圆锥角膜怎么发现

Nylon 10/0 (to sew the cornea)尼龙10/0(缝制角膜)

对于“最后机会”手术或角膜移植，需要供体组织。 (For the “last chance” operation or cornea transplant, donor tissue is needed. )

Specifically, we are interested in tissue with a thickness of 500–600 microns for penetrating keratoplasty. Next you need to work with this film with your hands, sew with a thin nylon thread. Then, when the cornea grows together, remove the suture. No biodegradable materials — their decay products will begin to lysing and can cause inflammation, which will exclude a positive result of the operation. Moreover, the transplant is recommended to flash twice around the perimeter — this increases the chances of its correct and uniform fixation. The second layer of nylon is most often not removed at all, because as long as it does not interfere, we don’t touch it.

具体来说，我们对穿透性角膜移植术厚度为500-600微米的组织感兴趣。 接下来，您需要用手处理该薄膜，并用细尼龙线缝制。 然后，当角膜一起生长时，移除缝线。 没有可生物降解的材料-它们的衰变产物将开始溶解并可能引起炎症，这将排除手术的积极结果。 此外，建议移植物在周长周围闪烁两次-这增加了正确正确固定的可能性。 第二层尼龙通常根本不会被去除，因为只要不干扰，我们就不会碰它。

But let's start from the beginning. Specifically, from situations where a person may need this difficult for Russia operation, but quite familiar in Germany. It is of three types:

但是，让我们从头开始。 特别是在某些情况下，一个人可能需要在俄罗斯进行手术，但在德国却非常熟悉。 它分为三种类型：

• PKP, that is, the removal of the entire cornea of ​​the patient, for example, with a diameter of 7 to 8.5 mm and sewing on a new one.PKP，即去除患者的整个角膜，例如直径为7至8.5毫米并缝制新的角膜。
• DALK, that is, corneal tissue transplantation with the exception of the Descemet's membrane and endothelium.DALK，即除Descemet膜和内皮外的角膜组织移植。
• DMEK, that is, the «installation» of only the layer of the Descemet's membrane and endothelial cells instead of the same layer in a patient.DMEK，即仅“ Descemet”膜和内皮细胞层的“安装”，而不是患者中的同一层。

适应症 (Indications)

DALK (Deep Anterior Lamellar Keratoplasty) is done if the upper layers of the cornea are damaged — most often keratoconus and scars, ulcers associated with accidents and other injuries that have not affected the endothelium. If the cornea has burst entirely — it is necessary to do a through, if the posterior part (endothelium layer) is preserved, try not to touch it in modern surgery. It is important that while you still have your own endothelium, which you need, because endothelial cells are not restored. This is the most difficult operation technically, and therefore quite time consuming. Well, and so dear.

如果角膜的上层受损-最常见的是圆锥角膜和疤痕，与意外相关的溃疡以及其他未影响内皮的损伤，则进行DALK(深层前角膜成形术)。 如果角膜完全破裂-如果保留了后部(内皮层)，则必须进行穿通，在现代手术中尽量不要触摸它。 重要的是，您仍然需要自己的内皮，因为内皮细胞无法恢复。 从技术上讲，这是最困难的操作，因此非常耗时。 好吧，亲爱的。

DMEK (Descemet Membrane Endothelial Keratoplasty) is done with problems with the endothelium, but while maintaining the anterior layer.

DMEK(Descemet膜内皮角膜移植术)发生了内皮问题，但同时保持了前层。

Pass-throughkeratoplasty can be done in both cases, but today it is just insurance in case something went wrong during the operation or, as mentioned above, if all layers of the cornea are damaged. Most often used for ulcers with perforation.

在这两种情况下都可以进行穿通角膜移植术，但是如今，这只是万一手术过程中出现问题或如果角膜的所有层均受损的情况下的保险。 最常用于穿Kong溃疡。

The main indications for DMEK in Germany are genetic problems with the endothelium (for example, Fuchs dystrophy), less often the consequences of complex cataract operations when it has matured for a long time — or after a very traumatic operation. Then there are postoperative injuries, for example, after two or three operations (cataract, glaucoma, vitreoretinal intervention using silicone oil, etc.). In Russia, on the contrary, genetic factors are much less represented (perhaps because of the difference in life expectancy — in Germany, patients have time to live or be investigated), but the cataract is brought to the limit, during the removal of the lens due to the excess amount of transmitted ultrasonic energy can begin to collapse eye endothelial cells and that's it. We arrived. The corneal endothelium in humans does not multiply. At the rabbit — please.

在德国，DMEK的主要适应症是内皮的遗传问题(例如，Fuchs营养不良)，而复杂的白内障手术长期成熟后或遭受严重创伤后，其并发症的后果较少。 然后，例如在进行两次或三次手术(白内障，青光眼，使用硅油进行的玻璃体视网膜干预等)之后，会有术后受伤。 相反，在俄罗斯，遗传因素的代表性要低得多(也许是由于预期寿命的差异—在德国，患者有时间生存或接受调查)，但是在去除白内障的过程中，白内障达到了极限。多余的超声能量会导致晶状体晶状体塌陷，仅此而已。 我们到了。 人的角膜内皮不会繁殖。 对兔子-请。

Previously, the cornea was transplanted in a fairly simple way: the patient was cut off the layer, the layer was sewn from the donor, and waited until it was overgrown. The problem is that the larger the transplanted layer, the deeper they went into the cornea. And the deeper — the greater the volume of tissue, and the higher the chances of tissue rejection. Through keratoplasty today is used only for rare indications. In our clinic it is about 15%. For almost all other indications, minimally invasive (relatively) DMEK and DALK compete with it today, depending on which layer has suffered. It is much more difficult to do at times, but the patient has much more positive chances.

以前，角膜的移植方法相当简单：将患者切下该层，从供体上缝合该层，然后等到长满为止。 问题在于，移植的层越大，进入角膜的深度就越深。 而且越深，组织的体积越大，组织排斥的机会就越大。 今天，通过角膜移植术仅用于罕见的适应症。 在我们的诊所中约为15％。 对于几乎所有其他适应症，微创(相对)DMEK和DALK如今与之竞争，这取决于遭受了哪一层伤害。 有时很难做，但是患者有更多积极的机会。

The DMEK method was developed by the Dutch doctor Gerrit Melles (by the way, like DSAEK, the method from which DMEK evolved). In our holding SMILE EYES she began to engage for the first time in 2010. So, the whole cornea is taken, and the necessary layer of 20-30 microns is separated from it. With due care, it is possible to separate in advance (for example, one hour before the operation) so that two grafts will be obtained at once — for DMEK and for DALK. Or you can order a transplant that is already prepared, but it is significantly more expensive and not always better, and any surgeon most often does it on his own. I recommend doing it yourself before the operation, because the surgeon personally controls the quality and receives fresh material. Those who perform few operations sometimes use ready-made ones (because separation is sometimes more difficult than the operation itself), but those who do not have both hands are left-handed.

DMEK方法是由荷兰医生Gerrit Melles开发的(顺便说一句，就像DSAEK一样，DMEK就是从该方法发展而来的)。 在我们持有的SMILE EYES中，她于2010年首次开始订婚。因此，整个角膜都被吸收了，并从中分离出了20-30微米的必要层。 通过适当的注意，可以提前分离(例如，在手术前一小时)，以便一次获得两个移植物-DMEK和DALK。 或者，您可以订购已经准备好的移植物，但价格昂贵，而且不一定总是更好，任何外科医生通常都会自己做。 我建议您在手术前自己动手，因为外科医生会亲自控制质量并接受新鲜的材料。 那些执行很少操作的人有时会使用现成的操作(因为有时分离比操作本身更困难)，但是那些没有双手的人则是左撇子。

The most important thing Melles came up with was not what everyone historically tried to do — sew a transplant. 150 years in a row people sewed. Dear Professor Buzin from Italy (one of my former mentors) — he tried the same thing on rabbits long before Melles, but he sewed. Did not work. And Melles said — I will inject the air bubble, and everything will suck. It was believed that he was crazy, but in fact he was a genius. It was a revolution in cornea transplantation, and it happened in a few years.

Melles想到的最重要的事情不是每个人历史上都想做的-缝移植。 人们连续缝制了150年。 亲爱的来自意大利的Buzin教授(我曾任导师之一)-在梅莱斯之前，他曾在兔子身上尝试过同样的事情，但他缝了缝。 不工作。 梅尔斯说-我要注入气泡，一切都会吸。 人们相信他是疯子，但实际上他是个天才。 这是角膜移植的一场革命，并且发生了几年。

Separated film is carefully placed in the eye and pressed down with an air bubble so as not to leave. Here is a DMEK video, roughly giving a presentation:

将分离的胶片小心地放在眼睛中，并用气泡压下，以免留下。 这是DMEK的视频，大致进行了演示：

What is important for this operation: the patient is highly recommended to be under anesthesia (to sleep and be immobilized) in order not to twitch. Under local anesthesia without tranquilizers, when a person is under tension in the eye, pressure rises, and this leaves less space in the anterior chamber of the eye for non-traumatic transplant manipulations. And the probability of hemorrhage under local anesthesia is higher. Especially important is good anesthesia for end-to-end transplants. And then, if the patient coughs during a through-transplant, we lose an eye.

对于该手术重要的是：强烈建议患者在麻醉状态下(睡觉并固定下来)，以免抽搐。 在没有镇静剂的局部麻醉下，当一个人在眼中处于紧张状态时，压力会升高，这会为非创伤性移植操作在眼前房留下更少的空间。 并且在局部麻醉下出血的可能性更高。 对于端到端移植，良好的麻醉尤其重要。 然后，如果患者在移植过程中咳嗽，我们就会失去视力。

In the video, the patient does not sleep, because the next anesthesia may well be the last in her life for medical reasons (does not tolerate). I operate it under local anesthesia, which somewhat increases the complexity of the operation.

在视频中，患者没有入睡，因为由于医学原因，下一次麻醉很可能是她生命中的最后一次麻醉(无法忍受)。 我在局部麻醉下进行手术，这在一定程度上增加了手术的复杂性。

The DMEK operation (on video) is performed without direct contact of the endothelial cells — the layer moves with an air bubble.

DMEK操作(视频)在不直接接触内皮细胞的情况下进行-该层随着气泡而移动。

Operations on the outer layers (DALK) are made with a thin hand tool with direct touch.

外层(DALK)的操作是通过直接触摸的薄手工具进行的。

并发症 (Complications)

Each operation is a lottery for tissue survival. In part, you can predict the chances of success on the quality of the donor product. Corneal banks consider cells and know their freshness, but vital quality cannot be predicted. That is, the cells can be «turned on», but their functionality is almost exhausted — maybe their resource will end in 2 months. As a result, transplantation in one patient allows seeing 10 years well, and in another — only a couple of years.

每次手术都是为了组织存活而进行的抽奖。 您可以部分地预测供体产品质量成功的机会。 角膜库考虑细胞并知道其新鲜度，但无法预测其生命质量。 也就是说，可以“打开”这些单元，但是它们的功能几乎耗尽了，也许它们的资源将在2个月内用完。 结果，在一名患者中进行移植可以使病情好转10年，而在另一名患者中进行移植仅数年。

In second place is the work of the surgeon. It is incredibly easy to make mistakes here, so no one ever promises a “clean” DALK. One layer of cells can break from anything — from the surgeon's wrong movement, from the patient's breathing, from the fact that something has changed in the eye, and so on. Yes, there are methods that reduce the likelihood, but still there is a risk of errors, and in the course of the play, you can switch to end-to-end keratoplasty if something goes wrong.

其次是外科医生的工作。 在这里犯错非常容易，因此没有人会承诺“干净”的DALK。 一层细胞可能从任何东西破裂，包括外科医生的错误动作，患者的呼吸，眼睛中某些东西发生改变等等。 是的，有一些方法可以降低可能性，但仍然存在出错的风险，在进行过程中，如果出现问题，可以切换到端到端角膜移植术。

Equipment from a certain moment almost does not affect — the operation depends entirely on skill. The cornea can also be operated with a laser at the first stage (removed by it), but the femtosecond laser has not yet shown significant results in comparison with traditional methods. There are minimal differences, but they are so small that it makes no sense to lengthen the operation (the laser increases the operation from 40 minutes to 70 minutes if the laser, for example, is in another operating room). Access is often done by hand, with good vacuum trepanning systems.

从某一刻起的设备几乎不受影响-操作完全取决于技能。 在第一阶段，角膜也可以用激光进行手术(已被去除)，但与传统方法相比，飞秒激光尚未显示出明显的效果。 差异很小，但差异很小，以至于无法延长操作时间(例如，如果激光在另一个手术室中，激光会将操作时间从40分钟增加到70分钟)。 进入操作通常是用手完成的，有好的真空破碎系统。

DMEK is almost always obtained from a trained surgeon, and my colleagues have never had a case of switching to a pass-through with DMEK.

DMEK几乎总是从受过训练的外科医生那里获得的，而我的同事们从未遇到过使用DMEK转换为直通的情况。

Risks are strongly influenced by the condition of the patient, in particular, his age. And the most unpleasant thing is vascularization of the cornea, the very blood vessels that sprout into the cornea as a result of lack of proper access of oxygen (most often from contact lenses, as well as after burns and infections). Sharply increases the likelihood of rejection. If the cornea is without vessels, then the immune system does not have direct access to the upper layer, all immune processes proceed slowly and gently. As soon as blood (vessels) appears, the immune system begins to react very sharply to the transplant. Therefore, they first try to remove the vessels in such cases, and they are removed by laser or direct cauterization, or by special injections of growth inhibitors.

风险受到患者状况(尤其是患者年龄)的强烈影响。 最令人不快的是角膜的血管形成，由于缺乏适当的氧气(最常见的是从隐形眼镜以及烧伤和感染后)进入角膜的血管会萌芽进入角膜。 大大增加了拒绝的可能性。 如果角膜没有血管，则免疫系统无法直接进入上层，所有免疫过程均缓慢而缓慢地进行。 一旦出现血液(血管)，免疫系统就会对移植物产生非常强烈的React。 因此，在这种情况下，他们首先尝试移除血管，然后通过激光或直接烧灼或通过特殊注入生长抑制剂将其移除。

Further, there is a risk of infection. It is predictable, and it can be stopped very much, especially if you lead a quiet lifestyle.

此外，存在感染的风险。 这是可以预见的，并且可以将其停止，特别是如果您过着安静的生活方式。

复苏 (Recovery)

The eye is kept under a protective bandage for 1 day.

眼睛在保护性绷带下保持1天。

In the case of DMEK, a gas bubble remains in the beginning in the anterior chamber of the eye. A patient from 5 days to two weeks sees almost nothing with the operated eye, only changes in the level of illumination. From about the third of the week, the picture becomes clear, and after a month already good vision is available. The longest, in the case of running states of Fuchs dystrophy — you can not see a month.

对于DMEK，气泡会残留在眼前房的开始处。 从5天到2周的患者，手术后的眼睛几乎看不到任何东西，只改变了光照水平。 从一周的大约三分之一开始，图片变得清晰，一个月后就已经有了良好的视野。 最长的情况是在Fuchs营养不良的跑步状态下-您看不到一个月。

According to our research, in 8% of cases you need to inject the second bubble — if the transplanted layer suddenly begins to move away. The need to do this is determined on inspections after surgery.

根据我们的研究，在8％的情况下，如果移植的层突然开始移开，则需要注入第二个气泡。 是否需要这样做取决于手术后的检查。

As the DALK heals and penetrates keratoplasty (but not after DMEK), the incision of the postoperative wound can be a complication. For example, the patient may fight with someone and get a fist in the eye. Older people lack a very small injury to the connection snapped.

当DALK愈合并穿透角膜移植术时(但在DMEK之后不能)，术后伤口的切口可能会很复杂。 例如，患者可能与某人打架并握紧拳头。 老年人对连接断开的伤害很小。

Nylon or mercyline (10/0 threads) are removed like this: in six months the first layer, and the second — up to 3-5 years, depending on the degree of engraftment. In older people, the second layer is often not removed at all, if it does not create problems, as long as the thread is well stretched, it does not interfere. It happens that the second thread is pulled out — and the vision drops, because this thread was the skeleton of the graft, and this induces astigmatism.

尼龙或巯基(10/0线)的去除方法是这样的：六个月后第一层，第二层-长达3-5年，具体取决于植入程度。 在老年人中，第二层通常根本不会被去除，如果它不会造成问题，只要线被很好地拉伸，它就不会干扰。 碰巧第二根线被拔出了-视力下降了，因为这根线是移植物的骨架，并引起了散光。

After end-to-end surgery or DALK, astigmatism often appears: because even if you sew very well, scars will depend on healing. The cornea does not engraft 360 degrees evenly. In two years, it is possible to do PRK, LASIK or ReLEx SMILE right inside the transplant (I did not do the last one myself, but my colleagues from the University of Alexandria did this already). Another elegant approach to the problem of astigmatism is to change the lens to a new one if cataracts have not been treated yet. If the cataract was operated, then put a toric backpack lens (Add-on) to an artificial lens — a lens in front of the primary lens in the capsular bag. If your own lens is still transparent, the patient is young, and surgery to remove the lens is not needed, then you can put the toric ICL.

在端到端手术或DALK之后，经常会出现散光：因为即使缝制得很好，疤痕也将取决于愈合情况。 角膜不能均匀地360度植入。 在两年内，可以在移植内进行PRK，LASIK或ReLEx SMILE(我自己没有做最后一个，但是我来自亚历山大大学的同事已经做了)。 解决散光问题的另一种优雅方法是，如果尚未治疗白内障，则将晶状体更换为新的。 如果进行了白内障手术，则将复曲面背包镜(附加)放在人造晶状体上—晶状体囊袋中主晶状体的前面。 如果您自己的晶状体仍然是透明的，患者还很年轻，并且不需要手术移除晶状体，那么您可以放置​​复曲面ICL。

您还需要了解俄罗斯角膜移植手术的哪些知识 (What else you need to know about keratoplasty operations in Russia)

Donor material in Russia is a pain. It comes in most cases with difficulty, long and expensive. Nevertheless, there are options, just the price is far from being the same as in Europe. It was a great success that canned material appeared in an eye bank in Russia, and people got a chance for recovery. There are very few doctors who can do layered transplants. Dozens of surgeons can do the cross-cutting, the benefit of manual surgeons with good skills is many, and both in the European part of the country and in the east.

俄罗斯的捐助者材料令人痛苦。 在大多数情况下，它带来困难，时间长且昂贵。 尽管如此，还是有选择的，只是价格与欧洲的价格相差甚远。 罐装材料出现在俄罗斯的眼库中是一次巨大的成功，人们得到了康复的机会。 几乎没有医生可以进行分层移植。 在该国的欧洲地区和东部地区，数十名外科医生都可以进行交叉切割，具有良好技能的体力外科医生的好处是很多的。

翻译自: https://habr.com/en/company/klinika_shilovoy/blog/503174/

圆锥角膜怎么发现