准分子激光原位角膜磨镶术中瞳孔中心移位及眼球旋转的研究

目的探讨准分子激光原位角膜磨镶术(laser insitu keratomileusis,LASIK)患者术前检查位(坐位)与术中体位(卧位)改变引起眼球旋转的规律及瞳孔中心移位的特点。方法LASIK手术患者285例(565眼),术前在暗室坐位自然瞳孔状态下,应用wavescan wavefrontTM system进行波前像差检查和虹膜纹理识别,在LASIK术中卧位应用激光机进行虹膜定位追踪手术,显示瞳孔中心移位(565眼)及眼球旋转(562眼)情况。结果术中565眼全部发生了瞳孔中心移位,双眼均以鼻上方移位明显。右眼平均移位距离为(0.33±0.25)mm,左眼平均移位距离为(0.34±0.27)mm。双眼平均移位距离差异无统计学意义(P>0.05)。556眼(98.9%)发生眼球旋转,右眼平均旋转3.80°±3.95°,左眼平均旋转2.40°±2.95°,右眼旋转度数大于左眼,差异具有统计学意义(P<0.01)。右眼外旋明显,左眼内外旋几率基本相当。结论LASIK术中眼球的旋转运动和瞳孔中心移位是普遍存在的,屈光手术医生应高度重视,在准分子激光手术中应注意眼球旋转及瞳孔中心移位所引起的偏中心切削和欠矫问...     

LASIK术中眼球旋转和瞳孔中心移位的相关因素分析

目的 探讨LASIK手术中发生眼球旋转和瞳孔中心移位的影响因素.设计 回顾性临床病例系列.研究对象近视患者131例262眼.方法 对接受双眼LASIK手术的近视患者,应用CustomVueTM软件测量术中眼球旋转及瞳孔中心移位,并探讨其影响因素;按照年龄、性别、眼别、角膜瓣制作方法、等效球镜、术前瞳孔直径、术中瞳孔直径、瞳孔直径差值等因素进行分组,对不同分组的眼球旋转和瞳孔中心移位的结果进行比较.主要指标 术中眼球旋转度数及瞳孔中心移位距离.结果 LASIK手术中平均眼球旋转度数(3.07°±2.07°)(0°～8.6°).平均瞳孔中心移位为(0.33±0.14)mm(0.04～0.51 mm).旋转度数与术前瞳孔直径、术前术中瞳孔差值、术前等效球镜度数具有相关性(r=0.188,0.156,0.130,P均<0.05).术前瞳孔>7.0 mm组眼球旋转度数为(3.35°±2.17°),明显高于术前瞳孔≤7.0 mm组(2.71°±1.89°,P=0.014).右眼瞳孔中心移位(0.39±0.12)mm,明显高于左眼(0.28±0.13)mm(P=0.000).结论 CustomVueTM系统可以测量LASIK术中发生的眼球旋转和瞳孔中心移位.术前瞳孔直径和手术中瞳孔直径变化值可影响眼球旋转度数.右眼的瞳孔中心移位高于左眼.     

1038眼LASIK术中应用虹膜定位技术校正眼球旋转及瞳孔中心移位的研究

目的 通过在LASIK术中进行虹膜定位技术校正眼球旋转、瞳孔中心移位的临床研究,探讨虹膜定位技术对LASIK手术的作用及意义。方法 选择成功接受波前像差虹膜定位LASIK手术的近视患者606例1038眼,术前应用Wavescan像差仪取坐位行波前像差检查和虹膜识别,术中应用VISXStar S4 IR手术,记录眼球旋转及瞳孔中心移位,对前后眼球旋转及瞳孔中心移位进行比较。结果 眼球旋转：顺时针旋转510眼,右眼160眼（31%）,左眼350眼（69%）。逆时针旋转514眼,右眼367眼（71%）,左眼147眼（29%）。双眼差异显著,有统计学意义（P〈0.05）。14眼未发生旋转。平均旋转度数为2.72°±1.98°,右眼与左眼平均旋转度数无显著性差异（P〉0.05）。瞳孔中心移位：右眼与左眼瞳孔中心均多向鼻侧移位,右眼平面位移平均为（0.360±0.138）mm,左眼平面位移平均为（0.361±0.144）mm,右眼与左眼瞳孔中心平均位移比较无显著性差异（P〉0.05）。结论 Custom VueTM虹膜定位能够有效地校正术中的眼球旋转和瞳孔中心移位,使手术达到最佳效果。     

角膜屈光手术中眼球旋转和瞳孔中心移位的测量

目的测量国内近视患者在角膜屈光手术中发生的眼球旋转和瞳孔中心移位。方法选择接受双眼CustomVueTM个体化角膜屈光手术的近视患者86例172眼,术前应用Wavesan像差测量仪在坐位时进行虹膜识别,术中应用VISX Star S4 IR进行卧位时虹膜定位,记录眼球旋转及瞳孔中心移位。结果虹膜定位成功147眼,其中63例126眼患者双眼均成功定位,其眼球旋转包括:(1)外旋(右眼逆时针旋转,左眼顺时针旋转)60眼;(2)内旋(右眼顺时针旋转,左眼逆时针旋转)4眼;(3)双眼逆时针旋转44眼;(4)双眼顺时针旋转18眼。在成功定位的147眼中,旋转≤1°者38眼,1.1°~2.0°者29眼,2.1°~3.0°者22眼,3.1°~4.0°者21眼,4.1°~5.0°者17眼,5.1°~6.0°者13眼,>6.1°者7眼;平均旋转度数2.6°±1.9°(0.1°~8.6°)。瞳孔中心移位平均为(0.348±0.144)mm(0.064~0.539mm),X轴移位为(0.27±0.16)mm(0~0.50mm),Y轴移位为(0.17±0.12)mm(0~0.48mm)。结论角膜屈光手术中从坐位改变到卧位会发生眼球旋转和瞳孔中心移位。CustomVueTM系统能够有效进行虹膜定位,测量眼球旋转和瞳孔中心移位。     

眼球旋转和瞳孔中心移位对角膜屈光手术的影响

目的 测量观察角膜屈光手术术中发生眼球旋转和瞳孔中心移位的程度和方位.方法 检查70例(140只眼)的近视和近视散光的患者的眼球旋转和瞳孔中心移位的程度和方位.在术前,坐位时,用Technolas Zy-wave相差仪进行每只眼虹膜识别.用Technolas 217Z激光机进行测量眼球的旋转度.结果 全部140只眼中128只眼成功进行虹膜识别,成功率91.4%.对于双眼成功定位(54例)的眼球旋转度数的统计结果发现:平均旋转偏移是2.59°4±1.91°(右眼2.67°±2°;左眼2.51°±1.98°).双眼比较具有显著性差异(P＜0.01).按移位的绝对值计算,X轴移位平均为(0.23±0.19)mm,Y轴移位平均为(0.11±0.27)mm.双眼均成功识别54例:右眼瞳孔中心移位平均(0.33±0.17)mm,左眼瞳孔中心移位平均(0.16±0.21)mm.双眼比较具有显著性差异(P＜0.01).结论 使用虹膜识别技术可减少眼球旋转和瞳孔中心移位,对改善屈光手术的效果是很有帮助的.     

散瞳对波前引导LASIK的影响

目的:探讨散瞳对波前引导的LASIK治疗近视的影响。方法:对216例(384眼)接受波前引导准分子激光原位角膜磨镶术(laser in situkeratomileusis,LASIK)的患者分两组,其中暗室条件下瞳孔直径<6.5mm行虹膜识别波前引导LASIK161例(291眼)为对照组;暗室条件下瞳孔直径≥6.5mm行无虹膜识别波前引导LASIK55例(93眼)为试验组,观察在暗室条件下对照组患者散瞳后瞳孔是否变形,暗室条件下试验组患者不散瞳,患者的瞳孔是否变形。对试验组瞳孔中心偏移者进行调整后再行手术,并与对照组比较。结果:两组瞳孔变形眼数比较(χ2=27.3814;P=0.000),有统计学意义。对无虹膜识别瞳孔中心有偏移的进行调整,两组比较(χ2=3.0944,P=0.0786;χ2=0.0017,P=0.9673;χ2=0.0706,P=0.7905),术后偏中心眼数、术后视力无统计学意义。结论:波前引导的LASIK在治疗近视时,散瞳易引起瞳孔变形和瞳孔中心偏移,有瞳孔中心偏移患者需进行调整,有益于提高视觉质量。     

应用虹膜识别技术测量准分子激光角膜原位磨镶术中瞳孔中心移位和眼球旋转

目的 探讨准分子激光角膜原位磨镶术(LASIK)中应用虹膜识别技术测量因瞳孔直径变化和体位改变引起的瞳孔中心移位和眼球旋转.方法 术前通过Zywave波阵面像差仪和术中Technolas 217z准分子激光机中虹膜识别软件测量81眼的瞳孔中心移位距离和眼球旋转角度.结果 瞳孔直径由4.5～5.5 mm散大至6.0～7.5 mm,瞳孔中心水平方向(X轴)移位(55.81±56.25)μm、范围为0～244 μm,垂直方向(Y轴)移位(74.01±53.75) μm,范围为5～246 μm,矢量方向移位(99.65±67.32) μm,范围为12 ～260 μm,眼球旋转1.15°±0.98°、范围为0～4.34°.体位改变引起的瞳孔中心水平方向(X轴)移位(59.23 ±.51.38) μm、范围为0～244 μm,垂直方向(Y轴)移位(73.12±56.08)μm、范围为1～250μm,矢量方向移位(100.04±64.68)μm、范围为13 ～265 μm,眼球旋转3.81°±2.75°、范围为0～9.9°,其中27只眼(33.33％)的眼球旋转超过5°.右眼和左眼因瞳孔直径和体位改变引起的瞳孔中心移位和眼球旋转角度之间差异均无统计学差异.结论 瞳孔直径变化和体位改变均可以导致瞳孔中心移位和眼球旋转,应用虹膜识别技术可以准确测量和校正移位距离和旋转度数.     

光亮度变化对虹膜定位波前引导LASIK手术的影响

目的 探讨准分子激光原位角膜磨镶术（LASIK）术中光线亮度改变对眼球旋转角度和瞳孔中心的影响.方法 前瞻性病例系列研究.LASIK患者140例（268眼）,术中通过调整激光机灯光亮度,以虹膜定位技术（VisxStar-S4-IR）分别测出高亮度和低亮度下眼球的旋转角度、瞳孔大小、瞳孔直径及瞳孔中心位置,并进行比较分析.在与基础眼位相比及亮度变化之间,眼球旋转方向在两眼的差异采用卡方检验;眼球旋转角度、瞳孔直径改变在两种亮度状态下的差异采用独立样本t检验.结果 灯光亮度改变后,268眼中有259眼（占96.6%）发生了眼球旋转,而且主要为外旋（180眼,69.5%）,其中有26眼（占10.0%）眼球旋转方向发生改变.大部分眼（247眼,占95.4%）旋转角度≤2°,且与基础眼位比较,右眼与左眼低亮度下的旋转角度大于高亮度（t=2.375、2.146,P均＜0.05）.在高亮度和低亮度下,患眼瞳孔直径分别为2.00～4.10 mm和2.40～5.80 mm,差异有统计学意义（t=2.1l,P＜0.05）.在高亮度和低亮度下,与术前检查结果相比,约2/3眼的瞳孔中心均向鼻上方偏移,但两种光亮度之间瞳孔中心的偏移差异无统计学意义.结论 准分子激光屈光手术中,亮度的改变会引起眼球旋转和瞳孔中心位置的改变,从而影响手术矫正的准确性.     

匹罗卡品对近视眼瞳孔中心位置的影响

目的：探讨缩瞳剂对瞳孔中心位置的影响及其在PRK和LASIK术中与激光切削中心偏移的关系。方法：对46例（92眼）拟行PRK和LASIK手术的近视眼患以1％及2％硝酸匹卡品眼液点眼,在解膜地形图上自动测量缩瞳前后的角膜直径,瞳孔中心偏离角膜光学中心的方向和距离。结果：自然状态成年近视眼瞳孔直径为：水平径3．86（0．93mm,垂直径3．96（02mm,73.91%的瞳孔中心位于角膜光学中心的鼻上方,平均偏离0．22（0．10mm,1％或2％硝酸匹罗卡品眼液缩瞳后,瞳孔中心平均偏离0．16（0．05mm和0．20（0．10mm。瞳孔中心的象限分布比例与缩瞳前无明显差异。结论：缩瞳使瞳孔中心相对于角膜光学中心的偏离减少,有利于减少PRK和LASIK术中激光切削中心大多向鼻上方的偏移。缩瞳的实际意义在于便于手术中心的定位。     

虹膜定位联合波前像差引导的LASIK术中眼球旋转的临床观察

目的 观察虹膜定位联合波前像差引导的准分子激光原位角膜磨镶术(laser in situ keratomileusis,LASIK)术中眼球旋转的特点与规律.方法 选择行虹膜定位联合波前像差引导的LASIK的近视患者560例(1117眼),其中,右眼558眼,左眼559眼.采用Zywave渡前像差仪(美国博士伦公司)采集患眼在暗室瞳孔自然散大状态下及明光小瞳孔时的虹膜数据及波前像差数据,通过网络传输,在切削角膜瓣后掀开角膜瓣前,启动虹膜定位功能,记录眼球旋转类型和度数(系统默认顺时针旋转角度为正值,逆时针旋转角度为负值).结果 双眼的外旋发生率明显大于内旋,差异均有统计学意义(均为P=0.000),右眼外旋377眼(占33.75%),左眼外旋373眼(占33.40%);双眼的旋转度:右眼-0.1°～-11.4°(平均-3.33°±2.28°),左眼0.1°～14.1°(平均3.03°±2.26°).双眼内、外旋转度≤5.0°者共950眼(占85.05%),其中右眼内旋169眼,外旋304眼;左眼内旋170眼,外旋307眼.结论 角膜行屈光手术时,从坐位的术前检查到仰卧位的屈光手术,眼球会发生内、外旋转,虹膜定位联合波前像差引导的LASIK,能将眼球内、外旋转进行准确定位.     

Efficacy of a hinged pupil expansion device in small pupil cataract surgery

Purpose:To evaluate the efficacy and safety of a hinged pupil expansion device (PED) in eyes with small pupils undergoing phacoemulsification.Methods:In this prospective, multicenter, interventional case series of 57 eyes with suboptimal pharmacologic pupil dilation (<5 mm diameter), a hinged PED (I-Ring, Beaver-Visitec International, Waltham, MA) was applied to facilitate surgical visualization during cataract surgery. The pupil diameters (PD) were measured at different stages of the procedure and at the 1-month follow-up visit. Rate of successful intraoperative PED deployment, pupil size, and shape were assessed.Results:The mean patient age was 70.5 ± 12.1 years. The I-Ring PED was successfully applied in all eyes. The mean PD at various stages were 4.1 ± 1.1 mm (dilation with eye drops only preoperatively), 4.3 ± 1.1 mm (dilation after intracameral epinephrine and ophthalmic viscoelastic device), 6.80 ± 0.00 mm (with PED applied), and 5.7 ± 1.1 mm (end of surgery). A statistically significant difference (P < 0.001) was observed between the mean PD with intracameral medications and with PED application. Postoperative circular pupil was observed in 54 of 57 eyes (94.7%) and the mean eccentricity index (n = 57 eyes) was 0.11 ± 0.22. No significant adverse events were observed.Conclusion:The I-Ring PED safely and effectively provided and maintained adequate pupil expansion and surgical visualization in eyes with small pupils undergoing cataract surgery. Postoperatively 95% of eyes attained circular pupils. This hinged PED is an additional instrumentation option for the safe and effective expansion of inadequately sized pupils during cataract surgery.     

临床瞳孔检查新进展

瞳孔每时每刻处于动态的变化之中,因此瞳孔的检查也是一个较为复杂的过程。随着对屈光手术质量要求的日益提高,特别是暗适应下瞳孔的大小往往在一定程度上可能决定着术后质量的好坏,因此暗适应下瞳孔的精确测量变得尤为重要。现对近年来涌现的瞳孔检查新技术作一简要概括。     

A Rare Presentation of Neurosyphilis Mimicking a Unilateral Adie’s Tonic Pupil

ABSTRACT

We describe a case of a female patient who presented with anisocoria and was initially diagnosed with a right acute Adie’s pupil on the basis of a right tonic pupil with absent oculomotor or neurological findings and hyper-responsiveness to dilute Pilocarpine. Two months later, the patient returned with bilateral tonic pupils and limitation of extraocular movement in the right eye. Subsequent laboratory testing revealed neurosyphilis. Our case, only the second ever reported, emphasizes the importance of considering the diagnosis of neurosyphilis in patients presenting with an isolated acute tonic pupil.     

严重粘连性小瞳孔的白内障超声乳化术

目的探讨严重粘连性小瞳孔白内障超声乳化术的安全性及手术技巧。方法对26例(32只眼)粘连性小瞳孔白内障,术中采用透明角膜切口,散瞳后瞳孔直径(2.5±0.5)mm。以晶状体调位钩及chopper钩辅助,松解粘连,扩大瞳孔至4~5 mm,连续环形撕囊后进行原位白内障超声乳化吸除及折叠人工晶状体植入。结果术后3个月随访,术眼视力均较术前提高,其中视力≥0.5者20只眼(62.5%)。术后患眼瞳孔接近圆形或椭圆形,部分患者瞳孔直径较术前偏大。但其中2只眼再发部分后粘连,1只眼后囊少许破裂,仍植入人工晶状体,无人工晶状体明显偏位。结论采用上述技术不仅顺利完成小瞳孔白内障超声乳化术,且手术安全有效,视力恢复较好,保持或接近生理性圆,手术并发症相对减少。     

The Pupil Response to Large Regional Stimuli in Patients with Focal Visual Field Loss

Objective: To develop and use an intraocular analysis of the focal pupil response to large-sized, regional stimuli as a means of detecting areas of visual field loss. Patients and methods: A total of 42 normal subjects and 14 patients were tested with automated threshold perimetry and infrared pupillometry using computer-controlled, large-sized light stimuli (arcuate and quadrant shaped) at 10 apostilb intensity. These novel stimuli were presented (0.2 second duration) to different regions of the visual field of each eye. Each stimulus sequence was repeated 6 times. Results: A regional pupil deficit was detected in 7 of 12 eyes of 14 patients with visual dysfunction. The regional pupil response correctly corresponded to the visual field in 93 of 156 (60%) regions tested in the 14 patients. Conclusion: Detection of regional pupil deficits using large-sized light stimuli generally underestimates the degree of visual dysfunction as compared to automated threshold perimetry. One reason may be that retinal ganglion cells subserving the afferent pupillomotor pathway have larger receptive fields and greater spatial summation properties compared with those subserving the cortical visual pathway.     

超声乳化联合IOL植入术围手术期瞳孔直径和反应的变化

探究晶状体超声乳化联合人工晶状体（IOL）植入术围手术期瞳孔直径、反应的变化。方法：前瞻性临床研究。收集于2016年1-9月上海交通大学医学院附属第九人民医院眼科行超声乳化联合IOL植入术的连续白内障和高度近视透明晶状体置换患者。采用动态瞳孔测量仪（Metro-vision MONCV3）测量术前、术后1周、术后1个月在4种光照度下（0、1、10和100 cd/m2 ）的瞳孔直径,并检测瞳孔反应（如瞳孔初始直径、收缩幅度、收缩潜伏期、收缩持续时间、收缩速度、扩张潜伏期、扩张持续时间和扩张速度等）。采用重复测量方差分析、Pearson相关分析及Spearman相关分析对数据进行分析。结果：共纳入患者53例（53眼）。在4种光照度下,术前瞳孔直径随年龄增加而下降（r0=-0.467,P0<0.001;r1=-0.383,P1=0.005;r10=-0.374,P10=0.006;r100=-0.312,P100=0.023）。 4种光照强度下瞳孔直径手术前后总体差异有统计学意义（F0=206.9,P0<0.001;F1=106.8,P1<0.001; F10=41.7,P10<0.001;F100=36.7,P100<0.001）,与术前相比,4种光照强度下瞳孔直径术后1周、1个月均下降（均P<0.001）。手术前后瞳孔反应的初始直径、收缩幅度、收缩和扩张速度总体差异有统计学意义（F初始直径=99.5,P初始直径<0.001;F收缩幅度=36.2,P收缩幅度<0.001;F收缩速度=51.9,P收缩速度<0.001;F扩张速度=23.8,P扩张速度<0.001）,与术前相比,术后1周、1个月初始直径、收缩幅度、收缩和扩张速度均下降（均P<0.001）。结论：超声乳化联合IOL植入术后1个月内可引起瞳孔缩小,瞳孔反应的收缩、扩张速度变慢,为IOL设计中确定有效光学区范围提供依据。     

Accommodation, pupil diameter and myopia

Concurrent measurements of steady-state accommodation response/stimulus curves and of pupil diameter were made in groups ( n  = 20) of young, adult myopes [age (mean ± SD) 23.1 ± 4.5 years, mean-sphere error (MSE) −3.06 ± 2.35 D, range −0.60 to −8.54 D] and emmetropes (mean age 25.3 ± 5.7 years, mean MSE −0.07 ± 0.26 D, range −0.50 to +0.50 D). The aim of this study was to explore the possibilities that pupil diameters with relaxed accommodation were larger, and that accommodative miosis was weaker, in the myopic group. Such behaviour would lead to relatively greater degradation of the retinal images in the myopic group, even though aberrations at constant pupil diameter and dioptric accommodative lags in the two groups were the same: this might result in excessive axial growth and further myopia development. No evidence for any systematic refractive dependence of pupillary characteristics or accommodative responses was found. Interestingly, those subjects whose response/stimulus curves had a higher slope tended to display greater accommodative miosis, irrespective of their refractive error.     

瞳孔缘环切法解除并发性白内障瞳孔粘连

目的：观察瞳孔缘环形切除法在处理葡萄膜炎并发白内障手术中瞳孔粘连的临床效果。

方法：葡萄膜炎并发白内障瞳孔粘连患者50例50眼随机分为观察组和对照组,每组25眼,均行超声乳化人工晶状体植入术,观察组术中采用瞳孔缘环形切除法处理瞳孔环形粘连或闭锁,对照组采用机械钝性分离法。

结果：术后3mo,两组视力均有提高,观察组视力<0.3者5眼(20%),0.3～0.6者7眼(28%),>0.6者13眼(52%); 对照组视力<0.3者6眼(24%),0.3～0.6者8眼(32%),>0.6者11眼(44%),两组比较差异无统计学意义(P>0.05)。观察组瞳孔呈圆形,且有对光反射者22眼(88%),对照组7眼(28%),两组比较差异有统计学意义(P<0.01); 所有患者均未见明显术中术后并发症。

结论：瞳孔缘环形切除法处理葡萄膜炎并发白内障术中瞳孔粘连能有效解决术中小瞳孔问题,保证超声乳化术安全进行,术后视力恢复满意,瞳孔成形良好。     

Technical Note: Comparison of the wavefront aberrations between natural and pharmacological pupil dilations

Ocular wavefront aberrations were tested with the wavefront-supported corneal ablation (WASCA) aberrometer when the pupil was dilated naturally under scotopic illumination levels, and pharmacologically using tropicamide. Wavefront aberrations were measured across a 5-mm pupil in one eye of each of 58 subjects. There was a significant difference in the pupil diameter between the scotopic and cycloplegic conditions (p < 0.001). For higher order aberrations (HOAs), no significant difference was found in Zernike coefficients between the scotopic and cycloplegic conditions. There was no significant difference in the spherical equivalent refraction. Accommodation can be neglected during the wavefront aberration measurement with the WASCA aberrometer. In view of the shift of the pupil centre caused by pharmacological pupil dilation, obtaining measurements under natural conditions rather than using mydriatics is recommended for customized laser in situ keratomileusis (LASIK) surgery.