儿童远视屈光参差性弱视LASIK远期临床研究
摘要
目的:探讨儿童远视屈光参差性弱视LASIK远期临床疗效和特点;探讨儿童远视屈光参差性弱视LASIK术后远期视觉质量及影响因素。
方法:远视屈光参差性弱视儿童按屈光矫正方法分组:LASIK组40人40眼(7～18岁),框架眼镜组57人57眼(8～17岁),RGP组10人10眼(6～16岁)。
LASIK组、框架眼镜组和RGP组行常规屈光检查,包括标准照明条件下标准对数视力表测量裸眼视力(UCVA)、1%阿托品扩瞳验光、最佳矫正视力(BCVA)。3组患者分别在屈光矫正基础上接受遮盖治疗。所有LASIK组患者行术前检查:Humphry Atalas 995(Carl Zeiss Meditec)测量角膜前表面K1/K2值及轴向;Oculus Pentacam测量角膜厚度;Hartmann-Shack像差仪(WASCA,Carl Zeiss Meditec)自然暗瞳下采集像差数据,测量结果采用5mm分析直径进行分析;IOL Master(Carl Zeiss)光学生物测量仪测量眼轴;2周后TAKAGI CGT-1000对比敏感度仪进行对比敏感度及眩光敏感度的测量。LASIK组和框架眼镜组2周后Titmus立体视检测图检测近立体视锐度。3组平均随访时间分别为21.65±13.09、18.93±8.83、21.50±13.68个月。Stata10.0统计软件分析治疗前后屈光度、屈光参差度、最佳矫正视力、对比及眩光敏感度、高阶像差、立体视功能等的改变。
结果:LASIK组手术后屈光度平均为1.22±1.34D,屈光参差度平均为1.80±1.07D,LogMAR BCVA平均为0.37±0.23,术后较术前均有显著统计学差异(P<0.05)。框架眼镜组和RGP组治疗后屈光度和LogMAR BCVA分别为5.39±1.24D、0.40±0.32和5.17±1.43D、0.30±0.19。术后首次随访至末次随访时角膜K值平均减少2.09±1.20D。87.5%的患者实际屈光度在预期屈光度±1D内(包括±1D)。当术前中央角膜厚度≤522um,手术光学区<6.5mm,手术切削深度≥116um,术后角膜屈率≥46.56D时,正确认为术后实际屈光度超过预期屈光度±1D的百分比分别是81.40%,65.12%,55.81%,67.44%。手术前后立体视锐度在60'内的比例从0%提高到23.5%。手术后0.7°、1°、1.6°时对比敏感度和0.7°、1°、4°时眩光对比度均较术前有显著提高(P<0.05)。手术后RMSh、RMS3、RMS4、RMS5、Z(4,0)均与术前存在显著统计学差异(P<0.05),但各阶像差的变化与年龄、术前中央角膜厚度、术前屈光度、光学区、切削深度均不相关(P>0.05)。手术组和框架眼镜组视力的提高程度无统计学差异(P>0.05),手术组较RGP组视力提高的程度大,有统计学意义(P<0.05)。术中及术后均无并发症发生。
结论:儿童远视屈光参差性弱视LASIK屈光矫正具有较好的有效性,可预测性和安全性;个体化设计手术方案有助于提高临床疗效;传统治疗不配合或效果不佳的远视屈光参差性中重度弱视儿童可考虑行LASIK术;儿童远视LASIK像差及对比敏感度的变化仍有待进一步探讨。
Objective:To evaluate the long-term outcomes of LASIK for hyperopic anisometropic amblyopia in children;to investigate the long-term visual quality and the factors affecting long-term visual quality of hyperopic LASIK in children.
Methods:40 eyes of 40 children(age 7 to 18 years),57 eyes of 57 children(8 to 17 years) and 10 eyes of 10 children(6 to 16years) with hyperopic anisometropic amblyopia were treated by LASIK,spectacles and contact lenses respectively. All the three groups were given the routine examination included UCVA, subjective manifest refraction and cycloplegic refraction,BCVA.Then all the three groups patched the dominant eyes,and the mean follow-up were 21.65±13.09m, 18.93±8.83m,21.50±13.68m respectively.In LASIK group,Humphry Atalas 995(Carl Zeiss Meditec) was used to measure corneal curvature K1/K2,Oculus Pentacam was used to measure corneal thickness,Hartmann- Shack aberrometer (WASCA,Carl Zeiss Meditec) was used to measure the overall wavefront aberrations in scotopic pupils and the data was analyzed in 5mm diameter,IOL Master(Carl Zeiss) was used to measure the length of axis.TAKAGI CGT-1000 was used to measure the contrast sensitivity and glare sensitivity in LASIK group after the correction of refractive errors 2 weeks later.Titmus Stereo Tests was used to measure the stereopsis in LASIK group and spectacles group with the correction of refractive errors 2 weeks later.Stata 10.0 was used to analyze the data of cycloplegic refraction,BCVA,high order aberration,contrast and glare sensitivity,and stereopsis.
Results:The mean postoperative SE refraction,SE anisometropia and LogMAR BCVA of the treated eyes in LASIK group were 1.22±1.34(D),1.80±1.07(D) and 0.37±0.23 respectively.All the changes postoperative were statistically significant(P＜0.05). Mean postoperative SE refraction,BCVA of the treated eyes in spectacles group and contact lenses group were 5.39±1.24(D),0.40±0.32 and 5.17±1.43(D),0.30± 0.19 respectively.The mean corneal curvature K decreased 2.09±1.20D by the latest follow up.87.5%of all LASIK eyes were within±1.00 D(including±1.00 D) of the attempt SE refraction.When preoperative central corneal thickness was not more than 522um,when optic diameter was less than 6.5mm,when the ablation depth was not less than 116um,and when the postoperative corneal curvature was not less than 46.56D,the correct assessment percent of that achieved SE was beyond±1.00 D of attempt SE refraction were 81.40%,65.12%,55.81%,67.44%respectively.The percent of stereopsis less than 60 seconds of arc was 0%preoperatively and 23.5% postoperatively.Contrast sensitivity were increased statistically significant in 0.7°、1°、1.6°and glare sensitivity were increased statistically significant in 0.7°、1°、4°(P＜0.05).The differences of Zerike coefficient Z(4,0),RMSh,RMS3, RJVIS4 and RMS5 between postoperative and preoperative were statistically significant.(P＜0.05),but all those differences were not related to age,preoperative central corneal thickness,preoperative refraction,optic diameter and the ablation depth.The difference of increased LogMAR BCVA between LASIK group and spectacles group was not statistically significant(P＞0.05).But the increased LogMAR BCVA was lager in LASIK group than in RGP group(P＜0.05).No intraoperative and postoperative complication was observed.
Conclusions:LASIK for hyperopic anisometropic amblyopia in Children was safe, effective,and predictable;individual design would improved the outcomes of LASIK for hyperopic anisometropic amblyopia in Children;LASIK was alternative treatment in children with moderate and severe hyperopic anisometropic amblyopia who were unable to tolerate or failed with conventional methods of treatment;the changes of high order aberrations,contrast sensitivity and glare sensitivity after hyperopic LASIK need further research.
方法:远视屈光参差性弱视儿童按屈光矫正方法分组:LASIK组40人40眼(7～18岁),框架眼镜组57人57眼(8～17岁),RGP组10人10眼(6～16岁)。
LASIK组、框架眼镜组和RGP组行常规屈光检查,包括标准照明条件下标准对数视力表测量裸眼视力(UCVA)、1%阿托品扩瞳验光、最佳矫正视力(BCVA)。3组患者分别在屈光矫正基础上接受遮盖治疗。所有LASIK组患者行术前检查:Humphry Atalas 995(Carl Zeiss Meditec)测量角膜前表面K1/K2值及轴向;Oculus Pentacam测量角膜厚度;Hartmann-Shack像差仪(WASCA,Carl Zeiss Meditec)自然暗瞳下采集像差数据,测量结果采用5mm分析直径进行分析;IOL Master(Carl Zeiss)光学生物测量仪测量眼轴;2周后TAKAGI CGT-1000对比敏感度仪进行对比敏感度及眩光敏感度的测量。LASIK组和框架眼镜组2周后Titmus立体视检测图检测近立体视锐度。3组平均随访时间分别为21.65±13.09、18.93±8.83、21.50±13.68个月。Stata10.0统计软件分析治疗前后屈光度、屈光参差度、最佳矫正视力、对比及眩光敏感度、高阶像差、立体视功能等的改变。
结果:LASIK组手术后屈光度平均为1.22±1.34D,屈光参差度平均为1.80±1.07D,LogMAR BCVA平均为0.37±0.23,术后较术前均有显著统计学差异(P<0.05)。框架眼镜组和RGP组治疗后屈光度和LogMAR BCVA分别为5.39±1.24D、0.40±0.32和5.17±1.43D、0.30±0.19。术后首次随访至末次随访时角膜K值平均减少2.09±1.20D。87.5%的患者实际屈光度在预期屈光度±1D内(包括±1D)。当术前中央角膜厚度≤522um,手术光学区<6.5mm,手术切削深度≥116um,术后角膜屈率≥46.56D时,正确认为术后实际屈光度超过预期屈光度±1D的百分比分别是81.40%,65.12%,55.81%,67.44%。手术前后立体视锐度在60'内的比例从0%提高到23.5%。手术后0.7°、1°、1.6°时对比敏感度和0.7°、1°、4°时眩光对比度均较术前有显著提高(P<0.05)。手术后RMSh、RMS3、RMS4、RMS5、Z(4,0)均与术前存在显著统计学差异(P<0.05),但各阶像差的变化与年龄、术前中央角膜厚度、术前屈光度、光学区、切削深度均不相关(P>0.05)。手术组和框架眼镜组视力的提高程度无统计学差异(P>0.05),手术组较RGP组视力提高的程度大,有统计学意义(P<0.05)。术中及术后均无并发症发生。
结论:儿童远视屈光参差性弱视LASIK屈光矫正具有较好的有效性,可预测性和安全性;个体化设计手术方案有助于提高临床疗效;传统治疗不配合或效果不佳的远视屈光参差性中重度弱视儿童可考虑行LASIK术;儿童远视LASIK像差及对比敏感度的变化仍有待进一步探讨。
Objective:To evaluate the long-term outcomes of LASIK for hyperopic anisometropic amblyopia in children;to investigate the long-term visual quality and the factors affecting long-term visual quality of hyperopic LASIK in children.
Methods:40 eyes of 40 children(age 7 to 18 years),57 eyes of 57 children(8 to 17 years) and 10 eyes of 10 children(6 to 16years) with hyperopic anisometropic amblyopia were treated by LASIK,spectacles and contact lenses respectively. All the three groups were given the routine examination included UCVA, subjective manifest refraction and cycloplegic refraction,BCVA.Then all the three groups patched the dominant eyes,and the mean follow-up were 21.65±13.09m, 18.93±8.83m,21.50±13.68m respectively.In LASIK group,Humphry Atalas 995(Carl Zeiss Meditec) was used to measure corneal curvature K1/K2,Oculus Pentacam was used to measure corneal thickness,Hartmann- Shack aberrometer (WASCA,Carl Zeiss Meditec) was used to measure the overall wavefront aberrations in scotopic pupils and the data was analyzed in 5mm diameter,IOL Master(Carl Zeiss) was used to measure the length of axis.TAKAGI CGT-1000 was used to measure the contrast sensitivity and glare sensitivity in LASIK group after the correction of refractive errors 2 weeks later.Titmus Stereo Tests was used to measure the stereopsis in LASIK group and spectacles group with the correction of refractive errors 2 weeks later.Stata 10.0 was used to analyze the data of cycloplegic refraction,BCVA,high order aberration,contrast and glare sensitivity,and stereopsis.
Results:The mean postoperative SE refraction,SE anisometropia and LogMAR BCVA of the treated eyes in LASIK group were 1.22±1.34(D),1.80±1.07(D) and 0.37±0.23 respectively.All the changes postoperative were statistically significant(P＜0.05). Mean postoperative SE refraction,BCVA of the treated eyes in spectacles group and contact lenses group were 5.39±1.24(D),0.40±0.32 and 5.17±1.43(D),0.30± 0.19 respectively.The mean corneal curvature K decreased 2.09±1.20D by the latest follow up.87.5%of all LASIK eyes were within±1.00 D(including±1.00 D) of the attempt SE refraction.When preoperative central corneal thickness was not more than 522um,when optic diameter was less than 6.5mm,when the ablation depth was not less than 116um,and when the postoperative corneal curvature was not less than 46.56D,the correct assessment percent of that achieved SE was beyond±1.00 D of attempt SE refraction were 81.40%,65.12%,55.81%,67.44%respectively.The percent of stereopsis less than 60 seconds of arc was 0%preoperatively and 23.5% postoperatively.Contrast sensitivity were increased statistically significant in 0.7°、1°、1.6°and glare sensitivity were increased statistically significant in 0.7°、1°、4°(P＜0.05).The differences of Zerike coefficient Z(4,0),RMSh,RMS3, RJVIS4 and RMS5 between postoperative and preoperative were statistically significant.(P＜0.05),but all those differences were not related to age,preoperative central corneal thickness,preoperative refraction,optic diameter and the ablation depth.The difference of increased LogMAR BCVA between LASIK group and spectacles group was not statistically significant(P＞0.05).But the increased LogMAR BCVA was lager in LASIK group than in RGP group(P＜0.05).No intraoperative and postoperative complication was observed.
Conclusions:LASIK for hyperopic anisometropic amblyopia in Children was safe, effective,and predictable;individual design would improved the outcomes of LASIK for hyperopic anisometropic amblyopia in Children;LASIK was alternative treatment in children with moderate and severe hyperopic anisometropic amblyopia who were unable to tolerate or failed with conventional methods of treatment;the changes of high order aberrations,contrast sensitivity and glare sensitivity after hyperopic LASIK need further research.
引文
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23.Phillips CB,Prager TC,McClellan G,et al.Laser in situ keratomileusis for treated anisometropic amblyopia in awake,autofixating pediatric and adolescent patients.J Cataract Refract Surg,2004,30:2522-2528.
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27.Salz JJ,Stevens CA,LADAR Vision LASIK Hyperopia Stu.LASIK correction of spherical hyperopia,hyperopic astigmatism,and mixed astigmatism with the LADARVision excimer laser system.OPHTHALMOLOGY,2002,109:1647-1657.
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38.Hosny M,Rageh M,Samir K.LASIK for juvenile anisometropia.J Refract Surg,2004,20:838.
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3.Weakley DR.The association between anisometropia,amblyopia and binocularity in the absence of strabismus.Trans Am Ophthalmol Soc,1999,97:987-1021.
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12.Astle WF,Fawcett SL,Huang PT,et al.Long-term outcomes of photorefractive keratectomy and laser-assisted subepithelial keratectomy in children.J Cataract Refract Surg,2008,34:411-416.
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15.Astle WF,Rahmat J,Ingram AD,et al.Laser-assisted subepithelial keratectomy for anisometropic amblyopia in children:Outcomes at 1 year.J Cataract Refract Surg,2007,33:2028-2034.
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23.Phillips CB,Prager TC,McClellan G,et al.Laser in situ keratomileusis for treated anisometropic amblyopia in awake,autofixating pediatric and adolescent patients.J Cataract Refract Surg,2004,30:2522-2528.
24.Utine CA,Cakir H,Egemenoglu A,et al.LASIK in Children With Hyperopic Anisometropic Amblyopia.J Refract Surg,2008,24:464-472.
25.Nucci P,Drack AV.Refractive surgery for unilateral high myopia in children.J AAPOS,2001,5:348-351.
26.Keefe M,Nolan L.LASIK surgery in children.Br J Ophthalmol,2004,88:19-21
27.Salz JJ,Stevens CA,LADAR Vision LASIK Hyperopia Stu.LASIK correction of spherical hyperopia,hyperopic astigmatism,and mixed astigmatism with the LADARVision excimer laser system.OPHTHALMOLOGY,2002,109:1647-1657.
28.Granet DB,Christian W,Gomi CF,et al.Treatment Options for Anisohyperopia.J Pediatr Ophthalmol Strabismus,2000,37:356-341.
29.Hutchinson AK.Pediatric refractive surgery.Curr Opin Ophthalmol,2003,14:267-275.
30.JaycockvPD,O'Brart DPS,Rajan MS,et al.5-year follow,up of LASIK for hyperopia.OPHTHALMOLOGY,2005,112:191-199.
31.Daoud YJ,Hutchinson A,Wallace DK,et al.Refractive Surgery in Children:Treatment Options,Outcomes,and Controversies.Am J Ophthalmol,2009,147:573-582.
32.Holmes JM,Melia M,Bradfield YS,et al.Factors Associated with Recurrence of Amblyopia on Cessation of Patching.OPHTHALMOLOGY,2007,114:1427-1432.
33.Tychsen L,Hoekel J.Refractive Surgery for High Bilateral Myopia in Children with Neurobehavioral Disorders:2.Laser-Assisted Subepithelial Keratectomy (LASEK).JOURNAL OF AAPOS,2007,11:420.
34.Tychsen L,Hockel J.Refractive surgery for high bilateral myopia in children with neurobehavioral disorders:2.Laser-assisted subepithelial keratectomy(LASEK).JOURNAL OF AAPOS,2007,10:364-370.
35.Taneri S,Feit R,Azar DT.Safety,efficacy,and stability indices of LASEK correction in moderate myopia and astigmatism.J Cataract Refract Surg,2004,30:2130-2137。
36.黄佳,瞿小妹,薛枫.视觉敏感期后弱视的可塑性研究进展.眼视光学杂,2006,8:338-340.
37.Wallau AD,Campos M.Photorefractive keratectomy with mitomycin C versus LASIK in custom surgeries for myopia:A bilateral prospective randomized clinical trial.J Refract Surg,2008,24:326-336.
38.Hosny M,Rageh M,Samir K.LASIK for juvenile anisometropia.J Refract Surg,2004,20:838.
39.Cook DR,Dhaliwal DK,Davis PJ,et al.Anesthetic interference with laser function during excimer laser procedures in children.ansethesia and analgesia,2001,92:1444-1445.
40.JaycockvPD,O'Brart DPS,Rajan MS,et al.5-year follow,up of LASIK for hyperopia.OPHTHALMOLOGY,2005,112:191-199.