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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 (05) : 273 -280. doi: 10.3877/cma.j.issn.2095-2007.2019.05.003

论著

颅内压下降所致眼颅压力梯度增大对视盘血流密度影响的临床研究
刘祥祥1, 林丹婷1, 孙云晓1, 甘嘉禾1, 金杉杉1, 玛依努尔·于苏甫1, 王宁利1,†()   
  1. 1. 100730　首都医科大学附属北京同仁医院眼科中心　北京市眼科研究所　北京市眼科学与视觉科学重点实验室
  • 收稿日期:2019-09-16 出版日期:2019-10-28
  • 通信作者: 王宁利
  • 基金资助:
    国家自然科学基金(GZR-2012-009); 北京市自然科学基金(BJZR-2011-004); 国家科技支撑计划(KJB-KJZC-2011-001)

Effect of increasing trans lamina cribrosa pressure difference due to lowering intracranial pressure on optic blood flow density

Xiangxiang Liu1, Danting Lin1, Yunxiao Sun1, Jiahe Gan1, Shanshan Jin1, Yusufu Mayinuer1, Ningli Wang1,†()   

  1. 1. Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Institute of Ophthalmology, Beijing Ophthalmology & Visual Sciences Key Lab, Beijing 100730, China
  • Received:2019-09-16 Published:2019-10-28
  • Corresponding author: Ningli Wang
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引用本文：

刘祥祥, 林丹婷, 孙云晓, 甘嘉禾, 金杉杉, 玛依努尔·于苏甫, 王宁利. 颅内压下降所致眼颅压力梯度增大对视盘血流密度影响的临床研究[J]. 中华眼科医学杂志(电子版), 2019, 09(05): 273-280.

Xiangxiang Liu, Danting Lin, Yunxiao Sun, Jiahe Gan, Shanshan Jin, Yusufu Mayinuer, Ningli Wang. Effect of increasing trans lamina cribrosa pressure difference due to lowering intracranial pressure on optic blood flow density[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2019, 09(05): 273-280.

目的

探讨颅内压(ICP)下降所致眼颅压力梯度(TLPD)增大与视盘血流密度改变的相关关系。

方法

前瞻性病例对照研究。收集2018年9月至2018年12月北京同仁医院神经内科行腰椎穿刺(LP)收集脑脊液后ICP降低的患者20例(26只眼)为实验组。其中，男性8例(12只眼)，女性12例(14只眼)；年龄23~61岁，平均年龄(41.7±2.8)岁；收集健康志愿者13例(26只眼)为对照组。其中，男性5例(10只眼)，女性8例(16只眼)；年龄21~62岁，年龄(46.9±2.7)岁。检测实验组患者的眼内压(IOP)、ICP、脑脊液压力(CSFP)、TLPD、眼灌注压(OPP)及血压；检测对照组健康志愿者的IOP、OPP及血压；根据CSFP计算ICP下降程度(CSFP)。实验组，根据CSFP分为亚组A(15 mmH2O<CSFP≤30 mmH2O，6只眼)、亚组B(30 mmH2O<CSFP≤45 mmH2O，5只眼)及亚组C(CSFP >45 mmH2O，15只眼)等三个亚组。实验组患者记录脑脊液初压与末压，并于LP前和LP后15 min进行眼底相干光层析血管成像(OCTA)检查，测量视盘区血流密度；对照组，检查其在与LP患者相同体位改变前后的视盘区血流密度。应用配对t检验分别评估两组组内IOP、血压、OPP及视盘区血流密度变化情况和实验组各亚组内视盘区血流密度在不同程度ICP改变后的变化情况。

结果

对照组在体位改变后IOP、OPP、视盘区及各象限血流密度均未发现明显改变，差异无统计学意义(t＝0.061，-0.361；P>0.05)。实验组LP后ICP由(11.8±2.2)mmHg下降至(7.8±2.0)mmHg，差异有统计学意义(t＝13.061，P<0.05)；TLPD由(5.2±3.2)mmHg升高至(9.3±2.9)mmHg，差异有统计学意义(t＝-8.621, P<0.05)；视盘内、视盘周及视盘周毛细血管血流密度均明显下降，差异有统计学意义(t＝2.502, 3.848, 3.389；P<0.05)。在ICP下降超过45 mmH2O时，视盘周平均血流密度及视盘周毛细血管血流密度改变最明显，差异有统计学意义(t＝4.043, 4.332；P<0.05)。

结论

ICP下降所致的TLPD增大可导致视盘区血供减少，同时引起视盘周毛细血管微循环障碍，ICP下降程度越大，视盘区微循环异常越显著。

关键词: 颅内压, 眼颅压力梯度, 视盘血流密度, 微循环障碍
Objective

To investigate the relationship between the increasing trans lamina cribrosa pressure difference (TLPD) due to lowering intracranial pressure (ICP) and optic disc blood flow density.

Methods

Prospective case-control study. From September 2018 to December 2018, the study group recruited 20 patients (26 eyes) with an average age of (41.7±2.8) years old ranging from 37.8 years old to 67.2 years old, including 8 males(12 eyes) and 12 females(14 eyes), who admitted to the Department of Neurology of Beijing Tongren Hospital and underwent lumbar puncture (LP) with reduced intracranial pressure after collecting cerebrospinal fluid. The control group recruited 13 healthy volunteers (26 eyes) with an average age of (46.9±2.7) years old ranging from 34.5 years old to 69.4 years old and included 5 males (10 eyes) and 8 females(16 eyes). The study group were divided into three subgroups according to the reduction degree of cerebrospinal fluid pressure (CSFP) including sub-group A (15 mmH2O<CSFP≤30 mmH2O, 6 eyes), sub-group B (30 mmH2O<CSFP≤45 mmH2O, 5 eyes), sub-group C (CSFP>45 mmH2O, 15 eyes). OCTA scans, IOP and BP were acquired before and 15 minutes after in patients undergoing lumbar puncture (LP) and collecting cerebrospinal fluid samples and leading to a lower ICP level in the study group, respectively. Same parameters measurements were taken in the control group when the subjects performed the same body position change with LP procedure. The paired t-test was used to evaluate the changes of intraocular pressure, blood pressure, intraocular pressure and optic disc blood flow density within the two groups, and the flow density differences of the optic disc area among subgroups after varied reduction of intracranial pressure.

Results

In the control group, after body position changing, there was no significant changes in the intraocular pressure, optic blood flow density (t=0.061, -0.361; P>0.05). In the study group, ICP was significantly decreased from (11.8±2.2) mmHg to (7.8±2.0) mmHg (t=13.061, P<0.05), while TLPD was increasing by (9.3±2.9) mmHg from (5.2±3.2) mmHg (t=-8.621, P<0.05). Optic disc blood flow density inside disc, peripapillary, and peripapillary capillaries decreased significantly after ICP lowering, respectively (t=2.502, 3.848, 3.389; P<0.05). When the ICP decreased more than 45mmH2O, the blood flow density in peripapillary and peripapillary capillaries decreased significantly (t=4.043, 4.332; P<0.05).

Conclusions

Increased TLPD due to lowering ICP caused a significant decreasing in optic blood flow density and led to optic microvascular circulation abnormality. With a more severe reduction of ICP, a more significant abnormality of optic microvascular circulation was observed.

Key words: Intracranial pressure, Trans lamina cribrosa pressure difference, Optic blood flow density, Microvascular circulation
表1 实验组患者与对照组健康志愿者基本检查项目的比较(±s)
分组 眼数 年龄 性别男/女 体质指数 眼内压(mmHg) 颅内压(mmHg) 收缩压(mmHg) 舒张压(mmHg) 眼轴(mm) 中央角膜厚度(μm) 最佳矫正视力
实验组 26 41.7±2.8 8/12 24.8±2.2 17.0±2.4 11.8±2.2 124.0±11.1 73.0±11.9 23.5±1.6 526.6±32.9 0.9±0.2
对照组 26 46.9±2.7 5/8 24.1±3.3 16.3±1.5   123.2±12.8 73.1± 6.6 23.0±0.6 536.2±39.7 0.9±0.2
t值   -1.320 0.000 0.842 1.259   0.240 -0.014 1.989 -0.929 -0.412
P值   >0.05 >0.05 >0.05 >0.05   >0.05 >0.05 >0.05 >0.05 >0.05
图1 实验组患者与对照组健康志愿者压力参数的变化情况　图A显示实验组患者眼内压、颅内压、眼颅压力梯度及眼灌注压的变化情况；图B显示对照组健康志愿者眼内压与眼灌注压的变化情况
表2 实验组患者与对照组健康志愿者压力参数的比较(±s，mmHg)
分组 眼数 颅内压 眼内压 眼颅压力梯度 眼灌注压
实验组 26        
  基线   11.8±2.2 17.0±2.4 5.2±3.2 48.8±7.6
  腰穿后15 min   7.8±2.0 17.1±2.6 9.3±2.9 47.0±9.2
对照组 26        
  基线     16.3±1.5   49.4±5.4
  卧位后45 min     16.2±2.1   49.7±5.2
t实验组值   13.061 -0.359 -8.621 2.000
t对照组值     0.061   -0.361
P实验组值   <0.05 >0.05 <0.05 >0.05
P对照组值     >0.05   >0.05
图2 实验组患者与对照组健康志愿者视盘区血流图像的对比　图A、B示实验组患者基线视盘区血流；图C、D示实验组患者颅内压下降后视盘区血流；图E、F示对照组健康志愿者基线视盘区血流；图G、H示对照组健康志愿者卧位45 min后视盘区血流
表3 实验组患者与对照组健康志愿者视盘区血流密度的变化情况(±s，%)
分组 眼数 视盘区血流密度
视盘内 视盘内毛细血管 视盘周 视盘周毛细血管 鼻上侧 鼻下侧 颞上侧 颞下侧 上方鼻侧 上方颞侧 下方鼻侧 下方颞侧
实验组 26                        
  基线   61.65±3.01 51.54±3.58 58.63±4.56 51.81±4.88 48.80±5.35 47.79±5.73 54.58±5.85 51.99±4.00 49.72±6.40 54.40±7.83 52.66±6.05 56.94±5.42
  腰穿后15 min   60.67±3.43 51.01±3.83 57.52±4.69 50.75±4.78 47.80±5.01 46.54±5.79 53.58±5.95 50.50±4.27 48.82±6.23 52.74±7.54 51.83±5.50 56.57±4.60
对照组 26                        
  基线   59.39±3.05 48.63±3.51 60.88±2.18 54.20±2.63 50.97±3.64 50.99±3.03 57.06±3.31 54.97±3.60 52.41±5.09 57.59±3.84 53.34±3.76 58.79±3.11
  卧位后45 min   60.87±3.41 50.19±3.42 61.39±2.04 54.63±2.29 51.34±2.99 51.75±3.03 57.80±3.23 54.92±4.23 53.27±4.23 57.55±4.29 53.87±4.01 58.83±3.10
t实验组值   2.502 1.015 3.848 3.389 2.822 2.981 2.960 3.005 1.665 3.256 1.522 0.825
t对照组值   -1.984 -1.961 -1.853 -1.232 -0.941 -1.368 -1.957 0.116 -1.035 0.070 -0.810 -0.069
P实验组值   <0.05 >0.05 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 >0.05 <0.05 >0.05 >0.05
P对照组值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
表4 实验组患者不同颅内压下降程度对视盘血流密度影响(±s，%)
分组 眼数 视盘区血流密度
视盘内 视盘内毛细血管 视盘周 视盘周毛细血管 鼻上侧 鼻下侧 颞上侧 颞下侧 上方鼻侧 上方颞侧 下方鼻侧 下方颞侧
亚组A 6                        
  基线   62.10±1.24 51.99±0.99 58.53±4.42 51.54±5.09 49.50±5.38 46.97±5.94 52.68±6.06 50.17±4.31 50.12±7.18 54.88±7.36 56.93±6.70 53.34±4.27
  颅内压下降后   61.48±2.24 52.44±3.52 58.37±3.32 51.36±3.80 48.50±4.01 46.82±5.36 52.19±5.81 50.60±2.71 50.77±5.66 53.47±6.78 56.86±5.23 54.44±2.24
亚组B 5                        
  基线   63.31±2.24 52.94±1.94 61.14±1.81 54.21±1.48 51.15±4.25 50.29±4.25 57.56±2.05 54.89±2.74 52.83±2.66 57.17±4.09 53.28±2.92 58.77±4.18
  颅内压下降后   62.20±2.67 51.87±2.67 60.34±1.63 53.20±1.36 50.09±3.49 48.86±3.21 57.16±1.62 54.36±1.72 50.63±1.25 56.09±4.37 51.87±2.54 59.05±3.38
亚组C 15                        
  基线   60.91±3.54 50.90±4.50 57.82±5.13 51.12±5.48 47.74±5.67 47.28±6.17 54.35±6.48 51.75±3.92 48.52±6.91 53.28±9.01 52.18±7.51 56.33±5.46
  颅内压下降后   59.83±3.93 50.16±4.23 56.25±5.45 49.68±5.62 46.76±5.79 45.65±5.79 52.94±6.67 49.18±4.68 47.44±7.25 51.32±8.56 50.78±6.81 55.62±4.64
t亚组A值   0.665 -0.335 0.288 0.263 1.123 0.296 0.728 -0.386 -0.705 1.331 -1.019 0.065
t亚组B值   2.453 2.071 2.234 2.350 1.353 2.168 0.682 0.711 2.380 1.817 2.445 -0.401
t亚组C值   1.896 1.025 4.043 3.332 2.106 2.517 2.940 4.630 1.411 2.534 1.851 1.118
P亚组A值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
P亚组B值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
P亚组C值   >0.05 >0.05 <0.05 <0.05 >0.05 <0.05 <0.05 <0.05 >0.05 <0.05 >0.05 >0.05
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