糖尿病视网膜病变患者全视网膜光凝后脉络膜厚度变化及视力预后的相关分析

发布时间：2019-06-24 14:36

【摘要】：糖尿病视网膜病变(diabetic retinopathy, DR)是糖尿病最常见的微血管并发症之一,常见于糖尿病病程10年以上的患者,给患者的视力造成极大的威胁。作为目前的主要治疗方法,激光治疗广泛应用于临床并获得了肯定的疗效。全视网膜光凝术(panretinal photocoagulation, PRP)通过破坏周边部的视网膜而降低视网膜的氧耗,以保证后极部能得到充分的氧供。传统的ETDRS (Early Treatment Diabetic Retinopathy Study)激光因激光能量较高、作用时间长而对视网膜及脉络膜造成一定损伤,术后患者发生黄斑水肿的概率增加。先进的Pascal激光系统采用创新性的点阵式激光模式,且激光作用时间缩短为20毫秒,大大提高了治疗效率,减轻了激光损伤。随着光学相干断层扫描(Optical Coherence Tomography, OCT)技术的飞速发展,其对于视网膜10层结构的分辨已相当清楚。近两年出现的EDI (enhanced-depth imaging)技术使脉络膜在OCT上清晰地显示成为了可能。脉络膜作为外层视网膜的主要血供来源,在DR这一类视网膜血管性疾病中扮演了怎样的角色呢?已有研究发现DR患者的脉络膜较正常对照组变薄,那么激光治疗前后脉络膜的厚度是否会发生变化呢?这一变化是否与视力预后相关呢?这是本课题的核心研究所在。作为视网膜功能学和形态学的客观评价工具,多焦视网膜电图(multifocal electroretinography, mfERG)和OCT已被用于多种疾病的视力预后研究,包括糖尿病视网膜病变、糖尿病黄斑水肿等。但尚未见到关于PRP的相关报道,那么mfERG与OCT是否与DR行全视网膜光凝术的预后密切相关呢?这是本课题关注的另一重点。第一部分糖尿病视网膜病变全视网膜光凝术前后脉络膜厚度变化目的研究糖尿病视网膜病变全视网膜光凝后黄斑区和光斑区脉络膜厚度变化。方法本部分研究纳入了34例需行全视网膜光凝的糖尿病视网膜病变患者(包括严重非增殖期糖尿病视网膜病变和早期增殖期糖尿病视网膜病变患者)。分别在基线、激光后1个月和激光后3个月,利用光学相干断层扫描仪的EDI模式扫描了黄斑区和光斑区的脉络膜厚度,并测量了患者的最佳矫正视力(best corrected visual acuity, BCVA)。结果黄斑区脉络膜厚度基线为307.2±70.7μm,激光后1个月为318.0±76.4μm(P0.001),3个月为317.4±75.3μm(P0.001),脉络膜厚度的增加具有统计学差异。而光斑区的脉络膜厚度则从基线的227.5±45.0μm降至术后一个月的206.9±41.1μm(P0.001)和术后三个月的206.0±41.4μm(P0.001)。无论是在PRP术后一个月还是三个月,脉络膜厚度的变化均与视力变化无关。在多元线性回归分析中,仅PRP术前的视力和中心凹视网膜厚度与视力变化具有统计学意义的相关性。结论在严重NPDR和早期PDR患者中,黄斑区平均脉络膜在PRP术后增加,而光斑区平均脉络膜厚度则减少。这一结果可能提示了PRP术后脉络膜血流的重新分布,对于保证视网膜的代谢至关重要。第二部分糖尿病视网膜病变全视网膜光凝术预后相关因素分析目的研究mfERG和OCT在判断糖尿病视网膜病变行全视网膜光凝术的预后中的价值。方法本部分研究纳入了42例需行全视网膜光凝的糖尿病视网膜病变患者(包括严重非增殖期糖尿病视网膜病变和早期增殖期糖尿病视网膜病变患者)。在基线时进行mfERG、OCT和BCVA的测量,并在PRP术后6个月再次测量BCVA。PRP术前的数据与术后6个月视力的关系采用了Pearson相关分析和多元线性回归进行分析。结果入选的42例患眼中,31例(73.8%)视力较术前提高或维持原状,11例(26.2%)激光术后视力下降。在全部9个区域中,最终BCVA与mfERG振幅和潜伏期均密切相关,且振幅与视力的相关性更显著。中心凹层面光感受器细胞内外节连接(photoreceptor inner and outer segment junction, IS/OS)和外界膜(external limiting membrane, ELM)连续性,以及大部分区域的视网膜厚度也与最终视力密切相关。在综合以上多种因素的多元线性回归模型中,中心区域的mfERG振幅、中心凹IS/OS连续性、患者PRP术前视力及患者年龄与最终BCVA的相关性具有统计学差异。在大部分区域,视网膜厚度也与mfERG振幅和潜伏期相关,颞侧和下方区域更明显,特别是外环。结论mfERG的振幅偏低或中心凹IS/OS紊乱与PRP术后视力预后不良关系密切。综上所述,本研究发现PRP术后黄斑区脉络膜厚度增加而光斑区脉络膜厚度减少,可能提示PRP引起了脉络膜血流的重分布,尽管与视力变化无直接关系,但是视网膜代谢的保障。mfERG和OCT检查所提供的视网膜结构和功能两方面信息均对PRP术后糖尿病视网膜病变患眼的视力预后有一定影响。其中,多焦视网膜电图的振幅和中心凹IS/OS连续性是最有价值的预测指标。
[Abstract]:Diabetic retinopathy (DR) is one of the most common microvascular complications of diabetes, which is common in patients with more than 10 years of diabetes. As the current primary treatment method, laser treatment is widely used in clinic and has obtained positive curative effect. All-retinal photocoagulation (PRP) reduces the oxygen consumption of the retina by destroying the retina of the peripheral part, so as to ensure that the posterior pole part can be provided with sufficient oxygen. The traditional ETDRS (ETDRS) laser has high laser energy, long acting time and some damage to the retina and the choroid, and the probability of macular edema in the patients after operation is increased. The advanced Pascal laser system adopts an innovative lattice-type laser mode, and the laser action time is shortened to 20 milliseconds, so that the treatment efficiency is greatly improved, and laser damage is reduced. With the rapid development of optical coherence tomography (OCT), the resolution of the structure of the retina 10 layer is quite clear. In recent two years, the development of the EDI (advanced-depth imaging) technique has made it possible to clearly display the choroid in the OCT. Choroid, as the main source of blood supply of the outer retina, plays an important role in the DR type of retinal vascular disease? It has been found that the choroid of the DR patient is thinner than that of the normal control group, and the thickness of the choroid before and after laser treatment will change. Is this change related to the visual prognosis? This is the core research institute of the subject. As an objective evaluation tool for retinal function and morphology, multi-focal electroretinography (mfrERG) and OCT have been used in the study of visual outcomes for a variety of diseases, including diabetic retinopathy, diabetic macular edema, and the like. But if the relevant reports on PRP have not been seen, it is closely related to whether the mfERG and OCT are closely related to the prognosis of DR-line full-retinal photocoagulation? This is another focus of the subject's attention. The changes of the choroidal thickness in the macular area and the spot area after the full-retinal photocoagulation of the diabetic retinopathy were studied with the aim of the changes of the choroidal thickness before and after the whole-retinal photocoagulation of the first part of the diabetic retinopathy. Methods Thirty-four patients with diabetic retinopathy (including severe non-proliferative diabetic retinopathy and early proliferative diabetic retinopathy) were included in this part of the study. The choroidal thickness of the macular region and the spot region was scanned with the EDI pattern of the optical coherence tomography scanner and the best corrected visual acuity (BCVA) was measured at baseline,1 month after laser and 3 months after the laser. Results The baseline of the choroidal thickness in the macular region was 307.2-70.7. m u.m, the first month after the laser was 318.0-76.4. m (P 0.001), the third month was 317.4-75.3. m (P 0.001), and the increase of the choroidal thickness was statistically different. And the choroidal thickness of the spot area decreased from 227.5 to 45.0. m in the baseline to 206.9 to 41.1. m after the operation (P0.01) and 206.0 to 41.4. m in the first three months (P0.001). The changes in the choroidal thickness were not related to the visual change, either one month or three months after the PRP. In the multivariate linear regression analysis, only the pre-operative visual and central retinal thickness of the PRP had a statistically significant correlation with the visual change. Conclusion In the patients with severe NPDR and early PDR, the average choroid in the macular area is increased after the PRP, while the average choroidal thickness in the spot area is reduced. This result may suggest a re-distribution of the choroidal blood flow after the PRP operation, which is critical for ensuring the metabolism of the retina. Objective To study the value of mfERG and OCT in determining the prognosis of all-retinal photocoagulation in diabetic retinopathy. Methods A total of 42 diabetic retinopathy (including severe non-proliferative diabetic retinopathy and early proliferative diabetic retinopathy) were included in this part of the study. The measurements of the mfrERG, OCT and BCVA were performed at baseline and the BCVA was again measured 6 months after the PRP. The relationship between the pre-operation data of the PRP and the 6-month visual acuity was analyzed using Pearson correlation analysis and a multivariate linear regression. Results The visual acuity of 31 patients (73.8%) was improved or maintained in the eyes of 42 patients, and the visual acuity of 11 (26.2%) patients decreased after operation. In all 9 regions, the final BCVA was closely related to the amplitude and latency of the mfERG, and the correlation between the amplitude and the vision was more significant. The continuity of photoreceptors and outer segment junction (IS/ OS) and external membrane (ELM), as well as the retinal thickness in most of the regions, are also closely related to the final vision. In the multiple linear regression model with multiple factors, the mfERG amplitude, the central concave IS/ OS continuity, the pre-operative visual acuity of the patient and the correlation of the patient's age with the final BCVA were statistically different. In most area, that thickness of the retina is also relate to the amplitude and latency of the mfERG, and the upper and lower regions are more pronounced, in particular the outer ring. Conclusion The low amplitude of mfrERG or the disorder of the central concave IS/ OS is closely related to the poor prognosis of the vision after the operation of the PRP. In conclusion, in the present study, the choroidal thickness of the macular area after the PRP is increased and the choroidal thickness of the spot area is reduced, which may prompt the redistribution of the choroidal blood flow by the PRP, although there is no direct relationship with the vision change, but the safety of the retinal metabolism is ensured. Both the retina structure and function provided by the mfERG and the OCT examination have a certain effect on the visual prognosis of the eyes of the diabetic retinopathy after the PRP operation. Among them, the amplitude of the multi-focal electroretinogram and the central concave IS/ OS continuity are the most valuable prediction indexes.
【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R587.1;R774.1

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