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腺管探通术治疗睑板腺功能障碍的临床观察

Clinical research on intraductal meibomian gland probing in the treatment of patients with meibomian gland dysfunction

摘要:

目的 探讨睑板腺腺管探通术治疗睑板腺功能障碍(MGD)的临床疗效及安全性.方法 前瞻性配伍组设计.111例睑板腺功能障碍患者,按性别年龄相匹配分为3组,每组37人(37眼),选择症状体征较重的眼作为观察眼.常规治疗组采用抗生素激素滴眼液+人工泪液+局部物理治疗;腺管探通术组在常规治疗组的治疗基础上用直径仅76 μm的不锈钢探针(美国Rhein Medical公司),每只眼探通6~9个睑板腺腺管;腺管探通联合管内注药组在腺管探通组治疗基础上,探通术中管内注入适量妥布霉素地塞米松滴眼液.分别于治疗前和治疗后1个月观察MGD患者主观症状指标眼表疾病指数(OSDI)量表、泪膜破裂时间(BUT)、基础泪液分泌试验(SIT)检查、角膜荧光素染色(CFS)、裂隙灯显微镜下睑缘评分共5项指标的变化并做对比分析.对实施探通术2组的MGD患者分别于探通前及探通后1个月进行共聚焦显微镜检查,观察睑板腺腺泡单位有无损伤改变,以评价探通术的安全性.组内定量指标比较采用配对t检验,多组之间比较采用配伍组设计的两因素方差分析,差异有显著性后采用q检验进行两两比较.结果 ①3组MGD患者治疗前OSDI、BUT、CFS、SIT、裂隙灯下睑缘评分共5项观测指标基线值对比差异无统计学意义.②治疗后1个月3组之间5项检测指标差异有统计学意义(F=4.68、4.17、3.98、3.67、4.12,P<0.05);腺管探通术组与腺管探通联合管内注药组各项观测指标改善程度均优于常规治疗组,差异有统计学意义(P<0.05).腺管探通联合注药组经治疗后改善程度虽优于单纯探通术组,但差异无统计学意义.③实施探通术的2组MGD患者治疗后5项观测指标较治疗前均有显著改善,差异有统计学意义(腺管探通术组:t=2.543、2.343、2.456、2.132、2.237;腺管探通联合管内注药组:t=2.713、2.443、2.496、2.143、2.249,P均<0.05).常规治疗组MGD患者经治疗后与术前相比虽有改善,但差异无统计学意义.④共聚焦显微镜下睑板腺腺泡单位因光学切面不同,呈现不同形态,有圆形、卵圆形、长条形、不规则形等,腺泡外圈为轮胎样上皮细胞,伴有高亮反光颗粒,胞腔内呈灰色伴点状高反光分泌物,团块状聚集分布,排列不规整.探通后未见萎缩腺泡增加或疤痕形成.结论 睑板腺腺管探通术能直接缓解睑板腺管阻塞,从而快速地缓解阻塞性MGD患者的症状和体征,是一种新的安全有效的治疗方法.

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abstracts:

Objective To investigate the clinical efficacy and safety of intraductal meibomian gland probing in the treatment of patients with meibomian gland dysfunction (MGD).Methods In a prospective randomized block design,111 consecutive patients (111 eyes) with MGD were divided into 3 groups.All subjects were age-and sex-matched among the 3 groups.The eye selected for the study in each subject was chosen on the basis of the most obvious symptoms.There were 37 eyes in each group.The conventional treatment group was treated only with antibiotic eye drops combined with topical steroids+artificial tears+local physical therapy; MGD patients in the intraductal probing group underwent intraductal probing with steel probes (Rhein Medical,Inc.USA) and 6~9 meibomian glands were probed in each eye; and the third group underwent intraductal probing combined with a drug (0.5% tobramycin dexamethasone eye drops) injected into the intraductal meibomian gland during the probing procedure.All subjects underwent sequential examinations before and after treatment as follows:evaluation of ocular surface disease symptoms using the ocular surface disease index (OSDI); tear film break-up time (BUT); corneal fluorescein staining (CFS); Schirmer I test (SIT),and lid margin and ocular surface examination by slit lamp.The parameters among the 3 groups were investigated and compared before treatment and 1 month after treatment.Confocal microscope was performed to detect the safety of the intraductal meibomian gland probing by observing both the morphology and density of meibomian gland (MG) acinar units.The data among the three groups were randomly compared by a two-way ANOVA and q test (Newman-Keuls); a paired t test was used to analyze the parameters in each group before treatment and 1 month after treatment.Results ①Before treatment,there were no statistical differences among the three groups in OSDI,BUT,CFS,SIT,or lid margin scores (P>0.05).②There were statistical differences among the three groups 1 month after treatment (F=4.68,4.17,3.98,3.67,4.12,P<0.05).The changes in every parameter in the conventional treatment group were significantly lower than for those in the intraductal probing group (P<0.05) and in the intraductal probing group that received drug injections (P<0.05).Improvement was better in the intraductal probing group that received injections compared to the intraductal probing group but no statistically significant differences were seen in the parameters.③ 1 month after treatment:except for the conventional treatment group,significant differences were noted in the data of OSDI,BUT,CFS,Schirmer I test,and lid margin scores in the intraductal probing group (t=2.543,2.343,2.456,2.132,2.237,respectively,P<0.05) and in the intraductal probing with drug injection group (t=2.713,2.443,2.496,2.143,2.249,respectively,P<0.05).④The MG acinar cells can be clearly observed with confocal microscope.MG acinar cells showed that different forms were due to the location in different optical sections.The outer sections of MG acinar cells were tire-like,accompanied by bright reflective and gray cell cavities with highly reflective dot secretion.MGs were distributed in group-like aggregations and arranged irregularly.There were no degenerative changes in the morphology of MG acinar units as well as MG scars 1 month after probing.Conclusion Intraductal meibomian gland probing seems to provide rapid and lasting symptom relief and significant improvement in symptoms and signs of MGD in patients.Intraductal meibomian gland probing is a safe,effective technique for MGD.

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