青光眼视神经损害进展的一致性分析研究

目的 分析眼底照相联合图像配准进行闪烁对比方法 评价青光眼视神经损害进展在观察者之间及观察者自身的一致性评价,分析视神经损害进展在青光眼病情进展评价的作用.方法 回顾性分析研究.对北京同仁医院1993年7月至2010年3月长期随诊的青光眼患者203例(273只眼),其基线眼底照片及随诊眼底照片在计算机图像配准软件处理后,两张眼底照片可进行闪烁显示,对比分析其视神经损害是否发生了进展,由三位青光眼专科医师进行判断.青光眼视神经损害进展的标准:(1)盘沿丢失发生进展.(2)神经纤维层缺损发生进展.每位观察者评价两次,时间间隔半年.应用一致率及Kappa分析评价观察者自身及观察者之间的一致性.结果 三位观察者自身对青光眼视神经损害进展的一致性评价均较好,判断的一致率在87.2%～93.4%,Kappa值在0.725～0.881(P值均＜0.05),观察者对结果 判断的可重复性均较好.三位观察者之间对青光眼视神经损害进展的一致性亦较好,观察者两两之间的一致率在87.5%～92.3%,Kappa值在0.718～0.851(P值均＜0.05),观察者之间的一致性在高度一致到近完全一致.三位观察者均认为发生青光眼视神经进展者178只眼,占65.2%,均认为无青光眼视神经进展者54只眼,占19.5%.结论 应用眼底照相联合计算机图像处理软件使前后两次视神经图像进行叠加闪烁法,在判断视神经损害进展方面,三位青光眼专科医师的一致性较好,视神经闪烁对比法是监测青光眼视神经损害进展一种较好地方法.

Abstract：

Objective To determine the inter-observer and intra-observer agreement in assessing progressive disc changes from alternation flicker photographs. Methods Retrospective cases series. Serial sets of optic nerve photographs of 273 eyes of 203 glaucoma patients followed up from July 1993to March 2010 in Tongren Hospital were included for analysis. The earliest baseline and most recent follow-up photos were included. The digital images were aligned and alternated to determine structural optic nerve change by three glaucoma specialists. The assessment criteria for the automated flicker images were the progression of disc rim loss and retina nerve fiber layer defect. Every observer evaluated the flicker images twice, time intervals was half a year. The statistical significance of differences between the levels of inter- and intra-observer agreement was performed using Kappa coefficients.Results The intra-observer agreement of the three specialists were all high, the concordance rate was 87.2% ~ 93.4%, Kappa value was 0.725 ～ 0.881 (P <0.05). Flicker inter-observer agreement was still high, the concordance rate was 87.5% ～ 92.3%, Kappa value was 0.718～0.851 (P <0.05). All the three specialists thought that there were 178 eyes (65.2%) with progressive optic nerve, and 54 eyes (19.5%) with non-progressive optic nerve. Conclusions Inter-observer and intra-observer agreement among three glaucoma specialists in judging progressive optic disc change from alternation flicker photographs are very high. Altemation flicker photograph is a good method to determine the progression of glaucoma.     

原发性开角型青光眼视神经损害进展的危险因素分析

目的 探讨青光眼患者视神经损害进展的全身及眼部危险因素.设计回顾性病例系列.研究对象原发性青光眼随诊3年以上患者591例.方法 北京同仁医院1987年至2008年间青光眼随诊在3年以上患者纳入研究,将患者基线的立体眼底照片与随诊眼底照片在计算机图像配准软件下,进行闪烁对比,发现青光眼视神经进展改变.青光眼进展的标准：视盘盘沿丢失进展及神经纤维层缺损进展.应用Iogistic回归分析青光眼患者的年龄、性别、随诊时间、基线青光眼视神经分期与青光眼视神经损害进展的相关性,分析视盘出血、视网膜血管改变、视盘周围萎缩弧与青光眼进展的关系.主要指标眼底照相视神经进展评价.结果 原发性青光眼患者共591例990眼,初诊时年龄平均（61±17）岁,随诊时间3～20年,随诊时间的中位数为5.4年.在990眼中,发生青光眼进展者为512眼,占51.7%.Logistic回归分析显示,年龄、随诊时间、青光眼视神经分期与青光眼进展的相关性有统计学意义,P均=0.000,OR值分别为1.26（95%CI 1.13,1.40）、1.24（95%CI 1.17,1.31）、3.23（95%CI 2.66,3.92）.年轻患者较年长患者更易发生进展,随着随诊时间的延长,青光眼视神经损害进展的危险性增加.早期青光眼患者进展的危险性较中、晚期患者增加.视盘出血、盘周萎缩弧扩大及视网膜血管管径改变与青光眼视神经损害进展有关,P均=0.0000男性与女性患者在青光眼进展方面无明显差异,P=0.266.结论 青光眼视神经进展是一个缓慢的过程,早、中期青光眼,随着随诊时间的延长,发生进展者多见.年轻患者更易发生青光眼进展.视盘出血、盘周萎缩弧扩大及视网膜血管管径改变时,预示着青光眼的进展.     

早期青光眼视神经损害评价一致性的研究

目的研究青光眼盘沿形态分析方法的强化训练在青光眼早期诊断一致性评价中的作用。设计前瞻性研究。研究对象临床医生与青光眼视神经诊断方法。方法选取早期青光眼及类似青光眼视神经改变的数码眼底照片共120张，其中早期青光眼眼底照片67张，易混淆为青光眼的眼底照片53张。眼底照片观察者分三组。Ⅰ组为接受过青光眼盘沿形态分析强化训练者，共5人；Ⅱ组为青光眼医生4人，未强化训练；Ⅲ组为非青光眼医生4人，未强化训练。重复阅片3次，每次间隔3天。主要指标观察者自身及观察者问的评价一致率，Kappa值。结果观察者自身一致性评价，Ⅰ组Kappa值（一致率）为0．779～0．966（90．0％～98．3％）；Ⅱ组为0．506～0．866（82．5％～93．3％）；Ⅲ组为0．094～0．778（54．2％～89．2％）。观察者间正确评估眼底照片的一致性分析结果，Ⅰ组Kappa值0．768～0．983，Ⅱ组0．354～0．834，Ⅲ组0．335～0．737。结论盘沿形态分析的强化训练可提高观察者对早期青光眼视神经损害评估的一致性，建立青光眼视神经诊断标准可提高青光眼的正确诊断率。（眼科．2007,16：20-23）     

青光眼视神经损害的远程筛查标准(征求意见稿)

为了提高远程眼科服务质量,国家卫生计生委医疗服务标准委员会委托北京市眼科研究所草拟了远程眼科影像学诊断标准。现将青光眼视神经损害的远程筛查标准的征求意见稿刊出,供眼科同道商榷。青光眼视神经损害远程筛查以眼底数码照相作为判定的基础。眼底数码照相质量标准见参考文献[1]。一、青光眼视神经损害的判定标准出现以下2条之一者可判定存在青光眼视神经损害:(1)正常视盘首先在颞下方或颞上方发     

原发性开角型青光眼视神经损害进展的相关危险因素研究:207例患者的随诊观察结果

目的 探讨原发性开角型青光眼(POAG)病情进展的相关危险因素.方法 回顾性分析北京同仁医院POAG患者中,随诊达3年以上,有5次以上眼压记录者的病情进展情况.将符合入选标准的207例(338眼)患者的基线立体眼底照片与随诊眼底照片,在计算机图像配准软件处理下进行闪烁对比,以发现盘沿及神经纤维层缺损进展情况.青光眼视神...     

青光眼临床研究的焦点及其争论与对策

现代青光眼防治的关键在于早期诊断及个性化治疗.国际上对青光眼筛查模式、青光眼诊断标准、青光眼损害监测及其资源管理等问题存在着争论.针对这些焦点问题,我们依靠互联网眼科影像数据库(PACS)平台,建立了低成本、高效率的青光眼、糖尿病视网膜病变、白内障联合筛查模式.筛查针对社区高危人群,采用非散瞳数码眼底照相及手电筒评估浅前房,每日可筛查100余人.筛查现场只需社区医务人员及技术员,专职医生在医院阅片诊断,社区医生在互联网上可获得患者的检查影像及诊断结果.为了监测青光眼视神经损害,我们采用计算机软件图像配准法校准随诊的图像,通过闪烁法可监测到微小病变.此外,可评估视网膜微血管病变,对高血压、糖尿病的并发症防治具有重要参考作用.(眼科,2008,17:1-3)     

中药复明片治疗原发性开角型青光眼视功能损害的疗效研究

目的:探讨中药复明片对原发性开角型青光眼视功能损害的治疗作用.方法:对用药物或手术控制眼压≤2.99 kPa(21 mmHg)的原发性开角型青光眼36例65眼随机分为复明片治疗组和甲钴胺片对照组.治疗组给予复明片(西安碑林药业),5片3次/d,对照组给予甲钴胺片,0.5 mg 3次/d,30 d 1疗程,治疗3疗程后,复查mfERG及进行HRT视盘扫描分析.结果:复明片治疗组患者mfERG N1波1环的振幅密度与对照组比较明显提高,5环的振幅密度与治疗前相比明显提高,P1波1,2,5环的振幅密度与治疗前相比均明显提高.复明片组治疗后视乳头盘沿面积(mm2)、视杯容积(mm3)、平均RNFL厚度(mm)与甲钴胺片对照组比较有改善,RNFL截面面积(mm2)与治疗前比较明显增大.结论:复明片对开角型青光眼患者具有较好的疗效,可以明显改善患者mfERG的振幅密度及改善患者视乳头部分结构参数,mfERG和HRT可以做为评估其有效性的敏感方法.     

青光眼视神经损害的分级评估方法

青光眼视神经损害的分级对青光眼诊断、治疗方法选择和病情评价等均有重要价值。本文介绍了目前国际上常用的几种青光眼视神经损害分级方法。视盘形态学分级方法包括杯盘比、Shiose法、Richardson法、Nesterov法、Jonas法和视盘损伤可能度等;视网膜神经纤维层评估法包括Quigley分期法、眼底照片参照分级法等。     

线粒体在原发性青光眼视神经损害中的作用机制

青光眼是全球常见且不可逆的严重致盲眼病,其视功能损害的病理基础是视网膜神经节细胞的进行性死亡和神经纤维的丢失.神经节细胞死亡主要是通过细胞凋亡的方式进行的,其在本质上与大多数神经系统疾病的病理生理特征包括氧化应激与能量障碍是一致的.而线粒体在细胞凋亡中起着主开关的作用.     

原发性开角型青光眼和闭角型青光眼早期视神经损害特征的比较

目的比较原发性开角型青光眼（POAG）和原发性闭角型青光眼（PACG）的早期视神经损害特征和视野损害特点的差异。设计前瞻性病例系列。研究对象早期POAG患者23例（30眼），早期PACG患者22例（30眼）。方法进行静态视野和偏振激光扫描仪GDx ECC检查。分别比较两组间GDx ECC各个参数和视网膜神经纤维层缺损（RNFLD）类型（弥漫性、局限性）的差异。在组间分别比较视野参数、视野检测光标点对点的光敏度丢失。主要指标GDx ECC参数及其RNFLD类型、视野参数、视网膜光敏度丢失。结果两组中GDx ECCTM参数除了上方均值和对称性以外，其余各个参数在两组间的差异均有统计学意义。弥漫性RNFLD在POAG和PACG中的比例分别为40％和10％（P〈0．05），局限性RNFLD分别为53％和63％。视野指数中PSD和CPSD在两组间差异有统计学意义（P〈0．05）。在视野检测的点对点比较中，早期PACG的局部光敏度丢失在颞上方视野中较早期POAG严重（P〈0．05）。结论早期POAG有较多弥漫性RNFLD，而早期PACG主要表现为局限性RNFLD。早期PACG在颞上方的局部光敏度丢失较早期POAG严重，这与其RNFL缺损特征相一致。POAG和PACG不同的发病机制可能是导致RNFL损害特征和视野损害特点差异的原因。（眼科，2007,16：28-32）     

Regional optic nerve damage in experimental mouse glaucoma

PURPOSE: To assess the relationship between regional variation of axon loss and optic nerve head anatomy in laser-induced experimental glaucoma in the mouse. METHODS: Experimental glaucoma was induced unilaterally in eight NIH Swiss black mice. Intraocular pressure (IOP) was measured for 12 weeks, and the mice were killed. The eyes were enucleated, and both optic nerves were dissected and processed conventionally for electron microscopy. Low- and high-magnification images of the optic nerve cross sections 300 microm posterior to the globe were collected systematically and masked before analysis. For each nerve, cross-sectional area was measured in low-magnification micrographs. Axon number and density were determined in the high-magnification micrographs. Loss of axonal density was compared between the superior and inferior and nasal and temporal areas of the optic nerve cross section. Additional cross-section micrographs were collected at 10- or 20-microm intervals throughout the optic nerve head. RESULTS: In the treated (glaucoma) eyes, mean IOP was 44% higher than that in the control eyes. The optic nerve cross-sectional area, mean axonal density, and total axonal number were significantly less than those in the control eyes (P < 0.01 for each). Axon loss in the superior optic nerve was greater than in the inferior optic nerve in each glaucomatous eye (P = 0.012). The ratio of axonal density in the superior and inferior optic nerve (superior-to-inferior [S/I] ratio) in all treated eyes was <1.0 and significantly lower than that in the control eyes (P = 0.012). The central retinal vessels occupied approximately 20% of the central optic nerve head cross-sectional area, gradually shifted position ventrally as they progressed toward the scleral foramen (the mouse does not have a lamina cribrosa), and exited the inferior retrobulbar optic nerve adjacent to the posterior of the globe. CONCLUSIONS: Ocular hypertension in the mouse eye sufficient to cause optic nerve damage induces preferential loss of superior optic nerve axons. Optic nerve axon loss appeared less among the axons that were near the major optic nerve blood vessels at the scleral foramen. Topographic differences in optic nerve axon loss should be considered when evaluating optic nerve damage in experimental laser-induced glaucoma in the mouse.     

The diagnostic value of optic nerve imaging in early glaucoma

In the last decade, new imaging techniques have been added to conventional fundus photography and have been evaluated for use in early glaucoma. They all measure the loss of neuroretinal rim or retinal nerve fiber layer as a correlate to glaucomatous ganglion cell and axon loss. The value of optic disc photography, planimetry, laser scanning tomography, laser scanning polarimetry, and optical coherence tomography for the diagnosis of glaucomatous eyes in a preperimetric or early perimetric stage is analyzed on the basis of sensitivity, specificity, and receiver operating characteristics (ROC) curves. It becomes clear that all these techniques allow a more or less semi-automated evaluation of the optic disc and retinal nerve fiber layer but still have their limitations in the diagnosis of a very early, preperimetric stage of the glaucoma disease.     

青光眼视神经损伤机制的研究进展

青光眼是目前全球范围内致盲性最高的疾病之一,是以进行性视网膜神经节细胞丧失、不可逆的视野损害等病理性改变为特征,最终导致视神经萎缩及视功能丧失的疾病。目前青光眼的发病机制并不完全清楚,其中视神经损伤的机制有多种学说,包括眼压因素及非眼压因素,非眼压因素包括血管因素、免疫作用、远端轴突病变、氧化应激作用、细胞因子的变化及自噬等机制。本文综述了有关青光眼视神经损伤机制的研究进展,为进一步研究青光眼视神经病变提供依据。     

Quantitative evaluation of the optic nerve head in early glaucoma

AIMS—Progressive loss of neuroretinal rim tissue is known to occur early in glaucoma and measurement of the neuroretinal rim area is possible by magnification corrected analysis of optic disc photographs (planimetry). This study was performed to determine whether the facility to distinguish between glaucomatous and normal optic discs could be improved upon by: (a) taking into account the known relation between optic disc size and neuroretinal rim area, and (b) measuring rim area in a number of segments, in order to detect focal changes.
METHODS—Planimetric examination of the optic disc photographs of 88 control subjects and 51 patients with early visual field defects was performed. In the control group, multiple linear regression analysis was performed between neuroretinal rim area and optic disc area, age, sex, eye side, refraction, and keratometry. This was repeated for the whole disc and for each of twelve 30 degree segments. Normal ranges were defined by the 98% prediction intervals of the regression analysis and the sensitivity and specificity for correct identification of optic discs in the two groups determined.
RESULTS—Multiple linear regression demonstrated significant associations between the neuroretinal rim area and optic disc area and age in normal subjects. Sensitivity and specificity for glaucoma diagnosis, using the cut off derived from the 98% prediction intervals, was 37.7% and 98.9% respectively when total neuroretinal rim area alone was considered, and 88.7% and 94.3% respectively when the 30 degree segments were included. The most frequent pattern of neuroretinal rim loss was diffuse, followed by thinning in more than one sector and then by thinning in the inferotemporal sector alone.
CONCLUSIONS—This method of optic disc analysis enables the examiner to identify glaucomatous optic discs at the stage of early perimetric loss with a high degree of precision. Optic disc photography is simple, and fundus cameras are widely available. This method for glaucoma case identification may therefore be suitable for the primary care setting as well as hospital practice.

Keywords: optic disc; glaucoma; case finding; imaging