2型糖尿病对年龄相关性白内障患者超声乳化术后角膜组织学影响的研究

Effect of type 2 diabetes on corneal histology in age-related cataract patients after phacoemulsification

背景合并2型糖尿病的年龄相关性白内障临床中多见,超声乳化术后存在较多眼前段并发症,如角膜水肿、干眼症明显加重等,其病理生理改变方面的研究尚不全面。目的分析2型糖尿病对年龄相关性白内障患者超声乳化术后角膜上皮下神经纤维层、基质细胞层及内皮细胞层的影响。方法收集2023年5—10月在解放军总医院第一医学中心眼科拟行白内障超声乳化术的年龄相关性白内障患者,根据是否患2型糖尿病,分为糖尿病组和对照组。应用角膜共聚焦显微镜(in vivo corneal confocal microscopy,IVCM)采集术前以及术后1周、1个月、3个月的中央角膜全层图像,使用Image J插件Neuron J测量角膜上皮下神经纤维长度(corneal nerve fiber length,CNFL),计数共聚焦显微镜图像中角膜上皮下神经纤维主干及分支数目,得出神经纤维密度(corneal nerve fiber density,CNFD)、神经纤维分支密度(corneal nerve fiber branching density,CNBD),计数前基质细胞密度(anterior keratocyte density,AKD)、后基质细胞密度(posterior keratocyte density,PKD)、内皮细胞密度(endothelial cell density,ECD)及代表炎症指标的朗格汉斯细胞(Langerhans cell,LC)数目,比较两组术前与术后1周、1个月及3个月角膜各指标的差异,以及不同时间点的变化。结果糖尿病组27例(32眼),男性13例,女性14例,平均年龄(70.34±8.99)岁;对照组30例(36眼),男性10例,女性20例,平均年龄(69.86±7.84)岁,两组性别、年龄及术中超声能量均无统计学差异(P>0.05)。糖尿病组的空腹血糖、糖化血红蛋白均显著高于对照组(P<0.001),术前CNFD较对照组显著降低(P=0.01),余术前角膜各指标无统计学差异(P>0.05)。两组CNFD、CNBD、CNFL在术后1周及1个月均较术前显著降低(多重校正P<0.013),且在术后1周及1个月糖尿病组CNFD显著低于对照组(P<0.05),两组术后CNBD、CNFL均无统计学差异(P>0.05);两组LC在组别及不同时间点上存在显著的交互效应(P<0.05),在术后1周及1个月均较术前显著升高(多重校正P<0.013),且在术后1周及1个月糖尿病组显著高于对照组(P<0.05)。两组AKD、PKD及ECD在术后1周、1个月及3个月较术前显著降低(多重校正P<0.013),且在术后1周及1个月糖尿病组AKD显著低于对照组(P<0.05),术后PKD、ECD均无统计学差异(P>0.05)。结论2型糖尿病患者白内障超声乳化术后角膜神经层及细胞层组织损伤更重,上皮下神经纤维于术后3个月恢复良好,而基质细胞层和内皮细胞层恢复较慢,前基质细胞层受血糖影响显著。警惕糖尿病患者白内障术后角膜并发症,适当延长修复角膜用药尤为必要。

Background Age-related cataracts associated with type 2 diabetes are becoming increasingly prevalent in clinical settings,with significant postoperative anterior segment complications after phacoemulsification surgery,such as corneal edema and exacerbation of dry eye syndrome.The study of its pathophysiological changes is not comprehensive.Objective To explore the effects of type 2 diabetes on the subepithelial nerve fiber layer,corneal stromal cells,and endothelial cell layer of the cornea in patients with age-related cataracts undergoing phacoemulsification surgery. Methods The study was conducted from May to October in 2023 at the Ophthalmology Department in the First Medical Center of our hospital. The patients were divided into the diabetes group and the control group. In vivo confocal microscopy (IVCM) was used to capture images of the central cornea before the surgery, and at 1 week, 1 month, and 3 months after the surgery to assess the corneal layers. Then Image J plugin Neuron J was used to measure the length of corneal subcutaneous nerve fibers (CNFL), count the number of main and branch nerve fibers in confocal microscopy images, and obtain the density of nerve fibers (CNFD), nerve fiber branching density (CNBD), and anterior stromal cell density (AKD), posterior stromal cell density (PKD), and endothelial cell density (ECD). The differences in preoperative corneal indicators between two groups, in preoperative and postoperative indicators at 1 week, 1 month, and 3 months, and the changes between the different time points were compared. Results There were 13 male patients and 14 female patients in the diabetes group (27 cases, 32 eyes), with an average age of 70.34±8.99 years;and 10 male patients and 20 female patients in the control group (32 cases, 36 eyes), with an average age of 69.86±7.84 years. No statistically significant differences were found in gender, age, and intraoperative ultrasound energy between the two groups. (P>0.05). The fasting blood glucose and HbA1c in the diabetes group were significantly higher than those in the control group (P<0.001). The preoperative CNFD in the diabetes group was significantly lower than that in the control group (P=0.01), and there was no statistical difference in the other two groups' corneal indicators before surgery (P>0.05);CNFD, CNBD, and CNFL in the two groups were significantly lower than those before operation, and at 1 week and 1 month after operation (multiple correction P<0.013), and CNFD in the diabetes group was significantly lower than that in the control group at 1 week and 1 month after operation (P<0.05), while there was no statistical difference in CNBD and CNFL between the two groups after operation (P>0.05). There was a significant interaction between two groups of LC at different groups and time points (P<0.05), LC in the two groups increased significantly at 1 week and 1 month after surgery compared with that before surgery (multiple correction P<0.013), and LC in the diabetes group were significantly higher than that in the control group at 1 week and 1 month after surgery (P<0.05). AKD, PKD and ECD in the two groups were significantly lower than those before surgery, and at 1 week, 1 month and 3 months after surgery (multiple correction P<0.013), and AKD in the diabetes group was significantly lower than that in the control group at 1 week and 1 month after surgery (P<0.05). There was no statistical difference between the two groups in PKD and ECD after surgery (P>0.05). Conclusion Patients with type 2 diabetes experience more severe damage to the corneal nerve and cell layers after undergoing phacoemulsification surgery. The subepithelial nerve fibers recover well after 3 months of surgery, while the stromal and endothelial cell layers recover slowly. The anterior stromal cell layer is significantly affected by blood sugar. Diabetic patients must be aware of the potential occurrence of postoperative corneal complications. Extending the use of medications for assisting in corneal repair after surgery will be particularly necessary.