【作者】 马群；

【导师】 曾水清；

【作者基本信息】 华中科技大学 ， 眼科学， 2009， 博士

【摘要】 目的光学相干断层扫描仪（Optical Coherence Tomography，OCT）检测无并发症超声乳化白内障吸除术后黄斑中央凹厚度的变化，检测糖尿病和高度近视并发白内障超声乳化吸除术后黄斑中央凹厚度的变化，分析引起黄斑中央凹厚度增加和黄斑水肿的可能因素，探讨黄斑水肿发生的可能机理及其超声乳化白内障吸除术后黄斑中央凹厚度增加是否会影响客观和主观视功能。方法OCT检测60例无并发症超声乳化白内障吸除术后黄斑中央凹厚度的变化，分析炎症反应程度和玻璃体后脱离对黄斑中央凹厚度的影响。22例糖尿病和24例高度近视并发白内障用OCT观察超声乳化吸除术后黄斑中央凹厚度的变化和黄斑水肿形态学特征，分析糖尿病和超声乳化手术对黄斑中央凹厚度的影响，分析高度近视病理眼白内障超声乳化吸除术后对黄斑中央凹厚度的影响。相关分析黄斑中央凹厚度与视功能的关系。无并发症白内障超声乳化吸除术后1月时黄斑中央凹厚度增加眼用Oculas静态视野计检查主观视功能，Veris多焦视网膜电图检查客观视功能。结果60例无并发症老年性白内障超声乳化术后用OCT检查黄斑中央凹厚度的变化，术前为148.6±11.5um，术后1周为152.8±13.5um，术后1月为159.7±18.9um，术后3月为155.2±16.2um，术后各个时间段黄斑中央凹厚度与术前比较均无显著性差异（F=0.87，P＜0.05）。炎症组术后1周和1月时黄斑中央凹厚度比术前明显增厚，有显著性差异（F=4.31，6.17，P＜0.05），术后三月时与术前比较无明显增厚（P＞0.05），轻度炎症组术后时间段与术前比较无显著性差异（P＞0.05）。完全PVD组和对照组超声乳化白内障吸除术后各个时间段黄斑中央凹厚度与术前比较无显著性差异（P＞0.05）。白内障超声乳化吸出术后1周、1月和3月最佳矫正视力与黄斑中央凹厚度相关系数为-0.78、-0.72和-0.81，有显著性差异（P＜0.05）。糖尿病并发白内障超声乳化吸除术后1周和1月时黄斑中央凹厚度比术前明显增厚，有显著性差异（F=5.62和4.19，P＜0.05），术后3月时与术前无明显增厚（P＞0.05）。OCT形态学分析有4例出现黄斑水肿，3例为视网膜海绵样肿胀，1例为黄斑囊样水肿。糖尿病并发白内障超声乳化吸除术后1周、1月和3月最佳矫正视力与黄斑中央凹厚度相关系数为-0.73、-0.82、-0.67，有显著性差异（P＜0.05）。高度近视眼术前黄斑中央凹厚度比对照组薄，有显著性差异（F=3.89，P＜0.05）。高度近视眼白内障超声乳化吸除术后1周和术后1月黄斑中央凹厚度比术前增厚，有显著性差异（F=4.97，和6.17，P＜0.05）。OCT形态学分析术后1月时有3例出现黄斑水肿，1例为海绵样水肿，1例为神经上皮浆液性脱离，1例为海绵样水肿、神经上皮浆液性脱离和黄斑囊样水肿的混合型。高度近视并发白内障超声乳化吸除术后1周、1月和3月最佳矫正视力与黄斑中央凹厚度相关系数为-0.21、-0.12、-0.18，无显著性差异（P＞0.05）。主观视功能检查静态视野0⁰点光刺激阈值黄斑中央凹增厚组为14.82±7.99dB，对照组为21.17±6.13dB，两组间有显著性差异（t=2.07，p＜0.05）。客观视功能多焦视网膜电图0⁰视网膜的功能N₁波和P波反应密度两组间有显著性差异（t=3.42和3.67，p＜0.05）。结论超声乳化白内障吸除术手术创伤小，术后反应轻，并不引起黄斑中央凹厚度的增加，但超声乳化术后24小时房水闪光++或++以上患眼术后1周和1月黄斑中央凹厚度比术前明显增厚，炎性反应较重患者可能与手术时间长、超声乳化所用能量大、误吸虹膜组织和前房不稳定等因素有关。完全PVD和对照组超声乳化术后黄斑中央凹厚度的变化无显著性差异，说明超声乳化吸除白内障并不明显地增加玻璃体前牵引的力量，人工晶体眼也不增加玻璃体前牵引的力量。黄斑中央凹厚度与超声乳化白内障吸除术后最佳矫正视力相关分析显示黄斑中央凹厚度越薄矫正视力越好，中央凹厚度的增加就有可能影响中心视力。血糖增高可导致视网膜、虹膜、血管完整性破坏和微循环混乱，在此基础上的超声乳化白内障吸除术可破坏血视网膜屏障，导致黄斑中央凹增厚，严重者可引起黄斑水肿，但术后3个月时基本恢复正常，表明糖尿病并发白内障超声乳化术后血-视网膜屏障的破坏是暂时和可逆的，相关分析表明黄斑中央凹厚度的增加可以影响最佳矫正视力。高度近视眼黄斑中央凹变薄与眼球扩张脉络膜厚度变薄、视网膜营养不良和视网膜神经上皮层发生变薄有关，高度近视病发白内障超声乳化吸除术后易发生黄斑中央凹厚度增加和水肿可能与中央凹视网膜对创伤的耐受性低有关，并且恢复的时间也较长，高度近视发白内障超声乳化吸除术后最佳矫正视力和黄斑中央凹厚度相关分析表现为复杂的非线性相关，说明很多因素可影响黄斑中央凹厚度和视功能。黄斑中央凹增厚组黄斑中央凹静态视野光刺激阈值比对照组低，说明要用更强的光刺激才能引起黄斑中央凹视网膜的反应。多焦视网膜电图N₁波和P波反应密度黄斑中央凹增厚组比对照组低，对刺激反应较弱，推测黄斑中央凹增厚有主观和客观视功能的改变。更多还原

【Abstract】 Objective To detect the changes of foveal thickness following uncomplicatedphacoemulsification of senile cataract by optical coherence tomography（OCT）, and detectthe changes of foveal thickness following phacoemulsification of cataract with diabeticand high myopia. Analysis the some factors that induced the increase of foveal thicknessand macular edema. To investigate the mechanism of macular edema and the influence onthe subjective and objective visual function with increase of foveal thickness afteruncomplicated phacoemulsification.Methods 60 eyes of the senile cataract following uncomplicatedphacoemulsification and IOL implantation were detected the changes of foveal thicknessby OCT. The results were analyzed the influence on the changes of postoperative fovealthickness according to the degree of inflammation and posterior Vitreous detachment（PVD）. Cataracts of 22 eyes with diabetics and 24 eyes with high myopia followingphacoemulsification were detected the changes of foveal thickness and morphologicalcharacters of macular edema by OCT. Influence on foveal thickness with diabetics, highmyopia or phacoemulsification procedure was studied. Analyzed the correlation of forvealthickness with visual function. 15 patients with increase of foveal thickness at 1 monthafter phacoemulsification were examined the subjective visual function with Ocular staticvisual field and objective visual function with Veris multifocal electroretinograms.Results 60 patients were examined the changes of foveal thickness afteruncomplicated phacoemusification for senile cataract by OCT, 148.6±11.5umpreoperatively, 152.8±13.5um at 1 week after operation, 159.7±18.9um at 1 month after operation and 155.2±16.2um at 3 months after operation. There were no significantdifference at difference time postoperative comparing to preoperative （F=0.87, P＜0.05）.The postoperative foveal thickness of mild inflammation group at 1 week or 1 monthfollowing uncomplicated phacoemulsification was increased obviously to preoperativeand had significant difference（F=4.31, 6.17, P＜0.05 ）, but had no difference at 3 monthsfollowing phacoemulsification （P＞0.05） . There were no difference of foveal thicknessafter phacoemulsification in moderate inflammation group （P＞0.05） . There wereno changes of foveal thickness for complete PVD, and had no statistical significant（P＞0.05） .The correlation between the best corrective visual acuity and foveal thicknessat 1 week, 1 month and 3 months following phacoemulsification was -0.78、-0.72 and-0.81, and had statistical significant （P＜0.05） .The foveal thickness at 1 week or 1 monthafter phacoemulsification in diabetics had been increased obviously to preoperative andhad significant difference（F=5.62 and 4.19, P＜0.05）, but had no significant difference at3 months （P＞0.05） . Morphological analysis of OCT showed that 4 patients had hadmacular edema at 1 month after phacoemulsification, 3 patients were spongy-like retinaledema, and 1 patient was retinal cystoid edema. The correlation between the bestcorrective visual acuity and foveal thickness at 1 week, 1 month and 3 months afterphacoemulsification in diabetics was-0.73、-0.82 and -0.67 , and had statisticalsignificant （P＜0.05） . the foveal thickness of high myopia preoperatively was thinnerthan that of control group and had significant difference （F=3.89, P＜0.05） . The fovealthickness at 1 week or 1 month after phacoemulsification in high myopia was increasedobviously comparing to preoperative and had significant difference （F=4.97 and 6.17,P＜0.05 ）.Morphological analysis of OCT showed that 3 patients had had macular edema at1 months after phacoemulsification, 1 patients had spongy-like retinal edema, and 1patient had serious detachment of neural epithelium and 1 patient had coexist of thespongy-like retinal edema, cystoid retinal edema and serious detachment of neuralepithelium. The correlation between the best corrective visual acuity and foveal thickness at 1 week, 1 month and 3 months after phacoemulsification in high myopiawas-0.21、-0.12、-0.18, and had no statistical significant （P＞0.05）. 0⁰ light stimulatingthresholds of increased foveal thickness group was 14.82±7.99dB by static visual fieldexamination of subject visual function, but the control group was 21.17±6.13dB, and hadsignificant difference（t=2.07, p＜0.05）. It had significant difference of 0⁰ retinal N₁ and Pwave response densities of objective visual function by multifocal electroretiongrams（t=3.42 and 3.67, p＜0.05）.Conclusions The foveal thickness was increased in mild inflammation group afteruncomplicated phacoemulsification with OCT and recovered normal at 3 monthspostoperatively. It might be related to long time operation, high phaco power, injure of irisin surgery and anterior chamber instability, etc. It suggested that this patients hadtemporary and reversely blood-retinal barrier disorder. There had no changes of fovealthickness in senile cataract with complete PVD after phacoemulsification. The visualconsequences were proportional to the degree of foveal thickness. The foveal thicknesswas increased significant at early stage after phacoemulsifucation in diabetics comparingto control group, it indicated that increase of blood sugar would induce the disorder ofretinal and micro-circulation.The phacoemulsification procedure might aggressive thedisorder of blood-retinal barrier, and induce the increase of foveal thickness or evenlymacular edema, but recover normal at 3 months after phacoemusificaion. The disorder ofblood-retinal barrier was temporary and reversely. The visual consequences afterphacoemusification in diabetics were proportional to the degree of foveal thickness. Thedecrease of foveal thickness in high myopia was related to expanding of eye, thin retinalnerve epithelial, thin choroidal and retinal malnutrition . The foveal thickness wasincreased significant and induced macular edema after phacoemusification in high myopia,it suggested that the fovea in high myopia had had low resistance to injury and neededlong time to recover. The regression analysis of best corrective visual acuity and fovealthickness after phacoemulsification in high myopia showed that it had had complex non-linear relationship, it suggested that many factors might influence on foveal thicknessand visual function. Subjective visual functional evaluation showed that the lightstimulating thresholds at central were low in the increased foveal thickness group, andindicated that the stronger light stimulation could induce the response of macular fovea.Objective visual functional evaluation showed that the response densities of N₁ and Pwave in the increased foveal thickness group were lower than control group and illustratedthat increased foveal thickness had a low reaction to stimulation, and suggested thatincreased foveal thickness had induced changes of subjective and objective visualfunction.更多还原