近视眼LASIK术后调节变化及手术前后调节致眼前节结构变化的比较
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摘要
研究背景准分子激光角膜原位磨镶术(Laser in situ keratomileusis, LASIK)是目前近视眼治疗的最主流手术,随着我国及亚洲各国近视发病率的逐年上升,每年全球约有数以百万计的近视患者接受该手术的治疗。科技的不断进步和人们生活需求的日益提高,近视治疗手术已经远非当初只是满足“摘掉眼镜”的需求了,人们不仅要求术后能看得清楚,而且还要求看清楚的同时,还要看得舒适和持久。LASIK术后早期近距离阅读困难及视觉疲劳症状的频发,对患者术后的生活和视觉质量存在不同程度的干扰。虽然有报道LASIK术后调节幅度等调节功能有一定变化,但对调节功能的评价均仅局限在一两个方面,不够全面且意见尚存分歧。其中,与调节有关的术后视觉疲劳症状加重和近距离工作困难由于直接影响患者的工作,越来越受到广泛关注。LASIK术后调节功能的改变如何,尚缺乏一致性意见,且其机制尚处于理论推测中。术后视觉质量关系患者的生存和生活质量,广大医学和科技工作者必须高度重视,追求良好的日间视力、清晰的裸眼远视力的同时,还要有良好的夜间视力和持久的近视力(工作视力),研究LASIK手术对近视眼调节的影响,解决术后视觉疲劳症状的发生,以实现这一屈光手术的最终目标。眼前段相干光断层扫描(Optic coherence tomography, OCT)图像分析系统可以定量分析调节时眼前段的结构变化,近视眼手术前后诱导相同的调节发生时,眼前段结构的变化是否存在差异是了解手术前后调节变化的本质所在,目前该问题的研究鲜有报道。本研究将分三个部分就手术前后调节功能各指标的变化以及术后视觉疲劳症状的发生情况的关系、不同程度调节的眼前段OCT眼前段结构的变化以及手术前后发生相同调节时眼前段结构变化的差异等展开研究。
第一部分近视眼LASIK手术对调节功能及视觉疲劳症状的影响
目的：研究近视眼LASIK术后调节幅度、调节灵敏度、相对调节及调节反应的变化,以及与术后视近所致的视觉疲劳症状相关因素的分析。
方法招募年龄在18至39岁拟行LASIK手术的近视患者64例(128眼),按近视程度分为轻中度近视组(<-6.0D)和高度近视组(≥-6.0D),同时根据年龄分成年轻组(<30岁)和年长组(≥30岁),统一行标准的LASIK手术,分别于术前、术后1周、术后1月及术后3月行规范的主觉验光、单眼调节幅度、单眼调节灵敏度、负/正相对调节及调节滞后等检查,并同时行视觉疲劳症状调查评价。
统计学处理采用重复测量的方差分析进行比较手术前及术后3个时期调节功能各指标的差异,两不同组别间各功能指标的比较采用独立样本的T检验进行,术后1周和术后3月视觉疲劳症状的相关因素分析采用线性回归分析进行。
结果64位入选者中,按近视程度分组：轻中度近视组36人,年龄平均(29.53±4.46)岁,术前平均等效球镜度-3.52±1.15D,高度近视组28人,年龄平均(29.57±5.89)岁,术前平均等效球镜度-7.05±0.85D；按年龄分组结果：29岁以下组33人,年龄平均(25.48±2.91)岁,术前平均等效球镜度-5.08±2.13D,30岁以上组31人,年龄平均(33.87±2.81)岁,术前平均等效球镜度-5.05±1.98D。
1.单眼调节幅度：推进法测得的调节幅度值均大于负镜片法测得的值(P均<0.05)。不同方法测得的调节幅度值,术前两个屈光度组间差异均无显著性(T=-1.072,0.192,P均>0.05),负镜片法测得的调节幅度值年龄较长组低于年轻患者组(T=8.041,P=O.000)。两不同程度近视及两不同年龄组内,手术前后单眼调节幅度的差异均有显著性(所有P<0.05),所有组别术后1周单眼平均调节幅度均较术前下降(LSD, P均<0.05)；轻中度近视组术后1月及术后3月单眼平均调节幅度与术前差异无显著性(LSD, P均>0.05),高度近视组术后1月单眼平均调节幅度与术前差异无显著性(LSD, P.均>0.05),而术后3月调节幅度较术前上升(LSD, P.均<0.05)。同时,负镜片法测得的调节幅度,30岁以下组术后1月仍低于术前(LSD, P<0.05)而30岁以上组术后3月高于术前(LSD,P<0.05)。
2.负相对调节：轻中度近视组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.16±0.49D、2.28±0.56D、2.14±0.63D和2.25±0.60D(F=0.682,P=0.565)；高度近视组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.24±0.65D、2.22±0.53D、2.11±0.55D和2.11±0.55D(F=2.023,P=0.117)。两屈光度组术前负相对调节差异无显著性(T=-0.510,P=0.612)。30岁以下组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.07±0.44D、2.09±0.49D、2.09±0.41D和2.29±0.47D(F=2.384,P=0.074)；30岁以上组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.33±0.65D、2.43±0.55D、2.16±0.74和2.31±0.74D(F=1.439,P=0.237)。两年龄组术前负相对调节差异无显著性(T=-1.927,P=0.059)。
3.正相对调节：轻中度近视组手术前、术后1周、术后1月以及术后3月平均正相对调节分别为：4.27±0.79D、3.66±0.88D、4.23±0.88D和4.29±0.86D,(F=30.928,P=0.000)；高度近视组手术前、术后1周、术后1月以及术后3月平均正相对调节分别为：3.88±0.67D、3.31±0.67D、3.97±0.65D和4.39±0.62D(F=39.662,P=0.000)。术前正相对调节轻中度近视组高于高度近视组(T=2.146,P=0.036),不同屈光度组均表现为术后1周正相对调节较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),仅高度近视组术后3月正相对调节较术前升高(LSD,P=0.000).两个年龄组术前正相对调节差异无显著性(T=0.336,P=0.738),各年龄组均表现为术后1周正相对调节较术前下降(LSD,P=均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月正相对调节较术前升高(LSD,P均<0.05)。
4.单眼调节灵活度：轻中度近视组手术前、术后1周、术后1月以及术后3月平均单眼调节灵活度分别为：9.80±2.39CPM.8.16±1.77CPM.9.96±2.09CPM和11.70±2.39CPM(F=183.151,P=0.000);高度近视组手术前、术后1周、术后1月以及术后3月平均调节灵活度分别为：8.42±1.48CPM.6.55±1.15CPM.8.52±1.68CPM和10.07±1.79CPM(F=181.595,P=0.000):两个屈光度组术前单眼调节灵活度差异有显著性,轻中度近视组高于高度近视组(T=2.831,P=0..006),不同屈光度组均表现为术后1周负单眼调节灵活度较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月单眼调节灵活度较术前升高(LSD,P均=0.000)。两个年龄组术前平均单眼调节灵活度差异无显著性(T=0.782,P=0.437)；各年龄组均表现为术后1周平均单眼调节灵活度较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月单眼调节灵活度较术前升高(LSD,P均<0.05)。
5.调节反应：轻中度近视组术前3.0D和5.0D调节刺激水平的调节滞后值分别为：0.61±0.18D和1.13±0.13D,高度近视组术前3.0和5.0D调节刺激水平的调节滞后值分别为：0.79±0.15D和1.27±0.15D,同一调节刺激水平的术前调节滞后值高度近视组均高于轻中度近视组(T=-4.447,-4.216,P=0.000,0.000)。两屈光度组各调节刺激水平的调节滞后值手术前后差异均有显著性(P均<0.05),术后1周各调节滞后值均较术前升高(LSD,P均<0.05),术后1月时均恢复至术前水平(LSD,P均>0.05)。轻中度近视组术后3月平均调节滞后值与术前差异无显著性(LSD,P均>0.05),而高度近视组术后3月调节滞后值较术前降低(LSD,P均<0.05)。不同年龄组中,两调节刺激水平(3.0D和5.OD)的调节滞后值术前差异均无显著性(T=0.178,-0.796,P=0.859,0.429)。两年龄组各调节刺激水平的调节滞后值手术前后差异均有显著性(P均<0.05),术后1周各调节滞后值均高于术前(LSD,P均<0.05),术后1月时均恢复至术前水平(LSD,P均>0.05),术后3月,30岁以下组两调节水平的调节滞后值均较术前下降(LSD,P均<0.05),30岁以上年龄组仅5.0D调节刺激水平的调节滞后值较术前下降(LSD, P<0.05)。
6.视觉疲劳症状：轻中度近视组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：5.27±1.59、8.46±1.66、5.26±1.52和5.14±1.54(F=794.495,P=0.000)；高度近视组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：7.09±1.71、10.26±1.69、7.02±1.89和5.94±1.69(F=314.525,P=0.000)；两屈光度组手术前症状分值差异有显著性(T=-4.414,P=0.000),轻中度近视组视觉疲劳症状分值低于高度近视组。两屈光度组手术前后视觉疲劳症状分值差异均有统计学意义,术后1周视觉疲劳症状分值均较术前升高(LSD, P=0.000, P=0.000),轻中度近视组平均分值由术前的轻度上升至中度,术后1月两组均恢复至术前水平(LSD, P均>0.05)；至术后3月,轻中度近视组视觉疲劳症状分值与术前比较差异无显著性,高度近视组术后3月视觉不适症状分值较术前降低(LSD,P=0.000),由中度疲劳下降至轻度。30岁以下组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：5.99±179、9.14±1.81、5.93±1.79和5.40±1.62(F=404.269,P=0.000)；30岁以上组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：6.15±1.98、9.36±1.99、6.09±2.02和5.58±1.69(F=311.114,P=0.000)；不同年龄组手术前症状分值差异无显著性(T=-0.349,P=0.728)。两个年龄组手术前后视觉疲劳症状分值差异有统计学意义,术后1周视觉疲劳症状分值较术前升高(LSD, P=0.000, P=0.000),30岁以下组平均分值由术前的轻度上升至中度,术后1月两组均恢复至术前水平(LSD, P均>0.05)；至术后3月,两个年龄组视觉不适症状分值均较术前降低(LSD,P=0.000,0.001)。术前各因素中,仅患者术前症状分值(preSCORE)对术后1周症状分值(postlweekSCORE)的影响有显著性意义(T=7.458,P=0.000),而患者术前症状分值(preSCORE)、术前屈光度(SE)、术前正相对调节(prePRA)、术前调节幅度(负镜片法preAMP2)和术前调节滞后(preLOAl)均对术后3月症状分值(post3monthSCORE)的影响有显著性意义(P=0.000,0.000,0.005,0.015,0.035)。
结论LASIK手术术后1周主要调节功能指标均呈一过性降低,术后1月基本可以恢复至术前水平,术后3月部分调节功能可能增强,术后视觉疲劳症状的加重和恢复与调节功能的改变相一致,从远期效果看,LASIK手术有利于近视患者视觉疲劳症状的改善。
第二部分近视眼在不同调节状态下眼前段结构变化的研究
目的探讨近视眼在不同调节状态下眼前段结构的变化。
方法：招募60位年龄在18至39岁近视患者,按近视程度分为轻中度近视组和高度近视组,用眼前段OCT对测试眼分别在调节放松(0D)、诱发3.0D和5.0D调节三种调节状态下进行眼前段扫描分析,分别测量不同调节状态下角膜后表面曲率、前房深度、晶状体厚度和暗瞳直径的大小,采用重复测量的方差分析比较不同调节状态下上述参数的差异以及不同程度近视在相同调节状态下各参数的差异。
结果60位入选患者中,年龄平均(29.45±5.22)岁,平均等效球镜度(SE, spherical equivalent)-5.27±1.93D,范围-2.15D至-8.63D。轻中度近视组32人,年龄平均(29.34±4.65)岁,平均等效球镜度-3.72±1.05D,高度近视组28人,年龄平均(29.57±5.89)岁,平均等效球镜度-7.05±0.85D。在调节放松的情况下(0D),轻中度近视组眼前段OCT测得的平均角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径分别为：6.92±0.91mm.2.67±0.19mm.4.17±0.21mm和6.21±0.56mm；高度近视组的平均角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径分别为：6.83±0.81mm.2.92±0.23mm.4.22±0.24mm和5.95±0.42mm。轻中度近视组与高度近视组在角膜后表面曲率和晶状体厚度方面的差异均无显著性(T=0.401,-0.742；P=0.690,0.461),而前房深度方面,高度近视组显著大于轻中度近视组(T=-4.637,P=0.000),高度近视组的瞳孔直径则小于轻中度近视组(T=2.011,P=0.049)。两不同程度近视组中,在0D、3.0D和5.0D三种不同的调节状态下测得的角膜后表面曲率的差异均无显著性(F=0.084,0.047；P=0.920,0.954)；前房深度随调节的逐渐增大而均变浅(F=19.44,8.455：P=0.000,0.001)；晶状体厚度随调节的逐渐增大而均增厚(F=31.149,15.245：P=0.000,0.000)；瞳孔直径随调节的逐渐增大而均减小(F=83.634,53.429：P=0.000,0.000)。
结论眼前段OCT可以定量观察近视眼调节时眼前段各部分的变化,发生不同程度调节时,角膜的形状相对稳定,晶体厚度、前房深度及瞳孔直径随调节量的增加其变化量逐渐增大。
第三部分近视眼LASIK手术前后调节所致眼前段结构变化的比较
研究目的探索近视眼LASIK手术前后调节致眼前段结构变化的差异。
方法招募60位年龄在18至39岁拟行LASIK手术的近视患者,按近视程度分为轻、中度近视组和高度近视组,统一行标准的LASIK手术,分别于术前、术后1周、术后1月及术后3月用眼前段OCT对非主导眼进行不同调节状态下眼前段扫描分析,测量该眼在调节放松(0D)、诱发3.0D和5.0D调节三种调节状态下的眼前段参数变化,包括角膜后表面曲率、前房深度、晶状体厚度和暗瞳直径的大小。采用重复测量数据的方差分析比较手术前后各时期在调节放松时(0D)上述各参数的差异以及在被诱发3.0D和5.OD调节时上述参数变化量的差异。结果60位入选患者中,年龄平均(29.45±5.22)岁,术前平均等效球镜度-5.27±1.93D,范围-2.15D至-8.63D。其中,轻中度近视组32人,年龄平均(29.34±4.65)岁,术前平均等效球镜度-3.72±1.05D；高度近视组28人,年龄平均(29.57±5.89)岁,术前平均等效球镜度-7.05±0.85D。两组患者在调节放松状态下(0D),角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径在手术前后各时期的差异均无显著性意义(P均>0.05)。在诱发3.0D调节时,轻中度近视组中,角膜曲率的变化量在术前、术后1周、术后1月及术后3月分别为：0.04±1.36mm、-0.03±1.26mm、-0.05±1.21mm和0.08±1.25mm (F=0.006, P=0.999);前房深度变化量分别为：0.16±0.23mm、-0.15±0.17mm、-0.16±0.26mm和0.17±0.28mm (F=0.024, P=0.995);晶体厚度变化量分别为：0.23±0.28、0.11±0.12、0.23±0.19和0.25±0.28(F=3.595,P=0.025)；瞳孔直径变化量分别为：-0.65±0.75、-0.59±0.75、-0.62±0.76和-0.67±0.78(F=0.071,P=0.975),术后1周晶体的变化量较术前减少(LSD,P<0.05);高度近视组眼前段参数变化情况与轻中度近视组各参数的变化情况一致,除晶体厚度的变化量手术前后差异有显著性外(F=3.310,P=0.046),其余各参数的变化量手术前后差异均无显著性(P均>0.05),术后1周晶体的变化量较术前减少(LSD,P<0.05)。在诱发5.0D调节时,两种不同程度近视组中,前房深度的变浅量和晶状体厚度的增加量手术前后各时期的差异均有显著性(P均<0.05)；而两不同近视组角膜后表面曲率和瞳孔直径的变化量手术前后各时期差异均无显著性(P均>0.05)。术后1周两近视组前房深度下降量和晶体厚度增加量均较术前降低(LSD,P均<0.05),术后1月与术前差异均无显著性(LSD,P均>0.05),术后3月时高度近视组晶体增厚量较术前增加(LSD,P<.05),其余各参数变化量与术前差异无显著性(LSD,P均>0.05)。
结论近视眼LASIK手术前后调节所致的眼前段改变,不同程度近视和不同部位在不同时期有所差异,不同程度调节所致的角膜后表面曲率和瞳孔直径的变化手术前后各时期无明显差异；术后早期(1周)不同程度调节所致的晶体改变量均低于术前,前房深度的变化量在发生较大调节时也低于术前,术后1月至3月均可以恢复至术前水平,术后远期(3月),高度近视调节所致晶体的变化量甚至高于术前水平。
Background
Laser in situ keratomileusis(LASIK) has quickly become one of the most popular procedures to reduce or eliminate myopic refractive error for its rapid recover of vision and little pain. Nowdays, more than a million procedures performed each year all around the world. Although the overall satisfaction was high and most patients were satisfied with their uncorrected visual acuity and visual recovery, quite a few patients whose visual acuity was20/20maybe complain of compromises in visual quality and comfort. Visual discomfort and difficulty in reading have been one of the most frequent symptoms after LASIK. Although there are many potential sources associated with asthenopia after surgery, accommodation disturbances may be the main cause for near-vision complaints.Some researchers found the amplidtude of accommodation is reduced in early days after LASIK, however, the other factors related to accommodation were still not known and the mechanism of accommodation disturbance was not full understood as yet. The purposes of these studies are to evaluate the all changes of accommodative functions and asthenopia after LASIK in myopes and to compare the changes of anterior segment resulted from accommodation before and after surgery.
Part1. Influence of LASIK on accommodation and asthenopia in myopia
Objective:To evaluate the changes of accommodation and asthenopia after LASIK in myopia.
Methods and materials:Sixty-four myopic patients (128eyes) who were going to receive standard LASIK were enrolled in this study with the age from18to40years and were divided into two groups:low to moderate myopic group(>-6.0D),and high myopic group(≤-6.0D).According to the age, the patients also were categorized into two groups:<30years and≥30years. Amplitude of accommodation,negative and positive relative accommodation,monocular accommodative facility and lag of accommodation were measured before and lweek,1month and3months after surgery. At the same time, asthenopia were scored by questionair.
Results:1.Amplitude of accommodation(AMP):The mean AMP was decreased significantly in all groups at1week after LASIK(all p<0.05),and rehabilitate to preoperative level except the elder group at1month postoperatively. There was no significant difference between before and3months after LASIK in AMP in low to moderate myopic group and younger group(all p>0.05). The AMP was significantly increased in high myopic group and elder group3months after LASIK compared with preoperation(LSD, all p<0.05).2. Negative relative accommodative (NRA): There was no significant difference in NRA in all groups between before and after surgery(all p>0.05).3.Postive relative accommodation (PRA):The mean PRA was decreased significantly in all groups at1week after LASIK (all p<0.05), and recovered to preoperative level at one month after LASIK(LSD, all p>0.05). The PRA was significantly increased in high myopic group at3months after surgery compared with preoperation (LSD, all p<0.05).4.Monocular accommodative facility (AF):The mean AF was9.80±2.39CPM、8.16±1.77CPM、9.96±2.09CPM and11.70±2.39CPM before LASIK and one week, one month,and three months after LASIK in low to moderate myopic group, respectively (F=183.151, P=0.000) The mean AF was8.42±1.48CPM.6.55±1.15CPM、8.52±1.68CPM and10.07±1.79CPM in high myopic group before LASIK and one week, one month,and three months after LASIK (F=181.595, P=0.000). The AF was decreased significantly at one week after LASIK in all groups compared with preoperation (LSD, all p<0.05).One month after surgery, there was no significant difference between preoperative AF and postoperative AF in all groups(LSD, all p>0.05).The mean AF was significantly increased at3months after surgery compared with preoperation(LSD, all p<0.05).5.Accommodation response:Both at3.0D and5.0D accommodative stimulus, the lag of accommodation (LOA) was significantly increased in all groups at one week after LASIK(all p<0.05), and recovered to preoperative level at one month after LASIK(LSD, all p>0.05).3months after surgery, the LOA was significantly decreased in high myopic group and elder group compared with preoperation (LSD, all p<0.05).6.Asthenopia score:The mean asthenopia score was increased significantly at one week after LASIK in all groups compared with preoperation (LSD, all p<0.05).One month after surgery, there was no significant difference between preoperative mean asthenopia score and postoperative mean asthenopia score in all groups(all p>0.05).The mean asthenopia score was significantly decreased in high myopia group and two age groups at3months after surgery compared with preoperation(p<0.05). The preoperative asthenopia score had significant effect on1week-postoperative asthenopia score by multiple linear regression analysis (T=7.458, P=0.000). The preoperative asthenopia score, spherical equivalent, PRA, amplitude of accommodation(minus lens) and lag of accommodation had significant effect on3month-postoperative asthenopia score (P=0.000,0.000,0.005,0.015,0.035)
Conclusion:Most of the parameters of accommodation show decreased in early days after LASIK,and almost all can guadually recovered in one to three months. Some of them may become better than before surgery3months after LASIK. So LASIK may be good for the accommodative function in myopes in the long run.
Part2. Anterior segment changes during accommodation in myopia
Purpose:To evaluate anterior segment changes during accommodation in different degree myopia.
Methods:Sixty myopes with the age from18to39years were enrolled in this study and were divided into two groups:low to moderate myopia group(>-6.0D),and high myopia group(≤-6.0D).Anterior segment measurements were performed by anterior segment optic coherence tomography (OCT) under three different accommodative state of relax (0.0D),3.0D and5.0D. The posterior corneal curvature(PCC), anterior chamber depth (ACD), lens thickness (LT), pupil diameter(PD) were compared at different different accommodative state using repeated measures ANOVA.
Results:Low to moderate myopia group comprised32myopes with the mean age29.34±4.65years, mean spherical equivalent-3.72±1.05D; High myopia group comprised28myopes with the mean age29.57±5.89years, mean spherical equivalent-7.05±0.85D; With the accommodation relaxed(OD), there was no difference between the low to moderate myopia group and high myopia group both in PCC and LT, ACD was2.92±0.23mm in high myoia and2.67±0.19mm in low to moderate myopia (T=-4.637, P=0.000). pupil diameter was6.21±0.56mm in low to moderate myopia and5.95±0.42mm in high myopia (T=2.011, P=0.049).With the accommodation increased, ACD decreased significantly, LT increased significantly, and PD decreased significantly in both groups (all P<0.05). The PCC has no significant change during accommodation in both groups(all p>0.05).
Conclusions:Anterior segment OCT can find the alteration of ACD,LT and PD with accommodation. During accommodation,the cornea is stable with anterior segment OCT.
Part3. comparison of the changes of anterior segment resulted from accommodation before and after LASIK in myopia
Objective:To evaluate the difference in changes of anterior segment resulted from accommodation between before and after LASIK in myopia.
Methods:Sixty myopic patients with the age from18to39years who were going to undergo standard LASIK were enrolled in this study and were divided into two groups:low to moderate myopic group(>-6.0D),and high myopic group(≤-6.0D). Anterior segment measurements were performed by anterior segment optic coherence tomography (OCT) in undominant eye under three different accommodative state of relax (0D),3.0D and5.0D before LASIK and one week one month,and3months after LASIK. The changes in posterior corneal curvature(PCC), anterior chamber depth (ACD), lens thickness (LT), pupil diameter(PD) with accommodation at different time after LASIK were compared with those measured before LASIK.
Results:There were no significant difference between preoperative PCC, ACD, LT, PD and those of postoperation at the state of non-accommodated in both groups(all p>0.05). Compared with preoperation, the mean changes of LT induced by3.0D and5.0D accommodation and the mean changes of ACD induced by5D were significantly decreased in both groups at1week postoperatively (LSD, all p<0.05). There were no significant difference between preoperative alteration in anterior segment induced by2level's accommodation and1-month postoperative alteration in both groups(all p>0.05). The mean changes of LT induced by5.0D accommodation were significantly increased at3months after surgery compared with preoperation in high myopia group(LSD, p<0.05).
Conclusions:The changes of LT and ACD induced by accommodation in myopia seem to be decreased in the early days after LASIK and may recover or even increase at one to three months, which may be the mechanism that accommodative function changes after LASIK.
第一部分近视眼LASIK手术对调节功能及视觉疲劳症状的影响
目的：研究近视眼LASIK术后调节幅度、调节灵敏度、相对调节及调节反应的变化,以及与术后视近所致的视觉疲劳症状相关因素的分析。
方法招募年龄在18至39岁拟行LASIK手术的近视患者64例(128眼),按近视程度分为轻中度近视组(<-6.0D)和高度近视组(≥-6.0D),同时根据年龄分成年轻组(<30岁)和年长组(≥30岁),统一行标准的LASIK手术,分别于术前、术后1周、术后1月及术后3月行规范的主觉验光、单眼调节幅度、单眼调节灵敏度、负/正相对调节及调节滞后等检查,并同时行视觉疲劳症状调查评价。
统计学处理采用重复测量的方差分析进行比较手术前及术后3个时期调节功能各指标的差异,两不同组别间各功能指标的比较采用独立样本的T检验进行,术后1周和术后3月视觉疲劳症状的相关因素分析采用线性回归分析进行。
结果64位入选者中,按近视程度分组：轻中度近视组36人,年龄平均(29.53±4.46)岁,术前平均等效球镜度-3.52±1.15D,高度近视组28人,年龄平均(29.57±5.89)岁,术前平均等效球镜度-7.05±0.85D；按年龄分组结果：29岁以下组33人,年龄平均(25.48±2.91)岁,术前平均等效球镜度-5.08±2.13D,30岁以上组31人,年龄平均(33.87±2.81)岁,术前平均等效球镜度-5.05±1.98D。
1.单眼调节幅度：推进法测得的调节幅度值均大于负镜片法测得的值(P均<0.05)。不同方法测得的调节幅度值,术前两个屈光度组间差异均无显著性(T=-1.072,0.192,P均>0.05),负镜片法测得的调节幅度值年龄较长组低于年轻患者组(T=8.041,P=O.000)。两不同程度近视及两不同年龄组内,手术前后单眼调节幅度的差异均有显著性(所有P<0.05),所有组别术后1周单眼平均调节幅度均较术前下降(LSD, P均<0.05)；轻中度近视组术后1月及术后3月单眼平均调节幅度与术前差异无显著性(LSD, P均>0.05),高度近视组术后1月单眼平均调节幅度与术前差异无显著性(LSD, P.均>0.05),而术后3月调节幅度较术前上升(LSD, P.均<0.05)。同时,负镜片法测得的调节幅度,30岁以下组术后1月仍低于术前(LSD, P<0.05)而30岁以上组术后3月高于术前(LSD,P<0.05)。
2.负相对调节：轻中度近视组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.16±0.49D、2.28±0.56D、2.14±0.63D和2.25±0.60D(F=0.682,P=0.565)；高度近视组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.24±0.65D、2.22±0.53D、2.11±0.55D和2.11±0.55D(F=2.023,P=0.117)。两屈光度组术前负相对调节差异无显著性(T=-0.510,P=0.612)。30岁以下组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.07±0.44D、2.09±0.49D、2.09±0.41D和2.29±0.47D(F=2.384,P=0.074)；30岁以上组手术前、术后1周、术后1月以及术后3月平均负相对调节分别为：2.33±0.65D、2.43±0.55D、2.16±0.74和2.31±0.74D(F=1.439,P=0.237)。两年龄组术前负相对调节差异无显著性(T=-1.927,P=0.059)。
3.正相对调节：轻中度近视组手术前、术后1周、术后1月以及术后3月平均正相对调节分别为：4.27±0.79D、3.66±0.88D、4.23±0.88D和4.29±0.86D,(F=30.928,P=0.000)；高度近视组手术前、术后1周、术后1月以及术后3月平均正相对调节分别为：3.88±0.67D、3.31±0.67D、3.97±0.65D和4.39±0.62D(F=39.662,P=0.000)。术前正相对调节轻中度近视组高于高度近视组(T=2.146,P=0.036),不同屈光度组均表现为术后1周正相对调节较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),仅高度近视组术后3月正相对调节较术前升高(LSD,P=0.000).两个年龄组术前正相对调节差异无显著性(T=0.336,P=0.738),各年龄组均表现为术后1周正相对调节较术前下降(LSD,P=均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月正相对调节较术前升高(LSD,P均<0.05)。
4.单眼调节灵活度：轻中度近视组手术前、术后1周、术后1月以及术后3月平均单眼调节灵活度分别为：9.80±2.39CPM.8.16±1.77CPM.9.96±2.09CPM和11.70±2.39CPM(F=183.151,P=0.000);高度近视组手术前、术后1周、术后1月以及术后3月平均调节灵活度分别为：8.42±1.48CPM.6.55±1.15CPM.8.52±1.68CPM和10.07±1.79CPM(F=181.595,P=0.000):两个屈光度组术前单眼调节灵活度差异有显著性,轻中度近视组高于高度近视组(T=2.831,P=0..006),不同屈光度组均表现为术后1周负单眼调节灵活度较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月单眼调节灵活度较术前升高(LSD,P均=0.000)。两个年龄组术前平均单眼调节灵活度差异无显著性(T=0.782,P=0.437)；各年龄组均表现为术后1周平均单眼调节灵活度较术前下降(LSD,P均=0.000),术后1月逐渐恢复至术前水平(LSD,P均>0.05),术后3月单眼调节灵活度较术前升高(LSD,P均<0.05)。
5.调节反应：轻中度近视组术前3.0D和5.0D调节刺激水平的调节滞后值分别为：0.61±0.18D和1.13±0.13D,高度近视组术前3.0和5.0D调节刺激水平的调节滞后值分别为：0.79±0.15D和1.27±0.15D,同一调节刺激水平的术前调节滞后值高度近视组均高于轻中度近视组(T=-4.447,-4.216,P=0.000,0.000)。两屈光度组各调节刺激水平的调节滞后值手术前后差异均有显著性(P均<0.05),术后1周各调节滞后值均较术前升高(LSD,P均<0.05),术后1月时均恢复至术前水平(LSD,P均>0.05)。轻中度近视组术后3月平均调节滞后值与术前差异无显著性(LSD,P均>0.05),而高度近视组术后3月调节滞后值较术前降低(LSD,P均<0.05)。不同年龄组中,两调节刺激水平(3.0D和5.OD)的调节滞后值术前差异均无显著性(T=0.178,-0.796,P=0.859,0.429)。两年龄组各调节刺激水平的调节滞后值手术前后差异均有显著性(P均<0.05),术后1周各调节滞后值均高于术前(LSD,P均<0.05),术后1月时均恢复至术前水平(LSD,P均>0.05),术后3月,30岁以下组两调节水平的调节滞后值均较术前下降(LSD,P均<0.05),30岁以上年龄组仅5.0D调节刺激水平的调节滞后值较术前下降(LSD, P<0.05)。
6.视觉疲劳症状：轻中度近视组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：5.27±1.59、8.46±1.66、5.26±1.52和5.14±1.54(F=794.495,P=0.000)；高度近视组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：7.09±1.71、10.26±1.69、7.02±1.89和5.94±1.69(F=314.525,P=0.000)；两屈光度组手术前症状分值差异有显著性(T=-4.414,P=0.000),轻中度近视组视觉疲劳症状分值低于高度近视组。两屈光度组手术前后视觉疲劳症状分值差异均有统计学意义,术后1周视觉疲劳症状分值均较术前升高(LSD, P=0.000, P=0.000),轻中度近视组平均分值由术前的轻度上升至中度,术后1月两组均恢复至术前水平(LSD, P均>0.05)；至术后3月,轻中度近视组视觉疲劳症状分值与术前比较差异无显著性,高度近视组术后3月视觉不适症状分值较术前降低(LSD,P=0.000),由中度疲劳下降至轻度。30岁以下组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：5.99±179、9.14±1.81、5.93±1.79和5.40±1.62(F=404.269,P=0.000)；30岁以上组手术前、术后1周、术后1月以及术后3月平均视觉疲劳症状分值分别为：6.15±1.98、9.36±1.99、6.09±2.02和5.58±1.69(F=311.114,P=0.000)；不同年龄组手术前症状分值差异无显著性(T=-0.349,P=0.728)。两个年龄组手术前后视觉疲劳症状分值差异有统计学意义,术后1周视觉疲劳症状分值较术前升高(LSD, P=0.000, P=0.000),30岁以下组平均分值由术前的轻度上升至中度,术后1月两组均恢复至术前水平(LSD, P均>0.05)；至术后3月,两个年龄组视觉不适症状分值均较术前降低(LSD,P=0.000,0.001)。术前各因素中,仅患者术前症状分值(preSCORE)对术后1周症状分值(postlweekSCORE)的影响有显著性意义(T=7.458,P=0.000),而患者术前症状分值(preSCORE)、术前屈光度(SE)、术前正相对调节(prePRA)、术前调节幅度(负镜片法preAMP2)和术前调节滞后(preLOAl)均对术后3月症状分值(post3monthSCORE)的影响有显著性意义(P=0.000,0.000,0.005,0.015,0.035)。
结论LASIK手术术后1周主要调节功能指标均呈一过性降低,术后1月基本可以恢复至术前水平,术后3月部分调节功能可能增强,术后视觉疲劳症状的加重和恢复与调节功能的改变相一致,从远期效果看,LASIK手术有利于近视患者视觉疲劳症状的改善。
第二部分近视眼在不同调节状态下眼前段结构变化的研究
目的探讨近视眼在不同调节状态下眼前段结构的变化。
方法：招募60位年龄在18至39岁近视患者,按近视程度分为轻中度近视组和高度近视组,用眼前段OCT对测试眼分别在调节放松(0D)、诱发3.0D和5.0D调节三种调节状态下进行眼前段扫描分析,分别测量不同调节状态下角膜后表面曲率、前房深度、晶状体厚度和暗瞳直径的大小,采用重复测量的方差分析比较不同调节状态下上述参数的差异以及不同程度近视在相同调节状态下各参数的差异。
结果60位入选患者中,年龄平均(29.45±5.22)岁,平均等效球镜度(SE, spherical equivalent)-5.27±1.93D,范围-2.15D至-8.63D。轻中度近视组32人,年龄平均(29.34±4.65)岁,平均等效球镜度-3.72±1.05D,高度近视组28人,年龄平均(29.57±5.89)岁,平均等效球镜度-7.05±0.85D。在调节放松的情况下(0D),轻中度近视组眼前段OCT测得的平均角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径分别为：6.92±0.91mm.2.67±0.19mm.4.17±0.21mm和6.21±0.56mm；高度近视组的平均角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径分别为：6.83±0.81mm.2.92±0.23mm.4.22±0.24mm和5.95±0.42mm。轻中度近视组与高度近视组在角膜后表面曲率和晶状体厚度方面的差异均无显著性(T=0.401,-0.742；P=0.690,0.461),而前房深度方面,高度近视组显著大于轻中度近视组(T=-4.637,P=0.000),高度近视组的瞳孔直径则小于轻中度近视组(T=2.011,P=0.049)。两不同程度近视组中,在0D、3.0D和5.0D三种不同的调节状态下测得的角膜后表面曲率的差异均无显著性(F=0.084,0.047；P=0.920,0.954)；前房深度随调节的逐渐增大而均变浅(F=19.44,8.455：P=0.000,0.001)；晶状体厚度随调节的逐渐增大而均增厚(F=31.149,15.245：P=0.000,0.000)；瞳孔直径随调节的逐渐增大而均减小(F=83.634,53.429：P=0.000,0.000)。
结论眼前段OCT可以定量观察近视眼调节时眼前段各部分的变化,发生不同程度调节时,角膜的形状相对稳定,晶体厚度、前房深度及瞳孔直径随调节量的增加其变化量逐渐增大。
第三部分近视眼LASIK手术前后调节所致眼前段结构变化的比较
研究目的探索近视眼LASIK手术前后调节致眼前段结构变化的差异。
方法招募60位年龄在18至39岁拟行LASIK手术的近视患者,按近视程度分为轻、中度近视组和高度近视组,统一行标准的LASIK手术,分别于术前、术后1周、术后1月及术后3月用眼前段OCT对非主导眼进行不同调节状态下眼前段扫描分析,测量该眼在调节放松(0D)、诱发3.0D和5.0D调节三种调节状态下的眼前段参数变化,包括角膜后表面曲率、前房深度、晶状体厚度和暗瞳直径的大小。采用重复测量数据的方差分析比较手术前后各时期在调节放松时(0D)上述各参数的差异以及在被诱发3.0D和5.OD调节时上述参数变化量的差异。结果60位入选患者中,年龄平均(29.45±5.22)岁,术前平均等效球镜度-5.27±1.93D,范围-2.15D至-8.63D。其中,轻中度近视组32人,年龄平均(29.34±4.65)岁,术前平均等效球镜度-3.72±1.05D；高度近视组28人,年龄平均(29.57±5.89)岁,术前平均等效球镜度-7.05±0.85D。两组患者在调节放松状态下(0D),角膜后表面曲率、前房深度、晶状体厚度和瞳孔直径在手术前后各时期的差异均无显著性意义(P均>0.05)。在诱发3.0D调节时,轻中度近视组中,角膜曲率的变化量在术前、术后1周、术后1月及术后3月分别为：0.04±1.36mm、-0.03±1.26mm、-0.05±1.21mm和0.08±1.25mm (F=0.006, P=0.999);前房深度变化量分别为：0.16±0.23mm、-0.15±0.17mm、-0.16±0.26mm和0.17±0.28mm (F=0.024, P=0.995);晶体厚度变化量分别为：0.23±0.28、0.11±0.12、0.23±0.19和0.25±0.28(F=3.595,P=0.025)；瞳孔直径变化量分别为：-0.65±0.75、-0.59±0.75、-0.62±0.76和-0.67±0.78(F=0.071,P=0.975),术后1周晶体的变化量较术前减少(LSD,P<0.05);高度近视组眼前段参数变化情况与轻中度近视组各参数的变化情况一致,除晶体厚度的变化量手术前后差异有显著性外(F=3.310,P=0.046),其余各参数的变化量手术前后差异均无显著性(P均>0.05),术后1周晶体的变化量较术前减少(LSD,P<0.05)。在诱发5.0D调节时,两种不同程度近视组中,前房深度的变浅量和晶状体厚度的增加量手术前后各时期的差异均有显著性(P均<0.05)；而两不同近视组角膜后表面曲率和瞳孔直径的变化量手术前后各时期差异均无显著性(P均>0.05)。术后1周两近视组前房深度下降量和晶体厚度增加量均较术前降低(LSD,P均<0.05),术后1月与术前差异均无显著性(LSD,P均>0.05),术后3月时高度近视组晶体增厚量较术前增加(LSD,P<.05),其余各参数变化量与术前差异无显著性(LSD,P均>0.05)。
结论近视眼LASIK手术前后调节所致的眼前段改变,不同程度近视和不同部位在不同时期有所差异,不同程度调节所致的角膜后表面曲率和瞳孔直径的变化手术前后各时期无明显差异；术后早期(1周)不同程度调节所致的晶体改变量均低于术前,前房深度的变化量在发生较大调节时也低于术前,术后1月至3月均可以恢复至术前水平,术后远期(3月),高度近视调节所致晶体的变化量甚至高于术前水平。
Background
Laser in situ keratomileusis(LASIK) has quickly become one of the most popular procedures to reduce or eliminate myopic refractive error for its rapid recover of vision and little pain. Nowdays, more than a million procedures performed each year all around the world. Although the overall satisfaction was high and most patients were satisfied with their uncorrected visual acuity and visual recovery, quite a few patients whose visual acuity was20/20maybe complain of compromises in visual quality and comfort. Visual discomfort and difficulty in reading have been one of the most frequent symptoms after LASIK. Although there are many potential sources associated with asthenopia after surgery, accommodation disturbances may be the main cause for near-vision complaints.Some researchers found the amplidtude of accommodation is reduced in early days after LASIK, however, the other factors related to accommodation were still not known and the mechanism of accommodation disturbance was not full understood as yet. The purposes of these studies are to evaluate the all changes of accommodative functions and asthenopia after LASIK in myopes and to compare the changes of anterior segment resulted from accommodation before and after surgery.
Part1. Influence of LASIK on accommodation and asthenopia in myopia
Objective:To evaluate the changes of accommodation and asthenopia after LASIK in myopia.
Methods and materials:Sixty-four myopic patients (128eyes) who were going to receive standard LASIK were enrolled in this study with the age from18to40years and were divided into two groups:low to moderate myopic group(>-6.0D),and high myopic group(≤-6.0D).According to the age, the patients also were categorized into two groups:<30years and≥30years. Amplitude of accommodation,negative and positive relative accommodation,monocular accommodative facility and lag of accommodation were measured before and lweek,1month and3months after surgery. At the same time, asthenopia were scored by questionair.
Results:1.Amplitude of accommodation(AMP):The mean AMP was decreased significantly in all groups at1week after LASIK(all p<0.05),and rehabilitate to preoperative level except the elder group at1month postoperatively. There was no significant difference between before and3months after LASIK in AMP in low to moderate myopic group and younger group(all p>0.05). The AMP was significantly increased in high myopic group and elder group3months after LASIK compared with preoperation(LSD, all p<0.05).2. Negative relative accommodative (NRA): There was no significant difference in NRA in all groups between before and after surgery(all p>0.05).3.Postive relative accommodation (PRA):The mean PRA was decreased significantly in all groups at1week after LASIK (all p<0.05), and recovered to preoperative level at one month after LASIK(LSD, all p>0.05). The PRA was significantly increased in high myopic group at3months after surgery compared with preoperation (LSD, all p<0.05).4.Monocular accommodative facility (AF):The mean AF was9.80±2.39CPM、8.16±1.77CPM、9.96±2.09CPM and11.70±2.39CPM before LASIK and one week, one month,and three months after LASIK in low to moderate myopic group, respectively (F=183.151, P=0.000) The mean AF was8.42±1.48CPM.6.55±1.15CPM、8.52±1.68CPM and10.07±1.79CPM in high myopic group before LASIK and one week, one month,and three months after LASIK (F=181.595, P=0.000). The AF was decreased significantly at one week after LASIK in all groups compared with preoperation (LSD, all p<0.05).One month after surgery, there was no significant difference between preoperative AF and postoperative AF in all groups(LSD, all p>0.05).The mean AF was significantly increased at3months after surgery compared with preoperation(LSD, all p<0.05).5.Accommodation response:Both at3.0D and5.0D accommodative stimulus, the lag of accommodation (LOA) was significantly increased in all groups at one week after LASIK(all p<0.05), and recovered to preoperative level at one month after LASIK(LSD, all p>0.05).3months after surgery, the LOA was significantly decreased in high myopic group and elder group compared with preoperation (LSD, all p<0.05).6.Asthenopia score:The mean asthenopia score was increased significantly at one week after LASIK in all groups compared with preoperation (LSD, all p<0.05).One month after surgery, there was no significant difference between preoperative mean asthenopia score and postoperative mean asthenopia score in all groups(all p>0.05).The mean asthenopia score was significantly decreased in high myopia group and two age groups at3months after surgery compared with preoperation(p<0.05). The preoperative asthenopia score had significant effect on1week-postoperative asthenopia score by multiple linear regression analysis (T=7.458, P=0.000). The preoperative asthenopia score, spherical equivalent, PRA, amplitude of accommodation(minus lens) and lag of accommodation had significant effect on3month-postoperative asthenopia score (P=0.000,0.000,0.005,0.015,0.035)
Conclusion:Most of the parameters of accommodation show decreased in early days after LASIK,and almost all can guadually recovered in one to three months. Some of them may become better than before surgery3months after LASIK. So LASIK may be good for the accommodative function in myopes in the long run.
Part2. Anterior segment changes during accommodation in myopia
Purpose:To evaluate anterior segment changes during accommodation in different degree myopia.
Methods:Sixty myopes with the age from18to39years were enrolled in this study and were divided into two groups:low to moderate myopia group(>-6.0D),and high myopia group(≤-6.0D).Anterior segment measurements were performed by anterior segment optic coherence tomography (OCT) under three different accommodative state of relax (0.0D),3.0D and5.0D. The posterior corneal curvature(PCC), anterior chamber depth (ACD), lens thickness (LT), pupil diameter(PD) were compared at different different accommodative state using repeated measures ANOVA.
Results:Low to moderate myopia group comprised32myopes with the mean age29.34±4.65years, mean spherical equivalent-3.72±1.05D; High myopia group comprised28myopes with the mean age29.57±5.89years, mean spherical equivalent-7.05±0.85D; With the accommodation relaxed(OD), there was no difference between the low to moderate myopia group and high myopia group both in PCC and LT, ACD was2.92±0.23mm in high myoia and2.67±0.19mm in low to moderate myopia (T=-4.637, P=0.000). pupil diameter was6.21±0.56mm in low to moderate myopia and5.95±0.42mm in high myopia (T=2.011, P=0.049).With the accommodation increased, ACD decreased significantly, LT increased significantly, and PD decreased significantly in both groups (all P<0.05). The PCC has no significant change during accommodation in both groups(all p>0.05).
Conclusions:Anterior segment OCT can find the alteration of ACD,LT and PD with accommodation. During accommodation,the cornea is stable with anterior segment OCT.
Part3. comparison of the changes of anterior segment resulted from accommodation before and after LASIK in myopia
Objective:To evaluate the difference in changes of anterior segment resulted from accommodation between before and after LASIK in myopia.
Methods:Sixty myopic patients with the age from18to39years who were going to undergo standard LASIK were enrolled in this study and were divided into two groups:low to moderate myopic group(>-6.0D),and high myopic group(≤-6.0D). Anterior segment measurements were performed by anterior segment optic coherence tomography (OCT) in undominant eye under three different accommodative state of relax (0D),3.0D and5.0D before LASIK and one week one month,and3months after LASIK. The changes in posterior corneal curvature(PCC), anterior chamber depth (ACD), lens thickness (LT), pupil diameter(PD) with accommodation at different time after LASIK were compared with those measured before LASIK.
Results:There were no significant difference between preoperative PCC, ACD, LT, PD and those of postoperation at the state of non-accommodated in both groups(all p>0.05). Compared with preoperation, the mean changes of LT induced by3.0D and5.0D accommodation and the mean changes of ACD induced by5D were significantly decreased in both groups at1week postoperatively (LSD, all p<0.05). There were no significant difference between preoperative alteration in anterior segment induced by2level's accommodation and1-month postoperative alteration in both groups(all p>0.05). The mean changes of LT induced by5.0D accommodation were significantly increased at3months after surgery compared with preoperation in high myopia group(LSD, p<0.05).
Conclusions:The changes of LT and ACD induced by accommodation in myopia seem to be decreased in the early days after LASIK and may recover or even increase at one to three months, which may be the mechanism that accommodative function changes after LASIK.
引文
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[7]David DD. Laser in situ keratomileusis for myopia and astigmatism:6 months results. J Cataract Refract Surg,1998,24:758-764.
[8]雷蕾,张建华.准分子激光角膜屈光术后夜间视觉质量探讨.眼科新进展.2008,28(3)：227-230.
[9]Villa C, Gutierrez R, Jimenez JR. Night vision disturbances after successful LASIK surger. Br J Ophthalmol 2007; 91:1031-1037.
[10]Pop M, Paytte Y. Risk factors for night vision complaints after LASIK for myopia. Ophthalmology 2004; 111:3210.
[11]Holladay JT, Dudeja DR, Chang J. Functional vision and coneal changes after laser in situ keratomileusis determined by contrast sensitivity, glare testing, and corneal topography. J Cataract Refract Surg 1999; 25:663-669.
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[45]黄佳,瞿小妹,褚仁远等.青少年近视在不同阅读距离调节状态下眼前段结构的变化.眼视光学杂志2008。(02)：92.95.
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[5]Brart DP, Lohlnann Cp, Fitzke FW, et,al.Night vision after execimer laser photorefraetive kerateetomy:haze and halos.J OPhthalmol,1994,4:43-51.
[6]Ghaith AA, Daniel J, Stulting RD, et,al.Contrast sensitivity and glare disability after radial keratotomy and Photorefractive kerateetomy, Arch OPhthalmol, 1998,116:12-18.
[7]David DD. Laser in situ keratomileusis for myopia and astigmatism:6 months results. J Cataract Refract Surg,1998,24:758-764.
[8]雷蕾,张建华.准分子激光角膜屈光术后夜间视觉质量探讨.眼科新进展.2008,28(3)：227-230.
[9]Villa C, Gutierrez R, Jimenez JR. Night vision disturbances after successful LASIK surger. Br J Ophthalmol 2007; 91:1031-1037.
[10]Pop M, Paytte Y. Risk factors for night vision complaints after LASIK for myopia. Ophthalmology 2004; 111:3210.
[11]Holladay JT, Dudeja DR, Chang J. Functional vision and coneal changes after laser in situ keratomileusis determined by contrast sensitivity, glare testing, and corneal topography. J Cataract Refract Surg 1999; 25:663-669.
[12]李凤鸣(主编).眼科全书(下册).北京：人民卫生出社,1996：2622-2633.
[13]汪芳润.近视眼.上海：上海医科大学出版,1996：135-137.
[14]Tychsen L,Scott C.Maldevelopment of convergence eyemovements in macaque monkeys with small and large-angle infantile esotropia.Invest Ophthalmol Vis Sci.2003:Aug:44(8):3358-3368.
[15]徐广第(主编).眼科屈光学.北京：军事医学科学出社,2001：103.
[16]16..李美玉,王宁利(主编).眼解剖与临床.北京：北京大学医学出版社,2003：271.
[17]Zhang H,Gamlin PD.Neurons in the posterior interposed nucleus of the cerebellum related to vergence and accommodation:Steady-state characteristics.J neurophy-siol,1998,79:1255.
[18]Mays LE,Porter JD.Neural control of vergence eye movements:activity of abducens 1956,32(13):145.
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[20]Gilmartin B,Hogen RE.The relationship between tonic accommodation and ciliary muscle innervation[J].Invest Ophthal Vis Sci,1985,26:1024-1028.
[21]Leibowitz HW,Qwens DA.New evidence for the intermediate position of relaxed accommodation.Doc Ophthalmol 1978,46:133-147.
[22]Gilmartin B, Bullimore MA. Adaption of tonic accommodation to sustained visual tasts in emmetropia and late-onset myopia. Optom Vis Sci,1991, 68:22-26.
[23]Simon JM,et al.The history of presbyopia.In:Agarwal Sed. Presbyopia:A Surgical Texbook. Chapterl, Thorofare:NJ, Slac-k Inc,2002:3-4.
[24]Goss DA. Clinical accommodation testing. Current opinion in ophthalmology. 1992;1(3):78-82.
[25]Ciuffreda KJ, Kenyon RV. The eye in focus:accommodation and presbyopia. Clinical and Experimental Optometry,2008,91(3):207-225.
[26]John w, Sons Maddox EE. The clinical use of prisms and the decentering of lenses. Bristol,1893.
[27]王幼生,现代眼视光学[M],广东科技出版社,2004,141-142.
[28]Wolffsotm JS, Gilmartin B, Li R,et al. Nearwork-Induced transient myopia in preadolescent HongKong Chinese[J]. Invest OphthalmolVis Sci 2003,44: 2284-2289.
[29]郑志刚.儿童、青少年近视与调节幅度关系的研究叨.中国实用眼科杂志2006,24(2)：86—87.
[30]Fong DS. Ismyop ia related to amplitude of accommodation. Am J Ophthalmol.1997,123(3):416-418.
[31]O'Leafy DJ, Allen PM. Facility ofaccommodation in myopia. Ophthalmic Physiol Opt,2001 Sep,21(5):321-324.
[32]周少博,胡群英,洪海峰,等.高度近视患者LASIK术后夜间眩光危险因素.中山大学学报,2007,28(2)：222-224.
[33]马小力,刘汉强,马长荣,等.近视眼LASIK术后早期单眼调节幅度的变化.眼视光杂志,2002；4(3)：141-147。
[34]叶璐,刘建国,杨新光,等.近视患者LASIK术后早期单眼调节幅度的变化观察。国际眼科杂志,2008,8(7)：1395-1397.
[35]潘冰心,楼倚天,周武英,等。老视前期近视患者LASIK术后调节幅度变化.中国实用眼科杂志,2009,27(8)：872-874.
[36]许琛琛,王勤美,余野。老视前期近视患者LASIK术后相对调节的变化.中国实用眼科杂志,2008,26(2)：157-159.
[37]庞彦利,吴小影,刘双珍,等.近视眼患者准分子激光角膜原位磨镶术术后正负相对调节的变化.国际眼科杂志2008；8(9)：1866-1868.
[38]吴小影,刘双珍.近视患者准分子激光原位角膜磨镶术后调节性集合与调节比值的变化.中华眼科杂志2003；39(3)：132·135.
[39]Von Helmholtz H. Physiological Optics. New York:Dover. 1962,375(1):143-172.
[40]Robertson DM, Ogle KN, Dyer JA. Influence of contact lenses on accommodation. Am J Ophthalmol,1967,64:860-870.
[41]Drexler W,Baumgartner A, Findl O,et al.Biometric investigation of changes in the anterior eye segment during accommodation. Vision Res,1997; 37(19):2789-2800.
[42]Jones CE, Atchison AA, Faao D,et al. Changes in lens dimensions and refractive index with age and accommodation. Optom Vis Sci,2007; 84(10):990-995.
[43]尤宇一,袁非.几种新型眼前节影像技术及临床应用.眼科研究,2010；8(9)：908-911.
[44]王冰松,王宁利。眼前段相干光断层成像术在眼科的应用.中华眼科杂志,44(2)：185-188.
[45]黄佳,瞿小妹,褚仁远等.青少年近视在不同阅读距离调节状态下眼前段结构的变化.眼视光学杂志2008。(02)：92.95.
[46]Zellers JA, Alpert TL, Rouse MW. A review of the literature and a normative study of accommodative facility. J Am Optom Assoc,1984; 55:31-7.
[47]Hennessey D, Iosue RA, Rouse MW. Relation of symptoms to accommodative infacility of school-aged children. Am J Optom Physiol Opt, 1984;61(3):177-83.
[48]David A, Atchison, Elizabeth J. Critical subjective measurement of amplitude accommodation. Optom Of Vis Sci,1994,71(11):699-706.
[49]陈洁,吕帆,于旭东,等.眼调节幅度与近视眼的关系研究.中国实用眼科杂志,2004,12：1010-1013.
[50]Sheldon, Ebenholtz.. Accommodation hysteresis:Fundamental asymmetry in decay rate after near and far focusing[J]. Invest Ophthalmol Vis Sci 1991, 32:148-153
[51]郭晓枚,李伟力,赵雅丽.国人和白种人近视患者LASIK手术前后正负相对调节的比较.国际眼科杂志,2009,9(11)：2123-2125.
[52]Garcia A, Cacho P, Lara Francisco. Evaluating relative accommodations in general binocular dysfunctions. Optom Vis Sci 2002;79 (12):779-787.
[53]买志彬,郝燕燕.老视手术治疗进展.国际眼科杂志,2007,6(7)：799.802.
[54]Cacho P, Garcia A, Lara F, et al. Diagnotic signs of accommodative insufficiency. Optometry and vision science,2002; 79(9):614-20.
[55]裘凯凯,吕帆.调节灵活性及其应用.国外医学眼科分册,2005,29(1)：4-7.
[56]Kedzia B, Pieczyrak D, Tondel G et al. Factors affecting the clinical testing of accommodative facility. Ophthal Physical Opt,1999,19(1):12-21.
[57]Rouse MW, Deland PN, Chous R,et al.Monocular accommodative facility testing reliability. Optom Vis Sci,1989,66:72-77.
[58]Goss DA. The relation between accommodative facility and general binocular dysfunction. Ophthal. Physical. Opt.2001,21(6):484-485.
[59]Garcia A, Cacho P, Lara F, Megias R. The relation between accommodative facility and general binocular dysfunction. Ophthalmic Physiol Opt 2000;20:98-104.
[60]Wick B, Hall P. Relation among accommodative facility,lag and amplitude in elementary school children. Am J Optom Physiol Opt,1987,64(8):593-598.
[61]Radhakrishnan H, Allen PM, Charman WN. Dynamics of accommodative facility in myopes. Invest Ophthalmol Vis Sci,2007; Sep,48(9):4375-8432.
[62]Pandian A, R.Sankaridurg P, Naduvilath T, et al. Accommodative facility in eyes with and without mypia. IOVS,2006;47(11):4725-31.
[63]陈世豪,吕帆,王勤美,等。LASIK对近视眼调节功能的影响及临床意义。眼视光学杂志,2000,2(1)：26-29.
[64]Karimian F, Baradaran-Rafii A, Bagheri A, et al. Accommodative changes after photorefractive keratectomy in myopia eyes. Optometry and vision science,2010; 87(11):833-8.
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