作者：吕沛霖，朱秀萍，石维华，燕芳
作者单位：710002）中国陕西省西安市第一医院眼科 西安市眼科医院 陕西省眼科研究所
【摘要】 目的：初步调查门诊2型糖尿病(diabetes mellitus,DM)患者糖尿病视网膜病变(diabetic retinopathy,DR)的发生情况，并探讨早期诊断的方法。方法：对我院眼科门诊及住院治疗的2型DM患者，经WHO有关IDDM诊断标准确诊，共565例1 130眼，通过询问获得病史以及相关检查和诊断资料，常规进行视力、眼压，以及散瞳检眼镜检查眼底，并采用眼底视网膜彩色照相检查，对镜下可疑及有明确视网膜病变的患者行荧光素血管造影（fundus fluorescein angiography，FFA）检查。结果：DM患者565例1 130眼中检眼镜下有视网膜病变417例825眼，9例为单侧患者，发生率73.80%。病程5a以上患者中，存在1期以上DR占78.0%。417例明确DR患者除造影禁忌证外，372例进行了荧光素眼底血管造影检查，其中1，2，3，4期患者造影确定病情程度与眼底镜下符合率90.6%（337例），9.4%（35例）严重于检眼镜下确定病情程度。检眼镜下无眼底改变0期糖尿病患者148例296眼，病程<5a患者61例，行造影检查38例，确诊DR为1期者12例，占检查人数32%；病程高于5a患者87例，26例行造影检查发现微血管瘤存在，占30%。565例患者中血糖不稳定和控制不好者共327例，占57.9%。结论：门诊2型DM患者DR并发症的高发生率需要密切关注。为避免患者视力丧失，常规检眼镜检查，尤其是数码眼底彩色照相图像分析对早期诊断有重要价值，需引起内科医师重视。
【关键词】 糖尿病视网膜病变；糖尿病；数码眼底检查；荧光素血管造影；诊断
Incidence and clinical conditions of diabetic retinopathy in 565 patients with type 2 DM by initial investigations and early diagnosis
PeiLin Lü, XiuPing Zhu, WeiHua Shi, Fang Yan
Department of Ophthalmology, the First Hospital of Xian, Xian 710002, Shaanxi Province, China
AbstractAIM: To examine the prevalence of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (DM), including the incidence and clinical conditions of DR and early diagnosis. METHODS: Totally 565 patients diagnosed DM by the WHO diagnostic criteria attending at Xi' an Eye Hospital. The median age of patients was 63.2±13.8 years old. All of 565 patients related to IDDM was asked whether the history of inspections and related information, combined with clinical examination such as the acuity vision, the conventional ophthalmoscope fundus examination, fundus color photography were performed, and great majority of patients accepted fundus fluorescein angiography (FFA) examination.RESULTS: The result showed that 417 DR cases (73.80%) in 565 DM patients occurred. Above 5 years disease stage DM in these patients diagnosis DR above stage I highly in 78.0%. In 417 cases of diabetic retinopathy in addition to the contraindication, 372 cases were performed fundus fluorescein angiography, in which 1, 2, 3, 4 stage imaging Consistency by fundus microscope was good in ratio of 90.6% (337 cases). 9.4% (35 cases) in a serious stage eye determined by FFA other than by microscope. Ophthalmoscope under the nondiabetic retinal changes in other 148 patients (296 eyes), 61 cases with the course of disease less than 5 years, 38 cases accepted FFA examination. Above these, 12 DR cases confirmed by FFA, accounting for 32% the number of inspections.Higher than 5year course of disease in 87 patients, 26 cases routine microscope examination did not find the existence of microvascular tumor, accounting for 30%. There was a strong correlation between duration of diabetes and some high degree of hyperglycaemia with the presence of diabetic retinopathy. Instability and poor blood sugar control were in 327 cases (57.9%). CONCLUSION: These findings emphasis the importance of earlier diagnosis of diabetic retinopathy and its complications. In order to prevent patients from blindness and bad vision, the fundus examination, especially Digital fundus examination on diabetic retinopathy is the effective method on clinical early diagnosis techniques in diabetic militia group.
KEYWORDS: diabetic retinopathy; diabetes mellitus; digital fundus photograph; FFA; diagnosis
糖尿病视网膜病变(diabetic retinopathy，DR)是糖尿病（diabetes mellitus，DM）患者微循环障碍引起视网膜血管损害的结果，是常见的四大致盲性眼病之一,多见于中老年人群。为进一步了解临床DM患者中DR的发生情况，以及探讨早期诊断的方法，对我院眼科门诊565例2型DM患者进行眼科检查和相关因素调查分析，结果报告如下。
1对象和方法
1.1对象 调查对象为200410/200703就诊于我院眼科门诊和住院治疗的DM患者。所有患者按照WHO规定非胰岛素依赖性糖尿病（IDDM，2型糖尿病）诊断标准确诊，即空腹血糖>7mmol/L，餐后血糖>11.1mmol/L。共调查565例DM患者，均为西安城区固定公民，居住本地10a以上。男247例，女318例，年龄40～85（平均63.2±13.8）岁。病程2mo～30a，平均13.6±7.97a，其中工人218例，职员112例，干部142例，农民93例。全身并发高血压177例，高血脂103例，糖尿病性肾病79例。
1.2方法 收集初诊或复诊DM患者临床资料，包括DM相关内容，视力情况，散瞳眼底检眼镜检查，视网膜照相检查采集数码眼底彩色图像资料，对进行了造影检查患者资料进行分类登记和分期统计分析。按照新的国际糖尿病视网膜病变分型依据进行分期，存在以下情况行荧光素血管造影(fundus fluorescein angiography，FFA)检查：(1)眼底镜下似可见到微血管瘤或出血、渗出、新生血管损害者；单/双眼玻璃体积血或视网膜脱离手术后；(2)眼底正常有DM病史，医师建议或患者自觉要求造影检查。造影检查排除禁忌证。
2结果
2.1眼底镜检查和眼底彩色照相检查 565例患者0期无眼底表现患者148例296眼(26.2%)；发生1期以上DR 417例825眼(73.8%)，可观察到视网膜微血管瘤、出血、硬性渗出或棉絮斑、黄斑局限或弥漫水肿和/或新生血管及增殖膜、视神经充血、边界不清、新生血管、玻璃体积血、牵拉性视网膜脱离等明显眼底损害存在，19例19眼表现为单侧性DR损害，眼底镜检查或眼底彩色照相检查均能确诊。按照新的国际糖尿病视网膜病变诊断标准，发生1期以上DR患者417例825眼(73.8%)，1，2期患者116例(27.8%)，3期患者138例(33.1%)，4期患者163例(39.1%)。调查统计DR患者中左右眼处不同级别改变患者26例，最低差1期，左右眼最高差3期。DM视力的损害结果分析也显示与DR级别的不一致性。
2.2 FFA检查结果 接受造影检查患者471例。DM患者平均臂视网膜循环时间延迟，为18±5.4s。造影图片结果：后极部散在或大量微血管瘤高荧光，点状、片状、条状视网膜深浅层出血遮蔽荧光，无灌注区低荧光，黄斑局限或弥漫毛细血管高荧光，视盘/视网膜新生血管性高荧光，包括新生血管芽状、叶状、扇状等形态改变，严重存在玻璃体积血遮挡。其中检眼镜下无眼底改变的0期DR糖尿病患者148例296眼，病程<5a患者61例，行造影检查38例，确诊DR为1期者12例，占检查人数32%；病程>5a患者87例，26例(30%)行造影检查发现微血管瘤存在。对检眼镜下DR 1期以上DM患者372例行FFA检查，初步统计诊断病情级别与检眼镜下诊断程度相符337例，符合率90.6%， 35例（9.4%）严重于检眼镜下确定病情程度，主要为2，3，4期判定存在差异。
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