羊膜遮盖手术时机对不同程度眼表烧伤患者视力预后的影响

The effect of timing of amniotic membrane transplantation on prognosis vision of different degrees of acute ocular surface burn

目的比较分析羊膜遮盖时机对不同程度眼表烧伤患者视功能转归的影响。方法采用回顾性研究方法。分析2012年1月至2016年12月于河南省立眼科医院就诊的眼表烧伤患者76例92眼,按照Dua方法对眼表烧伤程度进行分级,按照羊膜遮盖时机将患者分为伤后1 d内组、伤后2~6 d组和伤后6 d以上组,记录随访1年后患者最佳矫正视力及角膜缘干细胞缺乏程度评分,分析影响角膜缘干细胞缺乏及视力转归的危险因素。结果纳入的92眼中,热烧伤22眼,占23.9%,酸烧伤29眼,占31.5%,碱烧伤41眼,占44.6%。角膜缘干细胞缺乏评分0、1、2分患者平均烧伤程度评分分别为1.86±0.54、3.60±0.94和5.35±0.63,总体比较差异有统计学意义(F=65.532,P<0.01)。轻中度眼表烧伤患者中伤后6 d以上组患者角膜缘干细胞缺乏评分明显高于伤后1 d内组和伤后2~6 d组,差异均有统计学意义(Z=-2.21,P=0.03;Z=-2.33,P=0.02);重度眼表烧伤患者中,各组患者角膜缘干细胞缺乏评分总体比较,差异无统计学意义(P=0.26)。末次随访时所有术眼平均视力为3.19±1.47。COX回归分析结果显示,烧伤程度分级和手术时机是视力预后的主要危险因素(OR=4.925、1.368,均P<0.01)。预后视力与羊膜遮盖时机及烧伤程度均呈线性相关(R^2=0.078、0.685,均P<0.01)。在超过Ⅳ级的眼表烧伤患者中,羊膜移植时机不能改善预后角膜缘干细胞缺乏程度。结论Dua眼表烧伤分级方法对患者预后评估有重要意义。轻至中度眼表化学烧伤,早期羊膜遮盖可明显改善视力预后,且羊膜遮盖时机越早越好。然而对于重度眼表烧伤患者,羊膜遮盖时机对于视力预后无明显改善作用。

Objective To compare the morphological and functional outcomes of different degrees of ocular burns patients receiving amniotic membrane transplantation(AMT)at different time points after ocular burn.Methods A retrospective analysis was performed.Ninety-two eyes of 76 acute ocular chemical burn patients were enrolled from January 2012 to December 2016 in Henan Eye Hospital.The ocular chemical burns were classified by Dua classifications.According to the operation time of AMT,the patients were divided into within 1 day after injury group,2-6 days after injury group and more than 6 days after injury group.The best corrected visual acuity and limbal stem cell deficiency score were recorded during the at least one year of follow up.The risk factors affecting limbal stem cell deficiency and visual outcome were analyzed.Results Of all the burned eyes,29 eyes(31.5%)were result from acid burn,41 eyes(44.6%)were result from alkaline burns and 22 eyes(23.9%)were result from thermal burn.The average burn severity scores of patients with limbal stem cell deficiency score of 0,1 and 2 was 1.86±0.54,3.60±0.94 and 5.35±0.63,respectively,and the overall difference was statistically significant(F=65.532,P<0.01).In mild to moderate ocular surface burn patients,the limbal stem cell deficiency score in more than 6 days after injury group was significantly higher than that in within 1 day after injury group and 2-6 days after injury group(Z=-2.21,P=0.03;Z=-2.33,P=0.02).In severe ocular surface burn patients,there was no significant difference in limbal stem cell deficiency score between the groups(P=0.26).At the last follow-up,the average visual acuity of all eyes was 3.19±1.47.COX regression analysis showed that burn grade and operation timing were the main risk factors for visual prognosis(OR=4.925,1.368;both at P<0.01).Prognostic visual acuity was linearly correlated with the timing of amniotic membrane occlusion and degree of burn(R^2=0.078,0.685;both at P<0.01),but for the V grade andⅥgrade eyes,amniotic membrane timing couldn't improve the score of limbal stem cell deficiency.Conclusions Dua classifications is of great significance in evaluating prognosis of ocular burn patients.AMT is an effective adjunctive treatment in the management of acute ocular chemical burns to support epithelial healing and restore ocular surface integrity with potential to improve vision.AMT can't prevent limbal stem cell deficiency or restore vision in eyes with severe burns.