低能量小光斑氩激光光凝治疗糖尿病性视网膜病变的疗效观察
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摘要
前言
随着糖尿病的发病率逐年升高，糖尿病性视网膜病变(Diabetic Retinopathy，DR)已成为成人的主要致盲眼病之一，如何减少DR所致的失明是眼科界当务之急。激光光凝治疗DR已被临床证实具有显著疗效，有研究表明，治疗组比不治疗组失明率降低50％。然而，作为一种破坏性的治疗手段，激光光凝必然对视网膜的正常结构和功能造成一定的影响，并引起许多不良反应，甚至导致术眼视力的永久性下降。因此，在临床实践中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得良好的效果，同时又能将并发症降低到最少是值得研究的。我们将用低能量小光斑氩激光对20例DR患者进行光凝治疗，并将结果与本院以往用高能量大光斑进行光凝治疗的DR患者结果进行统计分析，以观察其疗效。
目的
观察低能量小光斑氩激光全视网膜光凝治疗DR的疗效及术后视网膜光损伤的临床表现，探讨低能量小光斑氩激光全视网膜光凝治疗DR是否既能取得很好的疗效，同时又能减轻光凝引起的不良反应。
方法
选取2003年于我院行氩激光光凝治疗的DR患者13例20眼作为A组，1998～2001年于我院行氩激光光凝治疗的DR患者14例20眼作为B组。两组所选病例均为根据我国现行的DR分期、分型标准确诊的Ⅲ～Ⅳ期DR患者，所有患眼屈光间质清晰，无合并其它眼底病，无既往眼部激光治疗史和眼部手术史。术前常规行血压、空腹血糖、糖化血红蛋白、血脂等全身检查和详细的眼科检查包括裸眼视力、验光、眼压、B超、眼前节裂隙灯显微镜检查、视野、视网膜电图(ERG)、眼底彩照和眼底荧光血管造影(FFA)检查。对每一名患者进行标准的氩激光全视网膜光凝术，分四次进行，每周一次。A组用低能量小光斑，B组用高能量大光斑。术后三个月复
查裸眼视力、最佳矫正视力、视野、ERG、眼底彩照及FFA。将两组的结果进
行比较并作统计学分析。
结果
1.两组患者术前的各项检查结果差异无显著性意义(P>0.05)。
2.术后3个月A组视力提高3例，占巧%;视力不变13例，占65%;视
力下降4例，占20%。B组视力提高4例，占20%;视力不变12例，占
60%;视力下降4例，占20%。两组比较差异无显著性意义(p>0.05)。
3.术后3个月经FFA证实光凝有效的A组巧例，占75%;B组14例，
占70%，无效的A组5例，占25%，B组6例，占30%。两组比较差异无显
著性意义(p>0.05)。
4.术前A组和B组中心30。的光敏感度分别为30 .4土2.gdB，28.6土3.
4dB;周边600的光敏感度分别为25.0士3.ldB，24.3*2.ZdB。术后3个月
A组和B组中心300的光敏感度分别为28.9士2.sdB，26.2土3.gdB;周边
60“的光敏感度分别为24.1士3.3dB，22.5土2.3dB。将两组术前术后的差
值进行比较，结果差异有显著性意义(p<0.05)。
5.术前A组和B组的a波振幅分别为12.79土1 .94uv，12.00土1 .88uv;
b波振幅分别为22 .95土1 .46uv，22.73土1 .76uv。术后3个月a波振幅分
别为11.08士1.79uv，9.64士2.15uv;b波振幅分别为21.24士1.59uv，
20 .36土2 .19u\l。将两组术前术后的差值进行比较，结果差异有显著性意义
(p<0 .05)。
6.术后3个月B组有4例出现视野缩小或暗点，4例有暗适应下降、畏
光等并发症。
讨论
激光全视网膜光凝(panretinal photoeoa列ation，PRP)是治疗DR的有效
手段，随之而来的光凝对视网膜的损害也是不可避免的。因此，在临床实践
中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得
良好的效果，同时又能将并发症降低到最少是值得研究的。近年来，国人激
光量和激光参数的选择及疗效是临床十分重要而又难以统一的问题。在临
床工作中，我们经常看到许多DR患者由于过度的视网膜光凝而引起视力
下降、一视野改变、暗适应下降和”不能忍受的幌眼”等并发症。因此，我们设
计了此实验，用低能量小光斑对DR患者进行光凝，来减少光凝所带来的不
良反应。从实验结果可以看出，1.两组均有数例患者术后出现不同程度的
视力提高或下降，其它患者视力基本保持不变，两组之间差异无显著意义。
视网膜光凝术后视力下降的主要原因是视网膜光凝所引起的黄斑水肿或原
有的黄斑水肿加重。2.术后3个月，A组75%的患眼，B组70%的患眼治
疗有效，两组之间差异无显著意义。3.术后3个月，两组的光敏感度均较术
前有所下降，B组更为明显，两组之间差异有显著意义。4.术后3个月两组
ERG的a波和b波振幅均有所下降，且差异有显著意义。从以上分析可以
看出，在对DR患者进行P即后，A组和B组疗效相同，而对视野和ERG的
影响B组却明显高于A组。从光凝治疗DR的原理分析，n级光凝固斑已
经破坏了耗氧量高的光感受器，可以取得光凝固的疗效。本实验也证实，A
组用低能量小光斑以11级强光凝固斑进行PRP，取得了与B组相同的效果，
且并发症明显低于B组。
结论
1 .PRP术后3个月，低能量小光斑组和高能量大光斑组的视力和FFA
结果比较无明显差别。
2.PRP术后3个月，高能量大光斑组对视野和ERG的影响及术后并发
症较低能量小光斑组更为明显。
3.低能量小光斑PRP治疗DR?
With rising incidence rate of diabetes year after year, diabetic retinopathy has become one of the major eye - diseases that may cause blindness among the adults. How to reduce the cases of blindness caused by DR has become the urgent task for ophthalmological research field. As the treatment for DR, photoco-agulation has been proved effective by clinic. It has been indicated that the rate of blindness of the treatment group was 50% lower than the non - treatment group. However as a distractive method, it is certain that photocoagulation will make some effect on the normal structure and function of retina and consequently cause many side - effects, even cause the lose of eyesight forever. Therefore, in clinical practice, it is worthy to study how to adjust the laser parameter reasonably , how to determinant the level of the laser reaction correctly and how to a-chieve the good effect and reduce the rate of syndrome at the same time. We will treat 20 cases of DR patients with Argon laser of low energy and sma
ll spot and statistically analyze the results and the one of DR patients who had been treated with Argon laser of high energy and big spot, and observe the effect.
Objective
To observe the effect of low energy and small spot Argon panretinal photo-coagulation on DR and the clinical findings of laser damage to retina after the treatment, and to investigate whether the treatment of low energy and small spot Argon panretinal photocoagulation can achieve the good effect and reduce the side - effects at the same time.
Methods
20 eyes of 13 DR patients who underwent Argon PRP in 2003 were chosen into A group and 20 eyes of 14 DR patients who underwent Argon PRP from 1998 to 2001 were chosen into B group. All the cases were diagnosed as HI ~ IV grade DR according to the current standard of DR type and stage in China. The refracting media of all the eyes were clear, no patient had other retina diseases and no previous photocoagulation and surgery had been carried out on any of these patients. The general exams including blood pressure, blood sugar , HbAlc, blood fat and detailed ophthalmologist exams such as naked eyesight , optometry, tonometry, B - scan, biomicroscopy of the anterior eye segment , visual field , ERG, FFA and color photo of fundus were carried out on every patient. Standard Argon PRP for every eye was divided into 4 times, once a week. The eyes of A group were treated by low energy and small spot laser and the eyes of B group were treated by high energy and big spot laser. Three months after the treatment , naked eyesight , the best corrective eyesight, visual field ,ERG, FFA and color photo of fundus were examined. The results of the two groups were compared and statistically analyzed.
Results
1. There was no significant difference between all the preoperative results of the two groups( p >0.05) .
2. Three months postoperatively in A group the eyesight of 3 eyes (15% ) were improved; the eyesight of 13 eyes (65% )were unchanged; the eyesight of 4 eyes were declined. In B group the eyesight of 4 eyes(20% ) were improved; the eyesight of 12 eyes(60% ) were unchanged; the eyesight of 4 eyes(20% ) were declined. There was no significant difference compared between the two groups (p >0.05).
3. Three months postoperatively 15 eyes (75%) of A group and 14 eyes (70%) of B group have been proved effective by FFA, 5 eyes (25%) of A
group and 6 eyes(30% ) of B group have been proved ineffective. There was no significant difference compared between the two groups (p >0. 05).
4. Preoperatively the light sensitivity of center 30 of the A group and B group were 30.4 2. 9dB ,28. 6 3. 4dBseparately, and that of peripheral 60 were25.0 3.1dB, 24. 3 2. 2dB separately. Three months postoperatively, the light sensitivity of center 30 of the A group and B group were28.9 2. 8dB, 26. 2 3. 9dB separately, and that of peripheral 60 were24.1 3. 3dB, 22.5 2.3dB separately. There was significant difference compared the differences of pre - operate and post - operate between the two
随着糖尿病的发病率逐年升高，糖尿病性视网膜病变(Diabetic Retinopathy，DR)已成为成人的主要致盲眼病之一，如何减少DR所致的失明是眼科界当务之急。激光光凝治疗DR已被临床证实具有显著疗效，有研究表明，治疗组比不治疗组失明率降低50％。然而，作为一种破坏性的治疗手段，激光光凝必然对视网膜的正常结构和功能造成一定的影响，并引起许多不良反应，甚至导致术眼视力的永久性下降。因此，在临床实践中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得良好的效果，同时又能将并发症降低到最少是值得研究的。我们将用低能量小光斑氩激光对20例DR患者进行光凝治疗，并将结果与本院以往用高能量大光斑进行光凝治疗的DR患者结果进行统计分析，以观察其疗效。
目的
观察低能量小光斑氩激光全视网膜光凝治疗DR的疗效及术后视网膜光损伤的临床表现，探讨低能量小光斑氩激光全视网膜光凝治疗DR是否既能取得很好的疗效，同时又能减轻光凝引起的不良反应。
方法
选取2003年于我院行氩激光光凝治疗的DR患者13例20眼作为A组，1998～2001年于我院行氩激光光凝治疗的DR患者14例20眼作为B组。两组所选病例均为根据我国现行的DR分期、分型标准确诊的Ⅲ～Ⅳ期DR患者，所有患眼屈光间质清晰，无合并其它眼底病，无既往眼部激光治疗史和眼部手术史。术前常规行血压、空腹血糖、糖化血红蛋白、血脂等全身检查和详细的眼科检查包括裸眼视力、验光、眼压、B超、眼前节裂隙灯显微镜检查、视野、视网膜电图(ERG)、眼底彩照和眼底荧光血管造影(FFA)检查。对每一名患者进行标准的氩激光全视网膜光凝术，分四次进行，每周一次。A组用低能量小光斑，B组用高能量大光斑。术后三个月复
查裸眼视力、最佳矫正视力、视野、ERG、眼底彩照及FFA。将两组的结果进
行比较并作统计学分析。
结果
1.两组患者术前的各项检查结果差异无显著性意义(P>0.05)。
2.术后3个月A组视力提高3例，占巧%;视力不变13例，占65%;视
力下降4例，占20%。B组视力提高4例，占20%;视力不变12例，占
60%;视力下降4例，占20%。两组比较差异无显著性意义(p>0.05)。
3.术后3个月经FFA证实光凝有效的A组巧例，占75%;B组14例，
占70%，无效的A组5例，占25%，B组6例，占30%。两组比较差异无显
著性意义(p>0.05)。
4.术前A组和B组中心30。的光敏感度分别为30 .4土2.gdB，28.6土3.
4dB;周边600的光敏感度分别为25.0士3.ldB，24.3*2.ZdB。术后3个月
A组和B组中心300的光敏感度分别为28.9士2.sdB，26.2土3.gdB;周边
60“的光敏感度分别为24.1士3.3dB，22.5土2.3dB。将两组术前术后的差
值进行比较，结果差异有显著性意义(p<0.05)。
5.术前A组和B组的a波振幅分别为12.79土1 .94uv，12.00土1 .88uv;
b波振幅分别为22 .95土1 .46uv，22.73土1 .76uv。术后3个月a波振幅分
别为11.08士1.79uv，9.64士2.15uv;b波振幅分别为21.24士1.59uv，
20 .36土2 .19u\l。将两组术前术后的差值进行比较，结果差异有显著性意义
(p<0 .05)。
6.术后3个月B组有4例出现视野缩小或暗点，4例有暗适应下降、畏
光等并发症。
讨论
激光全视网膜光凝(panretinal photoeoa列ation，PRP)是治疗DR的有效
手段，随之而来的光凝对视网膜的损害也是不可避免的。因此，在临床实践
中，如何合理调整激光参数和正确判定光凝反应级别，使光凝治疗既能取得
良好的效果，同时又能将并发症降低到最少是值得研究的。近年来，国人激
光量和激光参数的选择及疗效是临床十分重要而又难以统一的问题。在临
床工作中，我们经常看到许多DR患者由于过度的视网膜光凝而引起视力
下降、一视野改变、暗适应下降和”不能忍受的幌眼”等并发症。因此，我们设
计了此实验，用低能量小光斑对DR患者进行光凝，来减少光凝所带来的不
良反应。从实验结果可以看出，1.两组均有数例患者术后出现不同程度的
视力提高或下降，其它患者视力基本保持不变，两组之间差异无显著意义。
视网膜光凝术后视力下降的主要原因是视网膜光凝所引起的黄斑水肿或原
有的黄斑水肿加重。2.术后3个月，A组75%的患眼，B组70%的患眼治
疗有效，两组之间差异无显著意义。3.术后3个月，两组的光敏感度均较术
前有所下降，B组更为明显，两组之间差异有显著意义。4.术后3个月两组
ERG的a波和b波振幅均有所下降，且差异有显著意义。从以上分析可以
看出，在对DR患者进行P即后，A组和B组疗效相同，而对视野和ERG的
影响B组却明显高于A组。从光凝治疗DR的原理分析，n级光凝固斑已
经破坏了耗氧量高的光感受器，可以取得光凝固的疗效。本实验也证实，A
组用低能量小光斑以11级强光凝固斑进行PRP，取得了与B组相同的效果，
且并发症明显低于B组。
结论
1 .PRP术后3个月，低能量小光斑组和高能量大光斑组的视力和FFA
结果比较无明显差别。
2.PRP术后3个月，高能量大光斑组对视野和ERG的影响及术后并发
症较低能量小光斑组更为明显。
3.低能量小光斑PRP治疗DR?
With rising incidence rate of diabetes year after year, diabetic retinopathy has become one of the major eye - diseases that may cause blindness among the adults. How to reduce the cases of blindness caused by DR has become the urgent task for ophthalmological research field. As the treatment for DR, photoco-agulation has been proved effective by clinic. It has been indicated that the rate of blindness of the treatment group was 50% lower than the non - treatment group. However as a distractive method, it is certain that photocoagulation will make some effect on the normal structure and function of retina and consequently cause many side - effects, even cause the lose of eyesight forever. Therefore, in clinical practice, it is worthy to study how to adjust the laser parameter reasonably , how to determinant the level of the laser reaction correctly and how to a-chieve the good effect and reduce the rate of syndrome at the same time. We will treat 20 cases of DR patients with Argon laser of low energy and sma
ll spot and statistically analyze the results and the one of DR patients who had been treated with Argon laser of high energy and big spot, and observe the effect.
Objective
To observe the effect of low energy and small spot Argon panretinal photo-coagulation on DR and the clinical findings of laser damage to retina after the treatment, and to investigate whether the treatment of low energy and small spot Argon panretinal photocoagulation can achieve the good effect and reduce the side - effects at the same time.
Methods
20 eyes of 13 DR patients who underwent Argon PRP in 2003 were chosen into A group and 20 eyes of 14 DR patients who underwent Argon PRP from 1998 to 2001 were chosen into B group. All the cases were diagnosed as HI ~ IV grade DR according to the current standard of DR type and stage in China. The refracting media of all the eyes were clear, no patient had other retina diseases and no previous photocoagulation and surgery had been carried out on any of these patients. The general exams including blood pressure, blood sugar , HbAlc, blood fat and detailed ophthalmologist exams such as naked eyesight , optometry, tonometry, B - scan, biomicroscopy of the anterior eye segment , visual field , ERG, FFA and color photo of fundus were carried out on every patient. Standard Argon PRP for every eye was divided into 4 times, once a week. The eyes of A group were treated by low energy and small spot laser and the eyes of B group were treated by high energy and big spot laser. Three months after the treatment , naked eyesight , the best corrective eyesight, visual field ,ERG, FFA and color photo of fundus were examined. The results of the two groups were compared and statistically analyzed.
Results
1. There was no significant difference between all the preoperative results of the two groups( p >0.05) .
2. Three months postoperatively in A group the eyesight of 3 eyes (15% ) were improved; the eyesight of 13 eyes (65% )were unchanged; the eyesight of 4 eyes were declined. In B group the eyesight of 4 eyes(20% ) were improved; the eyesight of 12 eyes(60% ) were unchanged; the eyesight of 4 eyes(20% ) were declined. There was no significant difference compared between the two groups (p >0.05).
3. Three months postoperatively 15 eyes (75%) of A group and 14 eyes (70%) of B group have been proved effective by FFA, 5 eyes (25%) of A
group and 6 eyes(30% ) of B group have been proved ineffective. There was no significant difference compared between the two groups (p >0. 05).
4. Preoperatively the light sensitivity of center 30 of the A group and B group were 30.4 2. 9dB ,28. 6 3. 4dBseparately, and that of peripheral 60 were25.0 3.1dB, 24. 3 2. 2dB separately. Three months postoperatively, the light sensitivity of center 30 of the A group and B group were28.9 2. 8dB, 26. 2 3. 9dB separately, and that of peripheral 60 were24.1 3. 3dB, 22.5 2.3dB separately. There was significant difference compared the differences of pre - operate and post - operate between the two
引文
1．张承芬等．糖尿病的眼部并发症及治疗．人民卫生出版社．2003．
2. Saxena S, Jalali S, et al:Management of diabetic retinopathy. Indian J Ophthalmol 2000 Dec; 48 (4): 321.
3．张欣等 光凝所致糖尿病视网膜病变视网膜功能改变的定量研究．中华眼底病杂志．2001，17：181
4．李瑞峰主编．眼科激光治疗学概要．人民卫生出版社．1998．130．
5．第一届全国眼底病学术会议．糖尿病视网膜病变分期标准．眼底病，1985．1：42．
6. Tso MOM. Retinal photocoagulation therapy:Clinical application and biological basis of therapeutic effects. In: Tso MOM (ed). JB Retinal Diseases. Philadelphia: J B Lipppincott Company, 1998,247.
7. Bailey CE, Grey-RH, et al: The national diabetic retinopathy laser treatment aulit. Ⅲ clinical outcomes. Eye. 1999 Apr, 13: 151.
8. Basteauf F, Dorot M, et al: A new photocoagulation technic for server non-proliferative diabetic retinopathy. A prospective study apropos of 54 cases. J-Fr-Ophthamol. 1998; Feb, 21 (2): 83.
9．孙心铨等．中华眼底病杂志 1997 13：195．
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11. Seiberth V, Alexandridis E: Function of the diabetic retina after panretinal argon laser photocoagulation. Influence of the intensity of the coagulation spots. Ophthalmologica 1991; 202(1): 10.
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20. Stefansson E. The therapeutic effects of retinal laser treatment and vitrectomy. A theory based on oxygen and vascular physiology. Acta Ophthalmol Scand 2001 Oct;79(5): 435-40.
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6. Tso MOM. Retinal photocoagulation therapy:Clinical application and biological basis of therapeutic effects. In: Tso MOM (ed). JB Retinal Diseases. Philadelphia: J B Lipppincott Company, 1998,247.
7. Bailey CE, Grey-RH, et al: The national diabetic retinopathy laser treatment aulit. Ⅲ clinical outcomes. Eye. 1999 Apr, 13: 151.
8. Basteauf F, Dorot M, et al: A new photocoagulation technic for server non-proliferative diabetic retinopathy. A prospective study apropos of 54 cases. J-Fr-Ophthamol. 1998; Feb, 21 (2): 83.
9．孙心铨等．中华眼底病杂志 1997 13：195．
10. Seiberth V, Alexandridis E, et, al: Function of the diabetic retina after panretinal argon laser coagulation. Graefes Arch Clin Exp Ophthalmol 1987;225 (6): 385.
11. Seiberth V, Alexandridis E: Function of the diabetic retina after panretinal argon laser photocoagulation. Influence of the intensity of the coagulation spots. Ophthalmologica 1991; 202(1): 10.
12．齐慧君等．糖尿病视网膜病变激光治疗技术标准探讨．中国实用眼科杂志 2001 19：96．
13. Mainster MA. Decreasing retinal photocoagulation damage: principles andtechniques. Semin Ophthalmol 1999 Dec;14(4):200.
14. Pendergast SD, Singerman LJ, Zegarra H, et al. Lasers in the treatment of proliferative retinopathies. Philadelphia: Current Medicine Inc, 1999. 36-
53.
15. McDonald HR, Shatz H. Macular edema for following panretinal photocoagulation. Retina, 1985,5:5-10.
16．张欣等．光凝对糖尿病视网膜病变黄斑区视网膜厚度的早期影响．中华眼底病杂志 2002 18：31～33．
17. Photocoagulation for diabetic macular edema. Early treatment Diabetic Retinopathy Study report, number 2. Arch Ophthalmol, 1987, 94:961.
18. Berson EL. Electical phenomena in the retina. In: Moses RA, ed. Adler' s physiology of the eye. St Louis:Mosby 1981:466.
19. Funatsu H, Horin S, Yamashita H et al. Effective mechanisms of laser photocoagulation for neovascularization in diabetic retinopathy. Jpn Ophthalmol 1996,100 (5): 339-349.
20. Stefansson E. The therapeutic effects of retinal laser treatment and vitrectomy. A theory based on oxygen and vascular physiology. Acta Ophthalmol Scand 2001 Oct;79(5): 435-40.