目的通过对比不同分期糖尿病视网膜病变(DR)患者涡状区角膜上皮基底神经丛(sub-basal nerve plexus，SNP)的差别，探讨DR分期与糖尿病角膜神经损伤的相关性。
方法采用横断面研究，选取2018年9月至2019年1月就诊于山西省眼科医院的2型糖尿病患者66例66眼，年龄50～65岁，均以右眼为受检眼。按照DR分级标准将患者分为无糖尿病视网膜病变(NDR)组、非增生期糖尿病视网膜病变(NPDR)组和增生期糖尿病视网膜病变(PDR)组，并纳入年龄与性别匹配的年龄相关性白内障患者20例20眼作为对照组。所有受检者均接受角膜激光扫描共焦显微镜检查，观察涡状区SNP的形态，并测量神经纤维长度(NFL)。采用以病程为协变量的协方差分析比较各组间NFL值差异；采用Spearman秩相关分析NFL值与DR分期的相关性。
结果所有受检眼均可查见涡状区。对照组神经纤维粗细均匀、分布密集，走行规则，且多数受检眼涡状结构完整；各不同分期DR组神经纤维普遍变细、密度下降，走行迂曲，并伴有不同程度的涡状结构缺失。NDR组和NPDR组主要表现为涡状中心缺失；PDR组除涡状中心缺失外，部分受检眼还合并下方及颞侧的结构缺失。对照组、NDR组、NPDR组和PDR组NFL值分别为(21.08±4.74)、(16.47±6.35)、(14.95±3.90)和(11.61±3.24)mm/mm 2，总体比较差异具有统计学意义( F＝10.541， P<0.001)。对照组NFL值均明显高于各不同DR分期组，差异均有统计学意义(均 P<0.01)。Spearman秩相关分析结果显示，NFL值与DR分期呈负相关( r s＝-0.356， P＝0.003)。
结论糖尿病SNP损伤早于DR出现，且随着DR发展过程而逐渐进展；DR各分期均伴有不同程度的神经结构缺失，且缺失首先从涡状中心开始，逐渐向下方和颞侧发展。临床在治疗糖尿病患者眼底病的同时应当兼顾眼表的状况。
ObjectiveTo estimate the correlation between DR and diabetic corneal nerve damage by comparing changes of corneal sub-basal nerve plexus (SNP) in the whorl-like region in different DR stages.
MethodsIn this cross-sectional study, 66 eyes of 66 type 2 diabetes patients aged 50-65 years old in Shanxi Eye Hospital from September 2018 to January 2019 were included.The subjects were divided into non-diabetic retinopathy group (NDR), non-proliferative diabetic retinopathy group (NPDR) and proliferative diabetic retinopathy group (PDR) accordingly, the right eyes were enrolled.20 eyes of 20 age and gender matched age-related cataract patients were also included as control group.All the subjects underwent confocal corneal microscopy to observe the morphology of SNP in the whorl-like region and measure the nerve fiber length (NFL) in this area.Covariance analysis using disease course as the covariate was used to analyze the differences of NFL value among groups, and Spearman rank correlation analysis was used to analyze the correlation between NFL value and DR stages.The study protocol was approved by the Ethics Committee of Shanxi Eye Hospital.Written informed consent was obtained from each patient prior to entering the study cohort.
ResultsThe whorl-like region were observed in all the eyes.In the control group, nerve fibers were uniform in thickness, densely distributed with regular course, and most of the tested eyes had intact whorl-like structure.Nerve fibers in different DR groups all showed generally decrease in diameter and density, with increase in tortuosity, accompanied by different degrees of whorl-like structure loss.Eyes in the NDR group and NPDR group mainly showed nerve structure loss in the whorl-like center; while some eyes in the PDR group also showed nerve structure loss in the inferior and temporal of the whorl-like region.The NFL values were (21.08±4.74), (16.47±6.35), (14.95±3.90), and (11.61±3.24)mm/mm 2 in the control group, the NDR group, the NPDR group, and the PDR group, respectively, the overall difference was statistically significant ( F=10.541, P<0.001). The NFL value in the control group was significantly higher than those in the different DR groups, the differences were statistically significant (all at P<0.01). Spearman rank correlation analysis showed that there was a significant negative correlation between NFL value and DR stages ( r s=-0.356, P=0.003).
ConclusionsDiabetic SNP damage occurs earlier than DR, and progress gradually with the development of DR; Different stages of DR are accompanied by different degrees of nerve structure loss; The structure loss begins at the whorl-like center and gradually develops to downward and the temporal side.The ophthalmologists should take the condition of ocular surface into account when treating ocular fundus diseases of diabetic patients.
于花,苗英彬,赵少贞,等. 糖尿病视网膜病变程度与角膜上皮基底神经丛涡状区改变的关系[J]. 中华实验眼科杂志,2020,38(09)：767-772.
DOI:10.3760/cma.j.cn115989-2019-0618-00269版权归中华医学会所有。
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