本文選題：青光眼進(jìn)展 + 倍頻視野計(jì)��； 參考：《浙江大學(xué)》2016年博士論文

【摘要】：目的及時(shí)而準(zhǔn)確地判定進(jìn)展是青光眼病程臨床管理中最重要和最具難度的任務(wù)之一。雖然病程中結(jié)構(gòu)和功能均出現(xiàn)進(jìn)行性損害,但與青光眼患者生活質(zhì)量最直接相關(guān)的仍然是視功能的改變。早期并準(zhǔn)確地識(shí)別視功能損害進(jìn)展,有助于臨床醫(yī)師及時(shí)調(diào)整治療方案,從而更好地保護(hù)患者殘存的視功能、延緩其進(jìn)一步丟失。標(biāo)準(zhǔn)自動(dòng)視野計(jì)(SAP)是目前臨床中最為廣泛應(yīng)用的青光眼視功能監(jiān)測(cè)方法,但其重復(fù)檢測(cè)的波動(dòng)性(Test-retest variability)隨著視野缺損程度的加重而加重,而且周邊檢測(cè)位點(diǎn)的波動(dòng)性尤為顯著,因而SAP在縱向追蹤青光眼視野損害進(jìn)展方面存在不足。倍頻視野計(jì)(FDT)和短波長(zhǎng)自動(dòng)視野計(jì)(SWAP)是兩種以早期診斷青光眼視野缺損為目的而研發(fā)的新型視野檢查類型。當(dāng)前版本的FDT(Matrix)視野檢查,通過(guò)增加檢測(cè)位點(diǎn),采用與SAP類似的24-2檢測(cè)模式,可獲得較既往版本更為全面的視野信息；同時(shí),與SAP相比,其在不同階段病程中的檢測(cè)波動(dòng)性較低,且更為均勻一致。當(dāng)前版本的SWAP (SITA)較既往的全閾值模式檢測(cè)時(shí)間顯著減少,檢測(cè)波動(dòng)性亦得到顯著改善。大量的橫斷面研究資料已證實(shí)FDT和SWAP在青光眼視野損害早期診斷中的應(yīng)用價(jià)值,但FDT和SWAP應(yīng)用于青光眼視野損害進(jìn)展監(jiān)測(cè)中的可行性尚未明確。本研究通過(guò)對(duì)比分析FDT、SWAP 和 SAP追蹤正常眼視野年齡相關(guān)性改變、已確診原發(fā)性開角型青光眼(POAG)視野損害進(jìn)展和疑似POAG眼潛在視野損害進(jìn)展的效能,以明確當(dāng)前版本的FDT和SWAP在縱向監(jiān)測(cè)評(píng)估青光眼性視野損害進(jìn)展中的應(yīng)用價(jià)值。方法1.正常眼年齡相關(guān)性視野改變的FDT、SWAP 和 SAP評(píng)價(jià)本研究自DIGS和ADAGES數(shù)據(jù)庫(kù)中納入207例由綜合分析病史和眼科檢查結(jié)果(包括視力、色覺(jué)、屈光度、角膜厚度、眼壓、裂隙燈、房角鏡、散瞳眼底檢查、立體視盤照相、OCT和視野檢查)判定為正常的受試眼視野資料。納入分析的同一受試眼的FDT、SWAP和SAP數(shù)據(jù)獲取的時(shí)間間隔小于30天。FDT、 SWAP和SAP所報(bào)告的閾值敏感度值(單位dB)分別與受試者年齡(歲)行逐點(diǎn)普通最小二乘法線性回歸分析,從而將不同視野檢查類型中各個(gè)檢查位點(diǎn)的閾值敏感度值均表達(dá)為以年齡為自變量的一元線性回歸方程。2. 已確診POAG眼視野損害進(jìn)展的FDT、SWAP和SAP監(jiān)測(cè)效能對(duì)比分析本研究自DIG S和ADAGES數(shù)據(jù)庫(kù)中納入由FDT、SWAP 和 SAP共同隨訪的84名113例已確診P OAG患眼隊(duì)列資料,平均隨訪時(shí)間為4.4士0.9年。FDT、SWAP和SAP檢查所報(bào)告的以dB為單位的閾值敏感度數(shù)值均換算為相對(duì)于同年齡正常人群平均敏感度水平的百分?jǐn)?shù)值(%%%N)。在共同的正常百分?jǐn)?shù)度量體系下進(jìn)行視野敏感度的逐點(diǎn)線性回歸分析(PLR),并采用三種不同特異度水平的標(biāo)準(zhǔn)(嚴(yán)格、中等和寬松)判定視野變化趨勢(shì)；對(duì)比分析不同視野檢查類型的PLR判定結(jié)果以及相互的一致性。通過(guò)分層混合效應(yīng)線性模型分析在所納入的POAG隊(duì)列中,FDT和SWAP所追蹤到的視野平均敏感度的變化趨勢(shì),并于SAP作對(duì)比分析。3.疑似POAG眼視野損害進(jìn)展的FDT和SAP監(jiān)測(cè)效能對(duì)比分析本研究自DIGS和ADAGES數(shù)據(jù)庫(kù)中納入104名121例由FDT和SAP共同隨訪的疑似POAG患眼(存在明確的青光眼性視盤結(jié)構(gòu)改變和／或高眼壓癥,但SAP檢查未發(fā)現(xiàn)明確的青光眼性視野損害依據(jù))隊(duì)列資料,平均隨訪時(shí)間為6.6士1.5年。FDT和SAP檢查所報(bào)告的以dB為單位的閾值敏感度數(shù)值均換算為相對(duì)于同年齡正常人群平均敏感度水平的百分?jǐn)?shù)值(%N)。在共同的正常百分?jǐn)?shù)度量體系下進(jìn)行視野敏感度的逐點(diǎn)線性回歸分析(PLR),并采用兩種不同特異度水平的標(biāo)準(zhǔn)(嚴(yán)格和寬松)判定視野變化趨勢(shì)；對(duì)比分析FDT和SAP數(shù)據(jù)的PLR判定結(jié)果以及相互的一致性。通過(guò)分層混合效應(yīng)線性模型分析在所納入的疑似POAG隊(duì)列中,FDT所追蹤到的視野平均敏感度的變化趨勢(shì),并于SAP作對(duì)比分析。結(jié)果1.在所納入的40-75歲正常人群樣本中,FDT、SWAP和SAP均可追蹤到各個(gè)視野檢測(cè)位點(diǎn)上具有統(tǒng)計(jì)學(xué)意義的閾值敏感度隨年齡增加而線性遞減的趨勢(shì)(P0.05)。2.通過(guò)PLR分析,我們的研究表明根據(jù)更高特異度的嚴(yán)格判定標(biāo)準(zhǔn),不同視野檢查類型之間對(duì)于進(jìn)展/好轉(zhuǎn)的判定結(jié)果無(wú)統(tǒng)計(jì)學(xué)顯著性差異；根據(jù)中等判定標(biāo)準(zhǔn),FDT和SWAP報(bào)告的好轉(zhuǎn)眼比例多于SAP；根據(jù)寬松判定標(biāo)準(zhǔn),FDT所追蹤到的進(jìn)展眼比例少于SWAP和SAP。不同視野檢查類型之間判定進(jìn)展的一致性較低。二層次混合效應(yīng)線性模型擬合結(jié)果顯示在納入研究的POAG隊(duì)列中,FDT未能追蹤到顯著的平均敏感度進(jìn)行性丟失趨勢(shì),而SAP則報(bào)告以-1.69 %N/年的速率進(jìn)展；與SAP和FDT相比,SWAP顯著低估基線的視野平均敏感度水平。3.通過(guò)PLR分析,我們的研究表明在不同嚴(yán)格程度的判定標(biāo)準(zhǔn)下,FDT和SAP對(duì)于進(jìn)展／好轉(zhuǎn)的判定結(jié)果無(wú)統(tǒng)計(jì)學(xué)顯著性差異。FDT和SAP判定進(jìn)展的一致性為較低到一般。二層次混合效應(yīng)線性模型擬合結(jié)果顯示在納入研究的疑似POAG隊(duì)列中,FDT和SAP均追蹤到了顯著的平均敏感度進(jìn)行性丟失趨勢(shì),二者對(duì)進(jìn)展速率的估算無(wú)顯著性差異；與SAP相比,FDT估測(cè)的基線視野平均敏感度水平略低。結(jié)論1. FDT、SWAP和SAP均可追蹤到正常眼中年齡相關(guān)性的視野敏感度衰退改變。2.對(duì)于已確診的POAG患眼,FDT和SWAP檢查未能表現(xiàn)出顯著優(yōu)于SAP的視野損害進(jìn)展監(jiān)測(cè)效能。對(duì)POAG患者個(gè)體而言,視野損害進(jìn)展可能僅能被其中一種視野檢查類型所識(shí)別。3.在僅明確視盤結(jié)構(gòu)改變和/或高眼壓癥的疑似POAG眼中,FDT監(jiān)測(cè)視野損害潛在進(jìn)展的效能與SAP相仿。FDT可能有助于識(shí)別疑似POAG患眼中SAP檢查未能發(fā)現(xiàn)的潛行視野損害進(jìn)展趨勢(shì)。4.以正常人群平均水平作為參照的相對(duì)百分?jǐn)?shù)度量轉(zhuǎn)換方法,可滿足直接對(duì)比分析青光眼臨床評(píng)估中不同檢查類型(如視野vs.視野,或視野vs.結(jié)構(gòu))所獲得的數(shù)據(jù)資料、界定統(tǒng)一的判定標(biāo)準(zhǔn)的要求,且直觀明了,具有良好的臨床應(yīng)用價(jià)值。
[Abstract]:Objective to determine in a timely and accurate way that progress is one of the most important and difficult tasks in the clinical management of the course of glaucoma. Although structural and functional damage occurs during the course of the disease, the most direct correlation with the quality of life of glaucoma patients is the change of visual function. Early and accurate identification of visual impairment progress is helpful. The clinician adjusts the treatment plan in time so as to better protect the patient's residual visual function and delay its further loss. The standard automatic perimeter (SAP) is the most widely used clinical monitoring method of glaucomatous visual function in the current clinical practice, but the volatility of its repeated detection (Test-retest variability) is added with the aggravation of the degree of visual field defect. Heavy, and the peripheral detection loci are particularly volatile, so there is a shortage of SAP in longitudinal tracking of glaucomatous visual field damage. The frequency doubling perimeter (FDT) and the short wavelength automatic perimeter (SWAP) are two new types of perimetry for the purpose of early diagnosis of glaucoma visual field defects. The current version of the FDT (Matrix) field of vision Check, by adding the detection loci and using the 24-2 detection model similar to the SAP, the more comprehensive visual field information can be obtained from the previous version. At the same time, compared with the SAP, the detection volatility is lower and more uniform in different stages of disease. The current version of SWAP (SITA) is significantly less than the previous full threshold mode detection time. A large number of cross-sectional data have demonstrated the value of FDT and SWAP in the early diagnosis of glaucomatous visual field damage, but the feasibility of the application of FDT and SWAP to the monitoring of glaucomatous visual field damage is not clear. This study was conducted by comparison and analysis of FDT, SWAP and SAP to track the age related visual field of normal eyes. Sexual change, the effectiveness of the diagnosis of primary open angle glaucoma (POAG) visual field damage and the potential of potential visual field damage in POAG eyes, in order to identify the value of the current version of FDT and SWAP in the longitudinal monitoring of the progression of glaucomatous visual field damage. Method 1. the FDT, SWAP and SAP of the age-related visual field changes in normal eyes In the DIGS and ADAGES databases, 207 cases were determined by comprehensive analysis of medical history and ophthalmological examination results (including vision, color vision, refraction, corneal thickness, intraocular pressure, slit lamp, angle lens, pupil fundus examination, stereoscopic disc photography, OCT and visual field examination) as normal subjects' visual field data. FDT, SWAP, and SA of the same subjects were included in the analysis. The time interval of P data acquisition is less than 30 days.FDT, and the threshold sensitivity (unit dB) reported by SWAP and SAP is linear regression analysis with the subjects' age (year) by point by point ordinary least square method, thus the threshold sensitivity values of each check site in different field of vision are expressed as one linear regression with age independent variable. The comparative analysis of FDT, SWAP, and SAP monitoring effectiveness of the POAG eye visual field impairment in the.2. regression equation. This study was included in the DIG S and ADAGES database into the 84 patients who had been followed up by FDT, SWAP, and SAP. The average follow-up time was 4.4 and 0.9 years. The sensitivity values were converted to the percent value (%%%N) relative to the average level of sensitivity of the normal age population. The point by point linear regression analysis (PLR) was carried out under the common normal percentage measurement system, and the trend of visual field change was determined by three different levels of specificity (strict, medium and loose); Analysis of the PLR decision results and mutual consistency of different visual field check types. The variation trend of the average visual field sensitivity traced by FDT and SWAP in the included POAG queues was analyzed by the layered mixing effect linear model, and the FDT and SAP monitoring efficiency of.3. suspected POAG visual field damage progress was compared and analyzed in SAP. In the DIGS and ADAGES databases, 104 suspected POAG patients were followed up by FDT and SAP (there were clear glaucomatous optic disc structural changes and / or high intraocular pressure, but SAP examination did not find clear glaucomatous visual field damage basis). The average follow-up time was 6.6, 1.5 years,.FDT and SAP. The value of threshold sensitivity in the dB unit was converted to a percent value (%N) relative to the average sensitivity level of the normal age group. The point by point linear regression analysis (PLR) was carried out under the common normal percentage measurement system, and the visual field of two different levels of specificity (strict and loose) was used to determine the field of vision. Change trends; compare and analyze the PLR determination results of FDT and SAP data and the consistency of each other. The variation trend of the average visual field sensitivity traced by FDT in the suspected POAG queue is analyzed by the linear model of the mixed effect of the mixed effect, and the contrast analysis is made in SAP. Results 1. in the sample of the normal population aged 40-75 years, FDT, SWAP and SAP can track the statistically significant threshold sensitivity on the detection sites of various visual fields with the increase of age (P0.05).2. through PLR analysis. Our study shows that there is no significant difference in the determination of progress / improvement between different visual field test types according to the strict criteria of higher specificity. According to the medium criteria, the good turning ratio of the FDT and SWAP reports is more than that of SAP. According to the looser criteria, the proportion of the progressive eyes traced by the FDT is less than that between the SWAP and the SAP.. The two level mixed effect linear model fitting results show the POAG team in the study. In the column, FDT failed to track the significant average sensitivity progressive loss trend, while SAP reported the rate of -1.69%N/. Compared with SAP and FDT, SWAP significantly underestimated the baseline vision average sensitivity level.3. through PLR analysis. Our research shows that FDT and SAP are progressing / good under different stringent criteria. There was no statistically significant difference in the results of.FDT and SAP decision. The results of the two level mixed effect linear model showed that both FDT and SAP were traced to the significant average sensitivity progressive loss trend in the suspected POAG cohort, and the two had no significant estimation of the rate of progress. Difference; compared with SAP, the average baseline sensitivity of FDT was slightly lower than that of SAP. Conclusion 1. FDT, SWAP and SAP could track the age-related visual field sensitivity decline in normal eyes and.2. for diagnosed POAG eyes, FDT and SWAP failed to show significantly better monitoring effectiveness than SAP in visual field damage. For POAG patients In body, the development of visual field damage may only be identified by one of the type of visual field examination (.3.) in the suspected POAG eyes with only visual disc structure change and / or high intraocular pressure. The effectiveness of FDT monitoring the potential progression of visual field damage and SAP similar.FDT may help to identify the latent visual impairment that failed to be detected by the SAP examination in a suspected POAG eye. The trend.4. takes the average level of the normal population as a reference to the relative percentage measurement conversion method, which can satisfy the data obtained by the direct contrast analysis of different types of glaucoma clinical assessment (such as the visual field of vision, or the vs. structure of the field of vision), and define the requirements of the unified criteria, and have a good clinical response. Use value.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R775

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