青光眼损害程度分期诊断的意义

原发性青光眼作为慢病需要终生接受眼保健服务。本文重点介绍近年来美国青光眼协会依据标准化自动视野检查结果制定的基于ICD-9的青光眼分期诊断编码标准,该标准将青光眼分为轻度、中度、重度。国内一些医疗单位的PACS系统曾将青光眼视盘损害分为早、中、晚3期5级。目前尚缺乏视盘损害分期与上述视野损害分期对应关系的研究。青光眼损害分期诊断的研究具有重要的临床及社会学意义,它有利于眼科医师对患者区别治疗与评价治疗手段的有效性,有利于改善医患对青光眼病情的交流沟通,有利于卫生主管部门、医疗保险机构制定合理的青光眼防治策略及费用支付方案。（眼科,2014,23： 6-8）     

晶状体溶解性青光眼(附8例报告)

晶状体溶解性青光眼是一种由晶状体皮质溶解而引起的急性继发性充血性开角型青光眼。本文报告8例并结合复习文献,对本病的发病机制、临床特征及诊疗要点作一介绍。     

A new strategy to interpret OCT posterior pole asymmetry analysis for glaucoma diagnosis

AIM: To detect early glaucoma by optical coherence tomography (OCT) posterior pole asymmetry analysis. METHODS: Totally 39 eyes from 39 healthy subjects, 40 eyes from 40 mild glaucoma patients, 33 eyes from 33 moderate glaucoma patients and 41 eyes from severe glaucoma patients were included in this study. All subjects underwent posterior pole asymmetry analysis (PPAA) of OCT and the posterior pole area was divided into three zones. Means, standard deviations and 95% confidence intervals of each zone asymmetry in control group were assessed. Retina thickness asymmetry (RTA) of different stage of glaucoma were compared for each zone, and receiver operating characteristic (ROC) curves were made to test the efficacy of strategies using different zones to discriminate glaucomatous eyes from the healthy ones. RESULTS: In a healthy population, RTA of the centre zone showed the minimal mean value (3.085 μm), standard deviation (1.756), and the narrowest 95% confidence interval (from 2.360 to 3.810 μm). It was only in the center zone that RTA exhibited significant difference between control and moderate glaucoma group (P<0.01), as well as control and severe glaucoma group (P<0.00001). The strategy utilized in the center zone had the strongest diagnostic capability (zone 3 AUROC=0.816, P=0.0016) in comparison to that of the periphery area (zone 1 AUROC=0.675, P=0.0016; zone 2 AUROC=0.623, P=0.0197), the whole posterior pole involved interpreting strategy showed inferior diagnostic power than the centre zone dependent strategy (z=2.851, P=0.0044). CONCLUSION: Utilizing the posterior pole centre zone to interpret OCT PPAA results are more effective than making use of the whole posterior pole map.     

睫状环阻塞性青光眼的治疗方法的临床报道

目的探讨睫状环阻塞性青光眼的治疗方法及疗效。方法在本院行青光眼术后发生的睫状环阻塞性青光眼25例（27眼）,进行早期综合药物治疗,包括散瞳、皮质类固醇滴眼、碳酸酐酶抑制剂滴眼和口服,甘露醇静脉滴注等,疗程结束后所有患者均进行结果评定,并对其临床资料进行总结分析。结果术后早期均有轻度的角膜水肿,前房变浅或消失,眼压正常或升高。7眼青光眼联合白内障手术伴不同程度的前房渗出,2眼人工晶状体前膜形成,经皮质类固醇及散瞳局部治疗1周后角膜透明：渗出及膜均吸收,前房反应消失,前房深度恢复正常。此外,治疗后的平均眼压（17．3±2．3）mmHg,与治疗前平均眼压（25．0±2．0）mmHg比较,差异显著。结论早期综合药物治疗青光眼术后发生的睫状环阻塞性青光眼,眼压均得到有效的控制,治疗成功后部分患者继续长期滴用睫状肌麻痹剂的措施有一定效果。     

青光眼睫状体炎综合征并发原发性闭角型青光眼临床分析

目的探讨青光眼睫状体炎综合征(PSS)并发原发性闭角型青光眼(PACG)的临床特点和治疗方法。方法回顾性分析6例PSS并发PACG患者的临床资料并与146例一般的PSS患者的资料作对比分析。结果①并发PACG的PSS患者的年龄较大、病程较长,青光眼损害相对多而重;②6例中1例先诊断为PSS,其他5例先诊断为PACG;③YAG激光虹膜周边切除术治疗4例,PACG临床治愈3例,4例PSS仍有发作但未加重;④外引流手术治疗3例,PACG治愈,其中2例PSS已停止发作。结论PSS并发PACG是客观存在的;并发PACG的PSS患者具有年龄较大、病程较长及青光眼性视野损害较多较重等特点;对具有前述特点的PSS患者要注意PACG的有关检查,对PACG治疗后房角开放,单眼间歇性眼压升高的患者应警惕PSS;妥善把握好适应证和时机,并发PSS的PACG的激光治疗和外科手术的效果良好。     

Iris lymphoma—a systematic guide for diagnosis and treatment

Iris lymphomas are rare malignant neoplasms arising either as primary tumors in the iris or as secondary tumors involving the iris. We summarize previously published data and make recommendations for work-up strategies for cases of suspected iris lymphoma. Our objective is to provide a structured overview of the typical clinical symptoms and signs, the pathologic, ophthalmic, as well as hematologic work-up for diagnosis, treatment, and follow-up of iris lymphomas and offer a flowchart on how to diagnose and treat these tumors.     

A novel technique of ab interno glaucoma surgery: follow-up results after 24 months

Purpose It was the aim of this study to investigate the efficacy, longevity, and safety of a new ab interno intervention for the treatment of primary open-angle glaucoma (POAG). Methods The previously described method of radiofrequency-mediated “sclerothalamotomy ab interno” was applied in 53 eyes of consecutive patients with POAG between April 2002 and July 2002. Average preoperative intraocular pressure (IOP) was 25.6±2.3 mmHg (range 18–48 mmHg). Sclerothalamotomies were carried out with a custom-made high-frequency dissection 19 G probe (tip 0.3×1 mm) applying bipolar current with a frequency of 500 kHz (tip temperature 130°C). Results After a follow-up period of 24 months, the average IOP was 15.0±1.6 mmHg (range 11–20 mmHg) (p<0.005). The average number of topical agents was 2.6±1.0 (range 1–5) preoperatively. Twenty-four months after surgery such agents were used in only five (9.6%) eyes and the average was 0.21±0.53 (range 0–2). Transient IOP elevation was observed in 12 of 53 eyes (22.6%) postoperatively. In all cases elevated IOP could efficiently be controlled with topical medication. In general, IOP dropped continuously over the course of the 6 months following surgery and then remained constant. Conclusions This study indicates that sclerothalamotomy ab interno is a safe and efficient surgical method for the treatment of POAG. Long-term results clearly demonstrate the longevity of IOP reduction.     

Systems for staging the amount of optic nerve damage in glaucoma: a critical review and new material

The evaluation of the appearance of the optic disk is central to the diagnosis and management of patients with glaucoma. Grouping patients into categories, monitoring change, and quantitating the rate of change all require some type of quantitative staging of the amount of damage. Though the scientific literature regarding the appearance of the optic disk in glaucoma is extensive, there is remarkably little about quantitative staging of the amount of damage. We have identified eight systems, including the cup/disk ratio system of Armaly. Most of the earlier systems suffer from a failure to take into account the importance of the size of the optic disk. Furthermore, only one system includes early amounts of damage. This review is a critical appraisal of the known methods for staging optic disk damage in glaucoma, including the recent Disk Damage Likelihood Scale, which appears to offer substantial advantages over the other systems.     

青少年开角型青光眼118例临床分析

目的:探讨青少年开角型青光眼的临床特点,并对其早期诊断、治疗、预后进行分析讨论。方法:抽取1997/2007年收治的青少年开角型青光眼118例(236眼),对其性别、年龄、屈光状态眼压、房角、眼底、视野、家族史等各有关参数及治疗情况等,进行回顾性统计分析。结果:男51例(43.2%)、女67例(56.8%),发病年龄10~20岁占本组病例的70.3%,并发近视眼者占77.1%(182/236),治疗前最高眼压10~21mmHg者80眼(33.9%),21~25mmHg者52眼(22.0%),26~30mmHg者64眼(27.1%),31~40mmHg者29眼(12.3%),>40mmHg者11眼(4.7%)。C/D<0.6者146眼(61.9%),C/D0.6~0.8者81眼(34.3%),C/D>0.8者9眼(3.8%)。视网膜神经纤维层缺损阳性率为94.9%,视野缺损阳性率为65.2%。房角全部为开角未见特殊异常。有青光眼家庭史者13例(11.0%)。本组有28例(50眼)施行滤过性手术,其余均为药物保守治疗。治疗后眼压控制良好,但视力提高者仅57眼(24.2%)。结论:青少年开角型青光眼(juvenile open angle glaucoma,JOAG)的发病年龄越来越年轻化,近视眼是JOAG最主要危险因素之一,视网膜神经纤维层缺损是JOAG早期诊断的一个高敏感性和高特异性客观依据,JOAG应早期诊断、合理治疗、定期随访,其预后比较乐观。     

青光眼随诊时视盘出血的意义

青光眼随诊时采用系列眼底照相、计算机图像配比法是发现与追踪视盘出血（dischemorrhages,DH）及其相关改变的较好方法。观察DH对于青光眼病情随访、调整目标眼压及其他治疗方案具有重要意义。目前认为,DH是青光眼视网膜神经纤维层缺损加重及视野损害进展的重要危险因素,甚至认为是青光眼病情进展的先兆体征或标志。它可能是青光眼治疗不充分或未达到目标眼压的指征,对此应密切进行视神经形态与视野随访,并及时实施有效的降眼压治疗。（国际眼科纵览,2012,36：289—292）     

原发性开角型青光眼治疗进展

既往流行病学结果证明,除白内障以外,青光眼是世界第二大主要的致盲眼病,其中原发性开角型青光眼发病率高,发病机制复杂多样,且发展缓慢,病情隐匿,早期大多数无明显症状,大多数患者就诊时已进入中晚期,出现了不可逆的视功能损伤,对家庭、社会危害极大.因此,早发现、早治疗,防止视功能的进一步损伤是开角型青光眼防治的重中之重.近年来该病患病率在临床上所占的比例逐年上升,相应的诊断及治疗的新方法层出不穷.然而不论早期或是中晚期患者,降低眼压、将眼压控制在目标眼压范围,延缓视功能损害依旧是治疗的最终目标,本文将对近年来对原发性青光眼的诊疗现状及进展做一综述.     

Advanced glaucoma at presentation is associated with poor follow-up among glaucoma patients attending a tertiary eye facility in Southern Nigeria

Purpose: Globally, particularly in Africa, poor compliance with medication is a major problem in glaucoma management but little is known about follow-up rates among African glaucoma patients. The aim of this study was to determine rates of follow-up among glaucoma patients attending a tertiary hospital in southern Nigeria and investigate predictors of poor follow-up.

Methods: Data were extracted from medical records of new glaucoma patients who attended the hospital between June 2011 and May 2013. Socio-demographic and clinical parameters (visual acuity; stage of glaucoma) recorded at diagnosis were extracted using a pre-tested form. Follow-up was defined as good if they had attended within 9 months of the study date, inadequate when the last follow-up was more than 9 months and failed if they did not attend any follow-up or the most recent visit was more than 14 months from the study date. Univariate and multivariable analyses were undertaken to explore predictors of poor follow-up (inadequate plus failed).

Results: Three hundred forty-eight patients were recruited, 54% were male and the mean age was 52.7 (range 16–88) years. Follow-up was as follows: good 28.4%, inadequate 46.6%, failed 25%. Overall, 71.6% had poor follow-up. Independent predictors of poor follow-up were poorer visual acuity (OR 3.85, 95% confidence interval (CI) 1.25–11.80 for visual impairment; OR 4.11, 95% CI 1.32–12.81 for blind) and end-stage glaucoma (OR 3.55 (1.31–9.62), p = 0.01).

Conclusion: Enhanced counselling of patients with moderate to advanced glaucoma and visual impairment is required to improve follow-up and hence glaucoma management.     

青光眼诊断与治疗规范——2017年英国专家共识解读

青光眼是一组会损害视神经甚至可能导致不可逆失明的眼病。近年眼科学者对青光眼的诊断和治疗有了新的认识,本文将对2017年版英国国家卫生与临床优化研究所的青光眼诊断和管理指南进行解读。     

A scoping review of patients' barriers to eye care for glaucoma and keratitis

In this scoping review, we examine underlying causes of loss to follow-up for chronic (glaucoma) and acute (corneal ulcers) eye conditions using the Penchansky and Thomas access to care framework. We explore barriers by World Health Organization income levels and by studying geographical location. We identified 6,363 abstracts, with 75 articles retrieved and 16 meeting inclusion criteria. One article discussed barriers to follow-up care for people with corneal ulcers, and the other 15 were for people with glaucoma. The most frequent barriers to care were affordability, awareness, and accessibility. The international studies had a greater percentage of studies report acceptability as a barrier to loss to follow-up. Countries with universal healthcare included affordability as a loss to follow-up barrier, emphasizing that cost goes beyond the ability to pay for direct treatment costs. Understanding and addressing barriers to follow-up care can aid the goal of continued care and decrease the risk of poor outcomes and vision loss.     

The long-term results of fistulising trabeculotomy in chronic open-angle glaucoma

Background : Fistulising trabeculotomy has been used for nearly 20 years to combine the minimally invasive surgery of trabeculotomy with production of a subconjunctival fistula.
Methods : The canal of Schlemm was unroofed 2mm on one side of a 3mm half-thickness scleral flap. A trabeculotomy probe was passed about 30° along the canal on the opposite side and rotated into the anterior chamber.
Results : Of 99 eyes of 74 patients, 35 eyes of 25 patients were available for follow-up at 10 or more years. The mean IOP was 14 ± 4 mmHg (range 7 to 23 mmHg) from a preoperative IOP of 29 ± 8 mmHg (17 to 60 mmHg). Results in 44 similar patients undergoing trabeculectomy and 44 undergoing fistulising trabeculotomy were very similar at five-year follow-up.
Conclusion : Fistulising trabeculotomy was effective for lowering intraocular pressure with a low complication rate and a large area of subconjunctival fistulisation.     

恶性青光眼对侧眼青光眼治疗探讨

目的:初步探讨1眼发生恶性青光眼其对侧眼青光眼的手术治疗方法与疗效。方法:对9例单眼发生恶性青光眼患者其对侧青光眼施行透明角膜切口超声乳化白内障摘除+后房型折叠式人工晶状体植入+小梁切除术。结果:9眼恶性青光眼对侧眼联合手术后眼压控制正常,前房加深,视功能无进一步损害,未发生恶性青光眼。结论:透明角膜切口超声乳化白内障摘除+后房型折叠式人工晶状体植入+小梁切除术可作为恶性青光眼高危眼的治疗方法之一。     

眼压已控制的青光眼患者的随访研究

目的：观察24例28眼接受抗青光眼手术后眼压控制在18mmHg（1mmHg=0.133kPa）以内的患者视盘地形图、视乳头血流和视野的变化,探讨三者的关系.方法：采用Heidelberg Retina Topography（HRT）和Heidelberg Retina Flowmetry（HRF）进行视网膜断层扫描、视乳头血流检查,用Octopus101电脑视野计常规阈值程序进行检查,每隔2mo复查,随访6mo,对所得数据进行分析.结果：早期青光眼患者随访6mo,视力、视野、视盘地形图参数无明显变化,3/10眼（33%）视乳头血流参数下降超过10%;18/18眼中晚期患者中央视力无明显变化,但平均视网膜敏感度（mean sensitivity,MS）有下降的趋势,视网膜神经纤维层厚度逐渐变薄,视乳头血流参数下降.结论：早期青光眼患者术后短期随访部分患者视乳头微循环功能有下降;中晚期患者短期随访视野指数MS、视乳头微循环和平均神经纤维层厚度有下降的趋势,且MS下降与后两个变量相关.     

玻璃体积血的分期治疗

目的:观察分期治疗玻璃体积血的疗效。方法:将玻璃体积血的病程分早、中、晚3个时期,早期急则治其标,以凉血止血为主;中期以活血化瘀为主;晚期以益气、活血、软坚散结为主。14d为一个疗程,共治疗2个疗程。主要观察视力,玻璃体积血的吸收情况。结果:分期治疗玻璃体积血总有效率88.5%。结论:分期治疗玻璃体积血疗效显著。     

Patient satisfaction and follow-up adherence to glaucoma case management clinic in China

AIM: To assess glaucoma patient satisfaction and follow-up adherence in case management and identify associated predictors to improve healthcare quality and patient outcomes. METHODS: In this cross-sectional study, a total of 119 patients completed a Patient Satisfaction Questionnaire-18 and a sociodemographic questionnaire. Clinical data was obtained from the case management system. Follow-up adherence was defined as completing each follow-up within ±30d of the scheduled time set by ophthalmologists during the study period. RESULTS: Average satisfaction scored 78.65±7, with an average of 4.39±0.58 across the seven dimensions. Age negatively correlated with satisfaction (P=0.008), whilst patients with follow-up duration of 2 or more years reported higher satisfaction (P=0.045). Multivariate logistics regression analysis revealed that longer follow-up durations were associated with lower follow-up adherence (OR=0.97, 95%CI, 0.95-1.00, P=0.044). Additionally, patients with suspected glaucoma (OR=2.72, 95%CI, 1.03-7.20, P=0.044) and those with an annual income over 100 000 Chinese yuan demonstrated higher adherence (OR=5.57, 95%CI, 1.00-30.89, P=0.049). CONCLUSION: The case management model proves effective for glaucoma patients, with positive adherence rates. The implementation of this model can be optimized in the future based on the identified factors and extended to glaucoma patients in more hospitals.     

The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma

Aim

To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of glaucoma and the decision to treat with that of routine hospital eye care, against a reference standard of expert opinion (a consultant ophthalmologist with a special interest in glaucoma).

Methods

A directly comparative, masked, performance study was undertaken in Grampian, Scotland. Of 165 people invited to participate, 100 (61%) were examined. People suspected of having glaucoma underwent, within one month, a full ophthalmic assessment in both a newly established community optometry led glaucoma management scheme and a consultant led hospital eye service.

Results

Agreement between the AGO and the consultant ophthalmologist in diagnosing glaucoma was substantial (89%; κ = 0.703, SE = 0.083). Agreement over the need for treatment was also substantial (88%; κ = 0.716, SE = 0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation was moderate (83%, κ = 0.541, SE = 0.098, SE = 0.98; and 81%, κ = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 (95% confidence interval, 0.85 to 0.97)) but lower for sensitivity (0.76 (0.57 to 0.89)). Performance was similar when accuracy was assessed for treatment recommendation (sensitivity 0.73 (0.57 to 0.85); specificity 0.96 (0.88 to 0.99)). The differences in sensitivity and specificity between AGO and junior ophthalmologist were not statistically significant.

Conclusions

Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma, optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma are missed.