【作者】 李世宏；

【导师】 叶剑；

【作者基本信息】 第三军医大学 ， 眼科学， 2009， 博士

【摘要】 先天性白内障是最主要的儿童致盲疾病,发生率为1.2-15/10000。发展中国家先天性白内障发病率是发达国家的5倍。中国是世界上最大的发展中国家,因罹患先天性白内障所致盲占我国失明儿童总数的第2位。先天性白内障的治疗是防盲治盲工作的重要组成部分,而我国的防盲治盲总体水平仍相对落后,即便与人口相近、经济水平相似的印度相比仍有很大差距。同时,国内发达地区和欠发达地区先天障治疗水平也参差不齐。重庆是中国西部欠发达地区最大的城市,防盲工作相对滞后,同时各地区眼科技术水平差异较大,据我科前阶段调查,重庆绝大部分白内障手术是在主城区各眼科完成,因此重庆主城区先天性白内障的治疗效果和水平的调查可以反映西部欠发达地区的整体状况,为政府主管部门防盲治盲的政策制定提供有益的参考。目前,人工晶体植入已经成为先天性白内障手术治疗的重要手段之一。国外报道称至2001年,2岁以下患儿一期人工晶体植入率达81.9%,且手术年龄有越来越小的趋势。而在中国通常认为单眼先天性白内障在1岁内可考虑IOL植入,但需慎重;双眼先天性白内障在2岁以上方可考虑IOL植入。究其原因是对低龄患儿行一期人工晶体植入效果和风险的疑虑。并发症是临床医生考虑手术时机的另一个担心的问题。相对成年人而言,先天性白内障手术复杂,并发症发病率高。近年来,国外学者进行了大量的观察,特别是继发青光眼的问题有了不少的报道,但国内文献对这方面报道不多。先天性白内障患儿眼球正处在生长发育的高峰,手术创伤不可避免的对其结构发育产生影响,并可能祸及终身。近来国内医生对先天障术后患儿眼轴发育的关注较多,但是对患儿术后角膜的变化以及房角结构的影响报道较少,而这些变化又可能与继发性青光眼的诊断治疗有密切的关联,值得我们深入分析。目的:本研究对重庆9家医疗机构部分先天障术后患儿进行了回顾性调查和分析,旨在了解本地区患儿早期植入人工晶体疗效和并发症发生率;分析其视功能预后、主要并发症与患儿手术年龄、人工晶体植入和术前临床表现特征等因素间的相互关系;探讨手术对患儿角膜和房角结构造成的影响,以期客观的反映重庆地区先天性白内障的治疗的现状,为进一步提高先天性白内障的治疗水平贡献力量。对象和方法:1.对象:对1994年5月-2009年2月在重庆地区9所医院眼科行先天性白内障手术的患儿进行追踪调查。排除外伤性白内障、并发性白内障;排除先天性青光眼、早产儿视网膜病变、肿瘤、先天性视乳头缺损;马凡氏综合症以及智力障碍的患儿亦被排除。2.方法:患儿的临床表现特点(小角膜、单双眼白内障、眼球震颤等)以及患儿手术年龄、手术方式(未植入人工晶体、I期或II期晶体植入);术后最佳校正视力,并发症,中央角膜厚度、眼内压,房角结构变化等数据被详尽检查、记录和分析。应用SPSS10.0软件进行统计分析。计量资料用单向方差分析和T检验;频数资料用秩和检验及方差分析;P值<0.05有意义。结果:1. 112例患儿(165眼)参与本研究(研究项目的不同,参加调查的患儿/患眼数有所差异,具体见论文)。其中男:女为69:43;59例59眼是单眼白内障。28眼术前伴眼球震颤;17眼伴小角膜。平均手术年龄4.47岁,平均随访时间5.24年。一期IOL植入率为65.4%。手术年龄小于2岁的一期IOL植入率为21.2%。2.全组术后最佳矫正视力≥0.1有127眼(76.9%),≥0.3的有82眼(49.7%),≥0.6的有42眼(25.5%)。伴眼震及单眼白内障患儿最佳矫正视力均明显低于对照组(p<0.01)。I期人工晶体植入组中53.1%的患眼最佳矫正视力好于0.3,而在II期植入组和未植入人工晶体组中则各有37.5%和26.2%。前组与后两组有显著差异(P<0.01)。同手术年龄段(均小于2岁)比较,BCVA好于0.3的,在未植入IOL组中占29.6%,而在II期IOL组中为35.7%, I期IOL组占63.7%,后者明显好于前两组,有统计差异(P>0.05)。3.全组后发障发生率为41.8%,继发青光眼发生率是12.1%。伴小角膜患眼中继青发生率为29.4%,而对照组发生率是10.1%,相差显著(P<0.01);手术年龄<2岁组、2-6岁组、6-12岁组和≥12岁组中后发障的发病率分别为:51.9%、42.4%、39.2%和15.8%,≥12岁组与2岁组和2-6岁组有显著差异(P<0.01和0.05),但与6-12岁组差距不明显(P>0.05)。前3组间差异不明显。在2岁或1岁以内手术的患眼青光眼发生率分别是21.1%和27.8%,与各自对照组相差显著(P值均<0.05)。同手术年龄段(均小于2岁)各不同手术方式组青光眼发病率无统计差异。4.共完成术后组85眼,先天障未手术组28眼及健康儿童组28眼的中央角膜厚度检查。术后组患眼角膜厚度明显大于后两组;未手术组患眼角膜厚度与健康儿童组无统计差异(P=0.587)。回归分析显示术眼术后角膜厚度增加与患眼手术年龄呈明显的负相关。5.共完成术后组45眼、未手术组8眼及健康儿童组10眼的房角镜和UBM检查。术后组患眼房角开放距离明显小于未手术组及健康儿童组;不同手术方式组房角开放距离无明显差异。伴继发青光眼的患眼房角开放距离明显小于无继青术后眼及对照组。未手术组和健康组间无统计差异。手术年龄越小,术眼房角开放距离越短;手术年龄<2岁组、2-6岁组、≥6岁组等3组患眼房角色素分级达到三级以上的比例分别是80%、45.5%和25%,有明显差异(P<0.05)。结论:1.一期人工晶体植入更有利于患儿术后视功能的恢复;眼球震颤和单眼白内障则预示术后视力较差。2.手术年龄越小,手术后后发障和青光眼的发生率越高;小角膜是继发青光眼的重要危险因素之一。2岁内行人工晶体植入患眼青光眼发病率风险并不高于未植入人工晶体者。3.先天性白内障术后患眼角膜较厚。患眼角膜厚度改变与手术有关。手术年龄对角膜厚度的增加度有明显关联。4.手术后患眼易发生虹膜根部止点前移,房角色素沉着程度加重,与术后继发青光眼发病可能有关。低龄手术是重要的危险因素。人工晶体植入与否对患眼房角改变无明显关联。更多还原

【Abstract】 Background:Congenital cataract is the most important cause of treatable blindness, accounting for 1.2-15/10000 blind children worldwide. The incidence of congenital cataract in developing countries is 5-fold higher than that in developed countries. China is the largest developing country in the world. Infantile cataract is the second major cause of blindness in China.Treatment of congenital cataract is important for the prevention and treatment of blindness, which is still lagging behind in China. In this field, there is a big gap between China and India, another developing country. Our study investigated the status quo of congenital cataract treatment in Chongqing, one of the biggest city in west China, so as to provide references for the research of our counterparts and the policy-making of government.Compared with adult cataract surgery, pediatric cataract surgery is more complex and has more complications. In recent years, the technique of pediatric cataract surgery has been improved. However, some issues on optimal timing of surgery, timing of intraocular lens implantation, prevention of complications and influence of surgery on the structure and development of children eyes still need further research.Purpose:This study is to investigate the surgical outcomes and complication of congenital cataracts and to determine the relationship between visual prognosis and surgical complications according to age at operation and adopted surgical procedure and the general clinical features. Furthermore, the effect of surgery on the cornea and anterior chamber angle structures was evaluated.Methods:1. From May 1994 to February 2009, some children with congenital cataract who underwent surgery at the several medical centers in Chongqing were followed up. Eyes with traumatic cataracts, complicated cataract, congenital glaucoma, retinopathy of prematurity, systemic diseases, or neurological disorders were excluded.2. Study parameters included preoperative clinical characteristics (microcornea, unilateral or bilateral cataract, nystagmus, etc.), age at operation, time period of follow-up, operation (aphakia, primary IOL or secondary IOL). The postoperative best corrected visual acuity, intraocular pressure, central corneal thickness, postoperative complications and structural change of anterior chamber, optic nerve changes (if possible) were recorded and analyzed.3. Statistical data were obtained using SPSS10.0 software. Qualitative data (complication rates between the different age groups and between the three different groups associated with surgical procedures) were compared using the chi-square test. Visual outcomes were compared using the K-independent samples test. Quantitative data(CCT, AOD500, TIA)was compared with student T test.Results:1. Totally 112 children (165 eyes), 69 males and 43 females, were included in this study, including 59 cases of unilateral cataract. Before operation, 28 eyes were associated with nystagmus, 17 eyes microcornea. Mean age at operation was 4.47 years and mean time period of follow-up was5.24 years.the incidence of primary IOL implantation in children who was younger than 2 years old at congenital cataract surgery was 21.2% in Chongqing.2. The best corrected visual acuity (BCVA) were checked in 165 eyes with a Snellen chart. There were 127 eyes(76.9%)with BCVA≥0.1, 82 eyes (49.7%)≥0.3 and 42 eyes (25.5%)≥0.6. BCVA in patients with nystagmus or unilateral cataract were worse than their controls (P <0.01). Totally, 53.1% eyes in primary IOL group had BCVA>0.3, 26.2% eyes in aphakia group, 37.5% eyes in secondary IOL group. The difference was statistically significant (P <0.01). The prognosis had no significant difference at different age groups.3. The most common complication was posterior capsular opacity (PCO) in 41.8% of affected eyes. The incidence of PCO in the four age groups (<2 years, 2-6 years, 6-12 years and≥12 years) was 51.9%, 42.4%, 39.2% and 15.8%, respectively. There was significant difference . Secondary glaucoma occurred in 20 eyes (12.1%). The prevalence of secondary glaucoma was 29.4% in patients with microcornea, 10.1% in control group. The difference was significant. The occurrence of glaucoma were 30.5% in patients≤2 years and 41.6% in patients≤1 years, which had significant difference compared with control group (P values were 0.016 and 0.031, respectively).4. Central corneal thickness (CCT) was measured in 141 eyes (85 undergoing congenital cataract surgery, 28 non-operative eyes with congenital cataract and 28 eyes of healthy controls). The mean CCT of postoperative eyes was higher than that of non-operative eyes with congenital cataract and healthy controls. The CCT of non-operative eyes was similar to the healthy controls (P>0.05). The regression analysis suggested that the postoperative increase of CCT was negatively correlated with age at operation.5. Ultrasound biomicroscopy and gonioscopy were performed on 45 eyes undergoing congenital cataract surgery, 8 non-operative eyes with congenital cataract and 10 healthy eyes as control. The angle-opening distance at 500 um (AOD500) and trabecular-iris angle (TIA) were measured. Change of anterior chamber pigments was observed. AOD500 in congenital cataract surgery group was smaller than that in non-operative group and control group, and the difference was significant (P<0.01), but there was no statistical difference between non-operative group and control group. The angel opening distance of patients with secondary glaucoma record was significantly smaller than that in normal intraocular pressure group. It was suggested that the younger age at operation, the smaller AOD500. Trabecular iris angle in all groups showed no statistically significant difference (P >0.05). The pigment of anterior chamber angle over 3 degree in three age groups (<2 years,2-6 years and≥6 years) were 80%, 45.5% and 25% respectively. The difference was significant (P <0.05).Conclusions:1. Primary intraocular lens implantation for children with congenital cataract is effective for visual rehabilitation. Unilateral congenital cataract and infantile cataract with strabismus indicate worse postoperative visual acuity.2. The younger age at surgery, the higher occurrence of PCO and secondary glaucoma. Microcornea is an important risk factor for secondary glaucoma. Primary intraocular lens implantation does not increase the risk of postoperative complications.3. CCT in children with congenital cataract is normal. The postoperative change of CCT is due to the surgical procedure. Children‘s age at operation could influence corneal thickness. 4. Surgery causes the antelocation of iris root and the increased degree of anterior chamber angle pigmentation, which is correlated with pathogenesis about secondary glaucoma. The young age at surgery is a risk factor for surgery更多还原