探究角膜地形图引导(TOPO-G)准分子激光原位角膜磨镶术(LASIK)术后角膜上皮重塑规律及影响因素。

纳入2021年5月至2024年7月于首都医科大学附属北京同仁医院行TOPO-G LASIK的近视眼患者119例(237只眼)。其中，男性28例(56只眼)，女性91例(181只眼)；年龄18~40岁，平均年龄(27.9±4.7)岁。根据术前主觉验光等效球镜屈光度(MRSE)将患者分为高度近视眼组和中低度近视眼组，前者MRSE≤-6.00 D，后者MRSE>-6.00 D。分别于术前及术后1个月、术后3个月、术后6个月及术后12个月时测量两组患者角膜6 mm范围内0~2 mm中央区、2~5 mm内环区及5~6 mm外环区17个区域的上皮厚度(ET)。患者的年龄、视力、屈光度、角膜厚度及ET均符合正态分布，以±s形式描述，各组术前术后的比较采用配对t检验，两组患者间各时间点比较采用独立样本t检验，采用混合效应模型分析角膜ET变化的影响因素。

术前高度近视眼组患者MRSE、裸眼远视力、最佳矫正远视力及中央角膜厚度分别为(-7.66±1.29)D、(1.35±0.28)最小分辨视角的对数(logMAR)、(-0.04±0.05)logMAR及(535.12±22.98)μm；中低度近视眼组患者分别为(-4.27±1.26)D、(1.08±0.39)logMAR、(-0.05±0.04)logMAR及(529.63±29.76)μm。裸眼远视力中低度近视眼组优于高度近视眼组，差异有统计学意义(t＝0.79，P<0.05)；两组患者最佳矫正远视力和中央角膜厚度的比较，差异无统计学意义(t＝0.21，0.21；P>0.05)。高度近视眼组和中低度近视眼组患者术后1个月、术后3个月、术后6个月及术后12个月中央区2 mm平均ET分别为(55.17±4.19)μm、(57.73±4.41)μm、(57.94±3.99)μm、(58.35±3.70)μm、(53.99±4.45)μm、(54.74±3.24)μm、(55.36±3.36)μm及(56.66±4.34)μm，两组患者较术前均增加且高度近视眼组较中低度近视眼组增加明显，差异有统计学意义(t＝0.20，0.38，0.38，0.27；P<0.05)。两组患者术后各时间点内环区2~5 mm平均ET分别为(58.79±3.90)μm、(61.08±3.89)μm、(61.11±3.48)μm、(61.78±3.27)μm、(56.23±4.43)μm、(56.93±2.84)μm、(57.52±3.31)μm及(58.56±4.29)μm，两组患者较术前均增加且高度近视眼组较中低度近视眼组增加明显，差异有统计学意义(t＝0.43，0.62，0.55，0.53；P<0.05)。两组患者术后各时间点外环区5~6 mm平均ET分别为(56.84±3.57)μm、(58.94±3.12)μm、(58.55±3.18)μm、(59.32±2.87)μm、(55.68±4.19)μm、(56.29±2.73)μm、(56.76±2.92)μm及(57.19±3.98)μm，两组患者较术前均增加，高度近视眼组较中低度近视眼组增加明显，差异有统计学意义(t＝0.27，0.52，0.58，0.41；P<0.05)。2~5 mm和5~6 mm区内颞上、颞侧、颞下及下方各区ET变化量随时间逐渐增加，但与中低度近视眼组患者相比，各时间点高度近视眼组患者以上各区角膜ET增加量明显更高。经混合效应模型分析，患者切削深度、MRSE与2 mm ET变化量呈负相关且有统计学意义(β＝-1.27，-1.87；P<0.05)，术后3个月后的随访时间则与2 mm上皮变化呈正相关且有统计学意义(β＝1.72，1.92，2.70；P<0.05)。切削深度与随访时间的交互效应分析可见与术后1个月相比，术后3个月和术后6个月时2 mm ET变化呈正相关且有统计学意义(β＝0.60，0.73；P<0.05)。

TOPO-G LASIK术后角膜上皮重塑主要集中于颞下方、下方及颞侧的内外环区，术后各时间点高度近视组患者ET增加均高于中低度近视组，但两组患者术后1年内上皮均持续增殖且未达稳定状态。术前MRSE是术后上皮重塑的主要决定因素；切削深度则通过时间依赖的交互效应影响中央区上皮重塑且中远期影响更明显，临床需加强中长期随访。

The aim of this study is to investigate the patterns of corneal epithelial remodeling and related influencing factors after topography-guided laser in situ keratomileusis (TOPO-G LASIK).

A total of 119 patients (237 eyes) based on TOPO-G LASIK from May 2021 to July 2024 were retrospectively included in Beijing Tongren Hospital, Capital Medical University. There were 28 males (56 eyes) and 91 females (181 eyes) with an average age of 27.9±4.7 years (ranging from 18 to 40 years old). Patients were divided into the high myopia group (≤-6.00 D) and the moderate-to-low myopia group (>-6.00 D) based on the manifest refractive spherical equivalent (MRSE). The epithelial thickness (ET) of 17 regions in total within the 6 mm corneal range, which included 1 central zone (0 to 2 mm), as well as the inner ring zone (2 to 5 mm) and the outer ring zone (5 to 6 mm), was measured by the anterior segment optical coherence tomography preoperatively and 1, 3, 6, 12 months postoperatively. The age, visual acuity, MRSE, corneal thickness and epithelial thickness were all normally distributed and described as ±s. Paired t-tests were used in both groups before and after surgery, and independent sample t-tests were used between the two groups at different time points. And a mixed-effects model was applied to further explore the specific factors affecting postoperative ET changes.

The MRSE, uncorrected distance visual acuity, best corrected distance visual acuity, and central corneal thickness were (-7.66±1.29) D, (1.35±0.28) logarithm of the minium angle of resolution (logMAR), (-0.04±0.05) logMAR, and (535.12±22.98) μm in the high myopic group and (-4.27±1.26) D, (1.08±0.39) logMAR, (-0.05±0.04) logMAR, and (529.63±29.76)μm in the moderate-to-low myopic group. The uncorrected distant visual acuity of the moderate-to-low myopia group was better than that of the high myopia group (t=0.79, P<0.05), while no statistical differences were in the best corrected distance visual acuity and central corneal thickness (t=0.21, 0.21; P>0.05) between the two groups. The central 2 mm average ET of the two groups at 1, 3, 6, 12 months postoperatively was (55.17±4.19)μm, (57.73±4.41)μm, (57.94±3.99)μm, (58.35±3.70)μm, (53.99±4.45)μm, (54.74±3.24)μm, (55.36±3.36)μm, (56.66±4.34)μm, respectively; and the inner 2 to 5 mm ring average ET was (58.79±3.90)μm, (61.08±3.89)μm, (61.11±3.48)μm, (61.78±3.27)μm, (56.23±4.43)μm, (56.93±2.84)μm, (57.52±3.31)μm, (58.56±4.29)μm, respectively; and the outer 5 to 6 mm ring average ET was (56.84±3.57)μm, (58.94±3.12)μm, (58.55±3.18)μm, (59.32±2.87)μm, and (55.68±4.19)μm, (56.29±2.73)μm, (56.76±2.92)μm, (57.19±3.98)μm, respectively. Both groups increased compared with those preoperatively, and the high myopic group showed significant increases in the average corneal ET in the central 2 mm (t=0.20, 0.38, 0.38, 0.27; P<0.05), the inner ring 2 to 5 mm zone (t=0.43, 0.62, 0.55, 0.53; P<0.05), and the outer ring 5 to 6 mm zone (t=0.27, 0.52, 0.58, 0.41; P<0.05) at 1, 3, 6, 12 months postoperatively compared with the moderate-to-low myopic group. The superotemporal, temporal, inferotemporal, and inferior ET of the 2 to 5 mm and 5 to 6 mm zones gradually increased over time, and the increase in the high myopic group was higher than that in the moderate-to-low myopic group. The results of the mixed-effects model analysis showed that the ablation depth and MRSE were negatively correlated with Δ2 mm ET (β=-1.27, -1.87; P<0.05); the follow-up time at 3, 6, 12 months postoperatively was positively correlated with Δ2 mm epithelium (β=1.72, 1.92, 2.70; P<0.05). The interaction effect of cutting depth and follow-up time was positively correlated with Δ2 mm ET. There was statistical significance at 3 months and 6 m (β=0.60, 0.73; P<0.05).

Corneal epithelial remodeling after TOPO-G LASIK was mainly concentrated in the inferotemporal, inferior, and temporal regions of the inner and outer ring zones. The ET increase in the high myopia group was higher than that in the moderate-to-low group at all postoperative times. However, epithelial remodeling continued in both groups within 1 year after surgery and had not reached a stable state. Preoperative MRSE was the main determinant of postoperative epithelial remodeling. Ablation depth could not function independently of time, which influenced central epithelial remodeling through a time-dependent interaction effect with a more significant impact in the mid-to-long term. Therefore, enhanced mid-to-long-term follow-up is required.