【作者】 邱怀雨；

【导师】 张卯年；

【作者基本信息】 中国人民解放军军医进修学院 ， 眼科学， 2010， 博士

【摘要】 目的了解我国现役军人中眼外伤的人口学特征、致伤原因及伤情特点,并对不同军、兵种眼外伤特征进行比较,寻找致伤的高危因素,并有针对性地对眼外伤高危人群、高危行为提出有效的预防措施。同时,了解军人眼外伤患者的救治过程及预后特点。方法1、住院病例回顾性研究：在全国21家团级医院(跨越华北、东北、华东、中南、西南、西北地区)收集2002-01-01至2008-12-31间军人眼外伤住院病例资料,并填写“军人眼外伤住院病例登记表”。2、门诊现况调查：进行各医院登记人员的培训,在2009-01-01前,将“军人眼外伤病例登记表”分发到21家团级医院,在接诊军人眼外伤病例时,现场填写“军人眼外伤病例登记表”。调查时间段为2009-01-01至2009-12-31日。3、分别将两部分资料录入SPSS13.0数据库,并进行统计分析。结果1.眼外伤患者的一般情况：住院病例回顾性研究共收集953例(1012眼),男女比率为104.9：1,平均年龄23.57岁。门诊现况调查共收集502例(526眼)男女比率为54.8：1,平均年龄24.28岁。2.致伤原因2.1住院病例回顾性研究：①与工作相关眼外伤(占总数的29.2%)：陆军(34.7%)和海军(30.6%)的构成比高于空军(20.1%)和武警(20.5%)。海军以水面舰艇部队最多见(42.5%,其中82.4%的工作相关伤是由于船体维护、保养造成)。陆军多见于装甲兵(53.1%,其中65.4%为坦克的操作、维护及修理)、通信兵(46.2%,其中50%为野外架设电线)、工程兵(43.9%,均在工程施工中受伤)。②体育运动致伤(占27.9%)：海军的运动伤占比例(40.4%)最高。③与日常生活相关眼外伤(占15.3%)：其中69.2%的眼外伤致伤地点在家或住所,发生时间多见于节假日休假、回家探亲(91.1%)。④与军事训练有关的眼外伤(占14.1%)：海军的比例仅为3.3%,而武警的军事训练伤所占比例最高为30.8%。单兵对抗训练、体能训练最多见(占45.8%)。武警的擒拿格斗、倒功训练、棍术训练三项占武警军事训练伤总数的66.7%。2.2门诊现况调查：与工作相关伤(占27.9%)以水面舰艇部队所占比例最高(46.3%)；体育运动伤(36.1%)较住院病例明显增高(27.9%),在海军、空军的学员和后勤部队,空军空降兵,海军岸防兵中,所占的比例均大于40%,而干部的运动伤比例更是高达50%；军事训练伤中,陆军和武警的比例分别为21.4%和21.3%,海军军事训练伤所占比例仍然最低,仅为4.4%,技能性训练最多见(占49.2%),体能、对抗性训练仅占29.5%。3.伤情特点住院病例回顾性研究：闭合伤占眼外伤总数的65.5%；眼球开放伤占眼外伤总数的10.8%,陆军的开放伤比例最高(16.2%),陆军部队中,又以装甲兵的比例最高(21.6%)。陆军的球内异物伤(6.2%)较海军(0.4%)、空军(3.0%)和武警(2.4%)高发,占前三位的兵种是工程兵(9.76%)、步兵(9.62%)、装甲兵(8.16%)。门诊现况调查中,闭合伤占眼外伤总数的61.2%；眼球开放伤仅为8眼、占眼外伤总数的1.5%。异物伤以眼表多见,海军的比例最高(12.9%),但不同军种间未见差异。球内异物伤仅陆军1例。4.影响就诊时间因素分析首次就诊时间平均为32.56小时(标准差285.4),其中开放伤为5.683小时(标准差22.5),闭合伤为45.39小时(标准差350.4)。通过多元逐步回归分析得出眼球闭合伤的分区、玻璃体受累、视网膜脱离三项与首次就诊时间关系密切。其中玻璃体受累为负相关。就诊眼科医生时间平均为50.32小时(标准差324.7),其中开放伤9.39小时(标准差24.4),闭合伤71.77小时(标准差398.7)。首次就诊间隔时间、眼球闭合伤的分区、前房受累、视网膜脱离四项与就诊眼科医师时间有关。其中前房受累为负相关。5.救治情况卫生队或卫生所：化学烧伤的处置率为30.6%。眼睑皮肤裂伤缝合率10.2%。团级医院：在住院回顾性研究的病例分析中,眼球开放伤109眼,行眼球缝合术占89.9%。伤后24小时内行一期缝合占62.4%,大于24小时手术的占27.5%。另有10.1%未行手术治疗。首次手术时间间隔长的原因为：①转诊耽搁占46.7%；②伤情较重,手术准备时间长占16.7%；③病情许可,处理并发症13.3%；④误诊13.3%；⑤患者自身对眼病严重性认识不足10%。闭合伤663眼,行手术治疗161眼,占24.3%。其中钝挫伤122眼,板层裂伤16眼,眼球表面异物23眼；闭合伤的分区：Ⅰ区74眼、Ⅱ区22眼、Ⅲ区65眼。首次手术时间：Ⅰ区的首次手术时间平均为2.55天(标准差5.652)、Ⅱ区29.45天(标准差79.114)、Ⅲ区87.98天(标准差113.385)。6.影响视力结局和转诊次数的因素：明显影响视力结局的伤情因素依次为：眼球开放伤、视神经受累、视网膜脱离、累及玻璃体。各军种的视力预后间行单因素方差分析,海军、空军眼外伤的视力预后好与陆军、武警。陆军、武警的转诊次数高于海军、空军。对转诊次数影响较大的因素依次是：视网膜脱离、开放伤类型、爆炸伤、军种。结论1、军事训练伤中海军所占比例最低,而武警的军事训练伤所占比例最高。单兵对抗性训练、体能训练在各个军种中都是眼外伤发生的高危因素；武警的擒拿格斗、倒功训练、棍术训练是主要的军事训练伤发生科目。2、陆军、海军的与工作相关伤明显高于空军、武警。器械的维护、修理,工程施工、劳动作业是与工作相关眼外伤的高危原因。常见的军兵种为：陆军的装甲兵、通信兵、工程兵；海军的水面舰艇部队。3、现况调查中训练眼外伤的发生多与职业有关,以职业技能性训练常见；而住院病例回顾性研究中训练眼外伤的发生多与训练科目有关,以单兵对抗训练、体能训练常见。4、住院病例中,开放性眼外伤以陆军的装甲兵比例最高。球内异物伤也以陆军最常见,常见的兵种为工程兵、步兵、装甲兵。5、团级以下医疗机构对眼外伤的急救处理需要进一步加强。6、开放性眼外伤首次手术延迟的原因依次为路途较远,转诊耽搁；伤情较重,请外院会诊以及医生的误诊、漏诊。而闭合性眼外伤以Ⅲ区的手术时间耽搁最明显。7、对视力影响较大的因素依次是：眼球开放伤、视神经受累、视网膜脱离、累及玻璃体。影响转诊次数较大的因素依次是：视网膜脱离、开放伤类型、爆炸伤、军种。更多还原

【Abstract】 PurposeTo investigate the characters of military eye injury including demography, cause of injury, traumatic condition, treatment and prognosis, especially comparing the difference among various troops. Then provide effective methods to prevent ocular injury in the troops which have high possibility to be hurt.Methods1. The retrospective study of inpatients:Collected inpatients’record of military personnel with ocular injury in 21 regimental hospitals from 2002-01-01 to 2008-12-31, and filled in the "registered table of inpatient’s military ocular injury".2. Cross-sectional investigation in out-patient clinic:Distributed "registered table of military ocular injury" to 21 regimental hospitals before 2009-01-01. When the military personnel visited the doctor because of ocular injury, simultaneously, the doctor filled in the table. The time was from 2009-01-01 to 2009-12-31.3. The pooling datas were statistically analyzed by SPSS13.0.Results1. General information:There were 953 patients with 1012 injured eyes in retrospective study. The ratio of male to female is 104.9:1 and the mean age is 23.57 years. As for cross-sectional investigation, there were 502 patients with 526 injured eyes. The ratio of male to female is 54.8:1 and the mean age is 24.28 years. 2. Causes of injury2.1 The retrospective study of inpatients:①work-related injury(29.2%):The constituent ratios of the army(34.7%) and navy(30.6%) were much higher than air force(20.1%) and armed police(20.5%).It could be often seen in surface warship force (42.5%)of navy and in armored forces (53.1%)、communications corps (46.15%)、engineering corps (43.9%) of the army.②sports-related injury (27.9%):The highest service is navy(40.41%).③everyday life-related injury (15.3%):Most of the injury occurred in home or habitation and on holiday.④military training-related injury(14.1%):The constituent ratio of navy is only 3.3%, but 30.8% in armed police. It was most often occurred in solder’s counter-acting exercises and physical training(45.8%). In armed police, about 66.7% were occurred by exploring training methods of catching and grappling, fall training and cudgel play.2.2 Cross-sectional investigation in out-patient clinic:Work-related injury was often occurred in surface warship force (46.3%). The ratio of sports-related injury(36.1%) was higher than inpatient (27.9%); the ratio was more than 40% in trainee and administrative echelon of navy and air force, airborne troops and naval coast defense arm; the highest ratio was in cadre(50%). As for military training-related injury, the ratios of the army and armed police were 21.4% and 21.3% respectively; like retrospective study, the ratio of navy was the lowest (4.4%); and it was more often happened in skill-training (49.2%) rather than counter-acting exercises (29.5%).3. Traumatic conditionThe retrospective study of inpatients:the ratios of closed injury and opened injury were 65.5% and 10.8% respectively. Open injury was more often in the army (16.2%),especially in armored forces (21.6%).The ratio of intraocular foreign body occurred in the army was 6.2%, while navy, air force and armed police were 0.4%,3.0%,2.4% respectively.Cross-sectional investigation in out-patient clinic:the ratio of closed injury was 61.2%. There were only 8 cases of open injury. Foreign body was often involved on ocular surface and often happened in navy (12.9%)4. Analysis of the time seeing the doctorThe mean interval time of first seeing the doctor was 32.56 hours (standard deviation 285.4),with opened injury 5.683 hours (standard deviation 22.5) and closed injury 45.39 hours (standard deviation 350.4).We found that location of closed injury, involving of vitreous body and retinal detachment were close related to the interval time through analysis of gradual multivariate regression, and involving of vitreous body was negative relation.The mean interval time of seeing ophthalmologist was 50.32 hours (standard deviation 324.7),with opened injury 9.39 hours (standard deviation 24.4) and closed injury 71.77 hours (standard deviation 398.7).We found that interval time of first seeing the doctor, location of closed injury, involving of anterior chamber and retinal detachment were close related to the interval time of seeing ophthalmologist, and involving of anterior chamber was negative relation.5. The treatment of ocular injurySanitary corps or health center:the treatment rate of chemical burn was30.6% and the rate of sutured laceration in eyelid was10.2%.Regimental hospital:In the retrospective study of inpatients, there were 109 eyes with opened injury, and the rate of operation was 89.9%. Analysis of operative time showed that 62.4% operated less than 24 hours,27.5% more than 24 hours, furthermore,10.1% patients without operation. The reasons for delayed operation:①transfer treatment(46.7%);②heavy condition, need more time to prepare (16.7%);③permission of the injury, treating the complication lately(13.3%);④misdiagnosis(13.3%);⑤ignored by the patient (10%)There were 663 eyes with closed injury, and the rate of operation was 24.3%, and there were 74 eyes in regionⅠ,65 eyes in region II and 22 eyes in region III.The mean interval times of operation were 2.55 days in region I,29.45 days in region II and 87.98 days in region III. 6. The factors affecting the vision prognosis and transfer treatment:the factors strongly affected vision prognosis were open ocular injury, optic nerve’s trauma, retinal detachment and involving of vitreous body. One-Way ANOVA of different services showed the vision prognosis of navy and air force was much better than that of the army and armed police.The time of transfer treatment was higher in the army and armed police than in navy and air force. The effective factors were retinal detachment, the type of open ocular injury, explosion injury and involving of vitreous body.Conclusion1. Military training-related injury is less often in navy, but more often in armed police. It is most often occurred in solder’s counter-acting exercises and physical training. In armed police, exploring training methods of catching and grappling, fall training and cudgel play were the main subjects.2. Work-related injury is less often in air force and armed police, but more often in the army and navy. It is often seen in surface warship force of navy and in armored forces, communications corps, engineering corps of the army.3. In Cross-sectional investigation, military training-related injury is more often happened in skill-training, but in study of inpatients, the main causes are counter-acting exercises and physical training.4. In study of inpatients, open injury is more often in the army, especially in armored forces. Intraocular foreign body is also often seen in the army.5. The treatment of sanitary corps or health center need to enhance.6. The main reasons for delayed operation of opened ocular injury are transfer treatment, heavy condition needing more time to prepare, misdiagnosis. The delayed time is longest in closed injury of region III.7. The factors strongly affected vision prognosis are open ocular injury, optic nerve’s trauma, retinal detachment, involving of vitreous body. The factors impact the times of transfer treatment are retinal detachment, the type of open ocular injury, explosion injury and vious services.更多还原