糖尿病角膜神经病变与视网膜病变的相关性研究
发布时间：2018-07-13 10:41
【摘要】：研究背景和目的:糖尿病是目前全球关注的公共卫生问题。糖尿病视网膜病变(Diabetic retinopathy,DR)和糖尿病角膜神经病变(Diabetic corneal neuropathy,DCN)分别是眼部常见的微血管并发症和神经并发症。DR在屈光间质不清楚等情况下很难判断眼底微血管病变的严重程度;DCN由于检查手段有限,活体共聚焦显微镜(in vivo confocal microscopy,IVCM)是目前唯一可以活体观察角膜神经纤维的检查方法,因此未被广泛重视。糖尿病的全身神经并发症和微血管并发症之间具有非常密切的相关性,但在眼部DCN与DR在临床上是否也有密切相关性?如果两者病情密切相关,DCN则可以作为DR病情判断困难时的预测参考指标。另外,早期进行血糖、血压、血脂等干预对于预防DR的发展有重要意义,IVCM对角膜神经的检查具有微观、敏感的特点,角膜神经的损害如果能在尚未出现微血管病变时早期检测,则提示我们尽早干预DR。因此,本研究有两方面目的:一方面,通过IVCM观察不同时期DR的DCN超微结构改变,证实IVCM在DCN的临床应用价值,探索DCN和DR两者病情严重程度是否存在相关性。另一方面,观察DR早期尚未出现微血管病变时是否同时存在角膜神经纤维(Corneal nerve fibers,CNF)和视网膜神经纤维层(Retinal nerve fibre layer,RNFL)变化,并观察两者变化是否具有相关性,为干预DR提供早期筛查指标。研究对象和方法:第一部分:收集120例(120眼)2型糖尿病患者,按照糖尿病视网膜病变国际分期标准分为无视网膜病变(no diabetic retinopathy,NDR)组、轻中度非增生期(mild or moderate non-proliferative diabetic retinopathy,mNPDR)组、重度非增生期(severe non-proliferative diabetic retinopathy,s NPDR)组和增生期(proliferative diabetic retinopathy,PDR)组,每组30例(30眼);另收集30例(30眼)健康正常眼作为对照组。利用Heidelberg HRT3 IVCM观察角膜上皮下神经纤维的形态指标,包括角膜神经纤维长度(Nerve fiber length,NFL)、角膜神经纤维密度(Nerve fiber density,NFD)、角膜神经纤维分支密度(Nerve fiber branch density,NFB)和角膜神经弯曲度(Nerve tortuosity,NT)。第二部分:收集40例(40眼)2型糖尿病患者,经散瞳眼底检查未发现糖尿病视网膜病变,均接受光学相干断层扫描(Optical Coherence Tomography,OCT)检查和IVCM检查。另收集年龄匹配的80例(80眼)健康正常眼为对照,分为40例(40眼)只行OCT检查的RNFL对照组和40例(40眼)只行IVCM检查的CNF对照组。利用OCT观察视乳头上方、下方、颞侧、鼻侧和平均RNFL厚度,用IVCM观察角膜上皮下NFL和NFD。结果:第一部分:糖尿病各组的角膜NFL、NFD、NFB均比对照组减少(P0.01),而NT弯曲度比对照组增加(P0.01)。随着DR病情加重,NFL、NFD、NFB逐步减少(P0.01),NT增大(P0.01),但sNPDR组和PDR组间角膜神经各项指标差异均无统计学意义(P0.05)。NFL、NFD、NFB与DR严重程度呈负相关(r=-0.875、-0.866、-0.798,P=0.000、0.000、0.000),NT与DR严重程度正相关(r=0.693,P=0.000)。第二部分:糖尿病组的视乳头上方、颞侧、鼻侧及平均RNFL与RNFL对照组差异无统计学意义(P0.05),但视乳头下方RNFL糖尿病组比RNFL对照组减少(P=0.003)。糖尿病组的角膜NFL、NFD均比CNF对照组减少(P0.01)。糖尿病组中,平均RNFL与NFL、NFD呈正相关(r=0.518,P0.01;r=0.484,P=0.002),下方RNFL与角膜NFL、NFD呈正相关(r=0.607,P0.01;r=0.573,P0.01)。结论:1.IVCM是评估DCN的敏感、有效检查方法,糖尿病患者存在不同程度的角膜神经纤维丢失和角膜神经弯曲度增大;2.DCN与DR的病情严重程度具有明显的相关性,随着DR严重程度增加,DCN也逐渐加重,DCN可以作为DR病情程度预测指标;3.糖尿病患者在未发现视网膜微血管病变时,已经同时存在CNF和RNFL的丢失,RNFL变薄主要表现在下方象限;CNF的减少与RNFL的变薄呈正相关。CNF和RNFL可以作为早期干预DR的筛查指标。
[Abstract]:Background and purpose: diabetes is a global public health problem. Diabetic retinopathy (Diabetic retinopathy, DR) and diabetic corneal neuropathy (Diabetic corneal neuropathy, DCN) are the common microvascular complications of the eyes, and neuropathy.DR is difficult to judge under the uncertainty of the refractive interstitium. The severity of microvascular lesions in the fundus; DCN vivo confocal microscopy (IVCM), due to limited examination, is the only method that can be used to observe the corneal nerve fibers in vivo. Therefore, it is not widely recognized. There is a very close relationship between diabetic systemic neurosis and microvascular complications. Is there a close correlation between the DCN and the DR in the eye? If the two are closely related, DCN can be used as a predictor for the prediction of the difficulty of DR. In addition, early intervention in blood sugar, blood pressure, and blood lipid is important to prevent the development of DR. IVCM has a microcosmic and sensitive examination of the corneal nerve. Characteristics, the damage of the corneal nerve, if it can be detected early in the absence of microvascular lesions, suggests that we intervene DR. as early as possible. There are two aspects of this study. On the one hand, the DCN ultrastructural changes of DR in different periods are observed by IVCM, and the value of IVCM in DCN is confirmed and the severity of the severity of both DCN and DR is explored. On the other hand, whether the changes of corneal nerve fiber (Corneal nerve fibers, CNF) and retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were observed at the same time in the early stage of DR, and whether the changes of the retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were related, and to provide early screening indicators for intervention DR. The first part: 120 patients (120 eyes) with type 2 diabetes were divided into the no diabetic retinopathy (NDR) group, the mild to moderate non hyperplastic period (mild or moderate non-proliferative diabetic retinopathy, mNPDR) group, and the severe non hyperplastic period (severe). Retinopathy, s NPDR) group and hyperplastic period (proliferative diabetic retinopathy, PDR) group, 30 cases (30 eyes) in each group, and 30 cases (30 eyes) healthy and normal eyes as the control group. The morphological indexes of the corneal subcutaneous nerve fibers were observed by Heidelberg HRT3 IVCM, including the length of the corneal nerve fiber (Nerve fiber), corneal nerve fiber. The density (Nerve fiber density, NFD), the branch density of the corneal nerve fiber (Nerve fiber branch density, NFB) and the corneal nerve flexure (Nerve tortuosity, NT). Second: 40 patients (40 eyes) with type 2 diabetes were collected, and the retinopathy of diabetic retinopathy was not found by the pupil fundus examination. Omography, OCT) and IVCM examination. Another 80 cases of age matched (80 eyes) healthy and normal eyes were collected, divided into 40 cases (40 eyes), RNFL control group with OCT examination and 40 cases (40 eyes), only CNF control group with IVCM examination. Using OCT to observe the upper, inferior, temporal, nasal side and average RNFL thickness of the optic papilla with OCT, and observe the NFL and NFD of the upper cornea with IVCM. Results: the first part: the corneal NFL, NFD, and NFB in all groups of diabetes were lower than those of the control group (P0.01), while the NT flexural degree was higher than the control group (P0.01). With the aggravation of DR, NFL, NFD, NFB gradually decreased (P0.01) and NT increased, but there was no significant difference in the various indexes of the angular membrane nerve between the groups and the groups. The degree was negatively correlated (r=-0.875, -0.866, -0.798, P=0.000,0.000,0.000), NT was positively correlated with DR severity (r=0.693, P=0.000). The second part: there was no significant difference between the optic papilla, the temporal side, the nasal side and the average RNFL and RNFL control groups in the diabetic group (P0.05), but the diabetes group below the papilla was less than the control group. The NFL and NFD of the cornea of the disease group were lower than that of the CNF control group (P0.01). In the diabetic group, the average RNFL was positively correlated with NFL and NFD (r=0.518, P0.01; r=0.484, P=0.002). The loss of nerve fibers and the degree of corneal nerve flexure increased; 2.DCN had a significant correlation with the severity of DR. As the severity of DR increased, DCN was gradually aggravated, and DCN could be used as a predictor of the degree of DR. In 3. diabetic patients, the loss of CNF and RNFL and the thinning of RNFL had been found at the same time when retinal microangiopathy was not found. It is mainly manifested in the lower quadrant. The decrease of CNF is positively correlated with the thinning of RNFL..CNF and RNFL can be used as screening indicators for early intervention of DR.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R587.2;R774.1
本文编号：2119082
[Abstract]:Background and purpose: diabetes is a global public health problem. Diabetic retinopathy (Diabetic retinopathy, DR) and diabetic corneal neuropathy (Diabetic corneal neuropathy, DCN) are the common microvascular complications of the eyes, and neuropathy.DR is difficult to judge under the uncertainty of the refractive interstitium. The severity of microvascular lesions in the fundus; DCN vivo confocal microscopy (IVCM), due to limited examination, is the only method that can be used to observe the corneal nerve fibers in vivo. Therefore, it is not widely recognized. There is a very close relationship between diabetic systemic neurosis and microvascular complications. Is there a close correlation between the DCN and the DR in the eye? If the two are closely related, DCN can be used as a predictor for the prediction of the difficulty of DR. In addition, early intervention in blood sugar, blood pressure, and blood lipid is important to prevent the development of DR. IVCM has a microcosmic and sensitive examination of the corneal nerve. Characteristics, the damage of the corneal nerve, if it can be detected early in the absence of microvascular lesions, suggests that we intervene DR. as early as possible. There are two aspects of this study. On the one hand, the DCN ultrastructural changes of DR in different periods are observed by IVCM, and the value of IVCM in DCN is confirmed and the severity of the severity of both DCN and DR is explored. On the other hand, whether the changes of corneal nerve fiber (Corneal nerve fibers, CNF) and retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were observed at the same time in the early stage of DR, and whether the changes of the retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were related, and to provide early screening indicators for intervention DR. The first part: 120 patients (120 eyes) with type 2 diabetes were divided into the no diabetic retinopathy (NDR) group, the mild to moderate non hyperplastic period (mild or moderate non-proliferative diabetic retinopathy, mNPDR) group, and the severe non hyperplastic period (severe). Retinopathy, s NPDR) group and hyperplastic period (proliferative diabetic retinopathy, PDR) group, 30 cases (30 eyes) in each group, and 30 cases (30 eyes) healthy and normal eyes as the control group. The morphological indexes of the corneal subcutaneous nerve fibers were observed by Heidelberg HRT3 IVCM, including the length of the corneal nerve fiber (Nerve fiber), corneal nerve fiber. The density (Nerve fiber density, NFD), the branch density of the corneal nerve fiber (Nerve fiber branch density, NFB) and the corneal nerve flexure (Nerve tortuosity, NT). Second: 40 patients (40 eyes) with type 2 diabetes were collected, and the retinopathy of diabetic retinopathy was not found by the pupil fundus examination. Omography, OCT) and IVCM examination. Another 80 cases of age matched (80 eyes) healthy and normal eyes were collected, divided into 40 cases (40 eyes), RNFL control group with OCT examination and 40 cases (40 eyes), only CNF control group with IVCM examination. Using OCT to observe the upper, inferior, temporal, nasal side and average RNFL thickness of the optic papilla with OCT, and observe the NFL and NFD of the upper cornea with IVCM. Results: the first part: the corneal NFL, NFD, and NFB in all groups of diabetes were lower than those of the control group (P0.01), while the NT flexural degree was higher than the control group (P0.01). With the aggravation of DR, NFL, NFD, NFB gradually decreased (P0.01) and NT increased, but there was no significant difference in the various indexes of the angular membrane nerve between the groups and the groups. The degree was negatively correlated (r=-0.875, -0.866, -0.798, P=0.000,0.000,0.000), NT was positively correlated with DR severity (r=0.693, P=0.000). The second part: there was no significant difference between the optic papilla, the temporal side, the nasal side and the average RNFL and RNFL control groups in the diabetic group (P0.05), but the diabetes group below the papilla was less than the control group. The NFL and NFD of the cornea of the disease group were lower than that of the CNF control group (P0.01). In the diabetic group, the average RNFL was positively correlated with NFL and NFD (r=0.518, P0.01; r=0.484, P=0.002). The loss of nerve fibers and the degree of corneal nerve flexure increased; 2.DCN had a significant correlation with the severity of DR. As the severity of DR increased, DCN was gradually aggravated, and DCN could be used as a predictor of the degree of DR. In 3. diabetic patients, the loss of CNF and RNFL and the thinning of RNFL had been found at the same time when retinal microangiopathy was not found. It is mainly manifested in the lower quadrant. The decrease of CNF is positively correlated with the thinning of RNFL..CNF and RNFL can be used as screening indicators for early intervention of DR.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R587.2;R774.1
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