發(fā)布時(shí)間：2018-02-09 05:28

  本文關(guān)鍵詞： DDLS/視盤損害分級(jí)法 視野 光學(xué)斷層相干掃描 慢性閉角型青光眼 房角分級(jí) 眼壓　出處：《第三軍醫(yī)大學(xué)》2011年碩士論文　論文類型：學(xué)位論文

【摘要】：背景：中國(guó)人有2000萬(wàn)人以上青光眼患者,以原發(fā)性閉角型青光眼(Primary angle-closure Glaucoma,PACG)為主,其中原發(fā)性慢性閉角型青光眼(Primary chronic angle-closure glaucoma,PCACG)又占PACG總數(shù)的60%以上,視神經(jīng)乳頭(optical nerve head,ONH)客觀形態(tài)學(xué)檢查及(retina nerve fiber layer,RNFL)厚度變化的評(píng)估對(duì)青光眼的診斷與治療尤為重要,目前在國(guó)際上尚無(wú)統(tǒng)一的對(duì)青光眼性的ONH損害診斷標(biāo)準(zhǔn)。 視杯視盤比率(cup disc ratio, C/D)是使用最廣泛的視盤損害評(píng)估指標(biāo),但由于其測(cè)量值本身很不統(tǒng)一,而且視杯、視盤大小在人群中的差異很大,不能作為對(duì)青光眼定性和量化的一種可靠指標(biāo),單純用C/D判斷青光眼ONH損害很容易漏診和誤診。計(jì)算機(jī)輔助的客觀儀器能較為精確的對(duì)RNFL厚度及盤沿面積的檢測(cè),但是它們無(wú)法直觀觀測(cè)視盤盤沿形態(tài),視盤大小及其視乳頭顏色變化,難以判斷個(gè)體間的正常變異,此外,也難以鑒別非青光眼性視神經(jīng)損害導(dǎo)致RNFL丟失。針對(duì)以上不足Spaeth等提出青光眼ONH形態(tài)學(xué)損害的檢查需要結(jié)合視盤直徑大小及盤沿形態(tài)分析,并提出ONH損害分級(jí)法(disc damage likelihood scale,DDLS)對(duì)青光眼視神經(jīng)形態(tài)學(xué)描述。 DDLS分級(jí)法能對(duì)開角型青光眼(primary open angle glaucoma,POAG)視神經(jīng)損害進(jìn)行評(píng)估,在臨床上,PCACG與POAG視神經(jīng)損害具有相似性,該方法能否適用于PCACG視神經(jīng)損害評(píng)估迄今尚不明確。 本課題從以下方面進(jìn)行研究以期望擴(kuò)大DDLS分級(jí)方法臨床運(yùn)用范圍,并利用該分級(jí)方法指導(dǎo)PCACG的臨床治療,為后期臨床運(yùn)用提供研究依據(jù)。 一、合理規(guī)范臨床課題設(shè)計(jì),收集PCACG患者； 二、運(yùn)用DDLS分級(jí)法對(duì)視盤形態(tài)進(jìn)行分級(jí),與OCT視盤檢查參數(shù),視野變化值進(jìn)行相關(guān)性研究； 三、DDLS分級(jí)對(duì)PCACG臨床治療的指導(dǎo)。 目的： 1.探討DDLS分級(jí)值與OCT檢測(cè)視盤參數(shù)及視野(visual field, VF)變化的相關(guān)性,評(píng)估DDLS方法對(duì)PCACG視神經(jīng)損害可行性。 2.運(yùn)用DDLS分級(jí)對(duì)照房角分級(jí)指導(dǎo)PCACG臨床治療,觀察激光虹膜周切術(shù)(lase periperal iridotomy, LPI)、LPI聯(lián)合藥物治療及小梁切除手術(shù)三種治療方式對(duì)PCACG的眼壓控制情況,評(píng)估DDLS指導(dǎo)臨床治療的有效性。 對(duì)象與方法： 1、收集我院2008年12月—2011年03月PCACG患者病例,運(yùn)用Volk 90D前置鏡在裂隙燈下對(duì)視盤直徑及其盤沿最窄處寬度測(cè)量,按DDLS分級(jí)評(píng)分；Stratus OCT3000成像儀RNFL 3.4掃描程序?qū)σ暠P檢測(cè)獲取各象限、鐘點(diǎn)位及自選參數(shù)的RNFL厚度,視盤面積等參數(shù)；Humphrey視野計(jì)(humprey field analyzer,HFA)242程序(Swedish Interactive Threshold Algorithm standard,SITA 24-2)檢查視野變化,獲得平均缺損(mean deviation, MD)、模式標(biāo)準(zhǔn)差(pattern standared deviation, PSD)值。運(yùn)用SPSS15.0分析DDLS評(píng)分值、OCT視盤檢測(cè)參數(shù)、視野值的相關(guān)關(guān)系。 2、將PCACG患者隨機(jī)分為兩組,DDLS分級(jí)指導(dǎo)臨床治療組(實(shí)驗(yàn)組)與房角分級(jí)指導(dǎo)臨床治療組(對(duì)照組),DDLS分級(jí)分三階段,第一階段對(duì)照房角1800范圍且眼壓≥21mmHg,MD-6組接受LPI治療；第二階段對(duì)照房角1800范圍且眼壓≥21mmH-6≤MD-12組接受LPI聯(lián)合藥物治療；第三階段對(duì)照房角≥1800范圍,眼壓≥21mmHg,伴視野MD≥-12接受小梁切除手術(shù)治療,觀察兩組治療前后眼壓變化情況,運(yùn)用logistic回歸分析檢驗(yàn)兩組間關(guān)系,評(píng)估實(shí)驗(yàn)組指導(dǎo)臨床治療的有效性。 結(jié)果： 1.第二部分對(duì)例20例(38眼)結(jié)果進(jìn)行分析,大直徑視盤3眼(占7.9%),中等直徑視盤11眼(占28.9%),小直徑視盤24眼(占63.2%)；上方、下方、顳側(cè)象限RNFL厚度均值與DDLS分級(jí)評(píng)分相關(guān)(r=-0.673,P=0.0001；r=-0.605,P=0.0001,r=-0.499,P=0.0014),鼻側(cè)方象限RNFL厚度均值與DDLS分級(jí)評(píng)分不相關(guān)(r=-0.352,P=0.0602)；11、7、6、10、12鐘點(diǎn)位RNFL厚度與DDLS分級(jí)評(píng)分具有相關(guān)性(r=-0.673,P=0.0001；r=-0.605,P=0.0001；r=-0.531,P=0.0006；r=-0.525,P=0.0007；r=-0.520,P=0.0008),而3、2、8點(diǎn)位無(wú)統(tǒng)計(jì)學(xué)意義(r=-0.320,P=0.0501；r=-0.320,P=0.0510；r=-0.297,P=0.0702,)；DDLS分級(jí)評(píng)分與OCT檢查自選參數(shù)Avg、Smax、Imax的RNFL厚度也呈中度相關(guān)(r=-0.582,P=0.0001；r=-0.504,P=0.0012；r=-0.478,P=0.0024)。DDLS分級(jí)評(píng)分與OCT檢測(cè)視盤面積結(jié)果顯示相關(guān),下方區(qū)域相關(guān)系數(shù)最高(r=-0.878,P0.0001；r=-0.730,P0.0001)。DDLS分級(jí)評(píng)分與視野檢測(cè)結(jié)果顯示：DDLS評(píng)分與視野MD相關(guān)(r=-0.593,P0.0001),與PSD值相關(guān)(r=-0.60,P0.0001),OCT檢測(cè)參數(shù)與視野檢測(cè)結(jié)果顯示,全盤沿面積呈中度相關(guān)(r=-0.53,p0.0001),盤沿與視盤比率均與視野MD值呈低度相關(guān),水平方向盤沿面積與視野MD值無(wú)統(tǒng)計(jì)意義(r=-0.02,P=0.058)。 2.第三部分DDLS組29例(54眼),患者平均年齡(50.7±9.8)歲,房角組28例(53眼),患者平均年齡(52.2±10.1)歲；logistic回歸分析提示DDLS組與房角組分別接受的三種臨床治療方式組間統(tǒng)計(jì)無(wú)顯著差異(OR=0.81,p=0.624),小梁切除術(shù)優(yōu)于LPI(OR=4.88,P=0.0075),LPI聯(lián)合藥物與LPI之間無(wú)見統(tǒng)計(jì)學(xué)差異(OR=2.39,P=0.0946),小梁切除術(shù)組較其他兩種治療方式更為有效控制眼壓(OR=4.88,P=0.0075)。即兩種方法對(duì)治療的臨床指導(dǎo)無(wú)顯著差別,而不同治療方式對(duì)眼壓控制療效影響有統(tǒng)計(jì)學(xué)差異。 結(jié)論： 1、DDLS分級(jí)方法對(duì)PCACG視神經(jīng)損害的評(píng)估與OCT視盤主要檢查參數(shù)及視野檢查具有相關(guān)性,DDLS分級(jí)方法適用于PCACG視神經(jīng)損害的評(píng)估。 2、DDLS組與房角組對(duì)眼壓控制的有效率無(wú)統(tǒng)計(jì)學(xué)差異,DDLS分級(jí)指導(dǎo)PCACG臨床治療是對(duì)房角分級(jí)指導(dǎo)臨床治療的有益補(bǔ)充。
[Abstract]:Background: Chinese has more than 20 million glaucoma patients, with primary angle closure glaucoma (Primary angle-closure Glaucoma, PACG), the primary chronic angle closure glaucoma (Primary chronic angle-closure glaucoma, PCACG and PACG) accounted for 60% of the total. The optic papilla (optical nerve head, ONH) objective morphological examination (retina nerve and fiber layer, RNFL) diagnosis and treatment evaluation of thickness variation of glaucoma is particularly important, standards for glaucoma ONH damage diagnosis in the world at present there is no uniform.
Optic disc cupping ratio (cup disc ratio, C/D) is the most widely used disc damage assessment indicators, but because the measurement value itself is not unified, and the optic cup, differences in the size of the disc in the crowd, not as a reliable indicator of qualitative and quantitative glaucoma, only C/D in determining glaucoma ONH damage it is easy to misdiagnosis. The objective of computer aided detection instrument of RNFL thickness and rim area accurately, but they are unable to visually observe the morphology of optic disc, the size of the disc and optic color change, it is difficult to determine the normal variation between individuals, in addition, it is difficult to identify non glaucomatous optic nerve damage the loss of RNFL. To solve the above problem proposed by Spaeth in glaucoma ONH morphological examination need along the morphological analysis with optic disc diameter size and disk, and puts forward the classification method of ONH (disc damage likelih damage Ood scale, DDLS) the morphological description of optic nerve in glaucoma.
DDLS grading can evaluate the optic nerve damage of primary open angle glaucoma (POAG). In clinic, PCACG and POAG have similar optic nerve damage. Whether the method can be applied to evaluate the optic nerve damage of PCACG is not clear.
This research is conducted from the following aspects, hoping to expand the clinical application scope of DDLS classification method, and use this grading method to guide the clinical treatment of PCACG, so as to provide a basis for later clinical application.
First, we should standardize the design of clinical subjects and collect PCACG patients.
Two, the DDLS classification method was used to classify the optic disc morphology, and the correlation of the OCT disc examination parameters and the visual field values was studied.
Three, DDLS classification for the guidance of PCACG clinical treatment.
Objective:
1. the correlation between DDLS classification value and OCT detection of visual disc parameters and the changes of visual field (VF) was investigated, and the feasibility of DDLS method for PCACG optic nerve damage was evaluated.
2. using DDLS grading control angle to guide the clinical treatment of grade PCACG, observation of laser iridectomy (lase Periperal, iridotomy, LPI), three kinds of treatment of surgery intraocular pressure control of PCACG LPI resection combined with drug treatment and evaluation of DDLS beam, guide the clinical treatment is effective.
Objects and methods:
1, collected in our hospital from December 2008 to 2011 03 PCACG cases, the use of Volk 90D lens under slit lamp on the diameter of the optic disc along the narrowest width measurement score according to DDLS classification; Stratus OCT3000 imager RNFL 3.4 scanning program for each quadrant of the optic disc detection, the clock points and optional parameters of RNFL thickness and disc area parameters; Humphrey perimetry (humprey field analyzer, HFA) 242 (Swedish Interactive Threshold Algorithm standard program, SITA 24-2) to check the view changes, obtain the mean defect (mean deviation, MD), pattern standard deviation (pattern standared, deviation, PSD). Using SPSS15.0 analysis DDLS score, OCT video detection correlation between parameters, view value.
2 PCACG patients were randomly divided into two groups, DDLS grade guide clinical treatment group (experimental group) and angle classification to guide the clinical treatment group (control group), DDLS grade is divided into three stages, the first stage of the control angle range of 1800 and the pressure is larger than 21mmHg, MD-6 group received LPI treatment; the second phase angle control 1800 and the range of intraocular pressure is greater than or equal to 21mmH-6 = MD-12 group received LPI combined with drug therapy; third stage control angle is greater than or equal to 1800, the intraocular pressure is larger than 21mmHg, with the view of MD more than -12 accepted trabeculectomy surgery, to observe the changes of intraocular pressure before and after treatment in two groups, using logistic regression analysis to test the relationship between the two groups, the experimental group assessment guide the effectiveness of clinical treatment.
Result錛，

本文編號(hào)：1497185