如何鉴别青光眼与非青光眼性视神经病变

视乳头视杯扩大并非只见于青光眼,还可见于多种神经眼科疾病,其鉴别诊断是临床工作的重点与难点.据国外统计,非青光眼大视杯的患者有20％被误诊为青光眼视神经损害.因此,总结并准确地理解青光眼与非青光眼大视杯的鉴别要点显得非常重要.盘沿色泽以及视功能异常和视盘改变的相关性是视盘形态学上的重要鉴别点.另外,盘沿局限性丢失对于两者的鉴别具有重要的意义.现有的证据显示,其鉴别需详细地询问病史、仔细地观察视盘视杯形态和血管形态,综合视野、神经影像学检查等信息综合判断.     

共聚焦激光视网膜扫描仪对生理性大视杯与原发性开角型青光眼视盘的比较

目的 探讨生理性大视杯和原发性开角型青光眼视盘指标的区别.方法 健康对照25例(25眼),青光眼患者25例(25眼),生理性大视杯30例(30眼),3组受检者作共聚焦激光视网膜扫描仪(Heidelberg retinal tomograpby,HRT-Ⅱ)检查.结果 生理性大视杯组的视盘面积、杯面积、杯容积、杯盘面积比、杯盘直径比值、平均视杯深度、最大杯深、视杯形态与健康对照组和青光眼组比较差异有统计学意义.最大变异轮廓是惟一一个与健康对照组没有差异而与青光眼组有差异的指标.生理性大视杯更容易出现鼻侧改变.结论 生理性大视杯,不能仅靠杯/盘比(C/D)来判断,要结合视神经纤维和视野的检查;HRT-Ⅱ检查生理性大视杯的指标中,最大变异轮廓有特异性,有助鉴别.     

放射性碘125粒子致眼缺血并发新生血管性青光眼一例

一例35岁女性左眼眶局部放射性125I粒子植入1年半后相继发生视网膜中央动脉阻塞、视盘水肿及新生血管性青光眼,考虑与放射性视网膜脉络膜视神经病变导致眼缺血有关.     

青光眼视神经损害的三要素及其盘沿丢失的识别

诊断青光眼视神经损害的三要素为盘沿丢失、视网膜神经纤维层缺损（RNFLD）及视盘线状出血。三要素中如有两要素改变应诊断为视神经损害。对于盘沿丢失已往的教科书中均无明确描述,笔者认为识别盘沿丢失必须首先认识正常盘沿形态及其影响因素。大多数的正常盘沿形态符合ISNT法则,生理性大视杯也符合该法则。不符合ISNT法则者为盘沿丢失,或者为正常盘沿形态变异。后者如部分小视盘下方盘沿可比上方盘沿窄,判断是否上、下方盘沿丢失时应将其与鼻侧盘沿进行比较;横椭圆视盘鼻侧盘沿较宽,应上、下盘沿比较;视盘主干血管发出位置偏位、视盘倾斜也会影响盘沿形态。如果参照ISNT法则认识正常盘沿变异因素,就不难发现盘沿丢失。然而不是所有的盘沿丢失均为青光眼所致,应鉴别非青光眼性视神经损害。     

视乳头水肿的后天性视神经睫状分流血管

后天性视神经睫状分流血管(optociliary shunt vessels)罕见,临床表现独特。在蝶眶脑膜瘤、视神经胶质瘤、视神经蛛网膜囊肿、视盘玻璃疣、青光眼以及视网膜中央静脉阻塞后均可见有视神经睫状分流血管。本文7例因长期视乳头水肿而有此改变。例1女性37岁,进行性左臂、腿软弱2年,近发数次局灶性癫痫。有左侧锥体束征,整个头颅可闻声响传播。视力好,视野鼻侧稍缩小。视盘略苍白,边缘模糊有一些玻璃疣样小体,视盘上有数支扭曲的视神经睫状分流血管。荧光血管造影见视盘上及邻近视网膜的放射状毛细血管,轻度扩张,染料渗入其周围视网膜,证明有视乳头     

非青光眼性大视杯

病理性大视杯多见于慢性或正常眼压性青光眼,然而并非所有病理性大视杯都为青光眼所致,许多非青光眼疾病最终出现视神经萎缩也可引起病理性视杯扩大[1],称为非青光眼性病理性大视杯(NGODC).NGODC发生率较低,目前尚没有较大样本的研究证实视神经和视网膜疾病发生NGODC的比率,但正因为发生率低,因此经常不被临床医生发现和重视.据统计,在临床工作中,约20％的这类患者被误诊并按青光眼进行治疗[2,3].因此,对于神经眼科、眼底病和青光眼专业的医生而言,正确认识这一病理现象,合理诊断和治疗相关疾病具有重要的临床意义.     

青光眼视盘出血的部位和频率

青光眼视盘出血的部位和频率［英］／ＪｏｎａｓＪＢ…∥ＡｍＪＯｐｈｔｈａｌｍｏｌ．－１９９４，１１８（１）．－１～８青光眼视神经损害有以下几个动态学特征：视盘边沿形态和面积的改变、视杯加深、视盘颜色变苍白、视乳头旁的脉络膜视网膜萎缩扩大、视网膜小动脉直...     

先天性视盘缺损

本病常单眼患病,视力一般较差,但据视盘缺损程度不同可有较大差异。视野检查生理盲点扩大。眼底表现为视盘异常增大,视杯大而深,盘沿丢失,可合并有局限性或弥漫性视网膜神经纤维层缺损（RNFLD）,偶可伴有脉络膜缺损。根据眼压有无异常、双眼视盘面积不对称、损害呈非进行性等特征易于与青光眼鉴别。     

HRT-Ⅱ在青光眼随访中的应用

目的:应用HRT-Ⅱ检测青光眼视神经乳头的形态改变及视网膜神经纤维的丢失,探讨HRT-Ⅱ在青光眼随访中的意义。方法:已确诊的青光眼患者50例63眼纳入本研究,利用HRT-Ⅱ每6～12mo观察视盘及视神经纤维的变化。结果:盘沿面积、盘沿体积、最大视杯深度、平均视网膜神经纤维层(RNFL)厚度、RNFL截面面积等视盘参数前后2次检查结果差异有显著性意义(P<0.05)。结论:HRT-Ⅱ能够快速、可重复性地测量视盘形态及视神经纤维层的改变,并且可以重复分析视盘参数的变化。     

进一步提高视神经萎缩的诊断水平

视神经萎缩在眼科临床较为常见,患者通常有不同程度视功能损害。导致视神经萎缩的原因不同其临床表现和视功能预后也有所不同,应区分病因分别对待。在临床工作中可根据视盘形态的差异鉴别视神经萎缩,应注重区分视神经萎缩与先天性视盘形态异常、孤立性遗传性视神经病变与系统性神经系统疾病所致视神经改变以及视神经的生理性变异等。正确认识视神经萎缩,对于判断其病因,并采取适当的干预措施、保护患者视功能非常重要。     

Optic disk morphology in experimental central retinal artery occlusion in rhesus monkeys.

PURPOSE: To evaluate longitudinally the optic disk morphology of nonglaucomatous optic nerve damage secondary to retinal nerve fiber damage, using experimental central retinal artery occlusion in rhesus monkey eyes as a model. METHODS: This prospective study included 24 eyes of 16 monkeys. In eight eyes of eight animals, central retinal artery occlusion was produced by clamping the central retinal artery in the retrobulbar space. Occlusion was verified by fluorescein fundus angiography. The same eyes at baseline as well as the eight contralateral healthy eyes and eight monkey eyes with experimental high-pressure glaucoma served as control groups. Serially taken optic disk photographs were morphometrically evaluated. RESULTS: The area and shape of the neuroretinal rim and alpha zone and beta zone of parapapillary chorioretinal atrophy of eyes after central retinal artery occlusion did not vary significantly (P > .30) from the same eyes before central retinal artery occlusion nor from the normal contralateral eyes. In the glaucomatous eyes, the neuroretinal rim was significantly (P < .001) smaller and parapapillary atrophy significantly (P = .01) larger than in the eyes after central retinal artery occlusion. CONCLUSIONS: Experimental central retinal artery occlusion, in contrast to glaucoma, does not markedly change the size and shape of parapapillary atrophy and neuroretinal rim; this confirms previous clinical studies. Thus, assessment of parapapillary atrophy and neuroretinal rim may be helpful to differentiate between glaucomatous optic neuropathy and nonglaucomatous optic neuropathy secondary to retinal nerve fiber damage. Parapapillary atrophy is independent of decreased retinal blood perfusion and development of nonglaucomatous optic nerve atrophy following experimental central retinal artery occlusion.     

Iris colour, optic disc dimensions, degree and progression of glaucomatous optic nerve damage

PURPOSE: To evaluate whether iris colour influences size and shape of the optic nerve head and risk for glaucoma progression. METHODS: The hospital-based observational study included 1973 eyes of 1012 Caucasian subjects with ocular hypertension or chronic open-angle glaucoma. For all patients, colour stereo optic disc photographs were evaluated, and corneal pachymetry and achromatic perimetry were performed. Main outcome measures were optic nerve head parameters, the development or progression of visual field defects and iris colour. RESULTS: In most of the study groups, size of the optic disc, neuroretinal rim, alpha zone and beta zone of parapapillary atrophy, retinal vessel diameter and central corneal thickness did not differ significantly between eyes with blue, green, brown and mixed iris colour. In the normal-pressure glaucoma group, neuroretinal rim area was smallest in the population with mixed-coloured eyes and largest in the group of eyes with brown irides (P = 0.001 after correction for inter-eye dependency and multiple testing). For the ocular hypertensive subjects and glaucoma patients with follow-up examinations, the rate of development or progression of glaucomatous visual field loss was not significantly associated with iris colour (P = 0.060). CONCLUSIONS: In Caucasian subjects, iris colour does not have a major association with the size of the optic nerve head structures, central corneal thickness and retinal arterial diameter. In Caucasian patients with ocular hypertension or chronic open-angle glaucoma, an influence of iris colour on the risk for development or progression of glaucomatous visual field defects could not be confirmed.     

Glaucomatous versus nonglaucomatous optic disc cupping: clinical differentiation

Cupping of the optic nerve head associated with normal intraocular pressure (IOP) is a common clinical presentation for which clearly defined management guidelines have not been established. The clinical approach represents a diagnostic challenge because the mechanism of optic nerve injury is often difficult to objectively establish. Of paramount importance is the primary distinction between physiologic cupping and pathologic cupping, and the accurate subclassification of eyes with pathologic cupping. Therefore, it is essential for clinicians to differentiate glaucomatous from nonglaucomatous disc damage. This article reviews the clinical differentiation of eyes with glaucomatous and nonglaucomatous optic disc cupping.     

视盘的有效评估:与杯盘比的对比

青光眼是一种以进行性视盘变化和视野损失为特征的眼压相关性疾病。杯盘比在过去40a来都是评价视盘青光眼性改变的标准方法。然而我们却发现是一些小视盘的患者有典型青光眼性视野损失,而一些大视盘的患者却没有视野损失。杯盘比的检查效力和可重复性都低于一些新的检查方法。视盘损伤可能度分级(DDLS)是一种衡量视盘盘沿面积、并且校正了视盘大小等影响因素的新型视盘评价方法。DDLS也许是评价青光眼视盘的更为优化的方法。     

HRT视盘参数在原发性开角型青光眼早期诊断中的作用

目的:在众多海德堡视网膜断层扫描仪(heidelberg retina tomogragh,HRT)测定的视盘参数中,筛选出最有助于青光眼早期诊断的视盘参数。方法:用HRT测定23例视野损害较轻的青光眼患者和23例正常人的视盘参数(杯盘面积比、盘沿面积、盘沿容积、视杯容积、视杯形态测量、视杯高度变异轮廓和平均神经纤维层厚度)作逐步判别分析。结果:盘沿面积和杯盘面积比对青光眼早期诊断最有帮助,其诊断敏感度和特异度分别为87%和96%。结论:本组资料盘沿面积和杯盘面积比是区分青光眼和正常眼最好的判别因素。     

Thickness of the lamina cribrosa and peripapillary sclera in Rhesus monkeys with nonglaucomatous or glaucomatous optic neuropathy

Purpose: To measure the thickness of the lamina cribrosa and peripapillary sclera in monkeys with a nonglaucomatous optic nerve damage and to compare that with those of monkeys with glaucomatous optic neuropathy. Methods: The study included 22 monkey eyes (Macaca mulatta) which had undergone a temporary experimental central retinal artery occlusion (CRAO) and seven monkey eyes in which experimental glaucoma was unilaterally produced. We measured histomorphometrically the thickness of the lamina cribrosa and peripapillary sclera. Results: The lamina cribrosa was significantly thicker in the CRAO group than in the glaucoma group (central region: 212 ± 46 μm versus 167 ± 17 μm; p = 0.009). The thickness of the peripapillary sclera at the optic disc border (253 ± 39 μm versus 192 ± 21 μm; p = 0.001) and outside of the optic nerve meninges (408 ± 70 μm versus 314 ± 64 μm; p = 0.006) was significantly greater in the CRAO group. Conclusions: In monkey eyes with a temporary CRAO as a model for nonglaucomatous optic nerve damage, the lamina cribrosa is significantly thicker than in monkey eyes with experimental glaucomatous optic nerve damage. It may suggest that the loss of optic nerve fibres might not be the reason for the thinning of the lamina cribrosa in eyes with advanced glaucoma. The thinner peripapillary sclera in the glaucomatous eyes may suggest that the monkey sclera is more vulnerable to stretching with increased intraocular pressure than the human eye for which no glaucoma‐related lengthening of the eyeball and thinning of the peripapillary sclera have been observed.     

Parapapillary retinal vessel diameter in normal and glaucoma eyes. II. Correlations

The juxtapapillary diameters of the superior temporal and inferior temporal retinal artery and vein have been shown to be significantly smaller in glaucomatous eyes than in normal eyes. They had been measured in 473 eyes of 281 patients with chronic primary open-angle glaucoma and in 275 eyes of 173 normal subjects. In the current study the vessel diameters were correlated with intra- and parapapillary morphometric data and visual field indices. Only one eye per patient and subject was taken for statistical analysis. The retinal vessel calibers were significantly (P less than 0.001) correlated with: (1) the area of the neuroretinal rim as a whole and in four different optic disc sectors; (2) the rim width determined every 30 degrees; (3) the optic cup area and diameters; (4) the horizontal and vertical cup/disc ratios and (5) the quotient of them; (6) the retinal nerve fiber layer score; (7) the area of the parapapillary chorioretinal atrophy; and (8) the visual field indices. In the same eye the vessel caliber was smaller in that sector where the neuroretinal rim loss was highest and the retinal fiber layer score lowest. In intraindividual comparison the vessels were smaller in that eye with less neuroretinal rim tissue and lower nerve fiber layer score. No significant correlations were found with the form of the optic disc, the area of the peripapillary scleral ring, side, sex and refraction. The correlation coefficients were not significantly different when the control group was matched for age. The parapapillary retinal vessel diameter decreases with advancing glaucomatous optic nerve damage. It is correlated with morphometric intra- and parapapillary glaucomatous changes and perimetric defects.     

Clinical implications of peripapillary atrophy in glaucoma

PURPOSE OF REVIEW: To elucidate peripapillary atrophy in glaucomatous optic neuropathy; its ranking in the morphologic diagnosis of the glaucoma, and its value for the differentiation of various types of chronic open-angle glaucoma, for the separation of glaucomatous eyes from nonglaucomatous eyes, and for the detection of progression of glaucoma. RECENT FINDINGS: Recent studies showed an association of peripapillary atrophy with glaucoma and the eventual development of glaucomatous disc hemorrhages independent of a small neuroretinal rim area, and an association between increasing peripapillary atrophy and progressive glaucoma. A ranking of optic disc parameters to detect glaucomatous damage revealed that the alpha and beta zones of peripapillary atrophy, compared with neuroretinal rim parameters, are less useful. Pseudoexfoliation syndrome without glaucoma is not a risk factor for peripapillary atrophy. In arteritic anterior ischemic optic neuropathy, peripapillary atrophy does not enlarge. Peripapillary atrophy does not differ markedly between Europeans and South Indians. In contrast to the position of the central retinal vessel trunk, the presence and position of cilioretinal arteries do not markedly influence the progression of peripapillary atrophy in glaucoma. SUMMARY: Peripapillary chorioretinal atrophy is one among several morphologic variables to detect glaucomatous abnormalities. Ranking optic disc variables for the detection of glaucomatous optic nerve damage, peripapillary atrophy is a variable of second order. It is useful for the differentiation of various types of chronic open-angle glaucomas. In contrast to glaucomatous eyes, eyes with nonglaucomatous optic nerve atrophy, including eyes after arteritic anterior ischemic optic neuropathy, do not show an enlarged peripapillary atrophy.     

Anterior ischaemic optic neuropathy in a patient with optic disc drusen

Background: Although visual field defects are well-known complications of optic disc drusen, reduction in visual acuity with this condition is rare. Method/Results: We report on a 68-year-old male with bilateral optic disc drusen who presented with monocular loss of vision in the right eye associated with an inferior altitudinal visual field defect and signs consistent with acute anterior ischaemic optic neuropathy, confirmed on fluorescein angiography. He also had a left inferior nasal step, but no evidence of glaucomatous cupping. The disc drusen were documented clinically and on B scan ultrasound and computed tomography. Conclusions: The diagnosis of acute anterior ischaemic optic neuropathy should be considered in patients with optic disc drusen who present with reduced visual acuity, particularly when the visual loss has been acute and non-progressive and is associated with altitudinal field loss and characteristic fluorescein angiography signs.     

Outer retinal abnormalities associated with inner retinal pathology in nonglaucomatous and glaucomatous optic neuropathies

Inner and outer retinal morphology were quantified in vivo for 6 nonglaucomatous and 10 glaucomatous optic neuropathy patients. Custom, ultrahigh-resolution imaging modalities were used to evaluate segmented retinal layer thickness in 3D volumes (Fourier-domain optical coherence tomography), cone photoreceptor density (adaptive optics fundus camera), and the length of inner and outer segments of cone photoreceptors (adaptive optics-optical coherence tomography). Quantitative comparisons were made with age-matched controls, or by comparing affected and nonaffected retinal areas defined by changes in visual fields. The integrity of outer retinal layers on optical coherence tomography B-scans and density of cone photoreceptors were correlated with visual field sensitivity at corresponding retinal locations following reductions in inner retinal thickness. The photoreceptor outer segments were shorter and exhibited greater variability in retinal areas associated with visual field losses compared with normal or less affected areas of the same patient's visual field. These results demonstrate that nonglaucomatous and glaucomatous optic neuropathies are associated with outer retinal changes following long-term inner retinal pathology.