以虹膜萎缩为特征的继发性青光眼治疗方案的探讨

目的：分析以虹膜萎缩为特征的继发性青光眼的临床分类及疗效。方法：回顾性系列病例研究。收集2013年7月至2020年1月于石家庄市人民医院收治的以虹膜萎缩为特征的继发性青光眼患者60例（70眼）,年龄26~67（50.0±10.4）岁,其中男32例（36眼）,女28例（34眼）。随访12个月,观察患者最 佳矫正视力（BCVA）、眼压、抗青光眼药物的变化,分析其临床分类及治疗效果。采用重复测量设计资料的方差分析、Wilcoxon符号秩和检验对数据进行分析。结果：70眼中,患有葡萄膜炎的有54眼,Fuchs综合征10眼,角膜内皮炎6眼;虹膜弥漫性萎缩44眼,局限性萎缩26眼;经房水检测的有30眼,其中10眼房水病毒IgG抗体呈阳性,20眼房水白细胞介素-6（IL-6）、白细胞介素-8（IL-8）、白细胞介素-10（IL-10）、血管内皮生长因子（VCAM）升高。本研究患者采用青光眼药物治疗的有20眼,采用YAG激光周边虹膜切除术治疗的有12眼,采用青光眼手术治疗的有38眼。随访12个月,70眼治疗前后BCVA差异具有统计学意义（F=24.04,P<0.001）,治疗后1个月视力最好,治疗后3个月趋于平稳;治疗前后眼压差异具有统计学意义（F=445.16,P<0.001）,治疗后1个月眼压最低,之后逐渐回升,治疗后3个月趋于平稳;治疗后抗青光眼药物明显减少,差异有统计学意义（Z=-7.28,P<0.001）。结论：病毒性葡萄膜炎仍是以虹膜萎缩为特征的继发性青光眼的主要病因。在积极控制眼内炎症及抗病毒的基础上,降眼压药物和（或）YAG激光周边虹膜切除术对于首次发作、虹膜粘连时间短者疗效显著;对于反复发作、青光眼性损害较重者行抗青光眼手术治疗。     

虹膜角膜内皮综合征研究进展

虹膜角膜内皮综合征(ICE综合征)是一组累及虹膜、角膜、前房角的致盲性疾病。该疾病多单眼发病,少数为双眼,表现为角膜内皮异常进行性虹膜基质萎缩、虹膜周边前粘连、房角关闭以及继发性青光眼的一组疾病。临床上分为原发性进行性虹膜萎缩、Chandler综合征、Cogan-Reese综合征。本文就其病因、病理、临床表现、治疗的研究进展进行综述。     

虹膜角膜内皮综合征的临床研究现状

虹膜角膜内皮综合征(ICE综合征 )是关于角膜内皮异常改变和虹膜萎缩等病变的一组疾病。常见于中青年女性,多单眼发病,一般不涉及遗传倾向,早期无症状时无需治疗,当并发角膜水肿、青光眼时,主要采用对症治疗。在这组疾病中,其病因、临床表现、治疗等皆有许多相同点,也有一些相异之处,国际上尚未形成统一的标准,因此本文就ICE综合征的临床研究现状进行综述。     

曲伏前列腺素滴眼液对虹膜颜色改变的影响

目的观察应用曲伏前列腺素滴眼液后虹膜颜色的改变。方法采用前瞻性、观察者单盲和对照性研究的设计方法进行临床试验研究。选取北京大学眼科中心确诊为原发性开角型青光眼（POAG）的患者37例73眼为用药组,患眼每晚睡前点质量分数0.004%曲伏前列腺素滴眼液1次,共30 d。健康志愿者21例42眼为对照组,不点任何滴眼液。2组虹膜均为纯棕色。用药组和对照组受试者于试验前后分别进行裂隙灯虹膜照相,对虹膜颜色是否加深进行评估,结果判断为加深、不确定、无变化,并应用计算机颜色分析软件对2组虹膜颜色数值变化进行量化比较分析。结果肉眼观察发现,用药组患者26眼（35.6%）用药后虹膜颜色加深,对照组颜色无改变,用药组虹膜颜色加深和不确定的眼数与对照组比较,差异有统计学意义（χ2=21.467,P=0.000）。用药组用药后肉眼和计算机软件判断均为虹膜颜色加深者共17眼（23.3%）,计算机软件分析结果显示用药组共22眼虹膜颜色加深（30.1%）,仅肉眼判断为虹膜颜色加深者26眼（35.6%）。结论在应用曲伏前列腺素滴眼液3个月后,约1/3的纯棕色虹膜患眼虹膜颜色加深。     

Progressive hemifacial atrophy with ciliary body atrophy and ocular hypotony

Progressive hemifacial atrophy (PHA) is a disease of unknown etiology affecting one-half of the face. Ocular involvement is uncommon. Atrophy of iris is rare, with only a few cases of partial atrophy being reported in the literature. We report a case of total atrophy of iris and ciliary body with associated ocular hypotony in a 16-year-old girl with PHA. We believe this is the first reported case of complete atrophy of iris and ciliary body in PHA. Ocular hypotony in PHA was thought to be due to intra-ocular inflammation. However in our case it appears to be secondary to severe atrophy of the ciliary body.     

虹膜色素颗粒对兔眼小梁切除术后滤过通道瘢痕化影响的实验研究

目的探讨虹膜色素上皮(iris pigment epithelium,IPE)层色素颗粒对兔眼小梁切除术后滤过通道瘢痕化过程及Tenon囊成纤维细胞增生的影响。设计实验研究。研究对象新西兰大白兔18只。方法单眼做小梁切除手术模型。实验组巩膜瓣下放置0.1 ml(100μg/ml)猪IPE层色素颗粒并保留,阳性对照组和阴性对照组分别放置0.4 mg/ml丝裂霉素C棉片和生理盐水棉片3分钟。术后观察眼压、滤过泡形态30天,并对滤过泡及其周边组织进行组织病理学检查。主要指标眼压、滤过泡形态、手术滤过区瘢痕化程度。结果实验组、阳性对照组、阴性对照组兔眼术前平均眼压分别为(24.78±1.40)、(24.11±1.18)、(24.00±1.53)mmHg(F=0.241,P=0.789)。术后30天平均眼压分别为(20.28±1.87)、(20.39±2.28)、(23.33±1.14)mmHg(F=22.500,P=0.000)。实验组与阳性对照组无显著差异(P=0.86),实验组与阳性对照组均低于阴性对照组(P均=0.000)。滤过泡平均存留时间分别为(28.17±1.72)、(27.00±2.37)、(10.67±1.97)天(F=138.592,P=0.000)。组织病理学检查示实验组和阳性对照组兔眼滤过区结构相似,胶原纤维和瘢痕组织相对较少,而阴性对照组胶原纤维和瘢痕组织明显增生。结论小样本量短期实验研究表明,IPE层色素颗粒可能阻止Tenon囊成纤维细胞增生过程,有助于延缓小梁切除术后滤过通道瘢痕化。     

The differential diagnosis of malignant melanoma of the iris. A clinical study of 200 patients

The records of 200 consecutive patients referred to the Ocular Oncology Service of Wills Eye Hospital because of an iris lesion suspected of being an iris melanoma were reviewed. On clinical evaluation, 24% of the lesions met the criteria for the diagnosis of iris melanoma and 76% were diagnosed as simulating lesions (pseudomelanomas). The most common pseudomelanomas included primary iris cyst (38%), iris nevus (31%), essential iris atrophy (5.7%), iris foreign body (4.5%), peripheral anterior synechia (2.5%), and iris metastasis (2.5%). Less frequently encountered pseudomelanomas included aphakic iris cysts, leiomyoma, melanocytoma, reactive lymphoid hyperplasia, adenoma of iris pigment epithelium, iridoschisis, and other miscellaneous entities. The clinical features that are helpful in differentiating the more common iris pseudomelanomas from true melanomas are discussed. Correct clinical identification of these simulating lesions may prevent unnecessary surgery or other treatment.     

The iridocorneal endothelial syndrome

The iridocorneal endothelial syndrome represents a unique group of ocular pathologies (Chandler syndrome, progressive iris atrophy, and Cogan-Reese syndrome) characterized by the proliferation of corneal endothelial cells that migrate toward the iridocorneal angle and iris surface causing, to a degree varying according to the subtype, corneal edema and decompensation and secondary glaucoma, whether by obstructing the angle or producing peripheral anterior synechiae by contraction of the basement membrane of the migrating cells over the surface of the iris. A triggering factor, possibly viral, induces the corneal endothelial cells to proliferate and behave like epithelial cells. Diagnosis is made based on typical ocular findings on the cornea and iris. Iridocorneal endothelial syndrome is more frequent in young women, with unilateral involvement in most cases. In vivo confocal microscopy is an excellent diagnostic tool, especially in borderline presentations like early cases of Chandler syndrome, which affects the cornea predominantly. Typical clinical management consists of treating the corneal edema and decompensation, where endothelial keratoplasty techniques have replaced in many cases the need for a penetrating keratoplasty and treating the secondary glaucoma, which usually requires surgical intervention.     

先天性虹膜囊肿10例临床分析

目的:探讨先天性虹膜囊肿不同时期的临床表现及影像学特征,避免先天性虹膜囊肿继发青光眼期误诊为闭角型青光眼而延误治疗。方法:对10例先天性虹膜临床症状,眼部体征,影像学检查资料进行回顾性分析。其中6例以眼红、眼痛、头痛、视力下降等主诉就诊,疑似闭角型青光眼;2例以眼痛、畏光、流泪、视物模糊等主诉就诊,疑似前葡萄膜炎;2例无症状为体检时发现的。结果:典型患者具有裂隙灯检查前房深浅不一,虹膜局部前凸;前房角镜检查显示局部房角窄,部分或全部关闭;眼压测定10例中有6例患眼眼压高于正常;超声生物显微镜(UBM)检查示虹膜囊肿。结论:先天性虹膜囊肿尤其是色素上皮囊肿发病比较隐蔽,为防止先天性虹膜囊肿进展眼压升高继发青光眼期误诊为闭角型青光眼而行抗青光眼手术,术后眼压再次升高,手术失败,术前一定要明确诊断。     

新生血管性青光眼分期综合治疗的效果

目的探讨新生血管性青光眼按不同分期综合治疗的效果。设计回顾性病例系列。研究对象63例（69眼）新生血管性青光眼患者分为虹膜红变组（15例16眼）、开角型青光眼组（20例22眼）和闭角型青光眼组（28例31眼）。方法虹膜红变组行全视网膜光凝术治疗,其中3眼行白内障手术,1眼玻璃体内注射bevacizumab。开角型青光眼组在全视网膜光凝术基础上应用抗青光眼药物,其中8眼行小梁切除术,4眼行白内障手术,2眼白内障联合玻璃体切除,5眼玻璃体内注射bevacizumab。闭角型青光眼组在全视网膜光凝术、抗青光眼药物、小梁切除术或睫状体光凝术基础上,联合玻璃体内注射bevacizumab,其中21眼玻璃体切除联合白内障手术,12眼填充硅油。平均随访（18.6±15.3）个月。主要指标视力、眼压、虹膜红变、前房角及并发症。结果虹膜红变组、开角型青光眼组和闭角型青光眼组治疗后视力不变或提高分别为15眼（93.8%）、17眼（77.3%）和16眼（51.6%）（χ2=9.76,P﹤0.01）。治疗前眼压分别为（14.6±3.8）mmHg、（31.6±9.1）mmHg和（44.8±12.2）mmHg,治疗后眼压为（14.1±3.86）mmHg、（17.9±3.7）mmHg和（18.9±10.8）mmHg（F=185.8,P﹤0.001）。治疗后虹膜红变在虹膜红变组16/16眼消退,开角型青光眼组20/22眼消退及闭角型青光眼组28/31眼消退。治疗后前房角在虹膜红变组16眼仍为宽角,开角型青光眼组18/22眼前房角中的纤维血管膜萎缩,房角开放范围较治疗前扩大,闭角型青光眼组31眼房角中的纤维血管膜不同程度萎缩,但房角开放范围无扩大。三组患者治疗后并发症的发生率分别为6.3%、22.7%和48.4%（χ2=9.75,P﹤0.01）。结论新生血管性青光眼按临床分期差异化综合治疗对虹膜红变期及开角型青光眼期效果较好。     

Iridoschisis and glaucoma

Three patients with unilateral iridoschisis and glaucoma (1 with bilateral open-angle glaucoma, 1 with unilateral glaucoma) were observed for 3 to 15 years. In none of these patients did iridoschisis progress and a good control of the glaucoma was achieved. The mechanism of this rare condition is yet not clear.     

Changes in Iris Stiffness and Permeability in Primary Angle Closure Glaucoma

PurposeTo evaluate the biomechanical properties of the iris by evaluating iris movement during pupil constriction and to compare such properties between healthy and primary angle-closure glaucoma (PACG) subjects.MethodsA total of 140 subjects were recruited for this study. In a dark room, the anterior segments of one eye per subject were scanned using anterior segment optical coherence tomography imaging during induced pupil constriction with an external white light source of 1700 lux. Using a custom segmentation code, we automatically isolated the iris segments from the AS-OCT images, which were then discretized and transformed into a three-dimensional point cloud. For each iris, a finite element (FE) mesh was constructed from the point cloud, and an inverse FE simulation was performed to match the clinically observed iris constriction in the AS-OCT images. Through this optimization process, we were able to identify the elastic modulus and permeability of each iris.ResultsFor all 140 subjects (95 healthy and 45 PACG of Indian/Chinese ethnicity; age 60.2 ± 8.7 for PACG subjects and 57.7 ± 10.1 for healthy subjects), the simulated deformation pattern of the iris during pupil constriction matched well with OCT images. We found that the iris stiffness was higher in PACG than in healthy controls (24.5 ± 8.4 kPa vs. 17.1 ± 6.6 kPa with 40 kPa of active stress specified in the sphincter region; P < 0.001), whereas iris permeability was lower (0.41 ± 0.2 mm²/kPa s vs. 0.55 ± 0.2 mm²/kPa s; p = 0.142).ConclusionsThis study suggests that the biomechanical properties of the iris in PACG are different from those in healthy controls. An improved understanding of the biomechanical behavior of the iris may have implications for the understanding and management of angle-closure glaucoma.     

先天性青光眼虹膜血管的超微结构观察

对8例8只先天性青光眼虹膜手术切除标本进行了超微结构观察。结果显示:先天性青光眼的虹膜基质血管明显增多,管腔扩张。部分血管内皮细胞肿胀,基膜层次增多至2～4层。内皮细胞和其基膜分离形成间隙,间隙中可见块状纤维致密物沉积。对上述虹膜基质血管的病理改变及其临床意义进行了讨论。