目的:研究探讨阻塞性睡眠呼吸暂停综合征(OSAHS)及不同睡眠姿势与屈光参差的关系。方法:横断面研究,收集在我院呼吸科行多导睡眠监测并确诊为OSAHS的患者61例作为OSA组,年龄匹配的健康人群67例作为对照组,对所有研究对象询问相关个人基本资料及病史,进行眼部检查:电脑验光、角膜地形图及眼轴测定。并根据习惯睡眠姿势将OSA组患者分为侧睡组(OSA-S组)及非侧睡组(OSA-NS组),对照组分为侧睡组(Control-S组)及非侧睡组(Control-NS组)。分析屈光参差、角膜地形图参数及眼轴长度在各组的差异。结果:OSA组屈光参差发生率为(29/61, 47.54%)高于对照组(11/67, 16.42%) (χ2 = 14.40, P < 0.05)。OSA-S组屈光参差发生率(22/32, 68.75%)分别高于OSA-NS组(7/29, 24.14%)、Control-S (4/24, 16.67%)组和Control-NS (7/43, 16.28%) (χ2 = 12.14, χ2 = 14.96, χ2 = 21.30, all P < 0.05)。轻、中、重度OSAHS屈光参差的发生率分别是20.00%、26.32%、68.75%,重度OSAHS患者屈光参差的发生率最高(重度vs轻度,χ2=3.95,P < 0.05;重度vs中度,χ2 = 6.25,P < 0.05)。角膜地形图检查:OSA组SRI (Surface Regularity Index )、SAI (Surface Asymmetry Index)、CYL (Cylinder)明显高于对照组(t = 82.65, t = 16.65, t = 5.88, all P < 0.05);OSA-S组侧睡侧眼SRI、SAI、CYL明显高于对侧眼(t = 10.66, t = 2.65, t = 3.47, all P < 0.05)。OSA-S组22名发生屈光参差者侧睡侧眼的眼轴长度大于对侧眼(Z = 1.70, P < 0.05)。结论:习惯单侧睡眠姿势的OSAHS患者,易发生屈光参差,侧睡侧眼近视程度较对侧重,并与OSAHS严重程度相关。 Objective: To investigate the occurrence of anisometropia in patients with obstructive sleep apnea syndrome (OSAHS) in different sleeping posture. Methods: Cross-sectional study. Sixty-one patients diagnosed with OSAHS from the Second Affiliated Hospital of Fujian Medical University were sorted as OSA group. Sixty-seven healthy people were recruited as the Control group. All the cases were asked for personal information and medical history, and ophthalmological check-up involved computer optometry, corneal topography, and optical coherence interferometry. The patients in OSA group were divided into side sleeping group (OSA-S group) and non-side sleeping group (OSA-NS group) according to the habitual sleeping posture, and the control group was divided into side sleeping group (Control-S group) and non-side sleeping group (Control-NS group) on the same scenario. The differences in anisometropia, corneal topography parameters and eye axis length were analysed in each group. Results: The incidence of anisometropia in OSA group (29/61, 47.54%) was higher than that in control group (11/67, 16.42%) (χ2 = 14.40, P < 0.05). The incidence of anisometropia in the OSA-S group (22/32, 68.75%) was higher than that in the OSA-NS group (7/29, 24.14%), Control-S (4/24, 16.67%) group, and Control-NS (7/43, 16.28%) (χ2 = 12.14, χ2 = 14.96, χ2 = 21.30, all P < 0.05). The incidences of mild, moderate, and severe OSAHS anisometropia were 20.00%, 26.32%, and 68.75%, respectively. Severe OSAHS patients had the highest incidence of anisometropia (severe vs mild, χ2 = 3.95, P < 0.05; Degree, χ2 = 6.25, P < 0.05). Corneal topographic examination: OSA group SRI (Surface Regularity Index), SAI (Surface Asymmetry Index), CYL (Cylinder) were significantly higher than the control group (t = 82.65, t = 16.65, t = 5.88, all P < 0.05); OSA -The SRI, SAI, and CYL of the sleeping side eye in the S group were significantly higher than that of the contralateral eye (t = 10.66, t = 2.65, t = 3.47, all P < 0.05). In the OSA-S group, 22 patients with anisometropia had a longer axial length than the contralateral eye (Z = 1.70, P < 0.05). Conclusion: Patients with OSAHS who are accustomed to one-sided sleeping posture are prone to anisometropia. The refractive power of the side sleeping eye is higher than that of the contralateral eye and is related to the severity of OSAHS.
目的:研究探讨阻塞性睡眠呼吸暂停综合征(OSAHS)及不同睡眠姿势与屈光参差的关系。方法:横断面研究,收集在我院呼吸科行多导睡眠监测并确诊为OSAHS的患者61例作为OSA组,年龄匹配的健康人群67例作为对照组,对所有研究对象询问相关个人基本资料及病史,进行眼部检查:电脑验光、角膜地形图及眼轴测定。并根据习惯睡眠姿势将OSA组患者分为侧睡组(OSA-S组)及非侧睡组(OSA-NS组),对照组分为侧睡组(Control-S组)及非侧睡组(Control-NS组)。分析屈光参差、角膜地形图参数及眼轴长度在各组的差异。结果:OSA组屈光参差发生率为(29/61, 47.54%)高于对照组(11/67, 16.42%) (χ2 = 14.40, P < 0.05)。OSA-S组屈光参差发生率(22/32, 68.75%)分别高于OSA-NS组(7/29, 24.14%)、Control-S (4/24, 16.67%)组和Control-NS (7/43, 16.28%) (χ2 = 12.14, χ2 = 14.96, χ2 = 21.30, all P < 0.05)。轻、中、重度OSAHS屈光参差的发生率分别是20.00%、26.32%、68.75%,重度OSAHS患者屈光参差的发生率最高(重度vs轻度,χ2=3.95,P < 0.05;重度vs中度,χ2 = 6.25,P < 0.05)。角膜地形图检查:OSA组SRI (Surface Regularity Index )、SAI (Surface Asymmetry Index)、CYL (Cylinder)明显高于对照组(t = 82.65, t = 16.65, t = 5.88, all P < 0.05);OSA-S组侧睡侧眼SRI、SAI、CYL明显高于对侧眼(t = 10.66, t = 2.65, t = 3.47, all P < 0.05)。OSA-S组22名发生屈光参差者侧睡侧眼的眼轴长度大于对侧眼(Z = 1.70, P < 0.05)。结论:习惯单侧睡眠姿势的OSAHS患者,易发生屈光参差,侧睡侧眼近视程度较对侧重,并与OSAHS严重程度相关。
屈光参差,阻塞性睡眠呼吸暂停综合征,睡眠姿势,角膜地形图
Huaxuan Zhao1,2, Yingying Gao1*, Yang Yu1, Xiaoyang Chen3, Jimin Fan3
1Department of Ophthalmology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian
2Department of Ophthalmology, Affiliated Dongtai Hospital of Nantong University, Dongtai Jiangsu
3Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian
Received: May 10th, 2021; accepted: May 29th, 2021; published: Jun. 10th, 2021
Objective: To investigate the occurrence of anisometropia in patients with obstructive sleep apnea syndrome (OSAHS) in different sleeping posture. Methods: Cross-sectional study. Sixty-one patients diagnosed with OSAHS from the Second Affiliated Hospital of Fujian Medical University were sorted as OSA group. Sixty-seven healthy people were recruited as the Control group. All the cases were asked for personal information and medical history, and ophthalmological check-up involved computer optometry, corneal topography, and optical coherence interferometry. The patients in OSA group were divided into side sleeping group (OSA-S group) and non-side sleeping group (OSA-NS group) according to the habitual sleeping posture, and the control group was divided into side sleeping group (Control-S group) and non-side sleeping group (Control-NS group) on the same scenario. The differences in anisometropia, corneal topography parameters and eye axis length were analysed in each group. Results: The incidence of anisometropia in OSA group (29/61, 47.54%) was higher than that in control group (11/67, 16.42%) (χ2 = 14.40, P < 0.05). The incidence of anisometropia in the OSA-S group (22/32, 68.75%) was higher than that in the OSA-NS group (7/29, 24.14%), Control-S (4/24, 16.67%) group, and Control-NS (7/43, 16.28%) (χ2 = 12.14, χ2 = 14.96, χ2 = 21.30, all P < 0.05). The incidences of mild, moderate, and severe OSAHS anisometropia were 20.00%, 26.32%, and 68.75%, respectively. Severe OSAHS patients had the highest incidence of anisometropia (severe vs mild, χ2 = 3.95, P < 0.05; Degree, χ2 = 6.25, P < 0.05). Corneal topographic examination: OSA group SRI (Surface Regularity Index), SAI (Surface Asymmetry Index), CYL (Cylinder) were significantly higher than the control group (t = 82.65, t = 16.65, t = 5.88, all P < 0.05); OSA -The SRI, SAI, and CYL of the sleeping side eye in the S group were significantly higher than that of the contralateral eye (t = 10.66, t = 2.65, t = 3.47, all P < 0.05). In the OSA-S group, 22 patients with anisometropia had a longer axial length than the contralateral eye (Z = 1.70, P < 0.05). Conclusion: Patients with OSAHS who are accustomed to one-sided sleeping posture are prone to anisometropia. The refractive power of the side sleeping eye is higher than that of the contralateral eye and is related to the severity of OSAHS.
Keywords:Anisometropia, Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS), Sleeping Posture, Corneal Topography
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
阻塞性睡眠呼吸暂停综合征(OSAHS)主要是由于上呼吸道解剖结构狭窄致夜间反复发生呼吸暂停或呼吸不全,造成低氧血症、高碳酸血症,进而损害多种脏器功能的慢性综合症。临床表现主要包括嗜睡、头痛、打鼾、憋醒、头晕乏力、精神不集中、记忆力减退、多汗、夜尿及睡眠行为障碍等,常见于肥胖人群。在眼科,OSAHS也可导致多种眼部疾病,包括眼睑松弛综合征、圆锥角膜、青光眼等病变 [
OSAHS患者来自福建医科大学附属第二医院睡眠呼吸监测室,经多导睡眠检测仪(Neurotronick, USA)检测,确诊为OSAHS的患者共61人122眼为OSA组,轻度10人,中度19人,重度32人;平均年龄36.57 ± 11.27岁,男41人,女20人;正常对照组(Control组)为健康体检中心无肥胖、鼾症及过敏性鼻炎且体检结果正常的人群共67人134只眼,平均年龄37.27 ± 10.55岁,男性38例,女性29例。两组年龄、性别差异无统计学意义(t = 1.03, P > 0.05;χ2 = 1.16, P > 0.05)。所有病例均排除翼状胬肉、角膜瘢痕、干眼、角膜炎、青光眼、晶体异常及眼底病变等引起屈光度改变的眼部疾病,所有病例均无眼部外伤及手术史。本研究为横断面研究,课题经福建医科大学附属第二医院伦理委员会批准并遵循赫尔辛基宣言,所有研究对象均签署了知情同意书。
1、OSAHS诊断标准:指在每夜7 h睡眠过程中呼吸暂停及低通气反复发作30次以上,或睡眠呼吸暂停低通气指数(apnea hypopnea index, AHI) ≥ 5的患者 [
2、睡眠姿势定义:所有研究对象的睡眠姿势定义均采用自我描述法,按每月30天计算,观察记录晨起时身体的位置。右侧面部接触枕头者,为右侧睡眠(图1A,图1B),左侧面部接触枕头者为左侧睡眠(图1D,图1E),面部朝上不接触枕头为仰卧睡眠(图1C)。侧睡组定义为:每月超过15天,晨起时体位固定为右侧或左侧者;非侧睡组为:晨起时处仰睡状态超15天;或无确定睡眠姿势,晨起时记录每种睡眠姿势均小于15天。根据睡眠姿势将OSAHS组分为OSAHS侧睡组(OSA-S组)及OSAHS非侧睡组(OSA-NS组),对照组分为正常对照侧睡组(Control-S组)及正常对照非侧睡组(Control-NS组)。
3、采用SW-6000型角膜地形图仪(Tianjin, China)对所有病例行角膜地形图检查;由同一人操作摄下三张质量较高的图像,除外泪液和眼睑的干扰,然后选取质量最佳的一张进行分析,分别记录下角膜表面规则指数(surface regularity index, SRI)和角膜表面非对称指数(surface asymmetry index, SAI)、平坦子午线角膜屈光力(the values of flat keratometric power, K1)、陡峭子午线角膜屈光力(the values of sleep keratometric power, K2)。采用光学相干生物测量仪(Lenstar LS900, Switzerland)进行眼轴长度测量,连续5次,取其平均值,记录下所有被检病例的眼轴长度。对所有病例行散瞳验光:用0.5%复方托吡卡胺滴眼液滴眼,每隔5分钟滴眼一次,每次一滴,双眼同时进行,共3次,最后一次点眼30 min后用全自动电脑验光仪(Topcon, RM8900, Japan)进行验光 [
图1. 睡眠姿势:右侧睡眠(A和B),左侧睡眠(D和E),仰卧睡眠(C)
运用SPSS17.0数据统计软件包进行统计学分析,正态分布计量资料数据以 x ¯ ± s 表示,组间比较采用t检验;非正态分布计量资料以M(P25-P75)表示,组间比较采用Wilcoxon秩和检验;计数资料数据以绝对数表示,组间比较采用行×列表χ2检验,以P < 0.05作为具有统计学意义的标准。
1、OSA组61例有29例表现为屈光参差(47.54%),对照组67例有11例为屈光参差(16.42%);两组比较差异有明显的统计学意义(χ2 = 14.40, P < 0.05)。
屈光参差发生率为OSA-S组(22/32,68.75%),OSA-NS组(7/29,24.14%)、Control-S组(4/24, 16.67%)和Control-NS组(7/43, 16.28%),四组间进行比较,屈光参差的发生率不同,差异具有统计学意义(χ2 = 31.35, P < 0.05);OSA-S组屈光参差的发生率高于OSA-NS组、Control-S组和Control-NS组,差异有统计学意义(χ2 = 12.14, P < 0.05; χ2 = 14.96, P < 0.05; χ2 = 21.30, P < 0.05)。OSA-NS组与Control-S组、Control-NS组分别比较差异无统计学意义(χ2 = 0.45, P > 0.05; χ2 = 0.68, P > 0.05),Control-S组与Control-NS组比较差异无统计学意义(χ2 = 0.002, P > 0.05) (见表1)。
2、OSA-S组屈光参差者22例中,高达20例屈光参差患者表现为侧睡侧眼的近视程度较对侧重(90.90%);在该22例发生屈光参差的患者中,有11例表现为双眼球镜的屈光度不同,11例为柱镜的屈光度不同。
OSA组61人(122眼)CYL、SRI、SAI明显高于正常对照组67人(134眼),差异有统计学意义(all P < 0.05) (见表2)。OSA-S组侧睡侧眼CYL、SRI、SAI明显高于侧睡对侧眼,差异有统计学意义(all P < 0.05) (见表3)。OSA-NS组双眼、Control-NS组双眼、Control-S组双眼的SRI、SAI、CYL分别比较,差异均无统计学意义(all, P > 0.05) (见表3)。
3、分析OSA-S 组中22例屈光参差患者双侧眼轴长度的差别,其数值经正态性检验不符合正态分布,因此采用Wilcoxon秩和检验,侧睡侧眼的眼球长度为24.12 (23.61~25.13) mm对侧眼的眼球长度为23.82 (23.47-24.43) mm,差异有统计学意义(Z = 1.70, P < 0.05) (见表4)。
4、屈光参差发生率在OSA组轻,中,重中分别为20.00%、26.32%、68.75%,差异有统计学意义(χ2 = 14.25, P < 0.05);各组分别进行比较,其中轻度与中度相比差异无统计学意义(χ2 = 0.14, P > 0.05);重度OSAHS明显高于轻度、中度,差异有统计学意义(χ2 = 3.95, P < 0.05; χ2 = 6.25, P < 0.05) (见图2)。
Groups | anisometropia | no anisometropia | total |
---|---|---|---|
OSA-S group | 22 | 10 | 32 |
OSA-NS group | 7* | 22 | 29 |
Total OSA | 29 | 32 | 61 |
Control-S group | 4*◊ | 20 | 24 |
Control-NS group | 7*◊∆ | 36 | 43 |
Total Control | 11 | 56 | 67 |
表1. 各组别之间屈光参差发生率的比较
注:*:与OSA-S组比较,P < 0.05。◊:与OSA-NS比较,P > 0.05。∆:与Control-S组比较,P > 0.05。
Groups | t | p | ||
---|---|---|---|---|
OSA group (n = 122) | Control group (n = 134) | |||
SRI | 0.34 ± 0.04 | 0.053 ± 0.01 | 82.65 | <0.05 |
SAI | 0.37 ± 0.16 | 0.13 ± 0.26 | 16.65 | <0.05 |
CYL* | 0.87 ± 0.46 | 0.56 ± 0.36 | 5.88 | <0.05 |
表2. OSA组与对照组角膜地形图相关参数的比较
注:*:CYL = K2 − K1。
OSA-S group | t | p | ||
---|---|---|---|---|
Ipsilateral eye | Contralateral eye | |||
SRI | 0.40 ± 0.27 | 0.32 ± 0.32 | 10.66 | <0.05 |
SAI | 0.51 ± 0.22 | 0.36 ± 0.12 | 2.65 | <0.05 |
CYL | 1.18 ± 0.50 | 0.82 ± 0.43 | 3.49 | <0.05 |
OSA-NS group | t值 | p值 | ||
Right eye | Left eye | |||
SRI | 0.31 ± 0.31 | 0.32 ± 0.20 | 1.54 | 0.13 |
SAI | 0.30 ± 0.09 | 0.33 ± 0.11 | 1.30 | 0.20 |
CYL | 0.69 ± 0.27 | 0.67 ± 0.27 | 0.32 | 0.75 |
Control-S group | t值 | p值 | ||
Ipsilateral eye | Contralateral eye | |||
SRI | 0.054 ± 0.011 | 0.053 ± 0.013 | 0.24 | 0.81 |
SAI | 0.127 ± 0.025 | 0.130 ± 0.028 | 0.45 | 0.65 |
CYL | 0.625 ± 0.361 | 0.544 ± 0.289 | 0.85 | 0.40 |
Control-S group | t值 | p值 | ||
---|---|---|---|---|
Right eye | Left eye | |||
SRI | 0.052 ± 0.009 | 0.054 ± 0.007 | 0.79 | 0.43 |
SAI | 0.122 ± 0.028 | 0.123 ± 0.023 | 0.22 | 0.83 |
CYL | 0.518 ± 0.349 | 0.601 ± 0.491 | 0.98 | 0.33 |
表3. OSA-S组角膜地形图相关值在双侧眼的比较
OSA-S Group | Z | P | ||
---|---|---|---|---|
positional side eye(n = 22) | contralateral eye (n = 22) | |||
axial length | 24.12 (23.61~25.13) | 23.82 (23.47~24.43) | 1.702 | 0.045 |
Mean Rank | 25.8 | 19.2 | ||
Sum Rank | 567.5 | 422.5 |
表4. OSA-S组屈光参差者侧睡侧眼与对侧眼眼轴长度的比较
图2. 不同程度OSAHS屈光参差发生率比较,差异有统计学意义。(χ2 = 14.25, P < 0.05)
1、睡眠姿势是人体在睡眠中身体的位置,由于其睡眠空间的私密性强,以及睡眠时候人的自我认知程度无法十分精确,因而对睡眠姿势的精确判断仍然是一个难点,目前方法主要有视频监测法和自我回忆判断法 [
2、两眼屈光状态不一致称为屈光参差,目前考虑与遗传因素、年龄、种族、教育、歪头看书、书写姿势不正确,疾病因素如先天性白内障、Duane氏综合征等有关,很多研究发现除晶状体源性白内障引起的屈光参差外,屈光参差的主要原因是双眼眼轴长度发育不平衡,眼轴差异又主要因为玻璃体腔径的差异 [
3、在本次研究之前的临床观察中,我们发现当双眼球镜差 ≥ 1.00 D,柱镜差 ≥ 0.75 D,OSAHS患者屈光参差发生的概率较高,故在本次研究中定义双眼近视屈光度相差为球镜 ≥ 1.00 D或柱镜 ≥ 0.75 D为屈光参差。
4、本研究发现OSA组屈光参差发生率(47.54%)明显的高于对照组(16.42%),OSA-S组屈光参差发生率更是高达68.75%,高于OSA-NS组和对照组,提示了OSAHS,尤其是单侧睡眠姿势的OSAHS患者易出现屈光参差。对于出现这种现象的原因,我们认为可能与以下两方面因素有关,首先OSAHS是以慢性间断性缺氧为特征的疾病,缺氧可以导致眼球组织的代谢、功能和形态结构发生异常变化 [
1) 研究中我们还发现,OSA-S组22例发生屈光参差的患者中,有11例因双眼球镜的屈光度差异引起,11例因柱镜的屈光不同引起,我们推测这不同类型的屈光参差,可能与患者侧睡时眼部受压力量、部位不同有关,角膜地形图结果中OSA-S组侧睡侧眼CYL、SRI、SAI明显高于侧睡对侧眼(P < 0.05),表明了OSAHS侧睡可能导致角膜的形状规则性的改变。
2) 近视的形成主要是与巩膜的变薄延长致使眼轴长度增加有关 [
3) 本研究还发现屈光参差的发生率与OSAHS的严重程度相关,重度OSAHS患者屈光参差的发生率明显高于轻中度患者。该研究结果表明,当OSAHS发展到一定的程度,引起屈光参差的风险会明显增大。由于重度OSAHS患者夜间缺氧相对较重,各个器官的缺氧和病变也更显著;研究发现,重度OSAHS患者更易发生眼睑松弛且松弛程度更大,松弛眼睑中MMPs水平表达更高 [
本研究中,对睡眠姿势的判断,未使用视频监测法,而选取自我回忆法,对结果有一定的影响,在以后的研究工作中需改进,并扩大样本量及从病理生理学方面,进行进一步研究其发病原理。
小结:OSAHS患者,侧睡一侧的习惯,是造成屈光参差的危险因素,对于原因不明的屈光参差患者,视光学相关专业人员需要关注患者有无夜间睡眠打鼾或憋气等OSAHS症状,以便及早发现OSAHS并进行相关的治疗。反之,广大呼吸内科和耳鼻喉科医师也要警惕OSAHS患者的视物模糊等眼部症状,及时转诊至眼科进行验光检查,并进行相关的诊治和健康指导,切实提高OSAHS患者的生活质量。
本研究无任何利益冲突。
2013年福建省中青年教师教育科研项目(JB13081)。
赵华轩:酝酿和设计实验;实施研究;采集数据;分析、解释数据;起草并撰写文章;统计分析;获取研究经费;对编辑部的意见进行核修。高莹莹:酝酿和设计实验;实施研究;采集数据;分析、解释数据;对文章的知识性内容作批评性审阅;对编辑部的意见进行核修并对数据进行统计分析。于扬:采集分析数据,对文章的知识性内容作批评性审阅。陈晓阳、樊冀闽:分析、解释呼吸睡眠相关数据;对文章的知识性内容作批评性审阅;对数据进行统计分析,对OSAHS诊断提供了大量指导性意见。作者感谢汤采薇对睡眠姿势进行画图展示(图1)。
赵华轩,高莹莹,于 杨,陈晓阳,樊冀闽. 睡眠呼吸障碍综合征及睡眠姿势与屈光参差的关系The Relationship between Sleep Posture and Anisometropia in Patients with Obstructive Sleep Apnea-Hypopnea Syndrome[J]. 眼科学, 2021, 10(02): 50-58. https://doi.org/10.12677/HJO.2021.102005