青光眼的中医药治疗

青光眼是一组以特征性视神经萎缩和视野缺损为共同特征的疾病，是一种常见的不可逆性致盲眼病，其致盲率为10%。青光眼长期以来一直被认为是神经以外的因素导致的视神经疾病。最普遍认为的危险因素是眼压。但是，许多青光眼病人即使眼压已降至正常，患者的神经损害仍在继续；另外，六分之一的青光眼患者虽没有眼压升高，却也存在青光眼性视神经损害。因此，青光眼的发病尚有许多未知的原因。     

谁动了我的视神经？ -正常眼压性青光眼视神经损害探因

正常眼压性青光眼和高眼压原发性开角型青光眼是一个“连续体”。本文基于病理生理学,探讨了正常眼压性青光眼中眼压与视神经损害的关系,认为视盘筛板是上述关系及其“连续体”概念的中间环节,眼压和筛板共同构成青光眼视神经损害的始动因素。（眼科,2020, 29： 87-89）     

青光眼性视神经损害的成因及其防治（二）

第二部分:保护青光眼视神经功能的研究,一、保护青光眼患者视功能的根本方法——降低眼压从青光眼性视神经损害的成因方面考虑,眼压是重要的因素。临床发现,青光     

重新认识"正常眼压性青光眼"

正常眼压性青光眼(NTG)几乎是青光眼领域里最难以诊断的疾病,难点在于青光眼性视神经病变(GON)的症状和体征缺乏特异性,因此对NTG的重新认识实际上是对GON的重新认识。NTG虽然具有GON的表现,但其发病机制与眼压并无明确的关系,而一些病理因素引起的放射状视盘周围毛细血管网(RPCs)血流异常或轴浆流异常等所导致的...     

青光眼的视神经保护

青光眼是一种以特征性视野缺损、视盘凹陷病理性扩大为特点的致盲性眼病。到目前为止 ,青光眼的发病机理尚未完全明了。在众多的危险因子中 ,高眼压被认为是最重要的危险因素 ,该因素通过压迫筛板处的视神经纤维直接损害视神经和 /或影响视盘微循环间接损害视神经。虽然部分患者在整个病程中没有高眼压的表现 ,仍不能排除眼压在发病过程中的作用。因此 ,现有的治疗主要是以药物、手术或两者联合的途径降低眼压。眼压适当控制后 ,大部分患者的视功能损害能得以控制 ,但即使眼压低至 5～10mmHg仍有部分患者的青光眼性视野、视神经损害继续发…     

低颅压与正常眼压性青光眼的关系

青光眼作为导致人类不可逆性盲的头号杀手,是一组慢性进行性视神经病变疾病。虽然病理性眼压增高是青光眼发展的主要危险因素,但是其视神经病变机制始终不明。而且有部分患者眼压处于正常值范围内,却依然发生了青光眼性视神经损害,被称为“正常眼压性青光眼”。因此,我们不得不考虑,除眼压外还有其他因素参与青光眼视神经的损害。近年来有研究表明:颅内压与眼压的失衡有可能是正常眼压性青光眼的原因之一,本文就颅内压与正常眼压性青光眼的关系做一综述。     

关于青光眼定义之商榷

试图提出一个与目前研究及认识水平相适应的青光眼定义，即“青光眼是由于病理性高眼压以及其他相关因素，引起进行性视神经损害，导致视乳头进行性凹陷性萎缩和视功能、特别是视野损害的一类眼病”。定义强调4点：①视神经对眼压的耐受性有较大的个体差异；②眼压升高的机械压迫和血供障碍共同参与了青光眼的视神经损害，病理性高眼压是主要因素；③青光眼性视神经损害，导致眼底改变的特点是视乳头进行性凹陷性萎缩；④在青光眼性视功能损害方面，视野改变是主要的且具有特征性。本文从眼压、眼底、视野、青光眼视神经损害机制以及视神经保护五个方面对青光眼定义进行了阐述。用比较简明的语言揭示了青光眼的内涵，提出较为全面、科学的青光眼定义。     

正常眼压性青光眼的诊断和病因研究

眼压在青光眼的发病中是一个极其重要的因素 ,对于有些青光眼患者 ,眼压虽然在正常范围内 ,却发生了典型的青光眼视神经及视野损害 ,称为正常眼压性青光眼 (norm al tension glaucoma,NTG或 normal pressureglaucoma,NPG)。本文就正常眼压性青光眼的有关诊断及病因问题作一综述。     

颅内压与青光眼及其无创测量技术的研究进展

青光眼是世界上第二位致盲性眼病,第一位不可复性致盲性眼病。尽管眼压增高被认为是青光眼性视神经损害的主要危险因素,但是50%的原发性开角型青光眼患者的日常眼压正常,还有一些患者尽管眼压控制良好,但青光眼性视神经损害仍继续发展。这些现象无法用高眼压理论来解释,青光眼患者视神经损害的发病机制仍待探讨。目前国内外的一些研究表明：（1）视神经周围的生物力学的解剖结构包括眼内压,筛板和球后的脑脊液压力在原发性开角型青光眼的发病机制中发挥重要的作用;（2）正常眼压性青光眼患者的脑脊液压力比正常人低,而跨筛板压力差比正常人高;（3）高眼压症患者的脑脊液压力比正常人群高,而跨筛板压力差和正常人之间没有统计学意义。基于以上研究,本文就颅内压与青光眼性视神经损害之间关系的相关研究进展及临床上可行的无创颅内压测量方法作一综述。     

前部视神经微循环环异常与青光眼

18 5 7年 Von Graefe[1 ]描述青光眼为一视盘凹陷的黑朦 ,同时可伴有眼压的明显增高、轻度增高或甚至并不增高。然而 ,他仍然认为青光眼是一种眼压增高的疾病。至 1892年Schnabel首次提出视盘萎缩凹陷 ,而无眼压增高 ,也可以认为是青光眼病。自 190 5年 Schiotz[2 ]发明压陷式眼压计之后 ,大多数诊断检查集中于测量眼压 ,长期以来眼压被认为是青光眼的危险因素。最近被人们热衷研究的正常眼压青光眼(NTG )或低眼压青光眼 (L TG ) ,与原发性开角型青光眼(POAG)相似 ,都是属于开角型青光眼 ,具有相似的青光眼性视神经病变和视野缺损。虽…     

Glaucomatous-Like Cupping Associated with Slow-Growing Supra-Sellar Intracranial Lesions

Purpose: To demonstrate that slow-growing intracranial suprasellar mass lesions can be associated with optic disc cupping, clinically indistinguishable from glaucomatous optic neuropathy. Cases: At a neuro-ophthalmology tertiary clinic, a retrospective chart review identified four patients of presumed normal tension glaucoma and supra-sellar tumors. In all four patients with normal intraocular pressure, the appearance of the optic disc resembled typical glaucomatous optic nerve damage with disc cupping and parapapillary atrophy. Conclusion: In few patients, typical glaucomatous abnormalities of the optic nerve head may occur in association with slow-growing suprasellar tumors.     

Optic disc haemorrhages and vascular abnormalities in a glaucoma population

Purpose: To retrospectively examine the optic disc photographs of a glaucoma population for optic disc haemorrhages, vascular occlusions and vascular abnormalities. Methods: The optic disc photographs of 906 eyes of glaucoma and suspect glaucoma patients were examined. Optic disc photographs were taken annually, where possible, with the follow-up period varying between 1 and 14 years duration (mean, 2.89). Glaucoma patients are regularly reviewed every 4–6 months and glaucoma suspects every 1–2 years, depending on the ophthalmologist. Low-tension glaucoma patients were reviewed more frequently (mean, every 2.6 months). The results of the findings were compared to a control group of 39 subjects with a mean follow-up period of 7 years, using Fisher's exact test. Results: It was found that during the period under review, 7.4% (n= 67) of eyes had optic disc haemorrhages. The highest frequency of optic disc haemorrhages (37.5%) was found in the low tension glaucoma group (P= 0.0001) followed by 11.4% of primary open-angle glaucoma eyes (P= 0.03). In the normal group there were three eyes with optic disc haemorrhages and one with a disc collateral, which constitutes 5.1% vascular changes in this sub-group. Of the study eyes 2.8% had central retinal vein occlusions, 1.3% branch vein occlusion, 1.2% disc vessel abnormalities (loops) and 1.1% disc collaterals. Discrete nerve fibre layer haemorrhages and microaneurysms were found in 0.8% and 1.8% of eyes, respectively. Conclusions: A total of 16.8% of the eyes observed in this study had either disc haemorrhages or vascular changes. The underlying trend of vascular and haemorrhagic changes in glaucoma are demonstrated in this sample, which is in general agreement with previous studies. The high percentage of optic disc haemorrhages in low tension glaucoma is highlighted. The presence of microaneurysms and nerve fibre layer haemorrhages is interesting but of unknown significance.     

Preperimetric glaucoma diagnosis by confocal scanning laser tomography of the optic disc

AIM: To evaluate the ability of confocal scanning laser tomography of the optic nerve head to detect glaucomatous optic nerve damage in ocular hypertensive eyes without visual field defects. METHODS: The study included 50 normal subjects, 61 glaucoma patients with glaucomatous changes in the optic disc and visual field, and 102 "preperimetric" patients with increased intraocular pressure, normal visual fields, and glaucomatous appearance of the optic disc as evaluated on colour stereo optic disc photographs. For all individuals, confocal scanning laser tomographs of the optic nerve head were taken using the Heidelberg retina tomograph (HRT; software 2.01). RESULTS: Almost all investigated HRT variables varied significantly (p < 0.05) between the normal eyes and preperimetric glaucoma eyes with pronounced overlap between the two study groups. Corresponding to the overlap, sensitivity and specificity values were relatively low when HRT variables were taken to differentiate between normal and preperimetric glaucoma eyes. At a given specificity of 95% highest sensitivities were found for the variables "rim area in the superior disc sector" (24.8%), "nerve fibre layer thickness in the inferior disc sector" (26.5%), and "rim volume in the superior disc sector" (25.5%). A multivariate approach increased sensitivity to 42.2% at a given specificity of 95%. For the glaucoma group highest sensitivity values were reached by rim volume in the superior disc sector (73.8%) and rim area (72.1%); the multivariate approach reached 83.6%. CONCLUSIONS: Owing to pronounced overlapping between the groups, confocal scanning laser tomography of the optic nerve head has relatively low diagnostic power to differentiate between normal eyes and preperimetric glaucoma eyes. One of the reasons may be the biological interindividual variability of quantitative optic disc variables.     

Period prevalence and incidence of optic disc haemorrhage in normal tension glaucoma and primary open-angle glaucoma

Background: To investigate and compare the period prevalences and incidences of optic disc haemorrhages in normal tension glaucoma and primary open‐angle glaucoma. Design: Hospital‐based retrospective study. Participants: Four hundred and four patients with normal tension glaucoma and 210 patients with primary open‐angle glaucoma that underwent consecutive disc examinations at least quarterly for at least 1 year and stereoscopic optic disc photographs at intervals of 6 to 12 months between 1992 and 2007. Methods: The period prevalence of disc haemorrhages, gender predominance among patients with disc haemorrhage, and cumulative incidence of normal tension glaucoma and primary open‐angle glaucoma were compared. Main Outcome Measures: Period prevalence, cumulative incidence, and gender predominance of DHs in patients with NTG and POAG. Results: Three hundred and eighty‐seven patients (387 eyes) of normal tension glaucoma patients and 205 patients (205 eyes) of primary open‐angle glaucoma patients were finally enrolled in the study. The period prevalence and incidence rates of the stereoscopic optic disc photograph‐confirmed glaucomatous disc haemorrhages were 33.3% (129/387), 0.46 ± 0.18 times/year in the normal tension glaucoma group, and 17.6% (36/205), 0.34 ± 0.23 times/year in the primary open‐angle glaucoma group, respectively. The absolute values and ratios of primary open‐angle glaucoma and normal tension glaucoma in period prevalences and incidence rates in the present study were higher than in previous studies. No significant difference in gender ratios was found between patients that did or did not develop disc haemorrhage for both types of open‐angle glaucoma (P > 0.05, respectively). Conclusions: The primary open‐angle glaucoma group had higher period prevalences and incidence rates of disc haemorrhage than those reported previously. Disc haemorrhages were found to develop independent of gender.     

先天性视盘发育异常的临床特征及鉴别诊断

目的 对先天性视盘发育异常的类型及临床特征进行分析评价.方法 单中心病例回顾性分析.纳入2013年5～10月在复旦大学附属眼耳鼻喉科医院神经眼科就诊后诊断为先天性视盘发育异常的患者,收集其人口学特征及临床特征进行回顾性分析.采用Humphrey静态自动视野、Goldmann视野、频域相干光断层扫描、眼底自发荧光、头颅磁共振扫描、头颅断层扫描和眼部超声进行辅助检查.结果 诊断为先天性视盘发育异常的患者共25例,其中男性13例;年龄中位数21岁（1～51岁）.受累眼共40只,双眼受累15例、单眼10例.视力从正常至无光感.诊断包括：视神经发育不良3例,节段性视神经发育不良6例,倾斜视盘6例,牵牛花综合征2例,视盘小凹2例,视盘玻璃疣3例,有髓神经纤维2例,视盘缺如合并视盘小凹及黄斑发育不良1例.常见误诊诊断：视神经炎5例,正常眼压青光眼4例,鞍区占位3例,颅高压3例,视盘血管炎2例.结论 先天性视盘发育异常病种繁多,常累及儿童及青年人,视功能损害差异较大.一些隐匿性视神经发育不良误诊率高.正确识别不同类型的视盘先天发育异常有助于临床解读患者的症状、体征和辅助检查结果,避免过度诊疗.     

Is open‐angle glaucoma caused by impaired cerebrospinal fluid circulation: around the optic nerve?

Chronic open-angle glaucoma is the most frequent type of glaucoma and a leading cause for blindness. The role of intraocular pressure (IOP) in the pathogenesis of open-angle glaucoma has been challenged by patients with typical glaucomatous optic disc changes and visual field loss in whom the IOP never exceeded normal values (normal-tension glaucoma), as well as by patients with persistently elevated IOP who do not develop glaucomatous disc or field changes. Recent research has demonstrated that the cerebrospinal fluid (CSF) is not evenly distributed in all CSF spaces and that the subarachnoid space of the optic nerve can turn into a CSF compartment on its own. The biochemical components in this optic nerve compartment can differ markedly from normal CSF and some of its components (such as L-PGDS) may produce a toxic effect on the optic nerve and may therefore play an important role in the pathophysiology of open-angle glaucoma.     

Parameters associated with papillomacular bundle defects in glaucoma

To evaluate the relationship between the papillomacular bundle defect and glaucoma types, abnormalities of the optic disc, distance between the disc and foveola, and axial length, we examined one eye of 82 patients with normal tension glaucoma, 117 patients with chronic high tension glaucoma, and 102 controls. Two types (diffuse and focal types) were found in the papillomacular bundle defect, and the former predominated. Eyes with a long axial length (P<0.01), a diagnosis of normal tension glaucoma (P < 0.05), or a large optic disc (P<0.05) tended to have diffuse-type papillomacular bundle defects, while eyes with a short axial length, a diagnosis of high tension glaucoma, or a large ovalness index are less likely to have it. Thus, a long axial length, a large optic disc, and normal tension glaucoma are risk factors for the diffuse-type papillomacular bundle defect. Correspondence to: E. ChiharaThis study was supported by a grant-in-aid B-02454403 for Scientific Research from the Ministry of Education Science and Culture of Japan     

海德堡视网膜断层扫描仪测量正常人视盘参数

目的 :建立正常人群海德堡视网膜断层扫描仪 (Heidelbergretinatomograph ,HRT)视盘参数的正常值 ,明确哪些因素对正常人HRT视盘参数有影响。方法 :选用 10 2例 (13 2只眼 )正常人 ,用HRT进行视盘扫描 ,视盘参数包括视盘面积、视杯面积和容积、盘沿面积和容积、视杯形态、视杯平均深度和最大深度、杯 /盘面积比、沿 /盘面积比、平均视网膜神经纤维层(retinalnervefiberlayer,RNFL)厚度和横截面积、水平C/D和垂直C/D。计算正常人视盘参数范围 ,用直线回归的方法判断视盘大小和年龄对视盘参数的影响。结果 :正常人左右眼和男女间视盘各参数差异无显著意义 (P >0 0 5)。年龄与RNFL厚度及横截面积呈负相关 ,相关系数分别为 -0 2 3 4和 -0 2 3 5,其余各参数与年龄无关。盘沿容积和视杯最大深度不受视盘大小的影响 ,其余各参数均与视盘大小呈线性相关。结论 :HRT可定量检测正常人视盘参数 ;正常人视盘参数变异很大 ,盘沿容积不受视盘大小的影响 ,是一个区分正常与早期青光眼的很好的参数     

Cupped disc with normal intraocular pressure: the long road to avoid misdiagnosis

We present a series of six patients who had been receiving treatment for normal tension glaucoma (NTG; five patients) or primary open angle glaucoma (one patient). All of them were found to have optic neuropathy secondary to compression of the anterior visual pathway. Even though uncommon, compression of the anterior visual pathway is an important differential diagnosis of NTG. Diagnosis of NTG should be by exclusion. Here the possible causes of misdiagnosis are discussed. We present an approach to distinguish glaucomatous from nonglaucomatous optic neuropathy. The article also emphasizes how important it is for the clinicians to consider the total clinical picture, and not merely the optic disc morphology, to avoid the mismanagement of glaucoma, especially the NTG.     

HRT视盘参数在原发性开角型青光眼早期诊断中的作用

目的:在众多海德堡视网膜断层扫描仪(heidelberg retina tomogragh,HRT)测定的视盘参数中,筛选出最有助于青光眼早期诊断的视盘参数。方法:用HRT测定23例视野损害较轻的青光眼患者和23例正常人的视盘参数(杯盘面积比、盘沿面积、盘沿容积、视杯容积、视杯形态测量、视杯高度变异轮廓和平均神经纤维层厚度)作逐步判别分析。结果:盘沿面积和杯盘面积比对青光眼早期诊断最有帮助,其诊断敏感度和特异度分别为87%和96%。结论:本组资料盘沿面积和杯盘面积比是区分青光眼和正常眼最好的判别因素。