臺灣博碩士論文加值系統

目的：探討國內白內障手術現況；病患術後眼內炎、後囊混濁及視網膜剝離併發症之發生率及其危險因子。
設計：長期資料分析。
方法：以民國89年身分證加密之全民健保申報資料中，接受水晶體摘除及人工水晶體植入之白內障手術病患為對象，共108,736筆，門診95,791筆，住院12,945筆。樣本追蹤至民國91年底，以stepwise Cox regression進行分析。
結果：白內障手術病患以女性居多(54.0%)，年齡以70~79歲最多(41.2%)，其次為60~69歲(35.5%)。眼科病史前三名為視網膜病變(9.9%)、青光眼(8.2%)及角膜炎(4.6%)，內科病史則以高血壓(38.0 %)、關節炎(23.5%)、糖尿病(20.1%)較高。手術方式以囊外水晶體摘除術最多(41.8%)、其次為超音波水晶體乳化術(13.2%)，麻醉方式以球後麻醉為主(99.5%)。人工水晶體材質以植入PMMA(69.4 %)最高，其次為Acrylic (5.7%)，HSM PMMA及Silicone較低。病患就醫機構以私立(85.9%)，診所(57.2%)，及高手術量的院所(64.8%)為主。醫師特質方面，病患手術醫師以男性(84.3%)，年齡36~45歲(62.7%)，及高手術量(68.1%)為主。術後併發症方面，一年內狹義眼內炎發生率為0.24%，廣義眼內炎為0.71%。以廣義眼內炎進一步分析發現，男性，年齡小於50歲，患有糖尿病視網膜病變增殖型、青光眼、脈絡膜疾病、精神病性精神疾患及非老年性白內障，採住院手術，於中低手術量的醫院及接受男醫師手術者，術後發生眼內炎之危險性較高，而人工水晶體材質採Acrylic者，則發生眼內炎危險性顯著較低。排除50歲以下病患，術後二年內後囊混濁發生率為19.0%。二年內接受雅各雷射後囊切開術為15.2%，其危險因子為男性、患有糖尿病視網膜病變基礎型或增殖型、青光眼、脈絡膜疾病、高度近視、角膜炎、情感性疾病及免疫疾病，及採住院手術，由中/低手術量的醫院及年紀較輕醫師執行手術者。然病患年齡大於80歲，患有精神病性精神疾患、手術方式為超音波晶體乳化術、植入之人工水晶體為Acrylic 及HSM PMMA材質，由低手術量醫師執行手術者，較不需接受雅各雷射後囊切開術治療其後囊混濁。整體而言，術後二年內廣義視網膜剝離發生率為1.11%。狹義視網膜剝離發生率為0.90%，其危險因子包括男性、年齡較輕、病患有糖尿病視網膜病變基礎型、高度近視、視網膜剝離及黃斑部病變等病史，採住院手術，接受中手術量醫師及年紀較輕醫師執行手術者。
建議：建議臨床醫師，應慎選手術方式及人工水晶體材質，並密切追蹤危險性較高病患，以降低術後併發症之發生。建議健保局應鼓勵醫院及醫師使用較具成效之手術方式及人工水晶體材質，並建立臨床資料庫，以利於評估與監控白內障手術品質。國內雅各雷射後囊切開術之發生率偏高，建議健保局可進一步評估其適當性，以避免醫療資源過度使用。

Objective:
The purpose of this study is to explore current practice styles of cataract surgery and to investigate the incidence and risk factors of postoperative complications, including endophthalmitis, posterior capsular opacification and retinal detachment in Taiwan.
Methods:
longitudinal data analysis.
Participants:
108,736 patients who received cataract extraction and intraocular lens implantation in 2000 were identified from Bureau National Health Insurance(BNHI) claimed dataset, and followed up to the end of 2002. The stepwise Cox regression was used for risks analysis.
Results:
Approximately 54% of the patients received cataract surgery were female, 41.2% were aged between 70 and 79 years, followed by 35.5% between 60 and 69 years. The most common ophthalmic comorbidities of these patients are retinopathy (9.9%), glaucoma (8.2%), and keratitis (4.6%), and the medical comorbidities are hypertension (38%), arthritis (23.5%) and diabetic mellitus (20.1%).
Extracapsular cataract extraction was used in 41.8% of patients, followed by phacoemusification (13.2%) and intracapsular cataract extraction(5.7%). 99.5% method of anesthesia were retrobulbar anesthesia. As for the material of intraocular lens, PMMA (69.4%) is the most common, followed by acrylic (5.7%), HSM PMMA (5.2%) and silicone(4.4%). 85.9% patients received cataract surgery in the private medical institutions,57.2% in the clinics, and 64.8% in the institutions with high surgical volume. 84.3% patients performed by male surgeons, 62.7% by surgeons whose age between 36 and 45 years, and 68.1% by surgeons with high surgical volume.
The overall one year incidence of endophthalmitis was 0.71%, and rate of admitted postoperative endophthalmitis was 0.24%. The stepwise cox proportional hazard model that simultaneously evaluated the effects of many variables was used, and showed that male patients, under age 50, with proliferative diabetic retinopathy, glaucoma, choroidopathy, psychotic disorders and non-senile cataract, operated in the hospitals with middle-lower surgical volume and by male doctors were positively associated with the likelihood of endophthalmitis. Conversely, patients receiving acrylic intraocular lens were protected against endophthalmitis compared to those implanted with ordinary PMMA lenses.
After excluded patients under age of 50, the two year incidence of posterior capsular opacification was 19%, and the two year utilization rate of YAG Laser capsulotomy was 15.2%. Male patients, with background diabetic retinopathy, proliferative diabetic retinopathy, glaucoma, choroidopathy, high myopia, keratitis, non-psychotic mental disorders and immune disorders, in-patient surgery, performed in middle-lower volume hospitals, and operated by older doctors associated with higher risk of utilization of YAG capsulotomy. However, patients above 80 year of age, with psychotic disorders, use phacoemusification surgery, using acrylic and HSM PMMA intraocular lenses were less likely to receive YAG laser capsulotomy.
The two year incidence of retinal detachment after cataract surgery was 0.90%, and the two year incidence of retinal detachment and/or retinal breaks was 1.11%. Those patients which were males, young age, with background diabetic retinopathy, high myopia, retinal detachment, and maculopathy, received in-patient surgery, operated by doctors of middle surgery volume or by older doctors were with higher risks of developing post-operative retinal detachment or retinal breaks.
Suggestions:
We recommend that doctors should carefully choose surgery method and intraocular lends material to avoid surgical complications and should pay attention to high risks patients. The BNHI should set up clinical database and establish quality index to monitor the quality of cataract surgery. In Taiwan, the one year incidence of YAG laser capsulotomy is too high, and the BNHI should evaluate its propriety of medical services.

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