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中华眼科医学杂志(电子版)

中华眼科医学杂志(电子版) ›› 2019, Vol. 09 ›› Issue (04) : 218 -226. doi: 10.3877/cma.j.issn.2095-2007.2019.04.005

所属专题： 经典病例；

论著

基于住院病例资料对近10年青光眼手术方式变化的分析
田佳鑫1, 石砚1, 辛晨1, 曹凯1, 朱传安2, 刘艳亭2, 乔春燕1, 王怀洲1, 王涛1, 唐炘1, 李树宁1, 王宁利1,†()   
  1. 1. 100730　首都医科大学附属北京同仁医院　北京同仁眼科中心　北京市眼科研究所　北京市眼科学与视觉科学重点实验室
    2. 首都医科大学附属北京同仁医院信息中心
  • 收稿日期:2019-06-20 出版日期:2019-08-28
  • 通信作者: 王宁利
  • 基金资助:
    国家自然科学基金项目(81730027)

The analysis of glaucoma surgery method changes in the past 10 years based on clinical data of hospitalized patients

Jiaxin Tian1, Yan Shi1, Chen Xin1, Kai Cao1, Chuanan Zhu2, Yanting Liu2, Chunyan Qiao1, Huaizhou Wang1, Tao Wang1, Xin Tang1, Shuning Li1, Ningli Wang1,†()   

  1. 1. Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing Ophthalmology&Visual Sciences Key Lab.
    2. Information Center Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
  • Received:2019-06-20 Published:2019-08-28
  • Corresponding author: Ningli Wang
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引用本文：

田佳鑫, 石砚, 辛晨, 曹凯, 朱传安, 刘艳亭, 乔春燕, 王怀洲, 王涛, 唐炘, 李树宁, 王宁利. 基于住院病例资料对近10年青光眼手术方式变化的分析[J]. 中华眼科医学杂志(电子版), 2019, 09(04): 218-226.

Jiaxin Tian, Yan Shi, Chen Xin, Kai Cao, Chuanan Zhu, Yanting Liu, Chunyan Qiao, Huaizhou Wang, Tao Wang, Xin Tang, Shuning Li, Ningli Wang. The analysis of glaucoma surgery method changes in the past 10 years based on clinical data of hospitalized patients[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2019, 09(04): 218-226.

目的

探讨北京同仁医院青光眼科2009年1月至2019年7月近10年青光眼手术方式的变化趋势。

方法

横断面研究。纳入2009年1月至2019年7月北京同仁医院青光眼科住院病例8581例(8581只眼)，年龄范围1~94岁，平均年龄(50.4±24.7)岁。其中，男性4442例，女性4139例。依据临床诊断，将患者进一步分为闭角型青光眼、开角型青光眼、发育性青光眼三大主要类型。其中，闭角型青光眼4471例，开角型青光眼2530例，发育性青光眼1580例。将青光眼手术分为以依赖结膜滤过泡为主要降眼压方式的外引流手术和促进房水通过生理途径引流的内引流手术，以及单纯行睫状体破坏术、白内障摘除联合人工晶状体植入术等非引流手术。外引流手术，进一步分为外引流手术A组和外引流手术B组。其中，外引流手术A组为小梁切除术降眼压的外引流手术，外引流手术B组为外引流物(硅管、青光眼阀及EX-PRESS)植入手术组。内引流手术分为内引流手术A组和内引流手术B组。其中，内引流手术A组(基于schlemm′s管和小梁网切开术为主要方式的内引流手术)，包括小梁切开术、房角切开术、schlemm′s管扩张术及小梁消融术；内引流手术B组，包括前房角分离术、前房成形术、周边虹膜切除术、内窥镜下睫状体光凝术及激光小梁成型术。应用Cochra-Armitage统计学趋势检验，分析上述3种青光眼手术方式的变化趋势。

结果

2009年，闭角型青光眼中外引流手术者263例，占83.4%; 2019年为89例，占30.6%。而内引流手术2009年为45例，占14.3%；2019年上涨到201例，占69.1%。2009年，开角型青光眼中外引流手术者130例，占100%；2019年为82例，占38.8%。内引流手术，从2009年无应用上涨至2019年的124例，占60.2%。2009年，在发育性青光眼中，外引流手术者9例，占95.2%；2019年为47例，占32.6%；而内引流手术者从2009年1例，占2.4%，上涨至2019年的95例，占66.0%。自2009年1月至2019年7月，闭角型青光眼、开角型青光眼及发育性青光眼外引流手术的比例均逐年下降，差异有统计学意义(Z＝2.10，2.13，3.05；Ptrend<0.05)；内引流手术比例逐年上升，差异有统计学意义(Z＝2.31，2.61，3.61；Ptrend<0.05)。

结论

近10余年来北京同仁医院青光眼科住院患者青光眼手术方式逐渐改变；闭角型青光眼、开角型青光眼及发育性青光眼的手术方式均从外引流向内引流手术方式转变。

关键词: 闭角型青光眼, 开角型青光眼, 发育性青光眼, 外引流手术, 内引流手术
Objective

The aim of this study was to analyze the change trend of glaucoma surgery in Beijing Tongren Hospital from January 2009 to July 2019.

Methods

It was a cross-sectional observational study. 8581 cases of glaucoma inpatients (8581 eyes), aged from 1 to 94 years old, in Beijing Tongren Hospital were enrolled from January 2009 to July 2019, including 4442 males and 4139 females.The average age was 5(0.4±24.7) years old. According to the clinical diagnosis, the subjects included were further divided into angle-closure glaucoma, open-angle glaucoma, and developmental glaucoma. The number of subjects inangle-closure glaucoma was 4471. The number of subject in open-angle glaucoma was 2530. The number of developmental glaucoma was 1580 (73.2% of developmental glaucomapatients with congenital glaucoma). Glaucoma surgeries were divided into external drainage surgeries with conjunctival filtration bleb as the main method of reducing intraocular pressure and internal drainage surgeries to promote drainage of aqueous humor through physiological pathway and non-drainage surgery. Non-drainage surgery was defined as cyclodestructive procedures as well as single cataract extraction combined with intraocular lens implantation. The external drainage surgery was further divided into external drainage surgery group A and external drainage surgery group B. The external drainage surgery group A was for trabeculectomy. The external drainage surgery group B was external drainage implant surgery, including tube, Ahmed glaucoma valve implant, and Ex-PRESS implant surgery. The internal drainage surgery was divided into internal drainage surgery group A and internal drainage surgery group B. The operation of internal drainage surgery group A mainly focus on schlemm's canal and trabecular meshwork, including trabeculotomy, goniotomy, canaloplasty and trabectome; internal drainage surgery group B includes goniosynechialysis, gonioplasty, peripheral iridotomy, endocyclophotocoagulation and laser trabeculoplasty. Cochran-Armitage trend test were used to analyze the change of surgical methods in three types of glaucoma.

Results

The number of angle-closure glaucoma for external drainage was 263(83.4%)in 2009, and decreased to 89 (30.6%) in 2019, while the number of internal drainage surgery increased from 45 (14.3%) in 2009 to 201 (69.1%) in 2019. The number of open-angle glaucoma for external drainage was 130 (100%) in 2009 and was 82 (38.8%) in 2019, while the number of internal drainage surgery increased from zero in 2009 to 124 (60.2%) in 2019. The number of developmental glaucoma for external drainage was 39 (95.2%) in 2009 and was 47 (32.6%) in 2019, while the number of internal drainage surgery increased from 1 (2.4%) in 2009 to 95 (66.0%) in 2019. From January 2009 to July 2019, the proportion of external drainage operations significantly decreased year by year (Z=2.102, 2.183, 3.053; Ptrend<0.05), the proportion of internal drainage surgery remarkably increased year by year (Z=2.311, 2.609, 3.612; Ptrend<0.05) in angle-closure glaucoma, open-angle glaucoma, and developmental glaucoma.

Conclusions

In the past ten years, the methods of glaucoma surgery in our hospital has gradually changed. The surgical methods of angle-closure glaucoma, open-angle glaucoma, and developmental glaucoma have all changed from external drainage operations to internal drainage operations.

Key words: Angle-closure glaucoma, Open-angle glaucoma, Developmental glaucoma, External drainage surgeries, Internal drainage surgeries
图1 2009年1月至2019年7月北京同仁医院青光眼科外引流手术、内引流手术及非引流手术方式在闭角型青光眼、开角型青光眼及发育性青光眼中的应用比例趋势图　图A显示闭角型青光眼中外引流手术呈下降趋势；图B显示开角型青光眼中外引流手术呈下降趋势；图C显示发育性青光眼中外引流手术呈下降趋势；图D显示闭角型青光眼中外引流手术呈下降趋势，内引流手术呈上升趋势；图E显示开角型青光眼中外引流手术呈下降趋势，内引流手术呈上升趋势；图F显示发育性青光眼中外引流手术呈下降趋势，内引流手术呈上升趋势
表1 2009年1月至2019年7月北京同仁医院青光眼科闭角型青光眼手术方式的应用情况
时间 例数 年龄中位数(岁) 住院时间中位数(d) 外引流手术例(%) 内引流手术例(%) 非引流手术例(%)
2009 314 67(60，74) 11(8，14) 263(83.8%) 45(14.3%) 6(1.9%)
2010 243 64(58，72) 10(7，12) 199(81.9%) 43(17.7%) 1(0.4%)
2011 398 65(60，72) 8(7，12) 270(67.9%) 118(29.6%) 10(2.5%)
2012 518 65(59，73) 8(7，11) 370(71.4%) 139(26.8%) 9(1.7%)
2013 547 65(59，71) 9(7，12) 376(68.7%) 159(29.1%) 12(2.2%)
2014 407 66(61，74) 8(7，10) 269(66.1%) 134(32.9%) 4(1.0%)
2015 411 67(61，74) 8(7，12) 292(71.0%) 114(27.7%) 5(1.2%)
2016 412 66(61，73) 9(7，13) 276(67.0%) 135(32.8%) 1(0.2%)
2017 460 68(61，73) 9(7，14) 275(59.8%) 185(40.2%)  
2018 470 67(61，72) 12(8，15) 220(46.8%) 247(52.6%) 3(0.6%)
2019.1-2019.7 291 67(62，74) 10(7，14) 89(30.6%) 201(69.1%) 1(0.3%)
Z值       2.10 2.31  
Ptrend值       <0.05 <0.05  
表2 2009年1月至2019年7月北京同仁医院青光眼科闭角型外引流及内引流青光眼手术的应用情况
年份 外引流手术 内引流手术
外引流手术A组，例(%) 外引流手术B组，例(%) 内引流手术A组，例(%) 内引流手术B组，例(%)
2009 262(83.4%) 1(0.4%)   45(14.3%)
2010 199(81.9%)     43(17.7%)
2011 269(67.6%) 1(0.3%)   118(29.6%)
2012 370(71.4%)     139(26.8%)
2013 376(68.7%)     159(29.1%)
2014 268(65.8%) 1(0.3%)   134(32.9%)
2015 290(70.6%) 2(0.4%)   114(27.7%)
2016 265(64.3%) 1(2.7%)   135(32.8%)
2017 273(59.3%) 2(0.5%) 5(1.1%) 180(39.1%)
2018 220(46.8%)     247(52.6%)
2019.1-2019.7 88(30.2%) 1(0.4%)   201(69.1%)
Z值 2.55     2.46
Ptrend值 <0.05     <0.05
表3 2009年1月至2019年7月北京同仁医院青光眼科开角型青光眼手术方式的应用情况
时间 例数 年龄中位数(岁) 住院时间中位数(d) 外引流手术例(%) 内引流手术例(%) 非引流手术例(%)
2009 130 45(35，63) 12(9，17) 130(100.0%)    
2010 117 53(35，64) 12(9，17) 110( 94.0%) 4( 3.4%) 3(2.6%)
2011 198 53(38，65) 10(7，15) 179( 90.4%) 15( 7.6%) 4(2.0%)
2012 306 51(36，63) 9(7，13) 269( 87.9%) 19( 6.2%) 18(5.9%)
2013 311 53(39，65) 10(7，14) 300( 96.5%) 11( 3.5%)  
2014 257 49(34，60) 9(7，13) 228( 88.7%) 29(11.3%)  
2015 214 47(35，61) 9(7，14) 163( 76.2%) 51(23.8%)  
2016 248 50(36，65) 9(7，14) 192( 77.4%) 53(21.4%) 3(1.2%)
2017 221 49(34，63) 9(7，14) 146( 66.1%) 74(33.5%) 1(0.5%)
2018 322 48(34，60) 8(7，14) 157( 48.8%) 163(50.6%) 2(0.6%)
2019.1-2019.7 206 50(37，62) 8(7，14) 82( 38.8%) 124(60.2%)  
Z值       2.18 2.61  
Ptrend值       <0.05 <0.05  
表4 2009年1月至2019年7月北京同仁医院青光眼科开角型外引流及内引流青光眼手术的应用情况
年份 外引流手术 内引流手术
外引流手术A组，例(%) 外引流手术B组，例(%) 内引流手术A组，例(%) 内引流手术B组，例(%)
2009 128(98.5%) 2( 1.5%)    
2010 107(91.4%) 3( 2.6%)   4( 3.4%)
2011 175(88.4%) 4( 2.0%)   15( 7.6%)
2012 259(84.6%) 10(3.3%) 12( 3.9%) 7( 2.3%)
2013 258(83.0%) 42(13.5%) 2( 0.6%) 9( 2.9%)
2014 179(69.6%) 49(19.1%)   29(11.3%)
2015 155(72.5%) 8( 3.7%) 51(23.8%)  
2016 184(74.2%) 8( 3.2%) 53(21.4%)  
2017 142(64.3%) 4( 1.8%) 58(26.2%) 16( 7.3%)
2018 155(48.1%) 2( 0.7%) 148(46.0%) 15( 4.6%)
2019.1-2019.7 79(38.3%) 3( 0.5%) 107(51.9%) 17( 8.3%)
Z值 2.28   2.77  
Ptrend值 <0.05   <0.05  
表5 2009年1月至2019年7月北京同仁医院青光眼科发育性青光眼手术方式的应用情况
时间 例数 年龄中位数(岁) 住院时间中位数(d) 外引流手术例(%) 内引流手术例(%) 非引流手术例(%)
2009 41 6(2，19) 16(11，21) 39(95.2%) 1(2.4%) 1( 2.4%)
2010 71 9(3，20) 12( 8，17) 70(98.6%) 1(1.4%)  
2011 100 4(1，16) 13( 8，17) 74(74.0%) 13(13.0%) 13(13.0%)
2012 150 4(1，12) 13( 7，17) 148(98.7%)   2(1.3%)
2013 143 3(1，7 ) 12( 9，15) 108(75.5%) 26(18.2%) 10(7.3%)
2014 130 3(1，8 ) 12( 7，15) 87(66.9%) 37(28.5%) 6(4.6%)
2015 201 4(1，16) 9( 7，14) 118(58.7%) 75(37.3%) 2(1.0%)
2016 191 5(2，10) 11( 7，15) 107(56.0%) 82(43.0%) 2(1.0%)
2017 149 2(1，7 ) 12( 7，14) 59(39.6%) 88(59.1%) 2(1.3%)
2018 260 5(2，13) 9( 7，14) 87(33.5%) 170(65.4%) 3(1.1%)
2019.1-2019.7 144 6(2，15) 7( 7，14) 47(32.6%) 95(66.0%) 2(1.4%)
Z值       3.053 3.612  
Ptrend值       <0.05 <0.05  
表6 2009年1月至2019年7月北京同仁医院青光眼科发育性青光眼外引流及内引流青光眼手术的应用情况
年份 外引流手术 内引流手术
外引流手术A组，例(%) 外引流手术B组，例(%) 内引流手术A组，例(%) 内引流手术B组，例(%)
2009 37(90.3%) 2(4.9%)   1( 2.4%)
2010 68(95.8%) 2(2.8%)    
2011 72(72.0%) 2(2.0%)   13(13.0%)
2012 148(98.7%)      
2013 101(70.6%) 7(4.9%) 25(17.5%) 1( 0.7%)
2014 82(63.1%) 5(3.8%) 34(26.2%) 3( 2.3%)
2015 111(55.2%) 7(3.5%) 73(36.3%) 2( 1.0%)
2016 106(55.5%) 1(0.5%) 80(41.9%) 2( 1.1%)
2017 58(38.9%) 1(0.7%) 86(57.7%) 2( 1.3%)
2018 84(32.3%) 3(1.2%) 166(63.9%) 4( 1.5%)
2019.1-2019.7 46(31.9%) 1(0.7%) 92(63.9%) 3( 2.1%)
Z值 2.17   2.57  
Ptrend值 <0.05   <0.05  
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