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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) ›› 2022, Vol. 12 ›› Issue (06) : 341 -346. doi: 10.3877/cma.j.issn.2095-2007.2022.06.004

论著

断层扫描生物力学指数应用于屈光手术术前早期圆锥角膜筛查的临床研究
刘佳1, 贺瑞2,†(), 李晓娜3   
  1. 1. 030001　太原，山西医科大学第一临床医学院2019级研究生，2022年8月始在西北大学附属第一医院西安市第一医院陕西省眼科研究所工作
    2. 030002　太原，山西省眼科医院准分子激光科
    3. 030024　太原理工大学生物医学工程学院
  • 收稿日期:2022-10-19 出版日期:2022-12-28
  • 通信作者: 贺瑞
  • 基金资助:
    国家自然科学基金项目(12072218)

Application of tomography biomechanical index in preoperative screening of early keratoconus during refractive surgery

Jia Liu1, Rui He2(), Xiaona Li3   

  1. 1. Master′s degree 2019, the First Clinical Medical College of Shanxi Medical University, Taiyuan 030001, China; The First Affiliated Hospital of Northwestern University, Xi′an First Hospital, Shanxi Institute of Ophthalmology (from August 2022)
    2. Excimer Laser, Shanxi Eye Hospital, Taiyuan 030002, China
    3. College of Biomedical Engineering Taiyuan University of Technology, Taiyuan 030024, China
  • Received:2022-10-19 Published:2022-12-28
  • Corresponding author: Rui He
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引用本文：

刘佳, 贺瑞, 李晓娜. 断层扫描生物力学指数应用于屈光手术术前早期圆锥角膜筛查的临床研究[J]. 中华眼科医学杂志(电子版), 2022, 12(06): 341-346.

Jia Liu, Rui He, Xiaona Li. Application of tomography biomechanical index in preoperative screening of early keratoconus during refractive surgery[J]. Chinese Journal of Ophthalmologic Medicine(Electronic Edition), 2022, 12(06): 341-346.

目的

比较准分子激光原位角膜磨镶术(LASIK)及飞秒激光制瓣准分子激光原位角膜磨镶术(FS－LASIK)术前与术后角膜形态学及生物力学的变化，评估断层扫描生物力学指数(TBI)值在术前早期圆锥角膜筛查中的应用价值。

方法

收集2018年5月至12月于山西省眼科医院准分子激光科行LASIK或FS－LASIK手术患者72例(117只眼)的病例资料。其中，男性34例(52只眼)，女性38例(65只眼)。根据TBI<0.29及TBI≥0.29分为正常组40例(66只眼)和可疑组32例(51只眼)。收集所有患者的年龄、角膜直径，术前及术后1个月、术后3年的等效球镜屈光度、裸眼视力及最佳矫正视力。应用Pentacam眼前节分析系统测量中央角膜厚度(CCT)、角膜最薄点厚度、角膜最薄点后表面高度、角膜最大曲率(Kmax)上下方曲率不对称指数(I－S value)、前表面高度的标准偏差指数(Df)、后表面高度的标准偏差指数(Db)、厚度变化率的标准偏差指数(Dp)、最薄点厚度的标准偏差指数(Dt)、最薄点相对厚度标准偏差指数(Da)及Pentacam断层扫描综合指数(BAD－D)等指标；应用Corvis ST可视化角膜生物力学分析仪测量Pentacam随机森林指数(PRFI)、角膜第一压平时硬度参数(SP－A1)、综合半径指数(IR)、Ambrosio水平方向上相关厚度(ARTh)、角膜变形幅度比(DA ratio)、Corvis生物力学综合指数(CBI)及TBI等。各参数符合正态分布，以±s表示。两组患者年龄的比较采用χ2检验；术前、术后1个月及术后3年变化的比较采用重复测量方差分析或独立样本t检验；选取术前差异有统计学意义的参数，比较分析其术前与术后3年的差值(Δ)；对Δ有差异的参数进行多因素Logistics回归分析。

结果

可疑组患者术前、术后1个月及术后3年角膜最薄点角膜后表面高度分别为(7.74±1.65)μm、(5.19±1.68)μm及(4.67±1.73)μm，与正常组比较的差异无统计学意义(F＝0.120，0.055，0.407；P>0.05)。两组患者术前角膜最薄点后表面高度均高于术后，差异有统计学意义(t＝3.731，6.631，3.269，6.166；P<0.05)；且两组患者术前及术后角膜后表面高度图形态均为桥型递减型或不完全桥型。两组患者术前、术后1个月及术后3年角膜最薄点后表面高度的组间比较差异均无统计学意义(F＝0.120，0.055，0.407；P>0.05)。可疑组患者术前CBI、PRFI、I－Svalue、Kmax、Dp、Da及BAD－D高于正常组，差异有统计学意义(t＝－2.564，－5.629，－2.352，－2.551，－3.268，－2.596，－2.124；P<0.05)；ARTh低于正常组，差异有统计学意义(t＝3.239，P<0.05)；术前两组角膜直径、Db、Df、Dt、SPA1、IR及DA Ratio比较的差异无统计学意义(t＝0.235，－0.852，－0.898，－0.968，0.427，0.571；P>0.05)。两组患者ΔPRFI、ΔI－S value、ΔKmax、ΔDp、ΔDa及ΔARTh比较的差异均无统计学意义(t＝－1.778，1.054，1.407，1.599，－0.628，1.151；P>0.05)。将TBI作为因变量，PRFI、I－S value、Kmax、Dp、Da及ARTh作为协变量进行多因素Logistics回归分析，结果显示PRFI与TBI≥0.29具有相关性且有统计学意义(β＝2.717，95%CI：3.104~73.784，P<0.05)。

结论

在角膜后表面高度图形态为不完全桥型或桥型递减型时，TBI≥0.29主要与PRFI有关。当TBI≥0.29且因PRFI导致时，TBI值对术前筛查圆锥角膜的预测作用仍有待商榷；但若因其他因素导致，则仍应警惕术后角膜扩张的风险。

关键词: 激光角膜屈光手术, 筛查早期圆锥角膜, 角膜地形图, 角膜生物力学, 断层扫描生物力学指数
Objective

To evaluate the tomography biomechanical index (TBI) value in early corneal dilatation by observing the morphological and biomechanical changes of laser in situ keratomileusis (LASIK) and femtosecond laser-assisted excimer laser in situ keratomileusis (FS-LASIK).

Methods

72 patients (117 eyes) who received LASIK or FS-LASIK in the Excimer Laser of Shanxi Eye Hospital from January to December 2018 and had complete clinical data and routine follow-up after surgery for 3 years were collected. According to the TBI, they were divided into two groups normal group (TBI<0.29) and suspicious group (TBI≥0.29). The patient′s age, the corneal diameter, the vision and refraction before and after surgery were collected. Preoperative and postoperative parameters, including corneal central thickness (CCT), thickness of thinnest point of cornea, surface height behind the thinnest point of cornea, maximum keratometry (Kmax), inferior-superior difference value (I-S value), deviation of front elevation difference map (Df), deviation of back elevation difference map (Db), deviation of average pachymetric progression (Dp), deviation of minimum thickness (Dt), deviation of ARTmax (Da), total deviation value (BAD-D), were measured using Pentacam anterior segment analyzer; Pentacam random forest index (PRFI), stiffness parameter (SPA1), Ambrósio′s relational thickness to the horizontal profile (ARTh), integrated radius (IR), deformation amplitude ratio (DA ratio), Corvis biomechanical index (CBI), were measured using the corneal visualization scheimpflug technology. Parameters conform to normal distribution and were expressed by ±s, and compared by ANOVA and t test; the age was compared by chi-square. The preoperative parameters with statistically significant differences were selected and the D-value of preoperative and 3rd postoperative years compared (Δ). The Logistics analysis was performed if variables with statistical significance differences.

Results

The height of posterior corneal surface at the thinnest point in suspicious group was (7.74±1.65) μm, (5.19±1.68) μm and (4.67±1.73) μm before surgery, after surgery for 1 month and 3 years, respectively. There was no significant difference between them (F=0.120, 0.055, 0.407; P>0.05). The height of the corneal posterior surface of the thinnest point before surgery were higher than after surgery with statistical significance differences (t=3.731, 6.631, 3.269, 6.166; P<0.05). There was no significant difference in the surface height after the thinnest point between the two groups before surgery, after surgery for 1 month and 3 years (F=0.120, 0.055, 0.407; P>0.05). Preoperative CBI, PRFI, I-S value, Kmax, Dp, Da and BAD-D in the suspicious group were higher than those of the normal group, and the difference was statistically significant (t=-2.564, -5.629, -2.352, -2.551, -3.268, -2.596, -2.124; P<0.05). ARTh was lower than normal group, and the difference was statistically significant (t=3.239, P<0.05). There was no significant difference in ΔPRFI, ΔI-S value, ΔKmax, ΔDp, ΔDa and ΔARTh between the two groups (t=-1.778, 1.054, 1.407, 1.599, -0.628, 1.151; P>0.05). TBI was taken as the dependent variable, and PRFI, I-S value, Dp, Da, ARTh were used as concomitant variables for multiple Logistic regression analysis. The results showed that PRFI was associated with TBI value changes (β=2.717, 95%CI: 3.104 to73.784, P<0.05).

Conclusions

When the height pattern of the posterior corneal surface was incomplete or decreased, TBI≥0.29 was mainly associated with PRFI. The predictive role of preoperative screening for keratoconus remains to be discussed if TBI≥0.29 was caused by PRFI; the risk of postoperative corneal dilation should be vigilant if TBI≥0.29 was caused by others.

Key words: Laser corneal refractive surgery, Early keratoconus screening, Corneal topographic map, Corneal biomechanic, Tomographic biomechanical index
表1 两组屈光不正患者术前一般检查结果的比较(±s)
组别 眼数(只眼) 年龄(岁) 女性占比(%) 裸眼视力 BCVA CCT(μm) 角膜直径(mm) TBI
正常组 66 24.0±4.4 57.6 1.07±0.32 －0.17±0.04 539.52±23.23 11.28±0.33 0.14±0.09
可疑组 51 24.6±4.8 54.9 1.12±0.34 －0.17±0.03 536.21±26.94 11.30±0.40 0.61±0.26
t/χ2值   －0.579 0.084* －0.681 0.516 0.562 －0.178 －10.857
P值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 <0.05
表2 两组患者术前角膜形态学及生物力学参数的比较(±s)
组别 眼数(只眼) Kmax(D) DA Ratio Db Dp Df Dt Da
正常组 66 44.17±1.59 4.30±0.31 1.00±0.88 0.77±0.64 0.92±1.04 0.12±0.70 0.46±0.58
可疑组 51 45.11±1.62 4.27±0.37 1.17±0.78 1.34±0.84 1.13±1.01 0.19±0.64 0.84±0.67
t值   －2.551 0.235 －0.852 －3.268 －0.898 －0.968 －2.596
P值   <0.05 >0.05 >0.05 <0.05 >0.05 >0.05 <0.05
组别 眼数(只眼) BAD－D I－S value(D) ARTh PRFI SPA1 IR(mm－1) CBI
正常组 66 1.43±0.56 0.50±0.56 554.74±110.72 0.17±0.10 107.56±15.43 8.61±0.84 0.02±0.04
可疑组 51 1.68±0.49 0.81±0.58 490.43±60.23 0.34±0.16 105.95±16.92 8.36±1.05 0.08±0.56
t值   －2.124 －2.352 3.239 －5.629 0.427 0.571 －2.564
P值   <0.05 <0.05 <0.05 <0.05 >0.05 >0.05 <0.05
表3 两组患者ΔPRFI、ΔI－S value、ΔKmax、ΔDp、ΔDa及ARTh的比较(±s)
组别 眼数(只眼) Δ PRFI Δ I－S value (D) ΔKmax (D) Δ Dp Δ Da Δ ARTh
正常组 66 －0.35±0.16 －0.49±0.77 －0.50±1.16 －6.47±2.95 －2.05±0.69 357.78±102.44
可疑组 51 －0.27±0.19 －0.85±1.81 －0.16±0.95 －7.80±3.98 －1.92±0.96 334.48± 74.11
t值   －1.778 1.054 1.407 1.599 －0.628 1.151
P值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
表4 多因素Logistics回归分析
参数 β 标准误 Wald P值 OR 95%CI
PRFI 2.717 0.808 11.297 <0.05 15.132 3.104~73.784
I－S value 0.189 0.592 0.102 >0.05 1.208 0.378~ 3.857
Kmax 0.316 0.198 2.545 >0.05 1.371 0.930~ 2.021
Dp －0.309 0.756 0.167 >0.05 0.734 0.167~ 3.230
Da －0.240 0.780 0.095 >0.05 0.787 0.171~ 3.626
ARTh －0.009 0.005 3.410 >0.05 0.991 0.982~ 1.001
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