【作者】 尚志宏；

【导师】 陈蕾；

【作者基本信息】 中国医科大学 ， 眼科学， 2004， 硕士

【摘要】 前言 随着糖尿病的发病率逐年升高，糖尿病性视网膜病变(Diabetic Retinopathy，DR)已成为成人的主要致盲眼病之一，如何减少DR所致的失明是眼科界当务之急。激光光凝治疗DR已被临床证实具有显著疗效，有研究表明，治疗组比不治疗组失明率降低50％。然而，作为一种破坏性的治疗手段，激光光凝必然对视网膜的正常结构和功能造成一定的影响，并引起许多不良反应，甚至导致术眼视力的永久性下降。因此，在临床实践中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得良好的效果，同时又能将并发症降低到最少是值得研究的。我们将用低能量小光斑氩激光对20例DR患者进行光凝治疗，并将结果与本院以往用高能量大光斑进行光凝治疗的DR患者结果进行统计分析，以观察其疗效。 目的 观察低能量小光斑氩激光全视网膜光凝治疗DR的疗效及术后视网膜光损伤的临床表现，探讨低能量小光斑氩激光全视网膜光凝治疗DR是否既能取得很好的疗效，同时又能减轻光凝引起的不良反应。 方法 选取2003年于我院行氩激光光凝治疗的DR患者13例20眼作为A组，1998～2001年于我院行氩激光光凝治疗的DR患者14例20眼作为B组。两组所选病例均为根据我国现行的DR分期、分型标准确诊的Ⅲ～Ⅳ期DR患者，所有患眼屈光间质清晰，无合并其它眼底病，无既往眼部激光治疗史和眼部手术史。术前常规行血压、空腹血糖、糖化血红蛋白、血脂等全身检查和详细的眼科检查包括裸眼视力、验光、眼压、B超、眼前节裂隙灯显微镜检查、视野、视网膜电图(ERG)、眼底彩照和眼底荧光血管造影(FFA)检查。对每一名患者进行标准的氩激光全视网膜光凝术，分四次进行，每周一次。A组用低能量小光斑，B组用高能量大光斑。术后三个月复查裸眼视力、最佳矫正视力、视野、ERG、眼底彩照及FFA。将两组的结果进行比较并作统计学分析。结果 1.两组患者术前的各项检查结果差异无显著性意义(P>0.05)。 2.术后3个月A组视力提高3例，占巧%;视力不变13例，占65%;视力下降4例，占20%。B组视力提高4例，占20%;视力不变12例，占60%;视力下降4例，占20%。两组比较差异无显著性意义(p>0.05)。 3.术后3个月经FFA证实光凝有效的A组巧例，占75%;B组14例，占70%，无效的A组5例，占25%，B组6例，占30%。两组比较差异无显著性意义(p>0.05)。 4.术前A组和B组中心30。的光敏感度分别为30 .4土2.gdB，28.6土3.4dB;周边600的光敏感度分别为25.0士3.ldB，24.3*2.ZdB。术后3个月A组和B组中心300的光敏感度分别为28.9士2.sdB，26.2土3.gdB;周边60“的光敏感度分别为24.1士3.3dB，22.5土2.3dB。将两组术前术后的差值进行比较，结果差异有显著性意义(p<0.05)。 5.术前A组和B组的a波振幅分别为12.79土1 .94uv，12.00土1 .88uv;b波振幅分别为22 .95土1 .46uv，22.73土1 .76uv。术后3个月a波振幅分别为11.08士1.79uv，9.64士2.15uv;b波振幅分别为21.24士1.59uv，20 .36土2 .19u\l。将两组术前术后的差值进行比较，结果差异有显著性意义(p<0 .05)。 6.术后3个月B组有4例出现视野缩小或暗点，4例有暗适应下降、畏光等并发症。讨论 激光全视网膜光凝(panretinal photoeoa列ation，PRP)是治疗DR的有效手段，随之而来的光凝对视网膜的损害也是不可避免的。因此，在临床实践中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得良好的效果，同时又能将并发症降低到最少是值得研究的。近年来，国人激光量和激光参数的选择及疗效是临床十分重要而又难以统一的问题。在临床工作中，我们经常看到许多DR患者由于过度的视网膜光凝而引起视力下降、一视野改变、暗适应下降和”不能忍受的幌眼”等并发症。因此，我们设计了此实验，用低能量小光斑对DR患者进行光凝，来减少光凝所带来的不良反应。从实验结果可以看出，1.两组均有数例患者术后出现不同程度的视力提高或下降，其它患者视力基本保持不变，两组之间差异无显著意义。视网膜光凝术后视力下降的主要原因是视网膜光凝所引起的黄斑水肿或原有的黄斑水肿加重。2.术后3个月，A组75%的患眼，B组70%的患眼治疗有效，两组之间差异无显著意义。3.术后3个月，两组的光敏感度均较术前有所下降，B组更为明显，两组之间差异有显著意义。4.术后3个月两组ERG的a波和b波振幅均有所下降，且差异有显著意义。从以上分析可以看出，在对DR患者进行P即后，A组和B组疗效相同，而对视野和ERG的影响B组却明显高于A组。从光凝治疗DR的原理分析，n级光凝固斑已经破坏了耗氧量高的光感受器，可以取得光凝固的疗效。本实验也证实，A组用低能量小光斑以11级强光凝固斑进行PRP，取得了与B组相同的效果，且并发症明显低于B组。结论 1 .PRP术后3个月，低能量小光斑组和高能量大光斑组的视力和FFA结果比较无明显差别。 2.PRP术后3个月，高能量大光斑组对视野和ERG的影响及术后并发症较低能量小光斑组更为明显。 3.低能量小光斑PRP治疗DR?更多还原

【Abstract】 With rising incidence rate of diabetes year after year, diabetic retinopathy has become one of the major eye - diseases that may cause blindness among the adults. How to reduce the cases of blindness caused by DR has become the urgent task for ophthalmological research field. As the treatment for DR, photoco-agulation has been proved effective by clinic. It has been indicated that the rate of blindness of the treatment group was 50% lower than the non - treatment group. However as a distractive method, it is certain that photocoagulation will make some effect on the normal structure and function of retina and consequently cause many side - effects, even cause the lose of eyesight forever. Therefore, in clinical practice, it is worthy to study how to adjust the laser parameter reasonably , how to determinant the level of the laser reaction correctly and how to a-chieve the good effect and reduce the rate of syndrome at the same time. We will treat 20 cases of DR patients with Argon laser of low energy and small spot and statistically analyze the results and the one of DR patients who had been treated with Argon laser of high energy and big spot, and observe the effect.ObjectiveTo observe the effect of low energy and small spot Argon panretinal photo-coagulation on DR and the clinical findings of laser damage to retina after the treatment, and to investigate whether the treatment of low energy and small spot Argon panretinal photocoagulation can achieve the good effect and reduce the side - effects at the same time.Methods20 eyes of 13 DR patients who underwent Argon PRP in 2003 were chosen into A group and 20 eyes of 14 DR patients who underwent Argon PRP from 1998 to 2001 were chosen into B group. All the cases were diagnosed as HI ~ IV grade DR according to the current standard of DR type and stage in China. The refracting media of all the eyes were clear, no patient had other retina diseases and no previous photocoagulation and surgery had been carried out on any of these patients. The general exams including blood pressure, blood sugar , HbAlc, blood fat and detailed ophthalmologist exams such as naked eyesight , optometry, tonometry, B - scan, biomicroscopy of the anterior eye segment , visual field , ERG, FFA and color photo of fundus were carried out on every patient. Standard Argon PRP for every eye was divided into 4 times, once a week. The eyes of A group were treated by low energy and small spot laser and the eyes of B group were treated by high energy and big spot laser. Three months after the treatment , naked eyesight , the best corrective eyesight, visual field ,ERG, FFA and color photo of fundus were examined. The results of the two groups were compared and statistically analyzed.Results1. There was no significant difference between all the preoperative results of the two groups( p >0.05) .2. Three months postoperatively in A group the eyesight of 3 eyes (15% ) were improved; the eyesight of 13 eyes (65% )were unchanged; the eyesight of 4 eyes were declined. In B group the eyesight of 4 eyes(20% ) were improved; the eyesight of 12 eyes(60% ) were unchanged; the eyesight of 4 eyes(20% ) were declined. There was no significant difference compared between the two groups (p >0.05).3. Three months postoperatively 15 eyes (75%) of A group and 14 eyes (70%) of B group have been proved effective by FFA, 5 eyes (25%) of Agroup and 6 eyes(30% ) of B group have been proved ineffective. There was no significant difference compared between the two groups (p >0. 05).4. Preoperatively the light sensitivity of center 30 of the A group and B group were 30.4 2. 9dB ,28. 6 3. 4dBseparately, and that of peripheral 60 were25.0 3.1dB, 24. 3 2. 2dB separately. Three months postoperatively, the light sensitivity of center 30 of the A group and B group were28.9 2. 8dB, 26. 2 3. 9dB separately, and that of peripheral 60 were24.1 3. 3dB, 22.5 2.3dB separately. There was significant difference compared the differences of pre - operate and post - operate between the two更多还原