VEP技术在常见眼外伤最佳矫正视力检测中的应用研究
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摘要
【研究背景】:在涉及人体损伤的法医学鉴定实践中,眼损伤是常见的损伤类型。根据人体轻重伤标准及伤残等级的有关条款之规定,伤眼的最佳矫正视力水平是评价伤眼视功能的主要指标,是法医学鉴定及司法审判的重要依据。为了能够客观准确的反映伤眼的视力水平,视觉诱发电位( visual evoked potentials,VEP)在量化视力方面的作用受到越来越多的关注,并进行了深入研究。VEP技术的迅速发展和日益成熟,使得视力的客观量化成为可能并得以实现。VEP技术从理论上排除了受检者主观因素的影响,能够客观反映受检者的真实视力,成为目前眼外伤案件中鉴别伪盲,评价伤后视功能的重要手段。在目前的法医鉴定实践中,为了评价伤眼的最佳矫正视力,大都以临床常规验光方法如主觉插片验光、电脑验光等所测结果作为标准,而临床验光方法在法医学应用中的价值尚未得到有效证实,因此,评价主觉插片验光技术、电脑验光技术在法医学应用中的价值,探讨VEP验光方法在伤眼视力矫正中的准确性和适用性成为本试验的研究重点。
【目的】:探讨VEP验光技术、电脑验光技术及主觉插片验光技术在评价伤眼最佳矫正视力的法医学实践中的优劣性,寻求一种能够客观、准确评价伤眼最佳矫正视力的验光方法;通过对眼损伤类型进行分组比较,分析VEP验光技术在各种类型眼损伤中的应用价值。
【对象与方法】:第一部分:选取无眼外伤者50例(屈光不正眼86只),对各屈光不正眼依次行主觉插片验光及VEP验光,将两种方法所测的屈光度进行分析比较。第二部分:选取眼外伤后有视力下降者61例(外伤眼61只),根据眼损伤部位的不同将受检眼分为六组:角膜损伤组、虹膜睫状体损伤组、晶状体损伤组、玻璃体损伤组、视网膜与脉络膜损伤组及视神经损伤组。对所有受检眼依次行电脑验光、主觉插片验光及VEP验光,比较三种验光方法在各组眼损伤中所测屈光度及矫正视力之间的差异性,采用SPSS for windows 12.0统计学软件包进行分析,评价三种验光方法在法医学鉴定中的应用价值。
【结果】:在非外伤眼的屈光检测中,VEP验光与主觉插片验光所测结果无显著性差异(P>0.05);在各组外伤眼的屈光检测中,VEP验光结果与主觉插片验光结果之间均无显著性差异(p>0.05);电脑验光在近视和远视的屈光程度的检查方面与VEP验光和主觉插片验光方法之间有显著性差异(p<0.05),而三者在散光眼的屈光度检测上无显著性差异(p>0.05);对比各组损伤眼矫正视力发现,除视神经损伤组外,电脑验光所得矫正视力与主觉验光和VEP验光结果之间有显著性差异(p<0.05),在角膜损伤组、虹膜睫状体损伤组、晶状体损伤组及视网膜损伤组等累及屈光介质的眼损伤中差异更为显著(p<0.01)。
【结论】:在外伤眼及非外伤眼的屈光矫正中,主觉插片验光方法能够反映受检眼的屈光实际及生理需要,在受检者积极配合下可获得满意的矫正效果,但由于其具有较强的主观性,不适用于法医学鉴定工作;电脑验光虽有结果客观、验光快速的优点,但其结果存在较大误差,特别是在涉及屈光介质损伤的眼外伤中误差更为显著,因此,仅可作为眼外伤患者屈光矫正的初步检查依据,而不能作为最终的检查结果;VEP验光技术具有客观、准确的优点,能够为外伤眼最佳矫正视力的评价提供客观依据,特别适合于眼外伤的法医学活体鉴定中。但同时VEP验光方法的操作过程复杂且费时较长,需要进行进一步的改进,以求达到简单实用的效果。
【Background】Ocular trauma is a conventional category of injury in the practice of forensic identification. According to related subsection of the standards of mild and serious injuries and disability range of injury, the best corrected visual acuity of injured eyes were the chief index to evaluate their function, and it was important basis for forensic identification and justice trial. In order to examine the vision of injured eyes objectively and exactly, Visual Evoked Potentials deserve increasing concern for its function in the aspect of quantization of vision and it was got further research. The objective quantization of vision would be possible and come true as quick development and maturity of VEP. As VEP excluded the effects of subjective factors from theoretically point and it could examine their objective acuity of vision, it used to be an important method to distinguish fake blindness and evaluate visual function after injury. For the present practices of forensic identification, clinical conventional optometry, such as subjective optometry and computer optometry were used to evaluate the best corrected visual acuity of injured eyes. But the clinical optometry were not been proved to be effective in application of forensic medicine. Therefore, the focal point in the experiment was to evaluate the subjective optometry and computer optometry in application of forensic medicine and investigate the accuracy and applicability of VEP optometry in corrected visual acuity.
【Objective】Investigate the advantages and disadvantages of VEP optometry、subjective optometry and computer optometry in appraising the best corrected visual acuity of injured eyes in practice of forensic identification, and seek a way of optometry to evaluate the best corrected visual acuity objectively and exactly. Analyze the value of VEP optometry in different types of injured by comparison between different types of injured eyes.
【Method】Part 1: 50 people without ocular trauma (including 86 shortsighted eyes) were examined by subjective optometry and VEP optometry and compare and analyze difference of diopter. Part 2: Choose 61 people with vision descended after ocular trauma (61 examined eyes) and group those people into six according to different injured position: the group of corneal injury; the group of corpus ciliare choroideae injury, the group of crystalline lens injury, the group of hyaloid body injury, the group of retina and choroid injury and the group of optic nerve injury. Examine all the injured eyes by VEP optometry, subjective optometry and computer optometry respectively. Then compare the variability of diopter and corrected vision between those three methods in every group. Analyze them by the statistics package of SPSS for windows 12.0 and evaluate the application value of those optometry methods in forensic identification.
【Results】There were no significantly statistical difference between results of diopter detection of eyes without trauma obtained by VEP optometry and subjective optometry (P>0.05). There were no significantly statistical difference between results of diopter detection of trauma eyes obtained by VEP optometry and subjective optometry (P>0.05). There were also no significantly statistical difference among results of diopter detection of astigmatism eyes obtained by VEP optometry, subjective optometry and computer optometry (P>0.05). But there were significantly statistical difference (P<0.05) between results of diopter detection of hypometropia and hypermetropic obtained by VEP optometry and computer optometry and by subjective optometry and optometry with computer. Compare the corrected vision of every group, there were significant difference of results observed between VEP optometry and computer optometry and between subjective optometry and optometry with computer by analyzing corrected vision (p<0.05) except the group of optic nerve injury. And the statistical difference was more significant (p<0.01) in the patients whose trauma refers to refracting mediums such as cornea、crystalline lens or retina.
【Conclusion】In the rectification of trauma eyes and un-trauma eyes, the subjective optometry way could reflect the practical reflection and physiological need of eyes. Satisfactory results would be obtained under the condition of patients’active cooperation, but it wasn’t suitable in application of forensic medicine because of intense subjection. Though computer optometry was objective and quick, there were inaccuracies in the results, especially the eyes which got trauma in refracting medium. Therefore, it could be preliminary examine basis for the refractive inspection of the ocular trauma patient, but not the final result. The VEP optometry was objective and exact, and it could offer objective basis for evaluating the best corrected visual acuity of eye trauma. Especially, it was suitable for forensic identification about eye injuries. But at the same time, the VEP optometry was difficult to put into practice and it required intensive practical operation. Further studies were needed to make it simple and practical.
【目的】:探讨VEP验光技术、电脑验光技术及主觉插片验光技术在评价伤眼最佳矫正视力的法医学实践中的优劣性,寻求一种能够客观、准确评价伤眼最佳矫正视力的验光方法;通过对眼损伤类型进行分组比较,分析VEP验光技术在各种类型眼损伤中的应用价值。
【对象与方法】:第一部分:选取无眼外伤者50例(屈光不正眼86只),对各屈光不正眼依次行主觉插片验光及VEP验光,将两种方法所测的屈光度进行分析比较。第二部分:选取眼外伤后有视力下降者61例(外伤眼61只),根据眼损伤部位的不同将受检眼分为六组:角膜损伤组、虹膜睫状体损伤组、晶状体损伤组、玻璃体损伤组、视网膜与脉络膜损伤组及视神经损伤组。对所有受检眼依次行电脑验光、主觉插片验光及VEP验光,比较三种验光方法在各组眼损伤中所测屈光度及矫正视力之间的差异性,采用SPSS for windows 12.0统计学软件包进行分析,评价三种验光方法在法医学鉴定中的应用价值。
【结果】:在非外伤眼的屈光检测中,VEP验光与主觉插片验光所测结果无显著性差异(P>0.05);在各组外伤眼的屈光检测中,VEP验光结果与主觉插片验光结果之间均无显著性差异(p>0.05);电脑验光在近视和远视的屈光程度的检查方面与VEP验光和主觉插片验光方法之间有显著性差异(p<0.05),而三者在散光眼的屈光度检测上无显著性差异(p>0.05);对比各组损伤眼矫正视力发现,除视神经损伤组外,电脑验光所得矫正视力与主觉验光和VEP验光结果之间有显著性差异(p<0.05),在角膜损伤组、虹膜睫状体损伤组、晶状体损伤组及视网膜损伤组等累及屈光介质的眼损伤中差异更为显著(p<0.01)。
【结论】:在外伤眼及非外伤眼的屈光矫正中,主觉插片验光方法能够反映受检眼的屈光实际及生理需要,在受检者积极配合下可获得满意的矫正效果,但由于其具有较强的主观性,不适用于法医学鉴定工作;电脑验光虽有结果客观、验光快速的优点,但其结果存在较大误差,特别是在涉及屈光介质损伤的眼外伤中误差更为显著,因此,仅可作为眼外伤患者屈光矫正的初步检查依据,而不能作为最终的检查结果;VEP验光技术具有客观、准确的优点,能够为外伤眼最佳矫正视力的评价提供客观依据,特别适合于眼外伤的法医学活体鉴定中。但同时VEP验光方法的操作过程复杂且费时较长,需要进行进一步的改进,以求达到简单实用的效果。
【Background】Ocular trauma is a conventional category of injury in the practice of forensic identification. According to related subsection of the standards of mild and serious injuries and disability range of injury, the best corrected visual acuity of injured eyes were the chief index to evaluate their function, and it was important basis for forensic identification and justice trial. In order to examine the vision of injured eyes objectively and exactly, Visual Evoked Potentials deserve increasing concern for its function in the aspect of quantization of vision and it was got further research. The objective quantization of vision would be possible and come true as quick development and maturity of VEP. As VEP excluded the effects of subjective factors from theoretically point and it could examine their objective acuity of vision, it used to be an important method to distinguish fake blindness and evaluate visual function after injury. For the present practices of forensic identification, clinical conventional optometry, such as subjective optometry and computer optometry were used to evaluate the best corrected visual acuity of injured eyes. But the clinical optometry were not been proved to be effective in application of forensic medicine. Therefore, the focal point in the experiment was to evaluate the subjective optometry and computer optometry in application of forensic medicine and investigate the accuracy and applicability of VEP optometry in corrected visual acuity.
【Objective】Investigate the advantages and disadvantages of VEP optometry、subjective optometry and computer optometry in appraising the best corrected visual acuity of injured eyes in practice of forensic identification, and seek a way of optometry to evaluate the best corrected visual acuity objectively and exactly. Analyze the value of VEP optometry in different types of injured by comparison between different types of injured eyes.
【Method】Part 1: 50 people without ocular trauma (including 86 shortsighted eyes) were examined by subjective optometry and VEP optometry and compare and analyze difference of diopter. Part 2: Choose 61 people with vision descended after ocular trauma (61 examined eyes) and group those people into six according to different injured position: the group of corneal injury; the group of corpus ciliare choroideae injury, the group of crystalline lens injury, the group of hyaloid body injury, the group of retina and choroid injury and the group of optic nerve injury. Examine all the injured eyes by VEP optometry, subjective optometry and computer optometry respectively. Then compare the variability of diopter and corrected vision between those three methods in every group. Analyze them by the statistics package of SPSS for windows 12.0 and evaluate the application value of those optometry methods in forensic identification.
【Results】There were no significantly statistical difference between results of diopter detection of eyes without trauma obtained by VEP optometry and subjective optometry (P>0.05). There were no significantly statistical difference between results of diopter detection of trauma eyes obtained by VEP optometry and subjective optometry (P>0.05). There were also no significantly statistical difference among results of diopter detection of astigmatism eyes obtained by VEP optometry, subjective optometry and computer optometry (P>0.05). But there were significantly statistical difference (P<0.05) between results of diopter detection of hypometropia and hypermetropic obtained by VEP optometry and computer optometry and by subjective optometry and optometry with computer. Compare the corrected vision of every group, there were significant difference of results observed between VEP optometry and computer optometry and between subjective optometry and optometry with computer by analyzing corrected vision (p<0.05) except the group of optic nerve injury. And the statistical difference was more significant (p<0.01) in the patients whose trauma refers to refracting mediums such as cornea、crystalline lens or retina.
【Conclusion】In the rectification of trauma eyes and un-trauma eyes, the subjective optometry way could reflect the practical reflection and physiological need of eyes. Satisfactory results would be obtained under the condition of patients’active cooperation, but it wasn’t suitable in application of forensic medicine because of intense subjection. Though computer optometry was objective and quick, there were inaccuracies in the results, especially the eyes which got trauma in refracting medium. Therefore, it could be preliminary examine basis for the refractive inspection of the ocular trauma patient, but not the final result. The VEP optometry was objective and exact, and it could offer objective basis for evaluating the best corrected visual acuity of eye trauma. Especially, it was suitable for forensic identification about eye injuries. But at the same time, the VEP optometry was difficult to put into practice and it required intensive practical operation. Further studies were needed to make it simple and practical.
引文
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10赵文雅,李纪哲,等.小儿脑瘫的病因与早期诊断及治疗[J].中国妇幼保健,2007;8(1):493
11陈萍,李小敏.脑性瘫痪致病因素的临床分析[J].中国妇幼保健,2004;17(1) :89
12汪志国,等.125例脑瘫患儿病因调查分析[J].黑龙江医药科学,2004;27(2):24-25
13杨菊英.贫困地区脑瘫患儿筛查病因分析早期防治研究[J].社区防保,2005;7(118):96-97
14 Sindeelorovo R,Poul J. Prevention of development of hip joint instability in patients with the spastic form of juvenile cerebral palsy.Acta Chir Orthop Traumatol Cech. 2001; 68(3):176-83.
15王成贤,张凤梅,等.脑瘫患儿286例的病因分析[J].职业与健康,2005;21(3):437
16李松,刘建蒙,等.中国六省(区)小儿脑性瘫痪患病率及临床类型的调查分析[J].中华儿科杂志,2001;39(10):613-615
17郭先鸣,梁友玲,等.低出生体重与小儿脑性瘫痪的关系[J].实用儿科临床杂志,2002;17(1):30-31
18 Yasunaga Y,Takahashi K,Ochi M,Ikuta Y,Hisatome T,Nakashiro T , Yamamoto S. Rotational acetabular osteotomy in patients forty- six years of age or older: comparison with younger patients.J Bone Joint Surg Am. 2003 Feb;85-A(2):266-72
19李松,洪世欣,等.早产和低出生体重及小于胎龄儿与脑性瘫痪发病的关系[J].中华儿科杂志,2003;41(5):344-346
20 Parent HF,Mascard E,Zeller R,Seringe R. A new technique of osteotomy for femoral varisation in the management of hip dislocation and paralytic subluxation of the hip .Rev Chir Orthop Reparatrice Appar Mot. 1994;80(4):346-50. French
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22吴本清.早产儿脑室周围白质软化的多因素分析[J].中国实用儿科杂志,2003;18(9):540-542
23 Dwbnath UK,Guha AR,Karlakki S,Vae\rshese J,Evans GA.Combined femoral and Chiari osteotomies for reconstruction of the painful subluxation or dislocation of the hip in cerebral palsy. A long- term outcome study.J Bone Joint Surg Br. 2006 Oct;88(10):1373-8.
24 Spencer JA,Badawi N,Burton P,et.The intrapartum CTG prior to neonatal encephalopathy at term: a casa-control study[J].BrJ O bstet Gynaecol,1997;104 (1):25-28
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26 Garnier Y, Coumans A, Berger R,et al. Endotoxemia severely affects circulation during normoxia and asphyxia in immature fetal sheep[J].J Soc Gynecol Investig, 2001;8(3):134-142
27侯梅,赵建慧等.双胎脑瘫患儿56例临床分析[J].中华物理医学与康复杂志,2005;27(12):710-711
28 Kurdi AM,Mesleh RA, AL-Hakeem MM, et al. Multiple pregnancy and preterm labor. SaudiMed J, 2002; 25: 632-637
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6梁春萍,刘萍,等.207例脑瘫的病因分析[J].中国康复,2000;3(1):56-58
7赖燕全,黄玉珍.小儿脑性瘫痪195例的病因及CT改变分析[J].海南医学,2001;12(1):34
8周晓玉,等.婴儿脑性瘫痪的病因与防治探讨(附128例临床分析)[J].中国当代儿科杂志,2001;3(2):186-188
9张春娥,等.165例脑瘫病因分析[J].齐鲁护理杂志,2001;7(6):439-440
10赵文雅,李纪哲,等.小儿脑瘫的病因与早期诊断及治疗[J].中国妇幼保健,2007;8(1):493
11陈萍,李小敏.脑性瘫痪致病因素的临床分析[J].中国妇幼保健,2004;17(1) :89
12汪志国,等.125例脑瘫患儿病因调查分析[J].黑龙江医药科学,2004;27(2):24-25
13杨菊英.贫困地区脑瘫患儿筛查病因分析早期防治研究[J].社区防保,2005;7(118):96-97
14 Sindeelorovo R,Poul J. Prevention of development of hip joint instability in patients with the spastic form of juvenile cerebral palsy.Acta Chir Orthop Traumatol Cech. 2001; 68(3):176-83.
15王成贤,张凤梅,等.脑瘫患儿286例的病因分析[J].职业与健康,2005;21(3):437
16李松,刘建蒙,等.中国六省(区)小儿脑性瘫痪患病率及临床类型的调查分析[J].中华儿科杂志,2001;39(10):613-615
17郭先鸣,梁友玲,等.低出生体重与小儿脑性瘫痪的关系[J].实用儿科临床杂志,2002;17(1):30-31
18 Yasunaga Y,Takahashi K,Ochi M,Ikuta Y,Hisatome T,Nakashiro T , Yamamoto S. Rotational acetabular osteotomy in patients forty- six years of age or older: comparison with younger patients.J Bone Joint Surg Am. 2003 Feb;85-A(2):266-72
19李松,洪世欣,等.早产和低出生体重及小于胎龄儿与脑性瘫痪发病的关系[J].中华儿科杂志,2003;41(5):344-346
20 Parent HF,Mascard E,Zeller R,Seringe R. A new technique of osteotomy for femoral varisation in the management of hip dislocation and paralytic subluxation of the hip .Rev Chir Orthop Reparatrice Appar Mot. 1994;80(4):346-50. French
21周丛乐.早产儿脑室周围白质软化的发生与预后[J]. .小儿急救医学,2004; 11(4):207-209
22吴本清.早产儿脑室周围白质软化的多因素分析[J].中国实用儿科杂志,2003;18(9):540-542
23 Dwbnath UK,Guha AR,Karlakki S,Vae\rshese J,Evans GA.Combined femoral and Chiari osteotomies for reconstruction of the painful subluxation or dislocation of the hip in cerebral palsy. A long- term outcome study.J Bone Joint Surg Br. 2006 Oct;88(10):1373-8.
24 Spencer JA,Badawi N,Burton P,et.The intrapartum CTG prior to neonatal encephalopathy at term: a casa-control study[J].BrJ O bstet Gynaecol,1997;104 (1):25-28
25 Gibson CS,MacLennan AH,Goldwater PN,et al.Neurotropic vi-ruses and cerebral palsy: population based case-control study.BMJ,2006,332:76-79.
26 Garnier Y, Coumans A, Berger R,et al. Endotoxemia severely affects circulation during normoxia and asphyxia in immature fetal sheep[J].J Soc Gynecol Investig, 2001;8(3):134-142
27侯梅,赵建慧等.双胎脑瘫患儿56例临床分析[J].中华物理医学与康复杂志,2005;27(12):710-711
28 Kurdi AM,Mesleh RA, AL-Hakeem MM, et al. Multiple pregnancy and preterm labor. SaudiMed J, 2002; 25: 632-637
29施荣福,唐红霞,等.抽样调查95435名儿童发生脑性瘫痪的危险因素[J].中国临床康复,2004;3(1):434-435