老年性上睑下垂患者提上睑肌腱膜的病理学观察

Pathological features of levator aponeurosis in patients with involutional blepharoptosis

目的了解老年性上睑下垂患者提上睑肌腱膜组织的病理学特征。方法前瞻性研究。选取2007至2013年于首都医科大学附属北京同仁医院北京同仁眼科中心行提上睑肌缩短术的29例老年性上睑下垂患者，对术中获得切除的右眼或左眼提上睑肌腱膜共29份组织标本分别进行HE染色、VanGieson染色、Masson三色染色、免疫组织化学染色及透射电镜观察，同时于北京同仁医院眼库选取12份新鲜正常的提上睑肌腱膜组织，进行对照染色及观察。老年性上睑下垂患者提上睑肌腱膜组织与对照标本间各检测指标染色强度与病变严重程度的关系采用Mann．WhitneyU检验，患者提上睑肌腱膜组织病理改变与可疑因素的关系采用多元线性回归分析法。结果29例老年性上睑下垂患者中男性19例，女性10例；平均年龄59岁；14例为中度上睑下垂，15例为重度上睑下垂；9例双眼发病，9例右眼发病，11例左眼发病。12份对照眼睑组织来自男性5例，女性7例，平均年龄56岁。组织病理学染色结果显示，与对照标本比较，老年性上睑下垂患者提上睑肌腱膜可见肌束破裂（患者标本＋＋＋、＋＋、＋分别为24、2、3份，对照标本均为阴性；z=一5．666，P〈0．001）、横纹减少（患者标本＋＋＋、＋＋、＋分别为23、2、4份，对照标本均为阴性；乒一5．582，P〈0．001）、胶原纤维增生（患者标本＋＋＋、＋＋、＋分别为15、10、4份，对照标本均为阴性；z：-5．223，P〈0．001）、脂肪浸润（患者标本＋＋＋、＋＋、＋分别为24、5、0份，对照标本均为阴性；z-5．671，P〈0．001）、肌红蛋白表达降低（患者标本强阳性、中等阳性、弱阳性、阴性分别为9、1、1、15份，对照标本强阳性、中等阳性、弱阳性、阴性分别为8、1、0、O；z-3．004，P=0．005）。透射电镜观察显示老年性上睑下垂患者提上睑肌腱膜可见线粒体肿胀、增生、空泡、脂滴、核固缩、染色体凝聚、细胞器裂解、髓样体及自噬现象等病变。将可疑相关的临床特征作为自变量，将观察到的组织病理变化作为因变量，经多元线性回归分析发现脂肪浸润与年龄有相关性（标准化回归系数为0．425，P=0．043）。结论老年性上睑下垂患者提上睑肌腱膜组织病理学变化表现为肌纤维的退化性病变、胶原纤维增生及细胞退化性病变。r中华聪科杂志，2018，54j671．677）

Objective To observe pathological features of levator aponeurosis in patients with involutional ptosis. Methods A prospective study. Twenty-nine consecutive patients with involutional blepharoptosis who underwent levator aponeurosis advancement surgery for blepharoptosis correction were enrolled at Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University from 2007 to 2013. Twenty-nine specimens of the levator aponeurosis were obtained during surgery. Hematoxylin-eosin staining, Van Gieson staining, Masson staining, immunohistochemistry and transmission electron microscope observations were performed to observe the features of levator aponeurosis. Twelve normal specimens of fresh levator aponeurosis were obtained from Beijign Tongren Eyebank as control group. Mann-Whitney＇s U-test and multiple linear regression were used for statistical analysis. Results Among the enrolled cases, there were 19 males and 10 females;14 cases were diagnosed with moderate ptosis and 15 cases with severe ptosis;9 cases involved with both eyes, 9 cases with right eyes, and 11 cases with left eyes. The mean age was 59 years. Among the 12 normal cases, there were 5 males and 7 females. The mean age was 56 years. Histopathological observation showed fascicle disruption（＋＋＋, ＋＋, ＋ 24, 2, 3 vs. O, Z=-5.666, P〈0.001）, scarcity of cross-striations（＋＋＋, ＋＋, ＋ 23, 2, 4 vs. 0, Z=-5.582,P〈O.O01）, collagen fibers hyperplasia（＋＋＋, ＋＋, ＋ 15, 10, 4 vs. 0, Z=-5.223,P〈O.O01）, fatty infiltration（＋＋＋, ＋＋, ＋ 24, 5, 0 vs. 0, Z=-5.671,P〈O.O01）, and a decrease of myoglobin expression（＋＋＋,＋＋,＋,- 9, 1, 1, 15 vs. 8, 1, O, 0, Z=-3.004, P=O.005） in levator aponeurosis. Transmission electron microscope recorded presence of collagen fiber hyperplasia and cellular degeneration including mitochondria swelling and hyperplasia, vacuoles, lipid droplets, nucleus pycnosis, chromosome condensation, disintegrated organelles, myeloid body and autophagy. Multivariate linear regression showed a correlation between fat infiltration and age（15=0.425, P=0.043） while suspicious related clinical features as independent variables and observed histopathological features as dependent variables. Conclusion The levator aponeurosis appears to be involved with muscle fiber degeneration, collagen fiber hyperplasia and cellular degeneration in patients with involutional blepharoptosis. （Chin J Ophthalmol, 2018, 54： 671-677）