闭角性青光眼的诊治

原发性闭角型青光眼,张纯北京大学眼科中心,房水生成,睫状体Anterior pars plicata (2 mm wide)Posterior pars plana (4 mm wide),房水生成,睫状突位于Anterior pars plicata大约70-80个睫状突，放射状指向后房中心动脉与脉络膜血管网相连由内向外：无色素上皮（延续为Neuroretina）、色素上皮（延续为RPE）、基质、睫状肌、睫状体上腔无色素上皮细胞由紧密连接相连构成血-房水屏障,房水生成,房水生成房水由无色素上皮细胞分泌，Na/K-ATPase，Na泵入后房，水依渗透压变化被动入后房Carbonic anhydrase作用不清低氧、低温可抑制房水分泌不依赖于IOP,房水生成,抑制房水生成药物睫状体破坏炎症、网脱、睫状体脱离,Aqueous Humor Cycle,Formed by the ciliary epitheliumPasses between iris and lens to enter the anterior chamberLeaves the eye through the trabecular meshwork-Schlemms canal and choroid-scleral pathway,房水流出途径,传统途径（90%）小梁-Schlemm管-房水静脉脉络膜-巩膜途径（10%）睫状体表面-Suprachoroidal space-睫状体、脉络膜、巩膜静脉循环系统减少：miotics增加：atropine, sympathomimetics, prostaglandins虹膜途径（极少）,Intraocular Pressure (IOP),IOPRate of aqueous humor production at ciliary bodyResistance to the outflow of aqueous humor at the angle of the anterior chamberLevel of epi-scleral venous pressure,房水流出途径,Rate of aqueous outflowF = C (Po Pe) where:F = rate of aqueous outflow (normal 2 l/min)C = facility of aqueous outflow (normal 0.2 l/min per mmHg)Po = IOPPe = episcleral venous pressure (normal 10 mmHg),流行病学,Prevalence印度和蒙古：1.4%日本：0.34%泰国：0.9%台湾地区：3%欧美白人： 40岁以上0.1-0.64%阿拉斯加爱斯基摩人：10%女，2.1%男南非祖鲁人：0.1格林兰因纽特人： 40岁以上2.5-10中国：40岁以上1.37%,流行病学,住院的青光眼病人广州：1977-1982，慢闭占PACG61%广州：1990-1996，慢闭多北京：2000-2003，PACG 58.84%，其中，慢闭占55%，急闭逐年渐少,诱因,阅读、疲劳情绪激动、紧张暗室停留时间过长大量饮水，补液局部或全身应用抗胆碱类药物外伤透吸呼吸道感染,病理及病生理,解剖因素窄房角生理因素瞳孔阻滞虹膜膨隆病理因素瞳孔阻滞睫状阻滞前玻璃体阻滞虹膜膨隆房角关闭眼压增高,危险因素,年龄：55-65岁性别：女比男多2-3倍？种族：爱斯基摩、中国、东南亚、蒙古？屈光状态：远视眼季节性：冬季？晶状体厚度随年龄增厚(LT)眼轴短(AL)LT/AL ratio前房深度1.71.8 mm或更小遗传性！,The Complete Mechanism for PACG Remains Unknown,原发性闭角型青光眼的临床分类,急性6期慢性虹膜膨隆虹膜高褶（少见）Plateau iris configurationPlateau iris syndrome睫状环阻滞性青光眼,其他分类,LatentSubacuteAcute congestivePost-congestiveChronicAbsolute,瞳孔阻滞型瞳孔非阻滞型混合机制型,Pupillary blockNon-pupillary block,AcuteSubacuteChronicPlateau iris (syndrome)Combined mechanism,临床表现,Well Known,急性闭角性青光眼,50岁以上，女性多见，常有远视眼，家族史临床症状眼痛、头痛、虹视、视力下降、畏光、流泪,急性闭角性青光眼,临床分期临床前期：发作眼之对侧先兆期：可逆性症状和体征急性发作期：浅前房、棕色KP、虹膜节段性萎缩、青光眼斑、瞳孔中等扩大、眼压高间歇期：房角开放慢性期：房角受损绝对期：无光感,临床表现,临床表现,视力下降角膜水肿眼压高瞳孔扩大角膜后、晶状体表面棕色沉着物虹膜节段性萎缩晶状体青光眼斑前房浅,急性闭角性青光眼,鉴别诊断急性结膜炎急性虹膜睫状体炎：白色KP、瞳孔小胃肠道疾病颅脑疾病,慢性闭角型青光眼,眼部没有充血自觉症状不明显反复小发作眼压高,慢性闭角型青光眼,鉴别诊断POAG：高眼压下房角开放急性闭角型青光眼慢性期：病史、UBM,虹视?,闭角型青光眼患者的眼部特征,小角膜角膜曲率半径小前房浅晶状体厚晶状体前曲率半径小晶状体位置相对靠前眼轴短,诊断,IOP压陷眼压计：Schiotz压平眼压计：Goldmann,诊断,前房深度测量前房角观察 (once a year)房角开或闭？是否永久闭？窄角有关闭可能？其它结构异常？,前房角,Peripheral cornea：色素Schwalbes lineTrabecular MeshworkScleral spurCiliary body bandIris root：梳妆韧带,Shaffer system: TM to irisSpaeth system: Shaffer plus peripheral irisScheie system: Schwalbes line to iris,Classification,Shaffer system,Clinical Significance,Scheie system,宽角：静态可见全部结构窄角I：动态可见睫状体带,AC at Periphery,激发实验 (Provocative Test),暗室实验 (60-90 min, 8 mm Hg or greater)伏卧实验散瞳实验缩瞳实验结合房角镜检查！,视野检查,Retinal Nerve Fibers,Retinal Nerve Fibers,Normal Right Eye,3066% ganglion cells83% visual cortex,A Paracentral Scotoma,An Arcuate Scotoma,A Nasal Step,A Temporal Wedge,眼底检查,Normal ONH,原发性闭角型青光眼,急性视乳头水肿充血、动脉搏动、静脉扩张慢性视乳头病理性凹陷和萎缩,Cup/Disc Ratios,盘沿丢失,Hemorrhage in GONH,Vascular changes,Sever