廉井财医生的科普号

国内尤其是大城市的大中小学生，近视比率是相当的高。我们的身边好像总有那么几个近视的孩子。为了解决近视的问题，家长们也是操碎了心。近视的发生是遗传和环境等多因素综合作用的结果，确切的发病机制还在研究中。遗传因素：多因子遗传或常染色体隐性遗传，双亲高度近视100%，单亲高度近视57.5%，无高度近视22.2%。环境因素：学龄前3%左右，小学8%左右，中学22%左右，大学40~50%，学校性近视度数一般小于600度。通过药物散大瞳孔和麻痹睫状肌后，再进行医学验光，判定是真性还是假性近视真性近视：白天佩戴眼镜或者晚上佩戴OK镜假性近视：药物治疗、注意用眼卫生等为防止青少年体育活动、日常生活中的各种冲撞，防碎柔韧的镜框可以保护学生的视力安全。ok镜是一种特殊设计的硬性隐型眼镜，使用高透氧的聚合材料量身定做，在夜间睡眠时佩戴，白天起床时摘下，可达到视力矫正的目的；优势：白天无需佩戴任何眼镜，裸眼视力清晰，达到无近视的效果能够有效遏制近视的快速进展，延缓眼轴增长，降低高度近视眼底病变发生几率。角膜塑形镜佩戴的适应症：年龄：8岁---成年卫生习惯良好近视600度以下近视与散光度数比>2角膜曲率大于39D，小于46D眼压12～21mmhg瞳孔大小正常无干眼症其实我们医生与家长、孩子们的想法是一致的，都想安全有效的矫正视力，所以我在术前最重视的就是全面精准的眼科检查，根据患者的适应征为他建议最合适的手术方式。近视眼手术主要分为以下两类：近视眼手术是一项很专业很精细的手术，手术前到专业的医院进行仔细的检查，根据检查的结果，医生会判断是否符合手术条件，适合哪一种手术之后由患者和家属决定采取手术的方式。

婴幼儿、儿童是眼部发育的关键时期，在这个时期我们关注的是眼部的发育是否正常，儿童眼部发育异常的情况包括：各种屈光不正(近视、远视和散光)、斜视和弱视等眼部问题，我们幼儿园中开展的眼科筛查经常会发现这些问题。也就是这些眼部问题好发于低龄的幼儿之中吗？而且听您的意思，这些问题是否只有筛查的时候才能发现呢？廉井财：也不完全是这样，有些儿童的眼部问题，可以提早发现，如先天白内障、青光眼，斜视等，有些则不容易发现，如远视和弱视等，特别是单眼的弱视如果不及时发现，错过最佳治疗时期，则长大之后就无法治疗了。弱视的成因有几种如：斜视性、屈光参差性、屈光不正性和形觉剥夺性等等。

虽然准分子激光手术已经开展了20多年，全球每年有几百万人选择这项手术，但是更多的人还不了解这项手术，很多人仍然对近视手术持怀疑态度或者抱有不少偏见。偏见一：近视手术度数越高效果越好这种说法是不准确的，但临床中经常有近视者提出这样的问题。实际上，只要通过术前检查，确定适合手术，术后的效果都相当好，而且度数越低的近视患者视力恢复得越快。只是度数高的近视者做完手术后，一下子感觉视力清晰了很多，度数低的近视者则可能感觉与术前差别不太大，所以才会有人认为度数高手术效果更好。而且度数特别高的人，更适合ICL晶体植入的手术治疗。偏见二：近视手术不当会导致失明。近视手术不会导致失明。准分子激光手术只是在角膜上进行手术，手术时不会伤害眼球内部的其他器官。准分子激光采用的是冷激光，不会灼伤角膜。现在先进激光手术平台都拥有三维眼球定位系统，手术时，当眼球偏转超出正常位置时激光会自动停止发射，确保手术安全。因此，无论是从原理上还是设备上都能确保手术安全，最差的情况也只是术后的视力达不到术前预计的最佳效果，但也比手术前要好得多。偏见三：手术后几年视力会回退。手术以后，只要注意眼部卫生、合理用眼，就不会造成视力回退。手术是在安全稳定的环境下进行的，术前要经过详细的检查，确定患者是否能进行手术。而且度数要稳定两年以上，这样才有利于术后视力的恢复和稳定。偏见四：手术不能治疗远视、散光。准分子激光手术同样可以治疗远视和散光，但要求远视600度以下，散光600度以下。其他的手术条件与近视要求相同。近视和散光混合的屈光不正，同样也可以治疗，术后的视力同样可以达到术前戴镜的最佳视力。偏见五：到综合性大医院做手术才安全。很多人都认为大医院才可以保证手术的安全，实际上医院的大小并不能成为手术安全的保证。大医院一般是综合性的医院，开设的科目比较多，并不精通于一科。而专业的眼科医院，由于设立专业近视手术中心，而且开展手术时间长，设备先进、医生手术经验丰富。专业眼科医院同样能保证手术的效果及安全性，同时还可以享受到细致的医疗服务。

Purpose of reviewTo summarize the current opinion in implantable collamerlen(ICL) implantation including indication, contraindication, method ofsurgery, intraoperativeandpostoperative complication.RecentfindingsTheclinical results of ICL implantation were better than laser procedures. ICLs implantationoffer many potential advantages with a broader range of treatable ametropia,faster visual recovery, more stable refraction, better visual quality and quality-of-life gains in comparison with corneal refractivesurgery and contact lens wearers .SummaryICLimplantation is a good methods for the treatment of myopia, hyperopia, or astigmatism with limitedintraoperativeandpostoperative complicationsKeywordsImplantableCollamer Lens, implantation, indication,contraindication, complications.Keypoints:ICLimplantation is an efficient and safe surgery for correcting ametropia .Therewere still several intra-or-post operative complications inICL implantation surgery.ICLimplantation improved image quality , by less postoperative HOA especially coma and spherical aberration, betterthan LASIK. Muchbetter visual quality and quality-of-life gains in ICL-corrected patients comparedwith contact lens wearers with similar starting levels of myopia .IntroductionLaser surgery is ableto correct myopia by changing corneal curvature. A series of corneal refractivesurgeries have been the reliable workhorse of the treatment of low-moderatemyopia. However, it’s not good enough?for the patients with thincorneal thickness or functional limitation at higher level of refractive errorwhose have intolerance for the contact lenses and prefer to improve livingquality. The predictability and safety of LASIK (Laser Assisted In-situ Keratomiluesis)remain a challenge in patients with high myopia or astigmatism1-4.Recently, ICL (ImplantableCollamer Lens) implantation has been a safe, effective, and predictableprocedure for the correction of moderate to high myopia. Compared with laserrefractive surgery phakic intraocularlens(IOL) is safe and significantly less loss of best spectacle correctedvisual acuity (BSCVA) at 12 months postoperatively, andalso scored more highly on patientsatisfaction /preference questionnaires5. Phakic IOL includesanterior chamber phakic IOL, iris-fixed anterior chamber phakic IOL andposterior chamber phakic IOL. In practice, posterior chamber phakic IOL demonstrates better postoperative visualoutcomes with less complications. The ICLis a posterior chamber phakic IOL designed to vault anteriorly to thecrystalline lens and intended to have minimal contact with the natural lens.Studies on all versions of this lens have included patients with myopia from-5.0 to -24.75 D6,7..Accounting to these studies, ICL implantation showed asthe same predication as IOL implantation in cataract surgery, in addition,reported a high patient satisfaction rate with visual outcomes after surgery.On the other hand, ICL implantation is different from IOL implantation in axiallength measurements. Morales et al. statedthat the difference between the axial length measurements before andafter ICL implantation was small8. Thesefindings may account for the higher predictability of these combinedprocedures. Generally, as a symbol of asintraocular refractive procedures, ICLs offermany potential advantages: abroader range of treatable ametropia, faster visual recovery, more stablerefraction, and better visual quality9-11. Introductionof Visian ICL The VisianImplantable Collamer Lens (ICL; STAAR Surgical Co, Monrovia, California) is theonly posterior phakic IOL. It is generally accepted as a preferred ametropiacorrective treatment for moderate-or-high myopia, and its implantation is aperspective surgery within the field of refraction. Faster visual recovery, highefficacy and stability of visual quality, preservation of accommodation, andthe predictability are several advantages of ICLimplantation12,13. Several publishedstudies have confirmed ICL implantation as a feasible treatment to correctmyopia14,15, hyperopia14,16-18, or astigmatism10,19-23, with clinical andvisual results as good as or better than laser procedures24,25. In this review, wejust focused on the Visian ICL for myopia. The VisianICL is a foldable Phakic IOL made from a biocompatible material named Collamer composedof a hydrophilic porcine collagen (<0.1%) /hydroxyethyl which consists of aplate-haptic design with a central convex/concave optical zone and a forwardvault to minimize contact with the crystalline lens. The latest Visian ICL wasdeveloped from the ICMV4. Compared with the vault of the Visian V3the V4 has anadditional 0.13 to 0.21 mm of anterior vault height due to the steeper radiusof curvature of the base curve and dioptric power. When appropriately selected,the lens creates a clearance space over the whole anterior crystalline lenssurface26.A new Visian ICL V4Cdesign with a small central hole (Central flow model) eliminates concerns aboutpupillary block or glare from holes created in the iris27. The small centralhole does not significantly affect visual or optical quality. The new centralflow model further enhances safety by eliminating the need for an iridectomy oriridotomy.However,as an intraocular surgery, ICL implantation has some unavoidable and latentrisks. Although the published studies have reported the results of ICLimplantation have low rates of complications, cooperated of the occurrence andvisual outcomes of post operation have been proven difficult and variable28. This reviewprovides results and conclusions derived from peer-reviewed studies reportingthe outcomes, potential complications and threats of ICL implantation, sharingcomparison between ICL and LASIK or contact lens wear.A Medline search was performed to identifyall journal articles related to posterior Visian ICL(for myopia) or Torric ICL (for astigmatism) was included. Indicationof ICL implantationPatientsshould be a stable refraction for the past 12 months as documented by previousrecords, age between 18 to 45, endothelial cell count＞2500/mm 2（more thanthe age-minimum）,and anterior chamber depth of 3.0 mm or more, normal pupil and irisconfiguration; No history of glaucoma and preexisting corneal, lenticular, orretinal pathologic features are likely to affect vision. PreoperativeOcular ExaminationOcularexamination, including uncorrected visual acuity (UCVA), bestspectacle-corrected visual acuity (BSCVA), manifest refraction, IOP, slit-lampmicroscopy, dilated fundus examination and noncontact specular microscopy,ultrasound bio-microscope were performed in all eyes before surgery. If adiscrepancy of ＞0.2mm was noted between the right and left eyes white-to-white measurement, themeasurement should be confirmed with a caliper, at the same time with referencetomeasure sulus-to-sulus diameter.Ultrasound imaging that directly measures the sulus-to-sulus width may improvethe predictability of the crystalline lens vault and reduce the incidence ofcataract from inadequate clearance and pigment dispersion. Adverse events andcomplications were also assessed postoperatively.Surgery for ICL implantationA ＜3.2 mmcorneal incision (which has been shown to have a negligible effect onpostoperative astigmatism29) is indispensableand the second incision is necessary. The ICL was injected slowly into theanterior chamber allowing for slow unfolding, then the four footplates wereinserted behind the iris using a modified intraocular spatula and placed at theplanned ICL axis to minimize intraocular rotation. The viscoelastic materialwas removed and the final position of the ICL was checked before an intraocularmiotic was used to decrease pupil size. Some surgeons think intraocular mioticis unnecessary, but most of the performers still use it consideringpostoperative complications especially TICL implantation. IntraoperativeComplications of ICL implantation Operativetechnique and the surgeon’s ability in the mid-operative complication rates arealso relative, because it seems to be a typical learning curve. Althoughintraocular damage from significant blunt trauma is expected, it is possiblethat even lesser trauma, such as eye rubbing, the surgical manipulation, leadsto complications such as endothelial cell loss, particularly in eyes with TICLrotation10. When ICL insertingbehind the iris, unskilled and rough actions can lead to iris atrophy anddecentration of the implant. The pupil sphincter may be damaged insurgery, leading to flare post-operation30. Surgical traumaduring implantation of posterior-chamber ICL may lead to cataract formation,typically of the anterior subcapsular variety. Alternatively, chronic traumafrom contact of the ICL with the crystalline lens can also result in cataractformation. Lackner et al 31 reported 4 eyesdeveloping cataract due to a prolonged surgery in elderly patients with ashallow anterior chamber and narrow pupil. Sanchez-Galeana observed that mostof the early-onset cataracts occurred in the immediate postoperative period (upto 3 months) which was frequently asymptomatic and associated with surgicaltrauma32,33.Blunt external trauma in eyes with ICL hadbeen reported to cause lens dislocation and cataract. Hyphema or Descemet’smembrane detachmenthappenedoccasionally. PostoperativeComplications of ICL implantationCataractCataract was reportedas surgically induced, mostly associated to inadvertent lens touch during ICLinsertion. Surgeon’s abilities parallel the rates of the early development ofcataract32,33. Except foroperative cataract, more investigators have attributed cataract to lack ofenough space between ICL and crystalline lens. In astudy by Alfonso et al37, in 1.3% of eyes (13/964) developing cataract after ICLimplantation, patient age was the parameter with the highest correlation withcataract development. Additionally, those eyes tended to present lower vaultvalues, average lower ICL size, and shallower anterior chamber depth. Theysuggested that insufficient vault might induce cataract formation by mechanicalinteraction. Unquestionably, selection of the suitable ICL diameter wasdirectly associated with vault after surgery and anterior subcapsular cataract.Poor vault could also lead to disturbances in aqueous flow, interfering with lensnutrition and causing metabolic disturbances to the crystalline lens12,38,39.The duration of follow-up should also be taken into account given that theoccurrence of cataract is higher in patients with longer follow-up40,41. Sothe key to deal with sufficient vault is the properly suitable ICL length. Meanwhile,research conducted by Changconsidered location of the ICL footplates definitely influence of vault aswell. They revealed the footplates of ICL in the ciliary sulcus showed lowervault value than the footplates below the ciliary sulcus21.The otherside, the human crystalline lens increases in thickness with age, withcorresponding shallow of the anterior chamber42,43. Thesulcus-to-sulcus width of the posterior chamber also narrows with age44,45; Thus, ICLs may comeinto contact with crystalline lens and eventually cause pigment dispersion. Theeffect of these aging changes on the tolerance of ICL deserves further study.Sum up allstudies, postoperative vault hinge the success or failure of ICL implantation. IfICL implantation may affect metabolic disturbancesto the crystalline lens, it is still unclear. After all, futurepreclinical study should tap its potential and clinical research need to moveforward a single step at prospective and retrospective studies of long-term (＞10 years)efficacy and safety.Therise of IOP (Intraocular Pressure)The riseof IOP, in early 24-48 hours postoperation, an early rise in IOP was reportedfrequently and usually moderate (30 mmHg or so), is mainly caused by residualviscoelastic material. Droping temporary topical antiglaucoma medication or releasingaqueous fluid through incision can control intraocular pressure. If there werenot properly deals with the rise of IOP in time, the pupil sphincter would beout of control as abnormal pupil size as the result. However, as long-term riseof IOP, there are several possibilities. Instillation of steroid eye drops7,21,46, the reduction ofthe angle opening distance (41.5%) and reduction of the trabecular-iris angle(31.8%)46 were associated withthe rise of IOP, which was usually observed within the first month aftersurgery26. In some cases, therise of IOP remained persistent. Acute pupillary block 7,13,32,47, excessive ICL vault(usually by an overestimation of the ICL size) towards to subsequent narrowingof the iridocorneal angle and frequently associated with inadequatepreoperative iridotomies13,32. Smallman et al32 and Park et al48reported ICLexplanation because of the risk for further episodes of pupillary block in apatient with delayed pupillary block glaucoma from closure of iridotomies.However, in other cases, acute angle closure were secondary to non-pupillaryblock49-51. Chronic pigmentdispersion was also suggested as another potential cause of increased IOP52 and can be relatedto preoperative laser iridotomies or chronic iris chafing by the ICL. Chung etal46 found that the meantrabecular meshwork pigmentation at 1 month postoperatively was notsignificantly different from the preoperative value with the ICL V4 model, andonly one eye showed increased IOP with significantly increased trabecularpigmentation 1 week postoperatively, despite low ICL vaulting. It’s worththinking that, if the white-to-white distance and sulcus-to-sulcus diameter arethe optimal measures to determine the size of ICL, maybe there are othermeasures to be referenced, Anunderestimation in the selection of the ICL diameter is frequently associatedwith poor vault (＜250μm), thereby increasing the risk of cataract formation, whereas an oversizedICL may result in excessive vault (＞750 μm), thereby increasing the riskof angle-closure, pupillary block glaucoma, or pigment dispersion glaucoma. Theideal vault was recommended to be equal to 1.0 to 1.5 times the central cornealthicknesses on slit-lamp examination, which corresponds to an approximate vaultbetween 400 and 600 μm49. Therefore, there isno accurate anatomical relationship between external measurements and internaldimensions53-55. Moreover, it hasbeen reported that ICL length determined by high-resolution ultrasoundbiomicroscopy rendered significantly more ideal ICL vault than the conventionalwhite-to-white method56. In addition,changes made in size nomogram were alsoproved to provide a more satisfactory vault7.New ICLdesign with a small central hole eliminates the concerns about pupillary blockor glare from holes created in the iris, but it still has the risk ofinter-contact between iris and lens. As sandwich-like as ICL with crystallinelens and iris, we cannot imagine what’s happening when open-or-close of eyes, pupilwide-or-narrow. As we know, aqueous humor has itself rhythm producing more inthe morning and less in the evening, so there is a question if the vault of ICLis changed during normal intraocular rhythm and if this adjustment is long-termefficacious.In thelong time, the age of eyes play a less significant role that might compromisethe amount of safe space from the ICL must be considered. Indeed, it is wellknown that the anterior chamber decreases in the aging eye57. Such decrease inanterior chamber depth is likely to be induced by the thickening of the agingcrystalline lens at an average rate of 24 μm/year as reported by Atchison et al58. This might explainthe slight decrease in vault several years after surgery. Meanwhile, theanatomic configuration and age-related changes of the ciliary muscle must betaken into account59. The age-relatedincrease in anteroposterior thickness of the ciliary muscle might somewhat affectthe positioning of the ICL over time60. So there are stillfollow-up studies that needed to established about the long-term safety ofthese posterior ICL implantation.EndothelialCell LossEndothelialcell loss happens not only during surgery but also post-surgery. The mechanism isstill unclear. According to relative studies, there were different levels ofendothelial cell loss within several years of postoperation21,31,46,61-63. Althoughendothelial cell loss was significantly lower21,61, the total number ofendothelial cell was stable and in the normal-age-level throughout thepostoperative period. This loss continued at a rate of 2% to 3% per year over thefirst 3 years and a cell increase of 0.1% between 3 and 4 years of follow-up.From these results in cell loss behavior, they considered prolonged cornealremodeling following the surgical procedure to be the cause of the earlycorneal endothelial cell loss61 whereas furtherdecrease in cell density in the late postoperative period may be due to naturalcell loss64. However ECD (endothelial cell density) measurement wasnot standardized across each study center. The loss of corneal endothelialcells may occur primarily in the periphery post-surgery, but there were stillno researches focusing whether aqueoushumor dynamics would influence ECD, especially central endothelialcells progressive loss in follow-up test until several years later. AstigmatismMoreover, as a matter of fact, incision in ICLsurgery is unavoidable, so is the surgical astigmatism. Some researchersbelieved that astigmatism of postsurgery causes the not- incorporating theflattening effect of the incision. The exact effect of the incision on cornealastigmatism is difficult to predicate, and it depends on the amount ofpreoperative corneal astigmatism, incision location, incision width and patientage35,36. General consent, a ＜3.2 mmcorneal incision has had been shown to have a negligible effect onpostoperative astigmatism37. Simultaneously,misalignment of ICL implantation allow a mean error in placement of 5 degrees, atleast less-than 10 degrees. The less degrees of rotation, the much bettervisual quality after operation.RD (RetinalDetachment) and CME (CystoidMacular Edema)ICL implantationcarries a potential risk for intraocular complications such as RD and CME. Asmost of ICL implantations are performed in patients with high myopia and longaxial length; therefore, these eyes have high risks of RD and CME7,13,65. In a retrospectivestudy of 628 eyes implanted with the ICL V4, Martinez-Castillo et al65reported RD in 11 eyes, which occurred from 1 to 70months after surgery. In fact, the incidence rates of high myopia and longaxial length without ocular surgery is 0.3% as the same as the patients of ICLimplantation. There was one study reported the development of CMEfollowingICL implantation. One case report cannot suggest as the ironclad proof of postoperative complication but shouldalert the surgeons to closely follow the patients for early detection of CME.After all, the highly myopic eyes underwent ICL implantationsurgery are different ‘normal’ eyes66. EndophthalmitisEndophthalmitishappened at a rate of 0.0167% after ICL implantation between January 1998 andDecember 200634. Although thesecases were anecdotal, other than laser surgery, ICL implantation seemsreasonably lead to more intraocular damages.Correlational studies on ICL TICL(Toric Implantable Collamer Lens)Visian toricimplantable collamer lens (TICL, Star Surgical, Monrovia, CA, USA) weredesigned for treatment of myopic astigmatism. The toric ICLs had excellentpostoperative refractive stability in the published studies. A prospective,multicenter clinical trial of the TICL was initiated in the US in 2002.Designedto evaluate efficacy, this study enrolled 210 eyes and followed subjects forone year. At the 1-week postoperative exam, 77% of eyes were within ± 0.5D and97% were within ±1 D of the intended manifest refraction and these levels weremaintained over the 1-year study duration10. No complications were reported in this study.There is no deny that TICL is highly effective for correcting myopicastigmatism and more predictable and stable than laser refractive surgery forcorrecting high level of myopia and astigmatism, and especially it also had beenshown to correct astigmatism in complicated cases, in which corneal refractivetechniques were not necessarily a good or viable option. Haptic design of ToricICL was identical to that the spherical myopic ICL, and follow-up on a largeseries already has established its safety over a 3-year period67. Toric ICL should beseriously considered as an alternative option for corneal refractive proceduresthroughout its full ranges of approved spherical and astigmatic correction.ICLassociated with Keratoconus José F. Alfonso68 have described theuse of phakic posterior chamber Implantable Collamer Lens (ICL) to treatrefractive errors associated with keratoconus showing the effectiveness of theprocedure. The result showed thatICL was an effective and safe joint method improving visual acuity in keratoconuseyes with high myopia and astigmatism. The combination oftwo surgeries also poses a problem, because you can really only do theseincisions just once, in consideration of expense and the patient’s compliance.The combination surgery should not practiced until we have strong understandingof their pros, cons and mechanisms.ComparedICL implantation and LASIK to treat low-mediate myopiaAsrefractive surgery, a more rapid stability of refractive outcome would beexpected with the ICL compared with a LASIK procedure. In treatment oflow-mediate myopic9, LASIK series reported in the Summaries ofSafety and Effectiveness, refractive stability, defined by changes inrefraction of no more than 1.0 D in 95%. The ICL and LASIK outcomes presentedhere were safety and efficacy. The stability endpoint reached in ICL and LASIKseries at the early 1-week to 6 month follow-up, but the ICL percentage washigher at each interval and reached the level of statistical significance at 1to 6 months postoperatively but not at 1 week to 1 month postoperatively. Onequarter of the LASIK cases required enhancement surgery compared with none ofthe ICL cases, and astigmatism was treated routinely in the LASIK cases,whereas only spherical correction was attempted with the ICL.Previousstudies on HOA(High Order Aberration) changes after laser in situkeratomileusis (LASIK) flap creation reported an increase in coma69,70 or in trefoil71 and suggested thatthe position of the hinge, as well as the type of laser refractive correction,may influence the type of aberration induced after flap or non-flap creation. Incontrast to laser refractive correction which preserves the prolate shape ofthe cornea, implantable Collamer Lens insertion has relatively little risk ofHOA induction in the cornea. By analyzing in spherical aberration, coma,trefoil, and total HOA, HOA changed after Implantable Collamer Lens implantationwere increased trefoil and the lens induced negative spherical aberration.Laboratory measurements of aberration profiles of Implantable Collamer Lensesshowed HOA and spherical aberration is not different of each lens. In otherwords, the increase in trefoil is likely to be related to the corneal incision.A negative shift of spherical aberration induced by phakic IOL optic andincreased in trefoil by corneal incision after ICL insertion. In fact, thestudy has not assessed the change in HOAs associated with postoperativevaulting or decentering, so there are still some issues to be probed. Based onrecent results, ICL implantation improved image quality, the primary cause, byless postoperative HOA especially comaand spherical aberration reported after ICL implantation relative to LASIK72. The ICL offers thepatient with a low-mediate myopic refractive error a realistic alternative tocorneal laser refractive surgery. A randomized prospective study design wouldprovide a more precise comparison, yet a large case-control study of the ICLand LASIK series was well matched for key variables of preoperative MRSE, ageand gender.ICL Implantation versus Contact Lens WearComparevision-related quality of life in successful contact lens (CL) wearer and ICLimplantation with similar starting levels of myopia(MRSE, ＞7D) using the QIRC instrument (Quality of life impact of refractive correction),the QIRC scores in this study were significantly higher in ICL recipients.Although visual acuities were are similar in CL-corrected and ICL-correctedpatients, ICL implantation may offer gains in several areas of visual functionrelevant to quality of life. Overall levels of satisfaction with the results ofICL implantation were very high. Using the QIRC instrument, it demonstratedsignificant quality-of-life gains for ICL recipients in comparison withsuccessful CL wearers with a similar starting level of myopia72.CONCLUSIONICLresearch in the futureAtpresent, ICL implantation as a intraocular refractive surgery,showsfaster visual recovery, more stablerefraction, better visual quality and prolong safety. Compared with lasersurgeries or contact lens wear, ICL implantation reveals much more advantages. Eachcoin has two sides, as a intraocular surgery, ICL implantation may induce some intraocular complications. On the other hand,the lens itself design may cause progressive loss of ECD, iris complicationsand anterior subcapsular cataract. Retrospective studies on ICL implantation elicitecomprehensively, however, there are still some questions worth to seek.Different researches faced of a dissimilar range of patient’s age and pre -operationvisual levels, meanwhile, there are no criteria to evaluate the ability ofsurgeons, which directly affect the post-operation complications. The otherside, patients underwent ICL implantation were not followed-up enough time, 6months or 12 months was too limited to discover long-term complications. Futureresearch should be directed at prospective and retrospective studies of thelong-term (＞10years) efficacy and complications of ICL, imaging studies to evaluate thesizing and anatomic fit of ICL before surgery , assessing the results aftersurgery, meanwhile, randomized, controlled clinical trials on the merits ofdifferent lens models and types.Surgeryis no optimum choiceThesurgeon must advise patients on the pros and cons of the various reasonableoperative alternatives to eyeglass or contact lens wear, and help them to makethe proper choice consistent with their visual goals and occupational needs.REFERENCES AND RECOMMENDED READINGReferences1Donnenfeld, E. D. et al. Laser in situ keratomileusis for correction of myopia andastigmatism after penetrating keratoplasty. Ophthalmology106, 1966-1974; discussion1974-1965, doi:10.1016/S0161-6420(99)90410-4 (1999).2Perez-Santonja, J. J.,Bellot, J., Claramonte, P., Ismail, M. M. & Alio, J. L. 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摘要目的：本文探讨可植入人工晶体ICL V4(Implantable Collamer Lens，ICL V4)治疗高度近视眼的长期预测性、安全性和稳定性。方法：对手术3年以上ICL V4植入的128眼进行随访分析总结，手术前术后观察患者裸眼视力、矫正视力、屈光状态、眼压、角膜内皮、眼前节、眼底、ICL位置和拱高等变化、手术后出现异常情况的病例进行分析，寻找产生的原因。结果：手术前患者平均年龄25.38±3.42(22-40)岁、平均近视度数为-14.29±3.77D(-8.0-- -18.0D)；术前平均最佳矫正视力0.82±0.23(0.3—1.2)；至术后3年时，最佳矫正视力为0.91±0.12; 残余屈光度为-0.85±0.50D; 屈光度在±1.0D以内的百分率86%；手术后平均拱高为0.52±0.34(0.11—1.02)mm; 术后2年角膜内皮细胞计数、眼压和手术前相比无统计学差异；手术后主要并发症有虹膜后粘连2眼（1.56%）、ICL表面色素沉着10眼(7.81%)、虹膜脱色素5眼(3.91%)、瞳孔散大1（0.78%）眼、拱高异常（偏高和偏低）6眼（4.69%）、晶状体前囊下混浊4(3.13%)等。结论：ICL V4治疗高度近视在3年随访时间内显示了较好的预测性、安全性和稳定性; 但可能产生的并发症还是应引起重视, 如白内障、虹膜脱色素和拱高异常（偏高和偏低）等, 将对患者的视力和眼前节产生威胁，建议严格掌握手术适应症、规范手术前检查、特别是白到白的测量、认真细致的手术操作、定期随访、减少可能的手术并发症对患者视力的影响。

从LASIK激光手术到巩膜扩张术，从传导性热用膜成形术到调节性人工晶体植入术。随着眼科手术技术的飞速发展，对于老花眼这一人类无法避免的衰老性疾病，各种手术方法可谓层出不穷。那么，在老花眼手术逐步走进我国的今天，究竟何种方法最为安全、高效、主流呢？大量国内外临床经验已证明三焦点晶体置换术比起切削角膜的LASIK激光手术更为高效，且对比巩膜扩张术等全新技术，也更为成熟、安全。45岁后难逃老花眼困扰视觉的形成主要是透过光线的传导，经过角膜→晶状体→玻璃体光线聚焦于视网膜→达到大脑的一个过程。45岁以后，随着人体眼球机能老化，通常会造成控制晶状体的悬韧带张力丧失，晶状体退化变硬，造成自然晶状体近调节能力衰退，使人看近物模糊不清，此即为老花眼的形成机制。可以说，老花眼(晶状体失去调节能力)的问题几乎是人人都无法避免的。其最明显的症状就是，患者达到一定年龄后，看近不清楚，阅读困难容易疲劳、酸涩。目前最普通的治疗方式是配戴老花眼镜，症状轻微者只需阅读时配戴，症状严重者则需区分近、中、远距离三个不同度数分别佩带。由于老花眼镜的配戴方式不同于一般近视眼镜经常性的配戴方式，它仅使用于某特定距离如阅读或使用电脑，因此老花眼镜经常需反复戴上拿下，偶而还会被遗漏在某个角落遍寻不着，造成日常生活及工作上的不便。五大手术方法不尽相同伴随着眼科新技术的不断发展，30多年来，常见的老花眼手术方法共发展出了5个大类。这5大手术方法的原理不尽相同，其在安全性、成熟度、术后效果等方面也有着较大差异。1、巩膜扩张术：至今该手术论据不足，手术效果不太理想，尚存在争论。2、三焦点晶体置换术：适合于老花眼或合并白内障的患眼，术后对远、中、近不同距离的视力都有所保障，目前最为主流和成熟。3、单焦点人工晶体植入术：植入眼内镜片选择度数时预留一部分近视，看远处则戴近视镜片矫正，看近时不需要戴镜，从而解决老视，却无法彻底摆脱眼镜。4、LASIK手术(激光角膜原位磨镶术)：通过LASIK手术改变角膜的曲率，矫正其中一眼(主视眼)的远视力，用于视远，而矫正另一眼(非主视眼)的近视力，用于视近，达到单眼视的效果。手术历史最长，但一直是非完美的手术方案。5、传导性热用膜成形术(CK手术)：近几年新开展起来用于治疗远视及老视的一种新技术。其工作原理是用射频电流作用于周边角膜，使角膜胶原组织产生皱缩。达到改变中央角膜曲率(变凸)，从而矫正老视。临床手术经验有待完善。三焦点晶体置换术安全高效三焦点人工晶体是一种先进的医疗光学科技，可以将远、中与近处的物体同时呈像对焦于视网膜平面的手术技术。患者术后不必依赖眼镜就可以清楚地同时看远、看中和看近，从而有效地改善了患者的视力。”老花眼手术在国外经历了一个漫长的发展过程，从最初的依靠激光塑造一眼视近、一眼视远的单眼视效果，到植入单焦点晶体单纯解决视近需求，手术的方案一直没办法做到尽善尽美。直到三焦点人工晶体的出现，才使得老花眼合并近视、远视和白内障的患者，得到了彻底手术矫正的机会，让几乎所有患者在双眼植入后可不再依赖眼镜。三焦点晶体置换术只需要在角膜边做一个2毫米的微小切口，然后利用新型飞秒激光和超乳术，将患者失去调节机能的晶状体吸除干净，将三焦点晶体植入原来的晶状体囊袋内，取代原本丧失机能的晶状体。整个手术过程仅约6分钟，患者无疼痛感，第二天就可正常用眼，不需要过长的术后休息时间。三角点晶体置换术后，其效果及安全都比较理想，手术后患者的视力会明显提高，早期可能有光晕，适应一段时间后消失。

ICL手术治疗近视眼的适应症是什么？适应症为：年龄：18~50岁。近视：－1.0~18.0D；角膜内皮细胞计数>2800/mm2；前房深度>3.2mm，最好3.4mm以上；眼压<21mmHg；暗光下瞳孔直径<5.5mm；屈光度在两年内稳定；无眼科疾病及眼科手术史。ICL手术哪些情况不能手术治疗？当然不能实施手术的情况也很多如：进行性近视，年龄<18岁；角膜异常：小角膜、大角膜或角膜手术后；角膜内皮细胞营养不良；角膜内皮细胞计数<2800/mm2；前房深度<3.2mm青光眼或青光眼家族史，眼压>21mmHg；瞳孔异常或瞳孔直径>5.5mm；急慢性葡萄膜炎、各种虹膜异常：虹膜萎缩或虹膜新生血管等；视网膜脱离或视网膜脱离家族史；独眼；等等都不适合手术治疗。ICL手术前需要那些检查？手术前进行详细的眼科检查是必须的，这些检查包括：裸眼视力和矫正视力；屈光度；房角；眼压；角膜横径；角膜地形图(角膜曲率；角膜内皮计数；眼底；AB超(前房深度、晶体厚度和眼轴长度)；通过这些检查由医生来最后判定你是否是手术的合格人选。ICL手术安全吗？有那些可能的并发症？ICL手术作为一种矫正近视的方法目前在世界范围内得到广泛开展。其优点是矫正屈光的预测性好、准确性高和视力恢复快、可逆性等。但作为一种新的手术疗法，在手术中或手术后有极少数病人可能出现一些并发症。因此术前病人和家属有必要对这些并发症有所了解。手术中可能出现的并发症有：ICL可能由于出现的意外情况而无法植入、角膜损伤、虹膜损伤及根部离段、晶体损伤致白内障等。手术后可能出现的并发症有：矫正不足或矫正过度、最佳矫正视力下降、夜晚视力不如白天清晰、眩目或眩光、角膜一过性水肿、眼内压升高、ICL偏位或脱位、晶体表面色素沉着、白内障、继发性黄斑水肿、脉络膜和视网膜脱离等。上述并发症决大多数可以避免，万一产生后可通过药物或手术治疗；如果出现白内障、视网膜脱离等并发症，为了便于治疗，也可能将植入晶体取出。在极特殊情况下如果不能耐受植入的晶体，可再次手术取出晶体。ICL手术前需要准备什么及注意什么问题？手术前检查前一周起停戴软性隐形眼镜，硬性隐形眼镜要停戴4周；手术前开始滴抗菌眼药水；手术日面部禁用化妆品；手术日尽可能有家属陪同。ICL手术后随访及注意事项有哪些？手术后随访很重要，医生可以及时发现可能出现的问题，及时进行处理，随访的时间为：第1天、第7天、1月、3月、6月、12月和24个月复查。定期随访非常重要，应按时来眼科中心随访，进行必要的检查，防止产生术后并发症。术后注意事项包括：二周内避免眼内进水;术后不能用力揉眼或压迫眼球，绝对避免外力撞击眼球;强光或太阳光下可戴墨镜; 任何时间如果发现视物模糊、充血肿胀等症状，请即刻来眼科医院就诊。

随着年龄增长，晶状体逐渐硬化，弹性减弱，睫状肌的功能逐渐减低，从而引起眼的调节功能逐渐下降，这就是我们常说的老花眼。最近，记者从沪上眼科权威教授廉井财获悉，在国外已有多年临床经验的老花眼手术近日已被正式引入国内。据了解，这种通过飞秒激光联合超声乳化并植入人工多焦晶体的手术方法出了安全成熟外，还可一劳永逸地消除老年白内障隐患，对患者可谓一举两得。40岁后老花症状逐步加深据眼科医院院长廉井财教授介绍，老花眼一般从40-45岁期间开始出现，主要表现为近距离的阅读、识别困难，是一种由于年龄增长所致的生理性调节减弱。老花眼的整个发展过程，可以贯穿患者40-60岁之间。从最初的近距离识字不清，可逐步发展为识字困难、完全无法分辨。一般来说，普通人到达60岁后，其晶状体就会完全失去自主调节能力，对应的老花度数也会从45岁左右的100度、50岁左右的200度，逐步加深为300度以上。廉井财教授提醒，中年人群出现老花眼的最初征兆，往往就是看书读报半小时左右，就会出现明显地视觉疲劳，并且会逐步出现近距离识字的模糊不清。而且，当今社会的中年人群往往还要承担繁重的工作压力，需要长时间用眼，使用电脑等数码产品。这样一来，这些用眼过度和不良的用眼习惯，就会加速患者老花的过程，对其生活的影响也将更大。近视眼患者不会“因祸得福”“近视眼能不能‘因祸得福’，逃过老花眼的困扰？”长久以来，社会各界对于这个问题的疑惑可谓众人皆知。对此，廉井财在采访中解释称，近视患者同样会患上老花眼，只是因为其初期的发展过程不太明显，从而让众多患者产生了误解。廉井财告诉记者，伴随着人的一生，每个人的眼部晶状体密度都会逐步增加。即使近视患者到了40-45岁期间，其晶状体自身弹性自然也会下降了。并且，这时围绕在晶体四周的睫状肌也会随着时间的推移而失去原先的活力。主导晶体塑形、变凸的晶体囊，同样经不起岁月的折腾，其弹性也会逐渐下降。然而，因为近视患者本身伴有不同程度的近视度数，就会在老花眼发展过程中，间接地出现一定程度上的补偿。其具体表现就是，在看书读报或浏览电脑显示器时，摘下近视眼镜反而更为清楚。这样一来，就容易被误认为没有老花。“最终的临床结果还是告诉我们，度过了不明显的老花眼初期后，近视患者的老花度数加深并不比普通人慢，有时候甚至因为其不良的用眼习惯，在50岁前，就不得不完全依靠老花眼镜看报。”廉井财告诉记者。手术全程仅需10-15分钟作为一种脱胎于白内障手术技术的成熟疗法，老花眼手术目前的主要方法是飞秒激光联合超声乳化吸除术＋人工晶体植入术。其主要特点就是：手术时间短、患者痛苦小、损伤小，术后反应轻、恢复快，已经被大多数人所接受，并且绝大多数患者能有好的复明效果，术后并发症少。据了解，老花眼手术的术前检查颇为细致，其项目设置甚至超过了白内障手术的要求。通过眼压、眼底、角膜地形图等数十种眼科专项检查，以及血压、血糖等全身性体检，老花眼手术的术前检查总共需要2-3个小时，且项目收费可纳入医保范围。而在手术期间，主刀医生通过一个仅为2.8mm左右的细小切口，通过超声乳化技术将患者已经老化失去弹性的晶体吸出。然后通过专业仪器将折叠后的老花眼手术特制人工晶体仔细地植入患者眼中。因为切口本来很小，所以不需要缝合。通过适度水化，就能保证切口的密闭性。廉井财特别强调，在整个老花眼手术过程中，所运用的超声能量会比传统的超声乳化手术能量更低，对眼球损伤更小。而且其作为一种典型的门诊手术，也具有术后愈合快的特点。一般术后第二天就可摘下保护眼罩，获得正常视力。随后再使用一星期的抗菌类眼药水，患者就能彻底恢复。白内障隐患可一同消除“老花眼手术与白内障手术的原理基本相同，使用的特制人工晶体具有数十年的使用寿命。这样一来，患者在40-60岁期间接受老花眼手术，就可以在有生之年避免晶体再度老化，自然就没有了往后出现白内障的隐患。”据廉井财介绍，目前老花眼手术的最大优点，就是与白内障治疗“合二为一”。在国外十多年的临床经验显示，许多中年患者已经普遍接受了“提前进行老花眼手术，从而避免老年阶段白内障困扰”这一概念。目前，在美国、德国等老花眼手术较为普及的国家，接受手术的患者平均年龄都已降至50岁左右，而手术所具有的“一人一方案”的个性化优点，也使得患有散光等问题的疑难患者在术后的满意度依然很高。此外，作为老花眼手术的一大优势，特制的人工晶体在技术上已经具有“解决近视、远视、老花、散光等所有屈光问题”的能力。这就使得老花眼手术的适应症范围进一步扩大，患者门槛有所降低。

定义：是眼睑裂区的球结膜及纤维血管膜增生，向角膜中心方向呈三角状侵入角膜，因形态像鸟的翅膀而得名。多数位于角膜的内侧,一般肉眼即可识别。病因：有很多因素，主要是紫外线、风尘、烟雾等慢性刺激，因此，翼状胬肉比较常见于户外劳动者，如渔民、农民、海员等。临床表现：1、多双眼发病，以鼻侧居多，一般无自觉症状或仅轻微异物感。2、翼状胬肉长入角膜较多时，会接近瞳孔区，因而会直接遮盖瞳孔或牵拉产生角膜散光，引起视力下降。如果长到角膜中央、遮盖瞳孔区，会引起失明。预防：戴太阳镜减少阳光照射，减少户外劳动时间，能够起到一定作用。治疗：最根本的方法就是手术，药物治疗效果不理想。手术原则：翼状胬肉的治疗原则有两方面：治疗性和美容性。例如，患者翼状胬肉已经侵及瞳孔区域并影响视力时，此时必须进行手术恢复视力，此乃为治疗性作为首要目标；但是，目前绝大多数要求进行手术的患者希望达到美容的目的，因为胬肉的存在，已经影响了眼部的外观。因此，临床眼科医师应根据患者疾病严重程度、患者希望达到的目标等因素，灵活掌握手术指征和手术方法。手术方法：翼状胬肉手术方式多种多样，包括巩膜暴露、单纯闭合结膜切口、胬肉头部转埋法、结膜转位法、自体结膜移植、带角膜缘干细胞的自体结膜移植、羊膜移植、板层角巩膜移植等。目前需要提出的是，从国内外文献统计数据来看，临床上主流的手术方式为翼状胬肉切除联合羊膜移植或自体结膜移植。翼状胬肉是由于结膜受到慢性刺激而引起的一种慢性炎症性病变，形似昆虫翅膀而得名。在翼状胬肉进行性遮盖部分或全部瞳孔时影响视力及眼球运动，影响美观时可手术治疗。以往的手术方式有单纯胬肉切除、胬肉转移术、胬肉切除并结膜移植、角结膜瓣移植等，手术多种多样但没有一种手术方法明显优于其他方法，难点是无法使角巩膜表面光整平滑并尽快上皮修复。胬肉复发率约20～30%，再次手术较困难，所以应当争取手术一次成功。

医生提醒：购镜时应谨慎选择5岁宝宝佩戴太阳镜后头晕摔跤、女白领佩戴太阳镜后青光眼加重，险些失明……入夏以来，太阳镜“事故”在沪上各大医院眼科内频频出现。上海眼科教授廉井财表示，与“太阳镜”有关的眼疾和事故年年发生，患者和消费者应对太阳镜的选购更加谨慎。一副眼镜“事故”多王女士向记者展示了孩子的太阳镜，镜框颜色鲜艳，装饰有卡通人物。她表示，眼镜购自路边小店，孩子十分喜欢。没想到戴上太阳镜不久后孩子就说头晕，还时常摔跤。“拿到医院去验光，这才发现镜片竟然有度数，还好戴的时间不长，不然对孩子视力肯定有影响。”王女士心有余悸。而据资料，近年来不乏幼儿因佩戴不合格太阳镜患上近视的报道。而在医院接受采访的陈小姐，原本就有青光眼，此次是在戴太阳镜旅游后眼睛胀痛、发红，视物模糊，甚至出现恶心、呕吐等症状。“眼镜本身没问题，但有部分青光眼患者，特别是闭角型青光眼患者，本身就不适合戴深色太阳镜，会让瞳孔放大，加剧房水循环障碍，使眼内压进一步增高，甚至造成失明。”廉院长表示：“患者到院时双眼眼压均在50mmHg以上，幸好就诊及时，药物降压后症状得到缓解。”除此之外，记者了解到，太阳镜不合适，还可能间接导致交通事故。一位50岁的出租车司机在采访中表示，他就有过戴了太阳镜、看反红绿灯的经历。“眼镜不能选太深的，太深了看不清信号灯，而且进出隧道的时候，如果忘记摘眼镜，深色墨镜看出去就是一抹黑，之前有同事就因为这个差点撞车”。选购太阳镜应谨慎就太阳镜的选购问题，廉井财院长在采访中表示，应该先考虑配镜者的情况。“3岁之前的幼儿不应佩戴任何太阳镜；3-6岁的儿童在强光照下进行户外活动，可以短时间佩戴太阳镜，但要尽量少戴。老年人常有白内障、青光眼等眼部病变，也要少戴太阳镜。此外，有青光眼、色盲、夜盲症等疾病的患者也不适合佩戴太阳镜。”对于普通人，廉井财表示，镜片的颜色是判断太阳镜是否合适的直观因素。“镜片颜色不宜过深，颜色过深会使人眼瞳孔放大，降低我们颜色分辨的能力，还可能加深近视度数。”他表示，通常来说，戴上太阳镜后照镜子，能看清自己的瞳孔，镜片的深度就可以接受。廉井财还提醒道，因儿童处于视力发育的关键期，家长在挑选儿童太阳镜时，尤其要注意选择正规厂家，注意眼镜的防紫外线系数和透射比，并且要求镜框舒适，镜片具有一定的抗冲击性，避免孩子好动摔倒时镜片伤到眼睛。