抗青光眼药物对眼表及滤过手术效果的影响

长期局部应用抗青光眼药物可引起眼表改变。本文对其引起眼表改变的机理、临床表现、对滤过手术的影响以及如何预防和逆转眼表可能发生的变化,从而提高滤过手术的成功率进行综述。     

短期局部应用抗青光眼药物对眼表影响的前瞻性研究

目的探讨短期局部应用抗青光眼药物对患者眼表的影响。设计前瞻性病例系列。研究对象原发性开角型青光眼患者18例32眼,激光周边虹膜切除术后眼压偏高需要联合局部抗青光眼药物治疗的原发性闭角型青光眼患者9例12眼。方法将研究对象根据用药种类分为3组：噻吗洛尔组、酒石酸溴莫尼定组和布林佐胺组。所有患者均局部使用一种抗青光眼药物,每日滴用2次。用药前、用药后1个月、2个月和3个月行泪膜破裂时间（BUT）、基础泪液分泌试验（ST）、结膜印迹细胞（IC）检查和评分。主要指标泪膜破裂时间、泪液分泌值和印迹细胞检测评分。结果全部患者用药前BUT的平均值为（5．83±3．74）秒,用药后1个月、2个月和3个月分别为（5．75±3．32）秒、（5．14±3．02）秒和（4．58±2．87）秒;用药前ST平均值为（6．39±3．98）mm,用药后1个月、2个月和3个月分别为（6．16±3．52）mm、（5．59±3．62）mm和（5．02±3．23）mm。用药后1个月BUT值（P＝0．335）和ST值（P=0．504）与用药前比较无统计学差异;朋药2个月后BUT值和sT值均显著低于用药前水平（尸=O．000）。各用药组BUT和ST的变化趋势与总体变化趋势一致。用药后3个月结膜印迹细胞学发生改变,表现为结膜上皮细胞角化,杯状细胞减少,IC评分与用药前比较有统计学差异（P=0．046）。结论使用噻吗洛尔、酒石酸溴莫尼定或布林佐胺滴眼液2个月即可导致患者泪膜稳定性下降,泪液分泌减少;使用3个月后可引起结膜上皮的损伤。     

重视青光眼药物和滤过手术对眼表的影响

青光眼药物对眼表的损害或滤过手术后患者眼表的功能异常均已引起了国外学者的关注,但在我国的临床实践中还未引起应有的重视。青光眼药物和滤过性手术均可导致泪膜、结膜和角膜上皮的损害,从而引起患者的眼部不适症状以及其它并发症的发生。及时发现眼表功能的异常并正确处理,对改善青光眼患者长期用药的依从性、提高长期用药或滤过手术后的眼部舒适度、减少术后并发症、提高生活质量均有重要意义。（眼科,2009,18：6—9）     

闭合性眼外伤致黄斑裂孔的光相干断层扫描图像分析

Objective To observe the features of the images of optical coherence tomograpy (OCT) in patients with traumatic macular hole (TMH), and detect the clinical significance of OCT. Methods Consecutive 74 patients (74 eyes) diagnosed with TMH by examinations of visual acuity, slit lamp, and direct or indirect ophthalmoscopy underwent optical coherence tomography (OCT), The analysis software of OCT was used to make the quantitative measurements of TMH. And the TMH were classified according to the morphological characteristics of the images of OCT. 50°color fundus photography was performed on the patients after OCT. The relationship of TMH with the average visual acuity, disease duration, average neuroepithelial thickness on the margin of hole, and the base diameter and the apex diameter of macular hole were retrospectively analyzed. Results The characterisctics of the images of 74 cases (74 eyes) of TMH were classified into 5 types: macular holes with symmetric edema of the neurosensory retina at the margin in 27 eyes (36.5%), macular holes with asymmetric edema of the neurosensory retina at the margin in 12 eyes (16.2%), macular hole with full-thickness defect of neurosensory retina without edema or detachment at the margin in 14 eyes (18.9 %), macular hole with localized detachment of the neurosensory retina at the margin without edema in 17 eyes (23.0 %), and macular hole with thinning neurosensory retina in 4 eyes (5. 4 %).There was no significant difference of visual acuity among different types of TMH (F=1. 574, P=0. 191).The visual acuity was positively related with the marginal retinal thickness (r=0. 342, P=0. 003), but not related to age, diameter of macular hole or the disease duration(r value was from-0. 022 to-0. 134, P value was from 0. 863 to 0. 261). The disease duration of Type IV TMH was shorter than that of other TMH types. In the patients with the disease duration over 90 days, Type I TMH was predominant. The average retinal thicknesses at the margin of the hole showed significant differences among different TMH types (F= 13.921, P= 0.000). Conclusions TMH could be divided into 5 types according to the characteristics of images of OCT; the clinical characteristics of different types of TMH varies.     

小梁切除术后远期泪膜和眼表上皮改变及其影响因素研究

目的 探讨青光眼患者小梁切除术后远期泪膜和眼表上皮的情况及其影响因素.方法 对103例(139只眼)小梁切除术后6个月以上的患者进行眼表泪膜检查和结膜印迹细胞学检查,分析术后远期薄壁滤过泡的发生率与术中使用丝裂霉素C(MMC)的关系,分析术后远期泪膜和眼表上皮改变与术中使用MMC及术后滤过泡形态的相关关系.结果 小梁切除术后患眼与正常对照组相比,泪膜破裂时间缩短,眼表活体染色增多,结膜上皮鳞状化生改变明显.高浓度MMC组术后薄壁滤过泡的发生率明显高于低浓度MMC组和空白对照组.术后远期眼表上皮杯状细胞密度(GCD)与术中MMC的使用及术后滤过泡的形态呈负相关.结论 小梁切除术后远期患眼存在干眼表现.术中使用高浓度MMC可增加术后远期薄壁滤过泡的发生率.术后远期结膜上皮杯状细胞密度的降低与MMC的使用及隆起于眼表的滤过泡有关.     

复合式小梁切除术治疗原发性闭角型青光眼的临床观察

目的 了解复合式小梁切除术治疗原发性闭角型青光眼(PACG)的眼压控制情况及并发症.方法 回顺性系列病例研究.将PACG分为原发性急性闭角型青光眼(APACG)急性发作期、慢性期及原发性慢性闭角型青光眼(CPACG)慢性期和晚期,分别对复合式小梁切除术患者手术前后眼压、最佳矫正视力、手术并发症等指标进行观察,分析复合式小梁切除术治疗APACG与CPACG的眼压控制情况.采用SPSS 12.0统计学软件进行数据处理.手术后患者视力变化及转归情况的等级资料分析采用秩和检验,组间年龄、眼压等定量资料比较采用独立样本的t检验,手术前后不同时期眼压值的比较采用单因素重复测量资料的方差分析.结果 接受复合式小梁切除术的PACG患者共82例(96只眼).其中APACG患者37例(40只眼),CPACG患者45例(56只眼);术后随访时间(中位数)分别是24个月和25个月,APACG与CPACG患者术后随访时间差异无统计学意义(Z=-0.146,P=0.886).APACG患者术前眼压(53.6±17.9)mm Hg(1 mm Hg=0.133 kPa),术后出院时眼压(10.5±4.9)mm Hg,最终随访时眼压降至(14.0±10.3)mm Hg.CPACG患者的术前眼压(36.8±13.8)mm Hg,术后出院时眼压(11.7±4.2)mm Hg,最终随访时眼压(13.8±4.5)mm Hg.APACG患者(F=100.783)和CPACG患者(F=54.383)手术前与手术后眼压差异均有统计学意义(P<0.01).APACG患者中,有38只眼(95.0%)手术后无需使用降眼压药物,眼压即可控制在21 mm Hg以下;其中急性发作期33只眼,慢性期5只眼.CPACG患者中有50只眼(89.3%)手术后无需使用降眼压药物,眼压即可控制在21 mm Hg以下;其中进展期45只眼,晚期6只眼.所有PACG患者在小梁切除术后均以视力下降比例为高,手术后最常见的并发症为浅前房.结论 复合式小梁切除术后,APACG急性发作期和慢性期及CPACG进展期和晚期的眼压控制均较好,表明小梁切除术是治疗PACG和控制眼压的有效方式之一.但是复合式小梁切除术后视力降低比例较高是不可忽视的重要问题.     

瞳孔大小对光学相干断层扫描仪测量视网膜神经纤维层厚度的影响

 【目的】探讨瞳孔状态对光学相干断层扫描仪（OCT3）测量视网膜神经纤维层（RNFL）厚度值的影响及其诊断青光眼的准确性。【方法】正常人38例72眼，原发性开角型青光眼患者19例34眼，分别在自然瞳孔（2．5～3mm）和药物散瞳下（6～8mm）用OCT3成组扫描程序（RNFL Thickness3．4）进行检查。对散瞳前后各象限RNFL厚度及全周平均值进行对比，分别计算散瞳前后RNFL厚度测量值的ROC曲线下面积。【结果】正常人散瞳前颞侧、上方、鼻侧、下方、平均的RNFL厚度（μm）分别为77±12、122±16、68±13、125±16、98±9，散瞳后相应的RNFL厚度分别是75±13、122±17、71±13、125±14、98±10，散瞳前后比较，除鼻侧外（P为0．039），其余象限及全周RNFL厚度差异无显著性（P为0．478～0．870）。原发性开角型青光眼患者散瞳前颞侧、上方、鼻侧、下方、平均的RNFL厚度（μm）分别为63±13、90±20、58±15、72±22、71±9，散瞳后相应的RNFL厚度分别是65±13、93±22、60±12、74±22、73±10，散瞳前后颞侧和全周RNFL厚度平均值差异有显著性（P分别为0．011、0．008），其余各方位差异无显著性（P为0．109～0．172）。散瞳前后平均及下方视网膜神经纤维层厚度测量值的ROC曲线下面积最大，为0．971～0．983。【结论】应用OCT3测量RNFL厚度，瞳孔大小对测量值影响不大，但瞳孔不能小于2．5mm，屈光间质混浊时应散瞳检查。自然瞳孔及散瞳下运用OCT3测量RNFL厚度诊断青光眼的准确性高，结果可靠。     

周边虹膜切除术对原发性闭角型青光眼眼前段结构的影响

[目的]利用眼前段光学相干断层扫描仪(AS-OCT)观察原发性急性闭角型青光眼(APACG)和原发性慢性闭角型青光眼(CPACG)手术周边虹膜切除(SPI)前后眼前段结构的改变.[方法]连续性收集周边虹膜粘连＜6个钟点的、性别年龄匹配的APACG发作期患者37例(37眼)及CPACG患者25例(25眼),于SPI术前及术后1月行AS-OCT检查.比较术前及术后的中央前房深度(ACD)、房角开放距离(AOD)、小梁网虹膜间面积(TISA)、房角隐窝面积(ARA)、前房宽度(ACW)、前房容积(ACV)和晶状体矢高(CLR)的差异.[结果]与术前相比,APACG眼术后较术前AOD(0.096±0.063 vs 0.052±0.065,mm)、TISA(0.054±0.024 vs 0.030±0.029,mm2)、ARA(0.095±0.042 vs 0.059±0.057,mm2)和ACV(90±17 vs 73±17,mm3)增加(P＜ 0.001-0.032),而ACD、ACW及CLR无明显变化(P=0.102 ～ 0.609);CPACG眼术后较术前ARA (0.078±0.036 vs 0.065±0.024,mm2)及ACV(91±22 vs 83±22,mm3)明显增加(P=0.042和＜0.001),而AOD、TISA、ACD、ACW和CLR无明显变化(P=0.102-0.774).[结论]周边虹膜切除术可使APACG的房角开放和前房容积增加,使CPACG的前房容积增加,但不能改变APACG和CPACG眼的中央前房深度和晶状体的相对位置和CPACG眼的房角参数.     

复合式小梁切除术治疗抗青光眼术后眼压不降30例

目的探讨复合式小梁切除术治疗抗青光眼术后眼压不降的疗效。方法对30例抗青光眼术后眼压不降患者施行复合式小梁切除术。术后检查视力、眼压、滤过泡情况和前房深度。随访观察时间为2~33(11.80±7.40)个月。结果以眼压下降至6~21mmHg(用或不用降眼压药物)为标准,手术成功率为90%(27/30),术后视力提高、保持不变的有80%(24/30)。结论复合式小梁切除术是抗青光眼术后眼压不降再手术的一种有效治疗方法。     

中心性浆液性脉络膜视网膜病变频域光相干断层扫描与时域光相干断层扫描图像比较

Objective To compare difference of the cross-sectional pathological imaging and quantitative measurement of central serous chorioretinopathy (CSC) between time-and fourier-domain optical coherence tomography (OCT). Methods Consecutive 26 patients (26 eyes) with unilaterial CSC were subsumed. Bilateral eyes of all the patients underwent time-and fourier-domain OCT. Horizontal and vertical line scanning and radial six-line scanning protocols were used for time-domain OCT examination; horizontal and vertical high resolution five-line scanning and macular cube scanning protocols were used for fourier-domain OCT examination. The characteristics of OCT images, retinal segmentation and the quantitative measurement were compared between these two methods. Results Fourier-domain OCT could yield the three-dimensional images of surface of inner limiting membrane (ILM) and RPE. The band of external limiting membrane (ELM) of normal subjects and CSC patients, and the inner segment and outer segment (IS/OS) of normal subjects could be clearly shown by fourier-domain OCT. However, the band of IS/OS disappeared in 65.4 % of the CSC patients. The outer boundary of retina was defined in front of the retinal pigmental epithelia (RPE) by fourier-domain OCT. The foveal thickness of normal subjects and CSC patients was (180. 50 ±12.69) and (158. 41 ± 34.20) μm, respevtively. The height of detachment of neuralepithelial layer was (245.84± 154.61) μm measured by fourier-domain OCT. The band of IS/OS of normalsubjects could be clearly shown by time-domain OCT. However, the band of IS/OS disappeared in 73.4%of the CSC patients, which showed no difference with fourier-domain OCT (Z=-0. 108, P=0. 914). Theouter boundary of retina was defined in front of the IS/OS band by OCT. The foveal thickness of normal subjects was (141.16±12.75) μm, which was thinner than that measured by fourier-domain OCT (t= 20. 671,P= 0. 000). The foveal thickness and the height of detachment of neural epithelial layer was (146.40± 36.28) μm and (240. 32±156. 82) μm measured by time-domain OCT, respectively, which showed no significant difference with which measured by fourier-domain OCT (t value was from 0. 026 to 1. 517, P value was from 0. 144 to 0. 980). Conclusions Fourier-domain OCT yields better visualization of intraretinal layers and more accurate definition of outer boundary of retina than time-domain OCT. Thus the measurements by fourier-domain OCT were more accurate. Moreover, three-dimensional images of CSC shown by fourier-domain OCT enable the comprehensive observation of pathological morphology and location.