多酶洗涤剂对器械的浸泡洗涤导致SMILE术后弥漫性层间角膜炎

doi:10.3760/cma.j.cn115909-20190620-00178

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摘要目的：研究飞秒激光微切口角膜基质透镜取出术（SMILE）后群发弥漫性角膜层间炎（DLK）的发病原因、特点和治疗，为预防DLK的发生及治疗提供参考。方法：回顾性系列病例研究。收集2018年 6─8月期间于北京大学深圳医院眼科行SMILE术后出现DLK的患者，分析其发病原因、程度、相应的治疗及转归。结果：312眼行SMILE，其中69眼发生DLK，发生率为22.1%。DLK中右眼45眼（占 65.2%），左眼24眼（占34.8%）。其中Ⅰ级DLK43眼（占62.3%），Ⅱ级DLK18眼（占26.1%），Ⅲ级DLK 7眼（占10.1%），Ⅳ级DLK 1眼（占1.4%）。7眼Ⅲ级DLK术后第1天即行层间冲洗及激素和抗生素局部滴眼，取得良好效果。68眼术后1周裸眼视力（UCVA）达术前最佳矫正视力（BCVA）。但是1眼术后第1天确诊为Ⅱ级DLK，未行早期层间冲洗而仅激素和抗生素滴眼液频繁滴眼，于术后第5天转为Ⅳ级，术后1年UCVA达术前BCVA。在查找原因中进行器械细菌培养及类毒素培养均为阴性，角膜层间细菌培养阴性，经更换灌注液，更换一次性手术用品，加强手术室消毒隔离，降低飞秒激光能量后，DLK仍不断出现，直至停止使用多种生物酶洗涤剂浸泡及清洗术中器械后，DLK未再群发。结论：多酶洗涤剂对器械的浸泡及洗涤是此次群发DLK的原因。SMILE术后的器械处理过程中不建议使用多种生物酶浸泡及洗涤。SMILE术后早期发生的重度DLK除加强局部激素和抗生素滴眼外，应尽早进行层间冲洗。

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关键词 ：弥漫性层间角膜炎, 飞秒激光小切口角膜基质透镜取出术, 暴发性, 多酶洗涤剂

Abstract：Objective: To investigate the potential causes,characteristics and management of the fulmination of diffuse lamellar keratitis (DLK) treated by small incision lenticule extraction (SMILE) surgery. Methods: Retrospective case series study. Three hundred and twelve eyes were treated by SMILE surgery in June 2018 to August 2018. The incidence, severity, clinical outcome, and treatments of DLK were analyzed. Results: The study enrolled 312 eyes treated by SMILE, and 69 eyes (22.1%) developed DLK. There were 45 eyes (65.2%) in the right eyes and 24 eyes (34.8%) in the left eyes. Of these DLK cases, 43 eyes (62.3%) were grade Ⅰ DLK; 18 eyes (26.1%) were grade Ⅱ; 7 eyes (10.1%) were grade Ⅲ; 1 eye (1.4%) were grade Ⅳ. Seven eyes of grade Ⅲ DLK on the first day after SMILE with layers flushing and hormones and antibiotics eye drops frequently using to achieved good results. One week postoperative, uncorrected visual acuity (UCVA) in 68 eyes reached preoperative best corrected visual acuity (BCVA). But 1 eye on the first day identified as grade Ⅱ DLK without interlayer rinse, only with hormones and antibiotics eye drops frequently dispensing was worsen rapidly into stage Ⅳ on the fifth day after SMILE. Until one year later, UCVA reached preoperative BCVA. Then we searched for risk factors of the outbreak of DLK. The bacterial cultures and the toxoid tests of the sterilized instruments were negative. The bacterial cultures of corneal intralamellar were negative too. After we replaced the perfusate and medical disposable materials, strengthened sterilization and isolation of operation room, and reduced the femtosecond laser energy, the DLK still appeared constantly. The outbreak of DLK stopped until we forbade using multienzyme detergents to marinate and clean the surgical instruments. Conclusions: Multienzyme detergents soaking and cleaning the instruments were the major causes of the mass DLK. We didn't recommend to use multienzymes detergents to marinate the preoperative instruments. An interface washout should be performed immediately due to the risks of permanent haze and scarring in the primer early postoperative severe DLK, besides adding the intensive topical steroids and antibiotics.

Key words： diffuse lamellar keratitis small incision lenticule extraction outbreak multienzyme detergents

收稿日期: 2019-06-20

通讯作者: 陈伟（ORCID：0000-0002-7417-2564），Email：jennifercw6@163.com

引用本文:

陈伟杨琦丁清许美萍. 多酶洗涤剂对器械的浸泡洗涤导致SMILE术后弥漫性层间角膜炎[J]. 中华眼视光学与视觉科学杂志, 2020, 22(7): 524-530. Wei Chen, Qi Yang, Qing Ding, Meiping Xu. Clinical Analysis of the Diffuse Lamellar Keratitis Caused by Multi-Enzyme Detergents Soaking and Washing the Instruments after Small Incision Lenticule Extraction Surgery. Chinese Journal of Optometry Ophthalmology and Visual science, 2020, 22(7): 524-530. DOI: 10.3760/cma.j.cn115909-20190620-00178

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https://www.cjoovs.com/CN/10.3760/cma.j.cn115909-20190620-00178 或 https://www.cjoovs.com/CN/Y2020/V22/I7/524

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