【作者】 崔颖；

【导师】 郭海科；

【作者基本信息】 南方医科大学 ， 眼科学（专业学位）， 2013， 博士

【摘要】 近年来,我国糖尿病(Diabetes Mellitus, DM)患病率不断增加,预计DM患者将由2010年4315.7万增加至2030年6225.3万,特别是在包括珠江三角洲在内的经济发达地区,北京上海等地DM患病率已接近欧美发达国家的水平,DM及其并发症的治疗及护理势必将给国家造成巨大的经济和社会负担。糖尿病视网膜病变(Diabetic retinopathy, DR)是DM最常见的并发症之一,是目前世界范围内青壮年劳动人群首要致盲原因,是老年患者双眼盲主要原因之一,已经成为严重的全球性问题。国内外已经进行的以人群为基础的DR流行病学研究结果显示DM和DR发生发展具有显著的地域、种族和经济社会差异。此外,由于DM发生机制的复杂性以及DM群体的特殊性,DM患者盲与低视力原因也具有其特殊性。由于DM及其视网膜病变的发生率高、波及范围广、发病机制复杂、后果严重、治疗棘手,因此在宏观角度了解不同时期,不同地域DM患者群体流行病学研究工作,以了解DR的发生率,分布特点及其相关危险因素对于DR和DR盲的防治具有重要意义。改革开放三十年以来,包括东莞在内的广东珠江三角洲地区经济迅猛发展,城镇化进程加速、人民生活水平提高,公共卫生条件得到明显改善,随之而来的是人民生活方式(快节奏)和饮食结构(高热量、高脂肪和低纤维)的改变,体力活动的减少,这些因素可能导致DM或DR患病率增加。查阅文献,目前尚缺乏华南地区以人群为基础的DR流行病学调查研究,为了解我省经济发达地区,例如珠江三角洲居民DM及DR患病的相关数据,动态掌握DM患者盲与低视力主要原因,危险因素和变化趋势,为政府制定针对性的公共卫生政策和合理分配医疗卫生资源提供科学依据,我们在广东省东莞市开展DM、DR以及DM患者盲与低视力的普查,具体报告如下：第一章广东省东莞市横沥镇居民以人群为基础糖尿病视网膜病变调查方法和基本资料目的介绍广东省东莞市横沥镇居民以人群为基础的眼病流行病学调查,重点在DR以及DM盲与低视力患病率及危险因素的调查。方法以人群为基础的横断面流行病学调查。对广东省东莞市横沥镇16个自然村和1个社区,40岁及以上户籍常住居民进行普查。调查包括：一般情况(姓名、性别、年龄)、社会经济情况(职业、受教育程度、家庭人均月收入)、DM和DR问卷、身体测量(身高、体重、BMI、腰围、臀围、腰臀比、体表面积、血压和心率)、实验室检查(空腹血糖、糖化血红蛋白、餐后2小时血糖、胆固醇、甘油三酯、高密度脂蛋白、低密度脂蛋白、血肌酐、尿素氮和尿酸)和眼科一般检查和特殊检查；眼科检查包括眼病史和眼部手术史、视力(裸眼视力和日常生活视力)、电脑验光、矫正视力、眼压、裂隙灯眼检查、前置镜眼底检查；DM患者以及可疑眼底病患者进行眼底照相,可疑青光眼和视神经病变者行视野、OCT、角膜厚度和裂隙灯下房角镜检查。结果东莞市横沥镇11181名户籍常住居民中,8592人参加现场调查,应答率为80.06%；我们对未参加现场调查的2229人进行电话调查,1612人接受电话调查。参与现场调查的8952人中,男性3594人(40.1%),女性5358人(59.9%),平均年龄55.31±11.44岁,全部为汉族人。结论广东省东莞市横沥镇普查对8592人进行现场调查,应答率为80.06%；2229人进行电话调查。我们了解到经济发达地区广东省东莞市横沥镇≥40岁常住居民常见眼病患病情况,DM、DR患病率及危险因素,DM患者视力损伤情况。第二章广东省东莞市横沥镇居民糖尿病视网膜病变患病率调查目的调查东莞市横沥镇40岁及以上居民糖尿病视网膜病变(DR)患病率、糖尿病性黄斑水肿(diabetic macular edema,DME)、有临床意义黄斑水肿(clinically significant macular edema,CSME)和威胁视力的糖尿病视网膜病变(vision-threatening diabetic retinopathy,VTDR)的患病率。方法以东莞市横沥镇40岁及以上居民为调查对象,进行DM筛查,根据2010年美国ADA糖尿病诊断标准确诊DM,并根据2002年悉尼DR国际分期标准进一步进行DR筛查和分级。具体包括一般资料、问卷调查、实验室检测和眼科检查。对所有DM患者进行视力、验光、矫正视力、非接触眼压、裂隙灯、眼底检查和眼底照相。分析DM和DR、DME、CSME和VTDR患病率。结果8952人参与DM筛查和眼科检查,应答率为80.06%,现场调查筛查出DM患者1508人,电话问卷调查筛查出DM患者69人,DM患病率为17.62%。1508名DM患者中新诊断DM患者1072人(71.09%),有病史DM患者436人(28.91%)。DM患者(1508人)平均年龄59.47±11.19岁,男性619人(41.00%),女性889人(59.00%)；Ⅰ型DM8人,2型DM1500人。2型DM患者中参加眼底照相1351人。DR患病率17.94%,性别年龄标准化后,DR患病率为18.20%。新诊断DM患者DR患病率为11.55%,标准化后12.64%；有病史DM的DR患病率为33.87%,标准化后32.87%。NPDR患病率为17.33%,PDR患病率为0.92%。DME、CSME和VTDR患病率分别为2.90%、1.07%和2.82%,标准化后分别为2.54%、0.88%和2.62%。结论广东省东莞市横沥镇40岁及以上居民DM患病率为17.62%,71.09%患者为新诊断DM;DR患病率为18.20%,较以白种人、非洲裔美国人和西班牙人以及中国北方人群为研究对象的DR患病率低。NPDR占主要部分,即多数患者处于疾病的早期和中期阶段,需要得到及时的干预和治疗。第三章广东省东莞市横沥居民2型糖尿病患者糖尿病视网膜病变危险因素分析目的调查东莞市横沥镇40岁及以上居民2型糖尿病患者(Type2Diabetes Mellitus, T2DM)糖尿病视网膜病变(DR)危险因素。方法以东莞市横沥镇40岁及以上居民为调查对象,进行DM筛查,根据2010年美国ADA糖尿病诊断标准确诊DM,并根据2002年悉尼国际DR分期标准进一步进行DR筛查。具体包括-般资料、问卷调查、实验室检测和眼科检查。对所有DM患者进行视力、验光、矫正视力、非接触眼压、裂隙灯、眼底检查和眼底照相。使用Logistic相关回归模型进行DR危险因素的分析。结果Logistic逐步回归分析结果显示男性、DM病程、收缩压、空腹血糖和糖化血红蛋白是影响T2DM患者发生DR的独立危险因素。相对于女性DM患者,男性DM患者发生DR风险为1.914倍[95%CI(1.382-2.651)]；相对于新诊断DM患者,病程为1～4年、5～9年和≥10年的DM患者DR发生风险分别为3.336倍[95%CI(2.322-4.880)]、3.890倍[95%CI(2.327-6.503)]和12.499倍[95%CI(6.607-23.647)]；相对于收缩压≤120mmHg的DM患者,收缩压为120-139mmHg、≥140mmHg的DM患者发生DR风险分别为1.953倍[95%CI(1.081-3.528)]和1.950倍[95%CI(1.076-3.532)]；相对于空腹血糖≤5.6mmol/L的DM患者,空腹血糖为(5.6-6.9) mmol/L、≥7.0mmol/L的DM患者,DR发生风险分别为1.567倍[95%CI(0.889-2.732)]和2.170倍[95%CI(1.252-3.761)]；相对于糖化血红蛋白≥6.5%DM患者,糖化血红蛋白<6.5%的DM患者,DR发生风险为1.577倍[95%CI(1.105-2.253)]。对于新诊断DM患者,Logistic逐步回归分析,结果显示男性、空腹血糖、糖化血红蛋白和BMI是影响新诊断DM患者发生DR的独立危险因素。结论男性、DM病程、平均收缩压、空腹血糖和糖化血红蛋白是影响T2DM患者发生DR的独立危险因素。早期诊断、控制高血糖、高血压等相关危险因素可能可以减少DR患病率及控制其严重程度。第四章广东省东莞市横沥镇居民2型糖尿病患者盲与低视力患病率与原因分析目的探讨东莞市横沥镇居民40岁及以上2型糖尿病(T2DM)人群盲与低视力的患病现状,致盲原因及相关因素。方法以人群为基础的横断面现况调查。以东莞市横沥镇40岁及以上居民为调查对象,进行DM筛查,根据2010年美国ADA糖尿病诊断标准确诊DM,调查对象完成日常生活视力、验光、矫正视力、非接触眼压测量、裂隙灯眼前段检查、眼底检查和眼底照相,对于可疑青光眼或眼底病患者进行进一步眼科检查。分别根据最佳矫正视力和日常生活视力,采用世界卫生组织(1973年)盲与视力损害的标准评估DM患者盲与低视力患病率并分析主要致盲原因。结果8952人参与DM筛查和眼科检查,应答率为80.06%,现场调查筛查出DM患者1508人,2型DM患者1500人,其中完善眼科检查为1356人,应答率为90.46%。完成眼科检查男性550人(40.56%),女性806人(59.44%)。652人(48.08%)为农民,780人(57.52%)为文盲和接受小学以下教育。根据最佳矫正视力评估,横沥镇T2DM患者中双眼盲12人占0.88%,单眼盲45人占3.32%；双眼低视力35人占2.58%,单眼低视力63人占4.65%。视力损伤患者(包括双眼和单眼盲与低视力患者)155人,引起视力损害首要原因是白内障(58.06%)、眼底病变(除DR和AMD外,9.68%)、角膜混浊(6.45%)、翼状胬肉(6.45%)、弱视(3.87%)和DR(3.23%)。DR为第六位致DM患者视力损伤原因。按照日常生活视力进行盲与低视力评估,双眼盲17人(1.25%),单眼盲53人(3.91%)；双眼低视力105人(7.74%),单眼低视力116人(8.55%)。导致291例DM患者视力损害的首要原因仍然是白内障(44.33%)、屈光不正(包含高度近视,38.36%)、翼状胬肉(6.53%)眼底病变(4.81%)和角膜混浊(3.09%)。DR为第7位DM患者致盲原因占2.41%。结论东莞横沥镇居民T2DM患者中,白内障是致盲的首要原因,因此东莞市农村DM防盲工作重点是定期DR筛查和干预的基础上,进行白内障的防治,尤其需要重视高龄和低教育程度的DM患者视力损伤的防治。更多还原

【Abstract】 Diabetic retinopathy(DR) is the leading cause of blindness among working-aged adults around the world and one of the main causes of binocular blindness in elderly patients in the developed world.DR has become a serious global public and economic problems. As the prevalence of DM increases and patients live longer in China, the development of DR as a microvascular complication of DM also rises.In China’s mainland,the total number of people with DM is projected to rise from43.157million in2010to62.253million in2030.The prevalence of DM in economically developed areas in China is close to the developed countries,such as Beijing, Shanghai and the Pearl River Delta.Many previous reports have shown the higher rates of DR in population-based studies in Beijing, Handan Hebei province and Shanghai. These data is important for the formulation of public health policy and allocation of health resources in these area.The occurrence and development of diabetes is influenced by many factors, such as living habits, geographical distribution, economic level and environmental factors.In addition, because of complex mechanism of diabetes, the reasons of low vision and blindness in diabetes mellitus(DM) also has its particularity. Thirty years of reform and opening up, the economy has been developing rapidly in the Pearl River Delta region, including Dongguan.Accelerating the process of urbanization and better conditions of the public health have markedly improved the living condition of people.However, urbanization is associated with changes in lifestyle that lead to physical inactivity,an unhealthful diet(high-calorie, high fat and low fiber), and obesity, all of which have been implicated as contributing factors in the development of diabetes.There are limited researches on DR in the Southern areas in China, especially population-based studies in Guangdong province. Therefore,in order to identify the prevalence and risk factors of DM and DR in economically developed areas in Guangdong, grasp the reasons of blind and low vision in DM patients, we carried out this population-based study which was divided into four parts:Part1Rationale,Methodology, and Baseline Date for a Pupulation-based Study of Eye Dieases in Hengli town, Dongguan city, Guangdong provincePurpose:To describe the rationale and study design of a population-based study of eye dieases in permanent residents aged40years and older in Hengli town, Dongguan city in Southern China. Focus on the prevalence of diabetic retinopathy and blindness and low vision in diabetic patients. Methods:A population-based cross-sectional study. Public Security Bureau provided a list of15987residents aged40years and older from16villages and1community in Hengli town. Excluded4806no long-term residents(more than3years) living in Hengli town due to move outside Hengli town, work outside, immigration to HongKong or abroad and no answer to the telephone survey, the eligible permanent residents is11181people who were invited to the investigation sites by letter, telephone and home visits by village committee staff. Participants underwent standardized interview, physical and ocular examinations including:general message(name, gender and age), social and economic situation(occupation, education level, income), the questionnaire of diabetes and diabetic retinopathy, anthropometry(measurement of height, weight, BMI, waist circumference, hip circumference, waist to hip ratio, body surface area, blood pressure and heart rate), Laboratory examination(fast blood-glucose, OGTT, glycosylated hemoglobin, blood lipid level and urea nitrogen, serum creatinine and blood uric acid). Ocular examination included presenting visual acuity(PVA),best corrected visual acuity(BCVA), intraocular pressure(IOP), anterior and posterior segment examinations, fundus and optic disc photography. Selected participants underwent gonioscopy, visual field testing and optical coherence tomography(OCT). Results:Of11181eligible persons,8592(response rate:80.06%)were examined Among8952participants,3594men (40.1%),5358females (59.9%), mean age55.31±11.44years, Han Chinese(100%). We conducted a telephone survey of2229people who did not participate in the field investigation,1612participates in telephone survey with a response rate of72.32%. Conclusions:This study provides population-based data on major eye condition, the prevalence and risk factors of DR and visual impairment in diabetic patients in Han Chinese in Southern China.Part2Prevalence of Diabetic retinopathy in a Southern Chinese Population with Diabetes Mellitus in Dongguan city, Guangdong ProvincePurpose:To describe the prevalence of DR, diabetic macular edema(DME), clinically significant macular edema(CSME) and vision-threaten diabetic retinopathy (VTDR) in Hengli town, Dongguan city in Southern China. Methods:A population-based cross-sectional study. A total of8952Han Chinese from16villages and a community participated in the census of diabetes. Participants underwent standardized interview, physical and laboratory examination. Ocular examination included PVA and BCVA, IOP, anterior and posterior segment examinations, fundus and optic disc photography. The diagnosis of DM and DR were made according to American Diabetes Association (ADA,2010) for diabetes and international clinical classification system of DR and DME(Sydney,2002).Results:1508participants were diagnosed with diabetes mellitus in field investigation, and69diabetic patients were screened out from the telephone survey. The prevalence of diabetes mellitus was17.62%. Among1508diabetic patients,1500were type2diabetes mellitus (T2DM),1072(71.09%) were newly diagnosed and436(28.91%) subjects with known diabetes mellitus(DM). The age and gender standardized prevalence of DR was18.20%in total DM,12.64%in newly diagnosed DM patients and32.87%in patients with known DM. The standardized prevalence of NPDR and PDR was17.33%and0.92%. The age and gender standardize prevalence of DME, CSME and VTDR were2.54%,0.88%and2.62%, respectively. Conclusions:Our study shows a higher rate of DM and a lower prevalence of DR in Southern China. Newly diagnosed DM patients are the majority, accounting for71.09%. NPDR was more common. There is a strong requirement for screening, prevention and treatment to control for DR.Part3Risk Factors for Diabetic Retinopathy in a Southern Chinese Population with Type2Diabetes Mellitus in Dongguan City, Guangdong ProvincePurpose:To describe risk factors associated with DR in type2diabetes mellitus(T2DM) patients aged40years and older in Hengli town, Dongguan city in Southern China. Methods:A population-based cross-sectional study. A total of8952Han Chinese from16villages and a community participated in the census of diabetes. Participants underwent standardized interview, physical and laboratory examination. Ocular examination included PVA and BCVA, IOP, anterior and posterior segment examinations, fundus and optic disc photography. The diagnosis of DM and DR were made according to ADA diagnostic criteria (American,2010) for diabetes and international clinical classification system of DR and DME(Sydney,2002). Univariate and stepwise logistic regression analysis were used to identify independent risk factors. Results:Stepwise logistic regression analysis revealed that male, longer duration of DM, systolic pressure,hyperglycemia and glycosylated hemoglobin were the independent risk factors of DR. Compared with females, males had a higher risk of having any DR,OR=1.914[95%CI(1.382-2.651)].Compared with newly diagnosed DM patients, DM with duration of1-4years,5-9years and≥10years had a higher risk of having any DR,3.336[95%CI(2.322-4.880)],3.890[95%CI(2.327-6.503)] and12.499[95%CI(6.607-23.647)]. Compared with DM patients with BP<120mmHg, DM patients with BP(120-139)mmHg and≥140mmHg had a higher risk of having any DR1.567[95%CI(0.889-2.732)] and2.170[95%CI(1.252-3.761)]; Compared with DM patients with fasting blood glucose<5.6mmol/L, DM patients with (5.6-6.9)mmol/L and≥7.0mmol/L had a higher risk of having any DR,1.567[95%CI(0.889-2.732)]and2.170[95%CI(1.252-3.761)]. Compared with DM patients with glycosylated hemoglobin≥6.5%, DM patients with<6.5%had a higher risk of having any DR, OR=1.577[95%CI(1.105-2.253)].Factors independently associated with newly diagnosed DM patients were male, higher hyperglycemia and higher glycosylated hemoglobin and greater BMI. Conclusions:Our study shows that male, duration of diabetes, systolic pressure, hyperglycemia and glycosylated hemoglobin are independent risk factors of DR in T2DM patients. These findings suggest that controlling hyperglycemia, hypertension and BMI in this population may reduce the high risk of having DR associated with T2DM.Part4Prevalence and Causes of Low vision and Blindness in a T2DM Population in Southern China, in Dongguan City, Guangdong ProvincePurpose:To assess the prevalence and causes of low vision and blindness in a diabetic population in Southern China. Method:A population-based cross-sectional study. There are8592Han Chinese aged40years and older from16villages and1community to participate in the census of diabetes in Hengli town, Dongguan city, Guangdong province, in Southern China.1500T2DM patients were screened according to the diagnostic criteria(ADA,2010).All the diabetic patients underwent a standard interview, a comprehensive eye examination, including PVA and BCVA, intraocular pressure, slit lamp examination(external eye,anterior segment and ocular fundus) and fundus photography. Main outcome measures:Low vision and blindness were defined as VA<20/63to≥20/400and VA<20/400in the better eye following the World Health Organizaion definitions(WHO1973). Results:One thousand three hundred and fifty six(90.46%) of1500T2DM patients anticipated in this study and had VA data available. With best-corrected VA, the prevalence of bilateral low vision and blindness were0.88%and2.58%respectively. Leading causes of visual impairment were cataract (58.06%), other retinal diseases (except DR and AMD,9.68%), corneal opacity (6.45%), pterygium (6.45%), amblyopia (3.87%) and DR (3.23%). The prevalence of bilateral low vision and blindness (PVA) were1.25and7.74%; Cataract was also the principal cause of visual impairment in44.33%diabetic patients. Conclusions:In rapidly urbanized of Dongguan, cataract is still the leading cause of visual impairment in T2DM patients. Therefore, the focus of diabetic blindness prevention work is the intervention in cataract on the basis of the regular screening in DR, especially pay attention to the prevention of visual impairment in diabetic patients with older age and lower education level.更多还原