青光眼滤过手术对眼部结构和功能的影响

在以往的一个半世纪里，青光眼滤过手术先后经历了虹膜嵌顿术、全层小梁切除术、保护性板层小梁切除术、改良的小梁切除术及术中联合使用抗代谢药物等不同阶段，无数青光眼患者术后眼压得以有效控制，维持了残存的视功能。随着社会的发展，人们对生活质量的要求逐渐提高，治疗青光眼的目的不再是单一控制眼压，而是全方位维持与改善视觉质量和生活质量。滤过手术后由于破坏了眼球壁生理结构的完整性，且非生理性滤过泡隆起于眼表，故眼局部组织的结构和功能受到一定的影响。近10年来，眼科学界对此问题进行了大量研究，现综述如下。     

局部应用抗青光眼药物对眼部结构的影响

目的：探讨局部应用抗青光眼药物对患者眼表结构的影响。
　　方法：收集局部应用抗青光眼药物3mo以上的患者35例49眼和健康志愿者作为正常对照组45例45眼,药物治疗组分为A亚组（单独应用一种药物）和B亚组（联合应用两种及以上药物）。对所有患者及健康志愿者行泪膜破裂时间（BUT）、泪液分泌试验（SⅠt）、角膜上皮荧光素染色（FL）、结膜上皮虎红染色（RB）及结膜印迹细胞学检查（CIC）、黏蛋白MUC5AC检测。
　　结果：正常对照SⅠt（11．54±5．47）mm／5min,BUT（11．86±3．13）s,FL和RB评分为（0．42±0．61）分、（0．37±0．98）分,药物治疗组SⅠt（8．11±4．30）mm／5min,BUT（7．49±2．62）s,FL和RB评分为（1．15±0．87）分、（1．28±1．08）分,两组相比差异具有统计学意义（ t＝3．395,P＝0．001;t＝7．363,P＝0．001, t＝－4．266,P＝0．001;t＝7．363,P＝0．000）;A亚组SⅠt（9．51±4．76）mm／5min,BUT（8．46±1．24）s,FL和RB评分为（0．91±1．03）分、（0．85±1．07）分;B亚组SⅠt （6．34±4．05）mm／5min,BUT（6．38±1．25）s,FL和RB评分为（1．84±1．14）分、（1．56±1．31）分,A亚组与B亚组相比差异具有统计学意义（ t＝2．514,P＝0．012;t＝5．844,P＝0．000,t＝－2．992,P＝0．003;t＝－2．072,P＝0．043）。与正常对照组相比,药物治疗组的结膜上皮细胞体积变大,浆核比变小,细胞受损明显,药物治疗组的结膜印记细胞学检查评分明显增高,两组之间差异有统计学意义（u＝6．354,P＝0．000）,A亚组与B亚组的结膜印记细胞学检查评分无统计学差异（u＝0．69,P＝0．48）。正常对照组及药物治疗组的杯状细胞密度分别为（68．37±12．82）个／mm2及（32．83±10．68）个／mm2,差异显著（ t ＝14．610, P ＝0．000）。抗青光眼药物治疗后,A亚组和B亚组的杯状细胞密度分别为（39．12±9．35）个／mm2及（27．58±8．47）个／mm2,两者的差异具有统计学意义（ t＝4．530,P＝0．001）。正常对照组的泪液MUC5AC含量为（32．61±8．65） ng／mL,药物治疗组的泪液MUC5AC明显减少（13．84±6．72）ng／mL,差异具有统计学意义（t＝11．804,P＝0．000）。抗青光眼药物治疗后,B亚组的泪液MUC5AC含量（10．67±4．58）ng／mL较A亚组（20．17±5．84） ng／mL明显减少,两者差异显著（ t＝6．349,P＝0．000）。
　　结论：局部应用抗青光眼药物会导致患者泪液分泌减少、泪膜稳定性下降,眼表结构受损,增加用药种类会加重这种损害。     

颈内动脉阻塞致眼部缺血综合征并发新生血管性青光眼1例

患者男55岁因左眼阵发性视物不清1个月，于2003年7月3日入院。1个月前无明显诱因左眼视力突然下降至眼前手动伴畏光，不伴眼痛、虹视、流泪。无头痛、恶心及呕吐等症状，未予治疗。此后上述症状每日发作，均能自行缓解。20天前左眼突然视物黑朦，伴对侧肢体麻木、无力，持续约2分钟后自行缓解，此后，上述症状每隔3～5天发作1次。1天前左眼突然视力丧失伴眼胀痛、     

长期使用青光眼药物对眼表的影响

目的 探讨长期使用青光眼药物对患者眼表的影响.方法 收集局部使用青光眼药物3个月以上的患者65例108只眼,分为单种药物使用组(A组)和多种药物使用组(B组);另收集正常对照组(c组)25例25只眼.对所有观察对象进行泪膜破裂时间测定(BUT)、基础泪液分泌试验(ST)、角膜上皮荧光素染色、结膜上皮虎红染色以及结膜印迹细胞(IC)检查.结果 正常对照组BUT(12.25±5.40)s,ST(11.65±4.66)mm,A组BUT(6.97±4.87)8 9ST(7.19±5.36)mm,明显低于正常对照组(BUT P=0.000;STP=0.001). B组BUT(4.81±2.45)s,显著短于正常对照组(P=0.000)和A组(P=0.008);ST(5.20±2.97)mm,显著少于正常对照组(P=0.000)和A组(P=0.026).A组和B组的角膜荧光素染色评分和结膜虎红染色评分显著高于正常对照组.与正常对照组相比,A组和B组IC评分2-3级所占比例明显增高,结膜上皮表现出鳞状上皮化趋势.结论 长期使用青光眼药物会导致患者泪膜稳定性下降、泪液分泌减少,角膜上皮荧光素染色增多,结膜上皮杯状细胞减少、上皮细胞呈鳞状上皮化等泪膜、角膜和结膜的损伤.     

原发性闭角型青光眼眼部超声测量分析

为了进一步了解原发性闭角型青光眼(PCAG)与正常眼在解剖结构上的差异，我们对32例(64眼)PCAG，同时与25例(50眼)正常眼为对照进行了超声测量并进行分析，报告如下：     

双侧眼部缺血综合征一例

患者男 ,5 7岁。因双眼视力下降伴阵发性头痛、晕厥 10个月。发作时伴有一过性黑及眼痛 ,持续数分钟至数十分钟自行缓解。近 2周症状加重。于 2 0 0 0年 12月 2 1日来本院就诊。患者曾于 4个月前在外院就诊 ,诊断为双眼虹膜新生血管 ,双眼视网膜缺血病变。于外院行双眼视网膜光凝治疗 ,但视力仍继续减退。既往史 :1990年患鼻咽癌 (低分化鳞状细胞癌 ) ,曾于颈部行放疗痊愈。患者否认冠心病、高血压、糖尿病史。体检未见明显异常。眼部检查 :右眼视力0 2 ,左眼指数 / 2尺。眼压 (Ｇｏｌｄｍａｎｎ压平眼压计测定 ) :右眼16ｍｍＨｇ( 1ｍｍ…     

彩色多普勒血流显像评价正常眼压性青光眼眼部血供

目的：探讨正常眼压性青光眼与眼部血流的可能关系。方法：用彩色多普勒血流显像检测18例正常眼压性青光眼患眼的眼动脉和视网膜中央动脉血供情况,并与ll例正常人对照。结果：正常眼压性青光眼患眼的眼动脉收缩期峰值流速(Vmax)减少、舒张末期流速(Vmin)减少、搏动指数(PI)减低和阻力指数(RI)增大;视网膜中央动脉的砌与正常人比较差异也有显著性。结论：正常眼压性青光眼的眼部血流动力学异常和局部血管病变可能提示其发病机制。     

曲尼司特对青光眼患者体外培养的眼部Tenon囊成纤维细胞增殖和移行的影响

目的 探讨曲尼司特(tranilast)对青光眼患者体外培养的眼部Tenon囊成纤维细胞增殖及移行的影响。方法 取青光眼患者滤过术中剪下的Tenon囊组织,在体外进行成纤维细胞原代及传代培养。分别采用MTT法、细胞计数法、免疫组化加图像分析法及划线法,研究不同浓度的曲尼司特对体外培养的成纤维细胞增殖及移行的影响及其与蛋白激酶C(PKC)表达的关系。结果 当浓度在12．5～100．0mg／L之间变化时,曲尼司特能明显抑制成纤维细胞的增殖,强度呈剂量依赖性;50．0mg／L和100．0mg／L的曲尼司特能明显抑制成纤维细胞的移行,并下调细胞内PKC的表达。结论 曲尼司特能抑制成纤维细胞的增殖及移行,这种作用可能与下调细胞内PKC的表达有关。     

丝裂霉素所致眼部并发症的预防及处理

近年来，许多学者在滤过性手术易失败的难治性青光眼患者滤过手术中应用丝裂霉素，能够显著地延长滤过泡的功能及降低眼内压，取得了良好的临床效果，但同时也出现了一些眼部的副作用，甚至是严重的并发症。本文讨论了这些并发症的发生机制及预防和处理．一、丝裂霉素的作用机制丝裂霉素（uitomycinC，vuC）是一种具有抗肿瘤和抗增殖双重作用的蚓跺类抗生素。其作用的优势靶部位是DNA螺旋构型内鸟瞟吟NZ位置。它在螺旋构型内形成交链，阻止DNA的复制。这种交链的密度具有细胞循环特异性，即在细胞循环的早期S期和后期GI期作用最强．另…     

滤过泡形态对青光眼患者眼表结构和舒适度的影响

目的探讨不同形态滤过泡对青光眼患者眼表结构和舒适度的影响。设计前瞻性病例系列。研究对象滤过性手术成功并完成术后6个月随访的青光眼患者44例。方法采用手术前后的自身对照方法,通过问卷调查、眼表结构检查及裂隙灯显微镜滤过泡照相,比较滤过泡的存在及其不同形态引起青光眼患者眼表结构和舒适度的变化。主要指标问卷调查、角膜荧光素染色、结膜虎红染色、泪液分泌试验（Schirmer值）、泪膜仪脂质层测量、泪膜破裂时间（BUT）、角膜对称性指数（SRI）、角膜不规则指数（SAI）和角膜潜在视力（PUV）。结果滤过泡眼眼部畏光感和干涩感的发生明显增高（P=0．02,0．000）,眼部不适感评分显著升高（P=0．000）,荧光素染色、虎红染色、泪膜仪分级、SRI和SAI均较术前显著增高（P值均=0．000）,PUV和BUT较术前显著减小（P=0．000）,Schirmer值无显著变化（P=0．417）。患者年龄和性别与术后滤过泡形态及眼表结构和舒适度的变化程度无显著相关性。薄壁滤过泡组患者畏光感加重明显（P=0．002）,厚壁滤过泡组患者干涩感加重突出（P=0．003）。薄壁滤过泡组术后虎红染色评分、泪膜仪评级增加程度及BUT缩短程度均较厚壁滤过泡组明显（P=0．046,P=0．032,P=0．024）,而厚壁滤过泡组则以Schirmer值减小更为显著（P=0．027）。结论滤过术后晚期,滤过泡的存在破坏眼表结构,引起患眼明显的不适症状。薄壁滤过泡主要引起眼部刺激症状及角结膜组织结构的损害,厚壁滤过泡主要引起眼部干涩感及泪液量的减少。     

Measuring and interpreting ocular blood flow and metabolism in glaucoma

There is a growing body of evidence suggesting that vascular dysfunction is related to several prominent ophthalmic diseases, including glaucoma. The vast majority of studies providing data on ocular circulation and disease pathophysiology use a relatively small number of complicated ocular blood flow imaging techniques. Although these imaging technologies are not commonly used in clinical settings, understanding the medical literature characterizing ocular blood flow requires familiarity with their methodology and function. This review highlights the imaging technologies most commonly used to investigate ocular blood flow, including color Doppler imaging, confocal scanning laser ophthalmoscopic angiography with fluorescein and indocyanine green dye, Canon laser blood flowmetry, scanning laser Doppler flowmetry, and retinal photographic oximetry. Each imaging technique's ability to define vascular function and reveal pathology is discussed as are limitations inherent to each technology. The ultimate goal of this review is to provide the physician with a clinically relevant foundation for differentiating the various ocular blood flow outcome measures often presented in the literature and determine how they are related to ocular health and disease.     

Alteration in ocular blood flow and its effect on the progression of glaucoma

青光眼是由多种因素引起的神经退行性疾病,眼压过高会损害视神经而导致永久性视力丧失。虽然青光眼的基本病理生理机制尚未确定,但眼组织如视神经,视网膜,脉络膜以及虹膜的血流改变是青光眼发病的重要危险因素。由于不同因素所引发的视神经损害的有限认知,测量方法和治疗方面缺乏,人们对青光眼的理解存在障碍。尽管研究人员在不断地积累证据,力证眼血流的变化在青光眼发病机制中起着重要的作用,但大部分情况下,对于眼血流的变化和青光眼的患病风险之间的关系,他们都持有多样甚至矛盾的结论。本文中,我们回顾了青光眼的不同方面以及眼血流在疾病发展中的影响。     

Retinal vascular accidents in glaucoma and ocular hypertension

The incidence of primary open angle glaucoma in patients with central retinal vein occulusion is reported to be between 5.7 and 66%, while that of primary angle closure glaucoma is from 0 to 9%. (Corrected for the relative incidence of these two types of glaucoma in the general population, these rates are comparable.) There appears to be a causal relationship between elevated intraocular pressure and central retinal vein occlusion, which does not correlate with the height to which the pressure is elevated. Other etiologic factors may be important, particularly arteriosclerosis. The association between elevated pressure and branch vein occlusion is less clear. Central vein occlusions occur in 3.5 to 5% of patients with primary open angle glaucoma. Similarly, central vein occlusions occur in approximately 3% of patients with ocular hypertension. It is recommended that ocular hypertensive patients over the age of 65 be treated to lower their pressure below 25 mm Hg.     

开角型青光眼小梁切除前后搏动性眼血流量比较研究

目的：以OBF仪对开角型青光眼（primary open angle glaucoma,POAG)患者手术前后的搏动性眼血流量（pulsatile ocular blood flow,POBF）值及眼压进行测量，探讨POAG患者行小梁切除术后眼内血流变化。方法：本院诊断及手术治疗的POAG患者39例39眼，均在本院行小梁切除术，术中加用0．2g.．L^-1丝裂霉素C(mitomycin C,MMC)抗瘢痕，测量项目包括搏动眼血流量，脉搏周期内眼压变化值（pulse amplitude of IOP,PA IOP）,脉搏周期内眼容积变化值（pulse amplitude of volume,PV）,心率（pulse/heart rate,HR），最大眼压（Max-IOP），最小眼压（Min-IOP），平均眼压（Max-IOP Min-IOP）/2,Average IOP(Ave-IOP),手术前测量时间为药物治疗前，手术后测量时间为手术后1－2周，手术前后比较采用配对t检验，Ave-IOP的变化值与OBF的变化值作相关分析，结果：POAG患者手术后POBF，PV增高，Ave-IOP降低，差异有统计学,意义，Ave-IOP的变化值与OBF的变化之间有相关关系r=0.674,t=5.552,P=0.000，结论：POAG患者行小梁切除术后眼压降低有助于眼血流改善，但并不意味着所有POAG患者眼血流都得到改善，推测POAG发病部分原因是血管自身调节功能及供血异常。     

Pulsatile ocular blood flow investigation in asymmetric normal tension glaucoma and normal subjects

AIMS—This study was designed to investigate pulsatile ocular blood flow (POBF) in normal tension glaucoma (NTG) patients and in normal controls. NTG patients with unilateral field loss were evaluated to compare POBF values between eyes with and without field loss.
METHODS—POBF measurements from more than 1500 subjects were collected during a period of 6 months from six optometric centres. Subjects with systemic vascular diseases (such as systemic hypertension and diabetes), ophthalmic diseases, a positive family history of glaucoma, and those individuals receiving treatment with systemic β blockers were excluded on the basis of a questionnaire. For comparison, 95 NTG patients with unilateral field loss, selected from 403 consecutive patients with NTG, underwent POBF testing. For each individual age, sex, intraocular pressure, refraction, and pulse rate were entered into a database.
RESULTS—Data from 777 subjects were included in the analysis. POBF measurements of patients and subjects were compared allowing for differences in age, sex, intraocular pressure, refraction, and pulse rate. POBF was significantly lower in eyes of NTG patients with and without field loss (p <0.001 and p = 0.01 respectively). Eyes of NTG patients with field loss showed significantly lower POBF than the contralateral eyes with normal field (p < 0.001).
CONCLUSIONS—POBF was significantly lower in eyes of NTG patients with and without field loss than in normal subjects, suggesting that differences in ocular blood perfusion are relevant to the development of NTG and are detectable from the early stage of the disease. Furthermore, the finding of lower POBF in NTG eyes with field loss than in the contralateral eyes with normal field suggests that haemodynamic differences between fellow eyes contribute to determine the side of onset of the disease.

Keywords: pulsatile ocular blood flow; normal tension glaucoma; visual field asymmetry     

The role of blood pressure in glaucoma

Although intraocular pressure (IOP) remains an important risk factor for glaucoma, it is clear that other factors can also influence disease development and progression. More recently, the role that blood pressure (BP) has in the genesis of glaucoma has attracted attention, as it represents a clinically modifiable risk factor and thus provides the potential for new treatment strategies beyond IOP reduction. The interplay between blood pressure and IOP determines the ocular perfusion pressure (OPP), which regulates blood flow to the optic nerve. If OPP is a more important determinant of ganglion cell injury than IOP, then hypotension should exacerbate the detrimental effects of IOP elevation, whereas hypertension should provide protection against IOP elevation. Epidemiological evidence provides some conflicting outcomes of the role of systemic hypertension in the development and progression of glaucoma. The most recent study showed that patients at both extremes of the blood pressure spectrum show an increased prevalence of glaucoma. Those with low blood pressure would have low OPP and thus reduced blood flow; however, that people with hypertension also show increased risk is more difficult to reconcile. This finding may reflect an inherent blood flow dysregulation secondary to chronic hypertension that would render retinal blood flow less able to resist changes in ocular perfusion pressure. Here we review both clinical and experimental studies that have attempted to clarify the relationships among blood pressure, OPP and blood flow autoregulation in the pathogenesis of glaucoma.     

眼灌注压波动对青光眼患者病情的影响

目的：探讨眼灌注压波动对青光眼患者病情的影响。

方法：选取我院2013-01/2015-06收治的40例原发性开角型青光眼患者为观察组,同期我院患者家属40例为对照组。监测受试者24h的眼压、血压与眼灌注压的昼夜波动情况,得出收缩期眼灌注压(SOPP)、舒张期眼灌注压(DOPP)和平均眼灌注压(MOPP)。采用Pearson线性相关性分析MOPP昼夜波动与杯盘比、视野平均缺失(MD)及图形标准差(PSD)的相关性。

结果：观察组患者全天和夜间的MOPP、SOPP和DOPP波动均大于对照组(P<0.05)。MOPP 昼夜波动与MD存在显著的负相关(r=-0.389,95%CI：-0.612～-0.082; P=0.011); 与PSD呈正相关(r=0.512,95%CI：0.139～0.782; P=0.008); 与垂直杯盘比之间无相关性(r=0.115,95%CI：0.056～0.369; P=0.355)。

结论：原发性开角型青光眼患者眼灌注压波动可反映病情的严重程度,可能会导致疾病向严重方向发展,因此通过行24h的灌注压的监测可帮助我们了解原发性开角型青光眼患者全天的眼部血流状态,了解病情发展。     

降眼压药物对青光眼患者眼表影响的研究进展

青光眼是一种累及视网膜神经节细胞的慢性视神经病变,以视乳头萎缩、视野缺损及视力下降为共同特征的疾病。由于青光眼是一种慢性疾病,长期滴用局部降眼压药物往往会合并眼表疾病,从而降低药物依从性,最终影响治疗效果。目前局部降眼压药物主要有前列腺素类衍生物、β-肾上腺素能受体阻滞剂、α-肾上腺素能受体激动剂、局部碳酸酐酶抑制剂、拟胆碱能类药物。本文就以上5种降眼压药物对青光眼患者眼表影响和相关机制做一综述,并为青光眼患者的眼表保护提供预防性措施。     

眼外伤所致继发性青光眼临床分析

目的:探讨眼外伤的发生、治疗、转归以及眼外伤继发青光眼的发生、治疗及预后。方法:对305例眼外伤患者的致病因素、外伤部位、外伤类型进行分析,并对眼外伤患者进行随访,分析眼外伤继发青光眼的发生率。通过对眼外伤继发青光眼的药物及手术治疗,分析继发性青光眼的预后。结果:眼外伤部位、类型与眼外伤个体病因有关,病因以异物致伤最常见,外伤类型以角膜、巩膜穿孔伤最常见;眼外伤患者经治疗后视力均有不同程度的好转;眼外伤治疗后继发性青光眼的发生率高(10.82%),经药物和手术治疗,患者眼压均有不同程度的下降。结论:眼外伤病因、类型多样,应根据患者情况进行个体化治疗。对于存在易引起眼外伤的职业应该加强职业保护,做好眼防护。眼外伤治疗后继发性青光眼的发生率高,应尽早检查诊治以减少远期视力损害。