青光眼为什么需要精准的个体化治疗?

青光眼是一类不可逆性神经致盲性眼病,其病理机制及诊疗研究于近10年虽发展迅速,但其致盲率仍高居不下.究其原因,盖因疾病自身的复杂程度及我们对疾病认知尚存局限,因而需要应用基于大数据、精准的个体化治疗思路来诊治青光眼,以降低致盲率.     

Attributes Associated with Adherence to Glaucoma Medical Therapy and its Effects on Glaucoma Outcomes: An Evidence-Based Review and Potential Strategies to Improve Adherence

ABSTRACT

The treatment paradigm in glaucoma classically starts with exhausting all medical therapy prior to proceeding with laser or incisional surgery, although laser-first and surgery-first strategies have been explored in randomized clinical trials. Although glaucoma drops are proven to work well to lower intraocular pressure, slow the conversion from ocular hypertension, and slow the progression of disease in early open angle glaucoma, adherence to treatment is likely optimum in the randomized clinical trials that support these claims. In real-world scenarios, medical therapy often fails and practitioners are forced to proceed with more invasive treatment modalities to slow the progression of this blinding disease. This review aims to take an evidence-based approach to study the risk factors for poor adherence in glaucoma patients, to determine whether poor adherence is, in fact, associated with worse outcomes, and to seek potential strategies to improve adherence in these patients.     

Diagnosis and Management of Lens-induced Glaucoma

Lens-induced glaucoma may occur as either secondary angle-closure or open-angle glaucoma. Dislocation or swelling of the lens can cause papillary block and subsequent angle-closure glaucoma. Leakage of soluble lens proteins from a relatively intact cataractous lens can result in a severe secondary open-angle glaucoma (phacolytic glaucoma). Heavy molecular weight protein, believed to be of lens origin, has now been identified in 12 of 12 anterior chamber, specimens from such patients. This liberated lens protein can directly obstruct the trabecular outflow pathways. After extracapsular cataract surgery or after lens trauma, liberated fragments of lens material may mechanically impair the drainage of aqueous humor through the outflow channels (lens particle glaucoma). The diagnosis and management of these different lens-induced glaucomas are reviewed. With proper recognition; these glaucomas are promptly cured by the surgical removal of the lens (material).     

Recent Advances in the Management of Neovascular Glaucoma

ABSTRACT

The development of anti-vascular endothelial growth factor (VEGF) molecules has expanded the range of available treatment options for many ocular diseases, including neovascular glaucoma (NVG). A number of studies have explored the use of anti-VEGF agents as stand-alone or adjunctive treatment for NVG. Although no large, prospective, randomized trials have been performed to date, the growing body of knowledge suggests that anti-VEGF agents are effective at reversing iris and angle neovascularization and lowering intraocular pressure in patients with NVG. Response to a single injection is typically temporary; therefore, laser or incisional surgery is still necessary in most cases. Future research is needed to determine the optimal agent, dose, route of administration, and timing of treatment either as monotherapy or coupled with other medical and/or surgical interventions.     

Normal-tension Glaucoma Management: A Survey of Glaucoma Sub-specialists in Korea

PurposeTo investigate the current management patterns of glaucoma subspecialists with regard to normal-tension glaucoma (NTG) in Korea and to determine the effect of the two largest NTG trials on their clinical practice.MethodsA questionnaire survey was sent to glaucoma subspecialist members of the Korean Glaucoma Society. The questionnaire concerned regular practice with respect to NTG and the extent to which it has been influenced by the Collaborative Normal-tension Glaucoma Study and the Low-pressure Glaucoma Treatment Study (LoGTS).ResultsA total of 134 glaucoma subspecialists completed the survey, with a response rate of 56%. The survey reported that 88% and 78% of glaucoma subspecialists were familiar with the Collaborative Normal-tension Glaucoma Study and the LoGTS, respectively. With respect to mild or moderate NTG, most of the respondents (87%–91%) tended to treat their patients immediately without waiting for structural or functional progression. Among the respondents, 47 indicated that the LoGTS results—according to which, 20% of the respondents tended to use brimonidine more often—affected their management. The first-choice topical drugs for NTG were prostaglandin analogues (76%), brimonidine (9%), beta-blockers (8%), and topical carbonic anhydrase inhibitor (6%).ConclusionsRegarding mild-to-moderate NTG, Korean glaucoma subspecialists tended to initiate treatment without waiting for further progression. The impact of the LoGTS on NTG management was not dominant in clinical practice in Korea. Prostaglandin analogs are the most frequently selected first-choice drugs for the management of NTG in Korea.     

The Management of Secondary Glaucoma in Nanophthalmic Patients

Purpose:To investigate the clinical characteristcs,management of secondary glaucoma in nanophthalmos,and the prevention of its compications.Methods:Retrospectively,9 cases(17eyes)with nanophthalmic glaucoma were studied.Results:The axial length of the eyes ranged(14.36-19.33)mm;All of the cases combined with hyperopia ranged( 7.00- 16.00)D.All 17 eyes had the manifestation like angle-closure glaucoma.The glaucoma was controlled in 9 of 17 eyes at the early stage,which underwent laser iridotomy(4 of 9 eyes also underwent laser iridoplasty).1 eye underwent ciliary photocoagulation because its visual acuity was lost and the patient complained of pain.The other 7 eyes underwent filtration surgery and 3 of them had permanent loss of vision caused by disastrous complications after the surgery.Conclusions:Management of secondary glaucoma in nanophthalmos is complicated.The laser iris surgery is safe and effective in glaucoma at the early stage.Vortex vein decompression,sclerotectomy or anterior sclerotomy may be performed to reduce disastrous complications.     

Phacotrabeculectomy in Treatment of Primary Angle-closure Glaucoma and Primary Open-angle Glaucoma

Purpose To evaluate the surgical outcome of combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy) in patients with primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG).Methods The records of 57 consecutive patients (65 eyes) with PACG or POAG that were treated with phacotrabeculectomy were reviewed retrospectively. There were 31 eyes with PACG and 34 with POAG. The mean follow-up period was 21.0 ± 8.3 months. The visual acuity, intraocular pressure (IOP), number of medications, and complications were evaluated.Results The mean IOP and the number of glaucoma medications decreased significantly after phacotrabeculectomy in both groups. The mean IOP reduction was significantly greater in eyes with PACG (P < 0.05). The absolute success rates were 87.1% and 70.6% in PACG and POAG, respectively. The difference in the success rates was not significant (P = 0.297). The early postoperative complication rates were similar in both groups.Conclusions Phacotrabeculectomy results in greater IOP reduction in eyes with PACG than in those with POAG, but the overall success rates were not significantly different. Jpn J Ophthalmol 2004;48:408–411 © Japanese Ophthalmological Society 2004     

Glaucoma in China

The motivation for this paper is that, having come from China, a country which had closed herself to the outside world for three decades, I thought it might be interesting to compare glaucoma in the two countries. Since I am from only a municipal hospital of a small city Hangzhow (a sister city of Boston), whatever I say can only be accepted as personal view points. Presently I have this wonderful opportunity to be a research fellow at the world wide famous Massachusetts Eye & Ear Infirmary, which is affiliated with Harvard Medical School. The comparison therefore may not be exactly appropriate but may help to see where my country stands, what we have, what we lack and what goals to strive for to better the health of China. There may be some confusing terms in this paper such as Liberation, Cultural Revolution, etc. Table 1 may help give a clearer conception.     

青光眼阀植入物治疗难治性青光眼

目的观察Ahmed青光眼引流植入物治疗难治性青光眼的疗效.方法采用Ahmed青光眼引流植入物,共治疗28例(29只眼)难治性青光眼,其中新生血管性青光眼10例(10只眼),青少年型青光眼5例(6只眼),其它青光眼13例(13只眼).结果术后随访3～12个月,新生血管性青光眼的眼压由术前40.9±7.32 mmHg降至20.63±2.75 mmHg(1mmHg=0.133kPa);人工晶体联合玻璃体手术后青光眼的眼压由术前41±5.66mmHg降至术后18.00±2.12 mmHg;青少年型青光眼的眼压由术前33.65±5.28 mmHg降至术后16.45±1.48 mmHg;常规滤过性手术失败的青光眼的眼压由术前31.43±4.13 mmHg降至18.13±1.25 mmHg.术后常见并发症有浅前房、前房积血、前葡萄膜炎等.结论Ahmed青光眼引流植入物是治疗难治性青光眼的一种较为有效的降眼压方法.眼科学报2000;16259～261.     

Long-Term Outcome of Intravitreal Bevacizumab Followed by Ahmed Valve Implantation in the Management of Neovascular Glaucoma

Background: To report the outcome of intravitreal Bevacizumab followed by Ahmed valve implantation in the management of neovascular glaucoma in a patient group with extended follow-up. Methods: The records of 16 patients (18 eyes) with neovascular glaucoma refractory to medical therapy who presented to a single surgeon between 2006–2008 were reviewed. Patients received pan-retinal photocoagulation and then intravitreal Bevacizumab followed by Ahmed valve implantation. The main outcome measures were: control of IOP (with or without additional medication), visual acuity (VA) and failure (IOP >21 mmHg or <6 mmHg, reoperation for glaucoma, or loss of light perception). Results: Pre-operatively, all patients received pan-retinal photocoagulation followed by IVB at a mean of 15.9 (range 4–60) days prior to AGV. The mean pre-operative IOP was 37.1 mmHg (±13.4) on 3.2 (±0.87) medications. Of the 18 eyes, 14 eyes (78%) were treated with AGV alone and 4 eyes (22%) with AGV combined with cataract extraction. Sixteen eyes (89%) received mitomycin C treatment intraoperatively. Post-operatively, the mean follow-up period was 63 months (24–84). At final follow-up, the success rate was 50% (33.3% complete, 16.7% qualified) with a mean IOP of 18.1 mmHg (±9.5) on a mean number of 1.5 (±1.6) medications. The failure rate was 50%, with five eyes (27.8%) not meeting the IOP criteria for success (of these, three eyes required additional surgery to lower the IOP) and five eyes (22.2%) lost light perception. Conclusion: Intravitreal Bevacizumab followed by AGV offers long-term control of IOP without additional surgical intervention in the majority of cases.     

小瓣小梁切除术治疗青光眼

目的探讨小瓣小梁切除术治疗青光眼的方法及效果.方法治疗组各型青光眼40例40眼,行小瓣小梁切除术,巩膜瓣2 mm×2 mm,小梁切除1 mm×1 mm.对照组各型青光眼40例40眼,行复合式小梁切除术,巩膜瓣4 mm×3 mm,小梁切除1.0mm×3.0 mm.观察术后眼压及浅前房等并发症,并进行比较.结果治疗组术前眼压44.11±14.86 mmHg(1 mmHg=0.133 kPa),对照组术前眼压为46.45±11.27.随访12～18月,术后最后随访眼压治疗组为12.94±4.13 mmHg,对照组为13.51±3.56mmHg,两组差异无显著意义(t=0.66,P＞0.05).浅前房发生率治疗组为16%(6/40),对照组2.6%(1/40),两组差异无显著意义(X2=1.59＜3.84,P＞0.05).结论小瓣小梁切除术是一种安全、有效的抗青光眼滤过手术.眼科学报2001;17239～240.     

Glaucoma in Retinoblastoma

The association between retinoblastoma and secondary glaucoma is well known. The most common cause of secondary glaucoma in retinoblastoma is iris neovascularization (NVI) followed by pupillary block and tumor seeding of the anterior chamber. Although glaucoma is a secondary clinical issue in retinoblastoma (RB) management and care, awareness of its presence, revealed by a thorough ocular exam of the anterior segment, can guide the clinician in assessing the overall condition of the affected eye.     

原发性开角型青光眼和正常眼压性青光眼危险因素的研究

目的：探讨原发开角型青光眼（POAG）和正常眼压性青光眼（NTG）发病相关的危险因素。方法：对592例（1156眼）原发开角型青光眼和53例（100眼）正常眼压青光眼患者进行眼科常规检查,视野检查,屈光,血糖,血压检测,家庭史及药物史和全身病调查,结果：NTG组与POAG组相比较,在患病年龄的分布上有差异：POAG组以20－40岁年龄最常见,而NTG组以50－60岁年龄最常见;两组患者均有较高的近视患病率（POAG组为42．1％,NTG组为66．04％）,NTG组低血压患病率67．92％）,阳性家族史为20．75％,两者均明显高于POAG组,差异有显著性,结论：年龄,近视,低血压,青光眼家族史可能是POAG和NTG发病的重要因素。     

The Influence of Surgical and Medical Interventions upon Optic Disc Structure in Patients with Primary Open Angle Glaucoma

 Purpose: To evaluate the changes of optic disc parameters in primary open angle glaucoma (POAG) patients after surgical and medical treatment, and analyze the determinants of these changes. Methods: A total of 67 patients were enrolled in this study. Thirty nine patients (40 eyes) underwent trabeculectomy and 28 patients (32 eyes) received intra-ocular pressure (IOP) lowering medical therapy. All subjects underwent bilateral routine ocular examination and Heidelberg retina tomography (HRT) before treatment and 2 weeks, 1 month, 3 months, 6 months and 1 year after treatment. Changes in optic disc parameters in both the surgical and medical groups were analyzed, as was the influence of disease severity and IOP reduction on these changes. Results: In the surgical group, the average preoperative IOP was 32.8±8.64 mmHg, which showed a significant decline at each post-operative visit. Most optic disc parameters measured by HRT were significantly improved after trabeculectomy (P=0.001~0.01), though the amount of improvement declined gradually during the post-operative period. Rim volume (RV), cup shape measure (CSM ), mean RNFL (mRNFL), RNFL cross sectional area (RNFLA) and vertical cup-to-disc ratio (C/D) still remained significantly below the pre-operative mean one year after surgery. In the medical group, the mean IOP before treatment was 24.8±4.32 mmHg and remained <21 mmHg on all subsequent post-treatment visits. However, no significant changes in optic disc parameters were found after initiation of medical treatment (F=0.52~2.21, P=0.75~0.07). In the surgical group, the extent of reduction of IOP was positively correlated with the improvement in RV, CSM and vertical C/D（r=0.41~0.58,P=0.001~0.04） at one year after trabeculectomy. The absolute value of the mean deviation on visual field testing was negatively correlated with the improvement of RV and CSM (r=-0.43~-0.62, P=0.03~0.001). Conclusion: Improvement in optic disc parameters occurred more commonly after surgical than medical treatment in POAG patients. The amount of reduction of IOP was correlated with the extent of this improvement, which may be more limited in more severe glaucoma.     

青光眼与睡眠

睡眠对于每个人来说都是非常重要的,对于青光眼患者更有极其特殊的意义。睡眠质量对青光眼有很大影响,而青光眼的躯体症状和患者的心理因素又对睡眠产生较大的影响。夜间睡眠时眼压会升高,而眼压是影响青光眼病情最重要的因素,夜间眼压波动对视功能有很大的损害。睡眠期间是青光眼治疗的关键时段,应引起青光眼患者和医生的足够重视。     

青光眼的日间手术模式

日间手术模式的应用和规范管理对于解决目前我国医疗资源紧缺、提高医疗效率、降低医疗费用有明显的优势。眼科手术以其手术时间短、恢复快、患者全身状况良好、麻醉风险小（局部麻醉为主）等特点决定了其选择日间手术作为主要手术模式的优势和必要性。本文就目前我国日间手术发展近况,探讨我国开展青光眼日间手术的可行性及具体医疗管理流程。     

慢性青光眼的视诱发电位

对51例96只慢性青光眼和51例102只正常眼进行了视诱发电位试验,发现青光眼组的VEP波幅(amplitude)较正常组显著降低(P<0.001),青光眼的VEP潜伏期(Latency)和波幅与垂直杯盘比(C/D)的大小有关,显示VEP对慢性青光眼的早期诊断有一定价值。     

Biomechanical Glaucoma Factor and Corneal Hysteresis in Treated Primary Open-Angle Glaucoma and Their Associations With Visual Field Progression

PurposeTo investigate the relationship between biomechanical glaucoma factor (BGF) measured with Corvis ST and glaucomatous visual field (VF) progression, compared to corneal hysteresis (CH) measured with ocular response analyzer using a longitudinal dataset of primary open-angle glaucoma (POAG). The discriminative powers of BGF and CH were also compared using a cross-sectional dataset.MethodsThe longitudinal dataset included 166 POAG eyes. The rate of VF change during the follow-up period was evaluated using the mean of 52 pointwise total deviations in the Humphrey 24-2 field test. Variables associated with the VF progression rate were identified from BGF, CH, age, baseline VF severity, and intraocular pressure during the VF follow-up period by identifying the optimal model. The cross-sectional dataset included 68 POAG eyes and 68 healthy eyes. Using this dataset, the area under the curve (AUC) values of the receiver-operating curve were compared between CH and BGF.ResultsThe optimal multivariate linear mixed model to describe the VF rate included age and CH, but not BGF. Between POAG and healthy eyes, CH was statistically different (P < 0.001), although this was not the case with BGF. The AUC values were 0.61 and 0.71 for BGF and CH, respectively (P = 0.027).ConclusionsCH, but not BGF, was associated with VF progression in POAG patients under treatment. BGF was not useful to discriminate POAG between treated and normal eyes.     

Glaucoma following retinal detachment operations

After retinal detachment operations 1–5% of the patients develop glaucoma. If this occurs directly after the operation it is the result of mechanical narrowing of the chamber angle.This can be the result of indentation due to an exoplant or encircling band causing forward displacement of the lens/iris diaphragm. Other causes are torsion of the ciliary body or a ciliary block due to serous detachment of the choroid caused by venous compression or diathermy.Ischaemia of the anterior segment sometimes leads to glaucoma in the long run; this is then the result of rubeosis iridis. Conducive factors are detachment of the recti muscles, arterial and venous compression by the exoplant or encircling band and the use of diathermy. When performing such operations it is advisable to take these risks into account and to keep a check on the intraocular pressure after the operation.A patient is described who, as the result of ischaemia, eventually developed ribeosis iridis with neovascular glaucoma, leading to loss of the eye.     

Ghost Cell Glaucoma Following Trauma

Ghost cell glaucoma was described in 1975. The details of this glaucoma as it occurred following vitrectomy and following cataract extraction have been reported. This glaucoma occurred following trauma as well, and this report describes the clinical and pathologic characteristics. Fourteen patients, five with positive anterior chamber aspirate examinations, were studied. All had in common: (1) severe trauma to the eye, either blunt or penetrating, with hyphema and vitreous hemorrhage; (2) gradual clearing of the anterior chamber hemorrhage and conversion of fresh red blood cells to ghost cells in the vitreous cavity; (3) forward passage of ghost cells into the anterior chamber through a traumatic opening in the anterior hyaloid face; and (4) elevation of intraocular pressure caused by these cells approximately two weeks to three months following the trauma. The glaucoma required medical and often surgical therapy. The surgical procedure of choice was anterior chamber irrigation, which was often effective and is advised before proceeding to vitrectomy. The vitreous findings of an enucleated eye with ghost cell glaucoma are presented.