摘要目的 通过对囊袋内灌注联合双手法劈核晶状体原位超声粉碎技术改良在玻璃体视网膜手术中的应用,探讨高效、安全、保持晶状体原位的超声粉碎手术技巧.方法 在浙江大学附属第二医院眼科中心就诊的56例(58只眼)合并晶状体混浊需行玻璃体切割手术,或合并前段PVR需联合去除晶状体的玻璃体手术患者.其中31只眼为复杂性视网膜脱离,14只眼为增殖性糖尿病视网膜病变(Ⅴ～Ⅵ期),7只眼为玻璃体出血,6只眼为伴有前段增殖性玻璃体视网膜病变.晶状体核硬度为Ⅲ～Ⅳ级.手术中先行置人玻璃体腔灌注导管并关闭灌注,双手玻璃体切割穿刺口分别插入带灌注的9号(20G)针头和超声粉碎头(Millennium).刺破晶状体前囊,利用灌注液自行水力分层,超生粉碎刻槽,双手法“十字形”手工劈核,“分而治之”,双手协助挤夹碎核并“送入”超生粉碎头,完整清除皮质和核后,打开玻璃体腔灌注,转为玻璃体切割手术.对术中需联合眼内硅油填充的33只眼,均完整去除晶状体的前后囊膜；其余25只眼均保留完整的后囊膜.记录超声时间及能量.结果 所有病例均能在原位清除晶状体并保持了后囊膜的完整性,术中均能保持前房深度的正常稳定,术中无虹膜晶状体隔的前后移动,无晶状体核沉人玻璃体腔,无角膜、巩膜穿刺口、虹膜损伤的发生.25只保留完整后囊膜的患眼,均在术后1～3个月二次置人后房型人工晶状体,视力获得不同程度提高.整个操作便捷,快速有效,平均超声时间为50 s,最大超声能量均设定在20％以下.结论 囊袋内灌注联合手法劈核能有效控制晶状体的原位超声粉碎,手术快捷,损伤小,临床适用性显著.

abstractsObjective To investigate the application and effect of bimanual nucleus chopping combined with intracapsular infusion for in situ ultrasonic phacofragmentation in vitreoretinal surgery in order to explore the efficient,safe and maintain the lens in situ techniques of ultrasonic phacofragmentation.Methods Fifty-six patients (58 eyes) who were in need of vitrectomy with lens opacities or vitreous surgeries with anterior proliferative vitreoretinopathy which the joint vitreous surgeries were required to remove the lens.Among them,there were 31 complicated retinal detachment eyes,14 proliferative diabetic retinopathy eyes (stage Ⅴ～Ⅵ),7 vitreous hemorrhage eyes,6 preceding proliferative vitreoretinopathy eyes.The nucleus hardness were grade Ⅲ～Ⅳ.During the surgery,irrigation catheter was placed in the vitreous cavity and the perfusion was turned off at first,the 9#(20G) needle head with perfusion and the sonicate head (Millennium) were inserted into puncturing sites of bimanual vitrectomy,separately.Then the following procedures were performed:pierced the anterior capsule,hydrodissected the lens with perfusion and grooved with ultrasound,then the nucleus was chopped bimanual using the "cross-type" method,the nucleus was divided and phacoemulsificated,fragmentations of nucleus was squeezed and sent to the sonicate head with bimanual collaboration.After the cortex and the nucleus were completely removed,vitrectomy began with vitreous cavity perfusion on.Thirty-three eyes which needed the combined intraocular silicone oil tamponade surgeries were removed of anterior and posterior lens capsules completely,the posterior capsules of the other 25 eyes were retained.The ultrasound time and energy were recorded.Results The lens could be removed in situ with the posterior capsules intact in all cases; in addition,the anterior chamber depth was able to be maintained stably.During the surgeries,no black diaphragm moved back and forth,no lens nucleus sank into vitreous cavity and no cornea puncture,sclera puncture and iris were injured.Those 25 eyes which retained the intact posterior capsules would be implanted of posterior chamber intraocular lenses 1 to 3 months after the first surgeries,all subjects showed improved vision of various degrees after surgery.The entire procedure was convenient,fast and efficient.The average ultrasound time was 45.5s and the maximum ultrasonic energy was set at less than 12％.Conclusions Bimanual nucleus chopping combined with intracapsular infusion method is effective for the in situ ultrasonic phacofragmentation,the surgery is fast,has less injury and great clinical applicability.