重视原发性青光眼的早期诊断和干预

原发性青光眼是严重的不可逆转的致盲性眼病之一,早期诊断和干预是防止青光眼患者视功能严重丧失的关键措施。近年来,原发性青光眼的基础和临床研究均取得了重要进展,如对原发性闭角型青光眼（PACG）分类的认识,对PACG发病危险因素的认识,对PACG的处理,对原发性开角型青光眼（POAG）视乳头改变的认识,处理原发性青光眼中目标眼压概念的提出等,均有利于原发性青光眼的早期诊断和干预。加强对眼科医师青光眼早期诊断和干预的继续教育,向公众普及青光眼的防治知识,通过公共卫生的途径早期筛查原发性青光眼等措施,将使大量的原发性青光眼患者得到早期诊断和干预,从而降低青光眼的致盲率。     

青光眼患者生存质量的研究进展

青光眼是当今世界范围内不可逆盲的主要病因,同时也是导致视力丧失的主要原因之一。青光眼的症状、视功能的损害以及各种对症的治疗方式、不良反应使患者的日常生活、社会活动受到不同程度的限制,使患者的心理、社会和经济等方面受到影响,极大地影响患者的健康。就青光眼患者生存质量（QOL）测评的意义及工具、影响青光眼患者QOL的因素以及如何提高他们的QOL进行综述。     

Relationship between compliance and background factors of glaucoma patients

PURPOSE: To obtain useful information for the improvement of patient compliance in the medical treatment of glaucoma. SUBJECTS AND METHODS: An unsigned attitude survey on glaucoma and eye drops was conducted with 431 glaucoma patients. Correlation between compliance and individual(objective and subjective) factors was investigated. Objective factors were age, sex, number of eye drop products, duration of disease, and degree of visual field defects. Subjective factors were "stinging sensation with application of eye drops" and "worry about blindness". RESULTS: Thirty-eight percent of the glaucoma patients were compliant, instilling eye drops at the right time and with good technique. For the factor "duration of disease", patients who had glaucoma for 6-10 years had the best compliance. Compliance became poorer with an increasing number of eye drop products. In the subjective factors, less pain and worry led patients to better compliance. CONCLUSION: To improve compliance with medical treatment, we should categorize patients based on objective factors, eliminating their pain and worry, and instructing them not only in the frequency of instillation but also in the technique of administration.     

Quality of life in newly diagnosed glaucoma patients : The Collaborative Initial Glaucoma Treatment Study

OBJECTIVE: The Collaborative Initial Glaucoma Treatment Study (CIGTS) was designed to determine whether patients with newly diagnosed open-angle glaucoma are better treated initially by medicine or immediate filtering surgery. This paper describes the quality-of-life (QOL) measurement approach, instruments included, and the CIGTS participants' QOL findings at the time of diagnosis. DESIGN: Baseline results from a randomized, controlled clinical trial. PARTICIPANTS: Six hundred seven patients from 14 clinical centers were enrolled. INTERVENTION: Patients randomized to initial medication received a stepped medical regimen (n = 307). Those randomized to initial surgery underwent a trabeculectomy (n = 300). The baseline interview was conducted before treatment initiation. All baseline and posttreatment QOL assessments were conducted by telephone from a centralized interviewing center. MAIN OUTCOME MEASURES: The primary outcome measure described in this paper was QOL. The QOL instrument is multidimensional and incorporates both disease-specific and generic measures, including the Visual Activities Questionnaire, Sickness Impact Profile, and a Symptom and Health Problem CHECKLIST: RESULTS: The correlations between QOL measures and clinical outcomes were in the expected direction, but relatively weak. At initial diagnosis, difficulty with bright lights and with light and dark adaptation were the most frequently reported symptoms related to visual function, whereas visual distortion was the most bothersome. Approximately half of the patients reported at least some worry or concern about the possibility of blindness. Within the Visual Activities Questionnaire, higher scores on the Peripheral Vision subscale were associated with more field loss (P < 0.01). In regression analyses controlling for sociodemographics and nonocular comorbidities, increased visual field loss was significantly associated with higher dysfunction among five disease-specific QOL measures (P < 0.05). CONCLUSIONS: Newly diagnosed glaucoma patients reported experiencing some visual function symptoms at the time of diagnosis that would not be intuitively expected based on clinical testing. Some discussion about the association between clinical presentation and worry about blindness may reduce unnecessary concern. These results provide the basis for long-term comparisons of the QOL effects of initial medical and surgical treatment for open-angle glaucoma.     

青光眼知晓度研究进展

青光眼是全球主要的致盲眼病之一,由于其发病相对隐匿,若不急性发作,不易被发现,故其致盲率相当高.90％以上的青光眼患者并不了解此病,提高人们对青光眼的知晓度,有利于青光眼患者更早地发现疾病,避免不可挽回的视觉损失.提高人们对青光眼的知晓度是早期发现、早期诊断、及时治疗、挽救青光眼患者残存视功能的有效途径.国内外许多学者对青光眼知晓度做了一定的研究.本文从青光眼知晓度的现状、获得青光眼知识的途径、影响青光眼知晓度的相关因素、青光眼知晓度对心理障碍及生存质量的影响、主动学习和健康教育方式对知晓度的影响几个方面,就近年来关于青光眼知晓度的相关研究进行综述.     

On the socio-economic relevance of glaucoma

About 800,000 people in Germany suffer from glaucoma. As the population ages, the prevalence of glaucoma will rise and the socio-economic impact of the disease increase. The costs of glaucoma include those of diagnosis, medical, laser and surgical treatment, and costs of blindness as a result of glaucoma. So far the costs of diagnosis and screening programs are not well known but there is substantial knowledge of the therapeutic costs. Daily therapy costs are about 0.50 to 1.00 euro per patient. Every year the German statutory health insurance system pays about 1,000 euro per glaucoma patient. In addition, blindness due to glaucoma costs the German government over euro 150 million annually in Social Security benefits, lost income tax revenues, and health care expenditures. Demographic changes and scientific progress will even aggravate the socio-economic burden of this disease.     

Risk assessment in the management of patients with ocular hypertension

PURPOSE: To develop a model for estimating the global risk of disease progression in patients with ocular hypertension and to calculate the "number-needed-to-treat" (NNT) to prevent progression to blindness as an aid to practitioners in clinical decision making. DESIGN: Development of a mathematical model for estimating risk of glaucoma progression. METHODS: Population-based studies of patients with ocular hypertension and glaucoma were reviewed by a panel of glaucoma specialists. Measures of disease progression risks derived from three long-term studies and assumptions based on the available data were used to estimate the risk of progression from ocular hypertension to glaucoma and glaucoma to unilateral blindness for untreated and treated patients over a 15-year period. Using these estimates, the NNT (1/absolute risk reduction on treatment) to prevent unilateral blindness in one patient with ocular hypertension was calculated. RESULTS: In untreated patients, the estimated risk of progression from ocular hypertension to unilateral blindness was 1.5% to 10.5% and in treated patients, the estimated risk of progression was 0.3% to 2.4% over 15 years. From these estimates, between 12 and 83 patients with ocular hypertension will require treatment to prevent one patient from progressing to unilateral blindness over a 15-year period. CONCLUSION: Global risk assessment that incorporates all available data plays a vital role in managing patients with ocular hypertension. A more precise understanding of long-term vision loss should be factored into decisions pertaining to the initiation of glaucoma therapy. Undoubtedly, these estimates will evolve and change with the availability of new population-based epidemiologic information and improvements in multivariable model testing.     

Treating patients presenting with advanced glaucoma--should we reconsider current practice?

The management of patients presenting with advanced glaucoma presents a challenge to glaucoma clinicians. Presentation with advanced visual field loss is an important risk factor for progression to blindness in the affected eye(s) during the patients' lifetime. Maximising intraocular pressure (IOP) control in such situations is likely to minimise the risk of further visual field deterioration thus either preventing or slowing progression to blindness. Currently most patients presenting with advanced disease in the UK are managed on an escalating regime of medical treatment. Should this fail glaucoma surgery is usually employed to further lower IOP. Although glaucoma surgery is generally a safe and successful intervention it carries a small risk of severe visual loss and is considered by many clinicians as an intervention only to be used following failure of medical treatment. Recently however the National Institute for Clinical Excellence has suggested in its clinical guidelines for management of ocular hypertension and glaucoma that primary surgery should be offered to patients presenting with advanced glaucomatous visual field loss. This is contrary to the practice of most UK ophthalmologists. In this review the current available evidence underlying the management of presentation with advanced disease is examined.     

Glaucoma among patients enrolled in a national vision care plan

BackgroundGlaucoma is one of the leading causes of impaired vision and blindness in the United States. An understanding of the disease process and its risk factors by patients is essential if its consequences are to be mitigated. Among the known risk factors, family history is one that can help promote awareness for early recognition and treatment among potential patients. This study reports on the responses to a questionnaire by glaucoma patients on their use of vision care, their understanding of their disease, and whether they shared their medical history with other family members.MethodsA survey was mailed to members of a national vision care benefits plan who received an eye examination with a diagnosis of glaucoma. Patients were identified by diagnosis through the managed care organization's management information system. A survey instrument was designed to determine family history, use of vision care, medications used, and basic knowledge of glaucoma.ResultsOne hundred forty-eight surveys were returned; two thirds were from glaucoma patients and one third from glaucoma suspects. The frequency of eye examinations and the reason for their most recent examination differed between the 2 groups. Most glaucoma patients informed relatives of their condition. As expected, glaucoma patients were better educated than the glaucoma suspect group; however, knowledge of the disease process and its consequences was lacking even among those who were taking glaucoma medication.ConclusionsSome glaucoma patients appear to be unaware as to how glaucoma affects their vision. Understanding one's disease can enhance patient compliance and ensure that the patient returns for continued treatment and management. Patients with poor health literacy (especially with a disease with an asymptomatic beginning stage) are at a higher risk for noncompliance.     

Impact of impaired vision and eye disease on quality of life in Andhra Pradesh

PURPOSE: To determine the impact of visual impairment and eye diseases on quality of life (QOL) in an older population of Andhra Pradesh in southern India. METHODS: The World Health Organization (WHO) QOL (WHOQOL) instrument was adapted as a health-related quality of life (HRQOL) instrument for administration to adults participating in the Andhra Pradesh Eye Disease Study. Participants aged 40 years and older (n = 3702), 99.4% of the 3723 eligible, who underwent interview and detailed dilated ocular eye evaluation by trained professionals were included in this study. Psychometric properties of the HRQOL instrument were evaluated among visually impaired people. Relationships among overall QOL scores and presenting visual acuity in the better eye, specific eye diseases, and demographic variables were examined. RESULTS: Internal consistency was high for the entire questionnaire (alpha = 0.94). Each item of the QOL scale had an adequate item-total correlation (range, 0.25-0.77) greater than 0.2. After adjusting for demographic variables and ocular disease, Subjects with blindness had significantly lower QOL scores. Subjects with glaucoma or corneal disease independent of visual acuity had lower scores than subjects without those eye diseases. Subjects with cataract or retinal disease had significantly lower scores than those without cataract or retinal disease in the model without visual acuity but not when visual acuity was added to the model. CONCLUSIONS: Decreased QOL was associated with the presence of glaucoma or corneal disease independent of visual acuity and with cataract or retinal disease as a function of visual acuity. Visual impairment from uncorrected refractive errors was not associated with decreased QOL.     

青光眼固定配方复合制剂的发展和现状

青光眼是重要的不可逆转的致盲性眼病,药物治疗是其主要干预手段,尤其是原发性开角型青光眼。对于基线眼压较高的青光眼患者,单一用药往往不能有效控制眼压至安全水平,因此需选择联合用药方式。传统非固定配方的青光眼联合用药法存在用药次数多、频率高,影响患者正常工作和生活,影响用药依从性,增加药物防腐剂在眼局部浓度等问题。因此,研究新型的青光眼固定配方复合制剂成为青光眼药物治疗的新方向,有必要对目前青光眼新型固定配方复合制剂的优缺点、临床疗效评价等方面的研究进展作一综述。     

Glaucoma screening: current trends, economic issues, technology, and challenges

PURPOSE OF REVIEW: Glaucoma is one of the leading causes of irreversible blindness worldwide. Early glaucoma detection and treatment are currently the only known methods for preventing blindness and low vision resulting from this frequently asymptomatic disease. RECENT FINDINGS: New technologies for detecting early glaucomatous damage are important in diagnosing optic nerve disease, not only in community screening settings but also in clinics. Imaging of the optic nerve head and macula and retinal nerve fiber layer analysis can provide quick, automated, and quantitative measurements in agreement with clinical estimates of optic disc structure and visual function. In the area of perimetry, frequency-doubling technology is a promising and feasible mass-screening method with reasonable sensitivity for detecting visual field loss. Central corneal thickness has emerged as a new risk factor for the development and progression of glaucoma, thereby complicating the role of tonometry and measurement of intraocular pressure as screening parameters for glaucoma. Along with technological advances, strides are also being made with public policy and legislative efforts to bring glaucoma onto the national and global health care agenda. These initiatives incorporate vision-screening goals into national disease prevention programs emphasizing the need for early glaucoma detection and treatment. SUMMARY: Glaucoma awareness needs to be increased through better education, and compliance with follow-up care needs to be improved to decrease the economic and social costs from glaucoma. In addition, screening models need to be developed that will be effective in developing countries where the risk of blindness from glaucoma is highest.     

急性原发性闭角型青光眼

Acute primary closed angle glaucoma is fast becoming one of the most important causes of blindness in the 21 st Century. World bhnding statistics show that there are 60 million people suffering from glaucoma. Of these,approximately 6 million are blind and 1.5 million (25%) are due to acute closed angle glaucoma. With the aging population, the number of patients blind from glaucoma will continue to increase.Attacks from acute primary closed angle glaucoma can lead to irreversible blindness to the affected eye.Blindness can be effectively prevented in acute primary closed angle glaucoma because the severity of symptoms will draw the attention of the patient who will then seek for medical care. Therefore, it is essential to educate the public,doctors and healthcare workers about the danger and symptoms of acute glaucoma. With early diagnosis and treatment to the affected eye and laser iridotomy to the fellow eye-bilateral blindness from acute glaucoma can be prevented.This paper highlights important clinical advances in the management of acute primary closed angle glaucoma and also poses several questions for discussion.(1) What evidence is there to suggest that bilateral blindness from acute primary closed angle glaucom is preventable?(2) In what way is Ultrasonic Biomicroscopy (UBM) useful in clinical research in glaucoma?(3) Will UBM be important in clinical diagnosis in primary closed angle glaucoma?(4) What is the scientific basis of treatment in acute primary closed angle glaucoma?(5) What are the essential procedures to preserve vision in chronic primary closed angle glaucoma?(6) What are the reasons for blindness after laser iridotomy?(7) What is the mechanism of laser iridoplasty?(8) What are the reasons why laser iridoplasty should be combined with laser iridotomy?(9) Why there is an intraocular pressure increase in 50% of eyes within 3 months after laser iridoplasty?(10) Can UBM explain the changes in the angle after lens removal in primary closed angle glaucoma?(11) Are there reasons why trabeculectomy is infrequently used in acute glaucoma, yet it is an important procedure in chronic primary closed angle glaucoma?(12) The scientific reasons why laser iridotomy is essential in the fellow eye.     

西北地区眼科单中心1009例单眼盲患者致盲病因和手术疗效分析

目的　分析我国西北地区眼科单中心行白内障手术的单眼盲患者致盲病因和手术效果,为提高防治提供参考。方法　回顾性系列病例研究。纳入2016年7月至2020年11月陕西省眼科医院（西安市第四医院）收治的对侧眼行白内障手术的单眼盲（单眼裸眼视力＜0.05）患者1009例。采用χ²检验及logistic回归分析对患者致盲病因和白内障手术效果进行分析。结果　1009例单眼盲患者中,男465例（46.1%）,女544例（53.9%）,年龄（67.7±11.9）岁。前6种致盲病因分别为青光眼［29.7%（300例）］、视网膜脱离［15.3%（154例）］、眼外伤［14.4%（145例）］、角膜病［6.4%（65例）］、高度近视［6.1%（62例）］、白内障［5.7%（58例）］。对侧眼手术前、后视力完整者989例,术后视力提高者占90.2％（892例）,未提高者占9.8％（97例）;386例单纯白内障患者术后视力均提高,余603例术后视力提高者与未提高者间差异具有统计学意义的相关因素为眼部合并其他疾病及其治疗史(均为P<0.05),进行logistic回归分析后,有意义的独立因素包括青光眼和眼部合并其他疾病治疗史（均为P<0.05）,其中眼部合并其他疾病治疗史回归系数为-2.016,影响最大。结论　青光眼是我国西北地区行白内障手术的单眼盲患者中最常见的致盲病因,且女性多见。单眼盲对侧眼单纯白内障患者在无禁忌证时应尽早行白内障手术。眼部合并疾病尤其青光眼的及时诊治对白内障手术有积极作用。     

Practical approach to medical management of glaucoma

Primary open angle glaucoma (POAG) is usually a chronic, slowly progressive disease. At present, all resources are directed towards reduction of intraocular pressure (IOP), the only known causal and treatable risk factor for glaucoma, and medical management is frequently the first choice in most cases. With the introduction of innovative tools for early diagnosis and newer medications for treatment, decision-making in diagnosis and treatment of glaucoma has become more complex. The philosophy of glaucoma management is to preserve the visual function and quality of life (QOL) of the individual with minimum effects on QOL in terms of cost, side effects, treatment regime, follow-up schedules as well as socioeconomic burden. Our aim should be not to treat just the IOP, optic disc or visual field, but to treat the patient as a whole so as to provide maximum benefit with minimal side effects. In this article, we describe the scientific approach to medical management, mainly of POAG.     

The Collaborative Initial Glaucoma Treatment Study: interim quality of life findings after initial medical or surgical treatment of glaucoma.

OBJECTIVE: To present interim quality of life (QOL) findings in the Collaborative Initial Glaucoma Treatment Study (CIGTS) using all available follow-up through 5 years from treatment initiation. DESIGN: Randomized controlled clinical trial. PARTICIPANTS: Six hundred seven newly diagnosed patients with open-angle glaucoma from 14 clinical centers. INTERVENTION: Patients were randomly assigned to either initial medical therapy or initial trabeculectomy. After treatment initiation and early follow-up, patients received clinical and QOL evaluations at 6-month intervals. QOL assessments were administered by telephone at a centralized interviewing center. MAIN OUTCOME MEASURES: The CIGTS collected comprehensive QOL information that included both generic and vision-specific QOL measures. This article focuses on initial treatment group differences related to symptom reporting, as measured by a Symptom and Health Problem Checklist, and changes in daily visual functioning, as measured by the Visual Activities Questionnaire (VAQ). RESULTS: Across both treatment groups, there was an overall decline in the percent of participants reporting symptoms over time. Of 43 possible symptoms, 12 symptoms were reported with greater frequency by the surgically treated group and 7 symptoms more frequently by the medically-treated group. The surgical patients reported more total Symptom Impact Glaucoma (P = 0.005) and, in particular, more bother related to local eye symptoms. Very few treatment group differences were noted in visual functioning, although surgical patients reported more problems with activities related to their visual acuity (P = 0.024). The percentage of patients across treatment groups reporting worry about blindness was 50% at baseline but declined to approximately 25% over time. CONCLUSIONS: Overall, the QOL impact reported by the two treatment groups as measured by instruments used in this study is remarkably similar, with relatively few significant study group differences observed after up to 5 years of follow-up in the CIGTS. When significant differences in visual function have been detected using the VAQ, they are consistent with the clinical outcomes. To date, the most persistent QOL finding is the increased impact of local eye symptoms reported by the surgical group compared with the medical group. Although no changes are recommended in the treatment of newly diagnosed glaucoma patients at the time of this interim report, further follow-up will allow for more definitive answers to the QOL impact of these two treatment approaches.     

构筑我国防治青光眼的体系

青光眼是严重的不可逆的致盲性眼病,因此加强青光眼的防治工作非常必要。虽然我国已在防治青光眼方面做了大量工作,但是还存在着不少问题,主要表现在还没有将防治青光眼纳入全国防盲治盲的优先项目,还没有建立起全国性防治青光眼的队伍和机构,还没有在眼科医师中普及和及时更新防治青光眼的知识,还没有建立起青光眼的药品供应网络,还没有在公众中普及防治青光眼的知识。要解决上述问题,应当在我国构筑全国性防治青光眼的体系,其主要目标是提高青光眼的发现率,降低青光眼的致盲率,提高青光眼患者的生活质量,并节省因青光眼致盲的社会成本。为了能顺利地推行这项工作,需要采用公共卫生的途径,而不是仅仅依靠临床途径。在构筑全国防治青光眼的系统中,我们可以从以下几个方面着手开展工作,包括从我国各地的社会经济发展状况出发建立防治青光眼的机构;培训防治青光眼的专业队伍;建立防治青光眼的制度;以及加强防治青光眼的科研工作。     

Cost-effective evaluation of the glaucoma suspect

PURPOSE OF REVIEW: The number of glaucoma patients nationwide will increase appreciably over the coming years reflecting the increased number of elderly people. This increase will require efficient allocation of available healthcare resources for management of the entire spectrum of disease from glaucoma suspect to advanced glaucoma. This review considers the cost-effective management of glaucoma suspects. RECENT FINDINGS: Medications account for the majority of costs of managing glaucoma suspects while the cost of clinical evaluations has remained stable. Early disease recognition limits both direct and indirect costs. Risk stratification of glaucoma suspects can identify those who would benefit most from therapy. Newer structural modalities can be as predictive of early disease progression as stereo disk photography. Short-wavelength automated perimetry and frequency doubling technology may be more appropriate in confirming field changes in this patient population. SUMMARY: Overall costs of managing glaucoma can be limited by preventing early disease progression. Identification and monitoring of glaucoma suspects would help minimize overall costs if intraocular pressure lowering therapy is reserved for high-risk glaucoma suspects or those with early disease. Yet, since the rate of progression to blindness for a particular patient is not known, the most cost-effective time to begin intraocular pressure lowering therapy remains unclear.     

Glaucoma case report: a nutritional response.

BACKGROUND: Primary open-angle glaucoma (POAG) is a leading cause of blindness in aging adults. Intraocular pressure is one clinical sign of this complex chronic disease. Treatment is currently limited to intraocular pressure reduction. Despite advances in intraocular pressure management and treatment, primary open-angle glaucoma patients can experience significant vision loss. CASE REPORT: Clinical findings in a case involving primary open-angle glaucoma are reported. RESULTS: A patient with primary open-angle glaucoma had intraocular pressure that medical treatment was unable to control. After nearly four years of medical therapy, intraocular pressure (IOP) suddenly decreased by 45%. A patented nutritional supplement was used coincident to IOP reduction. CONCLUSIONS: Nutritional factors may be relevant in this case of 45% intraocular pressure lowering.