糖尿病角膜神經(jīng)病變與視網(wǎng)膜病變的相關(guān)性研究
發(fā)布時(shí)間：2018-07-13 10:41
【摘要】：研究背景和目的:糖尿病是目前全球關(guān)注的公共衛(wèi)生問(wèn)題。糖尿病視網(wǎng)膜病變(Diabetic retinopathy,DR)和糖尿病角膜神經(jīng)病變(Diabetic corneal neuropathy,DCN)分別是眼部常見(jiàn)的微血管并發(fā)癥和神經(jīng)并發(fā)癥。DR在屈光間質(zhì)不清楚等情況下很難判斷眼底微血管病變的嚴(yán)重程度;DCN由于檢查手段有限,活體共聚焦顯微鏡(in vivo confocal microscopy,IVCM)是目前唯一可以活體觀察角膜神經(jīng)纖維的檢查方法,因此未被廣泛重視。糖尿病的全身神經(jīng)并發(fā)癥和微血管并發(fā)癥之間具有非常密切的相關(guān)性,但在眼部DCN與DR在臨床上是否也有密切相關(guān)性?如果兩者病情密切相關(guān),DCN則可以作為DR病情判斷困難時(shí)的預(yù)測(cè)參考指標(biāo)。另外,早期進(jìn)行血糖、血壓、血脂等干預(yù)對(duì)于預(yù)防DR的發(fā)展有重要意義,IVCM對(duì)角膜神經(jīng)的檢查具有微觀、敏感的特點(diǎn),角膜神經(jīng)的損害如果能在尚未出現(xiàn)微血管病變時(shí)早期檢測(cè),則提示我們盡早干預(yù)DR。因此,本研究有兩方面目的:一方面,通過(guò)IVCM觀察不同時(shí)期DR的DCN超微結(jié)構(gòu)改變,證實(shí)IVCM在DCN的臨床應(yīng)用價(jià)值,探索DCN和DR兩者病情嚴(yán)重程度是否存在相關(guān)性。另一方面,觀察DR早期尚未出現(xiàn)微血管病變時(shí)是否同時(shí)存在角膜神經(jīng)纖維(Corneal nerve fibers,CNF)和視網(wǎng)膜神經(jīng)纖維層(Retinal nerve fibre layer,RNFL)變化,并觀察兩者變化是否具有相關(guān)性,為干預(yù)DR提供早期篩查指標(biāo)。研究對(duì)象和方法:第一部分:收集120例(120眼)2型糖尿病患者,按照糖尿病視網(wǎng)膜病變國(guó)際分期標(biāo)準(zhǔn)分為無(wú)視網(wǎng)膜病變(no diabetic retinopathy,NDR)組、輕中度非增生期(mild or moderate non-proliferative diabetic retinopathy,mNPDR)組、重度非增生期(severe non-proliferative diabetic retinopathy,s NPDR)組和增生期(proliferative diabetic retinopathy,PDR)組,每組30例(30眼);另收集30例(30眼)健康正常眼作為對(duì)照組。利用Heidelberg HRT3 IVCM觀察角膜上皮下神經(jīng)纖維的形態(tài)指標(biāo),包括角膜神經(jīng)纖維長(zhǎng)度(Nerve fiber length,NFL)、角膜神經(jīng)纖維密度(Nerve fiber density,NFD)、角膜神經(jīng)纖維分支密度(Nerve fiber branch density,NFB)和角膜神經(jīng)彎曲度(Nerve tortuosity,NT)。第二部分:收集40例(40眼)2型糖尿病患者,經(jīng)散瞳眼底檢查未發(fā)現(xiàn)糖尿病視網(wǎng)膜病變,均接受光學(xué)相干斷層掃描(Optical Coherence Tomography,OCT)檢查和IVCM檢查。另收集年齡匹配的80例(80眼)健康正常眼為對(duì)照,分為40例(40眼)只行OCT檢查的RNFL對(duì)照組和40例(40眼)只行IVCM檢查的CNF對(duì)照組。利用OCT觀察視乳頭上方、下方、顳側(cè)、鼻側(cè)和平均RNFL厚度,用IVCM觀察角膜上皮下NFL和NFD。結(jié)果:第一部分:糖尿病各組的角膜NFL、NFD、NFB均比對(duì)照組減少(P0.01),而NT彎曲度比對(duì)照組增加(P0.01)。隨著DR病情加重,NFL、NFD、NFB逐步減少(P0.01),NT增大(P0.01),但sNPDR組和PDR組間角膜神經(jīng)各項(xiàng)指標(biāo)差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。NFL、NFD、NFB與DR嚴(yán)重程度呈負(fù)相關(guān)(r=-0.875、-0.866、-0.798,P=0.000、0.000、0.000),NT與DR嚴(yán)重程度正相關(guān)(r=0.693,P=0.000)。第二部分:糖尿病組的視乳頭上方、顳側(cè)、鼻側(cè)及平均RNFL與RNFL對(duì)照組差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),但視乳頭下方RNFL糖尿病組比RNFL對(duì)照組減少(P=0.003)。糖尿病組的角膜NFL、NFD均比CNF對(duì)照組減少(P0.01)。糖尿病組中,平均RNFL與NFL、NFD呈正相關(guān)(r=0.518,P0.01;r=0.484,P=0.002),下方RNFL與角膜NFL、NFD呈正相關(guān)(r=0.607,P0.01;r=0.573,P0.01)。結(jié)論:1.IVCM是評(píng)估DCN的敏感、有效檢查方法,糖尿病患者存在不同程度的角膜神經(jīng)纖維丟失和角膜神經(jīng)彎曲度增大;2.DCN與DR的病情嚴(yán)重程度具有明顯的相關(guān)性,隨著DR嚴(yán)重程度增加,DCN也逐漸加重,DCN可以作為DR病情程度預(yù)測(cè)指標(biāo);3.糖尿病患者在未發(fā)現(xiàn)視網(wǎng)膜微血管病變時(shí),已經(jīng)同時(shí)存在CNF和RNFL的丟失,RNFL變薄主要表現(xiàn)在下方象限;CNF的減少與RNFL的變薄呈正相關(guān)。CNF和RNFL可以作為早期干預(yù)DR的篩查指標(biāo)。
[Abstract]:Background and purpose: diabetes is a global public health problem. Diabetic retinopathy (Diabetic retinopathy, DR) and diabetic corneal neuropathy (Diabetic corneal neuropathy, DCN) are the common microvascular complications of the eyes, and neuropathy.DR is difficult to judge under the uncertainty of the refractive interstitium. The severity of microvascular lesions in the fundus; DCN vivo confocal microscopy (IVCM), due to limited examination, is the only method that can be used to observe the corneal nerve fibers in vivo. Therefore, it is not widely recognized. There is a very close relationship between diabetic systemic neurosis and microvascular complications. Is there a close correlation between the DCN and the DR in the eye? If the two are closely related, DCN can be used as a predictor for the prediction of the difficulty of DR. In addition, early intervention in blood sugar, blood pressure, and blood lipid is important to prevent the development of DR. IVCM has a microcosmic and sensitive examination of the corneal nerve. Characteristics, the damage of the corneal nerve, if it can be detected early in the absence of microvascular lesions, suggests that we intervene DR. as early as possible. There are two aspects of this study. On the one hand, the DCN ultrastructural changes of DR in different periods are observed by IVCM, and the value of IVCM in DCN is confirmed and the severity of the severity of both DCN and DR is explored. On the other hand, whether the changes of corneal nerve fiber (Corneal nerve fibers, CNF) and retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were observed at the same time in the early stage of DR, and whether the changes of the retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were related, and to provide early screening indicators for intervention DR. The first part: 120 patients (120 eyes) with type 2 diabetes were divided into the no diabetic retinopathy (NDR) group, the mild to moderate non hyperplastic period (mild or moderate non-proliferative diabetic retinopathy, mNPDR) group, and the severe non hyperplastic period (severe). Retinopathy, s NPDR) group and hyperplastic period (proliferative diabetic retinopathy, PDR) group, 30 cases (30 eyes) in each group, and 30 cases (30 eyes) healthy and normal eyes as the control group. The morphological indexes of the corneal subcutaneous nerve fibers were observed by Heidelberg HRT3 IVCM, including the length of the corneal nerve fiber (Nerve fiber), corneal nerve fiber. The density (Nerve fiber density, NFD), the branch density of the corneal nerve fiber (Nerve fiber branch density, NFB) and the corneal nerve flexure (Nerve tortuosity, NT). Second: 40 patients (40 eyes) with type 2 diabetes were collected, and the retinopathy of diabetic retinopathy was not found by the pupil fundus examination. Omography, OCT) and IVCM examination. Another 80 cases of age matched (80 eyes) healthy and normal eyes were collected, divided into 40 cases (40 eyes), RNFL control group with OCT examination and 40 cases (40 eyes), only CNF control group with IVCM examination. Using OCT to observe the upper, inferior, temporal, nasal side and average RNFL thickness of the optic papilla with OCT, and observe the NFL and NFD of the upper cornea with IVCM. Results: the first part: the corneal NFL, NFD, and NFB in all groups of diabetes were lower than those of the control group (P0.01), while the NT flexural degree was higher than the control group (P0.01). With the aggravation of DR, NFL, NFD, NFB gradually decreased (P0.01) and NT increased, but there was no significant difference in the various indexes of the angular membrane nerve between the groups and the groups. The degree was negatively correlated (r=-0.875, -0.866, -0.798, P=0.000,0.000,0.000), NT was positively correlated with DR severity (r=0.693, P=0.000). The second part: there was no significant difference between the optic papilla, the temporal side, the nasal side and the average RNFL and RNFL control groups in the diabetic group (P0.05), but the diabetes group below the papilla was less than the control group. The NFL and NFD of the cornea of the disease group were lower than that of the CNF control group (P0.01). In the diabetic group, the average RNFL was positively correlated with NFL and NFD (r=0.518, P0.01; r=0.484, P=0.002). The loss of nerve fibers and the degree of corneal nerve flexure increased; 2.DCN had a significant correlation with the severity of DR. As the severity of DR increased, DCN was gradually aggravated, and DCN could be used as a predictor of the degree of DR. In 3. diabetic patients, the loss of CNF and RNFL and the thinning of RNFL had been found at the same time when retinal microangiopathy was not found. It is mainly manifested in the lower quadrant. The decrease of CNF is positively correlated with the thinning of RNFL..CNF and RNFL can be used as screening indicators for early intervention of DR.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R587.2;R774.1
本文編號(hào)：2119082
[Abstract]:Background and purpose: diabetes is a global public health problem. Diabetic retinopathy (Diabetic retinopathy, DR) and diabetic corneal neuropathy (Diabetic corneal neuropathy, DCN) are the common microvascular complications of the eyes, and neuropathy.DR is difficult to judge under the uncertainty of the refractive interstitium. The severity of microvascular lesions in the fundus; DCN vivo confocal microscopy (IVCM), due to limited examination, is the only method that can be used to observe the corneal nerve fibers in vivo. Therefore, it is not widely recognized. There is a very close relationship between diabetic systemic neurosis and microvascular complications. Is there a close correlation between the DCN and the DR in the eye? If the two are closely related, DCN can be used as a predictor for the prediction of the difficulty of DR. In addition, early intervention in blood sugar, blood pressure, and blood lipid is important to prevent the development of DR. IVCM has a microcosmic and sensitive examination of the corneal nerve. Characteristics, the damage of the corneal nerve, if it can be detected early in the absence of microvascular lesions, suggests that we intervene DR. as early as possible. There are two aspects of this study. On the one hand, the DCN ultrastructural changes of DR in different periods are observed by IVCM, and the value of IVCM in DCN is confirmed and the severity of the severity of both DCN and DR is explored. On the other hand, whether the changes of corneal nerve fiber (Corneal nerve fibers, CNF) and retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were observed at the same time in the early stage of DR, and whether the changes of the retinal nerve fiber layer (Retinal nerve fibre layer, RNFL) were related, and to provide early screening indicators for intervention DR. The first part: 120 patients (120 eyes) with type 2 diabetes were divided into the no diabetic retinopathy (NDR) group, the mild to moderate non hyperplastic period (mild or moderate non-proliferative diabetic retinopathy, mNPDR) group, and the severe non hyperplastic period (severe). Retinopathy, s NPDR) group and hyperplastic period (proliferative diabetic retinopathy, PDR) group, 30 cases (30 eyes) in each group, and 30 cases (30 eyes) healthy and normal eyes as the control group. The morphological indexes of the corneal subcutaneous nerve fibers were observed by Heidelberg HRT3 IVCM, including the length of the corneal nerve fiber (Nerve fiber), corneal nerve fiber. The density (Nerve fiber density, NFD), the branch density of the corneal nerve fiber (Nerve fiber branch density, NFB) and the corneal nerve flexure (Nerve tortuosity, NT). Second: 40 patients (40 eyes) with type 2 diabetes were collected, and the retinopathy of diabetic retinopathy was not found by the pupil fundus examination. Omography, OCT) and IVCM examination. Another 80 cases of age matched (80 eyes) healthy and normal eyes were collected, divided into 40 cases (40 eyes), RNFL control group with OCT examination and 40 cases (40 eyes), only CNF control group with IVCM examination. Using OCT to observe the upper, inferior, temporal, nasal side and average RNFL thickness of the optic papilla with OCT, and observe the NFL and NFD of the upper cornea with IVCM. Results: the first part: the corneal NFL, NFD, and NFB in all groups of diabetes were lower than those of the control group (P0.01), while the NT flexural degree was higher than the control group (P0.01). With the aggravation of DR, NFL, NFD, NFB gradually decreased (P0.01) and NT increased, but there was no significant difference in the various indexes of the angular membrane nerve between the groups and the groups. The degree was negatively correlated (r=-0.875, -0.866, -0.798, P=0.000,0.000,0.000), NT was positively correlated with DR severity (r=0.693, P=0.000). The second part: there was no significant difference between the optic papilla, the temporal side, the nasal side and the average RNFL and RNFL control groups in the diabetic group (P0.05), but the diabetes group below the papilla was less than the control group. The NFL and NFD of the cornea of the disease group were lower than that of the CNF control group (P0.01). In the diabetic group, the average RNFL was positively correlated with NFL and NFD (r=0.518, P0.01; r=0.484, P=0.002). The loss of nerve fibers and the degree of corneal nerve flexure increased; 2.DCN had a significant correlation with the severity of DR. As the severity of DR increased, DCN was gradually aggravated, and DCN could be used as a predictor of the degree of DR. In 3. diabetic patients, the loss of CNF and RNFL and the thinning of RNFL had been found at the same time when retinal microangiopathy was not found. It is mainly manifested in the lower quadrant. The decrease of CNF is positively correlated with the thinning of RNFL..CNF and RNFL can be used as screening indicators for early intervention of DR.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R587.2;R774.1
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