客观评价近视眼配镜过矫对人眼调节功能影响的临床研究

目的探讨客观评价近视眼配镜过矫对人眼调节功能影响的价值。 方法收集2010年1月至2014年6月就诊于首都医科大学附属北京同仁医院北京同仁眼科中心视光学门诊的近视眼配镜过矫伴视疲劳患者16例(30只眼)。其中，男性10例(19只眼)，女性6例(11只眼)，年龄14~38岁，平均年龄(23.7±7.2)岁。所有患者均进行视力检查、显然验光、复方托吡卡胺散瞳验光、原框架眼镜屈光度检查、主观调节幅度检查及客观调节功能检查。根据近视眼配镜过矫状态下患者主观调节幅度下降、客观调节不足、客观调节异常及客观调节微波动高频成分增加进行分组。使用均数±标准差描述年龄的分布情况；采用眼数和百分比描述各组的病例数量与病例分布情况。使用McNemar配对资料卡方检验和用Kappa一致性检验比较近视眼配镜过矫状态下主观调节幅度下降组与客观调节不足组、客观调节异常组及客观调节微波动高频成分增加组的差异。 结果近视眼配镜过矫伴视疲劳患者16例(30只眼)中，主观调节幅度正常者有8例(11只眼)，占36.7%(11/30)；主观调节幅度下降者有11例(19只眼)，占63.3%(19/30)；客观调节检查结果正常者有6例(7只眼)，占23.3%(7/30)；客观调节异常者有13例(23只眼)，占76.7%(23/30)；单纯客观调节不足者有3例(3只眼)，占10.0%(3/30)；单纯客观调节过度者有1例(2只眼)，占6.7%(2/30)；单纯客观调节紧张者有4例(7只眼)，占23.3%(7/30)；单纯客观调节痉挛者有1例(2只眼)，占6.7%(2/30)；客观调节不足伴调节紧张者有4例(7只眼)，占23.3%(7/30)；客观调节不足伴调节痉挛者有1例(2只眼)，占6.7%(2/30)。客观调节紧张者有7例(14只眼)，占46.7%(14/30)；客观调节不足者有8例(12只眼)，占40.0%(12/30)；客观调节微波动高频成分增加者有10例(18只眼)，占60.0%(18/30)。自身配对资料McNemar精确概率法卡方检验提示主观调节幅度下降组与客观调节不足组的差异有统计学意义(χ²＝5.143，P<0.05)。对比主观调节幅度下降组与客观调节异常组以及客观调节微波动的高频成分增加组的差异均无统计学意义(χ²＝2.250，0.000；P>0.05)。进一步经过Kappa一致性检验，主观调节幅度下降组与客观调节异常组有高度一致性(κ＝0.689，P<0.05)，而主观调节幅度下降组与客观调节微波动高频成分增加组一致性弱(κ＝0.366，P<0.05)。 结论近视眼配镜过矫常伴随调节功能异常的类型以调节不足和调节紧张为主。人眼调节功能客观检查可对近视眼配镜过矫视疲劳状态进行客观量化的评估。鉴于本研究中主观调节幅度下降组与客观调节异常组的高度一致性，推荐近视眼配镜过矫伴视疲劳患者中使用主观调节幅度检查作为客观调节功能详细检查的筛查指标。

The effect of over-correction for myopia on accommodative function of human eyes using objective evaluation method

ObjectiveTo investigate the effect of over-correction for myopia on the accommodative function of the human eyes. Methods16 patients (30 eyes) with over-corrected myopia in optometry clinic of Beijing Tongren Eye Center from Jan. 2010 to Jun. 2014 were selected and analyzed retrospectively, including 10 males (19 eyes) and 6 females (11 eyes). The average ages were (23.7±7.2) years-old with a range from 14 to 38 years. All the patients accepted examination of visual acuity, objective refraction, cycloplegic refraction, spectacle lenses test and subjective accommodative amplitude (AA) test, the over-corrected myopic patients were divided into groups according to the reduction in subjective AA test, the objective insufficiency of accommodation, the abnormality of objective accommodative measurement and the increase in HFC of accommodative micro-fluctuations. The distribution of age was described by mean± standard deviate. The number and distribution in different groups were described by the number of eyes and percentage. McNemar paired Chi-square test was used to compare the proportion of patients with over-correction of myopia differences among the group of reduction in subjective AA test, objective insufficiency of accommodation, abnormality of objective accommodative measurement and the group of increase in high frequency component (HFC) of accommodative micro-fluctuations. The Kappa coefficient of agreement was analyzed for the consistency of the group of reduction in subjective AA test, abnormality of objective accommodative measurement and increase in HFC of accommodative micro-fluctuations. ResultsAmong the 16 patients (30 eyes) with over-corrected myopia, 8 cases (11 eyes) accounting for 36.7% (11/30) were normal in the subjective AA test, and 11 cases (19 eyes) accounting for 63.3% (19/30) were reduced in the subjective AA test. In the objective accommodative function test, 6 cases (7 eyes) accounting for 23.3% (7/30) were normal, and 13 cases (23 eyes) accounting for 76.7% (23/30) were abnormal, in which 3 cases (3 eyes) accounting for 10.0% (3/30) with single objective accommodative insufficiency, 1 case (2 eyes) accounting for 6.7% (2/30) with single objective accommodative excess, 4 cases (7 eyes) accounting for 23.3% (7/30) with single objective accommodative strain and 1 case (2 eyes) accounting for 6.7% (2/30) with single objective accommodative spasm, 4 cases (7 eyes) accounting for 23.3% (7/30) with objective accommodative insufficiency and accommodative strain and 1 case (2 eyes) accounting for 6.7% (2/30) with objective accommodative insufficiency and accommodative spasm. The sum of all the objective accommodative strain was 7 cases (14 eyes) accounting for 46.7% (14/30). The sum of all the objective accommodative insufficiency was 8 cases (12 eyes) accounting for 40.0% (12/30). The sum of all the increase in HFC of accommodative micro-fluctuations was 8 cases (18 eyes) accounting for 60.0% (18/30). The comparison between the group of subjective AA test and the group of objective insufficiency of accommodation by McNemar paired Chi-square test showed statistically significant difference (χ²=5.143, P<0.05). The comparisons between the group of subjective AA test for abnormality of objective accommodative measurement and increase in HFC of accommodative micro-fluctuations by McNemar paired Chi-square test did not show statistically significant differences, respectively (χ²=2.250, 0.000; P>0.05). After using Kappa analysis, the agreement between the group of subjective AA test and increase in HFC of accommodative micro-fluctuations was weak (κ=0.366, P<0.05). The agreement between the group of subjective AA test and abnormality of objective accommodative measurement was significant (κ=0.689, P<0.05). ConclusionsThis small sample retrospective clinical case series showed that patients of over-corrected myopia had accommodative dysfunction, in which accommodative insufficiency and accommodative strain were the most common types. The objective accommodative analyzer can objectively and quantitatively evaluate the cases of over-corrected myopic asthenopia. According to the significant agreement between the group subjective AA test and objective accommodative function measurement, the subjective AA test might be regard as a practical screening indicator for the following detailed objective accommodative functional measurement in the cases of asthenopia with over-corrected myopia.