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。     

Intraocular pressure and central visual field of normal tension glaucoma

AIM—To study whether damage in the central 30° field of normal tension glaucoma (NTG) is relatively heterogeneous or homogeneous with respect to intraocular pressure (IOP) related damage.
METHODS—Using the results of Humphrey perimeter examinations, the central 30° field was divided into four subfields; superior and inferior hemifields excluding the caecocentral field (30-2 program) and superior and inferior 10° hemifields (10-2 program). In 103 NTG cases, the intraindividual bilateral difference in the mean of total deviations (mean TD) in the four subfields was analysed by multiple linear regression to correct the effects of factors other than IOP. Explanatory variables were the intraindividual bilateral difference in the mean of clinic IOP (IOP_mean), that in the ratio of area of peripapillary atrophy corresponding to each subfield to disc area, and that in myopic refraction.
RESULTS—The intraindividual bilateral difference in the mean TD was significantly and negatively correlated with that in IOP_mean in three of the above four subfields (p<0.005) and correlation tended to be negative (p=0.07) in the superior 10° hemifield.
CONCLUSIONS—Diffuse IOP related damage was suggested in the central 30° field of NTG; greater extent of the damage in the above four subfields was correlated with higher mean IOP. The present findings may have clinical implications.

     

Intraocular pressure rise after phacoemulsification surgery in glaucoma patients

PURPOSE: To examine the changes in intraocular pressure (IOP) and the incidence of substantial rises in IOP in the early period after cataract surgery in eyes with open-angle glaucoma (OAG). SETTING: Hayashi Eye Hospital, Fukuoka, Japan. METHODS: The study included 32 eyes of 32 patients with OAG and 31 control eyes of 31 age-matched patients scheduled for phacoemulsification surgery. The IOP was measured preoperatively and 1, 2, 3, 5, 7, 14, and 28 days postoperatively. The incidence of a substantial rise in IOP postoperatively was evaluated, with the criterion being an IOP higher than 30 mm Hg. RESULTS: In the OAG group, the mean IOP increased 1, 2, and 3 days postsurgery and then decreased, whereas in the control group, it decreased from day 1 postsurgery. Although no significant differences were found between groups preoperatively, the mean IOP in the OAG group was significantly higher than in the control group postoperatively. Furthermore, the mean IOP decrease was also less in the OAG group than in the control group. A substantial increase in IOP occurred at day 1 postsurgery in 4 eyes (12.5%) in the OAG group, whereas no eyes in the control group showed such an increase; this difference was significant (P =.0419). CONCLUSIONS: A substantial increase in IOP occurred in an approximately 13% of eyes with OAG 1 day after phacoemulsification surgery. The IOP shortly after surgery was significantly greater in the eyes with OAG than in nonglaucomatous eyes.     

Intraocular pressure elevation and post-DSEK glaucoma after Descemet`s stripping endothelial keratoplasty

Background

Intraocular pressure (IOP) elevation is a common problem in penetrating keratoplasty (PK), and possibly leads to graft failure. IOP elevation and secondary glaucoma may also be present after Descemet`s stripping endothelial keratoplasty (DSEK). This retrospective study analyzes the risk factors for IOP elevation and the functional outcome in those patients with post-DSEK glaucoma.

Methods

A retrospective analysis of case records of 72 DSEKs between 2007 and 2010 was performed. A total of 59 operated eyes were included. The assessment included the pre-operative history of corneal disease and glaucoma. Furthermore, the response to antiglaucoma treatment, the graft failure, the IOP, and visual acuity development were evaluated.

Results

The incidence of IOP elevation was 28.8 % and of post-DSEK glaucoma 11.9 %. Steroid-induced IOP elevation was the most frequent cause, with an incidence of 18.6 %. Patients with pre-existing glaucoma showed a significantly higher risk of developing IOP elevation, steroid-induced glaucoma and post-DSEK glaucoma (p?=?0.006, p?=?0.023, p?=?0.009). In all cases, IOP elevation was treated effectively by tapering down steroid medication and initiating or increasing antiglaucoma medication. Visual acuity after 6 and 12 months improved significantly in cases with and without pre-existing glaucoma (p?<?0.0001). After 24 months, clear grafts were achieved in 53 eyes (89.9 %). There was no significant difference in graft failure rates between cases with or without pre-existing glaucoma (p?=?0.581) and with or without post-DSEK glaucoma (p?=?0.306).

Conclusions

IOP elevation after DSEK shows a high incidence. Pre-existing glaucoma increased the risk of developing IOP elevation and post-DSEK glaucoma. Although steroid-induced IOP elevation was the most frequent cause and could be treated effectively by tapering down steroid medication; there are other reasons why post-DSEK glaucoma developed. Management by medical treatment results in good visual acuity and graft survival.     

Intraocular pressure asymmetry and undiagnosed open-angle glaucoma in an older population

PURPOSE: To quantify prevalence of asymmetric intraocular pressure (IOP) and assess associations with undiagnosed open-angle glaucoma. DESIGN: Population-based cross-sectional study. METHODS: Participants underwent applanation tonometry. Intraocular pressure asymmetry was defined for differences > or = 3 mm Hg; open-angle glaucoma was diagnosed if glaucomatous optic disk and field changes were congruous. Analyses excluded subjects using glaucoma medication, known glaucoma, pseudoexfoliation, and cataract surgery. RESULTS: Intraocular pressure asymmetry was present in 5.1% of subjects and was greater for patients older than 70 years (6.2%). Of subjects with maximum IOP > 21 mm Hg, IOP asymmetry was present in 41.1%. Undiagnosed open-angle glaucoma was more frequent among subjects with (4.8%) than without (1.2%) IOP asymmetry. This relationship remained significant for maximum IOP < or = 21 mm Hg. CONCLUSIONS: Intraocular pressure asymmetry may be a useful sign of undiagnosed glaucoma in subjects without elevated IOP.     

Intraocular pressure and primary open-angle glaucoma. Epidemiologic technics in practice

It is the object of this paper to familiarize the ophthalmologist with some modern epidemiological techniques and to present examples of their application to a consideration of the influence of the level of intraocular pressure on the development of the type of visual field loss characteristic of primary open angle glaucoma. Epidemiological methods are particularly required in chronic multifactorial diseases such as primary open angle glaucoma and arterial hypertension to obtain reliable guidance on practical measures for their treatment or control. Two basic requirements are reliable uniform data suitable for computer manipulation and epidemiological methods to exploit the data and yield conclusions as free of bias and confounding as possible. An example of a glaucoma data base is described and types of enquiry and the importance of standardising prevalence estimations are discussed. Analyses by the four-fold table, risk ratios, the effect of stratification, sensitivity, specifity and the decision curve are described. Attributable risk (potential for prevention) is indicated as yielding information suitable for public health programmes. The life table method is described when relating initial observations to subsequent progressive visual field loss. The factors to be considered in epidemiological work generally and the inferences concerning the early diagnosis of primary open angle glaucoma are discussed.     

Intraocular pressure -- all that is raised is not glaucoma

Increased intraocular pressure invariably sets our mind in the direction of either establishing or ruling out the diagnosis of glaucoma and in the process, sometimes, certain hidden factors may escape our attention, leading to some delay in delivering the specific treatment to the patient. We present a case whose underlying pathology remained obscured for more than 10 years before we examined this patient and discovered the hidden secret.     

Intraocular pressure reduction in normal-tension glaucoma patients in South Korea

To evaluate the potential benefit of intraocular pressure (IOP) reduction in normal-tension glaucoma (NTG) patients in South Korea. A retrospective, multi-center analysis of Korean NTG patients with 5-years follow-up, typical glaucomatous optic disc and/or visual field changes and no recorded IOP >21?mmHg. Progression was identified by Advanced Glaucoma Intervention Study visual field scoring. There were 90 (42%) progressed patients and 127 (58%) stable patients included in the study. Mean IOP measured higher in the progressed (14.3?±?2.2?mmHg) than stable patients (14.0?±?1.9?mmHg), but was not statistically different between the groups (P?=?0.29). The mean IOP that best discriminated stable patients was ≤15?mmHg, but no statistical difference existed in the numbers of progressed versus stable patients at ≤15?mmHg compared to >15?mmHg (P?=?0.07). Multivariate regression analysis showed that the baseline number of glaucoma medicines and visual field as well as mean, peak and fluctuation of IOP were significant risk factors for glaucomatous progression (P?相似文献   

曲伏前列腺素治疗残余性青光眼的疗效

目的:观察曲伏前列腺素对残余青光眼的降眼压效果。方法:对12例14眼残余青光眼患者(21mmHg≤眼压≤30mmHg)滴用曲伏前列腺素滴眼液,每晚1次,共观察3mo,记录用药前、用药后1wk;1,2,3mo的眼压。结果:所有患者用药后降眼压效果明显,3mo内平均降眼压幅度在37.69%～38.44%之间。结论:曲伏前列腺素可以作为残余青光眼眼压不甚高的患者的首选降眼压药物。     

Intraocular pressure control and persistence on treatment in glaucoma and ocular hypertension

BACKGROUND: The purpose of this study was to characterize current patterns of treatment of glaucoma and ocular hypertension and to examine the effect of those patterns on intraocular pressure (IOP) control and persistence on therapy. METHODS: A retrospective chart review was conducted at 3 ophthalmology practices in Alberta. Data were collected for patients who had begun therapy for newly diagnosed primary open-angle glaucoma or ocular hypertension between May 1, 1998, and Sept. 30, 1999 (phase 1), and for patients who had begun second-line therapy after initial therapy with a beta-blocker had failed (phase 2). Data were collected for a minimum of 24 months for phase 1 and a minimum of 18 months for phase 2. RESULTS: We included 115 patient charts in phase 1 and 93 in phase 2. In each phase, the patients for whom latanoprost had been prescribed in unfixed combination with a beta-blocker had the greatest mean percentage reduction in IOP at month 24, and the patients for whom latanoprost had been prescribed alone or in combination with a beta-blocker were more likely to still be on initial therapy at month 24; the difference in persistence on therapy was statistically significant only in phase 1 (p = 0.001). The mean number of switches in therapy was smaller in phase 1 than in phase 2 in all therapy groups. INTERPRETATION: Compared with other first- and second-line forms of therapy, treatment with latanoprost, alone or in combination with a beta-blocker, was associated with greater reductions in IOP, better therapeutic persistence, fewer therapy switches and fewer ophthalmologist visits over a 2-year period.     

Intraocular pressure and progression in exfoliative eyes with ocular hypertension or glaucoma

PURPOSE: This retrospective study was conducted in exfoliative eyes in order to study the influence of IOP and other possible factors on the conversion from ocular hypertension (OHT) to glaucoma and progression of glaucoma. METHODS: 139 patients with exfoliation OHT or glaucoma with exfoliation syndrome were included (mean follow-up 5.2 +/- 3.6 years). The effects of age, gender, weighted mean IOP, maximum IOP, stage of glaucoma at the first visit, refraction, glaucoma medication, and interventions on the hazard of progression were studied by multivariate survival analysis. RESULTS: Conversion from OHT to glaucoma or progression of glaucoma was detected in 63 eyes (45.3%). A significant association with progression was found for age (relative risk 1.042; p-value 0.043), weighted mean IOP (1.076; <0.001), and stage of glaucoma (1.436; <0.001). History of trabeculectomy (0.360; 0.002) related to a decreased risk. CONCLUSION: The risk of conversion from OHT to glaucoma and progression of glaucoma increased in exfoliative eyes with severity of stage of glaucoma, weighted mean IOP, and the age of the patient. A history of trabeculectomy was related to decreased risk of progression.