婴幼儿先天性白内障患者术后眼轴长度、角膜曲率及屈光状态变化研究

发布时间：2018-05-13 18:30

本文选题：先天性白内障 + 眼轴　；参考：《郑州大学》2017年硕士论文

【摘要】：背景和目的先天性白内障是指出生前后即存在或出生后才逐渐形成的先天遗传或发育障碍所致的晶状体部分或全部混浊,是一种常见的儿童眼病,是造成儿童失明和弱视的重要因素。在天津、上海和北京致盲原因调查结果提示:约22%~30%的盲童由先天性白内障致盲,是失明原因的第二位,我国先天性白内障的发病率约为0.5%~1.5%。先天性白内障患儿因视路不清晰而影响视觉正常发育,形成形觉剥夺性弱视,因此,对于影响视觉发育的先天性白内障应早发现早治疗。目前临床研究表明,治疗先天性白内障的较为理想的方法主要是手术治疗,即超声乳化+后囊膜切开+前段玻璃体切除+人工晶状体植入术。但是由于婴幼儿的视觉系统具有一定的特殊性,其眼球仍处于发育阶段,屈光状态不稳定,尤其是3岁以内的儿童眼球处于快速发育时期,再加上术后炎性反应相对较重、儿童依从性较差、可能伴有弱视等问题,增加了先天性白内障手术的复杂性与风险性。在植入人工晶状体手术时机方面,目前较多学者建议2岁后植入较为合适,2岁前植入人工晶状体是否安全有效尚存在较大的争议,需要进一步的临床实践和时间检验。随着先天性白内障手术方法、麻醉及显微手术技术的不断完善和发展,对于先天性白内障尽早行白内障摘除联合人工晶状体植入是治疗先天性白内障最主要的措施,因此植入理想的人工晶状体度数、确保术后长期稳定的视觉效果、尽可能降低术后屈光参差是我们必须亟待要解决的问题。目前我们面临的问题包括以下几个方面:对于年龄较小的患儿人工晶状体屈光度计算容易出现较大的误差,有统计显现1岁以内人工晶状体度数误差约-4.06D~+3.86D;暂时没有专用于儿童的人工晶状体计算公式;有关患儿眼的生物参数(包括眼轴长、角膜曲率)测量困难,尽管在一些设备条件较好的医疗中心我们可以在患儿麻醉状态下应用IOL-Master或便携式自动测量工具测量,但是在一些发展中国家或医疗条件较差的医院对生物参数的测量仍然无法实现;另外对于存在角膜混浊、外伤引起角膜变形等情况也会影响角膜曲率的测量,在这些情况下会选择代用正常成人角膜曲率42.5D~44.0D来估计人工晶状体的屈光度,因此这对于年龄较小的患儿会产生较大的误差。因为影响眼屈光变化的主要因素包括眼轴长、角膜曲率及晶状体的发育,3岁内患儿眼球仍处于快速发育阶段,眼轴及角膜曲率均处于一个不断变化的过程中,白内障摘除后的无晶状体眼状态及植入人工晶状体后,打破了发育过程中屈光变化的平衡状态,无晶状体眼及人工晶状体眼是否对眼轴及角膜曲率的发育产生一定影响,该影响是否会导致术眼的屈光状态发生相应的变化,是我们需要观察和研究的问题。当然,目前也有较多的文献报道了儿童正常眼及白内障眼的眼球发育情况,但是,关于儿童先天性白内障术后眼轴及角膜曲率变化的临床观察结果并不完全一致,对于配合程度较差的3岁以内的婴幼儿的临床研究报道更少。本课题针对3岁内单纯先天性白内障患儿术后眼轴长度、角膜曲率及屈光度变化进行观察及统计分析,进一步了解先天性白内障术前及术后无晶状体眼、人工晶状体眼对眼轴长度及角膜曲率的影响,为临床工作中手术时机的选择、人工晶状体屈光度的计算与术后屈光度的预留,减少术后屈光误差及屈光参差提供理论依据。研究对象研究对象选自2014年1月~2015年12月于我院诊治的3岁内的先天性白内障患儿158例246眼。纳入标准:1、单纯的双眼或单眼先天性白内障;2、手术时年龄为≤3岁;3、手术方法:?单眼先天性白内障:2岁内患儿超声乳化吸除+后囊膜切开+前段玻璃体切除术,2岁后行二期人工晶状体植入术;大于2岁行超声乳化吸除+后囊膜切开+前段玻璃体切除+人工晶状体植入术;?双眼先天性白内障:婴幼儿期行超声乳化吸除+后囊膜切开+前段玻璃体切除术,2岁半后行二期人工晶状体植入术;大于2岁半行超声乳化吸除+后囊膜切开+前段玻璃体切除+人工晶状体植入术;4、具有完整的术前检查资料,包括病史、家族史、眼轴长度、角膜曲率、人工晶状体植入屈光度数及预留度数;5、术后能坚持定期复诊、及时行屈光矫正、坚持弱视训练并保存有完整病例资料,且随访时间至少1年者。排除标准:1、眼部合并有其他异常疾病如先天性小眼球、先天性小角膜、高度近视、先天性青光眼、PHPV、视网膜脉络膜发育异常者等;2、术后出现严重并发症如葡萄膜炎、IOL瞳孔夹持、IOL脱位、后发性白内障、继发性青光眼者等;3、术后不能定期复诊、不能坚持弱视训练、缺乏完整的手术资料及术后门诊随访资料者。研究方法本研究为前瞻性研究,根据入选患儿按初次手术年龄分为5组:A组:3月~6月;B组:6月~12月;C组:12月~18月;D组:18月~24月;E组:24月~36月。术后随访1年,分别记录术后3月、术后6月及术后1年患儿眼压、眼轴长度、角膜曲率、主觉验光下的等效球镜度数及随访期并发症,配合患儿可查裸眼视力、最佳矫正视力(儿童视力表)。以SPSS 21.0统计软件对本研究的数据进行统计学分析。以Kolmogorov-Smirnov检验来检查计量变量是否符合正态分布,若符合正态分布采用两独立样本t检验,不符合正态分布者采用秩和检验;不同年龄阶段及性别比例比较采用单因素方差分析(ANOVA)检验。以P0.05为差异有统计学意义。结果1.术后各阶段眼轴长度变化比较:术后3月五组患儿眼轴长分别为18.82±1.219mm,20.61±0.796mm,21.28±0.987mm,21.60±0.836mm,21.94±0.992mm,较术前分别增长0.818±0.387mm,0.682±0.289mm,0.504±0.264mm,0.353±0.450mm,0.266±0.344mm;术后6月五组患儿眼轴长度较术前增长值分别为1.561±0.473mm,1.132±0.439mm,0.963±0.395mm,0.713±0.569mm,0.464±0.488mm;术后1年五组患儿眼轴长度较术前分别增长2.554±0.588mm,1.728±0.592mm,1.080±0.513mm,0.859±0.704mm,0.768±0.520mm。五组患儿术后3月、术后6月及术后1年眼轴增长值与术前比较差异有统计学意义(P分别0.05);五组间比较:术后3月,A、B、C三组的增长速率大于D、E组,差异有统计学意义(P0.05),A组增长速率大于B组,D组增长速率大于E组,但差异无统计学意义(P0.05);术后6月及术后1年,A、B两组增长速率大于C、D、E组,差异有统计学意义(P0.05),其中AB,CDE,但差异无统计学意义(P0.05)。2.五组中单眼先天性白内障患儿在术后各阶段术眼眼轴增长幅度大于健眼,但是差异无统计学意义(P0.05),并且增长幅度随年龄增大而减小。3.术后各阶段角膜曲率变化比较:患儿术后3月、6月及术后1年角膜曲率与术前角膜曲率相比A、B、C、D组差异均有统计学意义(P0.05),E组(24月~36月)术后与术前相比角膜曲率逐渐下降,但无统计学意义;术前、术后3月、6月及术后1年各组间角膜曲率相比差异有统计学意义(P0.05);五组间比较:术后3月,A、B两组的变化值大于C、D、E组,C组大于E组,差异有统计学意义(P0.05),C组变化率大于D组,D组变化率大于E组,但差异无统计学意义(P0.05);术后6月与术后1年,A组变化率大于C、D、E组,差异有统计学意义(P0.05),其中AB,CDE,但差异无统计学意义(P0.05);B组角膜曲率的变化率大于E组,差异有统计学意义(P0.05),其中BCDE组,但差异无统计学意义,(P0.05)。4.单眼先天性白内障术前术眼角膜曲率与健眼相比差异均无统计学意义(all P0.05);术后各阶段五组的术眼角膜曲率变化幅度与健眼基本一致,角膜曲率值逐渐下降,且随着年龄增加角膜曲率变化值逐渐变小,差异无统计学意义(P0.05)。5.术后1年屈光度变化比较:将术后2周时等效球镜作为初始屈光度,术后1年五组屈光度的变化分别是-2.89±0.975D、-2.51±0.732D、-2.28±0.837D、-1.94±1.035D、-1.85±0.897D,差异有统计学意义(P=0.015);组间多重比较A、B、C三组变化量大于D、E两组,差异有统计学意义,其中ABC、DE,但差异无统计学意义。各组屈光度均向近视漂移,随年龄增加,向近视漂移的趋势变慢。6.单眼大单眼先天性白内障术后屈光度的变化量与健眼相比差异均无统计学意义(P0.05),但高于健眼,屈光度均有向近视方向漂移的趋势,且随着年龄增长其变化量逐渐下降。7.双眼先天性白内障患儿与单眼先天性白内障患儿成组配对进行t检验,结果表示单眼与双眼先天性白内障术后眼轴长度、角膜曲率及屈光度变化在年龄段均无统计学意义(P0.05),其中眼轴长度与屈光度的变化量单眼大于双眼。8.随访期间未出现视网膜脱离、后发性白内障、继发性青光眼、IOL脱位等并发症,E组1例失访,C组2例因患儿不配合数据未测出已排除,数据未计入统计分析;E组5位患儿IOL表面出现少量色素颗粒沉着,对视觉发育无影响。结论1.18个月内眼轴增长速率较快,之后眼轴呈缓慢增长,单眼患儿眼轴增长幅度较健眼及双眼患儿增长较快;2.12个月内患儿角膜曲率变化较大,之后缓慢变化,24个月基本发育至正常成人水平;3.先天性白内障术后屈光度均有向近视方向漂移的趋势,且随着年龄增长转变趋势变慢;4.单眼先天性白内障术后眼轴长、角膜曲率及屈光度与健眼可保持协调发育。
[Abstract]:Background and objective congenital cataract is a part of the lens or all turbidity caused by congenital hereditary or developmental disorder before and after birth or after birth. It is a common child eye disease. It is an important factor causing blindness and amblyopia in children. In Tianjin, the cause of blindness in Shanghai and Beijing suggests that about 22%~30 Second of the blind children are blinded by congenital cataract, which is the second cause of blindness. The incidence of congenital cataract in our country is about the congenital cataract in children with visual development and form deprivation amblyopia. Therefore, early treatment should be found for the congenital cataract affecting visual development. Bed studies have shown that the ideal method for the treatment of congenital cataract is mainly surgical treatment, that is, phacoemulsification, posterior capsule incision + anterior vitrectomy plus intraocular lens implantation. However, the visual system of infants is still at the stage of development and the refractive state is unstable, especially within 3 years. The eyeball of children is in the period of rapid development, and the postoperative inflammatory response is relatively heavy, and the compliance of children is poor. It may be accompanied by amblyopia, which increases the complexity and risk of congenital cataract surgery. In the time of implantation of intraocular lens, many scholars suggest that the implantation is more appropriate after 2 years of age and be implanted before 2 years of age. Further clinical practice and time test are needed for the safety and effectiveness of the intraocular lens. With the continuous improvement and development of the methods of congenital cataract surgery, anesthesia and microsurgery, cataract extraction and intraocular lens implantation for congenital cataract are the most important for the treatment of congenital cataract. It is necessary for us to implant the ideal intraocular lens degree, ensure the long-term stable visual effect and reduce the postoperatively anisometropia as much as possible. The error, statistics show that the degree error of intraocular lens (IOL) is about -4.06D~+3.86D within 1 years of age; there is no calculation formula for children's intraocular lens for the time being; it is difficult to measure the biological parameters of the children's eyes (including the length of the eye axis and the corneal curvature), although we can apply the IO in the state of the children's anesthetic condition in some medical centers with better equipment conditions. L-Master or portable automatic measuring tools are measured, but the measurement of biological parameters in some developing countries or hospitals with poor medical conditions is still not possible. In addition to the presence of corneal opacity and corneal deformation caused by trauma, the measurement of corneal curvature can also be affected. In these cases, the normal adult cornea will be chosen. The curvature 42.5D~44.0D is used to estimate the diopter of the intraocular lens, so this will produce a larger error for the younger children. The main factors affecting the refractive changes of the eyes include the axial length of the eye, the curvature of the cornea and the development of the lens. The eyes of the children in the 3 year old are still in the rapid development stage, and the ocular axis and the corneal curvature are in a constant change. In the process of cataract extraction, the aphakic eye and the implantation of the intraocular lens break the balance state of the refractive changes during the development, and whether the aphakic eye and the intraocular lens have a certain effect on the development of the ocular axis and the corneal curvature, and whether the effect of this effect can lead to a corresponding change in the refractive state of the eyes. It is a problem we need to observe and study. Of course, there are also many reports on the development of eyeball development in children's normal eyes and cataract eyes. However, the clinical observation of the changes of ocular axis and corneal curvature after congenital cataract surgery in children is not entirely consistent, for infants less than 3 years old. The clinical research reports are less. We observe and analyze the changes of axial length, corneal curvature and diopter of children with simple congenital cataract in 3 years of age. To further understand the effect of aphakia and intraocular lens on the axial length and corneal curvature of the congenital cataract before and after the operation, which is the hand in clinical work. Choice of timing, calculation of intraocular lens photometry with postoperative refractive index retention, and reduction of postoperative refractive error and anisometropia. Subjects were selected from 246 eyes of 158 children with congenital cataract in 3 years of age in our hospital, January 2014 ~2015, which were included in the standard: 1, simple eyes or single eyes. 2, the age of the operation was less than 3 years old; 3, the operation method: monocular congenital cataract: phacoemulsification, posterior capsule incision + anterior vitrectomy in 2 year old children, two stage intraocular lens implantation after 2 years of age, and more than 2 years old with phacoemulsification plus posterior capsule incision + anterior vitrectomy + IOL implantation;? Congenital cataract: phacoemulsification and posterior capsule incision + anterior vitrectomy in infancy and two stage intraocular lens implantation after 2 and a half years; over 2 and a half years old with phacoemulsification plus posterior capsule incision + anterior vitrectomy + intraocular lens implantation; 4, complete preoperative examination data, including medical history, family history, Eye axis length, corneal curvature, intraocular lens implantation diopter and retention degree; 5, after operation, regular remission, timely refractive correction, persistent amblyopia training and preservation of complete case data, and follow-up time of at least 1 years. The exclusion criteria: 1, other abnormal diseases such as congenital small eyeball, congenital small cornea, high Degree myopia, congenital glaucoma, PHPV, retina choroid dysplasia, and so on; 2, postoperative severe complications such as uveitis, IOL pupil clamp, IOL dislocation, posterior cataract, secondary glaucoma, etc.; 3, can not be revisited regularly after operation, can not adhere to the training of amblyopia, lack of complete surgical data and postoperative follow-up data in outpatient clinic. The study method is a prospective study. According to the age of first operation, group A: group A: March ~6 month; group B: ~12 month in June; C group: December ~18 month; D group: ~24 month, ~24 month; E group: 24 month ~36 month. After 1 years of postoperative follow-up, intraocular pressure, axial length, corneal curvature, and equivalent ball under primary optometry for March, June and 1 years after operation respectively The data of the study were statistically analyzed with the SPSS 21 statistical software, and the Kolmogorov-Smirnov test was used to check whether the measurement variables were in the normal distribution. If the conic normal distribution was tested by the two independent sample t test, it did not conform to the normal distribution. The normal distribution was tested by the rank sum test; the age and sex ratio were compared with the single factor variance analysis (ANOVA) test. The difference of P0.05 was statistically significant. Results the changes of axial length in each stage after 1. were compared: the axial length of the five groups of children in March were 18.82 + 1.219mm, 20.61 + 0.796mm, 21.28 + 0.987mm, 21.60 + 0.836mm, 2, respectively. 1.94 + 0.992mm, respectively, increased 0.818 + 0.387mm, 0.682 + 0.289mm, 0.504 + 0.264mm, 0.353 + 0.450mm, 0.266 + 0.344mm, respectively. The axial length of the five groups of children in June were 1.561 + 0.473mm, 1.132 + 0.439mm, 0.963 + 0.395mm, 0.713 + 0.569mm, 0.464 + 0.488mm. It was 2.554 + 0.588mm, 1.728 + 0.592mm, 1.080 + 0.513mm, 0.859 + 0.704mm, 0.768 + 0.520mm. five, in March, after operation June and 1 years after operation, the difference between the eye axis growth and preoperative difference was statistically significant (P 0.05); the five groups in March, A, B, C three group increased more than D, E group, the difference was statistically significant (P0.05), the difference was statistically significant The growth rate of group D was greater than that of group B, and the growth rate of group D was greater than that of E group, but the difference was not statistically significant (P0.05). The growth rate of group A and B was greater than that of C, D and E group after operation in June and 1 years after operation, and the difference was statistically significant (P0.05), but there was no statistical significance in AB, CDE, but there was no significant difference between the five groups. The amplitude was greater than that of the healthy eyes, but the difference was not statistically significant (P0.05), and the growth amplitude decreased with the age of.3.. The corneal curvature of the children after operation in March, June and 1 years postoperatively compared with the preoperative corneal curvature was A, B, C, D group were statistically significant (P0.05), E group (24 months ~36 months) compared with preoperative Corneal curvature gradually decreased, but no statistical significance. Preoperative, postoperative, March, June and 1 years after 1 years of corneal curvature of the difference was statistically significant (P0.05); the five groups were compared: March, A, B two groups of changes more than C, D, E group, C group greater than the E group, the difference is statistically significant (P0.05), C group is greater than the D group, D group change rate is larger than the group, D group, greater than the group, D group, change rate is larger than the group, D group, But the difference was not statistically significant (P0.05). In June and 1 years after operation, the change rate of group A was greater than that of C, D and E, the difference was statistically significant (P0.05), but the difference was not statistically significant (P0.05), but the change rate of corneal curvature in B group was greater than that in E group (P0.05), but there was no statistical significance. There was no significant difference between the corneal curvature and the healthy eye (all P0.05). The corneal curvature of the five groups after the operation was basically the same as that in the healthy eyes, and the corneal curvature decreased gradually, and with the age increasing, the change of corneal curvature gradually became smaller, and the difference was not statistically significant (P0.05) 1 years after.5.. Comparison of photometric changes: the equivalent photoscope was used as initial diopter at 2 weeks after operation. The diopter changes in five groups were -2.89 + 0.975D, -2.51 + 0.732D, -2.28 0.837D, -1.94 + 1.035D, -1.85 + 0.897D, respectively, and the difference was statistically significant (P=0.015), and the three groups were more than two groups. The difference was statistically significant. ABC, DE, but the difference was not statistically significant. The diopter of each group drifted to myopia, with the increase of age, the trend of the drift to myopia was slower than that of the.6. monocular congenital cataract surgery. There was no significant difference in the diopter difference compared with the healthy eye (P0.05), but the diopter had a tendency to drift toward myopia. A group of children with.7. binocular congenital cataract and children with congenital cataract were paired with t test. The results showed that the axial length, corneal curvature and diopter of the eyes were not statistically significant in the age group (P0.05), and the axial length and diopter of the ocular axis were not significant. There were no retinal detachment, posterior cataract, secondary glaucoma, IOL dislocation, 1 cases in group E and 2 cases in group C were excluded from the data, and the data were not included in the statistical analysis. The 5 children in group E had a small amount of pigmentation in the IOL surface of group E, and no effect on visual development. Conclusion in 1.18 months, the growth rate of ocular axis is faster and the axis of eye is slowly increasing. The growth amplitude of ocular axis in children with monocular is faster than that in healthy eyes and binocular children. In 2.12 months, the change of corneal curvature is larger, then changes slowly, and 24 months basically develops to normal adult level; 3. the refraction of congenital cataract after operation has the direction of myopia. The trend of shift to drift and the tendency to change with age is slow. 4. the axial length of ocular axis, the curvature of the cornea and the diopter of the cornea can keep in harmony with the healthy eyes.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R779.66

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