激光乳化白内障吸除术屈光组业务学习课件

激光乳化白内障吸除术 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w21世纪将是激光乳化发展迅速的时期 w有望成为PHACO 术后另一主流术式 w已获FDA批准并用于临床 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 超声乳化手术 w优点：切口较小、散光少、恢复快 w缺点：操作复杂、学习曲线长、并发症 （后囊破裂、虹膜损伤、角膜热灼伤、 无调节等） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 问题的解决 w激光乳化白内障吸除术 w安全、操作简便 w切口更小、恢复快 w并发症少 w基本无热损伤 w调节注入式人工晶体的研究 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w1988年开始研制 w90年代至今：临床试验阶段 w2种红外激光已获FDA批准用于白内障 手术 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 类型 w准分子激光 wErYAG激光 wNdYAG激光 wHo: YA G 激光 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 准分子激光 w193nm(ArF) 、248nm( KrF) 、 308nm(XeCl) 、351nm(XeF) w351nm ：对晶体无切割能力 w193nm 波长是最佳选择,但不能通过光 导纤维限制 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. wNanevicz 等 w308nm 波长是白内障摘除的最佳选择 w它比193nm 波长有更高的切割阈 w比248nm 更精确 w能通过光导纤维 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 作用原理 w把晶体核击碎成直径小于0. 1mm 的小颗粒 w通过注吸口吸出小颗粒和皮质 w作用于组织的探针直径不超过1mm w离体实验：最大输出能量为250mJ ,脉宽17ns , 重频最大为100Hz。 w理论上能促进光化学反应,通过产生紫外线吸收 发光团而发挥切割作用 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 缺点 w准分子激光的实验时间较长,汽化速度 慢 w308nm 激光诱发的荧光对视网膜会产 生明显伤害 w308nm 紫外线照射致癌效应。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 前景 w至今FDA 尚未批准其应用于临床 w今后的研究热点：集术者眼部防护及术 眼结构防护为一体的防护装置 w前景不被看好 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Ho: YA G 激光 w90年代初研制 w 但由于未能解决抽吸问题而失败 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. N d: YA G 激光 w1988 年始研制时使用 w广泛应用于囊膜切开术 w易被虹膜和视网膜组织吸收而极少被眼 内透明组织及含水组织吸收 w曾被认为不适宜行白内障手术 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Dodick的贡献 w最先应用NdYAG激光进行白内障手术 的研究 w其设计的NdYAG 激光乳化系统目前是 经过美国FDA 认证可用于白内障吸出手 术 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w能量是8mJ / pulse w重频为(120) Hz w脉宽8ns w石英光纤直径300m w使用金属钛作为靶 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 特 点 w探头基本不产生热,不需外加冷却管套 ：探针直径很小。 w探针可以通过直径为1. 25mm 的切口 ：术后散光和并发症减少。 w激光能量作用于探针内的钛靶产生冲击 波：避免激光直接照射眼睛 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 离体人眼前房温度变化实验 w超声探针头末端的温度平均升高(7. 08 2. 51) w Dodick 激光探针头末端的温度平均升 高(0. 41 0. 41) 温度几乎没有变化, 不损坏周围组织。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 使用Dodick 激光乳化仪进行的白内障 手术 w每例平均能量为5. 65J，超声乳化能量 的1/ 1000 w但对硬核手术效果差,手术时间偏长 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Dodick-ARC 激光乳化 w德国ARC 激光有限公司生产 wNd : YAG 激光乳化系统 wQ2开关,激光波长为1 064 nm ; w激光手柄可发射激光并进行抽吸,外径为1.2 mm ,内径为0.9 mm ; w光导纤维直径为350m ; w手柄前端的档板向内,与手柄成33角,其表面 的钛板恰为激光的焦点平面。 w激光沿光导纤维传递,击射至钛板,产生震荡波 ,使周围组织碎裂。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w手柄前近顶端处侧壁上的孔为灌注口,此旁路 设计有利于术中前房稳定。 w手术时灌注手柄自侧切口进入前房,手柄的前 端向内弯成钩状,便于双手操作。 w每个脉冲的激光能量分为715 mJ 和1210 mJ 两档,负压为0650 mmHg。 w水压为0200 mm Hg。 w同时具有超声乳化功能,术中当激光无法完全 乳化晶状体核时可改变术式,使用超声乳化方 式粉碎晶状体核 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 手术方法 w颞上和颞下分别做透明角膜切口。 w右手切口长3.2 mm,可作为IOL主切口 w内切口长度以可进入激光探头为标准,约为 1.75 mm ; w左手切口长度为1.75 mm ,进入灌注手柄。 w前房内注入黏弹性物质后,行连续环形撕囊,水 分离、水分层后, 行激光乳化晶状体。 w每个脉冲的激光能量为12.0mJ ,激光发射频 率为2 Hz ,负压为250 300 mm Hg ,水压为 7580 mm Hg。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 手术方法 w当激光乳化无法清除晶状体核时(一般 在200 个脉冲后) ,可将术式改为超声乳 化。 w注吸分体式注吸手柄或注吸一体式注吸 手柄(扩大切口至3.2 mm) 清除晶状体 皮质。 w扩大主切口的内切口至3.23.5 mm , 植入IOL Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Er: YA G 激光 w1992 年美国的M ichoel Co lvardz 最先 应用进行白内障手术 w1996 年美国FDA 同意进行临床实验 w1997 年完成临床I 期实验 w 1997 年7 月通过美国FDA 批准应用于 临床 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 原理 wEr: YA G 激光的波长为2. 94mm, 最接 近水的吸收峰值2. 9mm, 其能量能最 大限度地被水吸收， 水中穿越深度仅 1mm w晶状体含有约63% 的水分，是吸收Er 激光的极好靶组织 w对晶状体的乳化作用主要是通过热效应 和机械效应 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 热效应 w激光在含水量高的组织中以水作为显色 团吸收光子, 其能量使组织温度升高, 并向周围组织扩散 w当能量足够大时, 可使局部温度升高至 沸点, 从而使细胞内外的水分变为水蒸 汽或发生微小爆破, 称为热汽化 w受激光波长、能量、曝光时间、组织成 分等因素的影响 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 机械作用 w主要是电离效应产生的机械效应 w热效应形成的热弹力波 w热汽化时产生的爆破作用 w激光能量聚集处高能电子场的效应 w可对组织产生机械作用。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. wStevens wErYAG 系统 w19 例白内障吸出术 w激光能量为45mJ / pulse , 重频( 5 30) Hz , 硅光纤直径600m Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w亚利桑那大学 w硬度为2 + 到4 + 晶体核 w激光能量为( 6 8) mJ / pulse , 重频为 200Hz , 光纤直径为365m Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w2001 年9 月荷兰举办的白内障手术会议 w 0 级晶体核：能量平均为24. 7J ,用时56. 1s , w3 级硬核分别为99. 1J 和222. 5s。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 手术结果证明铒激光的治疗 效果是安全有效的 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Er:YAG 激光乳化手术技巧 根据晶状体核的硬度选择激光能 量和频率 w能量较高机械作用增加, 作用范围 可达2mm , 易引起后囊膜破裂 w乳化晶状体核表面和中间时：高能量低 频率(10Hz) , 能量很少超过10mJ w乳化周边部及靠近后囊膜：降低能量提 高频率(30Hz) 。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w可用表面磨削式、分割式 w探头稍接触晶状体表面或距晶状体表面 1mm 时即可产生乳化作用 w切勿施加重力及将探头插入晶状体组织 内 w残留在周边部的晶状体碎核可吸至前房 再激光乳化 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. w由于激光乳化硬核所需时间比超声乳化 时间长 w4 级以上的硬核通常改用超声乳化手术 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 保护后囊膜 w探头始终应与后囊膜保持一定的距离, w手柄水平运动, 避免在垂直于后囊膜的 方向上形成大的空穴泡 w在晶状体核较硬时可通过降低频率而减 少后囊膜破裂的机会。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 激光乳化术的优点 w手柄针头头端外形平滑,不会引起囊膜 割裂 w手柄针头是真正的冷针头, 不需要依赖 灌注来防止烧伤 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. (3) 角膜切口更小 w手柄直径小, 仅0. 8 1. 0mm w手术切口小, 术后散光轻 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. (4) 手术安全性提高 w激光乳化所需能量仅为超声乳化的0.10 0.01 w使周围组织温度升高不超过0. 5 w角膜、前房、视网膜等敏感组织的损伤 降到了最低点 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. wHoh 等 w激光乳化术后2 个月未出现前房热反应 和前房炎症, 角膜内皮计数减少0. 96% w超声乳化易出现前房炎症, 角膜内皮计 数减少7. 2% 18%; Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 全部激光能量都是安全 w 能限制在探头, 仅仅传递到靶组织, 而 对于非目标组织如囊膜或虹膜是不产生 危害的; 激光波长不会侵袭到囊膜 w没有振动的超声能量释放到眼内, 对眼 内组织无损害 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. (5) 操作简便、安全、快速 w激光乳化的操作步骤要比超声乳化简便 利于眼科医师学习和掌握 w大大降低了后囊膜破裂的发生, 手术更 安全 w用囊膜切开探头可快速完成连续环行撕 囊; Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. (6) 为调节性人工晶状体的实施提供了基础 。 w保持晶状体囊的完整性及恢复调节力的 重要性和必要性。 w保持晶状体囊的完整性使调节力成为可 能 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. (7) 白内障手术的最新概念也是未来的发展 趋势 w为眼科医师提供了另一种手术方法 w光量子乳化一体化系统兼有激光和乳化 2 种功能超声 w医师能自由选择并在术中转换模式 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 激光乳化术存在的问题 w仍处于临床初步应用阶段, w对机器的性能及其对组织的作用尚未完 全了解 w 手术不够熟练而导致激光无效释放过 多, 乳化速度减慢 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 激光乳化术存在的问题 w我国白内障患者晶状体核过硬, 对4 级 以上的硬核乳化时间比超声乳化时间长 w纯粹以激光的能量破坏硬核而不损伤其 它组织有一定难度 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.