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rhEGF对LASIK术后角膜修复作用的临床观察

发布时间:2006-10-13 00:00 点击:492 字号:

rhEGF对LASIK术后角膜修复作用的临床观察
钟刘学颖  李莹  金玉梅  张潇
中国医学科学院 中国协和医科大学,北京协和医院眼科 100730
通讯作者:李莹  Liyingpumch@sohu.com
 
[摘要] 目的:观察准分子激光原位角膜磨镶术(LASIK)后早期应用重组人表皮生长因子衍生物(rhEGF) 的角膜反应,从而评价外源性表皮生长因子对术后角膜修复的促进作用。方法:采用随机、平行对照试验,试验组56眼/28人,双眼均采用rhEGF(金因舒)qid+0.1%氟米龙qid+0.3%氧氟沙星qid点眼;对照组52眼/26人,双眼均应用0.1%氟米龙qid+0.3%氧氟沙星qid点眼。术后观察疼痛、畏光、异物感、眼干、角膜上皮点状染色、混合性充血、泪膜破裂时间(BUT)、Schirmer试验、角膜上皮下雾状混浊(haze)等9项指标,BUT和Schirmer按数值记录,其余均按有或无分别记为“+”“-”、(“-”标记为0,“+”标记为1)。术后1天、1周、3周~1月、3月观察术后反应并评分,术后1周开始每次复查检查裸眼及矫正视力并记录矫正度数,观察Haze发生情况。结果:一般情况:两组间性别、年龄、术前屈光度没有统计学差异(p>0.05)。总体上,术后3月EGF试验组优于对照组,两者间有显著统计学差异(P<0.05)。症状指标:两组中术前、术后均无疼痛、畏光感。 术后1周时两组均出现个别患者觉异物感(P>0.05),随后症状消失。部分患者术后发生眼干感,1月时两组间差异无统计学意义(P>0.05),术后1周和3月两组间均有显著统计学差异,试验组优于对照组(P<0.05)。客观体征:两组均无发生Haze病例。术前及术后眼部混合性充血各观察点两组间均差异无统计学意义(P>0.05)。术前、术后1周、术后1月及术后3月角膜点染阳性患者实验组分别为10.7%,7.1%,3.6%,0%;对照组分别为11.5%,0%,3.8%,8.8%。试验组随时间呈递减趋势,对照组随时间呈递增趋势,差异无统计学意义(P>0.05)。Schirmer Test于术后1周和3月两组间比较有显著统计学差异,试验组优于对照组(P<0.05)。BUT试验组优于对照组,但差异无统计学意义(P>0.05)。结论:重组人表皮生长因子衍生物能减轻LASIK术后眼表刺激症状,安全、无毒副作用,促进角膜上皮生长,稳定泪膜;有助于LASIK术后角膜上皮化学性和机敌运鹕说男薷础?lt;/DIV>
[关键词]  准分子激光原位角膜磨镶术,重组人表皮生长因子
 
The clinic study of Recombinant Human epidermal growth factor used in corneal recovery after Laser assisted in situ keratomileusis
Liu-xue-ying ZHONG, Ying LI Yu-mei JIN, Xiao ZHANG
Chinese Union Medical College. Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, 100730, China
Corresponding auther: Ying Li  liyingpumch@sohu.com
 
Abstract ObjectiveTo evaluate the effect of ectogenous EGF on facilitating corneal epithelium recovery after Laser assisted in situ keratomileusis (LASIK) by observing postoperative inflammation clinically. MethodsA prospective, randomized, parallel group controlled study enrolled 56 eyes (28 patients) for treated group with therapy of Recombinant Human Epidermal Growth Factor derivative(rhEGF) eye drops+0.1%fluorometholone eye drops+0.3%ofloxacin eye drops, and 52 eyes (26 patients) for controlled group with therapy of 0.1%fluorometholone eye drops+0.3%ofloxacin eye drops. In this study, we observed symptoms like pain, photophobia, foreign body sensation and drying eye, and signs like corneal epithelial opacity, mixing hyperaemia,tear break-up time(BUT), Schirmer Test and haze at postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months. BUT and Schirmer Test were recorded with numerical value, others were recorded with “-” or “+” (“-” marked with 0, “+” marked with 1) respectively according to observations negatively or positively. Visual acuity was measured at 1st weeks postoperatively. Results: ①There was no difference between two groups on sexing, aging, achieving uncorrected visual acuity and diopter preoperatively and postoperatively(p≥0.50). Ensembly, treated group was significantly better than controlled group at 3rd months postoperatively. There was no patient complaining pain and photophobia preoperatively and postoperatively in each group at any time. Several patients felt foreign body sensation in each group at 1st week, and disappeared very soon(P>0.05). Drying eye feeling in treated group was slighter than in controlled group at 1st week and 3rd months (P<0.05). we had never observed haze preoperatively and postoperatively in each group at any time. There was no difference between two groups on mixing hyperaemia at any time(P>0.05). In the study, we found that no difference on corneal epithelial opacity, too. However, the rates of corneal epithelial opacity on treated group were 10.7%, 7.1%, 3.6%, 0%, whitch were decreasing tendency at each time we observed, while on controlled group were 11.5%, 0%, 3.8%, 8.8%, whitch were tending to increase. Schirmer Test value recovering was better than on controlled group at 1st week and 3rd months(P<0.05). BUT value recovering on treated group was better than on controlled group, but there was no difference between two groups(P>0.05). ConclusionrhEGF may relieve surface ocular irritation postoperatively after LASIK and toxicity comes from steroid eye drops, benefit to epithelium recovery from chemical and machinical injury safely and avirulently, and stabilize lacrimal film.
Key words】Laser assisted in situ keratomileusis; Recombinant Human Epidermal Growth Factor
 
准分子激光原位角膜磨镶术(LASIK)不可避免地造成了上皮细胞超微结构,特别是微绒毛的损伤,这是导致术后干眼、上皮愈合不良的主要原因。因此尽快恢复角膜上皮结构和功能完整性,可以延长泪膜破裂时间,减轻术后的不适反应,减少感染机会,促进视力恢复。表皮生长因子(EGF)是最早确立结构的生长因子,相比于角膜基质,其受体EGFR更强烈表达于角膜上皮的深层细胞和角膜缘上皮细胞[1]。目前已有多项体内、体外研究证明了EGF能有效刺激角膜上皮生长,促进损伤的角膜上皮修复[2-7]。但角膜损伤后自身分泌的EGF对角膜上皮作用甚微,因此采用外源性生长因子——重组人表皮生长因子衍生物(rhEGF)成为当前术后促进恢复的主要措施。为了评价rhEGF对减轻LASIK术后反应和促进上皮修复的作用,我们进行了以下研究。
一、资料与方法
1.1  试验对象选择标准:1)年龄18周岁以上  2)双眼LASIK术后患者  3)排除全身和其他眼部器质性病变
1.2  试验对象剔除标准:1)试验中发现不符合入选标准者  2)违反试验方案者  3)因用药所致不良反应中途退出者
1.3  试验制剂:重组人表皮细胞生长因子衍生物滴眼液(rhEGF,商品名金因舒滴眼液,深圳市华生元基因工程发展有限公司),规格:5 000IU/ml  3ml/支,保存条件:4~25℃。
1.4  试验方法:同一名医生使用同一机器完成LASIK手术操作。将患者随机分为两组,进行平行对照。试验组(组I)采用rhEGF滴眼液qid×1月+(0.1%氟米龙滴眼液qid+0.3%氧氟沙星滴眼液qid)×10天,对照组(组II)采用(0.1%氟米龙滴眼液qid+0.3%氧氟沙星滴眼液qid)×10天。
1.5  试验观察:术后1天、1周、3周~1月、3月观察疼痛、畏光、异物感、眼干、角膜上皮点染(FL)、混合性充血、泪膜破裂时间(BUT)、Schirmer试验、角膜上皮下雾状混浊(Haze)等9项指标并评分。BUT和Schirmer按客观数值记录,其余项目均按有或无分别记为“+”、“-”(“-”标记为0,“+”标记为1)。术后1周开始每次复查时检查裸眼及矫正视力并记录矫正度数,观察Haze发生情况、患者耐受性及不良反应。
1.6  统计方法:Kruskal-Wallis检验、Crosstab检验和t检验(SPSS11.5软件),P<0.05为差异有统计学意义。Excel软件作图。
二、结果
一般情况  试验组共完成随访病例56眼/28人,其中男性12眼/6人,女性44眼/22人,平均年龄25.64±4.91岁,术前平均等效球镜-6.17±3.89D;对照组完成随访病例52眼/26人,男性10眼/5人,女性42眼/21人,平均年龄26.19±6.14岁,术前平均等效球镜-4.98±1.93D。两组间性别、年龄、术前屈光度差异无统计学意义(p≥0.50,Crosstab检验)。术中无角膜瓣并发症发生。
2  术后治疗效果:
2.1  治疗前后视力恢复情况(表1):术后视力恢复总体上对照组优于试验组;但各时间点两组之间比较差异无统计学意义(P>0.05,Kruskal-Wallis Test)。治疗前后屈光度两组间差异无统计学意义(P>0.05)。
表1-1  两组治疗前后视力平均值
Tab 1-1  The averages of visual acuity of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.
 
术前
术后1天
术后1周
术后3周~1月
术后3月
组I
0.11±0.06
0.81±0.20
0.91±0.22
1.01±0.19
1.04±0.20
组II
0.10±0.01
0.83±0.22
0.99±0.19
1.07±0.21
1.07±0.18
P
0.306
0.621
0.059
0.179
0.536
 
表1-2  两组间治疗前后屈光度平均值变化情况
Tab 1-2  The changes of diopter of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.
屈光度
(D)
 
 
组别
术前
术后
组I
-6.17±3.89
-0.08±0.43
组II
-4.98±1.93
-0.08±0.21
P
0.050
0.989
 
2.2  两组治疗情况比较:同一观察点两组间眼部症状和体征改善情况比较。
2.2.1 总体分析(NPar Test):(表2、图2)试验组和对照组术前差异无统计学意义(P>0.05) ,术后3月EGF试验组优于对照组,两者间有显著统计学差异(P<0.05)。
 
表2   两组间治疗前后症状、体征总体改善情况
Tab 2  The whole relieves of the objections of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.
 
术前
术后1周
术后3周~1月
术后3月
组I
54.07
53.20
53.39
27.50
组II
54.96
53.81
53.62
34.79
P
0.811
0.871
0.945
0.006*
 
* P<0.01,有显著统计学差异. P<0.01, indicates statistical difference.
 
 
2.2.2主观症状和客观体征分析(表3-1、3-2):
(1)主观症状(Crosstab和NPar Test):
i) 两组中术前、术后均无疼痛、畏光感。
ii) 术后1周时两组均出现个别患者觉异物感(P>0.05),随后症状消失。
iii)术前两组患者均无眼干感,术后试验组仅于术后1月时出现眼干患者,术后1周、3月均无眼干患者,而对照组术后各观察点均有发生眼干感患者(见图3-1)。术后1月时两组间差异无统计学意义(P>0.05),术后1周和3月两组间均有显著统计学差异,试验组优于对照组(P<0.05)。
(2)客观体征(FL、混合性充血等采用Crosstab和NPar Test;BUT、Schirmer Test指标采用Kruskal-Wallis Test):
i) 两组均无发生Haze病例。
ii) 术前及术后1周试验组眼部混合性充血,术后1月后消失;对照组术前及术后1月有发生混合性充血者(图3-2);各观察点两组间均差异无统计学意义(P>0.05)。
iii) 试验组于术前、术后1周和术后1月角膜点染阳性,随时间呈递减趋势,对照组于术前、术后1月、3月角膜点染阳性,随时间呈递增趋势(图3-3);两组间均差异无统计学意义(P>0.05)。
iiii)试验组术后1周及1月时Schirmer Test有所下降,3月时恢复原有水平;对照组术后1周时Schirmer Test有所下降,1月、3月未恢复(图3-4)。术后1周和3月两组间比较有显著统计学差异,试验组优于对照组(P<0.05)(表3-1、3-2)。
iiiii) 两组均在术后1周~1月BUT轻度减少,术后3月恢复,试验组优于对照组,但差异无统计学意义(P>0.05)。
 
表3-1  各项观察指标各观察点结果(crosstab检验)
Tab 3-1  The results of the objections of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months. (Crosstab test)
 
组别
术前
术后1周
术后3周~1月
术后3月
疼痛(%)*
组I
0
0
0
0
组II
0
0
0
0
P
-
-
-
-
畏光(%)*
组I
0
0
0
0
组II
0
0
0
0
P
-
-
-
-
异物感(眼数/%)*
组I
0
2/3.7
0
0
组II
0
2/3.8
0
0
P
-
0.969
-
-
眼干(眼数/%)*
组I
0
0
4/7.1
0
组II
0
8/15.4
2/3.8
6/17.6
P
-
0.003
0.455
0.019
混合性充血
(眼数/%)*
组I
2/3.6 ^
2/3.6
0
0
组II
2/3.8
0
2/3.8
0
P
0.135
0.169
0.146
-
FL(眼数/%)*
组I
6/10.7
4/7.1
2/3.6
0
组II
6/11.5
0
2/3.8
3/8.8
P
0.896
0.050
0.940
0.107
BUT(秒) **
组I
10.20±1.66
10.21±1.43
10.11±1.27
10.57±1.32
组II
10.33±2.24
10.15±0.83
10.08±0.79
10.29±0.46
P
0.730
0.791
0.884
0.256
Schirmer Test
(mm) **
组I
10.85±2.96
8.85±3.87
8.96±2.97
11.14±5.61
组II
10.48±2.27
7.35±2.18
8.29±2.69
7.41±2.22
P
0.472
0.016
0.224
0. 001
屈光度(D)**
组I
-6.17±3.89
-
-
-0.08±0.43
组II
-4.98±1.93
-
-
-0.08±0.21
P
0.050
-
-
0.989
 
*   观察指标阳性结果占每组样本量的百分数。The percentage of the positive results in each sample.
**  观察指标平均值。The mean of the objections.
^   轻微充血。Mild hyperaemia.
-          无记录且P值无法计算。No records and inability of calculate P.
   P值<0.05,差异有统计学意义。P<0.05, indicates statistical difference.
 
表3-2  各项观察指标各观察点结果(Kruskal-Wallis Test)
Tab 3-1  The results of the objections of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.(Kruskal-Wallis Test)
 
充血术前
FL术前
异物感1W
眼干1W
充血1W
FL1W
眼干3W~1M
充血3W~1M
FL3W~1M
眼干3M
FL3M
组I
54.39
54.29
53.46
49.50
56.36
56.36
55.36
52.50
54.43
28.50
30.00
组II
54.62
54.73
53.54
57.65
52.50
52.50
53.58
54.54
54.58
33.97
32.74
方差
0.013
0.018
0.001
8.901
1.875
3.821
0.553
2.097
0.006
5.382
2.55
P
0.910
0.892
0.969
0.003*
0.171
0.051
0.457
0.148
0.940
0.020*
0.110
 
 
 
 
 
 
 
 
*P<0.05则结果有统计学意义。P<0.05, indicates statistical difference.
 
3   其他指标观察:
耐受性与副作用:全部病例治疗前后患者顺应性好,均未出现耐受不良及全身、局部不良作用。
三、讨论:
EGF 是最早确立结构的生长因子,由53个氨基酸组成,分子量为6021D,等电点4.6,对酸、热都很稳定。该因子可以自分泌和(或)旁分泌方式与绝大部分哺乳动物细胞表面的穿膜受体结合,激活EGF受体(EGFR)胞内段酪氨酸蛋白激酶,使其磷酸化,进而影响细胞内其他蛋白成分发挥生物学效应,促进细胞有丝分裂以及糖、蛋白质、DNA、RNA 合成,因此有着广泛的促进上皮细胞分裂增殖的作用[1,8]。EGFR在角膜上皮细胞和基质细胞均有表达,但更强烈表达于角膜上皮的深层细胞和角膜缘上皮细胞[1]
研究表明,在创面修复过程中,虽然EGFR数目增加,内源性EGF也在创面积聚,但因组织中EGF 的含量普遍较低,创面EGF数量仍难以满足组织自身修复所需。外源性rhEGF的补充一方面可促进内源性EGF的表达,从而刺激组织分泌EGF,另一方面,也可以补充创面内源性EGF 的相对不足,从而加速创面的愈合。邢帮荣等人在外源性生长因子对创面修复作用的研究中发现,重组人碱性成纤维细胞生长因子(rhbFGF)在修复早中期促进肉芽组织生成,rhEGF 在中晚期可加速创面的上皮化[9]。因此,补充同种外源性EGF,可以最大限度地发挥EGF本身的生物学作用,加速创面愈合[10]
rhEGF 也能刺激角膜基质或纤维细胞增生,改善角膜胶原纤维板层的排列使其更接近于正常的排列趋势[11,12]。这是由于rhEGF能稳定细胞表型的表达和调节细胞间质(胶原和纤维连接蛋白)的合成及分布,使修复的细胞在排列上趋于正常。
一定浓度下的EGF可促进表皮细胞增殖,并可通过刺激成纤维细胞和其他细胞的增殖,促进胶原的沉积[13],因此EGF同时又是角膜瘢痕形成、激光角膜光学切除术后上皮下混浊的主要病因[14]
LASIK术后角膜上皮愈合反应非常复杂:上皮细胞的自我重塑、上皮损伤启动的基质细胞迅速凋亡及重构、神经纤维的再生。某种意义上说,LASIK术后的角膜修复并未达到完整意义上的组织重构[15]。术后干眼导致的一系列不适症状及体征最为常见,以往认为是眼部神经和曲率改变造成的,多从补充人工泪液入手治疗。但实际上角膜上皮细胞的损伤是造成泪膜不稳定、导致干眼症的主要因素;另外,由于上皮缺损导致的术后感染、视力下降在临床工作中时常也会碰到。因此有必要采取措施促进上皮修复。
我们在本研究中发现:rhEGF能安全、有效地改善LASIK术后眼表刺激症状,促进角膜上皮修复,稳定泪膜,从而使角膜屏障功能得以尽快恢复,降低了角膜继发感染而致视力下降的几率,减少了视力损害;且至少5000IU/mL浓度的治疗剂量不会诱发Haze。
而LASIK术后不使用角膜保护剂或上皮生长因子等情况下,使用糖皮质激素易造成角膜上皮损伤,致使LASIK术后患者干眼感、混合性充血,泪液分泌减少,泪膜不稳定。
由此,rhEGF在LASIK术后角膜损伤中的应用具有一定优势。
班胜刚等人应用rhEGF治疗外伤性角膜上皮缺损时发现,单一应用rhEGF 并不能解决角膜外伤治疗上所面临的所有问题,如存在它刺激产生的上皮与基质粘附不牢的问题[16]。在本研究中未发现类似问题,这可能与观察方法、样本量有关,尚需进一步研究。
[引文]
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图1  两组治疗前后视力情况比较
Graph 1  The averages of visual acuity of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.
 
图2  两组间治疗前后总体改善情况
Graph 2  The whole relieves of the objections of two groups at preoperative, postoperative 1st day, 1st week, 3rd weeks to 1st month and 3rd months.
 
图3-1  二组间眼干感情况的比较
Graph 3-1  The comparison of dry eye between two groups
 
 
图3-2  二组间混合性充血情况的比较
Graph 3-2  The comparison of mixing hyperaemia between two groups
 
图3-3  二组间角膜点染改善情况比较
Graph 3-3  The comparison of FL between two groups
 
图3-4  二组间Schirmer 试验改善情况比较
Graph 3-4  The comparison of Schirmer between two groups
 
图3-5 二组间BUT改善情况比较
Graph 3-5  The comparison of BUT between two groups