【摘要】 目的：观察正常眼和临床前期原发性闭角型青光眼（primary angleclosure glaucoma, PACG）的海德堡视网膜断层扫描仪（HRTⅡ）视盘参数、视网膜神经纤维层厚度和Humphrey视野计视野指数，并观察预防手术对其影响。方法：PACG临床前期患者57例57眼，其中41例41眼经青光眼干预性处理（手术或激光周边虹膜切开）为T组，另16眼不进行干预性治疗为U组，正常对照（NC）30例60眼，NC组和T组眼在治疗前（0mo）和治疗后6mo时、U组眼在首诊时（0mo）和6mo后分别进行眼科常规检查、HRTⅡ和Humphrey视野计检查。获得视力、眼压、房角、视杯面积(cup area, CA)、视盘面积(disk area, DA)、盘沿面积(rim area, RA)、视杯容积(cup volume, CV)、盘沿容积(rim volume, RV)、杯盘面积比(cup/disk area ratio, CDAR)、线性杯盘比(linear cup/disk ratio, LCDR)、平均视杯深度(mean cup depth, MCD)、最大视杯深度(maximum cup depth, max CD)、视杯形态测量（cup shape measure, CSM）、视杯高度变异轮廓（height variation contour, HVC）、平均视网膜神经纤维层厚度(mean RNFL thickness, MRNFLT)、视神经纤维层横截面积（RNFL cross sectional area）和平均视野缺损（MD）等参数，对比分析NC组和T组眼0mo和6mo时、U组眼在0mo和6mo后的各参数的差异。 结果：NC组、T组眼0mo和U组眼0mo之间的视力和眼压差异无统计学意义，T组0mo、6mo和U组0mo、6mo视力、眼压和房角宽度变化差异无统计学意义。NC组和T组眼0mo之间MD差异无统计学意义，而HRTⅡ的CA、RA、CV、CDAR、CSM、HVC、MRNFLT和RCSA存在差异（P＜0.05）。T组眼MD绝对值增加率[48.61%(27.67%)]比U组[66.18%(21.33%)]低（P＜0.05），CA的增加率要小于U组的增加率（P＜0.05），相应，RA的减小幅度要低于U组（P＜0.05），T组6mo CDAR较U组6mo小（P＜0.05）。U组6 mo的CSM、HVC、MRNFLT较T组6mo小（P＜0.05）。结论：选择激光或单纯虹膜周边切除的干预性治疗可以延缓临床前期PACG的进展。
【关键词】 青光眼；预防性手术；视野；视网膜神经纤维层
Effect of prophylactic surgeries on HRTⅡ parameters and visual field of preclinical primary closedangle glaucoma patients
Bin Guo1, 2, XinGuang Yang2, QinHua Fan1, Zhao Liu3, JingNi Yu2, Li Chen2, Hua Ai2
Foundation item: Health Department Research Foundation of Shaanxi Province, China (No.06D17)
1Department of Ophthalmology, No.81 Hospital of PLA, Nanjing 210002, Jiangsu Province, China; 2Shaanxi Ophthalmic Medical Center, the Fourth Hospital of Xian City, Xian 710004, Shaanxi Province, China; 3College of Medicine, Xian Jiaotong University, Xian 710061, Shaanxi Province, China
AbstractAIM: To study the structural parameters of the optic nerve head and the retinal nerve fiber layer (RNFL) obtained by using Heidelberg Retina TomographII (HRTII) and the perimetric indices of Humphrey perimetry in normal and preclinical primary closedangle glaucoma (PACG) subjects and to observe the effect of prophylactic surgeries on these parameters of the preclinical PACG patients.
METHODS: Fiftyseven patients (57 eyes) and 30 healthy subjects (60 eyes) were enrolled in the study and classified into 3 separate groups: 60 healthy eyes for normal control, 41 PACG eyes to undergo preventive peripheral iridectomy with or without laser, 16 PACG eyes untreated with surgery. Of the normal control eyes, 41 PACG eyes treated with surgery before treatment and 6 months after treatment and 16 PACG eyes untreated at the first diagnosis and 6 months later were examined with ophthalmic routine examinations, HRTII and Humphrey perimetry. Visual acuity, intraocular pressure, anterior chamber angle width and cup area (CA), disk area (DA), rim area (RA), cup volume (CV), rim volume (RV), cup/disk area ratio (CDAR), linear cup/disk ratio (LCDR), mean cup depth (MCD), maximum cup depth (MaxCD), cup shape measure (CSM), height variation contour (HVC), mean RNFL thickness (MRNFLT), RNFL cross sectional area (RCSA) and mean defect (MD) values were obtained from the result reports. The differences of parameters between normal eyes, 41 treated PACG eyes of pre and posttreatment and 16 untreated PACG eyes at the first diagnosis and 6 months later were comparatively analyzed with statistic software.
RESULTS: Among the normal control group, the treated PACG group before surgery and the untreated PACG group at the first diagnosis, there were no significant differences of visual acuity and intraocular pressure. No statistically significant differences of visual acuity, intraocular pressure and the change of anterior chamber angle width were observed between pre and posttreatment of the treated PACG group and between at the first diagnosis and 6 months later of the untreated PACG group. The MD value was not different between the normal control group and the pretreated PACG group, but there was significant differences of CA, RA, CV, CDAR, CSM, HVC, MRNFLT and RCSA in HRTII between them (P<0.05). By the comparison between the PACG group of 6 months after treatment [48.61% (27.67%)] and the untreated group after 6 months of followup [66.18% (21.33%)], the preventive surgeries decreased the increasing rate of MD absolute value (P<0.05). The increasing rate of CA in treated PACG group was lower than that in untreated group (P<0.05), while the decreasing rate of RA in treated PACG group was lower than that in untreated group (P<0.05). The CDAR value in the PACG group with 6 months of treatment was lower than that in the untreated group after 6 months of followup (P<0.05). The CSM, HVC and MRNFLT values in the untreated group after 6 months of followup were less than those in the PACG group with 6 months of treatment (P<0.05).
CONCLUSION: The prophylactic (laser) peripheral iridectomy can delay the progression of preclinical PACG.
KEYWORDS: glaucoma; prophylactic surgery; visual field; nerve fiber layer
Guo B, Yang XG, Fan QH, et al. Effect of prophylactic surgeries on HRTⅡ parameters and visual field of preclinical primary closedangle glaucoma patients. Int J Ophthalmol(Guoji Yanke Zazhi)2008;8(11):22442247
0引言
青光眼是眼科常见的不可逆性致盲性眼病之一，和所有视神经疾病一样最终导致视网膜神经节细胞死亡，临床表现为不可逆、进行性的视功能损害[13]。由于青光眼致盲的严重性，且为不可逆性视功能损害，很多传统方法在检测出青光眼的视神经病变时往往已经到病变晚期，错过有效的检出时机，多年来许多学者对其早期诊断、治疗进行了多方面的探讨和尝试，也出现了许多诊断方法和标准，这些新方法仍在围绕着眼压、杯盘、视野等指标进行改进[47]。海德堡视网膜断层扫描仪（HRTⅡ）参数能较准确反映与视野损害相一致的视盘变化，其中尤以杯盘面积比、盘沿面积、视杯形态测量、平均视网膜神经纤维厚度及视网膜神经纤维层横断面积测量值较为准确[8]。而且对于早期视盘变化的检测有较高的特异性和灵敏度[6,912]。我们采用HRTⅡ和Humphrey视野计观察原发性闭角型青光眼临床前期的患眼自然病程和采用手术或激光等干预对其影响。
1对象和方法
1.1对象 2006 09/2007 09 PACG患者57例57眼，其中41例41眼经干预性处理（手术或激光周边虹膜切开）为治疗组（T），男17例17眼，女24例24眼，年龄49.3±15.4岁；另16例16眼未经干预性治疗为未治疗组（U），男11例11眼，女5例5眼，年龄54.4±7.4岁。正常对照眼（NC）为未查出眼病的体检人员30例60眼，女13例26眼，男17例34眼；年龄52.1±16.6岁。NC组、T组在治疗前（0mo）和6mo时、U组在首诊时（0mo）和随访6mo后分别进行眼科常规检查、HRTⅡ和Humphrey视野计检查。纳入标准：（1）年龄大于18岁；（2）双眼最佳矫正视力≥0.5；（3）双眼屈光度6.00～+6.00D，屈光参差<3.00D；（4）除屈光不正外无其他眼病；（5）双眼眼压均＜21mmHg，双眼C/D＜0.3且双眼差值＜0.2；（6）标准自动静态视野检查正常MD≤1dB且无青光眼视野改变特征(固视丢失率＜20%、假阳性率＜33%)。排除标准：（1）有糖尿病病史或控制不佳的高血压病史；（2）有青光眼家族史；（3)具有如下1个或多个视野表现：视野检查结果不可靠(假阳性率＞33%，固视丢失率＞20%)；或视盘有出血、盘沿切迹或盘沿变窄，视盘周围有视网膜脉络膜萎缩区；或双眼C/D比值差0.2以上；（4）伴有其他活动性眼病；（5）先天性眼部异常；（6）曾行眼内手术(包括白内障)；（7）曾行视网膜手术(包括外垫压及视网膜光凝)。PACG患者临床前期诊断标准：1眼已发生急性（或慢性）闭角型青光眼，另1眼前房角窄患者；或闭角型青光眼家族史合并前房浅及房角窄而无任何自觉症状，但激发试验阳性患者。排除标准：(1)近视度数＞5.00D；(2)屈光间质混浊明显，影响视盘图像质量者；(3)身体健康状况较差或理解力困难无法进行视野检查者。NC组屈光度为(0.73±1.24)D，T组屈光度为(1.95±2.54)D，U组屈光度为(1.33±1.74)D。各组年龄和屈光度经ANOVA检验分析，各组差异无统计学意义（F年龄=1.561，P年龄＞0.05；F屈光度=0.745，P屈光度＞0.05）。
1.2 方法 研究对象分别进行视力、屈光度、眼压、裂隙灯显微镜检查。视力检查采用国际标准视力表在同样照明条件下进行，并换算成对数视力（log MAR）进行统计学分析。屈光度采用全自动验光仪器检测。眼压测量用Canon TXF非接触眼压计进行眼压检查，3次测量取平均值，用裂隙灯显微镜和房角镜检查眼前段及房角情况，房角宽度按照Scheie法进行分级。
1.2.1 视野 Humphrey750型自动视野计（Zeiss公司，德国），采用中心302检查程序，I号白色视标，76个刺激点、背景光为31.5 asb，生理盲点固视监控，整个过程通过计算机处理后给出视野检查结果，全部受检查者固视丢失率≤20％，假阳性率＜33％，假阴性率＜33％，符合该仪器可靠标准。所有受检者均接受1次以上的自动视野模拟检查，受检前先在暗室中适应5～10min，自然瞳孔状态下进行检查。有屈光不正者选用合适的矫正镜片。视野异常的判断标准：相邻3个点敏感度下降≥5dB，其中1个点敏感度下降至少10dB；相邻2个点敏感度下降≥10dB；鼻侧水平子午线上下有相邻3个点的敏感度下降10dB。所有检测位点实际上所检测得到的阈值平均数与同年龄组正常组平均数之间的差值为平均视野缺损值（mean defect, MD）。
1.2.2 HRTⅡ 海德堡视网膜断层扫描仪（Heidelberg公司，德国)，软件版本IR1V1.7/49.5。检查范围设置为 表1PACG组视野参数和HRTⅡ参数M(QR)15°×15°，扫描深度范围为0.5～4mm，屈光度数调节范围为±12.00D。检查时被检查者不散瞳，坐位，非检查眼注视眼前注视目标，通过照相机前面的透镜来正确设置受检者眼睛的屈光，照相机镜头位于被检眼前15mm处，调节受检者颌托和激光扫描照相机之间的位置，使激光束正好从受检者瞳孔中心穿过，此时受检者应当看到照相机内部闪烁的绿点，按下记录按钮，HRTⅡ自动获取三次图像系列。成功获取图像后，由同一操作者使用鼠标描绘视盘轮廓线，得出视盘结构诸参数。计算机显示出以下参数[13]：视杯面积(cup area, CA)、视盘面积(disk area, DA)、盘沿面积(rim area, RA)、视杯容积(cup volume, CV)、盘沿容积(rim volume, RV)、杯盘面积比(cup/disk area ratio, CDAR)、线性杯盘比(linear cup/disk ratio, LCDR)、平均视杯深度(mean cup depth, MCD)、最大视杯深度(maximum cup depth, max CD)、视杯形态测量（cup shape measure, CSM）、视杯高度变异轮廓（height variation contour, HVC）、平均视网膜神经纤维层厚度(mean RNFL thickness, MRNFLT)、视神经纤维层横截面积（RNFL cross sectional area）等，并对数据进行进一步分析。
统计学处理：方差齐性时数据用均数±标准差(±s)表示，方差不齐时数据用中位数(四分位数间距)〔M(QR)〕表示，各组间的检测参数采用ANOVA（方差齐性）或KruskalWallis H检验（方差不齐性）。对于各组的房角分级变化分析采用χ2检验。P＜0.05时差异具有统计学意义。
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