發(fā)布時間：2018-05-13 18:30

  本文選題：先天性白內(nèi)障 + 眼軸��； 參考：《鄭州大學》2017年碩士論文

【摘要】：背景和目的先天性白內(nèi)障是指出生前后即存在或出生后才逐漸形成的先天遺傳或發(fā)育障礙所致的晶狀體部分或全部混濁,是一種常見的兒童眼病,是造成兒童失明和弱視的重要因素。在天津、上海和北京致盲原因調查結果提示:約22%~30%的盲童由先天性白內(nèi)障致盲,是失明原因的第二位,我國先天性白內(nèi)障的發(fā)病率約為0.5%~1.5%。先天性白內(nèi)障患兒因視路不清晰而影響視覺正常發(fā)育,形成形覺剝奪性弱視,因此,對于影響視覺發(fā)育的先天性白內(nèi)障應早發(fā)現(xiàn)早治療。目前臨床研究表明,治療先天性白內(nèi)障的較為理想的方法主要是手術治療,即超聲乳化+后囊膜切開+前段玻璃體切除+人工晶狀體植入術。但是由于嬰幼兒的視覺系統(tǒng)具有一定的特殊性,其眼球仍處于發(fā)育階段,屈光狀態(tài)不穩(wěn)定,尤其是3歲以內(nèi)的兒童眼球處于快速發(fā)育時期,再加上術后炎性反應相對較重、兒童依從性較差、可能伴有弱視等問題,增加了先天性白內(nèi)障手術的復雜性與風險性。在植入人工晶狀體手術時機方面,目前較多學者建議2歲后植入較為合適,2歲前植入人工晶狀體是否安全有效尚存在較大的爭議,需要進一步的臨床實踐和時間檢驗。隨著先天性白內(nèi)障手術方法、麻醉及顯微手術技術的不斷完善和發(fā)展,對于先天性白內(nèi)障盡早行白內(nèi)障摘除聯(lián)合人工晶狀體植入是治療先天性白內(nèi)障最主要的措施,因此植入理想的人工晶狀體度數(shù)、確保術后長期穩(wěn)定的視覺效果、盡可能降低術后屈光參差是我們必須亟待要解決的問題。目前我們面臨的問題包括以下幾個方面:對于年齡較小的患兒人工晶狀體屈光度計算容易出現(xiàn)較大的誤差,有統(tǒng)計顯現(xiàn)1歲以內(nèi)人工晶狀體度數(shù)誤差約-4.06D~+3.86D;暫時沒有專用于兒童的人工晶狀體計算公式;有關患兒眼的生物參數(shù)(包括眼軸長、角膜曲率)測量困難,盡管在一些設備條件較好的醫(yī)療中心我們可以在患兒麻醉狀態(tài)下應用IOL-Master或便攜式自動測量工具測量,但是在一些發(fā)展中國家或醫(yī)療條件較差的醫(yī)院對生物參數(shù)的測量仍然無法實現(xiàn);另外對于存在角膜混濁、外傷引起角膜變形等情況也會影響角膜曲率的測量,在這些情況下會選擇代用正常成人角膜曲率42.5D~44.0D來估計人工晶狀體的屈光度,因此這對于年齡較小的患兒會產(chǎn)生較大的誤差。因為影響眼屈光變化的主要因素包括眼軸長、角膜曲率及晶狀體的發(fā)育,3歲內(nèi)患兒眼球仍處于快速發(fā)育階段,眼軸及角膜曲率均處于一個不斷變化的過程中,白內(nèi)障摘除后的無晶狀體眼狀態(tài)及植入人工晶狀體后,打破了發(fā)育過程中屈光變化的平衡狀態(tài),無晶狀體眼及人工晶狀體眼是否對眼軸及角膜曲率的發(fā)育產(chǎn)生一定影響,該影響是否會導致術眼的屈光狀態(tài)發(fā)生相應的變化,是我們需要觀察和研究的問題。當然,目前也有較多的文獻報道了兒童正常眼及白內(nèi)障眼的眼球發(fā)育情況,但是,關于兒童先天性白內(nèi)障術后眼軸及角膜曲率變化的臨床觀察結果并不完全一致,對于配合程度較差的3歲以內(nèi)的嬰幼兒的臨床研究報道更少。本課題針對3歲內(nèi)單純先天性白內(nèi)障患兒術后眼軸長度、角膜曲率及屈光度變化進行觀察及統(tǒng)計分析,進一步了解先天性白內(nèi)障術前及術后無晶狀體眼、人工晶狀體眼對眼軸長度及角膜曲率的影響,為臨床工作中手術時機的選擇、人工晶狀體屈光度的計算與術后屈光度的預留,減少術后屈光誤差及屈光參差提供理論依據(jù)。研究對象研究對象選自2014年1月~2015年12月于我院診治的3歲內(nèi)的先天性白內(nèi)障患兒158例246眼。納入標準:1、單純的雙眼或單眼先天性白內(nèi)障;2、手術時年齡為≤3歲;3、手術方法:?單眼先天性白內(nèi)障:2歲內(nèi)患兒超聲乳化吸除+后囊膜切開+前段玻璃體切除術,2歲后行二期人工晶狀體植入術;大于2歲行超聲乳化吸除+后囊膜切開+前段玻璃體切除+人工晶狀體植入術;?雙眼先天性白內(nèi)障:嬰幼兒期行超聲乳化吸除+后囊膜切開+前段玻璃體切除術,2歲半后行二期人工晶狀體植入術;大于2歲半行超聲乳化吸除+后囊膜切開+前段玻璃體切除+人工晶狀體植入術;4、具有完整的術前檢查資料,包括病史、家族史、眼軸長度、角膜曲率、人工晶狀體植入屈光度數(shù)及預留度數(shù);5、術后能堅持定期復診、及時行屈光矯正、堅持弱視訓練并保存有完整病例資料,且隨訪時間至少1年者。排除標準:1、眼部合并有其他異常疾病如先天性小眼球、先天性小角膜、高度近視、先天性青光眼、PHPV、視網(wǎng)膜脈絡膜發(fā)育異常者等;2、術后出現(xiàn)嚴重并發(fā)癥如葡萄膜炎、IOL瞳孔夾持、IOL脫位、后發(fā)性白內(nèi)障、繼發(fā)性青光眼者等;3、術后不能定期復診、不能堅持弱視訓練、缺乏完整的手術資料及術后門診隨訪資料者。研究方法本研究為前瞻性研究,根據(jù)入選患兒按初次手術年齡分為5組:A組:3月~6月;B組:6月~12月;C組:12月~18月;D組:18月~24月;E組:24月~36月。術后隨訪1年,分別記錄術后3月、術后6月及術后1年患兒眼壓、眼軸長度、角膜曲率、主覺驗光下的等效球鏡度數(shù)及隨訪期并發(fā)癥,配合患兒可查裸眼視力、最佳矯正視力(兒童視力表)。以SPSS 21.0統(tǒng)計軟件對本研究的數(shù)據(jù)進行統(tǒng)計學分析。以Kolmogorov-Smirnov檢驗來檢查計量變量是否符合正態(tài)分布,若符合正態(tài)分布采用兩獨立樣本t檢驗,不符合正態(tài)分布者采用秩和檢驗;不同年齡階段及性別比例比較采用單因素方差分析(ANOVA)檢驗。以P0.05為差異有統(tǒng)計學意義。結果1.術后各階段眼軸長度變化比較:術后3月五組患兒眼軸長分別為18.82±1.219mm,20.61±0.796mm,21.28±0.987mm,21.60±0.836mm,21.94±0.992mm,較術前分別增長0.818±0.387mm,0.682±0.289mm,0.504±0.264mm,0.353±0.450mm,0.266±0.344mm;術后6月五組患兒眼軸長度較術前增長值分別為1.561±0.473mm,1.132±0.439mm,0.963±0.395mm,0.713±0.569mm,0.464±0.488mm;術后1年五組患兒眼軸長度較術前分別增長2.554±0.588mm,1.728±0.592mm,1.080±0.513mm,0.859±0.704mm,0.768±0.520mm。五組患兒術后3月、術后6月及術后1年眼軸增長值與術前比較差異有統(tǒng)計學意義(P分別0.05);五組間比較:術后3月,A、B、C三組的增長速率大于D、E組,差異有統(tǒng)計學意義(P0.05),A組增長速率大于B組,D組增長速率大于E組,但差異無統(tǒng)計學意義(P0.05);術后6月及術后1年,A、B兩組增長速率大于C、D、E組,差異有統(tǒng)計學意義(P0.05),其中AB,CDE,但差異無統(tǒng)計學意義(P0.05)。2.五組中單眼先天性白內(nèi)障患兒在術后各階段術眼眼軸增長幅度大于健眼,但是差異無統(tǒng)計學意義(P0.05),并且增長幅度隨年齡增大而減小。3.術后各階段角膜曲率變化比較:患兒術后3月、6月及術后1年角膜曲率與術前角膜曲率相比A、B、C、D組差異均有統(tǒng)計學意義(P0.05),E組(24月~36月)術后與術前相比角膜曲率逐漸下降,但無統(tǒng)計學意義;術前、術后3月、6月及術后1年各組間角膜曲率相比差異有統(tǒng)計學意義(P0.05);五組間比較:術后3月,A、B兩組的變化值大于C、D、E組,C組大于E組,差異有統(tǒng)計學意義(P0.05),C組變化率大于D組,D組變化率大于E組,但差異無統(tǒng)計學意義(P0.05);術后6月與術后1年,A組變化率大于C、D、E組,差異有統(tǒng)計學意義(P0.05),其中AB,CDE,但差異無統(tǒng)計學意義(P0.05);B組角膜曲率的變化率大于E組,差異有統(tǒng)計學意義(P0.05),其中BCDE組,但差異無統(tǒng)計學意義,(P0.05)。4.單眼先天性白內(nèi)障術前術眼角膜曲率與健眼相比差異均無統(tǒng)計學意義(all P0.05);術后各階段五組的術眼角膜曲率變化幅度與健眼基本一致,角膜曲率值逐漸下降,且隨著年齡增加角膜曲率變化值逐漸變小,差異無統(tǒng)計學意義(P0.05)。5.術后1年屈光度變化比較:將術后2周時等效球鏡作為初始屈光度,術后1年五組屈光度的變化分別是-2.89±0.975D、-2.51±0.732D、-2.28±0.837D、-1.94±1.035D、-1.85±0.897D,差異有統(tǒng)計學意義(P=0.015);組間多重比較A、B、C三組變化量大于D、E兩組,差異有統(tǒng)計學意義,其中ABC、DE,但差異無統(tǒng)計學意義。各組屈光度均向近視漂移,隨年齡增加,向近視漂移的趨勢變慢。6.單眼大單眼先天性白內(nèi)障術后屈光度的變化量與健眼相比差異均無統(tǒng)計學意義(P0.05),但高于健眼,屈光度均有向近視方向漂移的趨勢,且隨著年齡增長其變化量逐漸下降。7.雙眼先天性白內(nèi)障患兒與單眼先天性白內(nèi)障患兒成組配對進行t檢驗,結果表示單眼與雙眼先天性白內(nèi)障術后眼軸長度、角膜曲率及屈光度變化在年齡段均無統(tǒng)計學意義(P0.05),其中眼軸長度與屈光度的變化量單眼大于雙眼。8.隨訪期間未出現(xiàn)視網(wǎng)膜脫離、后發(fā)性白內(nèi)障、繼發(fā)性青光眼、IOL脫位等并發(fā)癥,E組1例失訪,C組2例因患兒不配合數(shù)據(jù)未測出已排除,數(shù)據(jù)未計入統(tǒng)計分析;E組5位患兒IOL表面出現(xiàn)少量色素顆粒沉著,對視覺發(fā)育無影響。結論1.18個月內(nèi)眼軸增長速率較快,之后眼軸呈緩慢增長,單眼患兒眼軸增長幅度較健眼及雙眼患兒增長較快;2.12個月內(nèi)患兒角膜曲率變化較大,之后緩慢變化,24個月基本發(fā)育至正常成人水平;3.先天性白內(nèi)障術后屈光度均有向近視方向漂移的趨勢,且隨著年齡增長轉變趨勢變慢;4.單眼先天性白內(nèi)障術后眼軸長、角膜曲率及屈光度與健眼可保持協(xié)調發(fā)育。
[Abstract]:Background and objective congenital cataract is a part of the lens or all turbidity caused by congenital hereditary or developmental disorder before and after birth or after birth. It is a common child eye disease. It is an important factor causing blindness and amblyopia in children. In Tianjin, the cause of blindness in Shanghai and Beijing suggests that about 22%~30 Second of the blind children are blinded by congenital cataract, which is the second cause of blindness. The incidence of congenital cataract in our country is about the congenital cataract in children with visual development and form deprivation amblyopia. Therefore, early treatment should be found for the congenital cataract affecting visual development. Bed studies have shown that the ideal method for the treatment of congenital cataract is mainly surgical treatment, that is, phacoemulsification, posterior capsule incision + anterior vitrectomy plus intraocular lens implantation. However, the visual system of infants is still at the stage of development and the refractive state is unstable, especially within 3 years. The eyeball of children is in the period of rapid development, and the postoperative inflammatory response is relatively heavy, and the compliance of children is poor. It may be accompanied by amblyopia, which increases the complexity and risk of congenital cataract surgery. In the time of implantation of intraocular lens, many scholars suggest that the implantation is more appropriate after 2 years of age and be implanted before 2 years of age. Further clinical practice and time test are needed for the safety and effectiveness of the intraocular lens. With the continuous improvement and development of the methods of congenital cataract surgery, anesthesia and microsurgery, cataract extraction and intraocular lens implantation for congenital cataract are the most important for the treatment of congenital cataract. It is necessary for us to implant the ideal intraocular lens degree, ensure the long-term stable visual effect and reduce the postoperatively anisometropia as much as possible. The error, statistics show that the degree error of intraocular lens (IOL) is about -4.06D~+3.86D within 1 years of age; there is no calculation formula for children's intraocular lens for the time being; it is difficult to measure the biological parameters of the children's eyes (including the length of the eye axis and the corneal curvature), although we can apply the IO in the state of the children's anesthetic condition in some medical centers with better equipment conditions. L-Master or portable automatic measuring tools are measured, but the measurement of biological parameters in some developing countries or hospitals with poor medical conditions is still not possible. In addition to the presence of corneal opacity and corneal deformation caused by trauma, the measurement of corneal curvature can also be affected. In these cases, the normal adult cornea will be chosen. The curvature 42.5D~44.0D is used to estimate the diopter of the intraocular lens, so this will produce a larger error for the younger children. The main factors affecting the refractive changes of the eyes include the axial length of the eye, the curvature of the cornea and the development of the lens. The eyes of the children in the 3 year old are still in the rapid development stage, and the ocular axis and the corneal curvature are in a constant change. In the process of cataract extraction, the aphakic eye and the implantation of the intraocular lens break the balance state of the refractive changes during the development, and whether the aphakic eye and the intraocular lens have a certain effect on the development of the ocular axis and the corneal curvature, and whether the effect of this effect can lead to a corresponding change in the refractive state of the eyes. It is a problem we need to observe and study. Of course, there are also many reports on the development of eyeball development in children's normal eyes and cataract eyes. However, the clinical observation of the changes of ocular axis and corneal curvature after congenital cataract surgery in children is not entirely consistent, for infants less than 3 years old. The clinical research reports are less. We observe and analyze the changes of axial length, corneal curvature and diopter of children with simple congenital cataract in 3 years of age. To further understand the effect of aphakia and intraocular lens on the axial length and corneal curvature of the congenital cataract before and after the operation, which is the hand in clinical work. Choice of timing, calculation of intraocular lens photometry with postoperative refractive index retention, and reduction of postoperative refractive error and anisometropia. Subjects were selected from 246 eyes of 158 children with congenital cataract in 3 years of age in our hospital, January 2014 ~2015, which were included in the standard: 1, simple eyes or single eyes. 2, the age of the operation was less than 3 years old; 3, the operation method: monocular congenital cataract: phacoemulsification, posterior capsule incision + anterior vitrectomy in 2 year old children, two stage intraocular lens implantation after 2 years of age, and more than 2 years old with phacoemulsification plus posterior capsule incision + anterior vitrectomy + IOL implantation;? Congenital cataract: phacoemulsification and posterior capsule incision + anterior vitrectomy in infancy and two stage intraocular lens implantation after 2 and a half years; over 2 and a half years old with phacoemulsification plus posterior capsule incision + anterior vitrectomy + intraocular lens implantation; 4, complete preoperative examination data, including medical history, family history, Eye axis length, corneal curvature, intraocular lens implantation diopter and retention degree; 5, after operation, regular remission, timely refractive correction, persistent amblyopia training and preservation of complete case data, and follow-up time of at least 1 years. The exclusion criteria: 1, other abnormal diseases such as congenital small eyeball, congenital small cornea, high Degree myopia, congenital glaucoma, PHPV, retina choroid dysplasia, and so on; 2, postoperative severe complications such as uveitis, IOL pupil clamp, IOL dislocation, posterior cataract, secondary glaucoma, etc.; 3, can not be revisited regularly after operation, can not adhere to the training of amblyopia, lack of complete surgical data and postoperative follow-up data in outpatient clinic. The study method is a prospective study. According to the age of first operation, group A: group A: March ~6 month; group B: ~12 month in June; C group: December ~18 month; D group: ~24 month, ~24 month; E group: 24 month ~36 month. After 1 years of postoperative follow-up, intraocular pressure, axial length, corneal curvature, and equivalent ball under primary optometry for March, June and 1 years after operation respectively The data of the study were statistically analyzed with the SPSS 21 statistical software, and the Kolmogorov-Smirnov test was used to check whether the measurement variables were in the normal distribution. If the conic normal distribution was tested by the two independent sample t test, it did not conform to the normal distribution. The normal distribution was tested by the rank sum test; the age and sex ratio were compared with the single factor variance analysis (ANOVA) test. The difference of P0.05 was statistically significant. Results the changes of axial length in each stage after 1. were compared: the axial length of the five groups of children in March were 18.82 + 1.219mm, 20.61 + 0.796mm, 21.28 + 0.987mm, 21.60 + 0.836mm, 2, respectively. 1.94 + 0.992mm, respectively, increased 0.818 + 0.387mm, 0.682 + 0.289mm, 0.504 + 0.264mm, 0.353 + 0.450mm, 0.266 + 0.344mm, respectively. The axial length of the five groups of children in June were 1.561 + 0.473mm, 1.132 + 0.439mm, 0.963 + 0.395mm, 0.713 + 0.569mm, 0.464 + 0.488mm. It was 2.554 + 0.588mm, 1.728 + 0.592mm, 1.080 + 0.513mm, 0.859 + 0.704mm, 0.768 + 0.520mm. five, in March, after operation June and 1 years after operation, the difference between the eye axis growth and preoperative difference was statistically significant (P 0.05); the five groups in March, A, B, C three group increased more than D, E group, the difference was statistically significant (P0.05), the difference was statistically significant The growth rate of group D was greater than that of group B, and the growth rate of group D was greater than that of E group, but the difference was not statistically significant (P0.05). The growth rate of group A and B was greater than that of C, D and E group after operation in June and 1 years after operation, and the difference was statistically significant (P0.05), but there was no statistical significance in AB, CDE, but there was no significant difference between the five groups. The amplitude was greater than that of the healthy eyes, but the difference was not statistically significant (P0.05), and the growth amplitude decreased with the age of.3.. The corneal curvature of the children after operation in March, June and 1 years postoperatively compared with the preoperative corneal curvature was A, B, C, D group were statistically significant (P0.05), E group (24 months ~36 months) compared with preoperative Corneal curvature gradually decreased, but no statistical significance. Preoperative, postoperative, March, June and 1 years after 1 years of corneal curvature of the difference was statistically significant (P0.05); the five groups were compared: March, A, B two groups of changes more than C, D, E group, C group greater than the E group, the difference is statistically significant (P0.05), C group is greater than the D group, D group change rate is larger than the group, D group, greater than the group, D group, change rate is larger than the group, D group, But the difference was not statistically significant (P0.05). In June and 1 years after operation, the change rate of group A was greater than that of C, D and E, the difference was statistically significant (P0.05), but the difference was not statistically significant (P0.05), but the change rate of corneal curvature in B group was greater than that in E group (P0.05), but there was no statistical significance. There was no significant difference between the corneal curvature and the healthy eye (all P0.05). The corneal curvature of the five groups after the operation was basically the same as that in the healthy eyes, and the corneal curvature decreased gradually, and with the age increasing, the change of corneal curvature gradually became smaller, and the difference was not statistically significant (P0.05) 1 years after.5.. Comparison of photometric changes: the equivalent photoscope was used as initial diopter at 2 weeks after operation. The diopter changes in five groups were -2.89 + 0.975D, -2.51 + 0.732D, -2.28 0.837D, -1.94 + 1.035D, -1.85 + 0.897D, respectively, and the difference was statistically significant (P=0.015), and the three groups were more than two groups. The difference was statistically significant. ABC, DE, but the difference was not statistically significant. The diopter of each group drifted to myopia, with the increase of age, the trend of the drift to myopia was slower than that of the.6. monocular congenital cataract surgery. There was no significant difference in the diopter difference compared with the healthy eye (P0.05), but the diopter had a tendency to drift toward myopia. A group of children with.7. binocular congenital cataract and children with congenital cataract were paired with t test. The results showed that the axial length, corneal curvature and diopter of the eyes were not statistically significant in the age group (P0.05), and the axial length and diopter of the ocular axis were not significant. There were no retinal detachment, posterior cataract, secondary glaucoma, IOL dislocation, 1 cases in group E and 2 cases in group C were excluded from the data, and the data were not included in the statistical analysis. The 5 children in group E had a small amount of pigmentation in the IOL surface of group E, and no effect on visual development. Conclusion in 1.18 months, the growth rate of ocular axis is faster and the axis of eye is slowly increasing. The growth amplitude of ocular axis in children with monocular is faster than that in healthy eyes and binocular children. In 2.12 months, the change of corneal curvature is larger, then changes slowly, and 24 months basically develops to normal adult level; 3. the refraction of congenital cataract after operation has the direction of myopia. The trend of shift to drift and the tendency to change with age is slow. 4. the axial length of ocular axis, the curvature of the cornea and the diopter of the cornea can keep in harmony with the healthy eyes.

【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R779.66

【參考文獻】

相關期刊論文 前6條

1 鄭新寶;黃鈺森;;單眼先天性白內(nèi)障形覺剝奪患者的眼軸發(fā)育特點[J];中華眼視光學與視覺科學雜志;2016年11期

2 李建昌;黃振平;;人工晶體度數(shù)測量的研究現(xiàn)狀[J];醫(yī)學研究生學報;2009年11期

3 姚瞻,謝立信,黃鈺森,王智鵬;折疊式人工晶狀體治療兒童白內(nèi)障的初步報告[J];中華眼科雜志;2002年08期

4 肖林;視網(wǎng)膜多巴胺神經(jīng)系統(tǒng)研究與近視基礎研究現(xiàn)狀與展望[J];國外醫(yī)學.眼科學分冊;1997年05期

5 賈曙光,王小炬,王爾光;從眼的解剖發(fā)育探討人工晶體植入的最佳年齡[J];中華眼科雜志;1996年05期

6 謝平;寧宏;;單眼先天性白內(nèi)障患者雙眼軸長比較分析[J];中國實用眼科雜志;2007年06期

，

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