漫谈眼压与青光眼的临床

眼压是青光眼最重要最易监控的临床指标,必须强调其测量的精确性。高眼压症、原发性开角型青光眼、正常眼压性青光眼和慢性闭角型青光眼都有其各自的特点以及独特的与眼压的关系。本文试从眼压的角度,结合近年来国外重要的多中心临床研究结果,讨论高眼压症和几种常见青光眼的临床诊治思路。     

EX-PRESS青光眼引流钉植入术和小梁切除术治疗原发性开角型青光眼的临床观察

目的与小梁切除术对比,观察EX-PRESS青光眼引流钉植入术治疗原发性开角型青光眼的有效性和安全性。方法对药物不能控制的原发性开角型青光眼患者进行手术,随机分为EX-PRESS青光眼引流钉植入术组和小梁切除术组,每组术中均联合使用丝裂霉素。收集术前,术后1 d,2周,1,3,6,12个月的视力、眼压等基本数据。结果评价主要为平均眼压和术后并发症的发生率。手术完全成功的标准为:在不使用任何降眼压药物的情况下,眼压控制在5~18 mm Hg或比基线眼压下降20%。结果 28例原发性开角型青光眼患者共32只眼纳入研究,每组各14例。EX-PRESS青光眼引流钉植入组术前平均眼压(34.5±5.6)mm Hg,小梁切除术组术前平均眼压(33.8±6.8)mm Hg。两组比较无差异(P>0.05)。术后1年两组平均眼压分别为(12.6±4.5)mm Hg和(11.5±4.6)mm Hg。两组比较无差异(P>0.05)。术后随访1年,完全成功者EX-PRESS青光眼引流钉植入组占69%,小梁切除术组占56%。相对成功者两组分别占87%和81%。两组比较无差异(P>0.05)。在手术时间和并发症发生率上两组比较无明显统计学差异。结论对于原发性开角型青光眼患者,巩膜瓣下植入EX-PRESS青光眼引流钉装置安全、有效。     

原发性开角型青光眼,低眼压性青光眼彩色多普勒图象研究

对原发性开角型青光眼３４例，低眼压性青光眼有３１例及正常对照机９０例进行彩色多普勒图象研究，到眼眼动脉，视纲膜中央动脉，睫状后动脉的收缩期血流速度，舒和末期血流速度、计算阻力指数。青光眼病人与正常对照组，结果表明：原发性开角青光眼及低眼压性青光眼两组，双眼视网膜中央动脉ＰＳＶ均值降低，ＥＤＶ均值降低，ＲＩ长高；原发性开角型青光眼组右眼睫状后动ＲＩ升高。统计学处理有显著性差异。     

正常眼压性青光眼的危险因素

正常眼压性青光眼（normal tension glaucoma,NTG）在临床特征上除了眼压在正常范围外,其余均与开角型青光眼有许多相同之处,故以往一直被认为是开角型青光眼的一个亚型.但随着对此疾病的认识逐渐加深,发现其危险因素与高眼压性开角型青光眼有所不同,全身情况及眼局部因素都对NTG的发生发展产生影响,主要包括性别、年龄、脑供血不足、眼压波动、眼轴长度、屈光度等方面.     

青光眼的眼压及眼脉动幅度比较分析

目的:观察比较慢性闭角型青光眼、原发性开角型青光眼、正常眼压性青光眼以及正常人的眼压,眼脉动幅度特征及其相关性。方法:收集临床确诊为慢性闭角型青光眼患者19例,原发性开角型青光眼18例,正常眼压性青光眼15例,正常人20例,用动态轮廓眼压计测量其眼压及眼脉动幅度,同时测量患者的血压及心率。运用SPSS14.0进行统计学分析。结果:慢性闭角型青光眼组的平均眼压为25.42±9.95mmHg,OPA为3.84±0.88mmHg;原发性开角型青光眼组的平均眼压为23.12±5.47mmHg,OPA为3.29±0.90mmHg;正常眼压性青光眼组的平均眼压为16.52±2.23mmHg,OPA为1.85±0.47mmHg;正常人组的平均眼压为16.31±2.67mmHg,OPA为2.47±0.80mmHg。前两组与后两组之间的眼压存在着显著性差异,四组之间的OPA均存在统计学差异。四组患者的眼压及眼脉动幅度之间存在着弱相关性,但无统计学意义。结论:慢性闭角型青光眼、原发性开角型青光眼及正常眼压性青光眼的OPA之间存在统计学差异,眼压与OPA之间存在弱相关性,但无统计学意义。     

正常眼压性青光眼研究新进展

正常眼压性青光眼研究新进展钟一声综述蒋幼芹审校湖南医科大学附属二医院眼科（４１００１１）正常眼压性青光眼（Ｎｏｒｍａｌｔｅｎｓｉｏｎｇｌａｕｃｏｍａ，ＮＴＧ）又称低眼压性青光眼，指除了无眼压增高外，其临床表现与原发性开角型青光眼相似的一类眼病，其眼压...     

依据24h眼压峰值的青光眼个性化药物治疗观察

目的 通过对开角型青光眼患者进行24h眼压监测后采用不同的降眼压用药时间,来探索青光眼的个性化治疗.方法 入选18例正常眼压性青光眼和14例原发性开角型青光眼,治疗前均给予视野检查,进行24 h眼压监测(每2h1次),并根据眼压波动曲线,给予前列腺素类降眼压药,1次/d,用药时间为峰值眼压提前12 h;1个月后复查24 h眼压,随访(23.7±12.4)个月,记录随访终末期的视野.结果 治疗前平均眼压(16.8±3.5)mm Hg(1 mm Hg=0.133 kPa),峰值眼压(20.8±4.6)mm Hg,谷值眼压(13.7±3.1)mm Hg,眼压波动值(7.1 ±2.4)mm Hg;治疗后平均眼压(13.2±2.6) mm Hg,峰值眼压(16.4±3.4) mm Hg,谷值眼压(10.7±2.3)mm Hg,眼压波动值(5.7±2.1)mm Hg.治疗前后平均眼压、峰值眼压、谷值眼压、眼压波动值的差异均具有统计学意义(P ＜0.000 1).治疗前视敏度(19.0±5.2)dB,视敏度缺损值(8.2±4.9)dB;治疗后视敏度(19.7±5.5)dB,视敏度缺损值(7.2±5.1)dB.结论 通过依据24h眼压峰值来确定青光眼的用药及其用药时点的选择,以及青光眼随访过程中治疗药物的调整,是一种值得推广的青光眼个性化治疗模式.(中国眼耳鼻喉科杂志,2012,12:36-39)     

青光眼昼夜眼压波动

病理性高眼压和较大的昼夜眼压波动是青光眼视神经损害进展的重要危险因素.眼压具有波动性,正常人眼压波动的峰值多出现于凌晨,这种波动与体位、眼灌注压、眼轴等有关.正常眼压性青光眼患者眼压波动是视野进展的重要危险因素,且经24小时眼压监测发现大部分眼压是存在异常的,因此需根据其昼夜眼压曲线明确诊断和针对性治疗;原发性开角型青光眼患者昼夜眼压波动规律与正常人相似,眼压高峰多在夜间,但波动范围可能比正常人大,且双眼的波动呈明显的一致性;激光周边虹膜切开术后的慢性闭角型青光眼患者的昼夜眼压波动较大,其眼压波动与基线眼压和房角粘连程度呈正相关.与激光和药物相比,小梁切除术更有利于控制长期和昼夜的眼压波动.抗青光眼药物中前列腺素类药物是控制昼夜眼压波动效果最好的滴眼剂.     

角膜中央厚度对高眼压症和开角型青光眼眼内压测量值的影响

目的研究角膜中央厚度对高眼压症和原发性开角型青光眼病人的眼内压测量值的影响.方法对44例(88眼)临床诊断为高眼压症的患者,31例(61眼)原发性开角型青光眼患者及52例(104眼)与高眼压症患者屈光状态相近的正常人的角膜中央厚度及眼内压进行检测,用统计学方法比较3组的角膜中央厚度的差异及高眼压症患者的眼内压值与角膜中央厚度的相关关系.结果①高眼压症组的角膜中央厚度的平均值585.6±35.7μm明显高于原发性开角型青光眼(54.1±38.7μm)(P＜0.01)及正常对照组(535.5±29.4μm)(P＜0.01),而原发性开角型青光眼的角膜中央厚度与正常对照组相比无显著性差异(P＜0.05).②将高眼压症患者的角膜中央厚度与眼内压测量值进行简单线性相关分析,可见角膜中央厚度与眼内压测量值呈明显正相关,相关系数为0.636(P＜0.01).角膜中央厚度每增加50μm可使眼内压测量值升高约2mmHg.结论①高眼压症患者的角膜中央厚度明显大于原发性开角型青光眼和正常眼,高眼压症患者的角膜中央厚度与眼内压呈明显的正相关,提示高眼压症患者是由于角膜中央厚度高于正常范围而造成眼内压测量值的升高.②角膜中央厚度值可作为高眼压症及原发性开角型青光眼的诊断与鉴别诊断的重要依据.提示临床工作中,可将角膜中央厚度检测作为排除青光眼的常规检查手段.③当角膜中央厚度在520±50μm的范围内,眼压读数相对准确,如果角膜中央厚度超过570μm,眼压读数相应增高,这可能是高眼压症患者眼压测量值高于正常范围的重要原因之一.     

原发性开角型青光眼和高眼压患者及正常人群结膜印迹细胞学检查的比较

目的：比较原发性开角型青光眼和高眼压患者及拥有健康眼球表面的正常人群的泪膜功能和印象细胞学检查的数值。
　　方法：此前瞻性研究中纳入了原发性开角型青光眼患者11例11眼(平均年龄：62.7±6.1岁),高眼压患者12例12眼(平均年龄：62.8±6.4岁)及健康人12例12眼(平均年龄：62.9±6.03岁)。这些患者均是最近被诊断出患有原发性开角型青光眼及高眼压,且之前未接受过抗青光眼方面的治疗。均行结膜印迹细胞学检查、泪膜破裂时间和基础泪液分泌试验。每组印迹细胞学检查的样本根据Nelson分级法分为0~3级。应用Kruskal-Wallis检验和Dunn多重比较检验进行统计分析。
　　结果：原发性开角型青光眼患者,高眼压患者及正常人群平均基础泪液分泌值分别为10.4±1.3,10.9±1.2和11.1±1.1 mm/5min,其差距没有统计学意义(P=0.33);三组的泪膜破裂时间分别为11.2±1.1,11.3±1.1和11.8±1.2s,其差距没有统计学意义(P=0.35)。原发性开角型青光眼患者中6眼(54.5%)为0级,5眼(45.5%)为1级。高眼压患者中6眼(50%)为0级,6眼(50%)为1级,健康人中6眼(50%)为0级,6只眼(50%)为1级(P=0.97)。
　　结论：氧化应激可能会导致青光眼,眼表疾病,泪腺功能障碍及机体杯状细胞所分泌的黏液减少。原发性开角型青光眼患者,高眼压症患者及健康人群间的印象细胞学检查数值并无显著差异。     

New thoughts on normal tension glaucoma.

Normal tension glaucoma (NTG) is considered a primary optic neuropathy within the glaucoma family. Whereas NTG shares many of the same pathologic characteristics as primary open angle glaucoma (POAG), there are several differences such as pattern of visual field defect and incidence of disc hemorrhaging. The most notable difference is that NTG does not manifest a recordable intraocular pressure (IOP) greater than 21 mmHg. Debate has existed as to whether NTG is a pressure-sensitive neuropathy and if pressure reduction affects the course of the disease. Likely, there are aspects in the pathophysiology of NTG that are both pressure sensitive and insensitive, and the etiology of NTG has never been adequately explained.     

应用海德堡视网膜断层扫描仪检测开角型青光眼的视盘改变

目的探讨海德堡视网膜断层扫描仪(Heidelberg retinal tomography,HRT)检测青光眼性视盘改变是否与视野损害的部位相一致,了解正常眼压性青光眼(normal tension glaucoma,NTG)与原发性开角型青光眼(primary open angle glaucoma,POAG)早或中期视盘形态是否异同.方法对64例(64只眼)仅有半侧视野异常的开角型青光眼(POAG27只眼、NTG37只眼)患者进行HRT检测,将Humphery视野与HRT的检测结果以0°～180°为界,分成上下两部分进行对应分析.结果与正常半侧视野对应的1/2视盘比较,显示异常半侧视野对应的1/2视盘HRT参数中,杯盘面积比、视杯形态测量值显著增大,而盘沿面积、视网膜神经纤维层厚度及视网膜神经纤维层横断面积值显著减少 (t=-2.625～3.025,P=0.003～0.05);NTG眼和POAG眼对应与异常半侧视野的HRT视盘参数差异无显著性(t=-0.98～1.511,P=0.14～0.97).结论 HRT参数能较准确反映与视野损害相一致的视盘变化,其中尤以杯盘面积比、盘沿面积、视杯形态测量、平均视网膜神经纤维厚度及视网膜神经纤维层横断面积测量值较为准确.NTG和POAG眼的视盘形态相似,可能具备某些相似的视神经损害发生机制.     

高眼压性和正常眼压性原发性开角型青光眼视神经损害特征的比较

目的探讨高眼压性原发性开角型青光眼(POAG)和正常眼压性青光眼(NTG)患者视神经损害的不同特点。方法应用德国Heidelberg公司生产的视网膜断层扫描仪对高眼压性POAG39例(47只眼)和NTG32例(38只眼)进行定量视盘参数和神经纤维层检查,并行眼底立体照相观察视网膜神经纤维层(RNFL)缺损类型,检测静态定量视野,并对检查结果进行比较。结果(1)NTG组视盘总体参数和分区(除颞侧外)盘沿面积、沿/盘面积小于高眼压性POAG组,而C/D大于高眼压性POAG组;平均RNFL厚度和RNFL面积在颞下和颞上小于高眼压性POAG组;总体盘沿容积小于高眼压性POAG组,总体平均视杯深度和颞下视杯面积大于高眼压性POAG组,两组差异均有统计学意义(P<005)。两组颞侧视盘各参数比较,差异无统计学意义(P>005)。(2)RNFL缺损类型高眼压性POAG组RNFL弥漫性缺损占5319%,局限性缺损占426%;NTG组弥漫性缺损占2105%,局限性缺损占5526%。两组RNFL缺损类型构成比比较,差异有统计学意义(P<001)。结论NTG较高眼压性POAG具有较大的C/D值、C/D面积比和窄盘沿面积,RNFL丢失严重。高眼压性POAG患者的RNFL以弥漫性缺损为主,NTG患者的RNFL以局限性缺损为主。两者视神经损害具有不同特点,其损害机制可能不同。(中华眼科杂志,2005,41136140)     

New directions in the treatment of normal tension glaucoma

Glaucoma is a progressive optic neuropathy that causes characteristic changes of the optic nerve and visual field in relation to intraocular pressure (IOP). It is now known that glaucoma can occur at statistically normal IOPs and prevalence studies have shown that normal tension glaucoma (NTG) is more common than previously thought. While IOP is believed to be the predominant risk factor in primary open angle glaucoma (POAG), IOP-independent risk factors, such as vascular dysregulation, are believed to play an important part in the pathogenesis of NTG. Though certain distinguishing phenotypic features of NTG have been reported, such as an increased frequency of disc hemorrhages, acquired pits of the optic nerve and characteristic patterns of disc cupping and visual field loss, there is much overlap of the clinical findings in NTG with POAG, suggesting that NTG is likely part of a continuum of open angle glaucomas. However, IOP modification is still the mainstay of treatment in NTG. As in traditional POAG, reduction of IOP can be achieved with the use of medications, laser trabeculoplasty or surgery. Studies now show that the choice of medication may also be important in determining the outcomes of these patients. Though it is likely that future treatment of NTG will involve modification of both IOP and IOP-independent risk factors, current efforts to develop IOP-independent neuroprotective treatments have not yet proven to be effective in humans.     

开角型青光眼与正常大陷凹眼中视乳头旁萎缩区的比较研究

目的研究原发性开角型青光眼(POAG)、正常眼压性青光眼(NTG)与正常大陷凹眼的视乳头旁脉络膜萎缩区(PPA)的差异及其与视野的关系。方法利用计算机图像分析系统对拍摄的视乳头立体图像进行测量,比较42例(42只眼)POAG、40例(40只眼)NTG与45例(45只眼)正常大陷凹眼之间PPA的发生率及大小差异,分析PPA的有关参数与视乳头结构指标、视野分级之间的相关性。所有入选患者的屈光度(等效球镜度数)均在+3.00~-3.00D之间。结果正常大陷凹组、POAG组及NTG组α区的出现率分别为85.4%、100.0%、95.0%,β区的出现率分别为19.1%、48.9%、37.5%,POAG组和NTG组的α区和β区的出现率均大于正常大陷凹组,差异均有统计学意义(P<0.05)。正常大陷凹组、POAG组及NTG组β区面积分别为(0.08±0.25)、(0.24±0.36)、(0.14±0.21)mm2,POAG组的β区面积大于正常大陷凹组,差异有统计学意义(P<0.05)。三组的α区面积差异无统计学意义(Chi-Square=4.534,P=0.104)。而POAG组与NTG组间上述各指标及α区和β区出现率的差异均无统计学意义(P>0.05)。青光眼患者视乳头结构指标与视野相关分析结果表明,杯/盘比值与视野受损分级之间有较强相关性(r=0.5624,P<0.01)。而α区面积、β区面积与视野受损分级之间均为低相关性(α区:r=0.246,P<0.01;β区:r=0.2302,P<0.01)。有无青光眼性视野缺损相关因素的Logistic回归分析结果显示,在包括年龄、性别、屈光度、杯/盘比值分级指标及α区面积和β区有无的多个因素中,仅年龄和杯/盘比值分级指标被证实为两个可能的影响因素。结论排除了-3.00D以上的中高度近视人群后,POAG和NTG患者的α区和β区出现率及β区面积虽与正常大陷凹者有所不同,但其与视野缺损程度的相关性较传统的视乳头结构指标低,在两组青光眼患者间也未见明显差异。由此认为PPA不能作为诊断POAG的独立指标,也不能作为POAG与NTG的鉴别诊断指标。     

原发性开角型青光眼进展的危险因素研究概况

原发性开角型青光眼(POAG)进展的危险因素包括全身性及眼部因素,眼部因素包括眼压及非眼压因素.在以往的多中心研究中,眼压对于由高眼压症发展为POAG及其在POAG进展中的作用已经明确,而目前降低眼压也是临床惟一有效地延缓、控制青光眼视神经损害进展的主要因素.制定目标眼压,进行降眼压治疗尤其是控制昼夜眼压波动对于阻止青光眼进展非常重要.非眼压危险因素包括高龄、中央角膜厚度增厚、视乳头出血、晶状体囊膜剥脱征、初始的青光眼严重程度及双眼罹患青光眼等.其他因素包括近视、青光眼家族史、眼部低灌注压、低血压、心血管疾病、高血压、高血脂等血管或血液性因素.POAG进展的危险因素研究在一定程度上揭示了POAG的发病机制及临床发病规律,对于指导临床医师决定随诊频率、选择治疗方案及提高治疗效率意义重大.     

吲哚青绿血管造影观察青光眼患者的盘周脉络膜血液供应分水带

目的 观察青光眼患者吲哚青绿血管造影（ICGA）中盘周脉络膜血液供应分水带与视盘的相对位置关系，探讨青光眼视神经病变的发病机制。 方法 对青光眼患者31例31只眼和对照组37例37只眼进行ICGA和荧光素眼底血管造影(FFA)同步检查。青光眼患 者中原发性开角型青光眼（POAG）17例17只眼、正常眼压性青光眼（NTG）14例14只眼。对比分析30 s内的ICGA和FFA图像，根据分水带与视盘的相对位置关系 ，将分水带分为3型。I型：分水带不包围视盘或未被观察到；II型：分水带部分包围视盘；III型：分水带完全包围视盘。并根据分水带类型记分（I型=1；II型=2,III型=3）。 结果 87.1%的青光眼患者的分水带全部或部分包围视盘，而在对照组中仅为56.8%的分水带全部或部分包围视盘，二者比较差异有非常显著性的意义（χ2=7.369；P=0.007）。青光眼组的分值显著大于对照组（t=3.001，P=0.004）。 结论 青光眼患者的盘周脉络膜分水带的位置较正常眼更多地包围视盘，提示青光眼视神经病变的发病机制可能与盘周脉络膜血液供应状态有关。 （中华眼底病杂志，2004，20：218-220）     

Normal tension glaucoma: diagnostic features and comparisons with primary open angle glaucoma

Background : A significant proportion of patients diagnosed under the broad classification of open angle glaucoma actually has normal tension glaucoma (NTG). It has many clinical features that overlap with primary open angle glaucoma (POAG), yet there is a question of whether it has a different aetiology in which intraocular pressure plays less of a role. Methods : The epidemiology and clinical features of normal tension glaucoma are reviewed with particular reference to possible differences from primary open angle glaucoma, which might permit differentiation. The pathophysiology is discussed, outlining recent research in cell death (apoptosis), axonal damage and neuroprotection. Discussion and Conclusion : There is considerable evidence that NTG develops with little contribution from the effect of intraocular pressure. However, the clinical diagnosis of NTG is often one of exclusion and the differentiation of NTG from POAG remains difficult because many clinical signs are suggestive but not definitive of NTG. More accurate diagnosis may be possible when individual patients exhibit a greater number of signs. Some evidence suggests that NTG with relatively high pressures (greater than 15 mmHg) is more likely to progress than NTG with relatively low pressures. Clinicians must be particularly alert to the possibility of NTG because IOP, a clinical marker for some glaucomas, is absent.     

早期开角型青光眼的视网膜神经纤维层缺损及相关临床特点

目的观察早期原发性开角型青光眼（primary open-angle glaucoma,POAG）及正常眼压性青光眼（normal tension glaucoma,NTG）的弥漫性及局限性视网膜神经纤维层缺损（retinal never fiber layer defect,RNFLD）的分布及相关的临床特点。方法通过对立体眼底像的观察,明确81例POAG及70例NTG的RNFLD类型,分析弥漫性及局限性RNFLD在两型青光眼中的分布,比较两型RNFLD患者未治疗的最高眼压及视盘出血发生比例的不同。结果81例POAG中,78例出现RNFLD,其中弥漫性RNFLD50例,局限性RNFLD28例。70例NTG中,弥漫性RNFLD27例,局限性RNFLD43例,两型青光眼的RNFLD的分布相比较,差异有显著性（χ     

A comparison of optic disc topographic parameters in patients with primary open angle glaucoma,normal tension glaucoma,and ocular hypertension

Background Heidelberg Retina Tomograph (HRT) findings have been employed to quantitatively assess the topography of optic discs. We measured topographic parameters of optic discs in patients with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), and ocular hypertension (OH) using an HRT in order to determine whether HRT topographic parameters can be used to differentiate those conditions.Methods Seventeen eyes in 17 patients with POAG, 23 eyes in 23 patients with NTG, and 15 eyes in 15 patients with OH were examined using an HRT, and the results were analyzed by age, refractive error, and topographic parameters.Results Among the HRT parameters, the mean values for rim area, rim volume, cup disk area ratio, and classification showed significant differences among POAG, NTG, and OH eyes. The mean values for cup area, cup volume, mean RNFL thickness, and RNFL cross section area showed significant differences between POAG and NTG eyes, and NTG and OH eyes, however, not between POAG and OH eyes. Cup shape measure showed significant differences between POAG and OH, and NTG and OH eyes, but not between POAG and NTG eyes.Conclusions Our results suggest that POAG is distinguishable from NTG and OH based on evaluations of rim area and rim volume. Patients with NTG tend to have larger cupping, smaller rims, and thinner retinal nerve fiber layers as compared to POAG and OH patients. Thus, HRT topographic parameters are useful to differentiate patients with POAG, NTG, and OH.