1、1,GLAUCOMA Chapter 11 第十一章 青光眼,2,第节 概述,Definition: Glaucoma is a group of characteristic in optic atrophy and visual field defects as the common characteristic disease. Pathologic intraocular pressure heighten is one of the main risk factors.青光眼定义：是一类以特征性视神经萎缩和视野缺损为共同特征的疾病.病理性眼压增高是其主要的危险因素.,3,Intrao
2、cular pressure(IOP) : the pressure of the eye content to the eye wall 眼压:眼球内容物作用于眼球内壁的压力Normal IOP: 102l mmHg Double IOP difference5mmHg IOP curve day and night8mmHg 正常眼压： 102lmmHg双眼压差5mmHg昼夜眼压曲线8mmHg。,4,Pathological IOP: IOP is beyond eyeball internal organization, especially the optic nerve bearin
3、g limit. Cause optic atrophy and visual field defects病理眼压:超越眼球内部组织，特别是视神经承受限度的眼压。 引起视神经萎缩和视野缺损,5,Ocular hypertension: IOP is higher than normal IOP range, but no damage of the nerve and visual field.高眼压症:眼压高出正常眼压范围，但无视神经和视野损害。Normal tension glaucoma: In the normal range of IOP, the optic nerve and v
4、isual field of the damage there.正常眼压性青光眼：眼压在正常范围,但出现视神经 和视野的损伤。,6,房水循环途径: Aqueous cycle way:,Ciliary process posterior chamber pupil 睫状突(产生房水) 后房 瞳孔 Anterior chamber Angle Anterior chamber 前房角(排出房水) 前房,房水产生率 房水排出率,维持正常眼压,大多数青光眼眼压升高的原因为房水排出受阻,7,8,pathophysiological process 病理生理过程：,Aqueous producing r
5、ate Trabecular meshwork resistance Sclera vein pressure三个因素：房水生成率小梁网阻力上巩膜静脉压aqueous outflow resistance Increased 大多数青光眼眼压升高的原因是房水外流阻力增高,9,Classification 分 类,Primary glaucoma: Angle-closure glaucoma: Acute angle-closure glaucomaChronic angle-closure glaucomaOpen-angle glaucoma: Primary open angle gla
6、ucomanormal tension glaucoma Secondary glaucoma: Congenital glaucoma: Infantile glaucoma Juvenile glaucomaCongenital glaucoma accompanied by other congenital anomaly glaucoma原发性：闭角型:急性闭角型青光眼慢性闭角型青光眼开角型：原发性开角型青光眼正常眼压性青光眼 继发性： (眼病、全身) 先天性：婴幼儿型青少年型先天性青光眼伴有其他先天异常,10,前房角的检查及分类,前房角位于前房的最周边前房角的构成：前壁角巩膜缘房角隐
7、窝睫状体前端后壁虹膜根部,11,第二节 原发性青光眼,原发性闭角型青光眼眼压升高 房角关闭Primary angle-closure glaucoma 原发性开角型青光眼眼压升高 房角开放Primary Open-angle glaucoma,12,13,Primary angle-closure glaucoma 一.原发性闭角型青光眼,Acute angle-closure glaucoma（一） 急性闭角型青光眼Etiology: genetic anatomyincentive Clinical features: age50y female pain red eye vision l
8、osswith headache nausea vomiting病因：具有遗传倾向，解剖结构异常，常有诱因。 临床特征：年龄50岁，女性多见。主诉为眼胀痛眼红，视力下降，伴头痛、恶心、呕吐。,14,Clinical stages 急性闭角型青光眼临床分期,Preclinical stage: No symptom, Shallow anterior chamber,One eye get disease, the other eye with no symptom .1.临床前期：没有自觉症状，具有浅前房，房角窄，虹膜膨隆。一眼发作，另眼没发作。Precursor stage: Transie
9、nt Ease fast 2.先兆期：一过性，多次小发作，自行缓解。,15,Acute stage: Symptom: eye: pain, photophobia, tears, severe vision loss.with headaches, nausea and vomiting. Sign: Eyelid edema, Conjunctival congestion, Corneal epithelium edema, Anterior chamber extremely shallow, The pupil dilated and light reflection disappe
10、ared, Anterior chamber angle closed. Intraocular pressure increased 50 mmHg.3.急性发作期：症状：眼部：眼痛、眼胀、畏光、流泪、严重视力下降。全身：头痛、恶心、呕吐。体征：眼睑水肿、 结膜混合充血、 角膜上皮水肿、角膜后色素沉着、 前房极浅、虹膜严重缺血、房水浑浊、絮状渗出、 瞳孔中等大、竖椭圆、光反射消失、局限后粘连、 房角关闭、 眼底不清、视网膜动脉搏动, 眼压明显升高50mmHg。,16,闭角青光眼前房和前房角,17,急性闭角型青光眼发作,18,Acute onset sequela: Visual acuity
11、 get better KP Iris: atrophy, pigmentation defects and limited sticky The pupil cant return to normal Cloudy-glaucoma spot on the anterior lens capsule Anterior chamber Angle extensive stick急性发作后遗症：视力好转角膜后色素沉着虹膜阶段性萎缩、色素脱失、局限后粘瞳孔不能恢复正常晶体前囊下片状白色混浊-青光眼斑房角广泛粘连,19,Remission stage : symptoms to ease and a
12、nterior chamber angle open Chronic stage: anterior chamber angle extensive stick Final stage: the continuous high intraocular pressure, poor eyesight or no light feeling.4 间歇期：小发作后自行缓解，房角开放，不用药或少量缩瞳药。5 慢性期：房角广泛粘连半周，眼压中度升高，视盘病理凹陷，视 野缺损。6 绝对期：持续高眼压，视力极差或无光感。,诊断,青光眼激发试验： 1.暗室试验 2.俯卧试验 3.暗室+俯卧试验,20,21,D
13、ifferential diagnosis 鉴别诊断Eye disease: Conjunctivitis, Anterior uveitisSystemic disease: gastrointestinal disease, brain disease, hypertension, etc眼病：结膜炎、前部葡萄膜炎。全身病：胃肠道疾病、颅脑疾患、高血压病等。,22,Treatment of primary angle-closure glaucoma 原发性闭角型青光眼的治疗,Drugs: increased aqueous eduction : myotic inhibit aqueou
14、s generated high permeability agent adjuvant treatment: calm or sleeping, purge, hormone reduce inflammation response. Laser: Operation: 药物:1.增加房水排出：缩瞳剂 2.抑制房水生成：醋氮酰胺、塞吗酰安3.高渗剂：20%甘露醇1一1.5gkg、50%甘油2一3ml/kg4.辅助治疗：镇静、安眠、通便、激素减轻炎反应。 激光： 手术：,23,Chronic angle-closure glaucoma （二）、慢性闭角型青光眼 Clinical sympto
15、m: Age is earlier Progressive Have no acute history Intraocular pressure increased gradually.临床症状：年龄较急性为早、渐进性、可无明确发病史。 一般无急性发作史，房角粘连和眼压增高逐渐进展。 眼压50mmHg,24,Signs: Optic atrophy and physiological concave expand Visual field gradually damage.体征： 视神经萎缩，生理凹扩大，视野进行性损害。,25,26,27,Primary open angle g1aucoma
16、 二、原发性开角型青光眼,Features: When IOP increased the anterior chamber angle keep opening The trabecular meshwork organization structure is abnormal特点：眼压升高，房角开放。小梁网内组织结构异常,28,Clinical: No self-conscious symptom and be found late.Intraocular pressure increased with angle openDepending on the optic disk damag
17、e C/D0.6Visual field defects 临床：无自觉症状，晚期发现。眼压升高，房角开放。视乳头损伤C/D0.6或双眼差0.2(火焰状出血)视野缺损(旁中心暗点、鼻侧阶梯、弓形暗点、 环形暗点、向心性性缩小、管状、颞侧视岛),29,Diagnosis: High IOPOptic disk damageVisual field defects 2 of the 3 signs +anterior chamber angle opening Others: electric physiology exam, family history, etc.Treatment: Drug
18、therapy:Laser therapy:Operation:诊断：眼压高、视乳头损害、视野缺损其中两项+房角宽其他：电生理、家族史等。 治疗：药物治疗：前列腺素衍生物激光治疗：手术治疗：滤过性手术,30,Ocular hypertension 第三节 高眼压症,Definition : Intraocular pressure is higher than normal, without the optic disk and vision field damage. Anterior chamber angle keep opening. Regularly return visit: T
19、o minimize risk factors.概念:眼压高于正常上限, 无视盘和视野损害,房角开放。 定期随访:使危险因素降到最小。,31,Secondary glaucoma 第四节继发性青光眼,Glaucomatocyclitic syndrome Corticosteroids glaucoma: Traumatic glaucoma Cataract expansion glaucoma Anterior uveal inflammatory glaucoma Neovascular glaucoma Ciliary ring obstructive glaucoma 一、青光眼睫状
20、体炎综合征:中年男性多见。 二、糖皮质激素性青光眼: 小梁细胞功能受损 三、眼外伤：溶血、晶体脱位、房角后退 四、白内障：膨胀期 过熟期 五、虹膜睫状体炎 六、新生血管性青光眼 七、睫状环阻塞青光眼(恶性青光眼),32,Congenital glaucoma 第五节 先天性青光眼,Infantile glaucoma: Photophobia, Tears, Corneal increases and cloudy, anterior chamber deepened. IOP Increased and physiological concave expand 一、婴幼儿型青光眼:常染色体隐性遗传，房角结构发育不良。 畏光，流泪。角膜增大，混浊，前房加深。眼压增高，视乳头凹陷增大。 Juvenile glaucoma:6yage30y二、青少年型青光眼: 6岁年龄30岁。同开角型青光眼。三、先天性青光眼伴有其他先天异常,33,思考题,定义：青光眼病理性眼压高眼压症正常眼压性青光眼 什么是眼内压？正常值的范围是多少？ 房水循环途径是什么？ 急性闭角型青光眼的临床分期 急性闭角型青光眼的临床表现 急性闭角型青光眼的治疗 急性闭角型青光眼与急性结膜炎和急性虹膜睫状体炎的鉴别诊断,
