频域OCT观察特发性黄斑裂孔手术前后光感受器内外节的变化
发布时间：2018-08-09 10:15
【摘要】：研究背景自上个世纪九十年代以来,眼科各项检查技术日新月异发展,光学相干断层扫描技术就是在这个时候迅速发展起来的一种新的医学断层成像分析技术,它融合了光学技术、半导体激光技术、数据模型计算和数字化图像处理技术等,在对人体进行非损伤性的活体形态学检测同时,获得生物组织内部微结构的横断面图像。特别是随着OCT从时域模式转变为频域模式,OCT发展也进入了新的时代。从OCT技术引入眼科伊始,其在黄斑裂孔诊断中的研究最早也最深入。在黄斑裂孔中,以特发性黄斑裂孔最为多见。研究者们发现OCT能清晰的发现视网膜内各层结构的形态学变化,对于黄斑裂孔的形成过程和分期,OCT检查能清晰的显示类似于病理切片的“解剖学”改变,因此能精确的解释患者与视网膜解剖结构变化相对应的视力改变和预后。在各种检查手段中,临床眼科医生发现OCT是优于各种传统检测手段的眼底影像学技术。随着手术技术和设备的日益完善,术后患者黄斑裂孔的裂孔封闭率日益提高。但是,术后OCT检查证实裂孔封闭的患者,视力改善的程度却不一致,有的患者术后视力甚至较术前下降,使得人们寻找影响IMH患者视力预后的各种原因。以往的时域OCT在特发性黄斑裂孔的观察上,多集中在黄斑裂孔直径、基底裂孔直径、裂孔面积、黄斑中央视网膜厚度、裂孔形态、裂孔鼻侧和颢侧边缘水肿程度等指标上。有的学者通过回顾性研究中发现裂孔大小、孔缘神经上皮层厚度与患眼视力密切相关。但是同时也有学者发现板层黄斑裂孔矫正视力与裂孔面积、裂孔基底宽度、裂孔位置均无相关性,而且与以往研究得出的“裂孔越大、视力越低,裂孔越小、视力越好”的结论并不一致,在径线选取的部位上也存在一定程度的主观性。所以,通过SD-OCT能够清晰分清视网膜各层组织结构的功能,寻找一个可以较好评估IMH患者手术视力预后的观察指标,成为学者们研究的热点。 由于光感受器内外节是将光信息转化成生物电信号后向中枢神经传递的重要一环,IS/OS层的完整性,被认为是光感受器完整性的重要标志,是评估患者视功能预后的重要指标。越来越多的研究,通过频域OCT观察发现,IS/OS层连续性的变化与患者的视力预后相关。在SD-OCT对IS/OS层连续性的评估上,国内外一些学者将IS/OS层分为连续、中断和缺失的不同形态,进行了定性分析。有的研究者甚至分别测量IS/OS层水平、垂直两方向上缺失区直径后相乘得出缺失区面积后进行分析。我们的研究目的即是观察手术前后水平方向上光感受器内外节缺失区直径的变化,分析其与患者视力预后的关系。 从“特发性黄斑裂孔”的命名上可见这一疾病的原因目前并不清楚,IMH的发病机制也一直是眼科领域一个探索了多年的课题。目前较为公认的是Gass提出的玻璃体的切向牵拉理论,认为玻璃体对黄斑中心凹切线方向上的牵拉是造成IMH的主要原因。有学者通过手术观察和后来出现的OCT技术检查发现,黄斑牵拉综合征的患者有半数病例最终会发展成为特发性黄斑裂孔,在完全后脱离的玻璃体后界膜上有时可见粘连的游离的孔盖组织。另一些学者通过OCT和手术发现玻璃体后脱离时对中心凹施加的向前的牵拉联合眼球转动时的反作用力是发生IMH的始动因素,以上观点均从玻璃体视网膜界面因素来考虑IMH的形成原因。但也有研究者为了了解在全层黄斑裂孔患者的手术前,其玻璃体是否仍粘连于后极部视网膜,对OCT检测未能清晰显示玻璃体后界膜的部分患者进行人工玻璃体后脱离,结果发现在玻璃体后皮质仍然与黄斑区视网膜贴合紧密的患者,依然发生了明显的黄斑裂孔,可见,除了玻璃体对黄斑切线方向牵拉力的作用之外,还有其他因素对特发性黄斑裂孔的形成产生作用。近来,国内外学者通过频域OCT的深度增强成像技术发现正常人群随着年龄的增加脉络膜厚度逐渐降低,而且女性的中心凹下脉络膜厚度值明显低于同龄男性,,而IMH多发于老年女性的特点也使学者们把目光转向脉络膜厚度因素上来探讨特发性黄斑裂孔的发生机制。 采用传统的频域OCT仪作脉络膜的扫描获取图像是很困难的,因为所用的红外光很难穿透视网膜色素上皮层到达下面的脉络膜层。最近,一项被称为深度增强成像技术(EDI)的革新出现后,以上的难题迎刃而解,使脉络膜扫描成像成为可能。传统SD-OCT的眼底扫描主要显示视网膜内界膜到RPE层之间的组织结构。而脉络膜,负责眼内循环主要的血液供应,是许多脉络膜血管相关疾病的组织起源,如息肉样脉络膜血管病变、恶性脉络膜黑色素等。同样,另一类与年龄和微循环相关的疾病,如老年性黄斑变性和微小动脉粥样硬化,也同样与脉络膜有关。但是,用传统的OCT完成对脉络膜的非侵入性检查很难成功。首先,传统OCT采用的光波波长不够,难以穿透视网膜色素上皮层到达深层的脉络膜组织。光波二相性原理告诉我们：光程增加,散射越发衰减,而离零延时越远,反射光灵敏度则越低,而传统SD-OCT所采用的傅里叶转换又一定程度上制约了光波的穿透性。总结来说,传统OCT不能扫描脉络膜成像的缺点是：(1)信号的清晰度和分辨率会随着脉络膜扫描零延迟距离的增加而降低；(2)傅里叶转换造成传统SD-OCT的最大探测范围降低；(3)反射光波长和信号会在光波散射的过程中逐渐衰减；(4)图像双侧边界产生对光柱的离焦现象。普通的SD-OCT采用的是800nm左右的红外光,而波长为1060nm的红外光才能穿透达到脉络膜。因此为了使更深层的组织成像清晰,人们采用深度增强扫描成像技术,即采用1060nm左右的红外光投射被检查者,使光源聚焦于更深层的脉络膜组织,当组织反射的光信号延迟为零时,成像最清晰：相反,前面的视网膜血管和神经纤维层则时间延迟增加,成像相对模糊。而目前最新的光学相干断层扫描EDI技术避免了以上缺点,可以使传统SD-OCT获得清晰脉络膜扫描图像的同时,视网膜组织的图像也不受任何影响。 第一部分频域OCT观察特发性黄斑裂孔手术前后光感受器内外节的变化 目的通过频域光相干断层扫描(SD-OCT)观察光感受器内外节在特发性黄斑裂孔手术前后的变化。 方法前瞻性对比分析23例(25只眼)确诊并接受玻璃体手术治疗的特发性黄斑裂孔患者的临床资料,采用Topcon公司Version3.21型频域OCT测量并对比分析手术前后水平方向上光感受器内外节缺失区直径(diameter of IS/OS absence,DIOA)的差别(配对资料的T检验)和相关性(Bivariate过程中的Pearson相关分析)。 结果手术后有18只眼黄斑裂孔闭合,裂孔封闭率为72%。术前DIOA范围为(551～2900)μm,平均(1933.16±650.80)μm；术后12月DIOA范围为(412-2811)μm,平均(1329.20±780.13)μm,术后12月DIOA较术前减少了约604μm。经配对样本的t检验,手术前后差异有显著性意义(t=3.73,P=0.001)。经Pearson相关分析,术前DIOA与术后DIOA之间不存在有统计学意义的相关关系(r=0.37,P=0.069)。 结论频域OCT能清晰观察视网膜IS/OS层的结构,特发性黄斑裂孔患者术后水平方向上光感受器内外节缺失区直径较术前明显减少,但两者无明显相关性。 第二部分频域OCT观察特发性黄斑裂孔手术前后光感受器内外节与视力的关系 目的通过频域相干光断层扫描观察光感受器内外节在特发性黄斑裂孔手术前后的变化并探讨与视力预后的关系。 方法前瞻性对比分析28例(30只眼)确诊并接受玻璃体手术治疗的特发性黄斑裂孔患者的临床资料,分别记录手术前后的最佳矫正视力(转换成logMAR视力)和水平方向上光感受器内外节缺失区直径(diameter of IS/OS absence,DIOA),分析两者手术前后的差别(配对资料的T检验)和相关性(Bivariate过程中的Pearson相关分析)。 结果手术后有22只眼黄斑裂孔闭合,裂孔封闭率为73.3%。术前logMAR视力为0.18-1.30,平均为0.99±0.37,术后12月logMAR视力为0.10-1.60,平均为0.75±0.46,术后12个月较术前平均下降了0.24。术前DIOA为551～2900μm,平均1945.57±609.33μm；术后12月DIOA为412～2811μm,平均1357.07±772.67μm,术后12个月较术前平均下降了589μm。经配对样本的T检验,术后12个月logMAR较术前logMAR明显减少,两者差异有显著性意义(t=2.859,P=0.008)；术后12个月DIOA较术前DIOA明显减少,两者差异有显著性意义(t=3.94,P0,001)。经Pearson相关分析,术前logMAR与DIOA之间具有显著正相关性(r=0.895,P0.01)；术后logMAR与DIOA之间同样也具有显著正相关性(r=0.921,P0.01)。 结论特发性黄斑裂孔患者手术后视力和光感受器内外节缺失区直径较术前明显改善；手术前后水平方向上光感受器内外节缺失区直径与logMAR视力具有明显正相关性,是评估患者视力预后的重要因素。 第三部分频域OCT观察特发性黄斑裂孔手术前后光感受器内外节与中心凹下脉络膜厚度的关系 目的通过频域相干光断层扫描(SD-OCT)及其深度增强成像技术(EDI)观察光感受器内外节和中心凹下脉络膜厚度在特发性黄斑裂孔手术前后的变化并探讨两者间的关系。 方法记录35例单眼确诊并接受玻璃体手术治疗的特发性黄斑裂孔患者的临床资料(年龄、性别),EDI模式扫描后测量手术前后水平方向上光感受器内外节缺失区直径(diameter of IS/OS absence,DIOA)和中心凹下脉络膜厚度(subfoveal chorodial thickness,SFCT),分析两者的差别(配对资料的T检验)和相关性(Bivariate过程中的Pearson相关分析)。 结果手术后有29只眼黄斑裂孔闭合,裂孔封闭率为83%。术前DIOA为386～2900μm,平均1257.49±678.39μm；术后6个月DIOA为203～1410μm,平均660.80±298.59μm,经配对资料的T检验,手术前后DIOA相比差异有显著性意义(t=6.926,P0.001)。术前SFCT为85～268μm,平均130.80±37.09μm；术后6个月SFCT为93～201μm,平均137.17±32.64μm,经配对资料的T检验,手术前后SFCT相比差异无显著性意义(t=-1.780,P=0.084)。经Pearson相关分析,术前DIOA与SFCT之间具有显著负相关性(r=-0.797,P0.001)；术后6个月DIOA与SFCT之间同样具有显著负相关性(r=-0.647,P0.001)。 结论特发性黄斑裂孔患者手术后6个月时水平方向上光感受器内外节缺失区直径较术前明显减小,但黄斑中心凹下脉络膜厚度无明显变化。特发性黄斑裂孔患者手术前与术后6个月时水平方向上光感受器内外节缺失区直径与黄斑中心凹下脉络膜厚度均具有显著负相关性,提示IMH的发生和严重程度与脉络膜的血流灌注状态可能存在一定关系。
[Abstract]:The research background has developed rapidly since the 90s of last century. Optical coherence tomography (OCT) is a new technique of medical tomography, which has developed rapidly at this time. It combines optical technology, semiconductor laser technique, data model calculation and digital image processing technology. At the same time, a cross-sectional image of the internal microstructures of the biological tissue is obtained at the same time with the noninvasive living body morphological examination of the human body. In particular, with the transformation of OCT from time domain to frequency domain model, the development of OCT has also entered a new era. From the introduction of OCT technology to the beginning of the ophthalmology, the research of the yellow spot hole is the earliest and most in-depth. The researchers found that OCT can clearly discover the morphological changes in the structure of each layer in the retina. For the formation and stages of the macular hole, the OCT examination can clearly show the "anatomical" changes similar to the pathological sections, so that the anatomical structure of the patients and the retina can be accurately explained. In various methods of examination, clinical ophthalmologists have found that OCT is superior to all kinds of traditional methods of Ophthalmology. With the increasing improvement of surgical techniques and equipment, the closure rate of the macular hole in the postoperative patients is increasing. However, the postoperative OCT examination confirms the closure of the hole. The extent of improvement of visual acuity is not consistent, and the visual acuity of some patients is even lower than before operation, which makes people look for various reasons that affect the visual prognosis of IMH patients. In the past time domain OCT, the diameter of the macular hole, the diameter of the basal fissure, the area of the fissure, the retinal thickness of the macula, and the hole in the macular hole were mostly observed in the observation of the idiopathic macular hole. In some scholars, some scholars found that the size of the hiatus and the thickness of the epithelial layer of the rim of the orifice were closely related to the visual acuity. But at the same time, some scholars found that the corrected visual acuity of the lamellar macular hole has no correlation with the area of the cracked hole, the width of the fissure basement and the position of the fissure. The conclusion is that "the bigger the hole, the lower the eyesight, the smaller the hole, the better the vision" is not consistent, and there is a certain degree of subjectivity in the selected parts of the path. Therefore, the function of the tissue structure of the retina can be clearly identified by SD-OCT, and finding a better evaluation of the visual prognosis of the operation of the IMH patients can be found. The observation index has become the hot spot of the scholars' research.
The integrity of the IS/OS layer is considered to be an important marker of the integrity of photoreceptors, and is an important indicator of the prognosis of the visual function of the patient. More and more studies have revealed the changes in the continuity of the IS/OS layer through the frequency domain OCT observation. It is related to the prognosis of the patient's vision. In the evaluation of the continuity of the IS/OS layer by SD-OCT, some scholars at home and abroad classify the IS/OS layer into successive, interruption and missing forms, and carry out qualitative analysis. Some researchers even measure the level of the IS/OS layer, and then analyze the area of the missing area after the missing area in the vertical two direction. The purpose of our study was to observe the changes of the diameter of the photoreceptor missing area in the horizontal direction before and after surgery, and to analyze the relationship between the diameter of the photoreceptor missing area and the visual prognosis of the patients.
It is not clear from the name of "idiopathic macular hole" that the pathogenesis of the disease is not clear. The pathogenesis of IMH has been a research subject in the field of ophthalmology for many years. At present, it is generally accepted that the vitreous tangential traction theory proposed by Gass is that the pulling of the vitreous body in the direction of the concave tangent is caused by IMH The main reasons. Some scholars have found that half of the patients with macular traction syndrome eventually develop into idiopathic macular holes through surgical observation and subsequent OCT technical examination. The free Kong Gai tissue is sometimes seen on the posterior vitreous membrane that is completely disconnected. Other scholars have found glassy through OCT and surgery. The reacting force of the forward pull combined with the eyeball during the posterior disengagement of the vitreous body is a starting factor for the occurrence of IMH. All these views consider the cause of the formation of IMH from the vitreoretinal interface factor, but the researchers also have to know whether the vitreous body still adheres to the posterior vitreous surgery before the operation of the whole layer of the macular hole. In the polar retina, a part of the patient who failed to clearly display the posterior vitreous membrane was detected by artificial vitreous detachment by OCT. It was found that a significant macular hole still occurred in the posterior vitreous cortex still closely associated with the retina of the macular region. It was visible, in addition to the effect of the glass body on the traction of the macular line. Other factors have been involved in the formation of idiopathic macular holes. Recently, domestic and foreign scholars have found that the normal population gradually decreases with the increase of age and the thickness of the choroid in the female is significantly lower than those of the same age, and the IMH is more frequent in the older women by the depth enhanced imaging of the frequency domain OCT. In addition, scholars have turned their attention to the mechanism of choroidal thickness in the pathogenesis of idiopathic macular hole.
It is difficult to use the traditional frequency domain OCT for choroidal scan to obtain images, because the infrared light is difficult to wear with the fluoroscopy epithelia layer to reach the following choroidal layer. Recently, after a innovation called EDI (depth enhanced imaging), the above problems are solved to make it possible. The fundus scanning of the traditional SD-OCT mainly shows the tissue structure between the inner boundary of the retina and the RPE layer, and the choroid, which is responsible for the main blood supply of the intraocular circulation, is the tissue origin of many choroidal vascular related diseases, such as polypoid choroidal vasculopathy, malignant choroidal melanin, etc., the other is associated with age and microcirculation. Diseases, such as age-related macular degeneration and micro atherosclerosis, are also related to the choroid membrane. However, the non-invasive examination of the choroid membrane by traditional OCT is difficult to succeed. First, the wavelength of the light wave used by the traditional OCT is not enough to penetrate the choroidal tissue that penetrated into the deep layer of the epiretinal layer of the omentum. The principle of light wave duality is reported. If the light path is increased, the scattering is more attenuated, and the farther away from the zero delay, the lower the reflective light sensitivity, and the Fourier transform used by the traditional SD-OCT restricts the penetration of the light wave to some extent. It is concluded that the shortcomings of the traditional OCT can not scan the choroidal imaging is: (1) the resolution and resolution of the signal will follow the choroid membrane The increase in zero delay distance of scanning is reduced; (2) the maximum detection range of the traditional SD-OCT is reduced by Fu Liye conversion; (3) the wavelength and signal of the reflected light attenuates gradually in the process of light scattering; (4) the defocus of the light column is produced by the two sides of the image. The ordinary SD-OCT uses the infrared light around 800nm, and the wavelength is 1060. Nm's infrared light can penetrate into the choroid. Therefore, in order to make the deeper tissue imaging clear, people use the depth enhanced scan imaging technique, that is, the infrared light projection of the 1060nm is used to focus the light source in the deeper choroidal tissue. When the light signal reflected by the tissue is delayed to zero, the imaging is the most clear: on the contrary, the imaging is the most clear. In front of the retinal vessels and the nerve fiber layer, the time delay increases and the imaging is relatively blurred, and the latest optical coherence tomography (EDI) technique avoids the above shortcomings, which can make the traditional SD-OCT image of a clear choroid scan, and the image of the retina tissue is not affected by any effect.
The first part is to observe the changes of photoreceptor outer and outer segments before and after idiopathic macular hole surgery in frequency domain OCT.
Objective To observe the changes of inner and outer segments of photoreceptors in idiopathic macular hole before and after surgery by frequency domain optical coherence tomography (SD-OCT).
Methods the clinical data of 23 patients with idiopathic macular holes (25 eyes) diagnosed and treated with vitreous surgery were compared and analyzed. The difference between the diameter of IS/OS absence (DIOA) diameter (diameter of IS/OS absence, DIOA) was compared and analyzed by Topcon company Version3.21 type frequency domain OCT. T test for data and correlation (Pearson correlation analysis in Bivariate process).
Results after operation, 18 eyes were closed with macular hole. The rate of DIOA was (551~2900) m before 72%., and the average (1933.16 + 650.80) mu m. The range of DIOA in December was (412-2811) mu m, average (1329.20 + 780.13) mu m. After operation, the DIOA was reduced by about 604 mu by t test of paired samples. There was a significant difference before and after operation. Pearson correlation analysis showed that there was no significant correlation between preoperative DIOA and postoperative DIOA (r = 0.37, P = 0.069).
Conclusion the structure of IS/OS layer in the retina can be clearly observed in the frequency domain OCT. The diameter of the internal and external nodes of the photoreceptor in the patients with idiopathic macular hole is significantly lower than that before the operation, but there is no significant correlation between them.
The second part is to observe the relationship between photoreceptor outer segment and visual acuity before and after operation for idiopathic macular hole in frequency domain OCT.
Objective To observe the changes of photoreceptor internals and externals before and after idiopathic macular hole surgery by frequency domain coherence tomography and to explore the relationship between the changes and visual prognosis.
Methods the clinical data of 28 patients with idiopathic macular holes diagnosed and treated with vitreous surgery were prospectively compared. The best corrected visual acuity before and after the operation (converted into logMAR vision) and the straight diameter of diameter of IS/OS absence (DIOA) in the level direction photoreceptor were recorded respectively, and the two operations were analyzed. The difference between before and after (T test of paired data) and correlation (Pearson correlation analysis in Bivariate process).
Results after operation, 22 eyes were closed with macular hole. The rate of logMAR vision was 0.18-1.30 before 73.3%., the average was 0.99 + 0.37. The logMAR vision in December after operation was 0.10-1.60, the average was 0.75 + 0.46. The average decrease of DIOA was 551~2900 mu m before operation 12 months after operation, and the average of 1945.57 + 609.33 m before operation. DIOA was 412~28 in December after operation. 11 mu m, average 1357.07 + 772.67 mu m, 12 months after operation, the average decrease of 589 u M. by paired sample T test, 12 months after the operation, logMAR compared with preoperative logMAR significantly decreased (t=2.859, P=0.008), and 12 months after the operation, DIOA is significantly less than the preoperative DIOA, the difference has significant significance (t=3.94, P0001). N correlation analysis showed significant positive correlation between logMAR and DIOA before operation (r=0.895, P0.01), and there was also significant positive correlation between logMAR and DIOA after operation (r=0.921, P0.01).
Conclusion the diameter of visual acuity and photoreceptor internal and external missing area in the patients with idiopathic macular hole is significantly better than that before operation, and the diameter of the internal and external node missing area in the horizontal photoreceptor before and after operation is positively correlated with the logMAR vision, which is an important factor in evaluating the prognosis of the patients.
Part III Frequency Domain OCT Observation of the Relationship between the Subfoveal Choroidal Thickness and the Internal and External Segments of Photoreceptors before and after Idiopathic Macular Hole Surgery
Objective To observe the changes of the internal and external segment of the photoreceptor and the choroidal thickness of the central fovea before and after the operation of the idiopathic macular hole through the frequency domain coherent optical tomography (SD-OCT) and its depth enhanced imaging (EDI) and explore the relationship between the two.
Methods the clinical data (age, sex) of 35 patients with idiopathic macular holes with monocular diagnosis and vitreous surgery were recorded. After EDI mode scan, the diameter of diameter of IS/OS absence (DIOA) and the choroidal thickness under the recess (subfoveal chorodial thickness) were measured before and after the operation. (SFCT), to analyze the difference (T test of paired data) and correlation (Pearson correlation analysis in Bivariate process).
Results macular hole was closed in 29 eyes after operation, and the rate of closure was 83%. before DIOA.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R779.6
本文编号：2173759
[Abstract]:The research background has developed rapidly since the 90s of last century. Optical coherence tomography (OCT) is a new technique of medical tomography, which has developed rapidly at this time. It combines optical technology, semiconductor laser technique, data model calculation and digital image processing technology. At the same time, a cross-sectional image of the internal microstructures of the biological tissue is obtained at the same time with the noninvasive living body morphological examination of the human body. In particular, with the transformation of OCT from time domain to frequency domain model, the development of OCT has also entered a new era. From the introduction of OCT technology to the beginning of the ophthalmology, the research of the yellow spot hole is the earliest and most in-depth. The researchers found that OCT can clearly discover the morphological changes in the structure of each layer in the retina. For the formation and stages of the macular hole, the OCT examination can clearly show the "anatomical" changes similar to the pathological sections, so that the anatomical structure of the patients and the retina can be accurately explained. In various methods of examination, clinical ophthalmologists have found that OCT is superior to all kinds of traditional methods of Ophthalmology. With the increasing improvement of surgical techniques and equipment, the closure rate of the macular hole in the postoperative patients is increasing. However, the postoperative OCT examination confirms the closure of the hole. The extent of improvement of visual acuity is not consistent, and the visual acuity of some patients is even lower than before operation, which makes people look for various reasons that affect the visual prognosis of IMH patients. In the past time domain OCT, the diameter of the macular hole, the diameter of the basal fissure, the area of the fissure, the retinal thickness of the macula, and the hole in the macular hole were mostly observed in the observation of the idiopathic macular hole. In some scholars, some scholars found that the size of the hiatus and the thickness of the epithelial layer of the rim of the orifice were closely related to the visual acuity. But at the same time, some scholars found that the corrected visual acuity of the lamellar macular hole has no correlation with the area of the cracked hole, the width of the fissure basement and the position of the fissure. The conclusion is that "the bigger the hole, the lower the eyesight, the smaller the hole, the better the vision" is not consistent, and there is a certain degree of subjectivity in the selected parts of the path. Therefore, the function of the tissue structure of the retina can be clearly identified by SD-OCT, and finding a better evaluation of the visual prognosis of the operation of the IMH patients can be found. The observation index has become the hot spot of the scholars' research.
The integrity of the IS/OS layer is considered to be an important marker of the integrity of photoreceptors, and is an important indicator of the prognosis of the visual function of the patient. More and more studies have revealed the changes in the continuity of the IS/OS layer through the frequency domain OCT observation. It is related to the prognosis of the patient's vision. In the evaluation of the continuity of the IS/OS layer by SD-OCT, some scholars at home and abroad classify the IS/OS layer into successive, interruption and missing forms, and carry out qualitative analysis. Some researchers even measure the level of the IS/OS layer, and then analyze the area of the missing area after the missing area in the vertical two direction. The purpose of our study was to observe the changes of the diameter of the photoreceptor missing area in the horizontal direction before and after surgery, and to analyze the relationship between the diameter of the photoreceptor missing area and the visual prognosis of the patients.
It is not clear from the name of "idiopathic macular hole" that the pathogenesis of the disease is not clear. The pathogenesis of IMH has been a research subject in the field of ophthalmology for many years. At present, it is generally accepted that the vitreous tangential traction theory proposed by Gass is that the pulling of the vitreous body in the direction of the concave tangent is caused by IMH The main reasons. Some scholars have found that half of the patients with macular traction syndrome eventually develop into idiopathic macular holes through surgical observation and subsequent OCT technical examination. The free Kong Gai tissue is sometimes seen on the posterior vitreous membrane that is completely disconnected. Other scholars have found glassy through OCT and surgery. The reacting force of the forward pull combined with the eyeball during the posterior disengagement of the vitreous body is a starting factor for the occurrence of IMH. All these views consider the cause of the formation of IMH from the vitreoretinal interface factor, but the researchers also have to know whether the vitreous body still adheres to the posterior vitreous surgery before the operation of the whole layer of the macular hole. In the polar retina, a part of the patient who failed to clearly display the posterior vitreous membrane was detected by artificial vitreous detachment by OCT. It was found that a significant macular hole still occurred in the posterior vitreous cortex still closely associated with the retina of the macular region. It was visible, in addition to the effect of the glass body on the traction of the macular line. Other factors have been involved in the formation of idiopathic macular holes. Recently, domestic and foreign scholars have found that the normal population gradually decreases with the increase of age and the thickness of the choroid in the female is significantly lower than those of the same age, and the IMH is more frequent in the older women by the depth enhanced imaging of the frequency domain OCT. In addition, scholars have turned their attention to the mechanism of choroidal thickness in the pathogenesis of idiopathic macular hole.
It is difficult to use the traditional frequency domain OCT for choroidal scan to obtain images, because the infrared light is difficult to wear with the fluoroscopy epithelia layer to reach the following choroidal layer. Recently, after a innovation called EDI (depth enhanced imaging), the above problems are solved to make it possible. The fundus scanning of the traditional SD-OCT mainly shows the tissue structure between the inner boundary of the retina and the RPE layer, and the choroid, which is responsible for the main blood supply of the intraocular circulation, is the tissue origin of many choroidal vascular related diseases, such as polypoid choroidal vasculopathy, malignant choroidal melanin, etc., the other is associated with age and microcirculation. Diseases, such as age-related macular degeneration and micro atherosclerosis, are also related to the choroid membrane. However, the non-invasive examination of the choroid membrane by traditional OCT is difficult to succeed. First, the wavelength of the light wave used by the traditional OCT is not enough to penetrate the choroidal tissue that penetrated into the deep layer of the epiretinal layer of the omentum. The principle of light wave duality is reported. If the light path is increased, the scattering is more attenuated, and the farther away from the zero delay, the lower the reflective light sensitivity, and the Fourier transform used by the traditional SD-OCT restricts the penetration of the light wave to some extent. It is concluded that the shortcomings of the traditional OCT can not scan the choroidal imaging is: (1) the resolution and resolution of the signal will follow the choroid membrane The increase in zero delay distance of scanning is reduced; (2) the maximum detection range of the traditional SD-OCT is reduced by Fu Liye conversion; (3) the wavelength and signal of the reflected light attenuates gradually in the process of light scattering; (4) the defocus of the light column is produced by the two sides of the image. The ordinary SD-OCT uses the infrared light around 800nm, and the wavelength is 1060. Nm's infrared light can penetrate into the choroid. Therefore, in order to make the deeper tissue imaging clear, people use the depth enhanced scan imaging technique, that is, the infrared light projection of the 1060nm is used to focus the light source in the deeper choroidal tissue. When the light signal reflected by the tissue is delayed to zero, the imaging is the most clear: on the contrary, the imaging is the most clear. In front of the retinal vessels and the nerve fiber layer, the time delay increases and the imaging is relatively blurred, and the latest optical coherence tomography (EDI) technique avoids the above shortcomings, which can make the traditional SD-OCT image of a clear choroid scan, and the image of the retina tissue is not affected by any effect.
The first part is to observe the changes of photoreceptor outer and outer segments before and after idiopathic macular hole surgery in frequency domain OCT.
Objective To observe the changes of inner and outer segments of photoreceptors in idiopathic macular hole before and after surgery by frequency domain optical coherence tomography (SD-OCT).
Methods the clinical data of 23 patients with idiopathic macular holes (25 eyes) diagnosed and treated with vitreous surgery were compared and analyzed. The difference between the diameter of IS/OS absence (DIOA) diameter (diameter of IS/OS absence, DIOA) was compared and analyzed by Topcon company Version3.21 type frequency domain OCT. T test for data and correlation (Pearson correlation analysis in Bivariate process).
Results after operation, 18 eyes were closed with macular hole. The rate of DIOA was (551~2900) m before 72%., and the average (1933.16 + 650.80) mu m. The range of DIOA in December was (412-2811) mu m, average (1329.20 + 780.13) mu m. After operation, the DIOA was reduced by about 604 mu by t test of paired samples. There was a significant difference before and after operation. Pearson correlation analysis showed that there was no significant correlation between preoperative DIOA and postoperative DIOA (r = 0.37, P = 0.069).
Conclusion the structure of IS/OS layer in the retina can be clearly observed in the frequency domain OCT. The diameter of the internal and external nodes of the photoreceptor in the patients with idiopathic macular hole is significantly lower than that before the operation, but there is no significant correlation between them.
The second part is to observe the relationship between photoreceptor outer segment and visual acuity before and after operation for idiopathic macular hole in frequency domain OCT.
Objective To observe the changes of photoreceptor internals and externals before and after idiopathic macular hole surgery by frequency domain coherence tomography and to explore the relationship between the changes and visual prognosis.
Methods the clinical data of 28 patients with idiopathic macular holes diagnosed and treated with vitreous surgery were prospectively compared. The best corrected visual acuity before and after the operation (converted into logMAR vision) and the straight diameter of diameter of IS/OS absence (DIOA) in the level direction photoreceptor were recorded respectively, and the two operations were analyzed. The difference between before and after (T test of paired data) and correlation (Pearson correlation analysis in Bivariate process).
Results after operation, 22 eyes were closed with macular hole. The rate of logMAR vision was 0.18-1.30 before 73.3%., the average was 0.99 + 0.37. The logMAR vision in December after operation was 0.10-1.60, the average was 0.75 + 0.46. The average decrease of DIOA was 551~2900 mu m before operation 12 months after operation, and the average of 1945.57 + 609.33 m before operation. DIOA was 412~28 in December after operation. 11 mu m, average 1357.07 + 772.67 mu m, 12 months after operation, the average decrease of 589 u M. by paired sample T test, 12 months after the operation, logMAR compared with preoperative logMAR significantly decreased (t=2.859, P=0.008), and 12 months after the operation, DIOA is significantly less than the preoperative DIOA, the difference has significant significance (t=3.94, P0001). N correlation analysis showed significant positive correlation between logMAR and DIOA before operation (r=0.895, P0.01), and there was also significant positive correlation between logMAR and DIOA after operation (r=0.921, P0.01).
Conclusion the diameter of visual acuity and photoreceptor internal and external missing area in the patients with idiopathic macular hole is significantly better than that before operation, and the diameter of the internal and external node missing area in the horizontal photoreceptor before and after operation is positively correlated with the logMAR vision, which is an important factor in evaluating the prognosis of the patients.
Part III Frequency Domain OCT Observation of the Relationship between the Subfoveal Choroidal Thickness and the Internal and External Segments of Photoreceptors before and after Idiopathic Macular Hole Surgery
Objective To observe the changes of the internal and external segment of the photoreceptor and the choroidal thickness of the central fovea before and after the operation of the idiopathic macular hole through the frequency domain coherent optical tomography (SD-OCT) and its depth enhanced imaging (EDI) and explore the relationship between the two.
Methods the clinical data (age, sex) of 35 patients with idiopathic macular holes with monocular diagnosis and vitreous surgery were recorded. After EDI mode scan, the diameter of diameter of IS/OS absence (DIOA) and the choroidal thickness under the recess (subfoveal chorodial thickness) were measured before and after the operation. (SFCT), to analyze the difference (T test of paired data) and correlation (Pearson correlation analysis in Bivariate process).
Results macular hole was closed in 29 eyes after operation, and the rate of closure was 83%. before DIOA.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R779.6
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