对青光眼盘沿及视网膜神经纤维层监视的评价

为了解青光眼盘治及RNFL改变的相互关系，评价各种眼底视神经监测方法的敏感性，本研究采用两种方法进行青光眼视神经的随诊监测，①常规法：并排投影显示法监测盘沿及RNFL的改变，②闪烁法：立体视下图象闪烁比较法监测盘沿的改变，将先后两次照的立体象对校正，交替显示两幅叠加好的立体象对，变化的部分有跳动感。随诊的青光眼、可疑青光眼451例，836只眼，平均随诊期2．8±1．3年。发现有盘沿改变者用常规法仅23例，而用闪烁法高达90例，其局限性、弥漫性最小改变量分别为0．032mm2及0．048mm2。用闪烁法对盘沿的监测与常规法对RNFLD监测的比较，对于局限性改变，采用闪烁法有盘沿丢失28例，其中12例不伴RNFLD的改变，而采用常规法有RNFLD改变者的17例，其中仅1例不伴有盘沿丢失。对于弥漫性改变者，采用闪烁法有盘沿改变的26例，其中不伴RNFLD改变者有20例。采用常规法有RNFLD改变者6例，此6例均伴有盘沿丢失。     

降眼压后青光眼视杯回复性缩小的形态特征

根据Ｑｕｉｇｌｅｙ的学说视神经筛板上、下极区域的结缔组织少、筛孔大最容易导致视神经的青光眼特征性损害。为了获得此学说的临床证据，本研究对降低眼压后回复性缩小的视杯（此变化主要是由于原受压向后膨隆变形的筛板向前回弹致视杯变小）进行监测观察。视杯监测采用立体视下图象闪烁比较法，即交替显示两幅叠加好的立体象对，变化的部分呈跳动感。通过立体镜下的观察，可发现视杯三维的变化，还能鉴别有否照象角度不一致、血管搏动等所致的假阳性。观察对象为高眼压的青光眼，共３ｌ只眼。经服Ｄｉａｒｎｏｘ或行小梁切除术降低眼压，降眼压前后分别拍立体眼底象。结果减压后视杯回弹性缩小不匀称，尤以上、下极回复为主。经多元逐步回归法分析，其改变量仅与初始眼压相关。我们认为：由于视神经筛板结缔组织及筛孔分布上的特点，其耐压力因人而异，因部位而异。正是筛板薄弱区的扭曲、变形所致的剪切力造成青光眼性形态、功能上的损害。     

早期青光眼的盘沿形态学研究

青光眼早期损害的特征是颞下、颞上的视网膜神经纤维层缺损(RNFLD),并于相应区的视野弓形缺损。为了探讨青光眼视神经损害的发生规律,本研究利用计算机图象分析技术,测定一周(每(?)度)的盘沿宽度,以此形态指标分析早期青光眼与正常眼的盘沿形态差异以指导临床诊断,检查对象分两组:①正常对照组183只眼。②早期青光眼组175只眼。结果:正常组盘沿形态特征是下方盘沿宽度较上方宽,颞侧盘沿最窄,鼻侧盘沿最宽;早期青光眼组盘沿形态特征是下方盘沿宽度较上方更窄。用多因素逐步判别法对早期青光眼与正常眼进行判别分类,单纯用盘沿面积为指标,正确判断率为78％;用系列盘沿宽度为指标,经逐步判别筛选,以颞下及上方盘沿宽度最为相关,其正确判断率为94％。因后者除了与盘沿面积大小有关外,还与盘沿形态有关,依据盘沿形态特征有助于鉴别生理性大视杯(①大视盘,②视杯大,但下方盘沿宽于上方),发及发现小视盘青光眼(①小视盘及扩大不明显的视杯,②下方盘沿宽度比上方窄)     

HRT-Ⅱ在青光眼随访中的应用

目的:应用HRT-Ⅱ检测青光眼视神经乳头的形态改变及视网膜神经纤维的丢失,探讨HRT-Ⅱ在青光眼随访中的意义。方法:已确诊的青光眼患者50例63眼纳入本研究,利用HRT-Ⅱ每6～12mo观察视盘及视神经纤维的变化。结果:盘沿面积、盘沿体积、最大视杯深度、平均视网膜神经纤维层(RNFL)厚度、RNFL截面面积等视盘参数前后2次检查结果差异有显著性意义(P<0.05)。结论:HRT-Ⅱ能够快速、可重复性地测量视盘形态及视神经纤维层的改变,并且可以重复分析视盘参数的变化。     

青光眼视乳头杯盘比检查法的探讨

视乳头改变是青光眼早期诊断的一项重要客观依据。目前,多数学者认为青光眼视乳头改变多发生在视野改变之前。青光眼视乳头改变的内容很多,其中较为重要的有:(1)局限性或弥漫性神经视网膜杯沿组织丧失。(2)杯扩大。(3)双眼杯不对称。(4)垂直椭圆杯等视乳头杯盘比(C/D)是临床常用评价青光眼视乳头改变的根据之一。我们以同一检查者不同方法和同一方法不同检查者(均为对     

青光眼视杯逆转的研究进展

先天性青光眼当其眼压获得有效控制时，青光眼视杯可出现可逆性改变。但成年青光眼视杯治疗能否使其逆转目前尚无定论。近年来随着计算机图像分析技术在青光眼诊断中的成功应用，使视乳头测量的精确度大大提高，为青光眼视杯逆转研究提供了客观的先进手段。     

青光眼视杯深度变化及其诊断作用的研究

目的探讨青光眼视杯深度变化规律及视杯深度在青光眼诊断中的作用。方法对正常人116例(116只眼)和原发性开角型青光眼患者63例(99只眼)进行了共焦激光扫描眼底镜(HRT)检查,获得12个视盘相关的参数,选取平均视杯深度(MCD)、最大视杯深度(MxCD)和视杯形态测量(CSM)进行两组间的比较。统计学采用双侧-t检验,方差分析,其在青光眼诊断中的作用采用受试者工作曲线(ROC)分析。结果MCD正常组和青光眼组分别为0.196±0.096mm和0.389±0.167mm;MxCD正常组和青光眼组分别为0.559±0.228mm和0.821±0.253mm;CSM正常组和青光眼组分别为-0.213±0.076mm、-0.056±0.088mm。正常人与青光眼患者间三个参数差异均有统计学意义(P值均为0.000)。正常人MCD和MxCD一般以颞侧最深,青光眼患者则多为上方最深。在诊断分析中,CSM、MCD和MxCD的ROC曲线下面积分别为0.892,0.850和0.757。结论视杯深度随着青光眼视杯的扩大、视网膜神经纤维的丢失逐渐加深,以上方的改变最明显。CSM、MCD和MxCD在青光眼的诊断分析有较重要的作用。     

青光眼视杯逆转的研究进展

先天性青光眼当其眼压获得有效控制时，青光眼视杯可出现可逆性改变。但成年青光眼视杯经治疗能否使其逆转目前尚无定论。近年来随着计算机图像分析技术在青光眼诊断中的成功应用，使视乳头测量的精确度大大提高，为青光眼视杯逆转研究提供了更为客观的先进手段。这对全面揭示青光眼视神经损害发生机制又迈进了一步，将为临床上青光眼的治疗提供新的治疗方法和理论依据。     

青光眼性视杯逆转研究进展

视杯的进行性扩大和加深是评价青光眼视神经损害和监测青光眼进展的一个重要指标。在先天性及青少年青光眼患者中,降低眼内压后视杯的可逆性改变已是公认现象[1,2],但成年青光眼患者的视杯改变是否具有可逆性改变目前尚无定论。随着计算机图像分析技术的迅猛发展及在青光眼诊断和随访中的成功应用,越来越多的研究发现降低眼内压能够成功逆转成年青光眼患者的视盘凹陷。本文主要对青光眼视杯逆转的机制及其影响因素作一概要综述。一、影响青光眼视杯逆转的因素1.眼内压降低的幅度:青光眼视杯能否发生逆转与眼内压的降低及降低的幅度密切相关…     

初期青光眼性视盘和视网膜神经纤维层异常及进展

作者试图识别初期青光眼性视盘和视网膜神经纤维层改变,并分析这些变化后来是如何发展的。在患高眼压症的61例病的61只眼中,23(38％)只眼随访了10年发展为青光眼(5～15年范围内)。青光眼初期损害的体征,23只眼中10只眼视杯广泛性扩大,在23只眼中12只眼有神经纤维层广泛变薄而无局部改变。作者发现,23只眼中10只眼有局限性视盘损害,23只眼中11只眼有局限性视网膜神经纤维层损害,或有广泛性损害相混。23只眼中13只眼,视杯凹陷呈广泛性扩大,在颞上、颞下缘盘沿显著变窄。在眼压升高的病人中,初期青光眼性视盘和神经纤维层异常的表现和发展,其变异性似乎很大。     

Optic Disc Cupping in Arteritic Anterior Ischemic Optic Neuropathy Resembles Glaucomatous Cupping

Five cases of anterior ischemic optic neuropathy secondary to biopsy-proven giant cell arteritis are presented. In each case, cupping of the optic disc, which closely resembled glaucomatous cupping, was observed in the affected eye. The presence of glaucoma was ruled out on the basis of normal intraocular pressures and normal tonographic measurements of facility of outflow. These cases indicate that arteritic ischemic optic neuropathy can result in optic disc cupping, which closely resembles glaucomatous cupping. The similarities in the appearance of cupping of these discs with that seen in eyes with glaucoma suggest that the pathogenesis of cupping in glaucoma and in arteritic ischemic optic neuropathy may share some common mechanisms.     

Measurements of Reversibility of Optic Disc Cupping and Pallor in Ocular Hypertension and Glaucoma

Four cases are presented of young and elderly glaucoma patients who had both surgical and medical therapy and showed reversal of cupping and pallor of the optic disc. The cupping was measured by photogrammetry and the pallor by computerized image analysis from photographs of the optic disc. Two patients showed regression of visual field loss. The optic disc and visual field changes corresponded to the changes in ocular pressures, generally showing worsening with an increase in ocular pressure. With a decrease in ocular pressure there was regression of visual field loss and a decrease in cupping; pallor did not decrease consistently. The changes in cupping and pallor in some patients followed similar courses but in others behaved in an independent manner. It is proposed that these new sensitive and reproducible techniques for measuring changes in the optic disc may allow the detection of disc changes early in the disease, prior to visual field loss. If treatment is begun at this time, reversal of optic disc changes may occur.     

Development of cupping and pallor in posterior ischemic optic neuropathy

A case of arteriosclerotic posterior ischemic optic neuropathy without optic disc edema is described and documented photographically. The development of optic disc cupping and pallor with ischemia in this patient supports the vascular basis for development of similar cupping and pallor in open angle glaucoma and low tension glaucoma.The work for this paper was done while Dr. S. Sonty was a Glaucoma Fellow at Tufts-New England Medical Center.     

Changes in reversal of cupping in experimental glaucoma. Longitudinal study.

BACKGROUND: The authors prospectively and longitudinally studied changes in optic disc topography during spontaneous reduction of intraocular pressure (IOP) in five monkeys with experimental glaucoma, using a computerized image analyzing system (Topcon IMAGEnet). METHODS: Glaucomatous optic neuropathy was produced in one eye of each animal by repeated argon laser photocoagulation of the trabecular meshwork. The duration of follow-up was 12 months. After laser treatment, IOP fluctuated and tended to increase. Spontaneous reduction in IOP was frequently observed during follow-up. Changes in optic disc parameters (vertical and horizontal cup-to-disc ratios, rim area/disc area, cup volume/disc area) that accompanied a given magnitude of spontaneous reduction in IOP at the early stage of glaucoma (first 4 months of follow-up) were compared with those at the later stage of glaucoma (last 4 months of follow-up). RESULTS: All optic disc parameters improved significantly during IOP reduction at each stage of glaucoma. Although there was no significant difference between the two stages in the magnitude of IOP reduction, the extent of improvement in each disc parameter was significantly less in the later stage than in the early stage. In both stages, reversal of cupping occurred symmetrically in the vertical and horizontal dimensions. Expansion of the cup occurred symmetrically in the early stage, but this was predominantly vertical in the later stage. CONCLUSION: These results suggest that the extent of cupping reversal after IOP reduction may decrease with progressive glaucomatous damage in primate glaucoma.     

Morphology of the optic papilla in glaucoma. I. Primary open-angle glaucoma

BACKGROUND: Previous studies have shown that the chronic open-angle glaucomas form a heterogeneous spectrum of diseases which have in common an open anterior chamber angle and glaucomatous optic nerve damage. Purpose of this study was to evaluate whether the appearance of the optic disc differs among the various types of primary open-angle glaucoma. METHODS: Color stereo optic disc photographs of 683 patients with primary open-angle glaucoma (POAG), and 481 normal eyes were morphometrically evaluated. RESULTS: Morphologic characteristics of the glaucoma types were as follows: Highly myopic POAG: secondary macrodiscs with abnormal shape; shallow, flat, concentric disc cupping; low frequency of disc hemorrhages; large parapapillary atrophy or myopic crescent; medium to low intraocular pressure. Juvenile-onset POAG: Optic disc of normal size and shape; deep and steep disc cupping; low frequency of broad rim notches or large disc hemorrhages; small parapapillary atrophy; high minimal and maximal intraocular pressure measurements. Age-related atrophic POAG: Optic disc of normal size and shape; shallow, flat and concentric disc cupping; medium to low frequency of disc hemorrhages; large parapapillary atrophy; medium to low intraocular pressure. Eyes with normal-pressure glaucoma: Optic disc of normal size and shape; deep and steep cupping; relatively small parapapillary atrophy; high frequency of disc hemorrhages and rim notches. CONCLUSIONS: These characteristics in the appearance of the optic disc may be helpful for clinical diagnosis and therapy and may give pathogenetic hints.     

Assessment of diagnostic criteria in management of infantile glaucoma

Background: Infantile glaucoma is characterized by increased intraocular pressure, enlarged corneal diameters, optic disc cupping and typical anamnesis. The aim of our study was to evaluate the validity of diagnostic criteria in differentiating between manifest infantile glaucoma and glaucoma-suspected eyes (e.g. megalocornea). Methods: We retrospectively analyzed consecutive charts of 87 children undergoing ophthalmic examination under general anesthesia because of manifest or suspected glaucoma. At first examination in our clinic age-related differences of diagnostic parameters between 52 children with infantile glaucoma requiring glaucoma-surgery (group A) and 35 glaucoma-suspect children requiring no surgery (group B) were assessed using non-parametric Mann-Whitney U Test. Influence of tonometry, optic disc cupping, and changes of axial length and corneal diameter during the follow-up on our decision for surgery were also investigated. Results: Tonometry, axial length of the eye, optic disc cupping, incidence of corneal opacities and age of onset of symptoms were significantly different in the two groups (p ≤ 0.002) from first through third year of life, whereas corneal diameters were not significantly different in the second and third year of life. Advanced disc excavation (C/D > 0.6) and increased IOP (> 16 mmHg) were significantly associated with the decision to undertake subsequent surgery (p < 0.0001). Changes of corneal diameter and axial length during follow-up showed no significant difference between those glaucoma patients who needed re-operation and those who did not, after the first year of life. Conclusion: Corneal diameters and axial length were helpful in the diagnosis of infantile glaucoma, but of limited use in the follow-up. The decision to undertake surgery was based upon tonometry and optic disc evaluation.     

Cupping of the optic disc with compressive lesions of the anterior visual pathway

Cupping of the optic nerve, classically a sign of glaucoma, was demonstrated in 16 patients with lesions compressing the anterior visual pathway. Color contrast determinations of the cup/disc ratio demonstrated a ratio greater than 0.49 in 31 eyes. Further evaluation by stereobiomicroscopy showed cavernous degeneration by contour changes in 25 of the optic nerves. None of the patients had intraocular pressures greater than 22, and seven had normal tonography. Visual fields demonstrated bitemporal field defects in most patients and none were typical of glaucoma. Snellen acuity loss, out of proportion to the extent of optic disc cupping was found in 12 patients. This study indicates that diseases other than glaucoma can cause significant cupping of the optic nerves. Detailed evaluation of the disc changes and the visual fields will prevent confusion between compressive lesions of the optic nerves or chiasm and glaucoma.     

Optic disc imaging in conscious rats and mice

PURPOSE:To determine whether useful images of the optic discs of conscious rats and mice can be obtained by using a photo slit lamp and a modified Goldmann-type fundus contact lens. METHODS: Testing was performed with a photo slit lamp equipped with two 2x teleconverters and a digital camera through a Goldmann-type fundus contact lens that was fabricated for the rodent eye. RESULTS: Images of the rat and mouse optic discs were obtained that are comparable to those used by ophthalmologists to assess optic neuropathy in glaucoma, a key part of the standard of care and of clinical investigation of this disease. The cup in the optic disc image of these rodents is darker than the neural rim of the disc, rather than lighter, as it is in humans. CONCLUSIONS: In addition to the application of this imaging method to studies of the effect on optic disc cupping of induced increased intraocular pressure in rats and mice, by detecting and documenting the onset and the course of optic neuropathy, it should be valuable in identifying animal models of glaucoma, in studying neuropathogenic mechanisms, and in assessing the effects of experimental therapies.     

Computer analysis of the optic cup in glaucoma

This paper describes two complementary methods for computer analysis of the optic disc in glaucoma. The objective of both techniques is to detect and monitor changes in the optic disc through the use of digital image processing techniques that allow user intervention. In the first method, optic disc photographs from successive years are digitized, scaled and registered (aligned) with each other, and are then displayed in rapid sequence on a television monitor. Changes in the optic cup thus appear as localized movement on the display, while stable regions of the optic cup appear stationary. Both monocular and stereo photographs can be processed by this technique. In the second method, stereo optic disc photographs are digitized and processed by a new, robust, photogrammetric computer algorithm that quantifies optic cup depth information. Together, these two techniques may be valuable for both clinical and research purposes in the detection and monitoring of glaucomatous optic cupping.     

Reversal of optic disc cupping after trabeculotomy in primary congenital glaucoma

BACKGROUND: The phenomenon of reversal of glaucomatous cupping of the optic disc following lowering of the intraocular pressure (IOP) was originally recognized in infants. We evaluated the change in optic disc cupping with normalization of the IOP after trabeculotomy in primary congenital glaucoma and assessed the factors associated with reversal of cupping. METHODS: We reviewed the records of 17 patients (24 eyes) who underwent trabeculotomy between July 1993 and June 1999 and who had been followed for at least 1 year. Surgical success was defined as IOP less than 22 mm Hg without anti-glaucoma medication, stable or reduced optic disc cupping, and lack of further corneal enlargement disproportionate to normal growth. Patients who required more than one surgical procedure to control the IOP and those with cloudy media that precluded documentation of cupping were excluded from analysis. Optic disc cupping was assessed independently before and after surgery by two clinicians. The cup:disc ratio was estimated as the percentage of surface area of the optic disc occupied by cupping in the vertical axis. We accepted a difference of 0.1 or 0.2 in the cup:disc ratio between the two observers in each subjective assessment and used the mean value of the two results for data analysis. If the difference was more than 0.2, the eye was excluded from further study. RESULTS: Of the 17 patients 4 were excluded: 2 because they received antiglaucoma medication to control the IOP postoperatively, 1 because he underwent more than one surgical procedure to control the IOP during follow-up, and 1 owing to disagreement in the assessment of the cup:disc ratio between the two observers. Eighteen eyes of 13 patients were thus included in the analysis. Twelve eyes were from boys and six, from girls. The patients were followed for a mean of 43.2 (standard deviation [SD] 30.4) months (range 12 to 90 months). The mean cup:disc ratios pre- and postoperatively were 0.74 (SD 0.20) and 0.60 (SD 0.21) respectively (p = 0.003). Of the 18 eyes 11 (61.1%) had documented reduction in optic disc cupping. The mean time to stabilization of cupping reversal was 4.8 (SD 2.8) months (range 2 to 12 months). In multivariable analysis the age of the patient at surgery was the only variable significantly associated with reversal of cupping (p = 0.027). The mean age at surgery for the 11 eyes with reduction in cupping was 6.9 (range 3 to 15) months, compared with 23.4 (range 12 to 42) months for the 7 eyes with unchanged cupping. The mean preoperative cup:disc ratio was 0.67 (SD 0.17) in the former group and 0.83 (SD 0.17) in the latter group. Six of the seven eyes with unchanged cupping had advanced cupping. INTERPRETATION: Optic disc cupping can be reversed at an early stage of primary congenital glaucoma following successful reduction of IOP. Younger age at surgery was associated with reversal of cupping.