飞秒激光小切透镜取出术与飞秒LASIK术后干眼与神经修复的比较研究

发布时间：2018-04-02 14:24

本文选题：飞秒激光　切入点：角膜　出处：《复旦大学》2014年博士论文

【摘要】：第一部分飞秒激光小切口透镜取出术(SMILE)干眼与角膜知觉变化的研究目的探讨飞秒激光小切口透镜取出术(SMILE)干眼与角膜知觉变化的规律。方法研究设计类型为前瞻性、非随机对照研究。收集2010年6月至2012年2月就诊于复旦大学附属眼耳鼻喉医院视光中心共71例符合常规近视手术适应证的患者。双眼接受同一手术方式者,随机选取一眼纳入统计分析,单眼手术者,手术眼入组。其中SMILE组共纳入38例38眼(男/女：10/28),平均年龄为28.2±7.04岁,平均等效球镜为-6.68±1.34 D。飞秒LASIK组33例33眼(男/女：6/27),平均年龄为27.3±6.6岁,平均等效球镜为-7.96±2.61 D。分别于术前、术后1周、术后1月、3月、6月测量泪膜破裂时间(Tear film breakup time, TBUT)、泪液分泌功能(Schirmer test, SIT),角膜荧光染色。利用Cochet-Bonnet角膜知觉仪分别于术前、术后1周、1月、3月、6月测量角膜中央、上方、下方、颞侧、鼻侧角膜知觉。采用mix-model分别分析SMILE、飞秒LASIK术后TBUT、SIT随时间的变化趋势；并对比两组之间在各时间点的差异；分析SMILE、飞秒LASIK术后角膜各测量区域的角膜知觉随时间的改变情况。并比较两种术式之间角膜知觉恢复快慢与恢复模式的差异。采用Spearman相关分析TBUT、SIT、角膜知觉与术前等效球镜、切削深度之间的相关性。结果SMILE组和飞秒LASIK组术后OSDI分值增加,但在术后1月时恢复至术前水平。两组BUT值较术前均显著下降。SMILE组患者术后发生角膜上皮染色的风险低于飞秒LASIK组(OR= 0.5047,95% CI:0.2753 to 0.9251, P=0.0270)。在6个月的随访时间内,角膜帽和角膜瓣上5个区域的角膜知觉较术前均显著下降(P0.05)。SMILE组角膜上方、下方、鼻侧三个测量区的角膜知觉在术后所有随访时间点均高于飞秒LASIK (P0.05)。SMILE组颞侧的角膜知觉在术后1周、1月时高于飞秒LASIK (P0.05)。在其他时间点两组之间无统计学差异。SMILE术后角膜下方、鼻侧和颞侧的角膜知觉较其他2个区域恢复更快。飞秒LASIK术后至术后6个月随访时间时,5个测量区的角膜知觉均未恢复至术前水平。在SMILE组,在5个测量区中,上方角膜知觉最差。飞秒LASIK组术后上方角膜知觉最好,中央区角膜知觉最差。患者术后的角膜知觉与术前等效球镜大小及切削深度无相关性(P0.05)。结论SMILE后可出现短暂性的干眼症状、泪膜稳定性下降。相比于飞秒LASIK, SMILE术后发生角膜上皮染色的风险更小。SMILE术后角膜知觉的下降较飞秒LASIK术后小。SMILE、飞秒LASIK术后角膜知觉的下降与术前等效球镜度、术中切削深度、及切削深度无相关性。第二部分飞秒激光小切口透镜取出术(SMILE)角膜基底膜下神经纤维与切口愈合变化的研究目的探索SMILE术后角膜基底膜下神经纤维密度与切口愈合变化,及相关影响因素。方法研究设计为前瞻性、非随机对照研究,SMILE组共入组了18例患者32眼(男/女：9/9),平均年龄为27.1±4.0岁,平均等效球镜度为-6.56±1.28 D；飞秒LASIK组共入组了22例42眼(男/女：6/16),平均年龄为28.3±5.5岁,平均等效球镜度为-8.46±2.15 D。分别在术前、术后1天、1周、1月、3月、6月利用角膜共聚焦显微镜测量角膜中央区、帽缘和瓣缘的角膜基底膜下神经纤维、角膜基质,角膜帽、角膜瓣缘切口改变。观察指标为：角膜基底膜下神经纤维密度、基质细胞、切面颗粒状物质、瓣缘切口愈合、上皮栓数量。采用Image-Pro进行神经纤维、基质细胞密度计数,mixed-model进行统计分析。结果SMILE组、飞秒LASIK组术后角膜基底膜下神经纤维密度与术前比较均显著下降(P0.05)。在术后1周、1月、3月的随访中,SMILE组与飞秒LASIK组比较,飞秒LASIK组的基底膜下神经纤维密度减少量大于SMILE组(1周：P=0.01；1月：P=0.02；3月：P=0.049)。在术后6个月时,两组之间比较差异无统计学意义(P=0.53)。相关性检验结果显示SMILE组与飞秒LASIK,角膜基底膜下神经纤维密度与角膜知觉呈正相关(SMILE:r=0.42, P0.0001,飞秒LASIK:r=0.26,P=0.004)。SMILE组术后发生角膜上皮栓植入的风险低于飞秒LASIK (P=0.0005)。结论SMILE术后角膜基底膜下神经纤维密度减少量小于飞秒LASIK。基底膜下神经纤维密度与角膜知觉呈正相关。
[Abstract]:Methods A prospective , non - randomized controlled study was performed in 33 eyes ( male / female : 10 / 28 ) . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D . The mean age was - 6.68 卤 1.34D .
and comparing the difference between the two groups at each time point ;
The changes of corneal perception with time were analyzed in SMILE and femtosecond LASIK . The correlation between corneal sensation recovery and restoration pattern was compared between the two groups . Results The postoperative OSDI score of SMILE group and femtosecond LASIK group increased significantly , but the risk of corneal epithelium staining was lower in SMILE group than that in femtosecond LASIK group ( OR = 0.5047 , 95 % CI : 0.2753 to 0.9251 , P = 0.0270 ) . There was no statistical difference in corneal sensation after LASIK ( P0.05 ) . There was no statistical difference between two groups after LASIK ( P0.05 ) .
A total of 22 cases 42 eyes ( male / female : 6 / 16 ) were enrolled in the femtosecond LASIK group . The average age was 28 . 3 卤 5 . 5 years .
January : P = 0.02 ;
March : P = 0.049 ) . At 6 months after surgery , there was no significant difference between the two groups ( P = 0.53 ) . The results of correlation test showed that the density of nerve fibers in SMILE group and femtosecond LASIK was positively correlated with corneal sensation ( SMILE : r = 0.42 , P0001 , femtosecond LASIK : r = 0.26 , P = 0.004 ) . Conclusion The risk of corneal epithelial plug implantation in SMILE group was lower than that of femtosecond LASIK ( P = 0.0005 ) . Conclusion The reduction of nerve fiber density in corneal basement membrane after SMILE operation is less than that of femtosecond LASIK . The density of nerve fiber under basement membrane is positively correlated with corneal sensation .

【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R779.63

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