Observation on the Efficacy of Optimal Pulse Technology in the Treatment of Meibomian Gland Dysfunction Related Dry Eyes Based on in Vivo Confocal Microscopy Classification
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摘要:
目的 通过活体共聚焦显微镜（IVCM）对睑板腺功能障碍（MGD）分类，比较优化脉冲光技术（OPT）联合睑板腺按摩（MGX）治疗不同类型MGD相关干眼的疗效。 方法 选取2021年11月至2022年10月来昆明医科大学附属甘美医院门诊就诊的MGD相关干眼患者60例（60眼），通过IVCM检查睑板腺并将其分为严重程度增加阶段的3种类型：阻塞型29例，炎症型18例，纤维化型13例；均采用每2周1次，共3次的OPT联合MGX治疗。观察并记录3型患者在治疗前、治疗后1月、治疗后3月眼表疾病指数（OSDI）评分、非侵入泪膜破裂时间（NIBUT）、角膜荧光素钠染色（CFS）评分、脂质层厚度（LLT）、睑板腺分泌评分（MGYSS）的结果。 结果 （1）OSDI评分：3型治疗后1月、治疗后3月与治疗前比较OSDI评分均下降，阻塞型和炎症型治疗后1月与治疗后3月比较OSDI评分持续下降，治疗后1月阻塞型OSDI评分下降优于炎症型，治疗后3月阻塞型OSDI评分下降优于炎症型和纤维化型（P < 0.05）；（2）BUT：3型治疗后1月、治疗后3月与治疗前比较BUT均上升，阻塞型治疗后1月与治疗后3月比较BUT持续上升，治疗后1月和治疗后3月阻塞型BUT升高优于炎症型和纤维化型（P < 0.05）；（3）CFS评分：阻塞型治疗后1月、治疗后3月与治疗前比较CFS评分均下降，炎症型和纤维化型治疗后3月与治疗前比较CFS评分下降，差异有统计学意义（P < 0.05），治疗后3型组间比较差异无统计学意义（P > 0.05）；（4）LLT：阻塞型治疗后1月、治疗后3月与治疗前比较LLT上升，差异有统计学意义（P < 0.05），炎症型和纤维化型在治疗前后比较差异无统计学意义（P > 0.05），治疗后3型组间比较差异无统计学意义（P > 0.05）；（5）MGYSS：3型治疗后1月、治疗后3月与治疗前比较MGYSS均下降，3型治疗后1月与治疗后3月比较MGYSS持续下降，阻塞型治疗后1月和治疗后3月MGYSS下降优于炎症型和纤维化型（P < 0.05）；（6）IVCM分类的MGD严重程度增加的阶段与睑板腺缺失评分呈正相关（rs = 0.474，P < 0.001）。 结论 （1）通过ICVM对MGD分类，可将其分为严重程度增加阶段的3种类型：阻塞型、炎症型、纤维化型。IVCM对MGD分类是一种新分类方法，且IVCM分类的MGD严重程度增加的阶段与睑板腺缺失评分呈正相关。（2）在IVCM对MGD分类的基础上，通过OPT联合MGX治疗不同类型MGD相关干眼，阻塞型疗效更佳。 -
关键词:
- 睑板腺功能障碍相关干眼 /
- 活体共聚焦显微镜 /
- 分类 /
- 优化脉冲光 /
- 临床治疗效果
Abstract:Objective To classify the meibomian gland dysfunction （MGD） with the use of in vivo confocal microscopy （IVCM）, and to compare optimal pulse technology （OPT） combined with meibomian gland expression （MGX） in the treatment of different types of MGD-related dry eyes. Methods A total of 60 patients （60 eyes） with dry eyes associated with MGD were selected from November 2021 to October 2022 in Outpatient clinic of our hospital.The meibomian glands were examined by IVCM and divided into three types in the stage of increased severity: obstructive type （n = 29）, inflammatory type （n = 18） and fibrotic type （n = 13）. All patients were treated with OPT combined with MGX once every 2 weeks. The ocular surface disease index （OSDI） score, Noninvasive break-up time （NIBUT）, corneal fluorescein staining （CFS）, lipid layer thickness （LLT） and meibomian gland yielding secretion score （MGYSS） were observed and recorded before treatment, 1 month and 3 months after treatment. Results （1） OSDI score: The OSDI score of the three groups decreased 1 month and 3 months after treatment, and the OSDI score of obstructive type and inflammatory type decreased continuously 1 month after treatment compared with 3 months after treatment, the decrease of OSDI score of obstructive type was better than that of inflammatory type 1 months after treatment, and the decrease of OSDI score of obstructive type was better than that of inflammatory type and fibrotic type 3 months after treatment （P < 0.05）; （2） BUT: BUT of the three groups increased 1 month and 3 months after treatment, and the BUT of obstructive type increased continuously 1 month after treatment compared with 3 months after treatment, and the increase of BUT of obstructive type was better than that of inflammatory type and fibrotic type 1 month and 3 months after treatment （P < 0.05）; （3） CFS score:The CFS score of obstructive type decreased 1 month and 3 months after treatment, and the CFS score of inflammatory type and fibrotic type decreased 3 months after treatment, and the difference was statistically significant （P < 0.05）, There was no significant difference among the three types after treatment （P > 0.05）; （4） LLT: The LLT of obstructive type increased 1 month and 3 months after treatment, and the difference was statistically significant （P < 0.05）, There was no significant difference between inflammatory type and fibrotic type before and after treatment （P > 0.05）, There was no significant difference among the three types after treatment （P > 0.05）; （5） MGYSS:MGYSS of the three groups decreased 1 month and 3 months after treatment, and MGYSS decreased continuously in 1 month and 3 months after treatment in the three groups. the decrease of MGYSS in the obstructive type was better than that in the inflammatory type and fibrotic type （P < 0.05）; （6） According to IVCM classification, the stage of increased severity of MGD was positively correlated with the score of loss of meibomian gland （rs = 0.474, P < 0.001）. Conclusion （1） According to the classification of MGD by ICVM, it can be divided into three types in the stage of increased severity: obstruction type, inflammatory type and fibrotic type. IVCM is a new classification method for MGD, and according to IVCM classification, the stage of increased severity of MGD was positively correlated with the score of loss of meibomian gland; （2） On the basis of IVCM's classification of MGD, Treatment of different types of MGD-related dry eyes with OPT combined with MGX, The effect of obstruction type treatment is better. -
图 1 IVCM下一例阻塞型MGD相关干眼患者同一部位从睑板腺开口到穹窿部
A：上睑睑板腺；B：睑板腺开口边界欠光滑；C：睑板腺开口周边；D：睑板腺近开口处；E：睑板腺开口和穹窿部之间；F：睑板腺穹窿部。
Figure 1. IVCM shows a patient with dry eye associated with obstructive MGD from the meibomian gland opening to the fornix at the same site
图 2 IVCM检查的MGD分类的不同阶段
A：阻塞型；B：炎症型；C：纤维化型。
Figure 2. Different stages of MGD classification of IVCM examination
表 1 3型MGD相关干眼OSDI评分治疗前后及组间比较[（
$\bar x \pm s $ ），分]Table 1. Comparison of type 3 MGD related dry eye OSDI score before and after treatment and between groups [（
$\bar x \pm s $ ），points]组别 治疗前 治疗后1月 治疗后3月 F P 阻塞型 32.65 ± 8.87 19.80 ± 6.23 a 15.46 ± 6.82 a，c 111.505 < 0.001*** 炎症型 33.57 ± 8.59 26.37 ± 10.36 a 23.21 ± 11.53 a，c 25.412 < 0.001*** 纤维化型 30.05 ± 8.48 24.54 ± 9.48 a 25.06 ± 11.50 a 7.567 0.001* F
P0.648
0.5273.780
0.029*6.180
0.004*与治疗前比较，aP < 0.05；与治疗后1月比较，cP < 0.05；*P < 0.05，***P < 0.001。 
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表 2 3型MGD相关干眼BUT治疗前后及组间比较[（
$\bar x \pm s $ ），秒]Table 2. Comparison of type 3 MGD related dry eye BUT before and after treatment and between groups [（
$\bar x \pm s $ ），s]组别 治疗前 治疗后1月 治疗后3月 F P 阻塞型 5.81 ± 2.18 10.02 ± 2.74 a 13.75 ± 4.59 a，c 50.197 < 0.001*** 炎症型 6.07 ± 2.40 8.19 ± 2.90 a 9.07 ± 3.16 a 5.705 0.006* 纤维化型 5.94 ± 2.06 8.07 ± 1.96 a 8.59 ± 3.63 a 3.808 0.028* F 0.074 3.799 11.145 P 0.929 0.028* < 0.001*** 与治疗前比较，aP < 0.05；与治疗后1月比较，cP < 0.05；*P < 0.05，***P < 0.001。
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表 3 3型MGD相关干眼CFS评分治疗前后及组间比较[M（P25，P75），分]
Table 3. Comparison of type 3 MGD related dry eye CFS score before and after treatment and between groups [M（P25，P75），points]
组别 治疗前 治疗后1月 治疗后3月 Waldχ2 P 总体 0.00（0.00，2.00） 0.00（0.00，0.00） a 0.00（0.00，0.00） a 26.181 < 0.001*** 阻塞型 0.00（0.00，1.50） 0.00（0.00，0.00） a 0.00（0.00，0.00） a 9.369 0.009* 炎症型 0.00（0.00，2.00） 0.00（0.00，0.00） 0.00（0.00，0.00） a 9.000 0.011* 纤维化型 0.00（0.00，2.00） 0.00（0.00，0.00） 0.00（0.00，0.00） a 9.628 0.008 与治疗前比较，aP < 0.05；与治疗后1月比较，cP < 0.05；*P < 0.05，***P < 0.001。
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表 4 3型MGD相关干眼LLT治疗前后及组间比较[（
$\bar x \pm s $ ），nm]Table 4. Comparison of type 3 MGD related dry eye LLT score before and after treatment and between groups [（
$\bar x \pm s $ ），nm]组别 治疗前 治疗后1月 治疗后3月 F P 总体 66.92 ± 12.67 72.83 ± 13.82 a 74.60 ± 15.23 a 4.234 0.019* 阻塞型 65.41 ± 12.33 74.41 ± 12.16 a 76.90 ± 14.34 a 10.251 < 0.001*** 炎症型 67.72 ± 14.20 73.67 ± 13.32 74.33 ± 14.77 2.642 0.107 纤维化型 69.15 ± 11.73 68.15 ± 17.66 69.85 ± 17.73 0.096 0.814 与治疗前比较，aP < 0.05；与治疗后1月比较，cP < 0.05；*P < 0.05，***P < 0.001。
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表 5 3型MGD相关干眼MGYSS治疗前后及组间比较[（
$\bar x \pm s $ ），分]Table 5. Comparison of type 3 MGD related dry eye MGYSS score before and after treatment and between groups [（
$\bar x \pm s $ ） ，scores]组别 治疗前 治疗后1月 治疗后3月 F P 阻塞型 57.28 ± 16.56 44.48 ± 17.03 a 34.83 ± 14.79 a，c 74.809 < 0.001*** 炎症型 66.39 ± 10.26 58.33 ± 11.50 a 52.78 ± 11.79 a，c 16.250 < 0.001*** 纤维化型 65.00 ± 17.80 58.08 ± 15.48 a 53.46 ± 17.72 a，c 8.287 0.001* F 2.374 6.091 11.598 P 0.102 0.004* < 0.001*** 与治疗前比较，aP < 0.05；与治疗后1月比较，cP < 0.05；*P < 0.05，***P < 0.001。
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