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GLAUCOMA

Chapter11

第十一章青光眼

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GLAUCOMA

Chapter11

第十一章青光2

第—節(jié)概述Definition:Glaucomaisagroupofcharacteristicinopticatrophyandvisualfielddefectsasthecommoncharacteristicdisease.Pathologicintraocularpressureheightenisoneofthemainriskfactors.青光眼定義：是一類以特征性視神經(jīng)萎縮和視野缺損為共同特征的疾病.病理性眼壓增高是其主要的危險因素.2

第—節(jié)概述Definition:Glauco3Intraocularpressure(IOP):thepressureoftheeyecontent

totheeye

wall眼壓:眼球內(nèi)容物作用于眼球內(nèi)壁的壓力NormalIOP:10—2lmmHgDoubleIOPdifference<5mmHgIOPcurvedayandnight<8mmHg正常眼壓：10—2lmmHg雙眼壓差＜5mmHg晝夜眼壓曲線＜8mmHg。3Intraocularpressure(IOP):t4PathologicalIOP:IOPisbeyondeyeballinternalorganization,especiallytheopticnervebearinglimit.Causeopticatrophyandvisualfielddefects病理眼壓:超越眼球內(nèi)部組織，特別是視神經(jīng)承受限度的眼壓。引起視神經(jīng)萎縮和視野缺損4PathologicalIOP:IOPisbeyo5Ocularhypertension:IOPishigherthannormalIOPrange,butnodamageofthenerveandvisualfield.高眼壓癥:眼壓高出正常眼壓范圍，但無視神經(jīng)和視野損害。Normaltensionglaucoma:InthenormalrangeofIOP,theopticnerveandvisualfieldofthedamagethere.正常眼壓性青光眼：眼壓在正常范圍,但出現(xiàn)視神經(jīng)和視野的損傷。56房水循環(huán)途徑:Aqueouscycleway:Ciliaryprocessposteriorchamberpupil睫狀突(產(chǎn)生房水)

后房

瞳孔

AnteriorchamberAngle

Anteriorchamber

前房角(排出房水)前房房水產(chǎn)生率房水排出率維持正常眼壓大多數(shù)青光眼眼壓升高的原因為房水排出受阻6房水循環(huán)途徑:Ciliaryprocess778pathophysiological

process

病理生理過程：

AqueousproducingrateTrabecularmeshworkresistanceScleraveinpressure三個因素：房水生成率小梁網(wǎng)阻力上鞏膜靜脈壓aqueousoutflowresistanceIncreased大多數(shù)青光眼眼壓升高的原因是房水外流阻力增高8pathophysiologicalprocess

病理9Classification

分類Primaryglaucoma:

Angle-closureglaucoma:

Acuteangle-closureglaucomaChronicangle-closureglaucomaOpen-angleglaucoma:PrimaryopenangleglaucomanormaltensionglaucomaSecondaryglaucoma:Congenitalglaucoma:

Infantileglaucoma

Juvenileglaucoma

Congenitalglaucomaaccompaniedbyothercongenitalanomalyglaucoma原發(fā)性：閉角型:急性閉角型青光眼慢性閉角型青光眼

開角型：原發(fā)性開角型青光眼

正常眼壓性青光眼繼發(fā)性：(眼病、全身)先天性：嬰幼兒型青少年型先天性青光眼伴有其他先天異常9Classification

分類Primarygl10前房角的檢查及分類前房角位于前房的最周邊前房角的構成：

前壁—角鞏膜緣

房角隱窩—睫狀體前端

后壁—虹膜根部10前房角的檢查及分類前房角位于前房的最周邊1111第二節(jié)原發(fā)性青光眼原發(fā)性閉角型青光眼—眼壓升高房角關閉Primaryangle-closureglaucoma

原發(fā)性開角型青光眼—眼壓升高房角開放PrimaryOpen-angleglaucoma12第二節(jié)原發(fā)性青光眼原發(fā)性閉角型青光眼—眼壓升高房13Primaryangle-closureglaucoma

一.原發(fā)性閉角型青光眼

Acuteangle-closureglaucoma（一）急性閉角型青光眼Etiology:geneticanatomyincentiveClinicalfeatures:age>50yfemalepainredeyevisionlosswithheadachenauseavomiting病因：具有遺傳傾向，解剖結構異常，常有誘因。臨床特征：年齡＞50歲，女性多見。主訴為眼脹痛．眼紅，視力下降，伴頭痛、惡心、嘔吐。13Primaryangle-closureglauco14Clinicalstages

急性閉角型青光眼臨床分期Preclinicalstage:Nosymptom,

Shallowanteriorchamber,Oneeyegetdisease,theothereyewithnosymptom.1.臨床前期：沒有自覺癥狀，具有淺前房，房角窄，虹膜膨隆。一眼發(fā)作，另眼沒發(fā)作。Precursorstage:TransientEasefast2.先兆期：一過性，多次小發(fā)作，自行緩解。14Clinicalstages

急性閉角型青光眼臨床分期15Acutestage:

Symptom:eye:pain,photophobia,tears,severevisionloss.withheadaches,nauseaandvomiting.Sign:Eyelidedema,Conjunctivalcongestion,Cornealepitheliumedema,Anteriorchamberextremelyshallow,Thepupildilatedandlightreflectiondisappeared,Anteriorchamberangleclosed.Intraocularpressureincreased>50mmHg.3.急性發(fā)作期：癥狀：眼部：眼痛、眼脹、畏光、流淚、嚴重視力下降。全身：頭痛、惡心、嘔吐。體征：眼瞼水腫、結膜混合充血、角膜上皮水腫、角膜后色素沉著、前房極淺、虹膜嚴重缺血、房水渾濁、絮狀滲出、瞳孔中等大、豎橢圓、光反射消失、局限后粘連、房角關閉、眼底不清、視網(wǎng)膜動脈搏動,眼壓明顯升高>50mmHg。15Acutestage:16閉角青光眼前房和前房角16閉角青光眼前房和前房角17急性閉角型青光眼發(fā)作17急性閉角型青光眼發(fā)作18Acuteonsetsequela:VisualacuitygetbetterKPIris:atrophy,pigmentationdefectsandlimitedstickyThepupilcan'treturntonormalCloudy-glaucomaspotontheanteriorlenscapsuleAnteriorchamberAngleextensivestick急性發(fā)作后遺癥：視力好轉角膜后色素沉著虹膜階段性萎縮、色素脫失、局限后粘瞳孔不能恢復正常晶體前囊下片狀白色混濁---青光眼斑房角廣泛粘連18Acuteonsetsequela:19Remissionstage:symptomstoeaseandanteriorchamberangleopenChronicstage:anteriorchamberangleextensivestickFinalstage:thecontinuoushighintraocularpressure,pooreyesightornolightfeeling.4間歇期：小發(fā)作后自行緩解，房角開放，不用藥或少量縮瞳藥。

5慢性期：房角廣泛粘連>半周，眼壓中度升高，視盤病理凹陷，視野缺損。6絕對期：持續(xù)高眼壓，視力極差或無光感。19Remissionstage:symptomst診斷青光眼激發(fā)試驗：1.暗室試驗2.俯臥試驗3.暗室+俯臥試驗20診斷青光眼激發(fā)試驗：2021Differentialdiagnosis鑒別診斷Eyedisease:Conjunctivitis,AnterioruveitisSystemicdisease:gastrointestinaldisease,braindisease,hypertension,etc眼?。航Y膜炎、前部葡萄膜炎。全身病：胃腸道疾病、顱腦疾患、高血壓病等。21Differentialdiagnosis22Treatmentofprimaryangle-closure

glaucoma

原發(fā)性閉角型青光眼的治療Drugs:increasedaqueouseduction:

myotic

inhibitaqueous

generatedhighpermeabilityagentadjuvanttreatment:calmorsleeping,purge,hormonereduceinflammationresponse.Laser:Operation:藥物:1.增加房水排出：縮瞳劑2.抑制房水生成：醋氮酰胺、塞嗎酰安3.高滲劑：20%甘露醇1一1.5g／kg、50%甘油2一3ml/kg4.輔助治療：鎮(zhèn)靜、安眠、通便、激素減輕炎反應。激光：手術：

22Treatmentofprimaryangle-c23

Chronicangle-closureglaucoma（二）、慢性閉角型青光眼

Clinicalsymptom:AgeisearlierProgressiveHavenoacutehistoryIntraocularpressureincreasedgradually.臨床癥狀：年齡較急性為早、漸進性、可無明確發(fā)病史。一般無急性發(fā)作史，房角粘連和眼壓增高逐漸進展。眼壓<50mmHg23Chronicangle-closureglauc24Signs:OpticatrophyandphysiologicalconcaveexpandVisualfieldgraduallydamage.體征：視神經(jīng)萎縮，生理凹擴大，視野進行性損害。24Signs:Opticatrophyandphy2525262627Primaryopenangleg1aucoma

二、原發(fā)性開角型青光眼Features:WhenIOPincreasedtheanteriorchamberanglekeepopeningThetrabecularmeshworkorganizationstructureisabnormal特點：眼壓升高，房角開放。小梁網(wǎng)內(nèi)組織結構異常27Primaryopenangleg1aucoma

28Clinical:Noself-conscioussymptomandbefoundlate.IntraocularpressureincreasedwithangleopenDependingontheopticdiskdamageC/D>0.6Visualfielddefects

臨床：無自覺癥狀，晚期發(fā)現(xiàn)。眼壓升高，房角開放。視乳頭損傷C/D>0.6或雙眼差＞0.2(火焰狀出血)視野缺損(旁中心暗點、鼻側階梯、弓形暗點、環(huán)形暗點、向心性性縮小、管狀、顳側視島)28Clinical:Noself-conscious29Diagnosis:HighIOPOpticdiskdamageVisualfielddefects

2ofthe3signs+anteriorchamberangleopening

Others:electricphysiologyexam,familyhistory,etc.Treatment:Drugtherapy:Lasertherapy:Operation:診斷：眼壓高、視乳頭損害、視野缺損其中兩項+房角寬其他：電生理、家族史等。治療：藥物治療：前列腺素衍生物激光治療：手術治療：濾過性手術29Diagnosis:HighIOP30

Ocularhypertension

第三節(jié)高眼壓癥Definition:Intraocularpressureishigherthannormal,withouttheopticdiskandvisionfielddamage.Anteriorchamberanglekeepopening.Regularlyreturnvisit:Tominimizeriskfactors.概念:眼壓高于正常上限,無視盤和視野損害,房角開放。定期隨訪:使危險因素降到最小。30Ocularhypertension

第三節(jié)高眼壓31Secondaryglaucoma

第四節(jié)繼發(fā)性青光眼GlaucomatocycliticsyndromeCorticosteroidsglaucoma:TraumaticglaucomaCataractexpans