准分子激光角膜屈光手术后开角型青光眼患者的临床特征

Clinical Characteristics of Patients with Open-Angle Glaucoma after Refractive Corneal Ablation Surgery

目的:观察具有准分子激光角膜屈光手术(简称准分子术)史的开角型青光眼患者的临床特征。方法:回顾性病例研究。纳入2005─2018年北京大学第三医院眼科中心就诊、具有准分子术史且随访2年以上的开角型青光眼患者。记录一般情况以及特殊检查结果,选取每例视野较差的眼或双眼相似者随机1眼作为研究眼。对视野进展分析采用非参数分析(NPA)法。采用独立样本t检验及秩和检验进行分析。结果:共纳入33例患者,青光眼确诊均在准分子术后,手术至青光眼确诊间隔(10.3±6.1)年,确诊时年龄(37.5±10.4)岁,最高眼压<21 mmHg(1 mmHg=0.133 kPa)者27例(82%);中央角膜厚度为(456±47)μm。眼底照相显示视网膜神经纤维层缺损18例(55%),无法辨认的15例(45%);杯/盘比为0.7±0.1。视野平均缺损(MD)绝对值小于6的有18例(55%),6~12有8例(24%),12以上有7例(21%)。其中随访2年以上21例,随访时间为(4.5±2.2)年;视野进展13例(62%),视野进展速度为(0.5±0.6)dB/年。视野进展组与非进展组治疗后降眼压幅度分别为(28.3±20.7)%和(15.4±11.0)%(t=-1.867,P=0.078),屈光回退发生率分别为92%和25%(P=0.003)。21例中屈光回退14例(64%),屈光回退组中12例(12/14)视野进展,无回退组中1例视野进展(1/7)(P=0.003);屈光回退组的视野进展[(0.7±0.7)dB/年]快于无回退组[(0.1±0.1)dB/年](t=-2.899,P=0.011)。结论:准分子术后的青光眼患者确诊时大多处于病情早中期,4/5患者眼压在21 mmHg以下,通过眼底照相能明确视网膜神经纤维层缺损的只占一半病例。随访中约2/3患者视野恶化,可能与屈光回退有关。

Objective:To observe the clinical characteristics of open-angle glaucoma patients with a history of refractive corneal ablation surgery(RCAS).Methods:This retrospective study reviewed and recorded the general situation and special examination results of open-angle glaucoma patients with a history of RCAS in Department of Ophthalmology,Peking University Third Hospital from 2005 to 2018.One eye of patients with a poorer visual field,or patients with a similar visual field was randomly selected for study.The patients who were followed up for more than 2 years were analyzed.NPA was used to analyze visual field progression.An independent samples test and rank sum test were used for analysis.Results:Thirty-three patients were included.The diagnosis of glaucoma was made after RCAS.The interval from surgery to glaucoma diagnosis was10.3±6.1 years.The age at diagnosis was 37.5±10.4 years.The highest intraocular pressure was less than 21 mmHg in 27 patients(82%).Central corneal thickness was 456±47μm.Fundus photography showed a retinal nerve fiber layer defect in 18 patients(55%),unrecognized in 15 patients(45%);cup/disc ratio was 0.7±0.1.There were 18 patients(55%)with a visual field MD of less than 6,8 patients(24%)of 6-12,and 7 cases(21%)of 12 or more.Twenty-one patients were followed up for more than 2 years with an average follow-up time of 4.5±2.2 years.There were 13 cases(62%)of visual field progression with an average rate of 0.5±0.6 dB/year.After treatment,the IOP in the visual field progressive group and the non-progressive group were 28.3%±20.7%and 15.4%±11.0%,respectively(t=-1.867,P=0.078).There were 12 cases(12/14)of visual field progression in the refractive regression group and 1 case(1/7)in the non-regression group(P=0.003).The visual field progression in the refractive regression group was 0.7±0.7 dB/year faster than that in the non-regression group 0.1±0.1 dB/year(t=-2.899,P=0.011).Conclusions:Most of the patients with glaucoma after excimer surgery were diagnosed in the early and middle stages of the disease.Four-fifths patients had an IOP below 21 mmHg.Fundus photography can identify only half of the cases of retinal nerve fiber layer defects.About two-thirds of patients with visual field deterioration during follow-up may be related to refractive regression.