管状视野晚期青光眼复合式小梁切除术的效果观察

目的探讨管状视野晚期青光眼复合式小梁切除术的效果。方法对78例（93眼）晚期原发性青光眼行复合式小梁切除术，术中应用0．2mg／mL的丝裂霉素及巩膜瓣可拆除缝线技术。结果术后平均随访18月（7～60月），术后6月眼压〈21mmHg者86眼（92.47％），眼压〈15mmHg者72眼（77.42％）（1mmHg=0．133kPa），无严重术中术后并发症发生。结论复合式小梁切除术是治疗管状视野晚期青光眼的有效方法，能较好地保存残存的视功能。     

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。     

复合式小梁切除术联合睫状体冷凝治疗晚期新生血管性青光眼

目的探讨复合式小梁切除术联合睫状体冷凝治疗晚期新生血管性青光眼的疗效。方法晚期新生血管性青光眼16例（16眼）．一次性施行180°睫状体冷凝联合复合式小梁切除术．观察术后眼压、新生血管消退情况及手术并发症。结果术后随访6—48个月,视力均无明显改善,平均眼压自（57．48±10．00）mmHg降至（12．46±4．36）mmHg,控制在21mmHg以下者13眼（占80．12％）,手术眼压控制较好。结论一次性施行复合式小梁切除术联合睫状体冷凝对晚期新生血管性青光眼有较好的长期疗效。     

青光眼滤过手术失败后复合式小梁切除术的疗效分析

目的探讨青光眼滤过手术失败后行复合式小梁切除术的治疗效果。方法采用复合式小梁切除术对青光眼小梁切除术失败的40例（58眼）进行再次手术（复合式小梁切除术）治疗。术后随访16-26月。结果手术前平均眼压为（36.62±9.02）mmHg,术后眼压平均为（10.21±4.12）mmHg。治疗前后平均眼压的差异有统计学意义（P〈0.05）。再次手术51眼（87.93%）获得成功。52眼（89.66%）为功能性滤泡。结论青光眼滤过手术失败后采用复合式小梁切除术进行治疗效果良好。     

虹膜光凝联合复合式小梁切除治疗新生血管性青光眼

目的评价倍频532激光虹膜表面新生血管光凝术联合复合式小梁切除术治疗新生血管性青光眼的效果。方法对31例（32只眼）新生血管性青光眼先用倍频532 nm激光封闭虹膜表面新生血管,1～d天后再行复合式小梁切除术。结果术后随访半年,27例（28只眼）眼压控制在21 mm Hg以下,有效率达85.71%。结论倍频532激光虹膜光凝联合复合式小梁切除术是治疗新生血管性青光眼较为满意的方法。     

小梁切除术后视盘形态学变化

目的研究小梁切除术后视盘的形态学变化,探讨眼压降低导致这种改变的临床意义。方法对19例(20眼)原发性青光眼患者行小梁切除术。采用海德堡视网膜断层扫描仪II型(HRT-Ⅱ)分析视盘的形态学改变,并检查视力、眼压、滤过泡、渗漏、前房深度等情况。结果术前及术后1周眼压分别为(36.83±14.10)mmHg(1kPa=7.5mmHg)和(12.00±5.05)mmHg,二者比较差异有显著统计学意义(P=0.000);术前及术后1周,杯盘面积比分别为0.666±0.212和0.574±0.236(P=0.001),术后明显缩小,缩小百分比为13.81%;与术前相比,术后1周盘沿面积和盘沿容积显著增大(均为P=0.001),分别增大了26.18%和47.93%;视杯形态测量值、视杯高度变异轮廓值、视网膜神经纤维层厚度与术前比较差异均无统计学意义(均为P>0.05)。眼压变化与上述参数变化无明显相关性(均为P>0.05)。结论眼压的大幅度下降可能是导致杯盘面积比变小、盘沿面积及容积增大的重要原因之一,而视网膜神经纤维层厚度尚未发生明显改变,视神经纤维可能未继续受到损害。     

原发性开角型青光眼视神经损害进展与眼压波动及视盘旁萎缩弧扩大的关系

目的 分析原发性开角型青光眼（POAG）视神经损害进展的相关危险因素。设计 回顾性病例系列。 研究对象 北京同仁医院眼科门诊确诊的POAG、随访3年以上、眼底照片及眼压资料完整的患者115例（197眼）。方法 将患者初次就诊和末次就诊的眼底图片在计算机图像处理软件下进行图像配准,通过叠加闪烁对比观察眼底病变的细微改变。平均随访（56.6±14.8）个月。青光眼视神经损害进展的标准为盘沿丢失进展或伴有视网膜神经纤维层缺损进展。主要指标 可能导致青光眼视神经损害进展的多因素Logistic回归分析。结果 视神经损害进展98眼,未进展99眼,进展率49.75%。单因素Logistic回归分析显示视神经损害进展与眼压波动（P=0.000）、峰值眼压（P=0.001）及随访时间（P=0.041）有关;卡方检验显示视神经损害进展与盘沿出血（P=0.02）及视盘旁萎缩弧扩大（P=0.000）有关。多因素Logistic 回归分析显示视神经损害进展与眼压波动（P=0.000）及视盘旁萎缩弧扩大（P=0.000）有关。视神经损害进展组与未进展组相比,眼压波动明显大,前者眼压波动值平均为（2.87±1.29）（0.89～7.21）,后者眼压波动值平均为（2.11±0.94）（0.25～4.97）;并且视盘旁萎缩弧扩大的比例明显增高,视神经损害进展组无β区萎缩弧者5眼（5.1%）,有β区萎缩弧扩大者75眼（76.53%）。结论 除峰值眼压外,过大的眼压波动及β区萎缩弧扩大是POAG视神经损害进展的重要危险因素。（眼科,2012,21：39-42）     

HRT-Ⅱ监测POAG复合小梁切除术后视盘主要参数变化

目的：通过海德堡共焦激光眼底扫描仪(HRT-Ⅱ) 随访监测不同病程的原发性开角型青光眼(POAG)患者术后视盘结构参数的变化,评价HRT-Ⅱ在抗青光眼术后随访的可行性。 方法：对20例20眼POAG行复合小梁切除术,其中早期8眼、进展期及晚期12眼,术后眼压控制稳定不需联合药物治疗,术后随访2a,分别于术后3,6,12,24mo行HRT-Ⅱ扫描。 结果:早期、进展期及晚期20眼视盘结构主要参数视杯/视盘面积比(C/D)、 盘沿面积(RA) 、平均视网膜神经纤维层厚度(mRNFL) 手术前后比较差异有统计学意义（P＜0.05）,视盘上下象限mRNFL厚度手术前后比较差异有统计学意义（P＜0.05）。 结论：HRT-Ⅱ应用于POAG患者术后随访监测是一种客观的观察方法,具有高度可重复性、客观性。     

青光眼患者小梁切除术后视盘及其周围血流密度的变化

目的　应用光学相干断层扫描血管成像（optical coherence tomography angiography,OCTA）观察青光眼患者小梁切除术后视盘和视盘周围血流密度的变化。方法　前瞻性纳入确诊为原发性青光眼并顺利完成现代复合小梁切除术的34例（52眼）患者为研究对象。对所有患眼术前及术后1周行眼压、OCT和OCTA等检查。观察手术前后患眼的眼压、视网膜神经纤维层（retinal nerve fiber layer,RNFL）厚度、神经节细胞复合体厚度、C/D值及视盘整体血流密度、视盘周围血流密度、视盘周围不同区域血流密度的变化。结果　术后1周眼压为（10.88±4.26）mmHg（1 kPa=7.5 mmHg）,与术前的（19.88±5.22）mmHg相比,差异具有统计学意义（P=0.002）。术后1周患眼C/D值、RNFL厚度和神经节细胞复合体厚度与术前相比,差异均无统计学意义（均为P>0.05）。术后1周视盘整体血流密度和视盘周围血流密度分别为（50.73±5.74）%和（42.77±4.32）%,与术前的（49.34±7.27）%和（39.38±2.75）%相比,差异均有统计学意义（P=0.028、0.021）。术后视盘周围鼻上、鼻侧、鼻下、颞侧和颞下血流密度与术前相比,差异均无统计学意义（均为P>0.05）;颞上血流密度术前及术后1周分别为（42.72±6.89）%和（43.09±6.83）%,差异有统计学意义（P=0.033）。术后视盘整体血流密度和视盘周围血流密度的增加仅与术后眼压下降值有关,与年龄、术前眼压、C/D值、神经节细胞复合体厚度及RNFL厚度均无相关性。结论　青光眼患者小梁切除术后OCTA检查提示,随着眼压的下降,视盘区整体血流密度以及视盘周围血流密度显著增加。     

高眼压下青光眼的手术治疗

目的探讨高眼压下行青光眼复合式小梁切除术的疗效.方法对33例(33只眼)应用药物不能控制眼压的青光眼患者,采取术中先缓慢降压的方法,进行复合式小梁切除术.结果术后视力提高20只眼,占60.61%,视力不变8只眼,占24.24%;术后眼压控制≤21mmHg21只眼,占66.67%,局部用药可控制者9只眼,占27.27%.结论对药物不能有效控制眼压的青光眼患者,在高眼压下采取必要措施,进行复合式小梁切除术是可行的.     

Changes in optic disc parameters after intraocular pressure reduction in adult glaucoma patients.

PURPOSE: To quantitatively evaluate the change in the optic disc topographic parameters associated with reduction in the intraocular pressure (IOP) after trabeculectomy in adult patients with glaucoma. METHODS: A series of 22 patients (mean age: 45.7+/-15.1 years) with several types of glaucoma were examined for various parameters of optic disc before and after trabeculectomy. Cup area, cup-to-disc area ratio, cup volume, rim volume, mean cup depth, and maximum cup depth were determined by means of laser scanning tomography (LST), and the parameters were correlated with the degree of postsurgical IOP decrease. RESULTS: The IOP in adult glaucoma patients showed significant reductions after trabeculectomy. The values for all topographic parameters examined. except cup volume, showed statistically significant postsurgical changes as compared to the presurgical values. Of all postsurgical changes in parameters. the increase in the rim volume was the most noticeable; it was remarkably evident in those eyes with postsurgical IOP levels less than 15 mm Hg. It was also demonstrated that the anterior displacement of the glaucomatous cupping may occur after surgery. CONCLUSIONS: It is obvious that optic disc parameters can change after IOP reduction after successful surgery in adult glaucoma patients as well as in infantile glaucoma patients. The site of changeable glaucomatous optic cupping is topographically variable among patients and it may be related to the presurgical shape of the optic cup.     

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.     

Quantitation of optic disc cupping

In population-based studies and in clinical practice a reliable, objective measure of optic disc cupping is needed. This measure is of special importance when following patients with diagnosed or suspected glaucoma. We have developed a new system using stereoscopic fundus photographs for quantitating optic disc cupping from these photographs. Measurements of the cup are based on cup contour. For this system, measurements of longest and shortest cup and longest and shortest disc diameters by two observers were highly correlated, with correlation coefficients of 0.88, 0.88, 0.77, and 0.82, respectively. Mean cup to disc ratios for long and short disc diameters were within 0.04 (n = 330) between the two observers. The measurements show a high degree of inter- and intra-observer reliability, and are inexpensive in time and materials to perform. This method is well suited to population-based studies.     

Automated segmentation of the optic disc from stereo color photographs using physiologically plausible features

PURPOSE: To evaluate a novel automated segmentation algorithm for cup-to-disc segmentation from stereo color photographs of patients with glaucoma for the measurement of glaucoma progression. METHODS: Stereo color photographs of the optic disc were obtained by using a fixed stereo-base fundus camera in 58 eyes of 58 patients with suspected or open-angle glaucoma. Manual planimetry was performed by three glaucoma faculty members to delineate a reference standard rim and cup segmentation of all stereo pairs and by three glaucoma fellows as well. Pixel feature classification was evaluated on the stereo pairs and corresponding reference standard, by using feature computation based on simulation of photoreceptor color opponency and visual cortex simple and complex cells. An optimal subset of 12 features was used to segment all pixels in all stereo pairs, and the percentage of pixels assigned the correct class and linear cup-to-disc ratio (LCDR) estimates of the glaucoma fellows and the algorithm were compared to the reference standard. RESULTS: The algorithm was able to assign cup, rim, and background correctly to 88% of all pixels. Correlations of the LCDR estimates of glaucoma fellows with those of the reference standard were 0.73 (95% CI, 0.58-0.83), 0.81 (95% CI, 0.70-0.89), and 0.86 (95% CI, 0.78-0.91), respectively, whereas the correlation of the algorithm with the reference standard was 0.93 (95% CI, 0.89-0.96; n = 58). CONCLUSIONS: The pixel feature classification algorithm allows objective segmentation of the optic disc from conventional color stereo photographs automatically without human input. The performance of the disc segmentation and LCDR calculation of the algorithm was comparable to that of glaucoma fellows in training and is promising for objective evaluation of optic disc cupping.     

The effect of the intraocular pressure reduction on glaucomatous disc changes and visual field defects]

The authors prospectively studied changes in the optic disc and visual field associated with intraocular pressure (IOP) reduction for one year after surgery in 12 primary open-angle glaucoma eyes of 7 patients who underwent trabeculectomy because of elevated IOP despite maximum tolerable medical therapy and whose cup volume was demonstrated to be decreased at 3 or 6 months after surgery. Topographic parameters including C/D ratio, rim area and cup volume were determined by the Optic Nerve Head Analyzer plus (Rodenstock). The 30-2 central threshold field was obtained with a Humphrey Field Analyzer at the same time. Mean deviation (MD), corrected pattern standard deviation (CPSD) and total deviation (TD) were used to evaluate visual field changes. Significant improvement of C/D ratio, rim area and cup volume and significant IOP reduction were noted at 1 year after surgery as compared with preoperative baseline value (p less than 0.01). Also the MD was significantly decreased at 1 year after surgery, compared with the preoperative baseline value (p less than 0.05). There was a significant negative correlation between the preoperative MD and the percent change of the MD at 1 year after surgery (r = -0.80, p less than 0.01). Our results suggest that the decrease of optic disc cupping can persist over one year after surgery and that the early visual field defects in glaucoma eyes can gradually improve in association with the decrease of cupping.     

Acquired peripapillary changes and progression in glaucoma

In a review of fundus photographs, changes in the degree of depigmentation or atrophy of the retinal pigment epithelium (RPE) were observed near the disc over time in 21% of cases with progressive glaucomatous cupping, but they also occurred as a natural phenomenon over time in 4% of eyes with nonprogressive glaucoma and in 3% of nonglaucomatous eyes. Thus, the peripapillary RPE shows some progressive alteration in normal individuals, but also may sometimes suffer along with the axons during glaucomatous damage. The acquired changes observed in the progressive glaucomatous eyes seem too small and too infrequent to account for the high prevalence of large haloes and crescents seen around the optic disc in glaucoma.     

Optic disc morphology after arteritic anterior ischemic optic neuropathy

OBJECTIVE: To evaluate the appearance of the nerve head in patients after giant cell arteritis-induced arteritic anterior ischemic optic neuropathy (A-AION). DESIGN: Noncomparative clinical case series. PATIENTS: The study comprised 29 patients who presented with unilateral A-AION and temporal artery biopsy-proven giant cell arteritis. Stereoscopic optic disc photographs, taken of both the affected and unaffected eyes at the onset of the disease and after a follow-up period of 20.10 +/- 25.36 months (median, 11 months; range, 2-102 months), were morphometrically evaluated. MAIN OUTCOME MEASURES: Size and shape of the optic disc, neuroretinal rim, optic cup, and alpha and beta zones of parapapillary atrophy. RESULTS: In the eyes after A-AION, at the end of the study, the neuroretinal rim was significantly (P = 0.002) smaller, and the optic disc cup area was significantly (P = 0.001) larger than those of the contralateral unaffected eyes. Alpha zone and beta zone of parapapillary atrophy did not vary significantly (P > 0.50). CONCLUSIONS: A-AION, like glaucomatous optic neuropathy, results in neuroretinal rim loss and optic disc cupping. However, in contrast to glaucoma, A-AION is not associated with an enlargement of parapapillary atrophy. The reasons and mechanisms responsible for these similarities and dissimilarities are discussed. Marked clinical, morphologic, and histopathologic similarities in optic disc cupping and loss of neuroretinal rim between A-AION and glaucomatous optic neuropathy are highly suggestive of a common mechanism for the development of the two diseases (i.e., ischemia of the optic nerve head). The subject is discussed at length.     

Characteristics of Reversal Optic Cupping in Adults Glaucoma after Reduction of Intraocular Pressure

Purpose:According to Quigley‘s hypothesis the dense of connective tissue is the least and the pores of the lamina cribrosa are the largest at the superior and infe-rior poles of the lamina cribrosa,therefore they are the most vulnerable location to be involved in the characteristic glaucomatous optic nerve damage,To get clin-ical evidence for the hypltheses,the reversal of optic cup in adults glaucoma after reduction of intraocular pressure(IOP)was examined.Methods:The stereoscopic flicker comparison on with computerized image sys-tem was used to monitor the optic cup‘s changing,2 serial superposed stereo pairs were displayed alternatively and rapidly and the changing parts appeared moving Under the stereoscopic observation ,hthe changes of 3-dimention optic cup could be seen and the false positive phenomena caused by photographic angle variation,vascular pulsation could be differentiated from the characteristic change of the cup.Stereo fundus photographs were taken from 31eyes with hy-pertension glaucoma before and after treatment of reduction of IOPs which was either diamox administration or trabeculectomy.Results:the result showed that the reversal of optic cups after reduction of IOPs were mostly asymmetrical,especially at the inferior and/or superior poles.By multiple stepwise regression.it is known that the amount of the change is only correlated with the initial elevated IOP.Conclusions:The study indicated that it was the distortion and deformity of the lamina cribrosa leading to shearing stress that results in glaucomatous character-istic damage in structure and function.The individul tolerance of the lamina cribrosa to the high intraocular pressure and the locations of indivdual vulnerable at he optic nerve head are various.Eye Science1995;11:155-160.     

The lamina cribrosa and visual field defects in open-angle glaucoma

Two types of lamina cribrosa, one with the classic dot-like openings and the other with striate openings, were seen in 71 pairs of optic disc photographs from patients who had chronic open-angle glaucoma, were suspected to have glaucoma or had normal eyes. Of the 11 eyes with a striate pattern 64% showed glaucomatous visual field defects, whereas of the 60 eyes with a dot pattern only 12% showed such defects, a highly significant difference (p less than 0.001); when patient age and ratio of the vertical diameters of the optic cup and disc were controlled the difference remained significant (p = 0.0402). The striate pattern was also significantly associated (p less than 0.05) with a large optic cup (vertical cup/disc ratio 0.7 or greater).