DDLS分级方法评估原发性慢性闭角型青光眼神经损害与OCT视野的相关性及指导临床治疗研究

发布时间：2018-02-09 05:28

  本文关键词： DDLS/视盘损害分级法 视野 光学断层相干扫描 慢性闭角型青光眼 房角分级 眼压　出处：《第三军医大学》2011年硕士论文　论文类型：学位论文

【摘要】：背景：中国人有2000万人以上青光眼患者,以原发性闭角型青光眼(Primary angle-closure Glaucoma,PACG)为主,其中原发性慢性闭角型青光眼(Primary chronic angle-closure glaucoma,PCACG)又占PACG总数的60%以上,视神经乳头(optical nerve head,ONH)客观形态学检查及(retina nerve fiber layer,RNFL)厚度变化的评估对青光眼的诊断与治疗尤为重要,目前在国际上尚无统一的对青光眼性的ONH损害诊断标准。 视杯视盘比率(cup disc ratio, C/D)是使用最广泛的视盘损害评估指标,但由于其测量值本身很不统一,而且视杯、视盘大小在人群中的差异很大,不能作为对青光眼定性和量化的一种可靠指标,单纯用C/D判断青光眼ONH损害很容易漏诊和误诊。计算机辅助的客观仪器能较为精确的对RNFL厚度及盘沿面积的检测,但是它们无法直观观测视盘盘沿形态,视盘大小及其视乳头颜色变化,难以判断个体间的正常变异,此外,也难以鉴别非青光眼性视神经损害导致RNFL丢失。针对以上不足Spaeth等提出青光眼ONH形态学损害的检查需要结合视盘直径大小及盘沿形态分析,并提出ONH损害分级法(disc damage likelihood scale,DDLS)对青光眼视神经形态学描述。 DDLS分级法能对开角型青光眼(primary open angle glaucoma,POAG)视神经损害进行评估,在临床上,PCACG与POAG视神经损害具有相似性,该方法能否适用于PCACG视神经损害评估迄今尚不明确。 本课题从以下方面进行研究以期望扩大DDLS分级方法临床运用范围,并利用该分级方法指导PCACG的临床治疗,为后期临床运用提供研究依据。 一、合理规范临床课题设计,收集PCACG患者； 二、运用DDLS分级法对视盘形态进行分级,与OCT视盘检查参数,视野变化值进行相关性研究； 三、DDLS分级对PCACG临床治疗的指导。 目的： 1.探讨DDLS分级值与OCT检测视盘参数及视野(visual field, VF)变化的相关性,评估DDLS方法对PCACG视神经损害可行性。 2.运用DDLS分级对照房角分级指导PCACG临床治疗,观察激光虹膜周切术(lase periperal iridotomy, LPI)、LPI联合药物治疗及小梁切除手术三种治疗方式对PCACG的眼压控制情况,评估DDLS指导临床治疗的有效性。 对象与方法： 1、收集我院2008年12月—2011年03月PCACG患者病例,运用Volk 90D前置镜在裂隙灯下对视盘直径及其盘沿最窄处宽度测量,按DDLS分级评分；Stratus OCT3000成像仪RNFL 3.4扫描程序对视盘检测获取各象限、钟点位及自选参数的RNFL厚度,视盘面积等参数；Humphrey视野计(humprey field analyzer,HFA)242程序(Swedish Interactive Threshold Algorithm standard,SITA 24-2)检查视野变化,获得平均缺损(mean deviation, MD)、模式标准差(pattern standared deviation, PSD)值。运用SPSS15.0分析DDLS评分值、OCT视盘检测参数、视野值的相关关系。 2、将PCACG患者随机分为两组,DDLS分级指导临床治疗组(实验组)与房角分级指导临床治疗组(对照组),DDLS分级分三阶段,第一阶段对照房角1800范围且眼压≥21mmHg,MD-6组接受LPI治疗；第二阶段对照房角1800范围且眼压≥21mmH-6≤MD-12组接受LPI联合药物治疗；第三阶段对照房角≥1800范围,眼压≥21mmHg,伴视野MD≥-12接受小梁切除手术治疗,观察两组治疗前后眼压变化情况,运用logistic回归分析检验两组间关系,评估实验组指导临床治疗的有效性。 结果： 1.第二部分对例20例(38眼)结果进行分析,大直径视盘3眼(占7.9%),中等直径视盘11眼(占28.9%),小直径视盘24眼(占63.2%)；上方、下方、颞侧象限RNFL厚度均值与DDLS分级评分相关(r=-0.673,P=0.0001；r=-0.605,P=0.0001,r=-0.499,P=0.0014),鼻侧方象限RNFL厚度均值与DDLS分级评分不相关(r=-0.352,P=0.0602)；11、7、6、10、12钟点位RNFL厚度与DDLS分级评分具有相关性(r=-0.673,P=0.0001；r=-0.605,P=0.0001；r=-0.531,P=0.0006；r=-0.525,P=0.0007；r=-0.520,P=0.0008),而3、2、8点位无统计学意义(r=-0.320,P=0.0501；r=-0.320,P=0.0510；r=-0.297,P=0.0702,)；DDLS分级评分与OCT检查自选参数Avg、Smax、Imax的RNFL厚度也呈中度相关(r=-0.582,P=0.0001；r=-0.504,P=0.0012；r=-0.478,P=0.0024)。DDLS分级评分与OCT检测视盘面积结果显示相关,下方区域相关系数最高(r=-0.878,P0.0001；r=-0.730,P0.0001)。DDLS分级评分与视野检测结果显示：DDLS评分与视野MD相关(r=-0.593,P0.0001),与PSD值相关(r=-0.60,P0.0001),OCT检测参数与视野检测结果显示,全盘沿面积呈中度相关(r=-0.53,p0.0001),盘沿与视盘比率均与视野MD值呈低度相关,水平方向盘沿面积与视野MD值无统计意义(r=-0.02,P=0.058)。 2.第三部分DDLS组29例(54眼),患者平均年龄(50.7±9.8)岁,房角组28例(53眼),患者平均年龄(52.2±10.1)岁；logistic回归分析提示DDLS组与房角组分别接受的三种临床治疗方式组间统计无显著差异(OR=0.81,p=0.624),小梁切除术优于LPI(OR=4.88,P=0.0075),LPI联合药物与LPI之间无见统计学差异(OR=2.39,P=0.0946),小梁切除术组较其他两种治疗方式更为有效控制眼压(OR=4.88,P=0.0075)。即两种方法对治疗的临床指导无显著差别,而不同治疗方式对眼压控制疗效影响有统计学差异。 结论： 1、DDLS分级方法对PCACG视神经损害的评估与OCT视盘主要检查参数及视野检查具有相关性,DDLS分级方法适用于PCACG视神经损害的评估。 2、DDLS组与房角组对眼压控制的有效率无统计学差异,DDLS分级指导PCACG临床治疗是对房角分级指导临床治疗的有益补充。
[Abstract]:Background: Chinese has more than 20 million glaucoma patients, with primary angle closure glaucoma (Primary angle-closure Glaucoma, PACG), the primary chronic angle closure glaucoma (Primary chronic angle-closure glaucoma, PCACG and PACG) accounted for 60% of the total. The optic papilla (optical nerve head, ONH) objective morphological examination (retina nerve and fiber layer, RNFL) diagnosis and treatment evaluation of thickness variation of glaucoma is particularly important, standards for glaucoma ONH damage diagnosis in the world at present there is no uniform.
Optic disc cupping ratio (cup disc ratio, C/D) is the most widely used disc damage assessment indicators, but because the measurement value itself is not unified, and the optic cup, differences in the size of the disc in the crowd, not as a reliable indicator of qualitative and quantitative glaucoma, only C/D in determining glaucoma ONH damage it is easy to misdiagnosis. The objective of computer aided detection instrument of RNFL thickness and rim area accurately, but they are unable to visually observe the morphology of optic disc, the size of the disc and optic color change, it is difficult to determine the normal variation between individuals, in addition, it is difficult to identify non glaucomatous optic nerve damage the loss of RNFL. To solve the above problem proposed by Spaeth in glaucoma ONH morphological examination need along the morphological analysis with optic disc diameter size and disk, and puts forward the classification method of ONH (disc damage likelih damage Ood scale, DDLS) the morphological description of optic nerve in glaucoma.
DDLS grading can evaluate the optic nerve damage of primary open angle glaucoma (POAG). In clinic, PCACG and POAG have similar optic nerve damage. Whether the method can be applied to evaluate the optic nerve damage of PCACG is not clear.
This research is conducted from the following aspects, hoping to expand the clinical application scope of DDLS classification method, and use this grading method to guide the clinical treatment of PCACG, so as to provide a basis for later clinical application.
First, we should standardize the design of clinical subjects and collect PCACG patients.
Two, the DDLS classification method was used to classify the optic disc morphology, and the correlation of the OCT disc examination parameters and the visual field values was studied.
Three, DDLS classification for the guidance of PCACG clinical treatment.
Objective:
1. the correlation between DDLS classification value and OCT detection of visual disc parameters and the changes of visual field (VF) was investigated, and the feasibility of DDLS method for PCACG optic nerve damage was evaluated.
2. using DDLS grading control angle to guide the clinical treatment of grade PCACG, observation of laser iridectomy (lase Periperal, iridotomy, LPI), three kinds of treatment of surgery intraocular pressure control of PCACG LPI resection combined with drug treatment and evaluation of DDLS beam, guide the clinical treatment is effective.
Objects and methods:
1, collected in our hospital from December 2008 to 2011 03 PCACG cases, the use of Volk 90D lens under slit lamp on the diameter of the optic disc along the narrowest width measurement score according to DDLS classification; Stratus OCT3000 imager RNFL 3.4 scanning program for each quadrant of the optic disc detection, the clock points and optional parameters of RNFL thickness and disc area parameters; Humphrey perimetry (humprey field analyzer, HFA) 242 (Swedish Interactive Threshold Algorithm standard program, SITA 24-2) to check the view changes, obtain the mean defect (mean deviation, MD), pattern standard deviation (pattern standared, deviation, PSD). Using SPSS15.0 analysis DDLS score, OCT video detection correlation between parameters, view value.
2 PCACG patients were randomly divided into two groups, DDLS grade guide clinical treatment group (experimental group) and angle classification to guide the clinical treatment group (control group), DDLS grade is divided into three stages, the first stage of the control angle range of 1800 and the pressure is larger than 21mmHg, MD-6 group received LPI treatment; the second phase angle control 1800 and the range of intraocular pressure is greater than or equal to 21mmH-6 = MD-12 group received LPI combined with drug therapy; third stage control angle is greater than or equal to 1800, the intraocular pressure is larger than 21mmHg, with the view of MD more than -12 accepted trabeculectomy surgery, to observe the changes of intraocular pressure before and after treatment in two groups, using logistic regression analysis to test the relationship between the two groups, the experimental group assessment guide the effectiveness of clinical treatment.
Result锛，

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