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引发全球可逆性致盲的主要原因是白内障,约占视力损失或盲的51%[1]。据各项有效实验数据报道,94%~98%的病人可以通过白内障手术提高至20/40及更好的矫正视力[2]。根据临床的实验研究表明,糖尿病(diabetes mellitus, DM)合并白内障的手术后视力常发生较大的波动,约有20%病人的术后视力会出现短期内的上升,而后伴随再度下降的情况[3]。出现此情况的可能原因是高糖、炎症等通过损坏黄斑结构和功能,造成视力损伤[4]。光学相干断层扫描(optical coherence tomography, OCT)是一种无损伤、高分辨率的横断面光学成像检查,已在眼科广泛使用,特别对黄斑区视网膜疾病的诊断、治疗后的评估与随访提供客观的依据。本研究使用OCT来研究超声乳化手术前后DM合并白内障病人中心黄斑区的视网膜厚度(central macular retinal thickness, CMT)的变化情况及其与视力相关性,旨在为临床上DM病人白内障术后出现视力再次下降的原因提供一定程度上的理论依据,为及时采取措施干预提供相关的参考资料。
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选取2017年在我科行单眼白内障超声乳化摘除手术联合眼内后房型人工晶状体植入术的90例病人(90眼),共分为2组。观察组:45例病人(45眼),均为DM同时合并白内障。对照组是与之年龄相匹配的白内障病人,共45例(45眼)。2组病人性别、年龄、合并高血压率及术前CMT值差异均无统计学意义(P>0.05)(见表 1),具有可比性。排除标准:DM性视网膜病变2期及以上,屈光间质影响眼底检查者,晶状体核硬度超过Ⅳ级者,合并玻璃体积血,变性近视、青光眼、眼底黄斑视网膜疾病等其他眼部疾病,先前眼部手术史,重度干眼症,术前已患有黄斑水肿。所有病人均了解治疗的益处和风险,自愿参加此项临床试验,符合医学伦理学要求。
分组 n 年龄/岁 男 女 高血压 术前CMT/μm 对照组 45 64.8±10.6 23 22 22 211.9±16.6 观察组 45 64.0±12.0 21 24 14 213.6±19.7 t — 0.33 0.18* 2.96* 0.44 P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般资料的比较
$ \overline{x}\pm s$ -
(1) 所有病人均在术前、术后1 d、1周、1个月、3个月行眼部裂隙灯检查及散瞳后行OCT下的CMT检查。(2)视力执行BCVA检测,并将视力十进制转换为最小分辨单位的对数以进行统计学分析。
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手术均由同一位主任医师完成,常规行超声乳化手术联合眼内后房型人工晶状体植入。所有白内障核的混浊程度为Ⅱ~Ⅲ级。术中操作的负压设为340 mmHg,超声波能量最大设定为40%~50%,流速为34 mL/min,注/吸负压设置为500 mmHg。所有病人术前及术后的处理相同。
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采用χ2检验、t检验、方差分析和q检验、wilcoxon秩和检验、pearson相关分析。
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观察组术后1 d和1周CMT较术前差异均无统计学意义(P>0.05),术后1个月和3个月的CMT值均显著厚于术前(P < 0.01),而对照组术后各时间点CMT较术前差异均无统计学意义(P>0.05)。观察组术后1个月和3个月的CMT均较术后1 d和1周增厚(P < 0.01),术后3个月较术后1个月降低(P < 0.05)。2组间比较:术后1个月、3个月,观察组CMT均比对照组厚(P < 0.01和P < 0.05)(见表 2)。
分组 n 术前 术后1 d 术后1周 术后1个月 术后3个月 F P MS组内 对照组 45 211.9±16.6 211.1±15.2 212.2±16.8 213.2±15.3 212.5±16.9 0.10 >0.05 261.708 观察组 45 213.6±19.7 212.8±18.7 215.5±18.0 231.1±25.0**△△## 223.1±24.0**△△##+ 6.01 < 0.01 452.556 t — 0.44 0.48 0.90 4.08 2.42 — — — P — >0.05 >0.05 >0.05 < 0.01 < 0.05 — — — q检验:与术前比较**P < 0.01;与术后1 d比较△△P < 0.01;与术后1周比较##P < 0.01;与术后1月比较+P < 0.05 表 2 2组术后1 d、1周、1个月、3个月与术前CMT比较
$ \overline{x}\pm s$ -
2组手术后各时间点的logMAR BCVA值与术前对比均呈现下降的趋势(P < 0.01)。术后1个月和3个月,观察组logMAR BCVA水平均高于对照组(P < 0.01)(见表 3)。
分组 n 术前 术后1 d 术后1周 术后1个月 术后3个月 H P 观察组 45 0.7(0.6, 1.0) 0.2(0.2, 0.2)** 0.2(0.2, 0.2)** 0.2(0.2, 0.3)**△△## 0.2(0.2, 0.3)** 146.017 < 0.01 对照组 45 0.5(0.5, 0.7) 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 108.326 < 0.01 Z — -1.57 -1.58 -1.86 -4.46 -3.38 — — P — >0.05 >0.05 >0.05 < 0.01 < 0.01 — — wilcoxon秩和检验:与术前比较** P < 0.01;与术后1 d比较△△P < 0.01;与术后1周比较##P < 0.01 表 3 2组各时间点logMAR BCVA[中位数(四分位数)]的比较
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2组术前的logMAR BCVA和CMT无相关性(P>0.05)。对照组:术前、术后各时间点的logMARBCVA和CMT之间无相关性(P>0.05)。观察组:术前和术后1 d、1周logMARBCVA和CMT无相关性(P>0.05),但在术后1个月、和3个月两者呈正相关性(P < 0.05),其中,在术后1个月时两者的相关性最强(P < 0.01)(见表 4)。
分组 术前 术后1 d 术后1周 术后1个月 术后3个月 观察组 -0.02 -0.12 -0.06 0.47** 0.36* 对照组 0.03 -0.14 -0.06 -0.23 -0.02 *P < 0.05,**P < 0.01 表 4 2组术后CMT与logMAR BCVA相关性
(r)
糖尿病病人白内障超声乳化术后黄斑区视网膜厚度及视力的变化分析
Analysis of the retinal thickness in macular area and visual acuity after cataract phacoemulsification in diabetic patients
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摘要:
目的 观察糖尿病(DM)病人白内障超声乳化摘除联合后房型人工晶状体植入术后中心黄斑区的视网膜厚度及视力的变化。 方法 选取行白内障超声乳化联合人工晶体植入术的病人90例,其中DM合并白内障病人45例(45眼,观察组),年龄相关性白内障病人45例(45眼,对照组)。分别于术前、术后1 d、1周、1月及3月使用光学相干层析成像扫描(OCT)检查中心黄斑区的视网膜厚度(CMT)和最佳矫正视力(BCVA)。分析2组间及组内各时间点CMT及视力的变化,并探讨CMT与BCVA之间的关系。 结果 观察组术后1个月及3个月的CMT较对照组均增厚(P < 0.01和P < 0.05);其中,观察组术后1个月的CMT增厚达最高值(P < 0.01)。2组手术后各时间点的logMAR BCVA值与术前对比均呈现下降的趋势(P < 0.01);观察组术后1个月和3个月的logMAR BCVA水平均高于对照组(P < 0.01)。观察组的术后1个月、3个月logMAR BCVA与CMT呈正相关(r=0.47、0.36,P < 0.05),对照组的术后各时间点logMAR BCVA与CMT无相关性(P>0.05)。 结论 DM病人接受白内障超声乳化摘除联合人工晶状体植入手术后,CMT显著增加。2组病人术后BCVA虽均有改善,但部分DM病人在随访期间出现了显著BCVA的再次下降,可能与术后的CMT增加有关。 Abstract:Objective To measure the changes the retinal thickness in macular area and visual acuity after cataract phacoemulsification combined with posterior chamber intraocular lens implantation in diabetic patients. Methods Ninety patients treated with phacoemulsification combined with posterior chamber intraocular lens implantation, which included 45 cases with diabetes mellitus complicated with cataract(45 eyes, observation group) and 45 cases with age-related cataract(45 eyes, control group), were investigated.The central macular thickness(CMT) and best corrected visual acuity(BCVA) in two groups were detected using the optical coherence tomography before operation, and after 1 day, 1 week, 1 month and 3 months of operation.The changes of the CMT and BCVA at each time-point were analyzed between two groups, and the relationship between CMT and BCVA was investigated. Results The CMT in observation group after 1 and 3 months of operation thickened compared with the control group(P < 0.01 and P < 0.05), and the most thickness of CMT in observation group was after 1 month of cataract surgery(P < 0.01).The post-operative logMAR BCVA value in two groups decreased compared with before operation(P < 0.01), and the levels of logMAR BCVA in observation group were higher than that in control group after 1 and 3 months of phacoemulsification(P < 0.01).The logMAR BCVA in observation group after 1 and 3 months of phacoemulsification were positively correlated with CMT(P < 0.05), and there were not correlation between logMAR BCVA and CMT in control group at all postoperative time points(P>0.05). Conclusions The CMT significantly increases in diabetic patients treated with phacoemulsification combined with posterior chamber intraocular lens implantation.The BCVA in two groups are improved, and the BCVA declines obviously in partial diabetic patients during the following-up, which may be related to the increasing of CMT after surgery. -
表 1 2组病人一般资料的比较
( $ \overline{x}\pm s$ )分组 n 年龄/岁 男 女 高血压 术前CMT/μm 对照组 45 64.8±10.6 23 22 22 211.9±16.6 观察组 45 64.0±12.0 21 24 14 213.6±19.7 t — 0.33 0.18* 2.96* 0.44 P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组术后1 d、1周、1个月、3个月与术前CMT比较
( $ \overline{x}\pm s$ ; μm)分组 n 术前 术后1 d 术后1周 术后1个月 术后3个月 F P MS组内 对照组 45 211.9±16.6 211.1±15.2 212.2±16.8 213.2±15.3 212.5±16.9 0.10 >0.05 261.708 观察组 45 213.6±19.7 212.8±18.7 215.5±18.0 231.1±25.0**△△## 223.1±24.0**△△##+ 6.01 < 0.01 452.556 t — 0.44 0.48 0.90 4.08 2.42 — — — P — >0.05 >0.05 >0.05 < 0.01 < 0.05 — — — q检验:与术前比较**P < 0.01;与术后1 d比较△△P < 0.01;与术后1周比较##P < 0.01;与术后1月比较+P < 0.05 表 3 2组各时间点logMAR BCVA[中位数(四分位数)]的比较
分组 n 术前 术后1 d 术后1周 术后1个月 术后3个月 H P 观察组 45 0.7(0.6, 1.0) 0.2(0.2, 0.2)** 0.2(0.2, 0.2)** 0.2(0.2, 0.3)**△△## 0.2(0.2, 0.3)** 146.017 < 0.01 对照组 45 0.5(0.5, 0.7) 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 0.2(0.1, 0.2)** 108.326 < 0.01 Z — -1.57 -1.58 -1.86 -4.46 -3.38 — — P — >0.05 >0.05 >0.05 < 0.01 < 0.01 — — wilcoxon秩和检验:与术前比较** P < 0.01;与术后1 d比较△△P < 0.01;与术后1周比较##P < 0.01 表 4 2组术后CMT与logMAR BCVA相关性
(r) 分组 术前 术后1 d 术后1周 术后1个月 术后3个月 观察组 -0.02 -0.12 -0.06 0.47** 0.36* 对照组 0.03 -0.14 -0.06 -0.23 -0.02 *P < 0.05,**P < 0.01 -
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