本文選題：晶狀體 + 人工��； 參考：《河北醫(yī)科大學(xué)》2013年博士論文

【摘要】：角膜散光是一種常見的屈光不正，約有20%的白內(nèi)障患者角膜有不同程度的散光。在白內(nèi)障手術(shù)中控制術(shù)后散光，一直是手術(shù)醫(yī)生關(guān)注的問題。通過白內(nèi)障手術(shù)切口的設(shè)計(jì)可以簡(jiǎn)便有效的矯正低度散光，但這種方法的可預(yù)測(cè)性較差，并且隨著白內(nèi)障手術(shù)技術(shù)的不斷進(jìn)步，手術(shù)切口越來越小，可以提供矯正散光的效果越小。不同技術(shù)的角膜松解切口術(shù)也可以用于手術(shù)中矯正角膜散光，主要缺點(diǎn)是穩(wěn)定性差，有出現(xiàn)角膜穿孔，甚至切口組織溶解的危險(xiǎn)，限制了其在臨床的應(yīng)用。 散光型人工晶狀體（intraocular lens，IOL）是一種將散光的toric面與球面相融合新型屈光型IOL，目前臨床研究表明，Toric IOL能有效地矯正角膜散光提高裸眼視力。對(duì)不規(guī)則的角膜散光-圓錐角膜、角膜移植術(shù)后、角膜外傷瘢痕等，使用Toric IOL仍然能矯正部分散光使患者視力獲得一定程度提高。 復(fù)曲面IOL雖然在屈光度上能有效矯正角膜散光，提高患者視力，但其復(fù)雜的光學(xué)結(jié)構(gòu)使其在很多方面的光學(xué)質(zhì)量仍然存在雙眼徑線成像不等大的融合問題、徑線屈光度差異對(duì)Toric IOL焦深、縱向色差的影響等疑問；同時(shí)Toric IOL不可避免存在偏心、傾斜和散光軸位旋轉(zhuǎn)等位置誤差對(duì)IOL成像質(zhì)量的影響是目前探討的熱點(diǎn)。 隨著波前像差技術(shù)的進(jìn)步人工晶狀體眼的像差的認(rèn)識(shí)及矯正使IOL成像質(zhì)量進(jìn)一步提高，患者的視覺質(zhì)量獲得更大的改善。對(duì)于Toric IOL進(jìn)行光學(xué)結(jié)構(gòu)的改進(jìn)，優(yōu)化球差(sphrecial aberration, SA)，是否能獲得和球面IOL相同的光學(xué)質(zhì)量的提高？由于Toric IOL存在著比旋轉(zhuǎn)對(duì)稱的IOL更多的誤差指標(biāo)，如何使Toric IOL光學(xué)質(zhì)量提高同時(shí)擁有對(duì)誤差更好的耐受性是本研究的目的。 第一部分基于模型眼復(fù)曲面人工晶狀體成像質(zhì)量實(shí)驗(yàn)研究 目的：評(píng)價(jià)復(fù)色光環(huán)境下球面、非球面、Toric IOL的成像質(zhì)量、焦深及縱向色差。 方法：在Zemax光學(xué)設(shè)計(jì)軟件中建立Hwey-Lan Liou模型眼，使用光線追跡法計(jì)算，評(píng)價(jià)TecnisZA9003IOL、SN60AT IOL、Toric IOL復(fù)色光的成像質(zhì)量、縱向色差和焦深。 結(jié)果：復(fù)色光環(huán)境下非球面IOL成像質(zhì)量仍然優(yōu)于球面IOL; ToricIOL與球面IOL有相近的成像質(zhì)量。材料色散系數(shù)小的IOL有較小的縱向色差；球面SN60AT和Toric IOL有相同的縱向色差；短波長(zhǎng)的光線的縱向色差大于長(zhǎng)波長(zhǎng)。球面IOL和Toric IOL隨著瞳孔直徑增大離焦調(diào)整傳遞函數(shù)降低，并且向負(fù)離焦方向偏移；非球面IOL隨著瞳孔直徑增大保持較好的離焦調(diào)制傳遞函數(shù)，但焦深明顯減小。 0小結(jié)：（1）Toric IOL有與球面IOL相近的成像質(zhì)量。（2）Abbe數(shù)越大，IOL的縱向色差越小。（3）Toric IOL、球面IOL和非球面IOL的焦深隨著瞳孔直徑的增大而減��；而且Toric IOL、球面IOL對(duì)負(fù)離焦耐受較好。（4）非球面IOL對(duì)離焦的耐受性較低，焦深較小。 第二部分復(fù)曲面人工晶狀體偏心及旋轉(zhuǎn)對(duì)成像質(zhì)量影響的實(shí)驗(yàn)研究 目的：評(píng)價(jià)Toric IOL旋轉(zhuǎn)偏心對(duì)成像質(zhì)量的影響和波前像差的改變。 方法：模型眼中550nm波長(zhǎng)單色光，研究SN60AT和Toric IOL分別沿從0o~90o每間隔5o子午線從中心偏離，分別偏心0.25mm、0.5mm、0.75mm， Toric IOL在模型眼中旋轉(zhuǎn)3o、5o、7o、10o，評(píng)價(jià)偏心和旋轉(zhuǎn)對(duì)的成像質(zhì)量和波前像差的影響及旋轉(zhuǎn)對(duì)殘留屈光度的影響。 結(jié)果：在IOL居中SN60AT IOL與Toric IOL的成像質(zhì)量非常接近，并且都隨著瞳孔直徑的增大成像質(zhì)量降低；在軸位準(zhǔn)確，散光完全矯正的情況下，Toric IOL偏心不受方向的影響，沿0o~90o各子午線屈光力不同方向偏心時(shí)成像質(zhì)量幾乎保持不變。 SN60AT IOL與Toric IOL隨著偏心增加RMS逐漸增大，主要是彗差的增加，伴隨少量三葉草像差和散光的增加。 隨著Toric IOL旋轉(zhuǎn)的增加，高空間頻率成像質(zhì)量降低明顯；ToricIOL旋轉(zhuǎn)主要引起散光的增大，不伴有高階像差的增加。Toric IOL旋轉(zhuǎn)不但造成殘留散光的增加，還伴有球鏡的增大。 小結(jié)：（1）Toric IOL成像質(zhì)量略低于球面IOL; Toric IOL偏心成像質(zhì)量不受偏心方向的影響，只與偏心量有關(guān)；Toric IOL對(duì)偏心的耐受性與球面IOL非常接近。（2）Toric IOL偏心引起波前像差的變化主要是彗差增加，同時(shí)有少量散光和三葉草像差的增加。（3）Toric IOL旋轉(zhuǎn)帶來散光和球鏡的增加，不伴有高階像差的增加。 第三部分復(fù)曲面人工晶狀體優(yōu)化及對(duì)成像質(zhì)量影響的實(shí)驗(yàn)研究 目的：對(duì)于Toric IOL的球差進(jìn)行優(yōu)化，設(shè)計(jì)不同球差的Toric IOL，并且對(duì)不同球差Toric IOL的旋轉(zhuǎn)、偏心的耐受性及成像規(guī)律進(jìn)行研究。 方法:模型眼中在550nm波長(zhǎng)單色光條件下，對(duì)復(fù)曲面人工晶狀體進(jìn)行兩個(gè)步驟的優(yōu)化：1.復(fù)曲面人工晶狀體球面結(jié)構(gòu)的優(yōu)化，，優(yōu)化函數(shù)設(shè)定人工晶狀體前、后表面曲率半徑和厚度為可變參量，以ZERN函數(shù)第11項(xiàng)C04最小為目標(biāo)進(jìn)行優(yōu)化。2.復(fù)曲面人工晶狀體球差的優(yōu)化，優(yōu)化目標(biāo)設(shè)計(jì)為：-0.26μm、-0.1μm和0μm球差的復(fù)曲面人工晶狀體。優(yōu)化函數(shù)設(shè)定ZERN函數(shù)第11項(xiàng)分別以C04為0μm、0.16μm、0.26μm為目標(biāo)，對(duì)人工晶狀體前表面Q值和2、4階非球面系數(shù)進(jìn)行優(yōu)化。 球面和非球面Toric IOL在模型眼中沿x軸分別偏心0.25mm、0.5mm、0.75mm，評(píng)價(jià)其成像質(zhì)量和波前像差的改變；；旋轉(zhuǎn)3o、5o、7o、10o，評(píng)價(jià)其對(duì)成像質(zhì)量及波前像差影響。 球面和非球面Toric IOL在模型眼中分別在3mm、4mm、5mm瞳孔直徑隨機(jī)偏心0~0.5mm，旋轉(zhuǎn)0o~5o，進(jìn)行1000次模擬，結(jié)果進(jìn)行蒙特卡洛分析。 結(jié)果：居中時(shí)非球面Toric IOL都有非常好的成像質(zhì)量，明顯優(yōu)于球面結(jié)構(gòu)的Toric IOL，隨著瞳孔直徑的增大更加明顯。3mm瞳孔偏心0.25mm，球面和非球面Toric IOL都有與居中時(shí)相近的MTF，對(duì)0.25mm偏心的耐受較好。偏心0.5mm時(shí)，-0.26μm球差的Toric IOL的成像質(zhì)量下降并且低于0μm球差和-0.1μm球差的IOL。偏心0.75mm時(shí)，0μm球差的Toric IOL在中低空間頻率優(yōu)于其他IOL。4mm瞳孔偏心0.25mm時(shí)，-0.1μm球差的Toric IOL成像質(zhì)量最好。偏心0.75mm時(shí)-0.1μm球差的Toric IOL優(yōu)于球面和其他非球面Toric IOL。5mm瞳孔直徑時(shí)，偏心0.25mm時(shí)-0.26μm球差的Toric IOL中低空間頻率優(yōu)于其他Toric IOL，高空間頻率MTF與0μm球差和-0.1μm球差的IOL接近。偏心0.75mm時(shí)-0.26μm球差I(lǐng)OL的MTF與球面Toric IOL接近，0μm球差和-0.1μm球差的IOL略優(yōu)于球面Toric IOL。 小結(jié)：(1)居中時(shí)非球面Toric IOL能有效的提高模型眼的光學(xué)質(zhì)量；-0.26μm球差的Toric IOL成像質(zhì)量最好。(2)存在偏心和旋轉(zhuǎn)誤差時(shí)非球面Toric IOL的成像質(zhì)量仍然優(yōu)于球面Toric IOL，-0.1μm球差的Toric IOL即有較好的成像質(zhì)量，又有較好的對(duì)誤差的耐受性。(3)對(duì)Toric IOL球差適量的優(yōu)化，可以提高模型眼的成像質(zhì)量，同時(shí)保持對(duì)偏心和旋轉(zhuǎn)誤差的耐受性，在綜合情況下獲得更好的光學(xué)質(zhì)量。 第四部分復(fù)曲面人工晶狀體個(gè)體化模型眼成像質(zhì)量的實(shí)驗(yàn)研究 目的：采集患者眼部解剖參數(shù)，利用Zemax光學(xué)設(shè)計(jì)軟件建立個(gè)體化模型眼，研究不同球差的Toric IOL植入后的視覺質(zhì)量。 方法：Pentacam采集患者手術(shù)前的角膜地形圖。IOLMaster測(cè)量患者眼軸長(zhǎng)。Matlab4.5數(shù)學(xué)計(jì)算軟件中采集5×5mm范圍角膜前表面高度圖數(shù)據(jù)使用最小二乘法根據(jù)雙二次曲線方程進(jìn)行擬合，建立前角膜表面散光模型，采集5×5mm范圍角膜后表面高度圖數(shù)據(jù)根據(jù)二次曲線方程擬合建立角膜后表面模型。在Zemax光學(xué)設(shè)計(jì)軟件構(gòu)建個(gè)體化模型眼。散光角膜模型的平坦軸置于y軸，陡峭軸置于x軸；角膜厚度使用該例角膜地形圖中央最薄點(diǎn)厚度數(shù)據(jù)；IOL的前表面置于相應(yīng)的ELP（effective thin-lensposition，ELP）。 在550nm波長(zhǎng)條件下，計(jì)算個(gè)體化模型眼6mm直徑角膜球差（sphericalaberration，SA）。 強(qiáng)光環(huán)境（300Td），瞳孔直徑為3mm；暗光環(huán)境（0.3-1Td），瞳孔直徑為5mm；根據(jù)兩種條件下的神經(jīng)傳遞函數(shù),計(jì)算每一個(gè)模型眼的對(duì)比敏感度。 結(jié)果：個(gè)體化模型眼角膜前表面平坦軸Q值：-0.12±0.22；陡峭軸Q值：-0.12±0.23；后表面Q值：-0.43±0.37；角膜平均球差為：0.23μm±0.18μm（-0.15μm~0.42μm）。 強(qiáng)光環(huán)境非球面Toric IOL的RMS和球差都優(yōu)于球面IOL；全矯球差的Toric IOL對(duì)比敏感度在各空間頻率都優(yōu)于其他IOL。暗光環(huán)境非球面Toric IOL的RMS和球差也優(yōu)于球面IOL；全矯球差的Toric IOL在中高空間頻率都優(yōu)于其他IOL，低空間頻率與其他球差的非球面Toric IOL對(duì)比敏感度差異無統(tǒng)計(jì)學(xué)意義。 小結(jié)：（1）角膜高度數(shù)據(jù)對(duì)雙二次曲面公式的擬合可以準(zhǔn)確建立角膜散光模型。（2）非球面Toric IOL能有效的抵消散光角膜球差，提高個(gè)體化模型眼大部分空間頻率的對(duì)比敏感度。 結(jié)論： 1Toric IOL與球面IOL有相近的成像質(zhì)量及離焦特性。 2Toric IOL與球面IOL對(duì)偏心的耐受性也相近。偏心造成波前像差的變化主要是彗差的增加。Toric IOL的旋轉(zhuǎn)主要造成散光的增加，不引入高階像差。 3對(duì)Toric IOL球差適量的優(yōu)化，可以提高的成像質(zhì)量，同時(shí)保持對(duì)偏心和旋轉(zhuǎn)誤差的耐受性，在綜合情況下獲得更好的光學(xué)質(zhì)量。 4角膜高度數(shù)據(jù)對(duì)雙二次曲面公式的擬合可以準(zhǔn)確建立個(gè)體化角膜散光模型。
[Abstract]:The corneal astigmatism is a common refractive error , and about 20 % of the cataract patients have different degrees of astigmatism .

The astigmatic intraocular lens ( IOL ) is a new type of refractive - type IOL combining astigmatism with spherical phase . At present , the clinical study shows that the Toric IOL can effectively correct corneal astigmatism and improve the visual acuity of the naked eye . The Toric IOL can correct some astigmatism after the irregular corneal astigmatism - cone cornea , corneal transplantation , corneal trauma scar , etc . The patient ' s vision is improved to a certain extent .

Although the complex surface IOL can effectively correct corneal astigmatism and improve the visual acuity of the patient , the complex optical structure still has large fusion problems such as binocular radial line imaging in many aspects , and has some doubts about the influence of the refractive power difference on the focal depth and longitudinal chromatic aberration of the Toric IOL ;
At the same time , the influence of position error such as eccentricity , tilt and optical axis position on IOL imaging quality is inevitable in Toric IOL .

With the improvement of the optical structure of the Toric IOL , it is an object of this study to improve the optical quality of the Toric IOL and to improve the tolerance of the Toric IOL at the same time .

Experimental study on the imaging quality of the first part based on the model eye complex curved surface intraocular lens

Objective : To evaluate the imaging quality , focal depth and longitudinal chromatic aberration of spherical , aspheric , Toric IOL in complex light environment .

Methods : The image quality , longitudinal chromatic aberration and focal depth of the TecnisZA9003IOL , SN60AT IOL , Toric IOL composite light were evaluated by using the ray tracing method in the Zemax optical design software .

Results : The imaging quality of aspheric IOL was still superior to that of spherical IOL in compound light environment . Toric IOL had similar imaging quality with spherical IOL . IOL with small material dispersion coefficient had smaller longitudinal chromatic aberration ;
spherical SN60AT and Toric IOLs have the same longitudinal chromatic aberration ;
the longitudinal chromatic aberration of the short wavelength light is greater than the long wavelength . The spherical IOL and the Toric IOL are reduced from the focus adjustment transfer function with the pupil diameter and are shifted towards the negative focus direction ;
The aspheric IOL maintains a better off - focus modulation transfer function as the pupil diameter increases , but the depth of focus is significantly reduced .

( 2 ) The larger the Abbe number , the smaller the longitudinal chromatic aberration of the IOL . ( 3 ) The focal depth of the Toric IOL , the spherical IOL and the aspherical IOL decreases with the increase of the pupil diameter ;
( 4 ) The tolerance of the aspheric IOL to the defocus is low and the depth of the focal depth is smaller .

Experimental study on the influence of the eccentricity and rotation of the second part complex curved intraocular lens on the imaging quality

Objective : To evaluate the effect of Toric IOL rotation eccentricity on imaging quality and the change of wavefront aberration .

Methods : The 550 nm wavelength monochromatic light was observed in the model eye . The SN60AT and Toric IOL were deviated from the center along the 5o meridian from 0o to 90o , respectively , eccentric 0.25 mm , 0.5 mm , 0.75 mm , and Toric IOL were rotated 3o , 5o , 7o , 10o in the eye of the model . The effects of eccentricity and rotation on the imaging quality and wavefront aberration and the effect of rotation on residual power were evaluated .

Results : The imaging quality of the IOL centered SN60AT IOL was very close to the imaging quality of the Toric IOL and decreased with increasing pupil diameter ;
Under the condition that the axial position is accurate and the astigmatism is completely corrected , the eccentricity of the Toric IOL is not influenced by the direction , and the imaging quality is almost unchanged when the optical power of each meridian of 0o - 90o is eccentric in different directions .

The SN60AT IOL and the Toric IOL gradually increase with the increase of the eccentricity , mainly the increase of coma , accompanied by a small amount of clover aberration and the increase of astigmatism .

With the increase of Toric IOL rotation , the quality of high spatial frequency imaging was reduced ;
Toric IOL rotation mainly results in an increase in astigmatism , not accompanied by an increase in higher order aberrations . Toric IOL rotation not only results in an increase in residual astigmatism but also an increase in the spherical mirror .

Summary : ( 1 ) The imaging quality of the Toric IOL is slightly lower than that of the spherical IOL ; the eccentric imaging quality of the Toric IOL is not affected by the eccentric direction , and is only related to the eccentric amount ;
Toric IOL ' s tolerance to eccentricity is very close to the spherical IOL . ( 2 ) The variation of wavefront aberration caused by the eccentricity of the Toric IOL is mainly the increase of coma aberration , while a small amount of astigmatism and the increase of the aberration of clover . ( 3 ) Toric IOL rotation brings astigmatism and increased spherical mirror , without the increase of higher order aberration .

Experimental study on the optimization of the third part complex curved surface intraocular lens and its effect on imaging quality

Objective : To optimize the spherical aberration of Toric IOL and to design Toric IOL with different spherical aberration .

Methods : In the eye of the model , the optimization of two steps : 1 . The optimization of the spherical structure of the complex curved lens was carried out . The curvature radius and thickness of the anterior and posterior surface of the artificial lens were optimized by the optimization function . The optimal objective was as follows : - 0.26 渭m , - 0.1 渭m and 0 渭m spherical aberration . The optimal objective was designed as : - 0.26 渭m , - 0.1 渭m and 0 渭m spherical aberration .

The spherical and aspheric Toric IOLs were respectively eccentric 0.25 mm , 0.5 mm and 0.75 mm in the eye of the model along the x - axis , and the imaging quality and wavefront aberration were evaluated .
Rotate 3o , 5o , 7o , 10o to evaluate its impact on imaging quality and wavefront aberration .

The spherical and non - spherical Toric IOLs were randomly eccentric 0 ~ 0.5mm and rotated 0o ~ 5o at 3mm , 4mm , 5mm pupil diameter in the eyes of the model . The results were analyzed by Monte Carlo .

Results : Toric IOLs with spherical aberration of 0.25 mm and 0 渭m were superior to those of other Toric IOLs in the middle and low spatial frequencies .

Summary : ( 1 ) The aspheric Toric IOL can effectively improve the optical quality of the model eye .
( 2 ) The imaging quality of the aspheric Toric IOL is superior to that of spherical Toric IOL , - 0.1 渭m spherical aberration Toric IOL , which is superior to spherical Toric IOL , - 0.1 渭m spherical aberration Toric IOL , which has better imaging quality and better tolerance to error .

Experimental study on the quality of eye imaging of the fourth part complex curved intraocular lens

Objective : To study the visual quality of Toric IOL implanted with different spherical aberration by using Zemax optical design software to establish a personalized model eye .

Methods : The corneal topography before operation was collected from Pentacam . The corneal anterior surface height map data collected in the Matlab4.5 mathematical calculation software was fitted with the biquadratic curve equation . The corneal posterior surface model was established by fitting the corneal posterior surface height map data with the quadratic curve equation .
the thickness of the cornea is the thinnest point thickness data of the cornea topography of the case ;
the anterior surface of the iol is placed in a corresponding elp ( effective thin - position position , elp ) .

The spherical aberration ( SA ) of 6 mm diameter was calculated at 550 nm wavelength .

Strong light environment ( 300Td ) , pupil diameter is 3mm ;
Dark light environment ( 0.3 -1Td ) , pupil diameter is 5mm ;
The contrast sensitivity of each model eye was calculated based on the nerve transfer function under both conditions .

Results : The Q value of the anterior surface of the corneal anterior surface was 0.12 鹵 0.22 ;
The Q value of the steep axis is - 0.12 鹵 0.23 ;
Rear surface Q value : - 0.43 鹵 0.37 ;
The mean spherical aberration of cornea was 0.23 渭m 鹵 0.18 渭m ( - 0.15 渭m ~ 0.42 渭m ) .

The RMS and spherical aberration of the aspheric Toric IOL in the strong light environment are superior to those of the spherical IOL ;
Toric IOL contrast sensitivity was superior to other IOLs at all spatial frequencies . The RMS and spherical aberration of aspheric Toric IOLs were also superior to spherical IOLs .
Toric IOLs with all - corrected spherical aberration were superior to other IOLs at medium and high spatial frequencies , with no statistically significant difference in contrast sensitivity between low spatial frequencies and other spherical Toric IOLs .

Conclusion : ( 1 ) The fitting of the corneal height data to the double quadratic surface formula can accurately establish the corneal astigmatism model . ( 2 ) The aspheric Toric IOL can effectively counteract the astigmatic corneal spherical aberration and improve the contrast sensitivity of the most spatial frequency of the individual model eye .

Conclusion :

The 1 Toric IOL has similar imaging quality and defocus characteristics to the spherical IOL .

The tolerance of the 2Toric IOL and the spherical IOL is similar to that of the spherical IOL . The change of the wavefront aberration caused by eccentricity is mainly the increase of coma aberration . The rotation of the Toric IOL mainly causes the increase of astigmatism and does not introduce higher order aberrations .

3 To optimize the spherical aberration of Toric IOL , the quality of imaging can be improved , while the tolerance of eccentricity and rotational errors can be maintained , and better optical quality can be obtained under comprehensive circumstances .

The fitting of the corneal height data to the double quadratic surface formula can accurately establish the individualized corneal astigmatism model .

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R779.66

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