| 目的 探讨全角膜或指环形上皮移植术治疗各种眼表疾病引发的角
膜缘干细胞功能障碍的手术技术和成败因素。方法 通过13例（14眼）各种
严重眼表疾病引发的角膜缘干细胞功能障碍（眼表烧伤11眼，单疱角膜基质
炎2眼，边缘性角膜变性1眼）的全角膜或指环形上皮移植术，系统观察该项
眼表重建术的临床规律和影响成败的多种因素。 结果 术后平均随访8.4个
月（3-24个月），12眼（86%）眼表稳定，未发生上皮缺损；术后视力显著提
高，有11眼达到脱盲以上水平（≥0.05），8眼获得能够自主生活的裸眼视力
（0.1-0.5）；失败病例一为Ⅳ度严重烧伤案例，在眼睑皮肤缺损和结膜囊挛
缩状态尚未得到充分改善以前匆忙施行上皮移植术，导致移植片干燥角化；
另一为术中植床穿破，术后长期双前房，导致植片水肿。在CsA与皮质类固醇
两种免疫抑制剂全身和局部联合治疗下，随访期间，未发生因免疫排斥引起的
上皮衰竭。结论 同种异体全角膜或指环形上皮移植术能够有效地为干细胞衰
竭眼提供新的眼表上皮来源，使绝大多数术眼回归正常或接近正常的生理状态，
获得有用视力；未能获得良好视力者，也因重新获得稳定的眼表，为尔后的增
视性角膜或/和晶体手术提供了组织解剖学基础。影响本手术成败的因素包括：
1）对烧伤病例，先行羊膜贴敷术控制结膜炎症，然后不失时机地施行角膜上皮
移植术。因为对于烧伤眼，即使用了免疫抑制剂，也不可能完全抑制新生血管
在角膜基质内的与日俱增趋势，使尔后的上皮移植术中难以剖尽接近后弹力层
水平的新生血管而影响植床的透明度，势必影响术后的增视效果，同时也加大
了术后免疫排斥的风险；2）术前恢复眼睑和结膜的组织解剖学完整性，是所有
烧伤眼必须完成的术前准备，否则有关角膜上皮移植术的一切努力都将化为乌
有；3）对缺乏粘蛋白性泪液者适度补充不含防腐剂的人工泪；4）全身和局部
联合应用CsA和皮质类固醇等免疫抑制剂，能够防范处于免疫高危状态的角膜移
植片发生排斥反应，提高植片成活率。
【关键词】 角膜上皮移植；干细胞；免疫抑制剂
Pan / annular keratoepithelioplasty for treating limbal stem cell
dysfunction ZHU Li, ZHU Zhi-zhong, LUO Qin, ZHANG Yanxia. Ocular
Surface Service, Shanghai Peace Eye Hospital, Shanghai 200437,China Corresponding author: ZHU Zhi-zhong, Email:zhuli@uninet.com.cn
【Abstract】 Objective To investigate the surgical techniques and
affected factors associated with success of surgery. Methods A
clinical study of pan / annular keratoepithelioplsty (KEP) was
performed retrospectively in fourteen cases with limbal stem cell
dysfunction (eleven cases of ocular surface burns ,two cases of
herpetic stromal keratitis and one case of Terrien's marginal degeration).
The clinical regularity and affected factors associated with success of
surgery were investigated. Results The patients followed up for a mean
of 8.4 months (ranged from 3 to 24 months) after surgery, 12 of 14 eyes
(86 percent) maintained a stable surface at last exam,and none had
epithelial defect. Mean visual acuity improved from ≤0.035 to 0.18;
of the 12 eyes, 11 eyes in which the cornea remained clear had a mean
visual acuity of ≥0.05 (the ability to distinguish the largest symbol
from a distance of 2.5 m). Eight cases had visual acuity 0.1 to 0.5. Two
cases had failure of surgery, one case with Ⅳ degree of chemical burns
complicated with severe lid defect and symblepharon; the other that failure
of surgery results from Descemet membrane perforation which inducing two
anterior chambers and corneal edema. No patients attribute the failure of
surgery to graft rejection because systemic and topical administration of
cyclosporin A combined with steroid was used after surgery. Conclusions
Allograft of pan / annular keratoepithelioplasty is an effective pathway
to supply epithelial cell regeneration resource for patient with limbal
stem cell dysfunction. 86 percent of patients after surgery maintained a
stable surface at last exam,and 79 percent of patients (11 of the 14 eyes )
acquired useful visual acuity; The others in which the cornea still remained
opacity, however in which to perform optical surgeries (penetrating
keratoplasty or lenticular surgery) will be possible because the patients
acquired a stable ocular surface. The affected factors associated with
success of surgery included: 1)limbal stem cell transplantation must be
performed in time in patients with ocular surface burns after amniotic
membrane patching because the neovascularization in the stroma grow with
each passing day, it means that if KEP was postponed the neovesseles will
be too much to dissected thoroughly from deep stroma approaching Descemet's
membrane. As a result of KEP,the patient couldn't get a good vision, and the
risk of rejection will be increase because the graft was transplanted on a
opaque and vascularized bed. 2)The lid and conjunctiva must be kept intact in
anatomy before KEP,otherwise it is impossible to obtain a transparent graft
after surgery. 3)It is important to supply nonpreserved artificial tears for
the patients with mucin tears defiencency;4) It is necessary to apply systemic
and topical cyclosporin A combined with steroid after surgery that may arrest
the occurrence of graft rejection in patients with high risk.
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