糖尿病中医证型与糖尿病视网膜病变分期关系的探讨

　　中国中医眼科杂志 2000年第1期第10卷 临床研究

　　作者：李志英　余杨桂　张淳　王燕　王小川

　　单位：广州中医药大学第一附属医院眼科广州 510405

　　关键词：糖尿病；视网膜病变；中医证型

　　摘　要　目的　探讨糖尿病中医证型与糖尿病视网膜病变分期之间的关系。

　　方法　185例(283只眼)糖尿病患者包括未发生糖尿病视网膜病变者90只眼和发生糖尿病视网膜病变者193只眼。按照中医辨证分型其中气阴两虚型200只眼，阴阳两虚型37只眼，血瘀气滞型46只眼。根据糖尿病视网膜病变的分期，193只视网膜病变眼中有单纯型糖尿病视网膜病变50只眼，增殖前期64只眼，增殖期79只眼。分别与病程、发病率、视力及中医证型进行了分析。

　　结果　在发生糖尿病视网膜病变的患者中病程5年以下者多为气阴两虚证；病程5～10年者多为血瘀气滞证；病程10年以上者多为阴阳两虚证。血瘀气滞组、气阴两虚组与阴阳两虚组在糖尿病患者中构成比之间差异均有非常显著性(P＜0.01)。糖尿病视网膜病变分期与中医证型的构成比差异有非常显著性(P＜0.01)。

　　结论　糖尿病患者中阴阳两虚证和血瘀气滞证者发生视网膜病变明显高于气阴两虚证，并与病程有一定关系。单纯期和增殖前期病变中多为气阴两虚证；增殖期则多为血瘀气滞证和阴阳两虚证。血瘀气滞证糖尿病视网膜病变患者的视力损害较为严重。

　　Study on relationship between traditional Chinese medicine syndrome types of diabetes mellitus and stages of diabetic retinopathy

　　Li Zhiying Yu Yanggui Zhang Chun

　　Department Ophthalmology, the First Affiliated Hospital of Guangzhou Traditional Chinese Medicine University , Guangzhou 510405，China

　　Abstract OBJECTIVE　To investigate a relationship between traditional Chinese medicine ( TCM ) syndrome types of diabetes mellitus ( DM ) and stages of diabetic retinopathy ( DR ).METHODS　One hundred and eighty five patients (283 eyes) with DM were observed, including 90 eyes without DR and 193 eyes with DR. The patients were classified as 200 eyes of qiyinliangxu (气阴两虚), 37 eyes of yinyangliangxu (阴阳两虚), and 46 eyes xeyuqizhi (血瘀气滞) according to TCM syndrome types. There were 50 eyes with background stage, 64 eyes with pre-proliferative stage, and 79 eyes with proliferative stage in 193 eyes with DR based on stages of DR. Course of disease, ratio of DR stage, visual acuity and TCM syndrome types were analyzed.RESULTS　In patients whose course of DR were no more than 5 years qiyinliangxu types comprised most part of patients, xeyuqizhi types comprised most part of patients with 5 to 10 years of DR. Over 10 years there were more yinyangliangxu types. Ratio of DR in DM of xieyuqizhi types, qiyinliangxu types of DR and yinyangliangxu types had a significant difference between them (P＜0.01 ). The ratio of stages of DR and TCM syndrome types had a significant difference (P＜0.01) in the patients.CONCLUSION　Incidence of retinopathy is higher obviously in the patients with diabetes mellitus as yinyangliangxu and xeyuqizhi than qiyinliangxu, and it is relevant with the courses of disease. There were more qiyinliangxu in the patients with background and pre-prolifrative retinopathy, but more xeyuqizhi and yinyangliangxu in the proliferative retionpathy. Loss of visual acuity is more severe in the patients with diabetic retinopathy as xeyuqizhi type.

　　To investigate a relationship between traditional Chinese medicine ( TCM ) syndrome types of diabetes mellitus ( DM ) and stages of diabetic retinopathy ( DR ).METHODS　One hundred and eighty five patients (283 eyes) with DM were observed, including 90 eyes without DR and 193 eyes with DR. The patients were classified as 200 eyes of qiyinliangxu (气阴两虚), 37 eyes of yinyangliangxu (阴阳两虚), and 46 eyes xeyuqizhi (血瘀气滞) according to TCM syndrome types. There were 50 eyes with background stage, 64 eyes with pre-proliferative stage, and 79 eyes with proliferative stage in 193 eyes with DR based on stages of DR. Course of disease, ratio of DR stage, visual acuity and TCM syndrome types were analyzed.RESULTS　In patients whose course of DR were no more than 5 years qiyinliangxu types comprised most part of patients, xeyuqizhi types comprised most part of patients with 5 to 10 years of DR. Over 10 years there were more yinyangliangxu types. Ratio of DR in DM of xieyuqizhi types, qiyinliangxu types of DR and yinyangliangxu types had a significant difference between them (P＜0.01 ). The ratio of stages of DR and TCM syndrome types had a significant difference (P＜0.01) in the patients.CONCLUSION　Incidence of retinopathy is higher obviously in the patients with diabetes mellitus as yinyangliangxu and xeyuqizhi than qiyinliangxu, and it is relevant with the courses of disease. There were more qiyinliangxu in the patients with background and pre-prolifrative retinopathy, but more xeyuqizhi and yinyangliangxu in the proliferative retionpathy. Loss of visual acuity is more severe in the patients with diabetic retinopathy as xeyuqizhi type.

　　Key words　diabetes mellitus　　retinopathy　　traditional Chinese medicine syndrome types

　　糖尿病视网膜病变(diabetic retinopathy,DR)是糖尿病(diabetes mellitus,DM)的严重并发症之一，随着DM患者的寿命延长，DR的发病率逐步增加，已成为主要致盲疾病〔1〕。近年国内外对DR的解剖生理、组织病理、临床经过及转归，中医病机及证型的研究已逐步深入，视网膜激光凝固，玻璃体切割和中医、中西医结合治疗都取得了一定疗效〔2～4〕。但是，由于DR的发病机理尚未完全阐明，治疗上未取得突破性进展，特别对视网膜微血管病变不断恶化的遏止无能为力。我们通过对DM中医证型与DR发病规律的研究，进一步阐明DR的证候规律，为中医、中西医结合有效防治DR提供客观依据。

　　1　资料与方法

　　1.1　一般资料

　　本组病例为1995年1月至1999年2月广州中医药大学第一附属医院眼科和糖尿病研究所确诊为非胰岛素依赖型糖尿病，需做荧光素眼底血管造影检查的患者。共185例283只眼。其中男76例，女109例，年龄20～65岁，平均53.67岁±8.82岁。

　　1.2　诊断标准

　　糖尿病诊断参照世界卫生组织1980年和1997年暂行标准〔5〕。

　　DR诊断参照1985年第三届全国眼科学术会议制定的糖尿病视网膜病变分期标准〔6〕。

　　DR荧光素眼底血管造影(FFA)参照我国DR诊断标准、国际三期分类法及中山医科大学中山眼科中心的标准确定(胡兆科.糖尿病视网膜病变眼底荧光血管造影分期.中华医学会广东省眼科分会学术资料.1999)。

　　DR分期均以检眼镜检查和荧光素眼底血管造影的结果综合确定。DM中医分型标准参照卫生部制定中药治疗消渴病(糖尿病)的临床指导原则分3型(中华人民共和国卫生部.中药新药临床研究指导原则.1993.215～218)。

　　①气阴两虚证：主证：倦怠乏力，气短懒言，五心烦热，舌体胖大，舌红少津，苔薄或花剥，脉细数。次证：自汗或盗汗，口渴喜饮，心悸失眠，溲赤便秘，脉弦细。

　　②阴阳两虚证：主证：形寒怯冷，耳鸣腰酸，时或潮热盗汗，小便清长，舌质淡红，舌体胖嫩，边有齿痕，脉沉细。次证：面色无华，四肢欠温，大便溏薄，苔薄白或白腻，脉细无力。

　　③血瘀气滞证：主证：面色晦暗，肢体麻木或刺痛，夜间加重，唇紫，舌暗或有瘀斑，或舌下青筋紫暗怒张，脉沉涩。次证：消瘦乏力，胸中闷痛，苔薄白，或少苔，脉弦。

　　凡符合上述主证中3个和次证2个以上者诊断为该型。

　　纳入病例标准：凡符合上述诊断标准及中医证型标准的DM患者均纳入观察病例。

　　排除病例标准：①年龄在18岁以下，或65岁以上者，妊娠或哺乳期妇女；②合并有其他严重原发性疾病，或有其他眼底疾病者。或伴玻璃体积血不能看清眼底者；③无法判断中医证型或资料不全者。

　　1.3　方法

　　以DM证型为基础，根据病程、DR的发生率、眼底改变及视力的情况，结合荧光素眼底血管造影的结果进行分析

　　1.3.1　分组

　　观察组中气阴两虚组83例116只眼；血瘀气滞组29例43只眼；阴阳两虚组20例34只眼。对照组中DM患者经DR诊断包括FFA检查未发现DR者53例90只眼。

　　1.3.2　眼科常规检查：包括视力、裂隙灯眼前段及眼底检查。

　　1.3.3　荧光素眼底血管造影：由二名研究者共同观察确认，按观察指标记录。

　　1.4　统计方法

　　用华西医科大学PEMS统计软件，数据用均数标准差(±s)表示，采用多个样本比较及两两比较。

　　为便于统计，病例中双眼病变程度不一致者，以眼底症状严重者纳入统计范围，例如一只眼属单纯期，另一眼属增殖前期，仅统计增殖前期眼，以此类推。

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