1、,青光眼,Glaucoma,青光眼,Glaucoma,北京大学第一医院眼科 李骏,定义 Definition分类 Classification流行病学 Epidemiology诊断 Diagnosis治疗 Management,Definition,定义：由于眼压超过了眼内组织，特别 是视神经所能耐受的程度，从而引起视 神经损害和视野缺损的一种致盲性眼病。,Three key points,眼压视神经损害视野缺损,intraocular pressure,IOPoptic nerve damage visual field defect,Intraocular pressureIOP,眼内容物
2、作用于眼球壁的压力称为IOP,眼内容物：,玻璃体 vitreous：凝胶 晶状体lens：囊膜,房水aqueous humor：液体,产生排出,vitreous,lens,aqueous humor,Aqueous Humor Dynamics,Ciliary body,posterior chamber,Trabecular meshworkAnterior chamberpupil,Schlemm canal,vein,小梁网通路,葡萄膜-巩膜通路,IOP生成率 aqueous 排出率（主）,humor,影响眼压的因素,睫状体分泌增加,前房角关闭小梁网阻力增加,房角正常,房角关闭,正常IO
3、P,正常值：1021mmHg24h眼压差小于8mmHg双眼压差小于5mmHg,如何正确理解病理性IOP？pathologic IOP,IOP,高眼压症ocular hypertension,Two theories,Mechanically pressBlood supply,观察指标-C/Dcup/disc,CUPPING EVALUATION,C/D=0.3,C/D=0.8,Advanced Glaucoma C/DRatio,C/D=1.0,0.2,0.5,0.7,0.9,典型的青光眼性视野改变typical glaucomatic visual field defect,早期：旁中心暗
4、点paracentral scotoma,Physical blind spot,进展：弓形暗点arcuate scotoma,旁中心暗点发展为弓形暗点,进展：环形暗点 鼻侧阶梯ring scotoma&nasal step,晚期：管状视野 颞侧视岛central island&temporal island,青光眼的分类classification,一、原发性青光眼primary glaucoma,闭角型青光眼急性闭角型青光眼 慢性闭角型青光眼开角型青光眼,angle-closure glaucomaPACG acute angle-closure glaucoma chronic angl
5、e-closure glaucoma open angle glaucoma POAG,二、继发性青光眼 三、先天性青光眼,secondary glaucoma congenital glaucoma,原发性闭角型青光眼,primary angle-closure glaucomaPACG,IOP升高时房角是关闭状态周边虹膜与小梁网(trabecular meshwork)相贴，机械性阻塞前房角(anterior chamber angle)，阻断aqueous humor 的出 路，IOP,共同的解剖因素：眼轴短（远视）浅前房、窄房角、晶体相对较大,房角关闭,房角关闭的机制,相对性瞳孔阻滞
6、relative pupillary block高褶虹膜 plateau iris,发病机制,相对性瞳孔阻滞（主）虹膜膨隆 房角关闭房水外流受阻眼压升高,诱发因素,瞳孔中度散大精神因素,Plateau iris,急性闭角型青光眼acute angle closure glaucoma,前房角突然关闭而引起眼压急剧升 高的青光眼,流行病学特点,发病年龄40y,6070居多性别女性多发眼别双眼病，多先后发病家族史多基因，遗传度65%我国患病率高于欧美,临床表现 clinical findings,临床前期 pre-clinical stage前驱期 prodromal stage,-无症状-轻,急
7、性发作期 acute attack stage-重,间歇期慢性期绝对期,intermittent stage chronic stage absolute stage,-无（缓解）-视神经、视野损害-视功能完全丧失,症状（急性发作期）,急性发病剧烈眼胀痛，多伴同侧头痛视力显著下降，虹视严重者恶心、呕吐,体征,结膜：睫状、混合充血角膜：上皮水肿前房：极浅(房角关闭)，轻度tyndall(+)瞳孔：半开大，竖眼压：明显升高（多50mmHg),虹膜：水肿-遗留扇形萎缩，是曾经急性发作的标志晶体：有青光眼斑-是曾经急性发作的标志视网膜动脉搏动,诊断及鉴别诊断Diagnosis&differential
8、 diagnosis,diagnosis急性期、慢性期、绝对期：症状+体征临床前期、前驱期：好发人群：老年女性 解剖特点激发试验：暗室+俯卧,Differential diagnosis,眼部：急性虹膜睫状体炎全身：脑血管疾病、胃肠道疾病,急性虹睫炎,共同点：眼疼、充血、KP、tyndall不同：,其他系统疾病,脑血管疾病胃肠疾病,治疗原则,手术为主、择期而定,临床前期、前驱期、间歇期周边虹膜切除术（现多用激光打孔，打通前后房，多将孔打在睑裂区以外，多在上方，避免外界 光透过孔引起光学不适）原理-解除瞳孔阻滞急性期慢性期小梁切除术原理-房水外引流（流到结膜下）绝对期对症治疗睫状体冷冻-减少房水
9、分泌,急性期治疗-药物为主,目的：尽快开放房角，避免粘连手术并发症多，疗效差,缩瞳剂-房角开放2%毛果芸香碱滴眼液 pilocarpine，36次，间隔5分钟高渗剂-脱水20%甘露醇 mannitol 250500ml静脉快点（20分钟内点完，迅速提高血浆渗透压，脱水，主要脱玻璃体的水，不仅 使眼压下降，而且可以使虹膜和晶状体后移，开放房角）房水生成抑制剂醋甲唑胺（尼目克司）已酰唑胺 diamox0.250.5g口服,三类降眼压药物,Summary,Primary angle-closure glaucoma(PACG)occurs when the IOP increases because
10、 the outflow of aqueous is mechanically impaired by closing of the anterior angle.Both eyes are involved.There is a familial tendency to the condition.,The anatomic characters of PACG consist of shallow anterior chamber and narrow angle.Relative pupillary block is the common pathological procedure t
11、o increasing IOP.,Acute angle-closure glaucoma has a high incidence in China.The attack stage has been described as acute congestive,epithelial corneal edema,shallow anterior chamber,dilation of the pupil and a high IOP always more than 50mmHg.Systemic symptoms include nausea and vomiting.,Operation
12、 is necessary to acute angle-closure glaucoma.There are two kinds of the operation:one is peripheral iridectomy the otheris trabeculectomy.,Medical treatment is indicated in attack stage.IOP is reduced by oral or intra-venous administration of Diamox and mannitol.Pilocarpine is appled to re-open the
13、 anterior angle.,开角型青光眼open angle glaucoma,IOP视神经损害、视野缺损房角开放发病机制：房水排出通道本身的病变：小梁网-Schlemm管内皮细胞变性、增生,流行病学,年龄：40岁以上，比闭角型年轻欧美患病率高近视,与闭角型相反糖尿病遗传倾向,临床表现,症状：慢性、隐匿发病体 征：1）眼前节：前房不浅，房角开放 2）IOP：日曲线视盘：C/D 动态视野缺损：,Diagnosis,IOP21mmHgOptic disc damageVisual field defect以上三项，1+2或 1+3,视野缺损,早期：旁中心暗点进展：弓形暗点、环形暗点晚期：管状
14、视野、颞侧视岛,治疗原则,药物为主Timolol-抑制房水生成手术（小梁切除手术）,Summary,Primary open-angle glaucoma(POAG)is characterized by an almost complete absence of symptoms and a chronic,insidious course.The increased IOP which is because of the obstruction between the trabecular meshwork and canal of schlemm leads to optic disc damage and visual field defect.,继发性青光眼,闭角：1）白内障肿胀期虹膜炎瞳孔闭锁新生血管性恶性青光眼 malignantglaucoma开角：1）白内障过熟期虹膜炎炎症渗出物堵塞小梁网（青睫征）激素外伤：出血块、血影细胞、房角劈裂,
