【摘要】：目的:應(yīng)用隱結(jié)構(gòu)法進行中老年瞼板腺功能障礙的證候分析,并運用全身辨證結(jié)合局部辨證指導(dǎo)臨床研究,從臨床檢查、微生物檢驗、瞼酯成分分析等方面觀察外洗劑的治療作用,對瞼板腺功能障礙及相關(guān)干眼的中醫(yī)規(guī)范診療進行較深入探討。內(nèi)容:1.應(yīng)用隱結(jié)構(gòu)法揭示中老年MGD疾病的中醫(yī)辨證分型,并明確患者的中醫(yī)基本證候要素和篩選對該病有明確意義的癥狀,為該病患者的辨證分型建立客觀和定量的診斷標(biāo)準(zhǔn)提供了可能性。2.以局部辨證為主,參考初期數(shù)據(jù)分析結(jié)果,對門診瞼板腺功能障礙合并干眼病人擬外洗方進行局部外用熏洗,觀察治療效果,探討作用機制。3.對比治療前后癥狀、體征、瞼板腺功能障礙分度、瞼板腺缺失情況、淚膜穩(wěn)定性等,進行臨床療效評價。4.通過質(zhì)譜法進行瞼酯成分分析,分析患者的瞼酯質(zhì)的變化,以明確治療后的改善情況及敏感性。5.通過治療前后瞼緣微生物檢驗分析局部微環(huán)境變化并分析損傷機制,以期找到臨床更有效、實用的治療方法。6.根據(jù)隱結(jié)構(gòu)明確的辨證分型,指導(dǎo)患者的長期中醫(yī)調(diào)理,延緩病情發(fā)展,尤其對于無癥狀或輕微癥狀的MGD患者具有積極意義,并利于MGD患者長期治療指導(dǎo)。方法:1.門診問卷調(diào)查,收集數(shù)據(jù),分析臨床常見證型分析了近5年的中醫(yī)文獻,結(jié)合臨床經(jīng)驗,建立了 MGD患者的問卷調(diào)查表。選擇臨床出現(xiàn)頻率較高的癥狀變量錄入數(shù)據(jù)庫。篩選了 2015年1月至2017年5月來中國中醫(yī)科學(xué)院眼科醫(yī)院就診的及北京各三級醫(yī)院眼科醫(yī)師的網(wǎng)絡(luò)問卷調(diào)查納入的MGD患者561例。通過數(shù)據(jù)分析得出臨床常見中醫(yī)證型。2.以局部辨證為主,擬外用熏洗方參照前期部分病例分析結(jié)果,臨床初步總結(jié)發(fā)現(xiàn)該病中老年人群更以肝腎陰虛及陰虛濕熱兩型常見,這部分病人局部多見濕熱蘊結(jié)之象,結(jié)合該病西醫(yī)病理學(xué)基礎(chǔ),同時參照文獻及結(jié)合現(xiàn)代藥理,課題采用苦參、百部、蒲公英、薄荷、野菊花等為主方清熱利濕殺蟲兼疏風(fēng),進行瞼緣局部外用熏洗,觀察治療效果,探討作用機制。3.觀察臨床療效對比治療前后患者的癥狀評分、瞼緣異常評分及干眼分析,進行臨床療效評價。其中干眼分析通過非接觸的紅外透射技術(shù)觀察瞼板腺的丟失率,觀察瞼板腺改善情況,視頻分析功能觀察淚膜破裂時間。4.觀察MGD病人瞼酯細菌情況MGD與瞼板腺細菌感染關(guān)系密切,細菌的膽固醇脂酶和脂肪蠟脂酶在瞼板腺功能障礙的發(fā)病中起很大作用。通過治療前后瞼酯細菌分析,檢測細菌陽性率及細菌種類,并觀察治療效果。5.觀察治療前后睫毛根部及瞼酯的螨蟲情況螨蟲的直接損傷、引起的免疫反應(yīng)都是老年人MGD的發(fā)病原因。螨蟲對于瞼板腺功能障礙致病機制尚未十分明確,但是研究發(fā)現(xiàn),檢出率與年齡呈正相關(guān),尤其對于合并MGD患者,更容易檢出,且治療有臨床意義。我們觀察部分中老年MGD病人,大量病人睫毛根部及瞼酯分泌物發(fā)現(xiàn)螨蟲滋生,甚至少量能發(fā)現(xiàn)皮脂螨。我們同時觀察治療前后睫毛及瞼酯螨蟲數(shù)量、種類,分析治療效果。6.分析瞼酯成分及治療前后變化各種內(nèi)源或外源性因素導(dǎo)致瞼酯成分變化,導(dǎo)致瞼酯熔點增高,課題旨在通過檢測硬脂酸、十六酸、角鯊烯等含量變化,來衡量脂肪酸變化情況,并以此判定治療效果。但具體實驗過程中,可能因MGD病人角鯊烯含量降低,其響應(yīng)值本身也較低,該實驗未能明確檢測出角鯊烯含量。結(jié)果:1.證候觀察:瞼板腺功能障礙中醫(yī)證候分析選取2015年1月至2017年5月來中國中醫(yī)科學(xué)院眼科醫(yī)院門診就診的中老年MGD患者561例。以隱結(jié)構(gòu)法進行分析,最后,根據(jù)分布特點,優(yōu)選出本問卷調(diào)查最優(yōu)隱樹模型的BIC評分為-20656.24,即考慮癥狀(1～44)的模型結(jié)構(gòu)圖。2.臨床試驗:選取2016年2月至2017年1月來中國中醫(yī)科學(xué)院眼科醫(yī)院門診就診的MGD患者共64例,隨機分組,進行辨證分型及治療前后各指標(biāo)檢測。3.臨床療效評價:瞼板腺功能障礙分度治療組及對照組治療后均無統(tǒng)計學(xué)差異(P0.05);干眼癥狀評分治療組治療前后有顯著統(tǒng)計學(xué)差異(P0.01),對照組治療后也有統(tǒng)計學(xué)差異(P0.05),治療組改善更明顯;瞼緣異常評分治療組治療前后有顯著統(tǒng)計學(xué)差異(P0.01),對照組治療后也有統(tǒng)計學(xué)差異(P0.05),治療組改善更明顯;干眼分析:瞼板腺功能分級治療組及對照組治療后均無統(tǒng)計學(xué)差異(P0.05),淚膜破裂時間治療組治療前后有統(tǒng)計學(xué)差異(P0.05),對照組無統(tǒng)計學(xué)差異。4.瞼酯分析:軟脂酸治療前后:治療組治療前后有統(tǒng)計學(xué)差異(P0.05),對照組治療后也略有改善,但無統(tǒng)計學(xué)差異。硬脂酸治療前后.:治療組有統(tǒng)計學(xué)差異(P0.05),對照組治療后也略有改善,但無統(tǒng)計學(xué)差異。5.螨蟲檢測:治療組治療前后有顯著統(tǒng)計學(xué)差異(P0.01),對照組治療后也有統(tǒng)計學(xué)差異(P0.05),治療組效果更顯著。6.細菌檢測:治療組治療前后有顯著統(tǒng)計學(xué)差異(P0.01),對照組治療后有統(tǒng)計學(xué)差異(P0.05),治療組效果更顯著。結(jié)論:1.根據(jù)隱樹結(jié)構(gòu)分析初步得出中老年瞼板腺功能障礙的臨床常見證型為肝腎陰虛、陰虛濕熱、心脾兩虛型。2.本病多以陰虛為基礎(chǔ),臨床局部辨證以濕熱為主,兼有風(fēng)邪,本虛標(biāo)實,擬清熱利濕殺蟲為主,兼以疏風(fēng)中藥外洗方。本外洗方可減輕臨床癥狀,改善瞼板腺功能,并可改善瞼酯成分,在抗螨蟲、抗菌方面都有顯著療效,較眼藥組明顯。初步該外洗方組方有效,可用于中老年瞼板腺功能障礙的治療。3.本病以局部辨證與全身辨證的結(jié)合應(yīng)用指導(dǎo)臨床治療,發(fā)揮了中醫(yī)治療外眼病的優(yōu)勢,急而治標(biāo);后期根據(jù)證型分析結(jié)果,指導(dǎo)調(diào)攝,減緩復(fù)發(fā),緩而治本,進行了慢病管理模式的初步探索。
[Abstract]:Objective: to analyze the syndrome of palpebral gland dysfunction in middle and old age by using the implicit structure method, and use the whole body syndrome differentiation combined with local syndrome differentiation to guide the clinical study, observe the therapeutic effect of the external lotion from clinical examination, microorganism test and the analysis of palpebral ester composition, and make a deeper diagnosis and treatment on the function of the palpebral gland function disorder and the related dry eyes. Contents: 1. use the implicit structure method to reveal the TCM syndrome differentiation of MGD disease in middle and old age, and make clear the basic syndrome factors of the patients and select the symptoms that have definite meaning for the disease. It provides the possible.2. for the establishment of the objective and quantitative diagnostic criteria for the syndrome differentiation of the patients. Analysis of the results of palpebral palpebral gland dysfunction combined with dry eye patients for external use of external use of fumigation to observe the effect of treatment, to explore the mechanism.3. before and after the treatment of symptoms, signs, meibomian gland dysfunction degree, tartaric gland loss, tear film stability and so on, the clinical effect evaluation of.4. by mass spectrometry of the palpebral composition component Analysis and analysis of patients' palpebral ester changes in order to clarify the improvement and sensitivity of.5. after treatment and to analyze the local microenvironment changes before and after treatment and analyze the mechanism of local microenvironment, so as to find a more effective and practical treatment method,.6., to guide the patient's long-term TCM conditioning according to the distinct classification of the implicit structure. Delay the development of the disease, especially for the patients with asymptomatic or mild symptoms of MGD, which is of positive significance, and is beneficial to the long-term treatment guidance of MGD patients. Methods: 1. outpatient questionnaire survey, data collection, analysis of clinical common syndrome type analysis of the recent 5 years of traditional Chinese medicine literature, combined with clinical experience, the establishment of a questionnaire of MGD patients. A high rate of symptom variables entered the database. 561 cases of MGD patients were selected from January 2015 to May 2017 in the ophthalmology hospital of the Chinese Academy of traditional Chinese medicine (Chinese Academy of science of traditional Chinese Medicine) and the network questionnaire survey of ophthalmologists in each of the three level hospitals in Beijing. Through data analysis, the clinical common TCM syndrome type.2. was based on the local syndrome differentiation. Early part of the case analysis results, preliminary clinical summary found that the elderly people in the disease are more common with liver kidney yin deficiency and yin deficiency and damp heat type two. This part of the patients mostly see the image of damp heat, combined with the pathological basis of Western medicine, referring to Literature and modern pharmacology, using Sophora flavescens, hundred Department, dandelion, menthol, chrysanthemum, etc. The main side of clearing heat, dampness, killing insects and wind, carrying out local external use of blepharius and washing, observing the effect of treatment, and exploring the effect mechanism.3. to observe the symptom score of the patients before and after contrast treatment, palpebral margin abnormality score and dry eye analysis, and evaluate the clinical efficacy. Loss rate, observation of improvement of palpebral gland gland, video analysis function observation of tear film rupture time.4. observation of MGD patients with palpebral ester bacteria condition MGD closely related to bacterial infection of palpebral gland, bacteria cholesterol lipase and fat wax lipase play a great role in the pathogenesis of palpebral gland dysfunction. The positive rate and the species of bacteria, and observe the therapeutic effect of.5., and observe the direct damage of mite in the eyelash root and the mites before and after treatment. The immune response is the cause of MGD in the elderly. The mechanism of the mites is not clear for the pathogenesis of the palpebral gland dysfunction, but it is found that the detection rate is positively related to the age. It is easier to detect and treat the patients with MGD, and the treatment has clinical significance. We observe some middle-aged and old MGD patients, a large number of patients with eyelash roots and eyelid exudates to find mites, and even a small amount of sebaceous mites. We also observe the number and type of eyelashes and palpebral mites before and after treatment, and analyze the effect of.6. for the analysis of palpepalate composition. And the changes of various endogenous or exogenous factors before and after treatment lead to the changes in the composition of palpebral ester, which leads to the increase of the melting point of palpebral ester. The aim is to measure the change of fatty acids by detecting the changes of stearic acid, sixteen acid, squalene and so on, and to determine the effect of the treatment. The response value itself is also low, the experiment failed to detect the content of squalene. Results: 1. syndromes: 561 cases of middle and old MGD patients in the outpatient department of the ophthalmology hospital of China Academy of traditional Chinese medicine (Chinese Academy of Chinese Medicine) from January 2015 to May 2017 were selected to be analyzed by the method of hidden knot structure. Finally, according to the distribution characteristics, the optimal selection was selected. The BIC score of the optimal hidden tree model was -20656.24, that is, the model structure map of the symptoms (1~44) was considered as.2. clinical trial: 64 cases of MGD patients in the ophthalmology hospital of China Academy of Ophthalmology from February 2016 to January 2017 were selected and randomly divided into different types of syndrome differentiation and the evaluation of the clinical efficacy of.3. before and after the treatment. There was no significant difference between the treatment group and the control group (P0.05), and there was significant difference in the treatment group (P0.01) before and after treatment (P0.05), and the improvement of the treatment group was more obvious, and there was significant difference before and after treatment in the treatment group (P0 .01), the control group was also statistically different after treatment (P0.05), the treatment group improved more obviously; dry eye analysis: the palpebral gland function group and the control group had no statistical difference after treatment (P0.05), the tear film rupture time treatment group had statistical difference before and after treatment (P0.05), there was no statistical difference between the control group and the.4. palpepalate analysis: before and after the palpebric acid treatment The treatment group had statistical difference before and after treatment (P0.05), and the control group was also slightly improved after treatment, but there was no statistical difference. Before and after stearic acid treatment, the treatment group had statistical difference (P0.05), and the control group was also slightly improved after treatment, but there was no statistical difference of.5. mites detection: the treatment group had significant statistical difference before and after treatment (P0.01), control group treatment. After treatment, there was also statistical difference (P0.05), the effect of the treatment group was more significant.6. bacteria detection: the treatment group had significant statistical difference before and after treatment (P0.01), the control group had statistical difference after treatment (P0.05), and the effect of the treatment group was more significant. Conclusion: 1. according to the structural analysis of hidden tree, the clinical common syndrome type of the middle and old age eyelid gland dysfunction is the liver. Kidney yin deficiency, yin deficiency and damp heat, heart and spleen two deficiency type.2. based on Yin deficiency as the basis, clinical local syndrome differentiation with damp heat mainly, both wind evil, this deficiency is the main, and the traditional Chinese herbal medicine outside washing prescription. The external washing prescription can alleviate the clinical symptoms, improve the palpebral gland function, and can improve the eyelid ester composition, anti mite, antibacterial aspects of the skin The curative effect, compared with the eye medicine group, is effective and effective. It can be used in the treatment of paltaral gland dysfunction in the middle and old age. The treatment of.3. is guided by the combination of the local syndrome differentiation and the whole body syndrome differentiation, which exerts the advantages of the treatment of the external ophthalmopathy in Chinese medicine. The management mode of chronic diseases was explored preliminarily.
【學(xué)位授予單位】：中國中醫(yī)科學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R276.7

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