【作者】 郝胜利；

【导师】 徐延山； 张红；

【作者基本信息】 天津医科大学 ， 眼科学， 2007， 硕士

【摘要】 糖尿病黄斑水肿是糖尿病患者视力下降最为重要的原因，其发生率随着糖尿病病程的延长和严重程度的加重而逐渐增高。黄斑水肿临床诊断通常是在散瞳的情况下，在裂隙灯下使用间接检眼镜进行眼底检查。但是此种方法比较主观，受到多种因素的影响。光学相干断层扫描(optical coherence tomography，OCT)是近年来新兴的眼科诊断仪器，它的分辨率高达10um，可以显示活体黄斑部的断层结构并定量测量，客观性强、重复性好，是观察黄斑部变化的最佳手段。激光全视网膜光凝(panretinal photocoagulation，PRP)是治疗重度非增殖型糖尿病视网膜病变和增殖型糖尿病视网膜病变标准的和应用最广泛的方法。尽管PRP可以延缓糖尿病视网膜病变的进展，但却可能引起黄斑水肿或使原有的黄斑水肿加重，引起视力暂时或者持久性的下降，是糖尿病视网膜病变患者接受PRP后视力下降的最常见的原因。目的1．对OCT与间接检眼镜在检测糖尿病黄斑水肿方面进行比较，对两种检查方法不相符的病例特点进行研究分析，从而积累OCT临床应用适应症的经验，指导其在临床中的合理应用。2．比较PRP前后视力、黄斑厚度的改变，发现PRP后黄斑水肿的发生及演变规律，以预防和减少PRP所致的黄斑水肿的发生。方法1．我们检查了糖尿病患者45人，78只眼，均于散瞳后前置镜(78D)下观察以及使用OCT测量患者黄斑厚度，比较了检测糖尿病黄斑水肿方面两种方法的异同，得出了两种检查方法在检测糖尿病黄斑水肿方而的符合程度并对两种检查方法不相符的病例特点研究分析。2．通过对接受PRP的糖尿病视网膜病变的50只眼分别于激光前、激光后1个月、3个月、6个月行视力、OCT测量黄斑厚度检查。结果1．间接检眼镜检查与OCT检查结果成正相关(r=0.575，P＜0.001)。间接检眼镜检查与OCT检查糖尿病黄斑水肿结果总的符合率为68％(kappa=0.359，P＜0.01)。假如排除OCT观测下的轻度黄斑水肿的病例，则间接检眼镜与OCT检查糖尿病黄斑水肿结果中，55只眼中有47只相符，总的符合率良好(86％，kappa=0.660，P＜0.001)。2．PRP前、后各期视力无显著性差异。PRP后1个月、3个月、6个月黄斑厚度较PRP前均有不同程度的增加；其中1个月时增加幅度最大(25％)，3个月(21％)与6个月(11％)时逐渐回落。黄斑厚度的两两比较结果发现：与PRP前相比，PRP后1个月(P=0.000＜0.01)、3个月(P=0.003＜0.01)黄斑厚度显著增加，6个月(P=0.132＞0.05)则无显著性差异。PRP前、后各期黄斑厚度均与视力的负对数呈显著正相关(相关系数r=0.5～0.8)。光凝前相关系数r=0.746(P=0.000)；光凝后1个月时相关系数r=0.570(P=0.000)；光凝后3个月时相关系数r=0.518(P=0.000)；光凝后6个月时相关系数r=0.599(P=0.000)。结论1．在无糖尿病黄斑水肿、中度糖尿病黄斑水肿、重度糖尿病黄斑水肿的检测方面，间接检眼镜与OCT相关性较好，但是在轻度糖尿病黄斑水肿(亦称为亚临床黄斑水肿，OCT测量为201～300um)的检测时，间接检眼镜与OCT相关性较差。2．PRP前、后各期视力无显著性差异，视力总体保持稳定。与PRP前相比，PRP后1个月、3个月黄斑厚度显著增加；但光凝后6个月时黄斑厚度逐渐回落到接近术前的水平，两者无显著性差异。OCT测量黄斑厚度与视力的负对数之间存在着显著的正相关，也就是说，黄斑部视网膜越厚，视力越呈低下的趋势。更多还原

【Abstract】 Diabetic macular edema is a leading cause of vision loss in patients withdiabetes mellitus. The incidence and prevalence of macular edema increase withlonger duration of diabetes and with increasing severity of concurrent retinopathy.Usually, the clinical diagnosis of macular edema is viewing the fundus using indirectophthalmoscope at the slitlamp through a pharmacologically dilated pupil. This is asubjective process that is dependent on many factors. Optical coherence tomography(OCT) is a new diagnostic technique in recent years that can provide cross-sectionalimages of macula in vivo and quantify macular thickness variation with a precision of10um. It appears to be more objective and reproducible which indicates that OCTmay be the best choice to investigate macular changes.Panretinal photocoagulation (PRP) is a standard and mostly common usedmethod for the treatment of severe nonproliferative diabetic retinopathy andproliferative diabetic retinopathy. Also PRP can delay the progression of diabeticretinopathy, but macular edema may be induced or increase, with either transient orsustained decrease of vision, that is the most common cause of visual loss in patientswith diabetic retinopathy after the treatment of PRP.Objectives1. To compare the two methods of OCT to indirect ophthalmoscope for the detectionof diabetic macular edema, search for case characteristics that predict disagreement,begin to build an evidence-based framework for clinical application of OCTmeasurement in diabetic retinopathy.2. To compare the changes of visual acuity and macular thickness before and after PRP, find the incidence and evolution of macular edema after PRP, and to prevent andreduce the incidence ofmacular edema induced by PRP.Methods1. We examined 45 patients with diabetes mellitus, 78 eyes. After pupil dilated, allpatients were under observation using pre-microscopy (78-diopter) and OCT tomeasure the macular thickness.2. 50 eyes of patients who were receiving panretinal photocoagulation, were under theobservation of eyesight, macular thickness by OCT before and 1, 3, 6 months aftertreatment.Results1. The indirect ophthalmoscopy was positively correlated with the results of OCT(r=0.575, P＜0.001). The overall agreement of indirect ophthalmoscopy and OCT onthe detection of diabetic macular edema was 68% (kappa=0.359, P＜0.01). Theoverall agreement excluding cases with mild edema by OCT was good (86%, kappa=0.660, P＜0.001), 47 cases of 55 were in line.2. There was no significant difference between the visual acuity before and after PRP.The macular thickness after 1 month, 3 months, 6 months of PRP had increased invarying degrees; among them, 1 month had the largest increase(25%), 3 months(21%)and 6 months(11%) edged down. We compared the macular thickness every two andfound: With the comparison of macular thickness before PRP, 1 month(P=0.000＜0.01) and 3 months (P=0.003＜0.01) after PRP, the macular thicknessincreased significantly; but 6 months (P=0.132＞0.05) after PRP, there was nosignificant differecne. The macular thickness was significantly positive correlatedwith the negative logarithm of visual acuity before and 1, 3, 6 months after PRP (thecorrelation coefficient r=0.5～0.8). Before PRP the correlation coefficient r=0.746 (P=0.000); after 1 month the correlation coefficient r=0.570(P=0.000); after 3 months the correlation coefficient r=0.518 (P=0.000); after 6 months the correlationcoefficient r=0.599 (P=0.000).Conclusions1. In nondiabetic macular edema, moderate diabetic macular edema, severe diabeticmacular edema detection, there was better relevance, but in mild diabetic macularedema (also known as sub-clinical macular edema, 201～300um-OCT measurement)detection, there was poor relevance.2. There was no significant difference of the visual acuity before and 1, 3, 6 monthsafter PRP. Visual whole, maintained stability. With the comparison of macularthickness before PRP, 1 month and 3 months after PRP, the macular thicknessincreased significantly; but 6 months after photocoagulation, the macular thicknessdecreased nearly to the levels before photocoagulation, there was no significantdifferecne between them. Macular thickness measured by OCT had significantlynegative correlation with eyesight. That’s the thicker of the macular thickness, thetrend of low vision was increasingly.更多还原