目的
深入了解复杂后弹力层脱离 (DMD) 眼睛的形态和功能特征，并报告手术干预后的临床结果。
方法
对 2010 年至 2022 年间 18 只患有复杂性 DMD 的眼睛进行回顾性研究。如果应用以下任何标准，则定义为复杂性 DMD：既往进行穿透性角膜移植术 (PKP)、角膜变薄、完全 DMD 或空气/气体后角膜固定术后持续性 DMD。分析了原因、手术治疗和临床结果。通过 Scheimpflug 断层扫描、眼前节光学相干断层扫描 (AS-OCT) 和组织学检查来表征 DMD 角膜。
结果
14 只既往患有 PKP 的眼睛在 24.2 ± 12.9 年后发展为自发性 DMD（范围 = 18 个月 – 47 年，中位数 = 25.7 年）。白内障手术后的三只眼睛和感染性角膜炎后的一只眼睛与未事先进行 PKP 的复杂性 DMD 相关。对于既往有 PKP 的病例，AS-OCT 显示有 5 只眼睛出现后弹力层破裂 (DM)，在初次诊断后 8 周内发现 4 只眼睛出现自发性复位，所有病例均未出现 DM 破裂。没有既往 PKP 的情况下，角膜中没有 DM 破裂。在先前的角膜移植术后，最终的手术治疗是 13 只眼睛的重复 PKP 和 1 只眼睛的空气/气体后角膜固定术。在未进行过角膜移植术的角膜中，三只眼睛接受了 PKP，一只眼睛接受了空气/气体后角膜固定术。对两个角膜外植体的组织学检查显示，移植物-宿主连接处严重变薄，移植物-宿主连接处附近的 DM 被破坏。既往 PKP 后，视力从 1.80 ± 0.58 logMAR 改善至 0.75 ± 0.69 logMAR，未进行既往 PKP 时，视力从 1.45 ± 0.65 logMAR 改善至 0.85 ± 1.13 logMAR。 18 只眼睛中，有 16 只眼睛的术后过程很顺利。
结论
PKP 是复杂 DMD 的有效治疗选择，尤其是扩张性角膜，而空气/气体后弹力层固定术或后弹力层内皮角膜移植术不能解决曲率异常的主要问题。
"点击查看英文标题和摘要"
Surgical management of complicated Descemet’s membrane detachment in corneas without prior endothelial keratoplasty
Purpose
To provide insights into morphologic and functional features of eyes with complicated Descemet's membrane detachment (DMD) and report clinical outcomes after surgical intervention.
Methods
Retrospective study of 18 eyes with complicated DMD between 2010 and 2022. Complicated DMD was defined if any of the following criteria applied: prior penetrating keratoplasty (PKP), corneal thinning, total DMD or persistent DMD after Air/Gas-Descemetopexy. Causes, surgical management, and clinical outcomes were analyzed. Scheimpflug tomography, anterior segment optical coherence tomography (AS-OCT) and histologic examination were performed to characterize corneas with DMD.
Results
Fourteen eyes with prior PKP developed spontaneous DMD after 24.2 ± 12.9 years (range = 18 months – 47 years, median = 25.7 years). Complicated DMD without prior PKP was associated in three eyes after cataract surgery and in one eye after infectious keratitis. In cases with previous PKP, AS-OCT demonstrated rupture of Descemet’s membrane (DM) in five eyes and spontaneous reattachment was found in four eyes within 8 weeks of initial diagnosis, with no rupture of DM in any of the cases. There was no rupture of DM in corneas without previous PKP. After prior keratoplasty, definitive surgical treatment was repeat PKP in 13 eyes and Air/Gas-Descemetopexy in one eye. In corneas without prior keratoplasty, three eyes underwent PKP and one eye Air/Gas-Descemetopexy. Histological examination of two corneal explants revealed a severely thinned graft-host junction and a disrupted DM close to the graft-host junction. Visual acuity improved from 1.80 ± 0.58 logMAR to 0.75 ± 0.69 logMAR after prior PKP and from 1.45 ± 0.65 logMAR to 0.85 ± 1.13 logMAR without prior PKP. The postoperative course was uneventful in 16 of 18 eyes.
Conclusion
PKP is an effective treatment option for complicated DMD, especially in ectatic corneas, whereas Air/Gas-Descemetopexy or Descemet Membrane Endothelial Keratoplasty do not address the primary issue of the curvature anomaly.
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