目的观察双眼先天性白内障儿童行白内障摘出联合人工晶状体(IOL)植入术后疗效的5年随访结果。
方法采用系列病例观察研究，对2007年1月至2012年1月在郑州大学第一附属医院行超声乳化白内障摘出联合后囊膜切除、前段玻璃体切割及IOL植入术的2～7岁双眼先天性白内障患儿72例144眼进行连续5年的随访观察，所有患儿均于第二眼术后2周行双眼屈光矫正和弱视训练。患儿根据手术时年龄不同分为2～3岁组32例64眼、4～5岁组24例48眼和6～7岁组16例32眼。对术眼术前、术后最佳矫正视力(BCVA)、屈光度变化、眼轴增长值、角膜曲率、视功能及手术并发症等结果进行系统观察，并分析手术时年龄与末次随访单眼BCVA的关系。
结果2～3岁组、4～5岁组和6～7岁组术眼平均屈光度数变化值分别为-2.10(-2.90，-1.90)、-1.73(-2.50，-2.10)和-0.52(-2.00，-0.28)D，总体比较差异有统计学意义( H＝19.85， P<0.01)；3个组眼轴长度分别平均增长(1.41±0.32)、(0.96±0.51)和(0.52±0.26)mm，总体比较差异有统计学意义( F＝13.24， P<0.05)；3个组手术前后角膜曲率比较，差异均无统计学意义(均 P>0.05)；3个组术眼术后BCVA较术前均明显提高，且获得一定的立体视觉，2～3岁组术眼BCVA优于4～5岁组和6～7岁组，差异均有统计学意义(均 P<0.05)。术眼术后BCVA≥0.3者占80.56%(116/144)，BCVA>0.8者占19.44%(28/144)。对患儿手术时年龄与术后BCVA进行回归分析，回归方程为术后BCVA＝0.959-0.104×手术年龄，患儿手术的年龄越小，术后单眼BCVA越好( R 2＝0.539， P<0.01)。
结论儿童双眼先天性白内障患儿术后视功能的恢复与手术年龄有关，手术年龄越小，视功能恢复越好。术后及时、系统、规范的屈光矫正、弱视治疗和双眼视功能训练有助于视功能的发育和重建。
ObjectiveTo observe the 5-year outcomes and complications after cataract extraction combined with intraocular lens implantation in children with bilateral congenital cataract.
MethodsAn observational case series study was performed.A total of 72 children (144 eyes), aged 2 to 7 years, who received intraocular lens (IOL) implantation combined with posterior continuous curvilinear capsulorhexies and anterior vitrectomy after cataract extraction for bilateral congenital cataract in The First Affiliated Hospital of Zhengzhou University from January 2007 to January 2012 were enrolled.All the patients underwent refractive correction and amblyopia training two weeks after the second operative eye underwent surgery.The patients were divided into 2-3 years old group (64 eyes), 4-5 years old group (48 eyes) and 6-7 years old group (32 eyes) according to their age at surgery.The preoperative and postoperative best corrected visual acuity (BCVA), refraction, axial length, corneal curvature, binocular visual function and postoperative complications were observed during the 5-year follow-up period.The influence of age at surgery on postoperative BCVA in one eye at the final follow-up visit was analyzed.This study adhered to the Declaration of Helsinki.The study protocol was approved by the Ethics Committee of The Affiliated First Hospital of Zhengzhou University (No.2020-KY-219), and written informed consent was obtained from guardians of the subjects before treatment.
ResultsThe mean myopic shift was -2.10(-2.90, -1.90), -1.73(-2.50, -2.10) and-0.52(-2.00, -0.28)D in the 2-3 years old group, 4-5 years old group and 6-7 years old group, respectively, and the axial elongation in the three groups was (1.41±0.32), (0.96±0.51), and (0.52±0.26)mm, respectively, and the differences among the three groups were statistically significant ( H=19.85, P<0.01; F=13.24, P<0.05).There was no statistically significant difference in preoperative and postoperative corneal curvature among the three groups (all at P>0.05).The BCVA was significantly improved in all the eyes after operation, and a certain binocular visual function was obtained, and the visual function in the 2-3 years old group was better than that of 4-5 years old group and 6-7 years old group (all at P<0.05).The BCVA at the end of following-up was 0.3 or better in 116 eyes (80.56%), and was better than 0.8 in 28 eyes (19.44%).The regression analysis results showed that children younger at surgery had better visual outcome (postoperative BCVA=0.959-0.104 operative age of patient; R 2=0.539, P<0.01).
ConclusionsThe recovery of visual function in children with binocular congenital cataract is related to the age at operation.The younger the age at operation is, the better the recovery of visual function will be.Timely, systematic and standardized refractive correction, amblyopia treatment and binocular visual function training after operation are helpful to the development and reconstruction of visual function.
谭楠,郑广瑛. 儿童双眼先天性白内障术后疗效5年随访观察[J]. 中华实验眼科杂志,2021,39(04)：305-312.
DOI:10.3760/cma.j.cn115989-20200202-00047版权归中华医学会所有。
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| 组别 | 眼数 | 性别构成比 a(男/女， n) | 术后2周屈光度 b[M( Q 1， Q 3)，D] | 眼轴长度 c(mean±SD，mm) | 角膜曲率 c(mean±SD，D) | 术前BCVA c(mean±SD，LogMAR) |
|---|---|---|---|---|---|---|
| 2-3岁组 | 64 | 18/14 | +3.00(+2.25，+3.75) | 22.28±1.09 | 43.98±1.87 | 1.06±0.19 |
| 4-5岁组 | 48 | 11/13 | +1.75(+1.25，+2.50) | 23.02±0.84 | 43.80±1.53 | 1.11±0.21 |
| 6-7岁组 | 32 | 9/ 7 | +0.25(-0.30，+0.75) | 23.93±1.16 | 43.38±1.72 | 1.08±0.05 |
| χ 2/ H/ F值 | 0.687 | 45.960 | 19.250 | 1.188 | -0.660 | |
| P值 | 0.706 | <0.01 | 0.010 | 0.308 | 0.530 |
注：(a： χ 2检验；b：Kruskal-wallis H检验；c：单因素方差分析) BCVA：最佳矫正视力
Note：(a： χ 2test；b：Kruskal-Wallis H test；c：One-way ANOVA) BCVA：best corrected visual acuity 先天性白内障是儿童主要的致盲眼病之一，国内报道先天性白内障的群体发病率约为0.05%，其中以双眼居多 [ 1 , 2 ] 。随着白内障超声乳化技术的日臻成熟和人工晶状体(intraocular lens，IOL)设计与材料的更新，超声乳化白内障摘出联合后囊膜切开、前段玻璃体切割及IOL植入术逐渐成为治疗儿童白内障的优先选择 [ 3 ] 。然而，临床工作中我们发现，手术的成功并不一定能给患儿带来令人满意的视功能恢复，迄今仍有许多先天性白内障儿童术后处于盲或低视力状态。手术年龄的选择、术后是否及时行屈光矫正和坚持正确而有效的弱视训练是视功能能否恢复的主要原因。因此客观评价手术后视功能的恢复情况、合理地选择手术时机、术后及时进行屈光矫正以及科学地进行改善视功能的训练将是治疗先天性白内障远期关注的重点和难点问题 [ 4 ] 。目前已有相关研究将单眼和双眼、先天性和外伤性、I期或II期IOL植入、同期是否行晶状体后囊膜撕开或切开和前段玻璃体切割等情况混合在一起研究，研究对象的同质性和可比性均不理想，且有关双眼先天性白内障术后患儿视功能长期变化的报道甚少 [ 5 ] 。本研究对2～7岁双眼先天性白内障患儿的术后疗效进行5年随访观察并对影响其预后的部分因素进行分析，为儿童白内障术后视功能的重建方法提供参考依据。
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