管理成人糖尿病进展

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管理近视通常是指童年近视，但是成年人的近视管理提出了自己的挑战和考虑因素。虽然重点通常从减速近视发展到监测成人近视的眼睛健康，但我们如何管理折射率的变化，眼睛健康和一般健康因素？这里有一个复杂情况from LM describing a young adult with aphakia and Type 1 diabetes whose myopia might be progressing.

diabetes_op

糖尿病如何影响折射率

Diabetes_2

关于糖尿病在影响该患者屈光不确定错误的作用的讨论很多。众所周知，血糖水平会影响折射率 - 血糖水平的急性变化会将折射转移到近视或远视，1although upon intensive treatment, hyperopic shifts are more common.2在管理良好的糖尿病中，在这里似乎是这样，血糖水平的每日波动似乎不会影响折射。3

糖尿病的折射变化通常是由于晶体晶状体的厚度和曲率变化所致。角膜曲率通常不受影响，并且对糖尿病患者和年龄匹配的对照组之间的角膜厚度差异的发现是模棱两可的。4在这个病人无晶状体,晶状体alteration due to diabetes is not a factor in her observed refractive changes.

If the lens is not a factor in the myopic shift observed in this patient, how can ocular measurements help to determine the cause?

角膜l curvature

角膜曲率通常不会因血糖水平而改变。4For this patient, measurement of corneal curvature would help to rule out any irregularity and/or steepening which could be contributing to the refractive change. Typically keratoconus onsets in the second decade of life, but it can progress in adults.5A case series showed 7 eyes of 4 patients with an average age of 29 years who demonstrated keratoconus progression in pregnancy.6

轴向长度

这是临床谜团变得更清晰的地方，轴向长度测量表明左眼明确轴向近视。由于轴向长度超过26mm会增加视力障碍的寿命风险，因此7必须密切监测这种“近视”眼睛的眼部健康。

An important note is that optical biometers typically have a phakic and aphakic or pseudophakic measurement setting, as the optical path length of measurement is influenced differently by the crystalline lens compared to an intraocular or absence of lens. Measurement of an aphakic eye in the phakic mode results in an error of 0.2mm8– if this patient had been measured in phakic mode, the true axial lengths would be 23.7mm in the right eye and 26.5mm in the left.

Is this patient a myope?

接受白内障手术的儿童通常会表现出近视折射率，在年轻时进行手术时会更大。9Even though the manifest refraction is highly hyperopic, the crystalline lens normally contributes 10-15D of refractive power to the eye.10Putting this alongside the patient's current refraction of R +13.50 and L +9.50, if the eyes were phakic, the right eye could be in the range of low myopia to moderate hyperopia. The left eye is almost certainly the equivalent of low-to-moderate myopia from a refraction point of view, and knowing that axial length is over 26mm, could be considered a high myope from a retinal point of view.7

There is little known about how axial length changes in adult myopia progression. Repeated axial length measurements, if available, would help to isolate axial growth as the cause of refractive change in this patient. Even just this single measurement, though, indicates left eye axial 'high myopia' and hence increased risk of ocular pathology,7需要频繁的眼睛健康监测。这对患者来说至关重要，因为她已经有右侧（轴向长度）的视网膜脱离病史。

The International Myopia Institute recommends that high myopes be reviewed annually with retinal health examination through dilated pupils.11

Treatment options

多灶软接触镜头

Diabetes_3

As the patient is already currently wearing soft contact lens, commenters suggested multifocal soft contact lens (MFCLs) as a form of myopia control. Others mentioned it could support her near vision. Her high hyperopic refractive error means that a customized MFCL would likely be needed, if prescribed.

MFCL通常用于慢慢儿童的近视进展，但是年轻人没有关于近视控制的数据。此外，该患者的不寻常临床特征在内，包括阿法基亚和糖尿病，使她的临床范围更远，超出了典型的近视控制研究范围。该患者由于阿法基亚（Aphakia）而需要全面添加 - 证据表明，与MFCL中提供的“接近添加”相比，眼镜将提供更有效和可预测的。12

监测折射和眼睛健康

Diabetes_4

Some other commenters were less convinced that this was a case of progressing myopia and suggested repeated measurement over time, with less focus on prescribing a myopia control solution. This is sensible given the patient's unusual clinical presentation and history, but the diagnosis of left axial myopia based on the axial length measurement does require ocular health management as for a refractive myope.

The original post described that the patient's near work habits had changed. One study has shown a link between visual environment habits in childhood and adulthood, and adult myopia progression.13The short-term impact of close reading distances on axial length has also been demonstrated.14Hence, reinforcing the need for good visual habits such as regular breaks from near work is useful advice for this patient.

带回家消息：

  1. When a patient is aphakic or pseudophakic from childhood, their refractive error may not necessarily reflect the reality of their axial length - measuring this helps to gauge the related retinal health risk
  2. Eyes with longer axial length (over 26mm) are recommended to have an annual retinal health examination through dilated pupils to monitor ocular health, regardless of the manifest refraction.
  3. There is little known about the typical course and frequency of adult myopia progression and whether myopia control strategies used for children will be effective in adults. Systemic health conditions like diabetes can further add to the complexity. Consideration of the best optical correction for the patient, and then regular monitoring, may be the ideal course of management.

进一步阅读

康妮头像120x120

关于Connie

康妮·甘是来自马来西亚Kedah的临床验光师，为儿童提供全面的视觉护理，并在其临床实践中运营近视管理服务。

Kimberley 120x120

关于金伯利

Kimberley Nguis a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

由于不受限制的教育赠款，这些教育内容是给您带给您的

References

  1. KaštelanS，Gverović-Antunica A，PelčićG，GotovacM，MarkovićI，KasunB。与糖尿病有关的折射变化。Semin Ophthalmol。2018; 33（7-8）：838-845。（（link）
  2. Li Hy，Luo GC，Guo J，Liang Z.血糖控制对糖尿病患者折射的影响。Int J Ophthalmol。2010; 3（2）：158-60。doi：10.3980/j.issn.2222-3959.2010.02.15。Epub 2010 Jun 18. PMID：22553542;PMCID：PMC3340779。（（link）
  3. Huntjens B, Charman WN, Workman H, Hosking SL, O'Donnell C. Short-term stability in refractive status despite large fluctuations in glucose levels in diabetes mellitus type 1 and 2. PLoS One. 2012;7(12):e52947. (link）
  4. Huntjens B，O’DonnellC。糖尿病的折射率变化。实践中的验光。2006; 7（3）：103-14。（关联）
  5. Romero-JiménezM，Santodomingo-Rubido J，Wolffsohn JS。角膜结构：评论。连续镜头前眼。2010年8月; 33（4）：157-66;测验205.（（link）
  6. Bilgihan K，Hondur A，Sul S，OzturkS。妊娠诱导的角膜结构。角膜。2011年9月; 30（9）：991-4。（（link）
  7. Tideman JW, Snabel MC, Tedja MS, van Rijn GA, Wong KT, Kuijpers RW, Vingerling JR, Hofman A, Buitendijk GH, Keunen JE, Boon CJ, Geerards AJ, Luyten GP, Verhoeven VJ, Klaver CC. Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia.JAMA Ophthalmol.2016; 134（12）：1355-1363。（关联）[链接到近视资料科学评论]
  8. Haigis W.光学生物特征法的假晶校正因子。Graefes Arch Clin Exp Ophthalmol。2001年8月； 239（8）：589-98。（（link）
  9. Borja D, Manns F, Ho A, Ziebarth N, Rosen AM, Jain R, Amelinckx A, Arrieta E, Augusteyn RC, Parel JM. Optical power of the isolated human crystalline lens. Invest Ophthalmol Vis Sci. 2008 Jun;49(6):2541-8. (link）
  10. 克劳奇,克劳奇,Pressman SH,前瞻性analysis of pediatric pseudophakia: myopic shift and postoperative outcomes. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2002 Oct 1;6(5):277-82.（关联）
  11. Gifford KL, Richdale K, Kang P, Aller TA, Lam CS, Liu YM, Michaud L, Mulder J, Orr JB, Rose KA, Saunders KJ, Seidel D, Tideman JWL, Sankaridurg P. IMI - Clinical Management Guidelines Report. Invest Ophthalmol Vis Sci. 2019 Feb 28;60(3):M184-M203. (link）
  12. Kim E, Bakaraju R, Ehrmann K. Power Profiles of Commercial Multifocal Soft Contact Lenses, Optometry & Vision Science. 2017 Feb 94(2):183-96.（关联）
  13. Pärssinen O, Kauppinen M, Viljanen A. The progression of myopia from its onset at age 8-12 to adulthood and the influence of heredity and external factors on myopic progression. A 23-year follow-up study. Acta Ophthalmol. 2014 Dec;92(8):730-9.（关联）
  14. Woodman EC, Read SA, Collins MJ, Hegarty KJ, Priddle SB, Smith JM, Perro JV. Axial elongation following prolonged near work in myopes and emmetropes. British Journal of Ophthalmology. 2011 May 1;95(5):652-656.（关联）
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