活体共聚焦显微镜检查对翼状胬肉活动性评价的应用研究

摘要

目的 探讨活体共聚焦显微镜(IVCM)检查对翼状胬肉活动性评价的应用价值.方法 前瞻性病例对照研究.2015年8月至2016年2月对北京同仁医院眼科中心28例(36只眼)原发性翼状胬肉患者纳入研究.所有受试者均通过如下检查:眼表症状评分、裂隙灯显微镜下翼状胬肉充血程度、翼状胬肉荧光素染色评分及有无Fuchs小岛,进行翼状胬肉活动性评分(PAS),其中低活动性翼状胬肉(PAS评分≤3分)12只眼,高活动性翼状胬肉(PAS评分≥4分)24只眼.翼状胬肉IVCM检查的主要评价指标包括:翼状胬肉头部与周边角膜边界是否整齐;有无Fuchs小岛;翼状胬肉头部及邻近角膜的树突状细胞密度;翼状胬肉体部新生血管数量及杯状细胞密度.对比分析不同活动性翼状胬肉患者IVCM表现差异并采用Spearman相关分析法对翼状胬肉裂隙灯显微镜PAS评分及IVCM评分进行相关性分析.结果 在IVCM下,翼状胬肉由表层的上皮细胞和其下的纤维组织、新生血管组成.病变组织中可见少许树突状细胞浸润及卵圆形杯状细胞散在分布.活动性较高的翼状胬肉(PAS评分≥4分)头部与周围角膜的边界不规则,其评分为(0.84±0.51)分,与低活动性翼状胬肉组[(0.23±0.12)分]相比,差异有统计学意义(t=2.68,P=0.009);活动性较高的翼状胬肉头部附近可见明显的Fuchs小岛,数量不等、形状差异性大,评分为(0.75±0.25)分,与低活动性胬肉组[(0.23±0.12)分]相比,差异有统计学意义(t=3.79,P=0.001);活动性较高的翼状胬肉及附近角膜上皮层均可见大量树突状细胞浸润,评分为(2.75±0.76)分,角膜基质层可见数量较多的活化角膜细胞[(1.92±0.68)分],与低活动性胬肉组相比,树突状细胞浸润及活化角膜细胞差异均有统计学意义(t=2.01,P=0.001;t=2.22,P=0.030);活动性较高的翼状胬肉的体部杯状细胞密度为(2.08±0.42)分,明显高于活动性翼状胬肉,差异有统计学意义(t=3.25,P＜0.001).IVCM对翼状胬肉的活动性评价与传统裂隙灯显微镜PAS评价之间存在明显的正相关(r=0.95,P＜0.05).结论 IVCM可定量分析翼状胬肉的炎症细胞密度、血管增生程度及基质细胞活化情况,是临床较可靠的评价翼状胬肉活动性的方法.%Objective To observe the characteristics of pterygium with in vivo confocal microscopy (IVCM) and understand pterygium activity with the density of inflammatory cells,formation of new blood vessels,and the number of activated keratocytes within the stroma.Methods A prospective casecontrolled study.Thirty-six pterygia from 28 patients were analyzed in this study.A pterygium activity score was obtained by summing four scores of ocular discomfort,pterygium hyperemia,keratitis,and the presence of Fuchs patches.Among them,the low activity of pterygium (PAS score less than 3 points) appeared in 12 eyes and high activity of pterygium (PAS score ≥ 4 points) in 24 eyes.All Patients underwent pterygium IVCM quantitative analysis by observing the boundaries between the pterygium and the adjacent cornea,the density of goblet cells and dendritiform inflammatory cells and Fuchs patches.The correlation of pterygium activity between IVCM and PAS with slit lamp was analyzed with Spearman correlation analysis.Results The presence of inflammatory cells,numerous blood vessels,and irregular boundary between the cornea and the pterygium with infiltration of hyper-reflective cells in the adjacent corneal epithelium were signs observed with IVCM associated with pterygium activity.With IVCM technique,epithelial cells,goblet cells,and dendritiform inflammatory cells of various sizes were observed within the pterygium epithelium.The active (PAS ≥4) pterygium showed irregular boundaries between the pterygium and the adjacent cornea (score,0.84±0.51) comparing with inactive subjects (score 0.23±0.12,t=2.68,P=0.009).Fuchs patches were observed as islets of hyper-reflective polygonal cells in front of the pterygium head with blurred boundary.The score (0.75±0.25) in active group showed significant changes as compared with normal subjects (0.23± 0.12,t=3.79,P=0.001).The score of dendritiform inflammatory cells,activated keratocytes,and goblet cells in active group were 2.75±0.76,1.92±0.68,and 2.08±0.42,which were significantly higher than those in inactive group (1.25 ±0.55,0.50±0.25,1.15 ±0.32,P=0.035,0.030,＜0.01).There was significant positive correlation between IVCM activity and traditional slit lamp PAS.Conclusion Quantitative analysis of dendritiform inflammatory cells,vascular proliferation and activated keratocytes of pterygium by IVCM may be a reliable evaluation method to evaluate the activity of pterygium.