白内障超声乳化术后黄斑部的光学相干断层扫描
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摘要
黄斑囊样水肿是白内障术后常见的眼底并发症，也是术后视力下降的常见原因之一。其发生率与手术方式、手术时间长短、术中后囊完整与否、玻璃体丢失程度、术后的炎症反应及糖尿病等潜在的视网膜异常有关。虽然超声乳化白内障吸出术具有切口小，术后恢复快的优点，但术后的黄斑囊样水肿仍时有发生。光学相干断层扫描是近年来新兴的眼科诊断仪器，它的分辨率高达10μm，可以活体显示黄斑部的断层结构，并定量测厚，客观性、重复性好，是观察白内障术后黄斑部变化的最佳手段。
本研究应用德国Zeiss-Humphrey公司产的光学相干断层扫描仪分析白内障超声乳化吸出术后黄斑部的变化。分别观察了60例正常人和50例白内障超声乳化吸出术后2周、4周、6周、8周、3个月的黄斑部图像的变化，其结果如下：
1．术后2周除1人视力0.1外，平均达0.65±0.1，至术后3个月，该患者视力仍为0.1，余平均0.8±0.15。
2．48眼(96％)患者术后黄斑部保持平滑的中心凹曲线，2眼(4％)出现黄斑部神经上皮层间低反射腔，其中1眼极端异常，出现在术后2周，范围较大，至今尚未完全恢复，另1眼于术后4周出现，为中心凹旁局限性水肿，视力仅下降2行，至术后8周，水肿恢复，视力回升。
3．正常人中心注视点厚度为151.5±11.1μm，白内障超声乳化术后中心注视点厚度增加，但仅于术后4～6周有显著性差异，术后8周起差异的显著性消失。3.5mm切口组与5.5mm切口组中心注视点厚度无显著性差异。将中心注视点厚度高于185m定为异常界限，则10眼(20％)出现术后黄斑水肿，均发
颀士研究生学位论文
生于术后2～6 周，其中8 眼为单纯中心凹增厚。9 眼（90％）
于6个月内自愈。
4．术后各期黄斑中心注视点厚度均与视力的负对数呈正相关
卜二0．6～0．8），其中术后4－6周相关性较高（r—0．7，0．8）。
5．术前黄斑部地形图呈现中心薄（蓝黑），四周厚（黄
绿）的山谷样外观。术后中心蓝黑区变浅，趋向穹隆样外观，尤
以术后4～6 周明显，术后8 周起中心蓝黑区渐回归原色。l 眼
明显黄斑囊样水肿者地形图始终为穹隆样。
总之，白内障超声乳化吸出术后黄斑部呈现厚度增加的趋
势，少数人会出现黄斑囊样水肿，造成视力轻到重度的下降，但
绝大多数人可自愈，预后良好。光学相干断层扫描分辨率高，可
重复性好，能客观准确的反应白内障术后黄斑部的变化，为临床
的早期诊断、早期治疗提供了重要依据。
Cystoid macular edema is a known complication of cataract extraction, as well as a common cause of visual loss. Many factors are thought to contribute to its incidence such as the type of cataract surgery, duration of surgery, posterior capsule intaction perioperation, vitreous loss , inflammation postoperation , and some latent retinopathy like diabetes. Although phacoemulsification has the advantages of small incision, quick rehabilitation, cystoid macular edema may still happen. Optical coherence tomography (OCT) is a new diagnostic technique in recent years that can provide cross-sectional images of macular in vivo and quantify macular thickness variation with a precision of 10 u m. It appears to be more objective and reproducible which indicates that OCT may be the best choice to investigate macular changes after cataract surgery.
In this study, we use Germany Zeiss-Humphery OCT to analyze macular changes at 2w, 4w, 6w, 8w, 3m after uneventful cataract phacoemulsification. 60 cases in normal group and 50 cases in PHACO group are enrolled. The results are as following:
1. At 2w postoperatively, the best-corrected visual acuity is 0.65 + 0.1. While 3m postoperatively it is 0.8?.15, except one 0.1.
2. 48(96%) eyes remain foveal contour, while 2 eyes appears low reflective cystoid spaces in the neural epithelium, of which one happens at 2w postoperatively with wide dimension which has not totally rehabitted recently , the other shows limited cystoid edema parafovea at 8w
postoperatively followed by 2 lines visual loss that resolved at 8w postoperatively.
3. The meanD of all 60 normal measurements of central foveal thickness is 151.5+ 11.1 u m. It increases after phacoemulsification, which has significant difference only at 4~6w postoperatively that disappears at 8w postoperatively. There is no significant statistical difference in foveal center between 3.5mm incision group and 5.5mm group. Central foveal thickness was considered to be abnormal when it was greater than 185 u m. In 10 eyes, the fovea appears abnormally thickened after operation, including 8 eyes of single foveal thickening , all of which happened at 2~6w postoperatively and 90%(9 eyes) resolved till six months postoperatively.
4.At all stages linear regression analysis showed a significant relationship(R=0.6~0.8) between the mean macular thickness in the central fovea and visual acuity reported on a log (MAR) scale which is much higher at 4~6w postoperatively(R=0.7, 0.8).
5.Retinal map of macular preoperatively shows valley figure which is thin (blue black) at center and thick (yellow green) peripheral. After operation blue-black area at center became thin like fornical figure especially at 4~6w which resolved till 8w postoperatively. One retinal map of significant cystoid macular edema remains fornical contour all along.
To sum up, macular thickness increases after phacoemulaification. Very little appears cystoid macular edema resulting in visual loss, but most of which can resolve. Optical coherence tomography can investigate macular changes perfectly after cataract surgery with high-resolution and better reproducibility to provide important evidence to early clinical diagnosis and treatment.
本研究应用德国Zeiss-Humphrey公司产的光学相干断层扫描仪分析白内障超声乳化吸出术后黄斑部的变化。分别观察了60例正常人和50例白内障超声乳化吸出术后2周、4周、6周、8周、3个月的黄斑部图像的变化，其结果如下：
1．术后2周除1人视力0.1外，平均达0.65±0.1，至术后3个月，该患者视力仍为0.1，余平均0.8±0.15。
2．48眼(96％)患者术后黄斑部保持平滑的中心凹曲线，2眼(4％)出现黄斑部神经上皮层间低反射腔，其中1眼极端异常，出现在术后2周，范围较大，至今尚未完全恢复，另1眼于术后4周出现，为中心凹旁局限性水肿，视力仅下降2行，至术后8周，水肿恢复，视力回升。
3．正常人中心注视点厚度为151.5±11.1μm，白内障超声乳化术后中心注视点厚度增加，但仅于术后4～6周有显著性差异，术后8周起差异的显著性消失。3.5mm切口组与5.5mm切口组中心注视点厚度无显著性差异。将中心注视点厚度高于185m定为异常界限，则10眼(20％)出现术后黄斑水肿，均发
颀士研究生学位论文
生于术后2～6 周，其中8 眼为单纯中心凹增厚。9 眼（90％）
于6个月内自愈。
4．术后各期黄斑中心注视点厚度均与视力的负对数呈正相关
卜二0．6～0．8），其中术后4－6周相关性较高（r—0．7，0．8）。
5．术前黄斑部地形图呈现中心薄（蓝黑），四周厚（黄
绿）的山谷样外观。术后中心蓝黑区变浅，趋向穹隆样外观，尤
以术后4～6 周明显，术后8 周起中心蓝黑区渐回归原色。l 眼
明显黄斑囊样水肿者地形图始终为穹隆样。
总之，白内障超声乳化吸出术后黄斑部呈现厚度增加的趋
势，少数人会出现黄斑囊样水肿，造成视力轻到重度的下降，但
绝大多数人可自愈，预后良好。光学相干断层扫描分辨率高，可
重复性好，能客观准确的反应白内障术后黄斑部的变化，为临床
的早期诊断、早期治疗提供了重要依据。
Cystoid macular edema is a known complication of cataract extraction, as well as a common cause of visual loss. Many factors are thought to contribute to its incidence such as the type of cataract surgery, duration of surgery, posterior capsule intaction perioperation, vitreous loss , inflammation postoperation , and some latent retinopathy like diabetes. Although phacoemulsification has the advantages of small incision, quick rehabilitation, cystoid macular edema may still happen. Optical coherence tomography (OCT) is a new diagnostic technique in recent years that can provide cross-sectional images of macular in vivo and quantify macular thickness variation with a precision of 10 u m. It appears to be more objective and reproducible which indicates that OCT may be the best choice to investigate macular changes after cataract surgery.
In this study, we use Germany Zeiss-Humphery OCT to analyze macular changes at 2w, 4w, 6w, 8w, 3m after uneventful cataract phacoemulsification. 60 cases in normal group and 50 cases in PHACO group are enrolled. The results are as following:
1. At 2w postoperatively, the best-corrected visual acuity is 0.65 + 0.1. While 3m postoperatively it is 0.8?.15, except one 0.1.
2. 48(96%) eyes remain foveal contour, while 2 eyes appears low reflective cystoid spaces in the neural epithelium, of which one happens at 2w postoperatively with wide dimension which has not totally rehabitted recently , the other shows limited cystoid edema parafovea at 8w
postoperatively followed by 2 lines visual loss that resolved at 8w postoperatively.
3. The meanD of all 60 normal measurements of central foveal thickness is 151.5+ 11.1 u m. It increases after phacoemulsification, which has significant difference only at 4~6w postoperatively that disappears at 8w postoperatively. There is no significant statistical difference in foveal center between 3.5mm incision group and 5.5mm group. Central foveal thickness was considered to be abnormal when it was greater than 185 u m. In 10 eyes, the fovea appears abnormally thickened after operation, including 8 eyes of single foveal thickening , all of which happened at 2~6w postoperatively and 90%(9 eyes) resolved till six months postoperatively.
4.At all stages linear regression analysis showed a significant relationship(R=0.6~0.8) between the mean macular thickness in the central fovea and visual acuity reported on a log (MAR) scale which is much higher at 4~6w postoperatively(R=0.7, 0.8).
5.Retinal map of macular preoperatively shows valley figure which is thin (blue black) at center and thick (yellow green) peripheral. After operation blue-black area at center became thin like fornical figure especially at 4~6w which resolved till 8w postoperatively. One retinal map of significant cystoid macular edema remains fornical contour all along.
To sum up, macular thickness increases after phacoemulaification. Very little appears cystoid macular edema resulting in visual loss, but most of which can resolve. Optical coherence tomography can investigate macular changes perfectly after cataract surgery with high-resolution and better reproducibility to provide important evidence to early clinical diagnosis and treatment.
引文
1. Wright PL,et al. Angiographic cystoid macular edema after posterior chamber lens implantation. Arch Ophthalmol 1988;108:740-744.
2. Jaffe NS, Clayman HM, Jaffe MS. Cystoid macular edema after intracapsular and extracapsular cataract extraction with and without an intraocular lens. Ophthalmology 1982;89:25-29.
3. Jampol LM, Sanders DR, Kraff MC. Prophylaxis and therapy of aphakic cystoid macular edema. Surv Ophthalmol 1984;28:535-539.
4．程冰等．糖尿病患者超声乳化白内障吸出术后黄斑改变的光学相干断层扫描．中华眼底病杂志 2001；17：175-177．
5. Ursell PG, et al. Cystiod macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity. J Cataract Refract Surg 1999;25:1492-1497.
6. Puliafito CA, et al. Imaging of macular diseases with optical coherence tomography. Ophthalmology 1995; 102:217-229.
7. Huang D, et al. Optical coherence tomography. Science 1991; 254:1178-1181.
8. Hee MR, et al. Quantitative assessment of macular edema with optical coherence tomography. Arch Ophthalmol 1995;113:1019-1029.
9．程冰等．光学相干断层扫描图像在白内障吸出术后黄斑病变诊断中的应用，中华眼底病杂志 1999；15：212-213．
10. Grewing R, Becker H. Retinal thickness immediately after cataract surgery measured by optical coherence tomography. Ophthalmic Surg Lasers 2000;31:215-217.
11. Dadeya S, Malik KPS, Gulliani BP. Angiographyic macular oedema after phacoemulsification. Asia-Pacific Journal of ophthalmology 2001;13:33-36.
12. Konari K, et al. Development of the blood-retinal barrier in vitro: formation of tight conjunction as revealed by occludin and ZO-1
correlates with the barrier function of chick retinal pigment epithelial celis. Exp Eye Res 1995;61:99-108．
13． Miyake K, Shirasawa E, Hikita M. Hypotheses on the role of prostaglandins in the pathogenesis of epinephrine maculopathy and aphakic cystoid macular edema. In: Bito LZ, Stjernschantz J, eds, The Ocular Effects of Prostaglandins and Other Eicosanoid. New York, NY, AlanRLiss, 1989;265-276．
14． Schepens CL, et al. Role of the vitreous in cystoid macular edema. Surv Ophthalmol 1984; 28(Suppl): 499-504．
15． Antcliff RJ et al. Comparison between optical coherence tomography and fundus fluorescein angiography for the detection of cystoid macular edema in patients with uveitis. Ophthalmology 2000;107:593-599．
16． Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol 1999; 127:688-693．
17． Yanoff M, et al. Pathology of human cystoid macular edema. Surv Opthalmol 1984; 28:505-511．
18． Hogan MJ, Alvarado JA, Weddell JE. Histology of the human eye. Philadelphia: WB Saunders, 1971:492．
19． Fine BS, Brucker AJ. Macular edemar and cystoid macular edema. Am J Ophthalmol 1981; 92:466-481．
20． Sourdille P, Santiago PY. Optical coherence tomography of macular thickness after cataract surgery. J Cataract Refract Surg 1999; 25:256-261．
21． Italian Diclofenac Study Group. Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. J cataract Refract Surg 1997; 23:1183-1189．
22． Bradford JD, Wilkinson CP, Bradford RH. Cystoid macular edema following extracapsular cataract extraction and posterior chamber intraocular lens implantation. Retina 1988; 8:161-164．
23． Nussenblatt RB , et al. Macular thickening and visual acuity. Ophthalmology 1987; 94:1134-1139．
24． Hee MR, et al. Topography of diabetic macular edema with optical coherence tomography. Ophthalmology 1998; 105:360-370．
25． Rivellese M , et al. Optical coherence tomography after laser photocoagulation for clinically significant macular edema. Ophthalmic Surg Lasers 2000; 31:192-197．
2. Jaffe NS, Clayman HM, Jaffe MS. Cystoid macular edema after intracapsular and extracapsular cataract extraction with and without an intraocular lens. Ophthalmology 1982;89:25-29.
3. Jampol LM, Sanders DR, Kraff MC. Prophylaxis and therapy of aphakic cystoid macular edema. Surv Ophthalmol 1984;28:535-539.
4．程冰等．糖尿病患者超声乳化白内障吸出术后黄斑改变的光学相干断层扫描．中华眼底病杂志 2001；17：175-177．
5. Ursell PG, et al. Cystiod macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity. J Cataract Refract Surg 1999;25:1492-1497.
6. Puliafito CA, et al. Imaging of macular diseases with optical coherence tomography. Ophthalmology 1995; 102:217-229.
7. Huang D, et al. Optical coherence tomography. Science 1991; 254:1178-1181.
8. Hee MR, et al. Quantitative assessment of macular edema with optical coherence tomography. Arch Ophthalmol 1995;113:1019-1029.
9．程冰等．光学相干断层扫描图像在白内障吸出术后黄斑病变诊断中的应用，中华眼底病杂志 1999；15：212-213．
10. Grewing R, Becker H. Retinal thickness immediately after cataract surgery measured by optical coherence tomography. Ophthalmic Surg Lasers 2000;31:215-217.
11. Dadeya S, Malik KPS, Gulliani BP. Angiographyic macular oedema after phacoemulsification. Asia-Pacific Journal of ophthalmology 2001;13:33-36.
12. Konari K, et al. Development of the blood-retinal barrier in vitro: formation of tight conjunction as revealed by occludin and ZO-1
correlates with the barrier function of chick retinal pigment epithelial celis. Exp Eye Res 1995;61:99-108．
13． Miyake K, Shirasawa E, Hikita M. Hypotheses on the role of prostaglandins in the pathogenesis of epinephrine maculopathy and aphakic cystoid macular edema. In: Bito LZ, Stjernschantz J, eds, The Ocular Effects of Prostaglandins and Other Eicosanoid. New York, NY, AlanRLiss, 1989;265-276．
14． Schepens CL, et al. Role of the vitreous in cystoid macular edema. Surv Ophthalmol 1984; 28(Suppl): 499-504．
15． Antcliff RJ et al. Comparison between optical coherence tomography and fundus fluorescein angiography for the detection of cystoid macular edema in patients with uveitis. Ophthalmology 2000;107:593-599．
16． Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol 1999; 127:688-693．
17． Yanoff M, et al. Pathology of human cystoid macular edema. Surv Opthalmol 1984; 28:505-511．
18． Hogan MJ, Alvarado JA, Weddell JE. Histology of the human eye. Philadelphia: WB Saunders, 1971:492．
19． Fine BS, Brucker AJ. Macular edemar and cystoid macular edema. Am J Ophthalmol 1981; 92:466-481．
20． Sourdille P, Santiago PY. Optical coherence tomography of macular thickness after cataract surgery. J Cataract Refract Surg 1999; 25:256-261．
21． Italian Diclofenac Study Group. Efficacy of diclofenac eyedrops in preventing postoperative inflammation and long-term cystoid macular edema. J cataract Refract Surg 1997; 23:1183-1189．
22． Bradford JD, Wilkinson CP, Bradford RH. Cystoid macular edema following extracapsular cataract extraction and posterior chamber intraocular lens implantation. Retina 1988; 8:161-164．
23． Nussenblatt RB , et al. Macular thickening and visual acuity. Ophthalmology 1987; 94:1134-1139．
24． Hee MR, et al. Topography of diabetic macular edema with optical coherence tomography. Ophthalmology 1998; 105:360-370．
25． Rivellese M , et al. Optical coherence tomography after laser photocoagulation for clinically significant macular edema. Ophthalmic Surg Lasers 2000; 31:192-197．