不同方法在白内障摘除手术中矫正低度角膜逆规散光效果的比较

Effects of three methods for correction of low-degree against-the-rule corneal astigmatism during cataract surgery

目的比较白内障摘除术中散光矫正型人工晶状体(IOL)、飞秒激光松解与手术刀松解3种方法矫正低度角膜逆规散光的临床效果和视觉质量。方法前瞻性队列研究。纳入2017年12月至2020年10月在重庆爱尔麦格眼科医院确诊的白内障合并低度角膜逆规散光的患者120例(120只眼),按照患者意愿分为3个组,即散光矫正型IOL组(行超声乳化白内障吸除联合散光矫正型IOL植入术)、飞秒激光松解组(白内障摘除术中采用飞秒激光行周边透明角膜松解)、手工松解组(白内障摘除术中采用手术刀行角膜缘松解),每组40例(40只眼)。于术前测量裸眼远视力和角膜散光,术后3个月和1年测量裸眼远视力(UDVA)、最佳矫正远视力(BDVA)、全眼残余散光、角膜散光、全眼高阶像差、调制传递函数。符合正态分布的数据组间比较采用方差分析,组内比较采用重复测量,不符合正态分布的数据采用秩和检验。结果 120例患者中100例完成随访,其中男性44例,女性56例,年龄(66.48±6.20)岁;失访率16.7%。3个组间性别分布、年龄、术前角膜散光、术前裸眼远视力和IOL球镜度数差异均无统计学意义(均P>0.05)。3个组术后3个月及1年UDVA分别优于术前UDVA,差异均有统计学意义(Z=5.18,5.04,4.98,4.99,4.90,4.89;均P<0.001)。术后3个月及1年,3个组患者全眼残余散光差异均有统计学意义(H=30.69,31.23,均P<0.001);两两比较,散光矫正型IOL组术后3个月全眼残余散光小于另外2个组,术后1年的全眼残余散光为0.25(0.00,0.50)D,也小于飞秒激光松解组的0.50(0.50,0.75)D和手工松解组的0.75(0.50,0.75)D,差异均有统计学意义(Z=-3.71,-5.18,-3.94,-5.15,均P<0.001)。术后3个月,术后1年3个组总高阶像差组间差异有统计学意义(H=36.30,34.38,均P<0.001);两两比较,散光矫正型IOL组HOA值高于与另外2个组,其差异均有统计学意义(Z=5.01,4.73,5.31,5.27,均P<0.001)。术后3个月,术后1年3个组调制传递函数组间差异有统计学意义(H=30.02,29.92,均P<0.001);其中飞秒激光松解组调制传递函数值高于与另外2个组,其差异均有统计学意义(Z=4.61,4.67,4.66,4.69,均P<0.001)。结论 3种方法均可以有效矫正低度角膜逆规散光,散光矫正型IOL植入术后全眼残余散光小、效果稳定,飞秒激光松解后的全眼高阶像差低、视觉质量佳。

Objective To compare the clinical effects of and visual quality after correction of low-degree against-the-rule(ATR)corneal astigmatism by implantation of an astigmatism-corrected intraocular lens(IOL),femtosecond laser release and manual release in cataract surgery.Methods It was a prospective cohort study.A total of 120 patients(120 eyes)with cataract combined with low-degree ATR corneal astigmatism diagnosed in Chongqing Aier Mega Eye Hospital from December 2017 to October 2020 were included and divided into 3 groups,each with 40 patients,according to their own selections of astigmatism correction methods during cataract surgery.In the astigmatism-corrected IOL group,phacoemulsification for cataract extraction combined with toric IOL implantation was performed.In the femtosecond laser release group,astigmatic keratotomy using a femtosecond laser was combined.In the manual release group,a limbal relaxing incision was made.Uncorrected distance visual acuity(UDVA)and corneal astigmatism were measured before surgery.At 3 months and 1 year after surgery,UDVA and best-corrected distance visual acuity were examined,as well as whole eye residual astigmatism by ARK-1,corneal astigmatism by the IOLMaster 500,whole eye high order aberration(HOA)and modulation transfer function(MTF)by the iTrace visual function analyzer.Analysis of variance was used for the comparison of data in a normal distribution.Repeated measures were used for the comparison within groups.The rank sum test was used for the comparison of data that were not normally distributed.Results Of the 120 patients,100 patients(100 eyes),including 44 males and 56 females,with an age of(66.48±6.20)years,completed the follow-up.Among the three groups,the differences were not statistically significant in terms of gender distribution,age,preoperative corneal astigmatism,UDVA and spherical equivalent of the IOL(all P>0.05).At 3 months and 1 year after surgery,the UDVA was significantly better than that before surgery in each group(Z=5.18,5.04,4.98,4.99,4.90,4.89;all P<0.001).At the two time points,the differences in the whole eye residual astigmatism among the three groups were statistically significant(H=30.69,31.23;both P<0.001).At 3 months,the whole eye residual astigmatism in the astigmatism-corrected IOL group was lower than that in the other two groups.At 1 year,the residual astigmatism in the astigmatism-corrected IOL group[0.25(0.00,0.50)D]was also lower compared to that in the femtosecond laser release group[0.50(0.50,0.75)D]and the manual release group[0.75(0.50,0.75)D](Z=-3.71,-5.18,-3.94,-5.15;all P<0.001).The differences in the HOA at 3 months and 1 year among the three groups were statistically significant(H=36.30,34.38;both P<0.001).The HOA in the astigmatism-corrected IOL group was significantly higher than that in the other two groups at the two time points(Z=5.01,4.73,5.31,5.27;all P<0.001).At 3 months and 1 year,the differences in the MTF value among the three groups were also statistically significant(H=30.02,29.92;both P<0.001),and the MTF value in the femtosecond laser release group was significantly higher than that in the other two groups(Z=4.61,4.67,4.66,4.69;all P<0.001).Conclusions All the three astigmatism correction methods used at the time of cataract surgery can effectively correct low-degree ATR corneal astigmatism.The residual astigmatism in the whole eye after astigmatism-corrected IOL implantation is small and stable,while the HOA after release using the femtosecond laser is low with good visual quality.