青光眼手术：从久经考验到新奇新奇。

IF 3.2 Q1 OPHTHALMOLOGY

Ophthalmology. Glaucoma Pub Date : 2025-09-01 DOI:10.1016/j.ogla.2025.06.009

Steven J. Gedde MD , Leon W. Herndon Jr. MD

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引用次数: 0

摘要

治疗青光眼的手术选择近年来呈指数增长。传统的青光眼手术包括小梁切除术和管分流手术。这些手术将水排入结膜下间隙，它们在降低眼压（IOP）方面非常有效。激光缝合线溶解和可释放缝合线允许外科医生在小梁切除术后选择性地增加流出量，并且术后滴定IOP的能力是小梁切除术优于其他青光眼手术的一个优势。丝裂霉素C和5-氟尿嘧啶是辅助抗纤维化药物，已被证明可以提高小梁切除术的成功率，但它们也增加了并发症的风险，如低眼压黄斑病变和泡相关感染。作为小梁切除术的一种替代方法，管分流术的使用频率越来越高。硅胶管维持引流瘘管的通畅并将房水分流至端板。端板较大的假体可以更好地降低IOP，在带瓣膜的假体中使用限流器可以降低低张力相关并发症的风险。微创青光眼手术（MIGS）是一种较新的不形成水泡的手术，通过腹腔入路进行，对眼部组织的破坏最小。小梁网/施勒姆管MIGS通过支架置入、扩张或切割/剥离小梁网和施勒姆管内壁，改善常规流出系统的水排水。脉络膜上MIGS通过连接前房和脉络膜上间隙的装置产生循环透析并增加巩膜血流。在轻度至中度开角型青光眼患者中，各种MIGS手术常与超声乳化术联合进行。微创青光眼手术提供了比传统青光眼手术更有利的安全性，但MIGS在降低IOP方面效果较差。目前所有青光眼手术的安全性和有效性都存在权衡。青光眼手术的创新为外科医生提供了为个体患者量身定制手术选择的机会。多中心随机临床试验为指导青光眼患者的手术治疗提供了有价值的信息。财务披露：作者在本文中讨论的任何材料中没有专有或商业利益。

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Glaucoma Surgery

The surgical options for managing glaucoma have expanded exponentially in recent years. Traditional glaucoma surgery includes trabeculectomy and tube shunt surgery. These procedures drain aqueous into the subconjunctival space, and they are highly effective at lowering intraocular pressure (IOP). Laser suture lysis and releasable sutures allow the surgeon to selectively increase outflow after trabeculectomy, and the ability to titrate IOP postoperatively is an advantage of trabeculectomy over other glaucoma procedures. Mitomycin C and 5-fluorouracil are adjunctive antifibrotic agents that have been shown to improve the success of trabeculectomy, but they also increase the risk of complications such as hypotony maculopathy and bleb-related infections. Tube shunts have been used with increasing frequency as an alternative to trabeculectomy. A silicone tube maintains the patency of the drainage fistula and shunts aqueous humor to an end plate. Devices with larger end plates produce greater IOP reduction, and the presence of a flow restrictor in valved implants serves to reduce the risk of hypotony-related complications. Minimally invasive glaucoma surgery (MIGS) is a newer group of nonbleb-forming procedures performed via an ab interno approach and involves minimal disruption of ocular tissues. Trabecular meshwork/Schlemm’s canal MIGS improve aqueous drainage through the conventional outflow system by stenting, dilating, or cutting/stripping the trabecular meshwork and inner wall of Schlemm’s canal. Suprachoroidal MIGS create a cyclodialysis and increase uveoscleral flow through a device that connects the anterior chamber and suprachoroidal space. The various MIGS procedures are frequently performed in combination with phacoemulsification in patients with mild to moderate open-angle glaucoma. Minimally invasive glaucoma surgery offers a more favorable safety profile than traditional glaucoma surgery, but MIGS are less effective in lowering IOP. A trade-off exists between safety and efficacy with all currently available glaucoma operations. Surgical innovation in glaucoma has provided surgeons with the opportunity to tailor the selection of a procedure to the individual patient. Multicenter randomized clinical trials have provided valuable information to guide the surgical care of glaucoma patients.