【作者】 李玮；

【导师】 吴强；

【作者基本信息】 上海交通大学 ， 眼科学， 2016， 硕士

【摘要】 目的:探讨不同类型糖尿病黄斑水肿(DME)患病率以及不同分型方法的相关性,并分析黄斑区视网膜厚度与视力的相关性及影响DME发生发展的全身相关危险因素,以期延缓其发生发展,保存视力。方法:对2015年1月至2015年11月在上海市第六人民医院眼科门诊诊断为DR的Ⅱ型糖尿病患者135例(242眼)的临床资料进行回顾性分析总结。根据眼底荧光血管造影(FFA)、光学相干断层扫描(OCT)及眼底摄片结果对糖尿病视网膜病变(DR)和DME进行诊断,并对DR进行分期,对DME进行分型。DME根据FFA结果分为三型:局限渗漏型、弥漫渗漏型和囊样弥漫渗漏型。根据OCT结果分为四型:海绵样水肿型(SME)、囊样水肿型(CME)、浆液脱离型(SRD)及牵拉水肿型(PHT)。分析各分型的患病率,两种分型结果的相关性,不同类型DME与DR分期的关系以及黄斑区视网膜厚度与视力的相关性,并从患者年龄、性别、体重质量指数(BMI)、糖尿病病程、空腹血糖、HbA1c、高血压病程、血压(收缩压、舒张压、脉压差)、血脂(四项)、微量白蛋白尿、蛋白尿、贫血(Hb)、吸烟史、胰岛素使用年限等方面分析不同类型DME的危险因素,采用SPSS 19.0统计学软件包对结果进行分析处理。结果:1.135例(242眼)DR患者中,轻度NPDR 75眼(30.99%,75/242),中度NPDR 79眼(32.64%,79/242),重度NPDR 56眼(23.14%,56/242),PDR 32眼(13.23%,32/242);根据OCT分型:无黄斑水肿(NME)43眼(17.77%,43/242),黄斑水肿199眼(82.23%,199/242),其中SME 165眼(68.18%,165/242),CME 22眼(9.09%,22/242),SRD 7眼(2.89%,7/242),PHT 5眼(2.07%,5/242);而根据FFA分型局限性渗漏共135眼(55.79%,135/242),弥漫性渗漏69眼(28.51%,69/242),囊样弥漫性渗漏14眼(5.78%,14/242),无渗漏24眼(9.92%,24/242),各分型所占比例具有显著差异(p<0.0001)。2.DR各分期中均有DME发生,且DME发生率随DR分期呈增长趋势,差异具有统计学意义(x~2)=21.077,p<0.0001)。3.FFA和OCT两种分型中各型DME患者在DR各分期中所占比例不同,差异具有统计学意义(p<0.0001)。4.在对FFA和OCT分型的对比研究中发现:FFA分型中的局限性及弥漫性渗漏均多表现为OCT分型中的海绵样水肿,而囊样弥漫性渗漏多表现为OCT分型中的囊样水肿,差异具有统计学意义(p<0.0001)。5.135例(242眼)DR患者平均最佳矫正视力(BCVA)为LogMAR(0.29±0.27),黄斑区视网膜平均厚度为(331.65±53.16)μm,黄斑区视网膜平均容积为(1.023±0.16)μm~3,经过Pearson相关分析,患者视力与黄斑区视网膜厚度及容积具有显著相关性(p<0.0001)。6.OCT分型中,各型黄斑水肿患者平均BCVA为:SME=LogMAR(0.29±0.23),CME=LogMAR(0.57±0.30),SRD=LogMAR(0.61±0.35),PHT=LogMAR(0.54±0.43),NME=LogMAR(0.24±0.26)μm;视网膜平均厚度值分别为:SME=(323.21±24.85)μm,CME=(418.85±95.25)μm,SRD=(422.25±109.83)μm,PHT=(369.44±42.16)μm,NME=(296.57±21.42)μm;视网膜平均容积值分别为:SME=(0.999±0.09)μm~3,CME=(1.256±0.28)μm~3,SRD=(1.249±0.28)μm~3,PHT=(1.196±0.15)μm~3,NME=(0.927±0.07)μm~3;各型水肿患者的平均BCVA、视网膜平均厚度及容积均有显著差异,具有统计学意义(P<0.0001)7.对全身各因素进行单因素分析发现:与DME相关的危险因素有性别、糖尿病病程、胰岛素治疗、HbA1c、吸烟、HDL-C、蛋白尿以及贫血;而以OCT分型,与SME相关的危险因素有性别、糖尿病病程、胰岛素治疗、HbA1c、吸烟史、HDL-C及蛋白尿;与CME相关的危险因素有糖尿病病程、胰岛素治疗、TC及蛋白尿;与SRD相关的危险因素有糖尿病病程、HbA1c、脉压差、HDL-C;而与PHT相关的危险因素有糖尿病病程、蛋白尿及贫血。以上各危险因素在与NME组的对比分析中均具有统计学差异(p<0.05)。8.对各危险因素进行Logistic回归分析结果显示DME的独立危险因素有糖尿病病程(OR=1.090;95%CI1.006,1.181),HbA1c(OR=1.510;95%CI1.087,2.099)及蛋白尿(OR=4.123;95%CI1.189,14.302)。OCT分型中,SME的独立危险因素有糖尿病病程(OR=1.092;95%CI1.004,1.188),HbA1c(OR=1.445;95%CI 1.024,2.039)及蛋白尿(OR=3.942;95%CI1.098,14.152),CME的独立危险因素为蛋白尿(OR=5.146;95%CI 1.094,24.211),而SRD的独立危险因素为HbA1c(OR=2.337;95%CI 1.063,5.139)。结论:1.DME可发生在DR各期,并随DR病变程度加重患病率增加。而在OCT分型中,SME所占比例最多,其多发生在轻中度NPDR期,其他三种类型相对较少,多发生在中重度NPDR及PDR期;FFA分型中局限性渗漏所占比例最多,其多发生在轻中度NPDR期,而弥漫性和囊样弥漫性次之,多发生在中重度NPDR及PDR期。2.FFA和OCT两种检查方法对DME的诊断重合率高达92.15%,两种分型方法具有一定的对应关系。3.DME患者的视力与黄斑区视网膜厚度及容积呈负相关。其中,OCT分型中SRD组患者的平均视网膜厚度最厚,SME组最薄,均比NME组增厚。而CME组患者的平均视网膜容积最大,SME组最小,均比NME组大。而SRD组患者的BCVA最差,SME组最好,但均比NME组降低。4.糖尿病病程是DME及OCT各分型的共同危险因素,性别、胰岛素治疗、HbA1c、吸烟、HDL-C以及蛋白尿是DME及分型SME发生的共同危险因素,而贫血也同样是DME的危险因素;另外,胰岛素治疗、TC、蛋白尿是CME发生的危险因素;HbA1c、脉压差、HDL-C为SRD发生的危险因素;蛋白尿及贫血为PHT发生的危险因素。5.糖尿病病程、HbA1c及蛋白尿是DME及其分型SME的共同独立危险因素,另外CME的独立危险因素为蛋白尿,而HbA1c为SRD的独立危险因素。更多还原

【Abstract】 PURPOSE: To elucidate the prevalence for different types of diabetic macular edema(DME)and relationship between different typing methods,then analyze the correlation between retinal thickness and visual acuity and the risk factors for DME,in order to delay thedevelopment of DME and save patients’ visual acuity.METHODS: The clinical and follow-up data of 135 patients(242 eyes)who were diagnosed diabetic retinopathy(DR)during January 2015 to November 2015 were reviewed.DR and DME were diagnosed based on the optical coherence tomography(OCT),fundus fluorescein angiography(FFA)andphotography,and they were divided into diffirent DME types and diffirent DR stages.DME were divided into three types according to FFA tests: focal leakage,diffuse leakage and diffuse cystoid leakage.And based on OCT tests they were divided into four types:sponge-like swelling macular edema(SME),cystoid macular edema(CME),serous retinal detachment(SRD)and posterior hyaloidal traction(PHT).Analyze the correlation betweenmacular thickness and visual acuity and the relationship between different types of DME and DR stages.Thenelucidate risk factors for diffirent types of DMEfrom the aspect of sex,age,body mass index(BMI),diabetes duration,fasting blood glucose,glycated hemoglobin(HA1c),duration of hypertension,blood pressure(systolic blood pressure,diastolic blood pressure,pulse pressure),hyperlipidemia(four types),microalbuminuria,proteinuria,anemia(Hb),smoking history andinsulin use.Results:1.Of all the 135 DR patients(242 eyes),75 eyes(30.99%)with mild NPDR,79 eyes(32.64%)with moderate NPDR,56 eyes(23.14%)with severe NPDR and 32 eyes(13.23%)with PDR;The proportion of OCT types: 43 eyes(17.77%)with no macular edema(NME),and 199eyes(82.23%)with macular edema,including165 eyes(68.18%)with SME,22 eyes(9.09%)with CME,7 eyes(2.89%)with SRD and 5(2.07%)with PHT;The proportion of FFA types:135 eyes(55.79%)with focal leakage,69 eyes(28.51%)with diffuse leakage,14 eyes(5.78 %)with diffuse cystoid leakage and24 eyes(9.92%)with no leakage.The proportion of each types were in different degrees(p <0.0001).2.DME can occur in every DR stage,anditsproportion ineach stage was in a increasing trend,there was a statistically significant difference(p <0.0001).3.The proportion of each type of DME patientsin different stages of DR was in a statistically significant difference(p <0.0001).4.We found that in the comparative study of FFA and OCT types,focal and diffuse leakage in FFA results are most performance for the sponge-like edema in OCT tests,and diffuse cystoid leakage most forcystoid edema,the difference was statistically significant(p <0.0001).5.Theaverage best-corrected visual acuity(BCVA)of 135 cases(242eyes)was Log MAR(0.29 ± 0.27),average macular thickness was(331.65 ± 53.16)μm,and the mean macular volume was(1.023 ± 0.16)μm3,with Pearson correlation analysis,we got a significant correlation between visual acuity and retinal thickness and macular volume(p<0.0001).6.The average BCVA of each OCT type were : SME = Log MAR(0.29 ± 0.23),CME =Log MAR(0.57 ± 0.30),SRD = Log MAR(0.61 ± 0.35),PHT = Log MAR(0.54 ± 0.43),NME =Log MAR(0.24 ± 0.26)μm;average macular thickness were: SME =(323.21 ± 24.85)μm,CME=(418.85 ± 95.25)μm,SRD =(422.25 ± 109.83)μm,PHT =(369.44 ± 42.16)μm,NME =(296.57 ± 21.42)μm;and average macular volume were: SME =(0.999 ± 0.09)μm3,CME =(1.256 ± 0.28)μm3,SRD =(1.249 ± 0.28)μm3,PHT =(1.196 ± 0.15)μm3,NME =(0.927 ± 0.07)μm3.There were significantly different in mean BCVA,macular thickness and volume of diffirent OCT types(P <0.0001).7.Inunivariate analysis,the risk factors associated with DME were sex,diabetes duration,insulin use,Hb A1 c,smoking,HDL-C,proteinuria and anemia;and SME-related risk factors include sex,diabetes duration,insulin use,Hb A1 c,smoking,HDL-C and proteinuria;CME-related risk factors were diabetes duration,insulin use,TC and proteinuria;SRD associated risk factors include diabetes duration,Hb A1 c,pulse pressure and HDL-C;and diabetes duration,proteinuria and anemia for PHT.Each of the above risk factors were statistically different from NME group(p <0.05).8.Logistic regression analysis showed that independent risk factors for DME werediabetes duration(OR=1.090;95%CI1.006,1.181),Hb A1c(OR=1.510;95%CI1.087,2.099)andproteinuria(OR=4.123;95%CI1.189,14.302)。The independent risk factorfor SME include diabetes duration(OR=1.092;95% CI 1.004,1.188),Hb A1c(OR=1.445;95% CI 1.024,2.039),and proteinuria(OR=3.942;95% CI 1.098,14.152);and proteinuria(OR=5.146;95% CI 1.094,24.211)and Hb A1c(OR=2.337;95% CI 1.063,5.139)for CME and SRD,respectively.CONCLUSION:1.DME can occur in every DR stages,and the prevalence increased with the aggravation of disease.SME of OCT type andfocal leakage of FFA type was in a highest rate,and theymostly occurredin mild and moderate NPDR,other types were relatively small,and they mostly occurs in severe NPDR and PDR stages.2.The coincidence diagnosis rate of these two tests was reach up to 92.15%.Two kinds of typing methods have a certain relationship.3.Visual acuity was negatively correlated withmacualr thickness and volume.The average macular thickness of SRD patients was thickest,SME was the thinnest,but all were thicker than NME.The average macular volume of CME was the largest,SME wasthe smallest,but allwere larger than NME.And the BCVA of SRD wasthe worst,SME was the best,but all wereworse than NME.4.Diabetes duration isthe common risk factors for DME and diffirent OCT types;sex,insulin use,Hb A1 c,smoking,HDL-C and proteinuria are the common risk factors for DME and SME;and anemia is also a risk factorfor DME,in addition,insulin use,TC andproteinuriaarethe risk factors for CME;Hb A1 c,pulse pressure and HDL-C for SRD;proteinuria and anemia for PHT.5.Diabetes duration,Hb A1 c and proteinuriaare the independent risk factors for DME and SME;proteinuriaand Hb A1 c for CME and SRD,respectively.更多还原