【作者】 王琴；

【导师】 彭绍民；

【作者基本信息】 安徽医科大学 ， 眼科学， 2025， 博士

【摘要】 目的本研究拟探索眼后房结构与有晶状体眼后房型人工晶状体(ICL)植入术后拱高和襻位置的相关性,为选择合适尺寸的ICL提供具有眼后房结构参数的新模型,为ICL尺寸选择提供另一种方案。1.评估健康屈光不正中青年人群眼后房结构的特征,分析其影响因素,以弥补健康屈光不正中青年人群眼后房结构特征的不足,为ICL植入术后异常拱高和异常襻位置的研究奠定基础。2.评估眼后房结构与ICL植入术后拱高的相关性,同时观察ICL植入术后襻位置,分析与ICL襻位置相关的包括眼后房结构的眼部生物参数,以降低ICL植入术后襻位置异常的发生率,最终为降低ICL植入术后拱高异常的发生率和二次手术率奠定基础。3.纳入眼后房结构相关参数,拟合得到ICL拱高预测新模型,评价新模型的准确性。方法研究一:选取2021年3月至2024年10月在爱尔眼科重庆眼视光眼科医院就诊拟行ICL植入术的健康屈光不正中青年人群102人(141眼),收集UBM检查的眼后房结构并测量相关参数,比较男性与女性及2、4、8、10点位置间后房结构参数的差异,并寻找影响眼后房结构的因素,使用SPSS(26.0)软件进行统计分析。男性与女性间的结构参数比较采用独立样本t检验或Mann-whitney U检验,4个象限间均数比较采用单因素方差分析,眼后房结构参数平均值与年龄、眼轴(AL)、中央前房深度(ACD)、白到白(WTW)的相关性采用Pearson相关系数检验分析,以P<0.05为差异有统计学意义。研究二:选取2021年3月至2021年12月在爱尔眼科重庆眼视光眼科医院就诊并实施ICL植入术的患者78人(101眼),收集其术前眼部结构参数及UBM测量的2、4、8、10点位眼后房结构参数,根据术后1月复查时拱高的高低分为三组:低拱高组(<250μm)、正常拱高组(250～1000μm)和高拱高组(>1000μm)。使用SPSS(26.0)对数据进行分析,3组间眼后房结构参数及基本资料比较采用单因素方差分析,以P<0.05为差异有统计学意义。研究三:选取2021年3月至2021年12月在爱尔眼科重庆眼视光眼科医院就诊并实施ICL植入术的患者70人(89眼),收集其术前包括UBM测量的后房结构在内的眼部结构参数,于术后一月使用UBM观察ICL襻位置,对襻位置进行描述性统计分析,并选取同一时间段的ICL植入术患者80人(127眼),根据术后一月ICL襻所在位置分为三组:睫状沟组,睫状体组,睫状体下组。使用SPSS(26.0)软件进行数据统计分析,三组襻位置间的各生物参数比较采用单因素方差分析,以P<0.05为差异有统计学意义。研究四:收集2021年03月至2022年12月于爱尔眼科重庆眼视光眼科医院就诊并实施ICL植入术的患者70人(92眼),收集其术前眼部结构参数,于术后一月测量拱高,使用SPSS(26.0)软件进行数据统计分析,采用Spearman相关分析和简单线性回归关系评估拱高与术前眼部生物参数的相关性,采用多元逐步回归分析构建预测拱高的模型。收集2023年01月至2024年10月于同院就诊并实施ICL植入术的患者140人(204眼),于术后1个月测量拱高,收集其术前眼部生物参数,并用UBM测量小梁-睫状突角(TCA),用新模型计算出预测拱高,评估预测拱高中达到正常拱高(250μm-1000μm)眼的百分比,采用组内相关系数(ICC)、Bland-Altman检验、95%可信区间(95%CI)和95%一致性界限(95%Lo A)评价新模型预测拱高与实际拱高的一致性和准确性。结果研究一:纳入102人(141眼),男性47人(70眼),女性55人(71眼),经统计分析发现,男女两组间睫状体最厚处(CBTmax)、小梁-睫状突距离(TCPD)、虹膜-晶状体悬韧带距离(IZD)、虹膜-晶状体角(θ)之间比较有统计学意义(P<0.05),女性的CBTmax比男性大0.07mm(P=0.02,95%CI:-0.12mm--0.01mm),女性TCPD比男性大0.18mm(P=0.000,95%CI:-0.26mm--0.06mm),女性IZD比男性大0.11mm(P<0.000,95%CI:-0.16mm--0.06mm),女性θ比男性大1.30°(P<0.01,95%CI:-2.23°--0.36°)。4个象线的眼后房各参数比较发现虹膜-睫状突距离(ICPD)和虹膜-晶状体悬韧带距离(IZD)间比较有统计学意义(P<0.05),颞上象线比鼻下象线的ICPD大0.06mm,其中IZD最大的是颞上象限,其次是颞下象限,最小的是鼻下象限。各眼后房结构参数与各生物参数的相关性研究结果显示年龄与TCA成正相关关系(P<0.05),等效球镜与ICPD成正相关关系(P<0.05),眼轴与TCA、θ成正相关关系(P<0.05),WTW与TCA、TCPD、ICPD成负相关关系(P<0.05),ACD与ICPD成正相关关系(P<0.05)。研究二:总纳入屈光不正患者78人(101眼),低拱高组26人(31眼),正常拱高组20人(37眼),高拱高组32人(34眼),三组间CBTmax、TCA、IZD、WTW、ACD差异有统计学意义(P<0.05),拱高随着CBTmax的增加而增加(F=5.03,P=0.01),随着TCA的减小而增加(F=8.87,P<0.0001)。研究三:总纳入患者70人(89眼),低拱高组24人(27眼),正常拱高组18人(34眼),高拱高组28人(28眼),三组ICL襻所在位置的描述性统计结果显示高拱高组中ICL襻主要位于睫状沟(70.54%),正常拱高组和低拱高组的ICL襻主要位于睫状体(61.76%)和(63.89%),位于睫状体下最多的是低拱高组(23.15%)。襻位置与拱高存在明显相关性(χ~2=98.73,P<0.001)。根据襻位置分成的三个组中,睫状沟组34人(47眼),睫状体组26人(42眼),睫状体下组20人(38眼),三组间拱高、WTW、ACD、等效球镜(SE)、前房容积(ACV)、晶状体厚度(LT)、矢高(CLR)、CBTmax、TCA、ICPD比较有统计学意义(P<0.05),襻位于睫状沟的拱高最高,屈光度数越高,襻越容易位于睫状体下,襻在睫状体下的LT最厚、CLR最大,襻在睫状体下的ACV比在睫状沟大39.46mm~3,襻在睫状沟的CBTmax比在睫状体下大0.15mm,襻在睫状体的CBTmax比在睫状体下大0.14mm,襻在睫状沟的TCA比在睫状体小11.69°,比在睫状体下小16.09°,襻在睫状沟的ICPD最大,在睫状体下最小。研究四:纳入预测模型的样本量为70人(92眼),平均年龄(28.18±7.07)岁,与术后拱高成正相关的是SE、WTW、ACD、ACV、睫状沟水平径(h STS)、瞳孔直径和CBTmax,与拱高成负相关的是年龄、眼压、CLR和TCA(p<0.05)。简单线性回归分析结果显示,与拱高有统计学意义的是年龄、SE、CBTmax、TCA、WTW、ACD、v STS和CLR(P<0.05)。多元逐步回归分析结果显示拱高的解释变量为ICL尺寸、WTW、ACD和TCA。回归方程为:中央拱高(μm)=-1711.69-166.80×ICL尺寸+378.62×WTW+506.75×ACD-11.75×TCA,调整R~2为0.54。纳入验证组的患者140人(204眼),实际拱高为(579.06±192.38)μm,预测拱高为(767.96±226.51)μm,预测误差68.14%(139/204)在±300以内,95.10%(194/204)在±500μm以内。在标准拱高(250-1000μm)的占比是88.24%(180/204),预测拱高与实际拱高的相关系数为0.51(P<0.01)。预测与实际拱高的偏倚为203.20μm,95%一致性界限(95%Lo A)为-175.30～581.70,偏倚的标准差(SD)为193.10,预测拱高与实际拱高的ICC为0.51(95%CI:0.40,0.60)。结论1.健康屈光不正中青年人群的眼后房结构表现为睫状体在颞侧象限增厚、鼻侧象限变薄。睫状体位置在鼻侧位置更靠前,颞侧更靠后;眼轴越长,睫状体位置越靠后,自身晶状体与虹膜间的距离越大。2.ICL植入术后拱高与眼后房结构密切相关,随着CBTmax的降低、TCA和ICPD的增加,拱高逐渐降低。ICL植入术后,睫状体越薄、位置越靠后,拱高越低。3.ICL植入术后襻位置与拱高和眼后房结构参数密切相关,CBTmax越小、TCA及ICPD越大,ICL襻越容易位于睫状体下方。即睫状体越薄、位置越靠后,其襻位置越容易位于睫状体下方,低拱高的风险也就越大。4.纳入眼后房结构参数TCA的拱高预测模型可以作为选择ICL尺寸的新方法。总体而言,本研究首次对眼后房结构参数与ICL植入术后拱高和位置的相关性进行了全面的研究,结果显示眼后房结构对ICL植入术后拱高和位置有明确的影响,纳入眼后房结构参数的拱高预测模型为ICL植入术尺寸的选择提供了新方法。更多还原

【Abstract】 ObjectiveThe study intends to explore the correlation between the posterior chamber structure and the vault and haptic position after implantable collamer lens(ICL)implantation,to provide a new model with parameters of the posterior chamber structure of the eye for the selection of the appropriate size of ICL,and to provide another option for ICL size selection.1.To evaluate the characteristics of the posterior chamber structure in young and middle-aged people with refractive errors,and to analyze its influencing factors to compensate for the lack of structural characteristics of the posterior chamber in young and middle-aged people with refractive errors,and lay the foundation for the study of abnormal vaulting and abnormal haptic position after posterior chamber phakic intraocular lens(ICL)implantation.2.To explore the correlation between the posterior chamber structure and the vault after ICL implantation,observe the position of the haptic after ICL implantation,and analyze the ocular biological parameters related to the position of the haptic,including the posterior chamber structure,to reduce the incidence of the abnormal vault and the rate of secondary surgery.3.A new prediction model of the ICL vault including parameters of the posterior chamber structure was fitted,and the accuracy of the new model was evaluated.MethodsStudy 1 Patients scheduled to undergo ICL implantation at the Chongqing Eye and Vision Care Hospital,Aier Eye Hospital Group from March 2021 to October 2024 were selected.The structural parameters of the posterior chamber were collected and measured by UBM.The differences in structural parameters between males and females,and between four quadrants,and the factors affecting the structure of the posterior chamber were found.SPSS(26.0)software was used for statistical analysis.Independent samples t-test or Mann-Whitney U test was used to compare the structural parameters between males and females,one-way ANOVA was used to compare the means of four quadrants,and the Pearson correlation coefficient test was used to analyze the correlation between the means of structural parameters and age,axial length(AL),central anterior chamber depth(ACD),white-to-white(WTW).P<0.05 was considered statistically significant.Study 2 101 eyes of 78 patients who underwent ICL implantation at the Chongqing Eye and Vision Care Hospital,Aier Eye Hospital Group from March 2021 to December 2021were selected.The preoperative ocular structural parameters and the posterior chamber structural parameters measured by UBM at 2,4,8,and 10 o’clock positions were collected.The patients were divided into three groups according to the vault level at 1month after surgery:low vault group(<250μm),normal vault group(250-750μm),and high vault group(>1000μm).SPSS(26.0)was used to analyze the data.One-way ANOVA was used to compare the structural parameters and basic data among the three groups,and P<0.05 was considered statistically significant.Study 3 Ninety-two eyes of 70 patients who underwent ICL implantation at the Chongqing Eye and Vision Care Hospital,Aier Eye Hospital Group from March 2021 to December 2021 were included.Collecting preoperative ocular structural parameters,including posterior chamber structural parameters measured by UBM.According to the location of ICL haptics one month after surgery,the patients were divided into three groups:ciliary sulcus group,ciliary body group,and under ciliary body group.SPSS(26.0)software was used for data statistical analysis.One-way ANOVA was used to compare the biological parameters between the three groups of haptics locations,and P<0.05 was considered statistically significant.Study 4 70 patients(92 eyes)who underwent ICL implantation surgery at the Chongqing Eye and Vision Care Hospital,Aier Eye Hospital Group from March 2021 to December2022 were included in the study.Preoperative ocular structural parameters were collected,and the vault was measured one month after surgery.SPSS(26.0)software was used for data statistical analysis.Spearman correlation analysis and simple linear regression were used to evaluate the correlation between vault and preoperative ocular parameters.Multiple stepwise regression analysis was used to construct a model to predict the vault.140 patients(204 eyes)who underwent ICL implantation surgery at Aier Ophthalmology Chongqing Ophthalmology Hospital from January 2023 to October 2024 were included.Preoperative eye examinations were completed,and their TCA was measured using UBM.The vault was measured one month after surgery.The percentage of eyes with normal vault(250μm-1000μm)was evaluated,and the interclass correlation coefficient(ICC),Bland Altman test,95%confidence interval(95%CI),and 95%limit of agreement(95%Lo A)were used to assess the consistency and accuracy of the new model’s predicted vault with the actual vault.ResultsStudy 1 A total of 104 subjects(141 eyes)were included,47 males(70 eyes)and 55females(71 eyes).There were significant differences in the maximum ciliary body thickness(CBTmax),trabecular ciliary process distance(TCPD),Iris-zonule distance(IZD),and iris-lens angle(θ)between male and female groups(P<0.05).CBTmax and TCPD of females were 0.07mm(95%CI:-0.12mm--0.01mm)and 0.18 mm(95%CI:-0.26mm--0.06mm)greater than those of males,respectively.IZD of females was0.10mm(95%CI:-0.15mm--0.06mm)greater than that of males,andθof females was1.3°(95%CI:-2.23°--0.36°)greater than that of males.The iris-ciliary process distance(ICPD)and IZD of the four image lines were statistically significant(P<0.05).The ICPD was 0.06mm greater in the superior temporal than in the inferior nasal image line,with the largest IZD in the superior temporal quadrant,followed by the inferior temporal quadrant,and the smallest in the inferior nasal quadrant.There was a positive correlation between age and TCA,a positive correlation between spherical equivalent(SE)and ICPD,a positive correlation between axial length(AL)and TCA,θ,a negative correlation between WTW and TCA,TCPD,ICPD,and a positive correlation between ACD and ICPD.Study 2 A total of 78patients(101 eyes)with ametropia were enrolled,including 26patients(31 eyes)in the low vault group,20 patients(37 eyes)in the normal vault group,and 32 patients(34 eyes)in the high vault group.There were significant differences in CBTmax,IZD,TCA,WTW,and ACD among the three groups(P<0.05).As CBTmax increased and TCA decreased,the vault gradually increased.Study 3 A total of 70 patients(89 eyes)were enrolled,including 24 patients(27 eyes)in the low-vault group,18 patients(34 eyes)in the normal-vault group,and 28 patients(28eyes)in the high-vault group.Descriptive statistical results showed that the ICL haptics were mainly located in the ciliary sulcus in the high-vault group(70.54%).The ICL haptics was mainly located in the ciliary body(61.76%)and(63.89%)in the normal vault group and the low vault group,and most ICL haptics were located under the ciliary body in the low vault group(23.15%).There was a significant correlation between haptics position and vault(χ2=98.73,P<0.01).They were divided into three groups according to the location of the haptics:34 people(47 eyes)in the ciliary sulcus.There were 26patients(42 eyes)with haptics in the ciliary body and 20 patients(38 eyes)with haptics under the ciliary body.There were significant differences in the vault,WTW,ACD,spherical equivalent(SE),anterior chamber volume(ACV),Lens thickness(LT),crystalline lens rise(CLR),CBTmax,TCA,and ICPD among the three groups(P<0.05),and the vault of haptics in ciliary sulcus was the highest.The higher the diopter,the more likely the haptics were to be located under the ciliary body.The LT of the haptics under the ciliary body were thickest;The CLR of the haptics under the ciliary body was the largest.The ACV of the haptics under the ciliary body was 39.46mm~3 larger than that in the ciliary sulcus.The CBTmax of the haptics in the ciliary sulcus was 0.15mm larger than that in the ciliary body,and the CBTmax of the haptics in the ciliary body was0.14mm larger than that in the ciliary body.The TCA of the haptics in the ciliary sulcus was 11.69°less than that in the ciliary body,and the TCA of the haptics in the ciliary sulcus was 16.09°less than that under the ciliary body.The ICPD of the haptics was greatest in the ciliary sulcus and smallest under the ciliary body.Study 4 The sample size included in the prediction model was 70 subjects(92 eyes)with a mean age of(28.18±7.07)years.SE,WTW,ACD,ACV,h STS,pupil diameter and CBTmax were positively correlated with vault(P<0.05),Age,intraocular pressure,CLR,and TCA were negatively correlated with vault(P<0.05).The results of simple linear regression analysis showed that age,SE,CBT max,TCA,WTW,ACD,v STS,and CLR were statistically significant about vault(P<0.05).Multiple stepwise regression analysis showed that the explanatory variables related to the vault were ICL size,WTW,ACD,and TCA.The regression equation was:Central vault(μm)=-1711.69-166.80×ICL size+378.62×WTW+506.75×ACD-11.75×TCA,adjusted R~2=0.54.140 subjects(204 eyes)were included in the validation combination.The actual vault was(579.06±192.38)μm,and the predicted vault was(767.96±226.51)μm,with a prediction error of68.14%(139/204)within±300 and 95.10%(194/204)within±500μm.The percentage of reaching the standard vault(250-1000μm)was 88.24%(180/204),the correlation coefficient between the predicted vault and the actual vault was 0.51(P<0.01).The bias between the predicted and actual vault was 203.20μm,with a 95%Lo A of(-175.30-581.70)μm and a standard deviation(SD)of 193.10μm,the ICC between the predicted vault and the actual vault was 0.51(95%CI:0.40,0.60).Conclusion1.The posterior chamber structure of healthy middle-aged and young patients with refractive errors is characterized by thickening of the ciliary body in the temporal quadrant and thinning in the nasal quadrant.The position of the ciliary body is further forward on the nasal side and further backward on the temporal side.The longer the axial length of the eye,the further backward the position of the ciliary body,and the greater the distance between the lens and the iris.2.Vault after ICL implantation is closely related to the structure of the posterior chamber of the eye.As CBTmax decreased and TCA and ICPD increased,the vault gradually decreased.After ICL implantation,the thinner and more posterior the ciliary body,the lower the vault.3.The position of the haptics after ICL implantation is closely related to the vault and posterior chamber structure of the eye,The smaller the CBTmax and the larger the TCA and ICPD,the easier it is for the ICL haptics to be located beneath the ciliary body.The thinner and more posterior the ciliary body,the easier it is for the haptics to be located below the ciliary body,and the higher the risk of low vault.4.The vaulting prediction model incorporating the posterior chamber structural parameter TCA can appropriately reduce the probability of vaulting abnormality after ICL implantation and can be used as a new scheme to select the size of ICL.更多还原