杜 波,范 琳

超聲乳化人工晶狀體植入對雙眼白內(nèi)障患者主視眼的影響

杜 波,范 琳

目的研究雙眼白內(nèi)障超聲乳化人工晶狀體植入術(shù)后主視眼轉(zhuǎn)變和對視覺質(zhì)量的影響。方法選擇我院診治的雙眼白內(nèi)障患者68例,根據(jù)手術(shù)前屈光度的大小分為：A組(29例)雙眼等效球鏡度數(shù)差異≥2 D,B組(39例)雙眼等效球鏡度數(shù)差異＜2 D。兩組均行進行白內(nèi)障超聲乳化人工晶狀體植入術(shù),分別于術(shù)前和術(shù)后3個月,用盲法檢查主視眼、屈光度和對比敏感度。結(jié)果術(shù)后3個月,A組有6例,轉(zhuǎn)變率為8.82%,B組有9例,轉(zhuǎn)變率為13.24%,兩組間轉(zhuǎn)變率比較無統(tǒng)計學(xué)差異(P> 0.05)。術(shù)后3個月時,主視眼矯正視力與非主視眼矯正視力均明顯高于術(shù)前(P<0.05),而主視眼與非主視眼比較無統(tǒng)計學(xué)差異(P>0.05);在術(shù)后3個月;主視眼屈光度與非主視眼屈光度均明顯高于術(shù)前(P<0.05),但主視眼與非主視眼比較無統(tǒng)計學(xué)差異(P>0.05);在術(shù)后3個月,主視眼轉(zhuǎn)變者與未轉(zhuǎn)變者對暗適應(yīng)條件下不同空間頻率的對比敏感度均無統(tǒng)計學(xué)差異(P> 0.05)。結(jié)論雙眼白內(nèi)障超聲乳化人工晶狀體植入術(shù)后,部分患者會發(fā)生主視眼轉(zhuǎn)變,但主視眼轉(zhuǎn)變對視覺質(zhì)量無明顯影響,不同大小屈光度患者術(shù)后主視眼轉(zhuǎn)變也無明顯差異。

白內(nèi)障;超聲乳化;人工晶體;主視眼轉(zhuǎn)變;視覺質(zhì)量

白內(nèi)障是臨床主要的致盲眼病之一,目前仍以手術(shù)治療為主[1］。隨著超聲乳化人工晶狀體植入術(shù)的發(fā)展和普及,目前已廣泛應(yīng)用于白內(nèi)障的臨床治療中。手術(shù)治療雖能改善白內(nèi)障患者視力,但仍有部分患者術(shù)后存在視疲勞、視物重影、視覺質(zhì)量下降等問題,這可能與術(shù)后球面像差和淚膜質(zhì)量的改變、對比敏感度下降等因素相關(guān)[2-4］,但其是否與術(shù)后主視眼發(fā)生改變有關(guān)的臨床研究較少。本研究主要探討了雙眼白內(nèi)障超聲乳化人工晶狀體植入術(shù)后主視眼轉(zhuǎn)變和對視覺質(zhì)量的影響。

1 資料與方法

1.1 病例資料 68例雙眼白內(nèi)障患者來自我院2010年1月～2015年2月收治患者,均行白內(nèi)障超聲乳化人工晶狀體植入術(shù),排除合并有角膜病變、葡萄膜炎、青光眼、糖尿病視網(wǎng)膜病變和眼部外傷者。根據(jù)手術(shù)前屈光度的大小分為：A組(29例)雙眼等效球鏡度數(shù)差異≥2 D,男13例,女16例;年齡38～79(61.23±7.52)歲。B組(39例)雙眼等效球鏡度數(shù)差異＜2 D,男16例,女23例;年齡37～80(62.45± 8.12)歲。

1.2 手術(shù)方法 術(shù)前1 h滴復(fù)方托吡卡胺眼液散瞳,常規(guī)麻醉。做膜緣輔助切口及顳上方透明角膜隧道切口,往囊袋和前房內(nèi)注射入黏彈劑,行核-皮質(zhì)水分離,晶體核原位乳化吸出,于囊袋內(nèi)植入人工晶狀體。吸凈囊袋和前房內(nèi)的黏彈劑,沖洗房角,向角膜切口實質(zhì)層內(nèi)注入平衡鹽溶液以閉合切口和恢復(fù)眼壓。術(shù)后結(jié)膜下注射地塞米松和妥布霉素,包扎術(shù)眼。手術(shù)均由專人進行。

1.3 觀察指標 于術(shù)后3個月,采用美國Vector Vision公司CSV-1000E型遠距式客觀(眩光)對比敏感度儀測量最佳矯正視力的對比敏感度;采用中央帶孔的紙板測試法檢查主視眼;采用標準對數(shù)視力表檢測患者的矯正視力。

1.4 統(tǒng)計學(xué)方法 應(yīng)用SPSS15.00統(tǒng)計軟件分析,計量資料以±s表示,組間比較采用t檢驗,組內(nèi)比較用單因素方差分析,組間率的比較采用χ2檢驗,P<0.05為差異有統(tǒng)計學(xué)意義。

2 結(jié)果

2.1 手術(shù)前后主視眼的分布 在術(shù)前左眼為主視眼25例(36.76%),右眼為主視眼43例(63.24%);術(shù)后3個月,左眼為主視眼29例(42.65%),右眼為主視眼39例(57.35%)。

2.2 手術(shù)前后主視眼的轉(zhuǎn)變 術(shù)后3個月,有15例出現(xiàn)主視眼轉(zhuǎn)變,轉(zhuǎn)變率為22.06%,其中A組有6例,轉(zhuǎn)變率為 8.82%,B組有9例,轉(zhuǎn)變率為13.24%,組間轉(zhuǎn)變率比較無統(tǒng)計學(xué)差異(P>0.05)。

2.3 主視眼矯正視力與非主視眼矯正視力比較術(shù)前主視眼矯正視力明顯高于非主視眼矯正視力(P<0.05);術(shù)后3個月時,主視眼矯正視力和非主視眼矯正視力均明顯高于術(shù)前(P<0.05),而主視眼與非主視眼比較無統(tǒng)計學(xué)差異(P>0.05),見表1。

表1 主視眼矯正視力和非主視眼矯正視力比較

2.4 主視眼屈光度與非主視眼屈光度比較 在術(shù)后3個月;主視眼屈光度與非主視眼屈光度均明顯高于術(shù)前(P<0.05),但主視眼與非主視眼比較無統(tǒng)計學(xué)差異(P>0.05),見表2。

表2 主視眼屈光度與非主視眼屈光度比較(D)

2.5 主視眼轉(zhuǎn)變者與未轉(zhuǎn)變者對比敏感度的比較

在術(shù)后3個月,與主視眼未轉(zhuǎn)變者比較,轉(zhuǎn)變者對暗適應(yīng)條件下不同空間頻率的對比敏感度均無統(tǒng)計學(xué)差異(P>0.05),見表3。

表3 術(shù)后3個月主視眼轉(zhuǎn)變者與未轉(zhuǎn)變者對比敏感度的比較

3 討論

白內(nèi)障的臨床表現(xiàn)主要包括視力模糊、衰退,嚴重者甚至失明[5］。隨著白內(nèi)障超聲乳化技術(shù)與顯微器械的不斷發(fā)展進步,白內(nèi)障超聲乳化人工晶狀體植入術(shù)的優(yōu)點日益突顯,主要包括手術(shù)切口小、術(shù)中不需要打開結(jié)膜、手術(shù)過程中前房深度較為穩(wěn)定、切口自閉、手術(shù)器械對虹膜的刺激性較小、術(shù)后炎癥反應(yīng)輕、屈光狀態(tài)穩(wěn)定、視力恢復(fù)迅速、對角膜散光的影響小等[6-7］。在手術(shù)后,人們多關(guān)注散光和屈光度的變化,但關(guān)于主視眼的研究報道較少。主視眼,又稱優(yōu)勢眼、主導(dǎo)眼,指的是一眼在視覺輸入過程中比另一側(cè)眼占優(yōu)勢地位[8-9］。目前主視眼在眼科研究中引起廣泛關(guān)注,例如在角膜屈光手術(shù)及驗光配鏡時,存在雙眼屈光矯正不能平衡的情況下,選擇讓主視眼獲得更佳的視覺質(zhì)量;在小兒弱視治療方面,6歲前將弱視眼轉(zhuǎn)變?yōu)橹饕曆?治療將獲得更好的效果;在斜視手術(shù)中確定主視眼還可為手術(shù)設(shè)計方案提供依據(jù)。主視眼的轉(zhuǎn)變和研究對評估白內(nèi)障患者術(shù)后的生活和視覺質(zhì)量有重要的意義。

眼優(yōu)勢柱的發(fā)育分為三期：關(guān)鍵期前期、關(guān)鍵期、關(guān)鍵期后期。關(guān)鍵期,即出生后到3歲這一年齡段,是人類神經(jīng)發(fā)育成熟的關(guān)鍵時期。傳統(tǒng)觀念認為關(guān)鍵期后主視眼及優(yōu)勢柱的發(fā)育趨于穩(wěn)定,主視眼的可塑性消失[10］。但也有人認為,主視眼并不是一成不變的,可能發(fā)生反轉(zhuǎn)[11］。本研究通過觀察雙眼白內(nèi)障患者手術(shù)前后主視眼的變化,探討關(guān)鍵期后主視眼是否存在轉(zhuǎn)變。結(jié)果發(fā)現(xiàn),術(shù)后1個月,共有19例出現(xiàn)主視眼轉(zhuǎn)變,轉(zhuǎn)變率為27.94%;術(shù)后3個月,有15例出現(xiàn)主視眼轉(zhuǎn)變,轉(zhuǎn)變率為22.06%。提示在白內(nèi)障超聲乳化人工晶狀體植入術(shù)后,部分患者主視眼會出現(xiàn)轉(zhuǎn)變,原因可能是術(shù)前的晶體混濁會造成視力降低,注視物體時輸入信號的強弱程度就會隨之發(fā)生改變。手術(shù)后接受視信號的清晰度發(fā)生變化,主視眼可能會轉(zhuǎn)變?yōu)榉侵饕曆?非主視眼也會轉(zhuǎn)變?yōu)橹饕曆?。Nakayama等[12］研究發(fā)現(xiàn),在主視眼前戴上不同程度的正鏡片,使主視眼前發(fā)生霧化,就會使主視眼轉(zhuǎn)變?yōu)榉侵饕曆?另一側(cè)的非主視眼也會轉(zhuǎn)變?yōu)橹饕曆邸p少主視眼的輸入信號會使主視眼逐漸發(fā)生轉(zhuǎn)變,當持續(xù)時間足夠長時,主視眼就會逐漸轉(zhuǎn)變?yōu)榉侵饕曆?可能是由于視皮層中的一部分細胞能刺激雙眼并使其興奮,但雙眼的反應(yīng)程度不一致,一般情況下,一眼會占相對的優(yōu)勢,即一眼受刺激后皮層細胞的放電頻率會明顯高于另一側(cè)眼。

術(shù)前主視眼屈光度明顯高于非主視眼屈光度(P<0.05),術(shù)后3個月時,主視眼矯正視力和非主視眼矯正視力相比無統(tǒng)計學(xué)差異(P>0.05),術(shù)后3個月的主視眼矯正視力和非主視眼矯正視力均明顯高于術(shù)前(P<0.05)?？赡苁怯捎诎變?nèi)障患者周邊皮質(zhì)的不均勻混濁影響了等效球徑值,造成主視眼屈光度值更高。而超聲乳化人工晶狀體植入術(shù)后,晶體混濁現(xiàn)象消失,因而屈光度也隨之得到改善。對比敏感度檢查能對患者的視覺質(zhì)量狀態(tài)進行量化評估,針對不同空間頻率及不同環(huán)境進行定量檢查,全面反映患者的視功能狀態(tài)。在術(shù)后3個月,主視眼轉(zhuǎn)變者與未轉(zhuǎn)變者對暗適應(yīng)條件下不同空間頻率的對比敏感度均無統(tǒng)計學(xué)差異(P>0.05)。提示這種主視眼的轉(zhuǎn)變對患者的視覺質(zhì)量無明顯影響。

綜上所述,雙眼白內(nèi)障超聲乳化人工晶狀體植入術(shù)后部分患者會發(fā)生主視眼轉(zhuǎn)變,但主視眼轉(zhuǎn)變對視覺質(zhì)量并無明顯影響,不同大小屈光度患者術(shù)后主視眼轉(zhuǎn)變也無明顯差異。

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Effects of phacoemulsification and intraocular lens implantation on dominant eye of patients with binocular cataract

Du Bo,Fan Lin Department of Ophthalmology,No.215 Hospital of Shaanxi Nuclear Industry,Xi'an,Shaanxi,712000,China

cataract;phacoemulsification and intraocular lens implantation;dominant eye turnover;visual function

］ObjectiveTo study the effects of phacoemulsification and intraocular lens implantation on the turnover of the dominant eyes of binocular cataract patients and visual function.MethodsA total of 68 patients with binocular cataract admitted to our hospital were selected and divided into group A(n=29)(difference in binocular equivalent spherical lens≥2 D)and group B(n=39)(difference in binocular equivalent spherical lens<2 D)according to the preoperative diopter.The two groups were treated with cataract phacoemulsification and intraocular lens implantation,and the dominant eye,diopter and contrast sensitivity were examined by means of blind method three months before and after the operation.ResultsThree months after the operation,the turnover rate in group A was 8.82%(6 cases)and 13.24%in group B(9 cases),showing no significant difference(P>0.05).Three months after the operation, the corrected visual acuity of the dominant eye and non-dominant eye was much better than that before the operation (P<0.05),and there was no significant difference between the dominant eye and non-dominant eye (P>0.05);the diopter of the dominant eye and non-dominant eye was much higher than that before the operation (P<0.05),and there was no significant difference between the dominant eye and non-dominant eye (P>0.05);the contrast sensitivity of patients with or without turnover of dominant eye to the different spatial frequency under dark adaptation showed no great difference(P>0.05).ConclusionAfter cataract phacoemulsification and intraocular lens implantation,some patients may have dominant eye turnover,but such turnover has no obvious influence on visual function.There is no difference between the dominant eye turnovers in patients with different diopter.

2016-05-03)

712000西安,核工業(yè)215醫(yī)院眼科

R 779.66

A

1004-0188(2016)11-1241-04doi:10.3969/j.issn.1004-0188.2016.11.007

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