屈光手术后干眼患者角膜共焦镜观察

发布时间：2018-03-31 08:03

本文选题：准分子激光原位角膜磨镶术　切入点：干眼症　出处：《北京协和医学院》2013年博士论文

【摘要】：目的观察LASIK术后角膜中央基底层下上皮神经丛的再生,研究其数量及形态参数与干眼指标间的关系,以及神经再生及干眼程度与术后时间、不同术式、切削深度等指标之间的相关性,从而帮助我们更全面地了解LASIK术后干眼症的病理生理机制,以期优化其治疗方案。方法随机入选2011年10月至2012年9月在北京协和医院眼科行传统LASIK/飞秒LASIK手术的近视患者42例(84眼)。根据患者随访时间分为LASIK术后半年组19例(38眼)和LASIK术后一年组23例(46眼)。对患者进行的术后检查主要包括干眼相关检查和角膜共聚焦显微镜检查两部分,其中前者又可分为泪液三项试验和OSDI问卷调查,后者即采用HRT III共聚焦显微镜着重对基底层下上皮神经丛进行观察,在单眼的角膜中央区域内任意选择三点行立体扫描,从中挑选出基底层下上皮神经最丰富且最清晰的三幅图像后使用ACCMetrics软件对这些图像进行神经数量及形态参数的统计并取平均值,具体参数包括神经纤维主干及主干上分支的密度(CNFD和CNBD)、神经纤维长度(CNFL)、神经总分支节点的密度(CTBN)、以及神经纤维的宽度(CNFW)和弯曲度(CNFT)等。采用独立样本t检验的方法比较术后不同随访时间组(半年组、一年组)之间,以及不同种类LASIK术式组(传统组、飞秒组)之间神经参数与干眼指标的差异；此外,根据实际情况对神经参数与干眼指标,以及两者分别与切削深度及基质层厚度之间的关系行偏相关及双变量相关性分析。结果 1.干眼指标,LASIK术后一年组患者的Schirmer试验值和TBUT值均显著大于半年组(t=-2.340,-5.403,P0.05),荧光素染色分值显著小于半年组(t=2.634,P0.05),但两组间的OSDI评分未见统计学显著性差异(t=1.207,P0.05)。神经参数,LASIK术后一年组患者的CNFD、CNBD、CNFL、CTBN值均显著大于半年组(t=-3.293,-4.501,-7.091,-4.240, P0.01),但是两组间的CNFW、CNFT值均未见显著性差异(t=1.480,0.474,P0.05)。 2. LASIK术后半年组,CNBD值与荧光素染色评分值呈负相关(r=-0.346,P0.05),其余神经参数与干眼指标均无相关性(P值均0.05)。LASIK术后一年组,CNFD值与Schirmer试验值呈正相关(r=0.321, P0.05), CNBD、CTBN、CNFT值与Schirmer试验值呈负相关(r=-0.347,-0.340,-0.325,P0.05),而CNFW值则与OSDI评分值呈正相关(r=0.342,P0.05),其余神经参数与干眼指标均无相关性(P值均0.05)。 3.无论是LASIK术后半年组还是一年组,行传统LASIK手术的患者其各项干眼主客观指标和神经数量及形态参数与行飞秒LASIK手术的患者相比不存在任何显著性差异(P值均0.05)。 4. LASIK术后半年组,神经纤维的数量及形态参数以及干眼指标与手术切削深度及残留基质床厚度均无相关性(P值均0.05)。LASIK术后一年组,TBUT值与手术切削深度呈负相关(r=-0.297,P0.05),而其余神经参数及干眼指标与手术切削深度及残留基质床厚度均无相关性(P值均0.05)。结论 1. LASIK术后一年患者的干眼客观指标较术后半年患者显著改善,且其角膜中央基底层下上皮神经丛主干及分支的数量、神经纤维的长度均较术后半年患者显著增加。 2. LASIK术后半年及一年患者角膜中央基底层下上皮神经丛的某些神经参数与干眼指标存在相关性,尤以术后一年者较为明显。 3.传统LASIK与飞秒LASIK相比,其对术后半年及一年患者的干眼指标和神经参数所产生的影响无显著差异。 4. LASIK术后一年患者的TBUT值与手术切削深度呈负相关。
[Abstract]:objective
The regeneration of central corneal basal epithelial nerve plexus under observation after LASIK, and the number and morphological parameters of dry eye index, and dry eye and nerve regeneration degree and postoperative time, different surgical methods, the correlation between the cutting depth and other indicators, so as to help us a more comprehensive understanding of the pathophysiology of dry eye after LASIK, in order to optimize the treatment plan.
Method
From October 2011 to September 2012 were randomly selected in 42 cases in Peking Union Medical College Hospital underwent conventional LASIK/ femtosecond LASIK surgery patients (84 eyes). According to the follow-up time were divided into 19 cases of group six months after LASIK (38 eyes) and LASIK 1 year after surgery group 23 cases (46 eyes). The postoperative patients were examined including the two part dry eye related examination and corneal confocal microscopy, which can be divided into three tear test and OSDI questionnaire, which is used by HRT III confocal microscope focuses on the observation of the basal layer of epithelial plexus, choose three bit stereo scan in the central region of the cornea from monocular. Selected three images under basal epithelial nerve most abundant and most clear statistics using ACCMetrics software for nerve number and morphology parameters of these images and averaged, the specific parameters include the nerve fiber The main trunk and branch density (CNFD and CNBD), nerve fiber length (CNFL), nerve branch node density (CTBN), and the width of nerve fibers (CNFW) and curvature (CNFT). By using the method of independent sample t test to compare the different postoperative follow-up group (six months group. A group of years) between, and different types of LASIK surgery group (traditional group, femtosecond group) between the neural parameters and the differences of dry eye index; in addition, according to the neural parameters and dry eye index analysis for the actual situation, and the relationship between cutting depth and matrix respectively with the thickness of bivariate correlation and partial correlation.
Result
1. dry eye index, after LASIK Schirmer in experimental group and TBUT values were significantly greater than half the group (t=-2.340, -5.403, P0.05), fluorescein staining scores were significantly less than half the group (t=2.634, P0.05), but OSDI score no statistically significant difference between the two groups (t=1.207, P0.05) nerve. CNFD, a group of parameters in patients after LASIK CNBD, CNFL, CTBN were significantly greater than half the group (t=-3.293, -4.501, -7.091, -4.240, P0.01), but the CNFW between the two groups, there were no significant differences in CNFT values (t=1.480,0.474, P0.05).
2. LASIK six months after operation group, the CNBD score was negatively correlated with fluorescein staining (r=-0.346, P0.05), the neural parameters and dry eye were no correlation (P 0.05) group one year after.LASIK, CNFD value was positively correlated with the experimental data of Schirmer (r=0.321, P0.05), CNBD, CTBN. CNFT was negatively correlated with the experimental data of Schirmer (r=-0.347, -0.340, -0.325, P0.05), while the CNFW value was positively correlated with OSDI score (r=0.342, P0.05), the neural parameters and dry eye were no correlation (P 0.05).
3., whether in the half year group or the one year group after LASIK, there was no significant difference in the subjective and objective indexes and nerve number and morphological parameters of dry eye between those who underwent traditional LASIK operation and those who underwent femtosecond LASIK surgery (P = 0.05).
4. LASIK six months after operation group, the number and morphology of nerve fibers and parameters of dry eye index and ablation depth and residual stromal bed thickness had no correlation (P = 0.05) group one year after.LASIK, TBUT was negatively correlated with surgical cutting depth (r=-0.297, P0.05), while the remaining parameters and neural stem eye index and ablation depth and residual stromal bed thickness had no correlation (P = 0.05).
conclusion
After 1. LASIK, the dry eye index of one year after operation was significantly improved compared with that of half a year after operation, and the number of trunk and branch of corneal central basal layer and the length of nerve fiber were significantly higher than those of half a year after operation.
2., half a year and a year after LASIK, there were correlations between some nerve parameters of corneal central basal layer and epithelial nerve plexus and dry eye index, especially in one year after operation.
3. compared with the femtosecond LASIK, there is no significant difference in the effects of LASIK and femtosecond LASIK on the dry eye index and the nerve parameters in the six months and one year after the operation.
4. LASIK after one year, the TBUT value of the patients was negatively correlated with the depth of the surgical cutting.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R779.63

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