指南, 促进全亚太地区临床医生临床实践的标准化, 提高白内障手术预后 这些指南面向所有的执业眼科医生, 重点聚焦这个地区的特殊情况和可能会遇到的问题 4 APACRS 实践指南

7 证据分级和推荐等级 2 证据分级 水平 Ia 证据类型 来自随机对照研究的荟萃分析证据 Ib 来自至少一项随机对照研究的证据 IIa 来自至少一项设计良好的非随机对照研究的证据 IIb III 来自至少一类设计良好的准实验性研究的证据 来自设计良好非实验描述性研究的证据, 例如对照研究, 相关性研究以及病例研究 IV 来自专家委员会报告 意见或权威专家临床经验证据 推荐等级 水平 A ( 证据水平 Ia, Ib) 证据类型 所有高质量文献中至少有一项随机对照实验, 特定的建议具有一致性 B ( 证据水平 IIa, IIb, III) 针对建议有开展良好的非随机临床实验 C ( 证据水平 IV) 来自专家委员会报告或观点和 / 或权威临床经验证据 提示缺乏直接可参考的高质量临床研究 GPP ( 操作规范 ) 基于指南工作组临床经验的最佳实践建议 APACRS 实践指南 5

8 3 总体推荐意见 GPP 手术 根据患者白内障和视力损伤的临床严重程度决定是否做白内障 C 单纯 Snellen 视力不能作为计划白内障手术的标准 需要在特定条 4 件下做眩光和对比敏感度试验评估白内障对于患者视功能的影响 Grade C Level IV C 一般不推荐双眼同时白内障手术, 因为存在双眼盲的风险 5 Grade C Level IV A 当前白内障手术的方式包括白内障囊外摘除术 (ECCE), 小切口白内障囊外摘除术 (MSICS), 超声乳化和飞秒激光辅助白内障手术 这些手术方式都可以采用, 如果有可能, 应该给患者选择的机会 6-10 Grade A Level Ia B 接受白内障手术的患者, 如果没有眼部合并症, 至少 90% 的患者视力应该能够达到 6/12 或以上 11,12 Grade B Levell III 6 APACRS 实践指南

9 术前评估和决策 何时做白内障手术 : 手术时机 GPP 如果患者有可能从白内障手术中获益, 就应该做手术 对于成熟或膨胀期白内障, 应该尽可能早地实施白内障手术 一般情况下, 白内障手术是在视力下降到 6/12 以下时实施 而现在白内障手术可以在视力更好的时候实施 13 这些病例, 需要记录更早实施白内障手术的原因, 例如眩光 屈光参差 单眼复视 对比敏感度丢失以及日常生活出现困难 GPP 应该考虑患者的功能视力, 而不是仅仅考虑 Snellen 视力 GPP 一般情况下, 如果患者的视力下降至无光感, 则不建议做白 内障手术 但是, 如果患眼白内障膨胀或出于美容考虑, 也可以做白 内障手术 但应该事先告知患者视力的恢复预后很差 存在视网膜或视神经病变的患者, 即使术后视功能恢复欠佳, 也可 行白内障手术 术前必须清楚地向患者解释 : 术后视力可能不会提 高, 但视野可能会有改善 总之, 在白内障手术之前, 手术医生应该根据临床情况做出判断, 同时也要考虑患者的希望和诉求 例如,6/18 的视力对于一位 80 岁退休的患者可能就够用了, 而对于 35 岁, 生活方式很积极的患者, 可能会给日常生活带来困难 APACRS 实践指南 7

10 术前评估和决策 4.2 扩大早期白内障手术适应证 根据新的医学证据, 提出了两个新的早期白内障摘除甚至透明晶 状体摘除的适应证 : 闭角型青光眼 / 青光眼疑似者 14 A 越来越多的证据显示透明晶状体在原发性房角关闭中起重要的作用 原发性房角关闭 / 原发性闭角型青光眼, 摘除透明或早期混浊晶状体减少了虹膜向前膨隆, 可以引起前房加深, 开放房角, 提高这些眼长期眼内压 (IOP) 的控制 Grade A, Level Ib 晶状体摘除效价比也高于激光虹膜周切术 17 但是, 应该告知患者眼 内手术可能的风险 A 早期白内障手术可以作为闭角型青光眼的初始治疗 Grade A, Level Ib 屈光性晶状体置换 因为患者希望看远看近都不戴眼镜, 透明晶状体摘除联合老视矫正人工晶状体植入 ( 可调节或多焦 ) 常常作为屈光性手术 但是, 和其它白内障手术一样, 有发生包括眼内炎在内的并发症的风险, 需要向患者解释 另外, 因为这些患者好多是近视, 比较年轻, 他们在晶状体摘除手术后发生视网膜脱离的风险较高 18,19 在这一点上, 因为存在不同的选择和实践模式, 必须根据病例自 身的特点进行评估, 做出临床判断, 并且让患者签署知情同意书 Level IV 8 APACRS 实践指南

11 术前评估和决策 4.3 白内障手术禁忌证 虽然白内障手术没有绝对的禁忌证, 以下情况不建议做白内障手 术, 除非有迫不得已的理由 : 患者不愿意接受手术 ( 只要白内障没有发生过熟而引发并发症 的风险 ); 患者不需要白内障手术 ; 眼镜或其它视觉辅助措施能够提高视力令患者满意 ; 白内障没有影响患者的生活方式 ; 患者的全身情况导致手术风险大于白内障手术可能的效益 4.4 白内障严重程度评价 : 临床检查和研究 C 白内障严重程度的评价应该包括以下所有及部分内容, 需要根据患者及其眼部状况而定 虽然眼科医生有责任检查回顾数据, 在眼科医生指导下, 其它受过培训的人员也可以协助收集一定的资料 20,21 Grade C, Level IV 视力评估 GPP 任何白内障手术之前必须记录 Snellen/logMAR/ 小数视力表视力 但是, 安排白内障手术并没有一个单一的标准 APACRS 实践指南 9

12 术前评估和决策 对比敏感度 C 对比敏感度 22 眩光 22,23 和强光下视力检查能提供更多白内障 引起总体视觉损伤的信息 Grade C, Level IV 临床检查 原瞳以及充分散瞳后裂隙灯检查是诊断白内障的标准操作 应该对白内障类型和严重程度进行分级, 最好采用标准化计分系统 例如晶状体混浊分级系统 (LOCS)III 24 安排白内障手术之前必须检查睑缘和眼表 应该检查角膜表面和内皮 如果没有内皮镜, 用裂隙灯做镜面反射 检查可以让手术医生了解角膜内皮的健康状态 中央和周边前房深度对计划手术和预测手术困难是很重要的 检查 只要有可能, 必须检查视网膜, 包括视神经乳头 黄斑和周边视 网膜 应该观察是否存在合并症, 例如高度近视 青光眼 黄斑疾病 假性 囊膜剥脱和瞳孔不能散大的情况 10 APACRS 实践指南

13 术前评估和决策 4.5 术前检查 生物测量 可以使用激光干涉测量 (OLIB) A 超或 OCT 角膜曲率 手动或自动 B 超 用于不能清晰观察视网膜的病例 角膜地形图 检查角膜散光大小 轴位和规则性对于决定是否适合使用散光 IOL 很重要 像差仪和视网膜光学相干断层扫描 (OCT) 如果有条件可以检查 视功能问卷 用于一定的情况 患者的总体健康状态评估 ( 如能否平躺 合作和交流 ) 4.6 独眼患者白内障手术特殊注意 功能性独眼患者白内障手术和其它患者没有差别 这些患者的白内障手术能够提高功能视力 25 这些眼可能会有其它合并症, 需要仔细检查 另外, 手术的风险需 要向患者交代清楚 B 过度推迟独眼患者的手术可能会造成晚期白内障, 增加发生 手术并发症的风险, 甚至影响视力的恢复 Grade B, Level III 还必须注意其它围手术期和术中的注意事项 APACRS 实践指南 11

14 术前评估和决策 4.7 第二只眼手术 临床研究提供了确凿的证据, 双眼视力类似的患者会出现双眼叠 加现象 双眼视力不同的患者 ( 屈光参差或单眼人工晶状体眼而对侧眼白 内障 ) 会出现双眼抑制现象 31 另外, 双眼做过白内障手术的患者满意度和功能视力较高 Level Ib 第二只眼手术的决定取决于多个因素, 例如对侧眼视力和功能状 态, 患者的视力需求以及是否存在眼部合并症 GPP 做第二只眼手术之前, 需要明确第一只眼的屈光不正状态, 有助于更好地选择第二只眼的 IOL 度数 38, 双眼同时白内障手术 大多数眼科医生不开展双眼同时白内障手术 随着手术预后的提高, 人们开始对在同一天完成双眼白内障手术感 兴趣, 尤其是卫生保健系统手术等候时间很长的地区 一些前瞻性研究比较了双眼同时白内障手术和延期序列白内 障手术, 发现前者在短期内获得了更好的功能性视力及效 价比 43,46,47 Level IIa 12 APACRS 实践指南

15 术前评估和决策 B 如果同一天做双眼手术, 第二只眼要按照独立的患者对待 这意味着必须采用独立的器械 药品和手术铺巾 ; 手术医生和助手在双眼之间都需要重新刷手 有一些报道, 因为双眼手术没有严格遵循这些指南意见, 发生了双眼眼内炎 另外, 如果第一只眼术中发生了并发症, 当天不能开展第二只眼手术 Grade B, Level III 目前, 这个问题存在很大的争议 支持者指出, 双眼同时手术最大的忧虑在于可能双眼同时发生眼内炎, 分析了近 100,000 例病例中并没有发生双眼眼内炎的情况 此并发症只出现在没有彻底分离双眼 严格遵循无菌方案的情况下 44 另一方面, 大多数眼科医生认为同时手术的好处不足以抗衡双眼并发症的风险 不能够预测屈光结果 不能调整 IOL 选择以及可能带来法律后果的坏处 45 C 根据当前的证据, 双眼同时白内障手术不应该被推荐为标准操作, 因为它会导致双眼眼内炎的风险, 虽然概率较小, 但是一旦发生可能会造成全盲 5 Grade C, Level IV 4.9 白内障手术技巧选择 当前白内障手术联合人工晶状体 (IOL) 植入的技巧包括 : 白内障囊外摘除 (ECCE) 小切口白内障囊外摘除 (MSICS) 超声乳化 飞秒激光辅助白内障手术 APACRS 实践指南 13

16 术前评估和决策 手术方式的选择取决于手术医生, 根据他们的经验和技术的掌握程 度以及是否拥有这项技术而定 6-10 Level Ia 大部分病例应该植入 IOL, 最好是植入到囊袋内 但是, 如果后囊膜 支撑不足,I O L 可以固定在睫状沟 前房 虹膜或巩膜上 严重持续性葡萄膜炎或高度近视大范围后囊膜破裂等罕见的情况下 可能不适合一期植入 IOL 4.10 超声乳化和白内障囊外手术比较 (ECCE/MSICS) 白内障囊外手术通常会联合非折叠 IOL 植入, 比可折叠 IOL 便宜 白内障囊外手术的设备和消耗的成本低于超声乳化 缝合的 ECCE 需要做多个缝线 ; 因此视力恢复较慢, 需要 6-8 周愈合 可以说在全球, 即使是在发展中国家, 超乳都是眼科医生和患者中 最流行的手术方式 尽管一定的研究显示 MSICS 并发症发生情况及 视力预后与超乳类似 10,52 Level Ia 4.11 飞秒激光辅助白内障手术 飞秒激光辅助白内障手术 (FLACS) 目前已经被批准用于做角膜切 口, 治疗角膜散光, 前囊撕囊和劈核 今天可以用于常规以及复杂病 例, 例如后极性白内障 晶状体半脱位以及儿童白内障 APACRS 实践指南

17 术前评估和决策 有关这项技术和传统超乳技术优缺点比较的文献很多 但是, 目前为止, 已发表的结果并没有显示 FLACS 在视力预后 屈光预后或术中并发症方面有显著优势 57,79-81 事实上, 最近的一项大型病例对照研究甚至显示 FLACS 后早期术后并发症发生率高于传统超乳 79 Level IIa 因此, 根据现有的证据,FLACS 和传统超乳都能获得优异的视 力和屈光结果, 术中和术后并发症发生率很低 ;FLACS 并不比传统 超乳能获得更好的结果 Level IIa 当前,FLACS 的效价比不如传统超乳, 尤其是在发展中国家和医疗 费用完全由公共卫生系统承担的国家 82,83 Level IIb 4.12 白内障手术预后 根据当前的研究, 如果没有眼部合并症, 至少 90% 的患者接受白内 障手术之后, 术后视力可达 6/12 及以上 12,84,85 Level III 一项研究发现获得更好的预后的预测指标是 : 年轻 ( 小于 65 岁 ) 较少 合并症 白内障症状分数较高和视功能问卷分数较低 (VF-14) 86 Snellen 视力单独不能预测术后视功能的改善 APACRS 实践指南 15

18 术前评估和决策 4.13 人工晶状体的选择 C 白内障摘除术后最好能够将 IOL 植入到囊袋内, 除非存在特殊 的禁忌症 87,88 Grade C, Level IV 可折叠 IOL 是现在最常用的 IOL 可以由亲水性丙烯酸 疏水性丙烯 酸 硅胶或共聚物材料制成 硬性聚甲基丙烯酸甲酯 (PMMA)IOL 也用于联合 ECCE 植入 为患者选择 IOL 需要考虑 IOL 材料 设计 焦点模式 植入难易度和葡萄膜及囊膜生物相容性 IOL 材料亲水性和疏水性丙烯酸及硅胶材料具有很好的葡萄膜和囊膜生物相容性 ( 后囊膜混浊发生率很低 ), 也很容易植入 IOL 材料的选择总体上是手术医生的个人喜好 但是, 硅胶材料对于存在后节病变或可能会需要做玻切手术做硅油填充或膨胀气体填充的患者应该避免, 因为这可能会妨碍玻切手术中手术医生的视线 今天的 IOL 大多数具有防紫外线功能, 有些带有不同波长蓝光阻断功能 但是, 文献关于阻断一定波长的蓝光能否防止黄斑损伤的观点存在争议 93,94 IOL 设计 IOL 设计对于预防后囊膜混浊 (PCO) 以及 IOL 稳定性非常重要 证据显示方边设计 IOL 对于降低 PCO 发生率有效 95 但是, 方边设计可能会增加不良视觉现象 16 APACRS 实践指南

19 术前评估和决策 最适合的 IOL 植入位置是囊袋内 但是, 在特殊情况下可能会没有充分的后囊膜支撑 对于这些病例,IOL 可以前房固定, 虹膜后固定, 睫状沟植入, 巩膜缝合固定以及胶粘或无胶巩膜内固定 只要将 IOL 植入到睫状沟, 都需要调整 IOL 的度数 ( 一般降低 0.5 到 1.0D) B 一片式可折叠 IOL 是特别为囊袋内植入设计的 如果发生后囊膜破裂, 绝对不要把这些一片式可折叠 IOL 放置在睫状沟 96,97 Grade B, Level III 这些 IOL 植入睫状沟后, 会造成虹膜刺激 青光眼 炎症 前房出血 和黄斑水肿 96,97 Level III IOL 焦点模式传统 IOL 是单焦 IOL 患者可能需要根据残留屈光不正度数, 佩戴眼镜看远 看中以及看近 现在, 球面和非球面 IOL 可供选择 非球面 IOL 的优势在于, 它通过降低球差, 提供更好的对比敏感度和清晰的视觉, 尤其是在昏暗光线下 但是, 他们的疗效会受到瞳孔大小 原有角膜像差和 IOL 中心性的影响 A 角膜散光的矫正越来越重要 现有的散光矫正方式包括角巩膜缘松解切口 (LRI) 散光 IOL 和飞秒角膜散光切削术 散光 IOL 具有可预测性, 能够精确矫正规则角膜散光, 其有效性已经得到全球多个研究的证实 Grade A, Level Ia 对于规则散光患者, 散光 IOL 比单焦 IOL 更能降低患者对眼镜的依 赖程度 107,108 APACRS 实践指南 17

20 术前评估和决策 老视矫正 IOL 在患者和手术医生中非常流行 目前有多种设计, 例如 可调节 IOL 双光 IOL 以及衍射和折射多焦点 IOL 当前最多见的 多焦点 IOL 是衍射型多焦点 IOL B 认识到并让患者了解大多数多焦点 IOL 会带来不同程度对比 敏感度丢失 眩光 光晕和雾视现象非常重要 最近的一项研究 109 报告 多焦点 IOL 植入后不满意 是 IOL 置换手术第二常见的原因 因此, 仔细选择患者, 进行术前咨询非常重要 Grade B, Level III 20 项单焦 IOL 和不同类型多焦 IOL 效果比较的随机临床试验综述, 110 以及另一项多焦 IOL 文献综述, 111 得出的结论是单焦和多焦 IOL 的远视力相当 植入多焦 IOL 的患者, 可能近视力略好 ; 但是, 不良事件发生率, 例如眩光 光晕以及 IOL 取出率, 多焦 IOL 较高 Level Ia 为了延长远中距离视程, 降低眩光和光晕发生率, 现在出现了低近焦附加屈光度的多焦点 IOL 112,113 可调节 IOL 通过调节作用改变屈光特性, 可以提供不同水平的调节潜能 但是, 和传统多焦 IOL 不同, 这些 IOL 不会有对比度丢失, 不会出现眩光或光晕现象 单焦 IOL 的单眼视和微小单眼视对于降低看远和看近时的眼镜依赖度非常成功 单眼视方法是主视眼正视, 另一眼保留不同程度的近视 ( 通常 1.0 到 2.5D) 有报道, 应用这种技术, 远视力和传统单焦 IOL 一样好, 但是中间距离视力更好 但是, 多焦 IOL 的脱镜率高于单眼视 APACRS 实践指南

21 术前评估和决策 4.14 生物测量和 IOL 度数计算 B 准确的角膜曲率和生物测量, 加上利用合适的 IOL 度数计算 公式, 是获得目标屈光预后的决定性因素 Grade B, Level III A 超和光学生物测量仪都可以测量眼轴和其它眼部生物测量参数 光学生物测量仪是非接触 高分辨率 无创测量方法, 可测量眼轴及其它生物测量参数例如角膜曲率 前房深度 晶状体厚度 角膜水平直径和中央角膜厚度 部分相干干涉测量和扫频源 OCT 技术可以用于精确地测量眼睛的屈光性轴长而不是 A 超测量的解剖性轴长 B 在测量眼轴方面, 光学生物测量仪优于接触性 A 超, 至少和浸入法 A 超相当 研究显示, 使用光学生物测量仪获得的实际术后验光结果和 A 超一样接近目标屈光结果 Grade B, Level IIa 因此, 光学生物测量是首选方法 但是, 这项技术并不是很普及, 尤其在发展中国家 另外, 在晚期白内障和患者不能注视的情况下, 光学生物测量困难 B A 超可以采用接触式或浸润式技术 接触式技术高度依赖检查者的技巧和经验 119,125,126 接触式 A 超, 由于对角膜产生不同程度的压迫, 会引起眼轴测量人为变短 和接触式 A 超相比, 浸入式 A- 超能更准确地测量眼轴 127 Grade B, Level III GPP 对于眼轴 <20mm 或 >30mm 或硅油填充或屈光手术后 IOL 计算的病例, 需要特别小心, 要重复检查 APACRS 实践指南 19

22 术前评估和决策 GPP 至于 IOL 度数计算公式, 应该采用新型理论的 IOL 计算公式, 例如 SRK-T Holladay 1 和 Hoffer Q 新型公式, 例如 Haigis- L Olsen Holladay 2 Barrett 的 Universal 公式以 Hill RBF 公式需要额外的数据, 例如前房深度 晶状体厚度和白 - 白角膜直径来更好地预测有效晶状体位置 Barrett 公式以及 Hill RBF 公式分别见于 和 对于某些特别情况, 例如屈光手术后和极端眼轴长病例, 使用这些新型 IOL 公式计算更准确 结果可预测性更佳 4.15 麻醉选择 麻醉方式包括全麻 表麻和局部麻醉 麻醉方式的选择通常由手术医生和患者因素决定, 但是更倾向于局麻和表麻, 因为全麻存在一定的风险 但是, 术前应控制全身疾病, 尤其是糖尿病和呼吸性疾病 大多数手术医生不会停用抗血小板药物 但是, 对于特定的病例, 应该向内科医生咨询, 是否停用抗凝药物 Cochrane 比较了球周和球后麻醉的随机临床试验, 发现这两种技术的疗效没有差异 137,138 另一篇综述, 比较了表麻和 Tenon 囊下麻醉, 发现, 虽然表麻的术中疼痛较明显, 但术后 24 小时的疼痛较轻 139 Level Ia A 局麻类型应该由患者 手术医生和麻醉师共同选择, 要考虑 多个因素 目前文献并不支持某种麻醉方式具有显著优势 Grade A, Level Ia 20 APACRS 实践指南

23 术前评估和决策 4.16 白内障术后随访和药物 A 白内障手术病例的术后随访, 总体建议安排在术后第一天, 以后在术后 1-4 周之间, 根据医疗条件和遵循的方案而定 140 但是, 有研究发现顺利的白内障手术, 不做术后第一天随访并不增加并发症风险 Grade A, Level Ib B 手术医生有责任向患者和他们的看护人员解释必须立即咨询 医生的症状 Grade B, Level III 对于 ECCE, 如果需要, 通常在术后 4-6 周拆除缝线 拆线后任何时 候都可以做最终验光配镜 验光师或眼科医生可以在超乳术后 2-4 周给患者做最终验光配镜, 因为有报导, 角膜散光到 2 周可以稳定 145,146 需要根据合并症 并发症 眼部状态和屈光稳定性个性化增加额 外的随诊 GPP 术后表面抗生素 激素 非甾体抗炎药甚至口服止痛片的使用还没有达到共识 但是, 大多数手术医生喜欢术后立即开始使用表面抗生素和甾体滴眼液, 术后持续 2-4 周 一般会选择使用第四代氟喹诺酮类和强的松龙或地塞米松滴眼液 但是, 不同的手术医生可以根据经济状况和操作喜好使用不同的表面药物 APACRS 实践指南 21

24 术前评估和决策 4.17 白内障手术并发症 术中和术后可能会发生一些并发症 最可能威胁视力的是后囊膜破裂 ( P C R ) 感染性眼内炎 毒性前房综合征 ( T A S S ) 视网膜脱离 脉络膜上腔出血 黄斑囊样水肿 (CME) 和持续角膜水肿 每个手术医生密切检查患者的术中和术后并发症很重要 具体的并发症讨论如下 : 后囊膜破裂 文献报道的 PCR 发生率, 从顺利的超乳手术后 2% 到高危眼的 9% PCR 的危险因素包括但不限于白色白内障 致密棕褐色白内障 假性囊膜剥脱综合征 后极性白内障 术前看不清眼底 高度轴性近视 合并症 术中虹膜弛缓综合症 (IFIS) 老龄和住院医操作的 手术 152,153 对于术中发生 PCR 病例, 白内障手术医生应该准备好做局限性前部玻切的设备, 最好是自动化玻切仪 如果没有充分的囊膜支撑, 要有备选的 IOL GPP PCR 发生后, 做或不做前玻切, 患者都应该更密切随访, 要特别检查是否发生青光眼和视网膜脱离 应该告诉患者出现视网膜脱离的表现, 主要是闪光感 漂浮物和突然视觉变暗 因此, 在术后早期, 这些患者要更加密集地随访, 然后 4-6 周左右随访 22 APACRS 实践指南

25 术前评估和决策 黄斑囊样水肿 现代化小切口白内障手术, 临床显著性 CME 的发生率低至 1 到 3% 148,159,160 通常,CME 对表面抗炎药物的反应很好 ; 但是, 顽固病例可能会合并中央视力的永久性损伤 发生 CME 的危险因素包括既往葡萄膜炎 后囊膜破裂玻璃体溢出 糖尿病视网膜病变 既往玻璃体视网膜手术和对侧眼人工晶状体性 CME 病史 目前术后 CME 的预防没有固定的方案 普通病例在围手术期预防性使用 NSAID 预防 CME 效果并没有得到证实, 虽然对于高危眼可能有效 Level IV 眼内炎及其预防 当前趋势 眼疼 眼红 视物模糊和眼睑水肿是眼内炎的主要症状 要向每个患者介绍这些症状, 教导患者, 如果出现这些表现需要即时联系医疗机构 体征包括角膜水肿 前房积脓 严重睫状充血和玻璃体渗出 这种疾病要和毒性前房综合征 (TASS) 相鉴别, 因为治疗有所不同 A 任何时候发现或怀疑出现眼内炎, 必须马上在显微镜下做前房穿刺和 / 或玻璃体穿刺检查, 进行微生物培养, 然后同时玻璃体腔内注射抗生素 眼内炎玻切研究推荐, 对于视力达到手动或以上的患者, 需要联合玻璃体注射和玻璃体穿刺 对于视力低于手动的患者, 应该做睫状体平部玻切 161 Grade A, Level Ia 眼内炎发生率很低, 全球报告的发生率在 0.04% 和 1.6% 之间 APACRS 实践指南 23

26 术前评估和决策 眼内炎危险因素包括后囊膜破裂 玻璃体丢失 过长手术时间 住 院医完成的手术 免疫功能低下患者 切口构建不当发生伤口漏 聚维碘酮消毒前使用局部麻醉凝胶和老龄患者 162,164, Level III GPP 眼内炎预防至关重要 需要关注眼附属器, 尤其是白内障手 术前炎症性鼻泪道堵塞和睑板腺疾病 A 白内障术前至少 2 分钟结膜囊滴入 5% 聚维碘酮被证实可以减少结膜囊微生物量, 因此能降低感染发生率 Grade A, Level IIa B 仔细构建伤口, 缝或不缝合水密切口非常重要, 因为渗漏的切口会增加感染的风险 180 Grade B, Level III 聚维碘酮之前使用利多卡因凝胶会降低其疗效 180 虽然一些研究显示 ECCE 的眼内炎发生率高于超乳, 163, 如果仔 细关闭切口, 手术类型可能不会影响眼内炎的发生率 Level III IOL 材料和眼内炎没有相关性 181, 但是,I O L 袢的聚丙烯材料和其它材料相比, 细菌的黏附性更强 植入过程中,IOL 和眼部菌群的接触可以是感染源 187 采用推注器系统可以避免 IOL 和眼表的接触, 降低发生污染的风险 24 APACRS 实践指南

27 术前评估和决策 当前, 关于白内障术中前房抗生素的使用存在争议 ESCRS 眼内炎研究是针对表面和前房使用抗生素的作用的一项标志性研究 这项研究纳入了 13,000 多只眼, 发现没有做前房头孢呋辛注射的组, 发生眼内炎的相对危险度值为 ,185 Level Ib 但是现在一定的国家还没有商业化的供前房注射用的头孢呋辛, 同期配制的抗生素溶液不是商品化前房使用的剂型, 存在稀释和配药错误的风险, 可能会导致严重的毒性反应 ,181,183,185,186, 随后, 一些研究显示了不同种前房抗生素 ( 头孢呋辛, 莫西沙星和头孢唑林 ) 可以降低眼内炎风险 目前并不推荐使用前房万古霉素, 因为出现了这种药物引起出血性堵塞性视网膜血管炎 (HORV) 的报告 209 另一方面, 许多研究支持前房使用不含防腐剂的莫西沙星的安全性和疗效 194,181,200,208, Level Ia 灌注液内添加抗生素降低感染的作用没有得到证实 另外, 它们的 浓度和持续时间是可变的 213 Level III 同样, 结膜下抗生素或白内 障术前开始使用表面抗生素, 也没有很强的证据 有研究显示, 手术当日开始滴表面抗生素可能比术后第一天使用更 具有保护力 175 总之, 由于缺乏足够大的前瞻性临床试验, 并且很难开展这样的试验, 目前还没有充分的证据为眼内炎预防推荐特别的抗生素或给药途径 但是, 随机临床试验发现了两种可以降低眼内炎风险的干预措施 : a) 前房使用抗生素 ; b) 术前结膜囊使用 5% 聚维碘酮 APACRS 实践指南 25

28 术前评估和决策 毒性前房综合症 (TASS) 毒性前房综合症 (TASS) 是一种无菌性术后炎症反应 最大的诊断困难是鉴别 TASS 和感染性眼内炎 TASS 通常表现在术后 小时 TASS 的临床表现为 : 弥漫的角巩膜缘到角巩膜缘的角膜水肿 严重的前房细胞和浮游物 纤维蛋白反应和前房积脓 181 严重的疼痛通常不是突出表现, 眼底检查或 B 超发现, 后节通常不受累 TASS 通常对抗炎药物有反应, 但是如果怀疑有感染因素, 应该做前房和玻璃体培养明确感染因素, 开始抗生素治疗 186 TASS 最常见的因素与眼科器械清洗和消毒不够相关 : 超乳和灌注 / 抽吸手柄冲洗不足, 酶性清洗剂及去污剂使用不当, 器械超声清洗和消毒不当 175 有粉手套也和 TASS 病因相关, 因此美国 FDA 已经禁止含粉手套在眼科手术中的应用 26 APACRS 实践指南

29 培训和认证 5 受训者培训很重要, 需要培训者和受培训者的合作 世界不同地区甚 至一个地区内, 白内障手术培训模式有很大的不同 因此很难给予特定的推荐 但是, 开始手术培训之前, 根据现有的条件, 受训者在手术实验室开展模拟手术或动物眼手术非常重要 他们也需要在自己手术之前作为助手参与几台白内障手术 他们需要全面了解手术显微镜和超乳机的理论和操作知识 受训者需要完成的白内障手术数量和白内障手术类型, 各个地区各个培训中心存在差异 更重要的是要通过分步方式, 在有经验的培训者指导下开始手术 所有的受训者都需要保留并发症和手术记录, 理想的情况下, 培训者应该定期检查监督 APACRS 实践指南 27

30 6 手术预后评估建议 术后 3 个月内每个患者都应该有随诊记录 : a) 视力 ( 裸眼和最佳矫正视力 ); b) 屈光不正测量以及与预期术后验光结果的偏差 ; c) 术中和术后并发症 ; d) 任何因为再次手术干预, 重返手术室的情况 28 APACRS 实践指南

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45 编辑组 8 5% ry. 主编 ral ral of Dr. Vaishali Vasavada 印度 申屠形超教授 中国 审稿组 Prof. Graham Barrett Dr. Abhay Vasavada Dr. Chan Wing Kwong Prof. Chee Soon Phaik Prof. Hiroko Bissen-Miyajima Prof. Hungwon Tchah Dr. Johan Hutauruk Dr. Pannet Pangputhipong Adj. Assoc. Prof. Ronald Yeoh Prof. Yao Ke 澳大利亚 韩国 印度 印度尼西亚 新加坡 泰国 新加坡 新加坡 日本 中国 编辑支持 项目总监: 文字编辑: 中文翻译: Ms Kathy Chen Mr Chiles Samaniego 周崎副教授 设计: 助理编辑: Ms Alicia Long Mr Javian Teh Ms Huang Weitian Ms Pamela Tan APACRS 实践指南 43 PPP for Cataract Surgery Chinese 19/7.indd 43 19/7/17 5:57 PM

46 致 感 教 C 包 求 公 帮 44 APACRS 实践指南 PPP for Cataract Surgery Chinese 19/7.indd 44 19/7/17 5:57 PM

47 致谢 感谢蔡司为 APACRS 白内障手术实践指南提供无限制的教育基金 Carl Zeiss Meditec AG 为眼部及眼科疾病的诊断和治疗提供全方面的解决方法, 包括晶状体和各种耗材 蔡司公司全面的投资组合能够满足眼保健专业人员的需求, 帮助他们应对日具挑战性的医疗环境 公司推动了大多数眼科常见病的诊断 治疗 随访和处理的先进技术的发展 旨在帮助医务工作人员应对每日的挑战, 让他们能够集中精力最大可能地为患者服务 APACRS 实践指南 45

48 Annual Meetings 1987 ~ 2017 APACRS 庆祝引领亚太地区白内障和屈光手术领走过的 30 年历程! Published by The Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) 11 Third Hospital Avenue, Singapore apacrs@apacrs.org