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‘复发型翼状赘片’---切除合并羊膜移植复盖

眼翳(pterygium)又称翳状赘片(如图1,2,3),这个常见的眼科疾病起因于长期户外工作受到紫外线的照射、风沙刺激、强光刺激…等,在眼球的表面形成一片增生血管纤维组织,会随着时间慢慢增大、增厚,虽然此疾病没有要立即手术处理的必要,但是如果面积太大就会需要手术,因为会影响外观、屏蔽视力、造成高度散光、眼球转动时受到限制,也会引起视力模糊、眼睛易红、易酸涩…等问题。
标题3图1 各种型式的翼状赘片
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图2 各种型式的翼状赘片
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图3 各种型式的翼状赘片
我们一般处理翳状赘片是采用手术切除刮除的方式,但是单纯使用此手术方式的病人需忍受约一个月的手术後眼睛红及疼痛,而且手术後又再长翼状赘片的几率相当高(约90%)。当前我们有商品化的羊膜可以使用,健保无给付需自费,效果及反应均非常良好。

我们的实际案例:这是一位59岁的男性病人,他在12年前有手术过右眼翼状赘片,由于上次手术後2周内就复发了,于是没有信心且害怕就没有再处理了直到3个月前来到我们诊所,希望做一个复发率较低且较不疼痛的处理方式。

于是我们安排再切除一次,不同的是这次加上“排多癌(Amniotic membrane transplantation AMT)复盖伤口及排多癌(Mitomycin-c)的治疔”

在翼状赘片(pterygium)手术时,使用羊膜移植复盖(amniotic membrane transplantation AMT)的好处:
1.  减低复发率:减少手术後再长翼状赘片的几率

2. 减低手术後的疼痛感:由于羊膜可以扮演类似人工皮的功能,在手术後的当下可以成为眼球表面的替代表皮

3. 增进眼球结膜表皮的复原:羊膜上有干细胞及增生因子,可以促进伤口愈合及促进眼结膜、角膜的表皮生长

4. 减少手术後的发炎反应
 

病人手术後至今,情况良好,手术後无疼痛感、眼睛不红、也没有再复发的现象。所以,翼状赘片切除的同时,再加做羊膜的移植复盖,可以减少复发率、减少发炎、增加伤口复原、并大幅减低手术後眼睛的疼痛。

参考资料:
Recurrent pterygium is a challenging condition that usually resists to conventional surgery and its rate of recurrence after surgery is also high. Moreover, recurrent pterygium surgery is usually accompanied by scarring, more risk of intra and post- complications. This video aims to generate amniotic membrane and mitomycin-c as treatment modality for recurrent pterygium.

Management of primary and recurrent pterygium using amniotic membrane transplantation.

This review discusses the relative merits of the various techniques used in pterygium surgery with particular reference to the growing interest in the use of amniotic membrane transplantation (AMT)because it is safe, effective, and may be employed in conjunction with other techniques, such as limbal transplantation. The efficacy of AMT is comparable to the established method of conjunctival autograft transplantation (CG) and it is especially indicated when there exists a very large conjunctival defect to cover as in primary double-headed pterygium, or in the context of preserving superior bulbar conjunctiva for future glaucoma surgeries. The authors explain how current management principles (eg, use of anti-inflammatory agents, adequate removal of fibrovascular tissue) are based on known differences in pathogenesis and clinical behavior between primary and recurrent pterygium.

Adjunctive use of AMT and short exposure of MMC can reduce recurrence after pterygium surgery. The procedure is less tedious and less time consuming, resulting in early recovery while saving the conjunctiva for future surgeries.

Key Words: amniotic membrane, fibrin glue, mitomycin C, pterygium, recurrence

Pterygium is a wing-shaped superficial overgrowth on the ocular surface, which is characterized by inflammation, fibrovascular conjunctival proliferation, and invasion of the corneal surface. It is presumably due to ultraviolet-induced damage to the limbal stem cells and hence considered as focal limbal stem cell deficiency. Surgical excision is indicated for either optical or cosmetic reasons. In the former, visual disturbances are caused by irregular astigmatism, blocking of the visual axis, or restricted ocular motility.

The most daunting challenge of pterygium surgery is the high incidence of recurrence, as high as 88% with simple excision involving an uncovered bare sclera. Surgical techniques in more recent years, in which scleral defects are covered with conjunctival autograft or cryopreserved amniotic membrane (CAM) with or without mitomycin C (MMC), have resulted in much better outcomes, with less than 10% recurrence rates and minimal complications postoperatively. However, some debate still continues regarding which graft offers the better outcome.

The purpose of this retrospective analysis is to provide compelling long-term evidence that CAM grafts,combined with short exposure to MMC, can reduce recurrence and complications after pterygium surgery. To the best of our knowledge, this is the largest sample size reported with a long-term follow-up.
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