【作者】 王莹；

【导师】 赵少贞；

【作者基本信息】 天津医科大学 ， 临床医学（专业学位）， 2023， 博士

【摘要】 目的:研究有晶状体眼后房型人工晶状体（implantable collamer lens,ICL）植入术中应用改良技术与常规手术的安全性和角膜术源性散光（surgically induced astigmatism,SIA）,原发性虹膜睫状体囊肿患者术后ICL偏心和倾斜,以及ICL术后不同偏心程度对患者的视觉质量的影响。方法:1、选取在天津医科大学眼科医院屈光手术中心行ICL植入手术的患者81例153眼,采用改良手术技巧,包括3 mm透明角膜单切口和ICL植入前免前房黏弹剂技术,作为改良技术组（41例80眼）;采用常规手术方法的作为常规技术组（40例73眼）。两组监测术后2小时和24小时眼压（intraocular pressure,IOP）,术后1个月,6个月,12个月随访观察裸眼远视力（uncorrected distance visual acuity,UDVA）,矫正远视力（corrected distance visual acuity,CDVA）,IOP,ICL拱高,前房深度（anterior chamber depth,ACD）,术后6个月和12个月复查角膜内皮细胞密度（endothelial cell density,ECD）,术后1个月计算角膜前表面、后表面及全角膜SIA,比较两组之间的差异。2、选取在天津医科大学眼科医院屈光手术中心行ICL植入手术的患者48例91眼,通过超声生物显微镜（ultrasound biomicroscopy,UBM）检查按有无虹膜睫状体囊肿,分为有囊肿组和无囊肿组比较。术前,术后1个月,6个月和12个月检测患者UDVA,CDVA,IOP,ACD,前房角开放度（anterior chamber angle,ACA）,前房容积（anterior chamber volume,ACV）,术后1个月,6个月和12个月检测患者ICL拱高,偏心和倾斜。3、选取在天津医科大学眼科医院屈光手术中心行ICL植入手术的患者65例65眼,均选择主视眼进行研究,根据接受ICL的术后偏心程度不同,将其分为两组:第1组,ICL中央孔距角膜地形轴（corneal topographic axis,CTA）在1个孔直径（hole diameter,HD）以内;第2组,ICL中央孔距CTA在1个HD到2个HD之间。术后6个月,比较两组患者UDVA,CDVA,等效球镜（spherical equivalent,SE）,IOP,ACD,ACA,ACV,ICL拱高以及4.0 mm瞳孔的眼调制传递函数（objective scatter index,MTF）,斯特列尔比（Strehl ratio）和客观散射指数（objective scatter index,OSI）。结果:1、两组在各时间点的UDVA,CDVA,ICL拱高,ACD的差异无统计学意义（P>0.05）。改良技术组术后2小时IOP（16.22±2.22 vs.18.37±1.92 mm Hg,P<0.05）明显低于常规技术组。术后24小时IOP逐渐恢复至术前水平,且术后12个月内IOP平稳。各组间术后6个月和12个月的角膜ECD差异无统计学意义（P>0.05）。术后1个月两组角膜前表面、后表面及全角膜SIA的比较差异无统计学意义（P>0.05）。2、有囊肿组与无囊肿组比较:两组术后UDVA均较术前有显著改善（P<0.05）,但两组在整个随访期间差异无统计学意义（P>0.05）。两组患者术后ACD,ACA和ACV值与术前比较差异有统计学意义（P<0.05）,两组术后值比较差异无统计学意义（P>0.05）。术后1个月,6个月和12个月,两组IOP,ACD,ACA,ACV,ICL拱高,偏心和倾斜比较,差异均无统计学意义。两组ICL偏心和倾斜与CDVA无显著相关性（P>0.05）。3、患者术后UDVA和CDVA均较术前有显著改善（P<0.05）,两组术后UDVA,CDVA和SE组间比较,差异无统计学意义（P>0.05）。所有患者术后ACD,ACA和ACV值均低于术前,差异有统计学意义（P<0.05）。两组术后IOP,ACD,ACA ACV和ICL拱高组间比较,差异无统计学意义（P>0.05）。两组术后的MTF _cutoff,Strehl ratio和OSI组间比较,差异无统计学意义（P>0.05）。结论:1、ICL植入术中采用的改良方法安全有效,在视觉和眼前段结构方面的效果可与常规手术媲美,且不会增加角膜内皮细胞的损伤,同时减少术后早期阶段的眼压波动,常规手术的辅助侧切口不会增加术源性角膜散光,对于经验不足的手术医生可以选择做辅助侧切口。2、原发性虹膜睫状体囊肿没有增加术后ICL的偏心和倾斜,患者术后ICL一定限度内的偏心和倾斜可能对视力没有影响。3、ICL中央孔存在一定范围内的偏心,ICL术后一定范围内的偏心程度对患者的视觉质量没有影响,ICL植入均可提供良好的视觉质量。更多还原

【Abstract】 Objective:To investigate the application effect of the modified technique and its impact on the change in corneal astigmatism in implantable collamer lens（ICL）implantation,the decentration and tilt of ICL post-implantation in primary iridociliary cysts,and the visual quality according to different degrees of decentration.Methods:1、A total of 81 patients（153 eyes）that underwent ICL surgery at the Center of Refraction Surgery of Tianjin Medical University Eye Hospital were included.An ICL was inserted by modified surgical skills,including a single 3.0 mm corneal incision and no ophthalmic viscosurgical device（OVD）before the insertion of the ICL（modified technique group:41 cases,80 eyes）and standard procedure（standard technique group:40 cases,73 eyes）.Early postoperative intraocular pressure（IOP）was monitored at 2 and 24 h.The uncorrected distance visual acuity（UDVA）,corrected distance visual acuity（CDVA）,IOP,ICL vault,and anterior chamber depth（ACD）were measured 1,6,and 12 months following the initial examination.The corneal endothelial cell density（ECD）was monitored at 6 and 12 months after the operation.Surgically induced astigmatism（SIA）in the total,anterior,and posterior corneal surfaces was analysed 1 month after the operation.2、A total of 48 patients（91 eyes）that underwent ICL surgery at the Center of Refraction Surgery of Tianjin Medical University Eye Hospital were split into two groups based on the absence or presence of primary iridociliary cysts established by ultrasonic biological microscopy（UBM）examination.UDVA,CDVA,IOP,ACD,ACA,ACV were recorded pre-and postoperatively at 1,6,and 12 months.Additionally,we performed an analysis of the ICL vault,decentration,and tilt using a rotating Scheimpflug Oculus Pentacam camera system at 1,6,and 12 months after surgery.3、A total of 65 patients（65 eyes）that underwent ICL surgery at the Center of Refraction Surgery of Tianjin Medical University Eye Hospital were divided into two groups according to the degree of decentration of central hole of ICL:group 1,the central hole was within 1 hole diameter（HD）from the CTA,and group 2,the distance between the central hole and the CTA was between 1HD and 2 HD.UDVA,CDVA,spherical equivalent（SE）,IOP,ACD,ACA,ACV,ICL vault and modulation transfer function（MTF）,Strehl ratio and objective scatter index（OSI）in 4.0 mm pupil size were measured at 6 months after surgery.Result:1、The two groups had no difference in visual outcomes,ICL vaults,or ACD at any time point（P>0.05）.Two hours postoperatively,IOP was significantly lower in the modified technique group（16.22±2.22 vs.18.37±1.92 mm Hg,P<0.05）than in the standard technique group.IOP decreased gradually after 24 h to preoperative levels.The postoperative IOP remained stable over a 12-month period.The ECD at 6 and 12months was not significantly different between the groups（P>0.05）.SIA in the total,anterior,and posterior corneal surfaces were assumed to have no clinically meaningful differences between groups at one month after operation（P>0.05）.2、Significant postoperative improvement（P<0.05）of UDVA was established in the two studied groups;however,we did not observe statistically significant intergroup differences（P>0.05）throughout the entire research period.In each group,the preoperative ACD,ACA,and ACV were statistically significantly reduced （P<0.05）,but no such decrease was established between their postoperative values（P>0.05）.We observed no statistical differences between both groups about theirvalues of IOP,ACD,ACA,ACV,ICL vault,ICL decentration,and tilt at 1,6,and 12months after surgery.Similarly,no statistically significant within-group correlation（P>0.05）of the decentration of ICL and the tilt and the CDVA values was established.3、The postoperative UDVA and CDVA were significantly improved compared with their preoperative values（P<0.05）,but there was no significant difference in postoperative UDVA,CDVA and SE between the two groups（P>0.05）.The values of ACD,ACA and ACV in all patients after surgery were significantly lower than their preoperative values（P<0.05）.No significant difference was found in postoperative IOP,ACD,ACA,ACV and ICL vault between the two groups（P>0.05）.There was no significant difference in postoperative MTF _cutoff,Strehl ratio and OSI between the two groups（P>0.05）.Conclusion:1、The modified technique is efficient and safe,producing comparable visual and structural outcomes without adversely affecting ECD,and reduces fluctuations in IOP at the early postoperative stages.The auxiliary incision in the standard technique does not increase corneal SIA,which is also a factor to consider for inexperienced surgeons.2、Primary iridociliary cysts does not increase the decentration and tilt of postoperative ICL,within certain limits of ICL decentration and tilt values may not affect the visual acuity.3、There is a certain range of decentration of central hole of ICL,and different degrees of decentration in a certain range after ICL surgery had no effect on the visual quality of the patients,indicating that ICL implantation can provide satisfactory visual quality.更多还原