原发性开角型青光眼中枢视觉通路的改变

原发性开角型青光眼是临床上常见的一种不可逆性致盲眼病,对于青光眼所造成的视网膜神经节细胞水平及视神经水平的损害已得到广泛研究.最近研究表明,青光眼患者的上行视路部分,如外侧膝状体及枕叶视皮质等,存在损伤,提示青光眼可能同时也是一种中枢神经退行性疾病,早期对青光眼进行视神经保护治疗有助于减缓视神经节细胞的凋亡并阻止视功能的进一步损害.本文将从青光眼中枢损伤的发病机制、临床诊断及青光眼视神经保护治疗方面的研究进展进行综述,并对青光眼的研究前景进行展望.     

兴奋性氨基酸与青光眼

近年来随着对青光眼性视神经病变机制的深入研究,已证实兴奋性氨基酸与青光眼视网膜神经节细胞凋亡密切相关。21世纪青光眼的治疗模式正从传统的单纯降眼压向降眼压的同时从其他途径进一步加强神经保护转变,基础实验及部分临床研究证实干扰兴奋性氨基酸产生神经毒性的各环节均对神经元有保护作用,由此可以推测通过对兴奋性氨基酸的研究有望实现青光眼治疗史上的重大突破。     

青光眼视神经损伤与修复期待精准的个体化治疗

青光眼是临床上常见的以视神经损害为主要特征的致盲眼病,降低眼压仍是目前治疗青光眼的主要方法,但一些患者眼压虽然得到合理控制,视神经损害却难以恢复,甚至持续发展,因此其病理机制的研究和视神经损害的防治研究一直是近年来青光眼治疗研究的热点.最近随着生物医学研究的快速发展,尽管青光眼视神经损伤和修复的基础研究已经取得了显著进展,青光眼视神经损伤的机制已得到阐明,但是鲜见证据充分的、有确定疗效的临床研究报道.目前基因组学研究、干细胞研究、分子生物学研究、电子技术在医学中的应用研究等取得了长足进步,尤其是大数据时代的到来更为临床上青光眼的神经保护研究奠定了良好的基础.眼科医生应关注大数据信息时代为疾病精准化治疗带来的机遇和挑战,聚焦于青光眼视神经保护的精准个体化治疗,降低青光眼的致盲率.     

青光眼视神经保护性治疗的进展

青光眼是一种致盲率高且不可逆转的严重性眼病,严重影响患者的生活质量,随着对青光眼诊治水平的提高和青光眼视神经损害机制的研究,青光眼视神经的保护越来越受到人们的高度重视。本文主要就青光眼视神经损害的机制和视神经保护性治疗等方面进行综述,以其阻止视神经进一步损害,保护视功能,使治疗达到最佳效果。     

原发性青光眼基础临床研究进展与发展趋势

青光眼是全球第二大致盲眼病、不可逆性盲最主要的原因.青光眼的流行病学、发病机制、早期诊断、基础与临床研究、致病基因筛选及视功能测定、视神经损伤与保护等问题尚处于探讨阶段.因此,有必要回顾国内近年来青光眼的基础与临床研究进展情况,分析青光眼研究领域存在的问题,明确今后青光眼的研究方向,进一步推动青光眼的基础与临床研究深入发展.文中就近年来原发性青光眼的流行病学状况、基础研究、视功能检测、临床治疗方法的研究进展做一综述.     

青光眼视神经保护离我们有多远

尽管在基础研究中,Memantine、Calpain、促红细胞生成素等药物均显现出喜人的青光眼视神经保护潜能,但随着Memantine等Ⅲ期临床试验的失败,目前仍无一种视神经保护药物能够通过美国食品药品管理局的审核批准并投入临床应用,使临床青光眼视神经保护的研究面临近乎尴尬的困境.青光眼视神经保护的迫切性要求我们必须从新的视角审视问题,充分利用人类基因组计划、蛋白质组计划、干细胞和转基因动物研究成果,对其实施分期靶点干预,以使青光眼视神经保护的梦想变成现实.     

我国近五年青光眼临床与基础研究进展

由于青光眼的早期诊断、发病机制、致病基因筛选及功能测定、视神经损伤与保护、滤过术后瘢痕调控、干细胞培养与自然动物模型形成、流行病学研究等基本问题尚处于探讨阶段,因此有必要回顾我国近5年来青光眼的临床与基础研究进展情况,分析青光眼研究领域存在的问题,明确今后青光眼的研究方向,进一步推动青光眼的临床与基础研究深入发展。     

青光眼视神经病变的免疫学研究

近年的研究显示免疫系统调节在青光眼视神经病变中起到损伤和保护两种矛盾的作用。青光眼产生的免疫应答能够致神经元损伤,然而直接针对特异性抗原的T淋巴细胞却能保护神经元避免轴突受损后的进一步损伤。所以在受益于保护性自身免疫和诱发自身免疫性神经元变性疾病之间的平衡成为关键。胶质细胞的免疫调节和机体的组织应激是决定其平衡的重要因素。深入地研究免疫系统在青光眼视神经变性中的不同作用,能更有效地促进青光眼视神经保护策略的发展。     

青光眼治疗对眼表组织结构的影响

青光眼是一组以视神经凹陷性萎缩和视野缺损为共同特征的疾病,病理性眼压增高是其主要危险因素.目前青光眼的治疗方法主要包括抗青光眼药物治疗、激光治疗、手术治疗以及视神经保护治疗等.研究证明,青光眼各种临床治疗对患者的眼表组织结构(泪膜、结膜、角膜上皮)均会产生明显影响,引起泪膜功能破坏、球结膜亚临床炎症、球结膜和角膜上皮细胞的损伤,导致患者眼部不适、长期用药依从性降低、干眼的发生甚至降低手术成功率等.本文主要针对抗青光眼治疗对眼表组织结构的影响作一简要综述.     

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     

Seven steps to assure the best possible treatment of persons with glaucoma or suspected of having glaucoma

Glaucoma causes more blindness and disability than any other eye disease except for cataract. Cataract surgery is highly successful, even intracapsular cataract surgery. The major problem, then, with regard to relieving or preventing disability related to cataract is one of access to care. Though access to care is a major problem with glaucoma, it is by no means the only problem. Many patients with glaucoma get worse, even when they are being treated. Additionally, it is not only glaucoma itself that causes disability. In the recent past, far more damage was caused by treatment for glaucoma than by glaucoma itself. To repeat, summarized slightly differently, glaucoma and its treatment damage health more than any other eye disease except cataract, and the medical profession is responsible for a major part of that problem. How can it be that glaucoma and its treatment still cause so much disability? In the first place, care is unavailable in many areas, and, second, care is not utilized even where available, and third, care is often inappropriate even where available. The first two issues are of great importance but are not the subject of this discussion. It is my belief that the major explanation for why care is often poor is because the goals of care are often wrong. Specifically, the goals of care are to lower intraocular pressure, or to prevent visual field loss. These may be appropriate intermediary steps on the way to achieving the appropriate goal, but they are not the goal itself.     

高度近视与原发性开角型青光眼关系的研究进展

近年来,在青光眼及近视发病机制研究中发现,高度近视与原发性开角型青光眼的发病有明显相关性.高度近视眼底病理改变是开角型青光眼的高危因素,且高度近视眼底改变与早期开角型青光眼眼底改变容易混淆,造成青光眼早期诊断困难.如何从高度近视患者中早期发现青光眼,并进行早期干预治疗成为难点.本文回顾分析近年文献,对高度近视与原发性开角型青光眼的关系做一综述.     

减少青光眼导致的盲和视力损伤是防盲的重要内容

由于国际眼科学界和世界卫生组织(WHO)已经注意到青光眼问题的严重性和加强青光眼防治的重要性,因此WHO采取了一些可行措施,以加强全球因青光眼致盲和视力损伤的防治工作.之所以采取这些措施是由于青光眼已经对全球的公共卫生造成了沉重负担,而且采用目前循证的临床干预措施治疗青光眼是有效的.将防治青光眼纳入防盲的重点就意味着不仅采用临床的途径,还要采用公共卫生的途径,整合各种眼保健力量做好青光眼的防治工作,这是青光眼防治策略的重要改变.筛查和早期诊断青光眼是防治青光眼的一项非常重要的工作,目前主要通过加强机会性筛查青光眼的工作,以发现更多的未诊断和未治疗的青光眼患者.所采用的防治青光眼的策略应当与当地的社会经济状况相适应,这样才能有利于推进防盲工作的顺利开展.     

Was bringt die prophylaktische YAG-Iridotomie beim Pigmentdispersionssyndrom?

Despite theoretical considerations concerning the advantage of iridotomy in eyes with pigment dispersion syndrome or early pigment glaucoma, there is a lack of clinical evidence that this procedure has a long-term effect in preventing glaucoma damage under these circumstances. However, several factors may contribute to this lack of evidence, e.g. the statistical problem of a low conversion rate from pigment dispersion syndrome to pigment glaucoma or the inclusion criteria in the studies treating patients older than 40 years or genetic dispositions in pigment glaucoma that are not yet fully clear. On the basis of current data the decision for YAG iridotomy should only be taken in patients younger than 40 years, if the midperipheral iris shows an inverse bowing and the intraocular pressure is normal or slightly increased with no progressive signs of optic nerve damage. In cases of insufficient intraocular pressure and visual defects due to glaucomatous optic nerve damage, incisional glaucoma surgery is usually necessary especially in younger patients with a long life expectancy.     

青光眼遗传学研究的现状与挑战

青光眼是常见且病变不可逆转的严重致盲眼病,遗传因素对于青光眼的发生具有重要作用。人类基因组计划的完成及相关分子遗传学技术在青光眼研究领域的应用,使青光眼的病因学研究取得了重要进展。目前人们难以预计新的研究成果将对青光眼的预防、早期诊断及治疗所产生的重要影响,但却引发出一系列值得思考的问题,这可能预示着青光眼遗传学研究方向的变化趋势。     

21st century management of glaucoma

According to a recent epidemiological study done in Japan, 2 or 3 million Japanese people are thought to be suffering from glaucoma, and 70-80% of them have not been examined or diagnosed by ophthalmologists. Therefore, the problem is how to find these untreated and undiagnosed people. At present, treatment of glaucoma continues to be directed at lowering intraocular pressure to prevent progression of glaucomatous optic neuropathy. However, theoretically, there are three stages in the prevention of progression of glaucoma. In the first stage, diagnosis of glaucoma can be done by genetic examination, before occurrence of glaucoma. The MYOCILIN/trabecular meshwork-inducible glucocorticoid response gene and the optineurin gene were identified as the genes that cause open angle glaucoma. Although some Japanese patients have sequence changes in the myocilin gene, there are no apparent specific mutations in Japanese glaucoma patients, in the MYOCILIN/TIGR and optineurin genes. Secondary glaucoma such as steroid glaucoma, induced by allergic diseases, and neovascular glaucoma, induced by retinal circulatory insufficiency, are preventable by improving the causal diseases, diabetes and hypertension. The education of doctors and laymen is important to reduce the occurrence of diabetes, and hypertension to prevent diabetic retinopathy, and retinal vessel occlusion. The second stage in preventing progression of glaucoma is to find the disease as early as possible. In Japan, a physical examination system is in place for everybody over 40 years old, in companies and local districts. Therefore, ocular examination, specially non-mydriatic fundus photographs should be taken in these examinations, and the film should be evaluated by an ophthalmologist, to search for retinal and optic disc abnormalities. Primary open angle glaucoma can be detected through this system in early stages. In primary angle closure glaucoma, instruments for estimating anterior chamber rapidly and accurately are necessary for the diagnosis. There is a special machine which can be handled easily, safely, and economically for detecting angle closure glaucoma, has been developed by Yamanashi University. This machine might help to reduce the number of angle closure glaucoma patients in the world. In the near future, a glaucoma network system should be put in place all over Japan. This organization consists of central headquarter and local central office. Most hospitals and private offices will belong to a local central office, and several glaucoma specialists will work in central and local offices. All glaucoma patients will be registered in local glaucoma office. The information on glaucoma patients will be communicated in the system the through light fiber cables or a satellite system. The patients can ask about their own disease through this glaucoma center system. In the third stage of glaucoma prevention, progression of glaucomatous optic neuropathy is retarded by conventional IOP lowering treatment or neuroprotective drugs. This stage compromises rehabilitation of visual function, implant of artificial visual systems, and regeneration of retinal ganglion cells(RGC). The disturbances of axonal flow in guinea pig optic nerve fibers was demonstrated electromicroscopically by quick-freeze, deep-etching method and, the decrease in numbers of motor proteins like "Kinesin" "Dynein" and "MAP-1" was shown in guinea pig eyes with elevated intraocular pressure by immunohistochemistry. Retinal glanglion cells have been isolated and new findings have been reported using this RGC culture system. Therefore, new neuroprotective drugs will be developed through this culture system.     

Glaucoma in aphakia and pseudophakia after congenital cataract surgery

Glaucoma is one of the most common causes of visual loss despite successful congenital cataract surgery. The overall incidence does not appear to have decreased with modern microsurgical techniques. The onset of glaucoma may be acute or insidious and notoriously refractory to treatment. Angle closure glaucoma may occur in the early postoperative period; but the most common type of glaucoma to develop after congenital cataract surgery is open angle glaucoma. Several risk factors have been identified and both chemical and mechanical theories have been proposed for its pathogenesis. Unlike children with congenital glaucoma, those with paediatric glaucoma following congenital cataract surgery are usually asymptomatic despite high intraocular pressure. They may require regular evaluation under anaesthesia, whenever there are any suspicious findings. Unlike congenital glaucoma, the first line of treatment for glaucoma in aphakia/pseudophakia may be medical. Traditional trabeculectomy in paediatric glaucoma following congenital cataract surgery has met with limited success. The addition of antimetabolites to trabeculectomy is known to inhibit fibrosis and enhance the success, but carries the lifelong risk of bleb-related endophthalmitis. Drainage implant surgery is a viable option to achieve longterm intraocular pressure control in this refractory group of patients. Cycloablative procedures may provide temporising treatment and should be reserved for patients with low visual potential. Diagnosis of glaucoma following congenital cataract surgery requires lifelong surveillance and continuous assessment of the problem. Further research is needed to understand the pathophysiology, prevention and treatment of this sight-threatening complication following successful cataract surgery in children.     

Pediatric glaucoma--case report

Pediatric glaucoma is an interdisciplinary problem because of it's many systemic abnormalities which may encounter with this disease. In this paper we present the follow up and the treatment of a clinical case. We point once again that the therapy used is a most important attitude for the future prognosis.     

The Ahmed Glaucoma Valve – a new implant for high intraocular pressure Ein neues Implantat zur operativen Drucksenkung

In incurable glaucoma the implantation of traditional drainage systems (such as the Molteno implant) usually leads to extreme hypotension in the eye in the first postoperative period. The Ahmed Glaucoma Valve presents an alternative method to avoid this problem.     

The combined use of apraclonidine and pilocarpine during laser iridotomy in a Hispanic population

Early postoperative intraocular pressure (IOP) rise is a frequent and vision-threatening complication of laser surgery for glaucoma. Recent studies show that apraclonidine, a new alpha-2 adrenergic agonist, can reduce the incidence of this problem. In a randomized, double-masked prospective study, we explored the efficacy of apraclonidine combined with pilocarpine during laser iridotomy in a Hispanic population. A significantly lower early postoperative IOP with less frequent severe pressure spikes occurred in the apraclonidine-treated patients. The addition of pilocarpine did not interfere with the beneficial effect of this medication. Of particular interest was the fact that chronic angle-closure glaucoma was the diagnosis in all patients who had a significant postoperative IOP rise in this study.